Transcriber’s Notes

  Text _between underscores_ and =between equal signs= represent texts
  printed in italics and in bold face, respectively. Small capitals
  have been replaced with ALL CAPITALS.

  More Transcriber’s Notes may be found at the end of this text.




  THE
  PRINCIPLES AND PRACTICE
  OF
  MODERN SURGERY

  BY

  ROSWELL PARK, A.M., M.D., LL.D. (YALE)

  PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY AND OF CLINICAL
  SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF BUFFALO,
  BUFFALO, NEW YORK; MEMBER OF THE GERMAN, ITALIAN AND FRENCH SURGICAL
  SOCIETIES; EX-PRESIDENT OF THE AMERICAN SURGICAL ASSOCIATION AND OF
  THE MEDICAL SOCIETY OF THE STATE OF NEW YORK; SURGEON TO THE BUFFALO
  GENERAL HOSPITAL, ETC.

  WITH 722 ENGRAVINGS AND 60 FULL-PAGE PLATES IN COLORS
  AND MONOCHROME

  [Illustration]

  LEA BROTHERS & CO.
  PHILADELPHIA AND NEW YORK
  1907


  Entered according to Act of Congress, in the year 1907, by
  LEA BROTHERS & CO.
  in the Office of the Librarian of Congress. All rights reserved.




PREFACE.


A new work on Surgery enters a field of literature already rich in
excellent books differing widely in plan and viewpoint. Fortunately
nothing else is possible in representing so vast a subject, for it
is obviously advantageous that the reader should have the benefit of
the personal equation of his author as reflected in his knowledge,
experience, and assimilation from the writings of others. When Surgery
can be represented by a conventional and well-settled type of book it
will have ceased to advance. There is still room for many a serious
effort to place the subject before students and practitioners in
a way to instruct from the beginning through to the operative and
postoperative treatment. This has been the object of the present
volume, upon which the author has brought to bear the experience
of many years as a teacher and surgeon, and into which he has also
endeavored to infuse the most advanced knowledge gleaned from the
surgical literature of America and Europe.

To the extent of the author’s ability the work therefore represents the
_net_ Surgery of to-day, obsolete and obsolescent material having been
excluded, and the pages being devoted to sound principles and practice,
stated as clearly and succinctly as possible. The author has been free
to employ illustrations wherever a point could be so explained to the
eye. In the pictorial department utility and effectiveness have been
considered of more importance than extreme and unusual cases. Simple
drawings and even diagrams are often most instructive, and such have
been accordingly liberally used.

With every effort at conciseness it has not been practicable to cover
the subject in less than the equivalent of about fifteen hundred
ordinary octavo pages. By adopting a larger form the publishers have
presented this material in a convenient volume. In justification of
the size of the work it should be borne in mind that its scope is
very extensive, for it aims to cover the Principles as well as the
Practice of Surgery, thus supplying the needs of students and general
practitioners, and, the author hopes, also interesting his surgical
confrères.

He takes this opportunity to extend his warmest acknowledgments to his
fellow-collaborators of the _Treatise on Surgery by American Authors_,
who on the exhaustion of the third edition most kindly consented
to allow it to be succeeded by this individual work, placing their
material and illustrations freely at his command. He also wishes to
acknowledge the kindness of Dr. H. R. Gaylord, who has contributed
certain material utilized in the chapter on Tumors, the assistance of
Dr. E. R. McGuire, who has helped in many ways during the preparation
of the book, and that of other colleagues who have furnished
illustrations that are duly credited in their proper places.

  R. P.

  BUFFALO, N. Y.
  1907.




CONTENTS.


                                                                    PAGE

  INTRODUCTION                                                        17


  PART I.
  SURGICAL PATHOLOGY.

  CHAPTER I.
  HYPEREMIA: ITS CONSEQUENCES AND TREATMENT                           19

  CHAPTER II.
  SURGICAL PATHOLOGY OF THE BLOOD                                     28

  CHAPTER III.
  INFLAMMATION                                                        43

  CHAPTER IV.
  ULCER AND ULCERATION                                                65

  CHAPTER V.
  GANGRENE                                                            73


  PART II.
  SURGICAL DISEASES.

  CHAPTER VI.
  AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS                     79

  CHAPTER VII.
  THE SURGICAL FEVERS AND SEPTIC INFECTIONS                           85

  CHAPTER VIII.
  SURGICAL DISEASES COMMON TO MAN AND DOMESTIC ANIMALS                97

  CHAPTER IX.
  SURGICAL DISEASES COMMON TO MAN AND DOMESTIC ANIMALS (CONTINUED)   111

  CHAPTER X.
  SYPHILIS.                                                          122

  CHAPTER XI.
  CHANCROID OR VENEREAL ULCER                                        144

  CHAPTER XII.
  GONORRHEA                                                          146

  CHAPTER XIII.
  SCURVY AND RICKETS                                                 160

  CHAPTER XIV.
  THE STATUS LYMPHATICUS                                             163

  CHAPTER XV.
  SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND DISEASES      166

  CHAPTER XVI.
  POISONING BY ANIMALS AND PLANTS                                    171

  CHAPTER XVII.
  ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS                    174


  PART III.
  SURGICAL PRINCIPLES, METHODS AND MINOR PROCEDURES.

  CHAPTER XVIII.
  DISTURBANCES OF BLOOD-PRESSURE; SHOCK AND COLLAPSE                 177

  CHAPTER XIX.
  ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS;
  TRANSFUSION; CATHETERIZATION; SKIN GRAFTING; BANDAGING             182

  CHAPTER XX.
  ANESTHESIA AND ANESTHETICS, GENERAL AND LOCAL                      192


  PART IV.
  INJURY AND REPAIR.

  CHAPTER XXI.
  WOUNDS AND THEIR REPAIR                                            211

  CHAPTER XXII.
  GUNSHOT WOUNDS                                                     220

  CHAPTER XXIII.
  PREVENTION AND CONTROL OF HEMORRHAGES; SUTURES; KNOTS              234

  CHAPTER XXIV.
  ASEPSIS AND ANTISEPSIS; TREATMENT OF WOUNDS                        243

  CHAPTER XXV.
  PREPARATION OF PATIENTS FOR OPERATION AND THEIR AFTER-TREATMENT    250


  PART V.
  SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE SYSTEMS.

  CHAPTER XXVI.
  CYSTS AND TUMORS                                                   255

  CHAPTER XXVII.
  THE SKIN                                                           299

  CHAPTER XXVIII.
  SURGICAL DISEASES OF THE FASCIÆ; APONEUROSES; TENDONS AND TENDON
  SHEATHS; MUSCLES AND BURSÆ                                         319

  CHAPTER XXIX.
  SURGICAL DISEASES OF THE HEART AND VASCULAR SYSTEM                 334

  CHAPTER XXX.
  INJURIES AND DISEASES OF THE LYMPH VESSELS AND NODES               368

  CHAPTER XXXI.
  SURGICAL DISEASES OF THE JOINTS AND JOINT STRUCTURES               379

  CHAPTER XXXII.
  SURGICAL DISEASES OF THE OSSEOUS SYSTEM                            416

  CHAPTER XXXIII.
  DEFORMITIES DUE TO CONGENITAL DEFECTS OR ACQUIRED DISEASES OF THE
  LOCOMOTOR APPARATUS; ORTHOPEDICS                                   444

  CHAPTER XXXIV.
  FRACTURES                                                          479

  CHAPTER XXXV.
  DISLOCATIONS                                                       524


  PART VI.
  SPECIAL OR REGIONAL SURGERY.

  CHAPTER XXXVI.
  INJURIES AND SURGICAL DISEASES OF THE HEAD                         545

  CHAPTER XXXVII.
  THE ORBIT AND ITS ADNEXA; THE EXTERNAL AUDITORY APPARATUS; THE
  ACCESSORY SINUSES; THE CRANIAL AND CERVICAL NERVES; THE ORBITAL
  CONTENTS AND ADNEXA                                                592

  CHAPTER XXXVIII.
  THE SPINE, THE SPINAL CORD AND THE PERIPHERAL NERVES               621

  CHAPTER XXXIX.
  THE FACE AND EXTERIOR OF THE NOSE AND MOUTH                        638

  CHAPTER XL.
  THE MOUTH, THE TONGUE, THE TEETH AND THE JAWS                      652

  CHAPTER XLI.
  THE RESPIRATORY PASSAGES PROPER                                    671

  CHAPTER XLII.
  THE NECK                                                           698

  CHAPTER XLIII.
  THE THORAX AND ITS CONTENTS                                        718

  CHAPTER XLIV.
  THE BREAST                                                         755

  CHAPTER XLV.
  THE ABDOMEN AND ABDOMINAL VISCERA                                  767

  CHAPTER XLVI.
  THE PERITONEUM AND ITS DISEASES                                    785

  CHAPTER XLVII.
  INJURIES AND SURGICAL DISEASES OF THE STOMACH                      793

  CHAPTER XLVIII.
  THE SMALL INTESTINES                                               822

  CHAPTER XLIX.
  THE APPENDIX AND ITS DISEASES                                      851

  CHAPTER L.
  THE LARGE INTESTINES AND THE RECTUM                                869

  CHAPTER LI.
  HERNIA                                                             890

  CHAPTER LII.
  THE LIVER                                                          910

  CHAPTER LIII.
  THE OMENTUM, THE MESENTERY, THE SPLEEN AND THE PANCREAS            934

  CHAPTER LIV.
  THE KIDNEYS                                                        955

  CHAPTER LV.
  THE BLADDER AND PROSTATE                                           977

  CHAPTER LVI.
  THE MALE GENITAL ORGANS                                           1004

  CHAPTER LVII.
  AMPUTATIONS                                                       1023




GENERAL SURGERY.

INTRODUCTION.


An ultimate analysis of the primary causes of disease, excluding
traumatisms, will permit their reduction to one or the other of the
following categories: _nutritional_ (functional) and _parasitic_. These
may co-exist, in which case each tends to modify the other more or
less, usually unpleasantly, or either may precede and perhaps pave the
way for the other. In general, it may be said that parasitism perverts
nutrition, locally or generally, and, _per contra_, that perverted
nutrition often prepares the way for parasitic infection, so that even
between these primary causes there may occur all possible combinations.

With traumatisms surgery alone is mainly concerned, but its conceded
scope is now widened to include an ever-increasing number of morbid
conditions, which, in time past, were treated medicinally--or not at
all. Thus it has come to pass that it is no longer possible to make an
abrupt distinction between medicine and surgery, nor even briefly to
define the words “surgery” and “surgeon,” nor yet to ascribe to either
the physician or the surgeon his exact functions as such. In centuries
past physicians were exceedingly jealous of their vested rights, and
with propriety, when the only surgeons were uneducated barbers. But
about one hundred years ago conditions were materially altered for the
better, and surgery, liberated from its medieval environment, and from
the restrictions imposed by the clergy, rapidly developed into both a
science and an art, while the surgeon came to take that position in
society to which his increasing attainments entitled him. During the
past thirty years surgery, thanks to earnest workers in the surgical
laboratories of the world, has made progress scarcely equalled by the
science of electricity, and the impossibilities of yesterday have
become the routine of today.

Thus has come about the earlier separation, and now, in some respects
at least, the closer appreciation of the respective scope and functions
of the physician and the surgeon. Between them lies yet what has been
felicitously called the “borderland,” where they meet on common ground,
too often as rivals and not often enough as co-workers. Nowhere do
comprehensive knowledge, wide experience, and trained judgment appear
to better advantage, nor lead to better results, than when exhibited
where co-operation in these respects is most hearty. Someone has most
happily said that “the surgeon is a physician who knows how to use his
hands,” yet to regard a course in surgery as one in manual training
would be a most lamentable conception of its purposes. Rather is
it to be regarded as a superstructure, to be built upon a thorough
familiarity with anatomy, physiology, pathology, and therapeutics. In
fact, the better general practitioner a man is, the better surgeon may
he thereby become, providing he possess the other necessary attributes.
John Hunter took this view, but too many since his day have forgotten
or never realized it.

In the pages which follow it has been impossible to do more than
epitomize our present-day knowledge of surgery, an early disavowal
which is intended to save too frequent repetition of the advice to
consult, as needed, other larger and more specialized works. The
attempt here has been rather to build up a framework upon which the
student and the investigator may build with such other material as they
may later select from the quarries which are accessible to them. Hence
it has been impossible to describe or even mention all the operations
which have been devised to meet various indications. Preference has
therefore been given to those which have best served the author in his
personal experience.

Because of the numerous interrelations between surgery and internal
medicine, so called, I have not hesitated to insert paragraphs and even
whole chapters on subjects hitherto omitted from the later works on
surgery. To teach a student how to recognize nasopharyngeal adenoids,
to appreciate the widespread harm they may cause and how to cope with
them, and at the same time to leave him quite unfamiliar with their too
frequent relation to the status lymphaticus and its dangers, and to
omit in such a work all reference to the latter, is to put knowledge
and instruments into his possession without teaching him how rightly
to employ them. A case of exophthalmic goitre affords another equally
apt illustration, as being one in which the physician and the surgeon
should heartily co-operate.

The surgeon and the physician have drifted too far apart. It is time
that they met again in the presence of the pathologist. Such a group,
when properly constituted, forms an almost invincible triumvirate.

It has been said that “the resources of surgery are rarely successful
when practised on the dying.” Throughout these pages the attempt has
been made to impress the fact that delay, in many of the borderland
cases, is dangerous, and, often fatal, and that it is not just to
charge to surgery the blame for such a result due to the physician’s
dilatoriness.

It may lead to a better understanding of the teaching contained in
the following pages if it is here made clear just what is understood
by the suffix “_itis_” in medical terminology. The old tendency was
to regard all morbid conditions as expressions of inflammation in
some of its protean manifestations. The attempt has been made in this
work to distinguish as clearly as possible between _inflammation,
as an expression of infection_, and the vascular, nutritional, and
other changes which may be brought about by perverted nutrition
without necessary participation of parasites. To describe “ostitis,”
for example, as “inflammation of bone,” is to revert to an obsolete
definition. Let us, then, always translate the termination “itis”
as implying an _affection_, not necessarily an inflammation, of
the structure named in the word to which it is affixed. With this
conception of the word or the term there can be no contradiction in
its use under various conditions, and one does not necessarily commit
himself, by using it, to any definite view concerning the pathology of
the affection which is thereby implied.

With regard to one other feature there has been also a departure from
previous nomenclature. The term “lymph glands” or “lymphatic glands”
has always seemed objectionable, because, although they belong to the
lymphatic system, they are in no sense glands, having no ducts, and no
distinct secretion to be discharged through passageways. Whether in any
sense they are to be regarded as furnishing an “internal secretion”
is not the question here, their most obvious function being to act
as filters. Throughout the work, then, the term “lymph gland” has
been carefully excluded and the more accurate and far preferable term
“lymph node” has been substituted. This seems to be a suitable place to
explain the substitution and the reason therefor.




PART I.

SURGICAL PATHOLOGY.




CHAPTER I.

HYPEREMIA: ITS CONSEQUENCES AND TREATMENT.


The reactionary results of injury to various tissues and the first
local appearances due to the surgical infectious diseases are indicated
by certain appearances, which, for a few hours at least, are in large
measure common to both. Their beginnings being pathologically similar,
their results depend not alone on the violence or intensity of the
process, but also, and in predominating measure, upon the primary
influences at work. The consequences of mere mechanical injury--such as
strain, laceration, etc.--are in healthy individuals promptly repaired
by processes which will be taken into consideration in the ensuing
chapters. They are throughout conservative and reparative, and are
directed toward restoring, as far as possible, the original condition.
The consequences, on the other hand, of the surgical infections are
more or less disastrous from the outset, although the extent of the
disaster may be localized within a very small area, as after a trifling
furuncle, or they may be so widespread as to disable a limb or an
organ, or they may even be fatal. It is of the greatest importance, not
alone for scientific reasons, but also because treatment must in large
measure depend upon the underlying conditions, to differentiate between
these two general classes of disturbance, which we speak of as--

A. _Those produced by external or extrinsic disturbances_, _i. e._,
traumatisms, sprains, lacerations, etc.; and

B. _Those produced by internal and intrinsic causes_, which, for the
main part, are the now well-known microörganisms, such as cause the
various surgical diseases.

These latter disturbances may be imitated or _simulated_ in the
presence of certain irritants within the tissues, such as the poisons
of various insects and plants; the irritation produced by foreign
bodies, minute or large; and possibly the presence within the system
of certain poisons whose nature is not yet known, such as that of
syphilis, or certain others whose chemistry is fairly well understood,
but whose presence cannot be easily explained, as uric acid, etc.

Clinically, all these disturbances are manifested by certain phenomena
common to each, which may present themselves at one time more
prominently, at another less so. These significant appearances have
been recognized from time immemorial as the _calor_, _rubor_, _dolor_,
_tumor_, _et functio lesa_ of our ancestors, or as the heat, redness,
pain, swelling, and loss of function of our common experience. When one
or more of these are present, the surgeon cannot afford to disregard
the fact, while he should, moreover, be able to account for each on
general principles which should to him be well known.

To their more exact study we must, however, make some preface in the
way of general remarks concerning a phenomenon everywhere easily
recognized, but as yet incompletely understood. This phenomenon has
reference to an undue supply of blood to a part, and is commonly known
under two terms which are practically synonymous, namely, _congestion_
and _hyperemia_. To begin with these, then, we must note, first of all,
that congestion and hyperemia may be--

  A. _Active_; and

  B. _Passive_.

They may also be spoken of as--

  1. _Acute_; and

  2. _Chronic_.

Considering first the two latter distinctions, it will be found that
the acute hyperemias are met with most often in consequence of sharp
mechanical disturbances. The chronic hyperemias, on the contrary, are
conditions which in many individuals are more or less permanent. Note
accurately here the proper significance of certain terms. Hyperemia
means, in effect, an oversupply of blood to the given part; the term
should have only a local significance. When the entire body seems to be
too well supplied with blood, the condition is known as _plethora_, the
counterpart of which term is usually _anemia_. The direct counterpart
of the term _hyperemia_ should perhaps be _ischemia_, meaning a
perverted blood supply in reduced amount. With plethora and anemia
as terms implying general conditions, with hyperemia and ischemia
implying local conditions, there should be little room for confusion in
phraseology.

The active form of hyperemia used to be called “fluxion,” a term now
rarely used. _Active hyperemia_ means an increased supply of _arterial_
blood. In _passive hyperemia_ the oversupply is rather of _venous_
blood. In the former case the condition seems due to overactivity of
the heart, with such local tissue changes as permit it to occur. In
passive hyperemia the blood current is slower--there is a tendency
toward, and sometimes an actual, stagnation; all of which is usually
due to obstruction of the return of blood to the heart. The conditions
permitting these two results may be widely variant.


=Active Hyperemia.=--Active hyperemia may be produced by purely
nervous influences, even those of emotional origin. The flushing of
the face which is known as “blushing” is, perhaps, the most common
illustration of this fact. It is well known also that this is, in
some degree at least, the result of division of certain nerves which
have to do with the regulation of the blood supply. The cervical
sympathetic is the best known and most often studied of these, and the
consequences of division of this nerve in the neck are stated in all
the text-books on physiology. So also by electrical stimulation of
certain nerves the parts supplied by them can be made to show a very
active hyperemia, which will subside shortly after discontinuance of
stimulation, providing this has not been kept up too long. In active
hyperemia there is absolute increase of intra-arterial tension, and
under these circumstances pulsation may be noted in those small vessels
in which commonly it is not seen nor felt. This is the explanation
of the throbbing pain complained of under many actively hyperemic
conditions. This hyperemia affords the explanation of the clinical
signs to which attention has already been called. The increased heat
of the part is the result of greater access of blood, which prevents
cooling by radiation and evaporation; the peculiar redness is due to
the greater filling of the capillaries with the blood, which gives the
peculiar hue to the skin and visible textures; while to the increased
pressure upon sensory nerves is also due the pain. The minuter changes
occurring within the congested part call for more accurate description.
Whether or not there is actual dilatation of capillaries under these
circumstances is a matter still under dispute, but of the dilatation of
the larger vessels there can be no possible question.

As hyperemia is to such a great extent brought about by action
of the nervous system, it is well to divide it more accurately
into the hyperemia of paralysis, or _neuroparalytic congestion_,
which is the result of a paralysis of the constrictor fibers of
the vasomotor system, and into the hyperemia of irritation, or
_neurotonic congestion_, which is due to the irritation of the dilators
(Recklinghausen). Physiologists are fairly well agreed that as between
the dilating and the constricting apparatus of the vasomotor system
there is ordinarily preserved a certain degree of equilibrium; to which
fact is probably due that normal condition of affairs inaugurated after
temporary disturbance, since overaction in one direction succeeds
reaction in the other. As Warren has illustrated this, our common
treatment of frostbite by cold applications is a concession to this
fact, since by the cold applications we endeavor to limit the reaction
which would otherwise follow after thawing out the frozen part.

The best examples of the _hyperemia of paralysis_ are perhaps to be
met with after certain injuries to nerves, as, for instance, flushing
of the face and hypersecretion of nasal mucus, tears, etc., after
injury to the cervical sympathetic. Such, too, in its essentials is
that form of shock known as brain concussion, which is often followed
by nutritive disturbances among the brain cells, with consequent
perversion of brain function.

Waller’s experiment of placing a freezing mixture over the ulnar
nerve at the back of the elbow is also significant, the result being
congestion and elevation of surface temperature of the fingers supplied
by this nerve. Congestion and swelling have also been observed after
fracture of the internal condyle of the humerus, by which this nerve
was pressed upon; and similar phenomena may be noted in fingers or toes
as the result of injuries of other nerves.

Hyperemia due to _paralysis of the perivascular ganglia_ is observed
sometimes in transplanted flaps, in the suffusion of a limb after
removal of the Esmarch bandage, in the congestion of certain sac walls
after tapping, in the hyperemia of, perhaps even hemorrhage from, the
bladder wall after too quickly relieving its overdistention, and in
the swelling of the extremities when they begin to be first used after
having been put at rest because of injury.

The _hyperemias of dilatation_ are more acute in course and
manifestation. Along with them go sharp pain, hypersecretion of
glands, edema, and sometimes desquamation of superficial parts. The
facial blush due to effusion; the temporary flushing due to indulgence
in alcohol; the suffusion of the conjunctiva, perhaps the face,
with hyperlacrymation, accompanying facial neuralgia or hemicrania;
and the hyperemia consequent upon herpes zoster, urticaria, etc.,
are illustrative examples of this form. The erythema due to nerve
irritation or injury, the swelling of the joints which appears
after similar lesions, and that condition described by Mitchell as
_erythromelalgia_, probably also belong here. In fact, almost all the
reflex hyperemias are hyperemias of dilatation.

The forms of hyperemia considered above belong mainly to the
designation of _active_.


=Passive Hyperemia.=--Passive hyperemia is most often a mechanical
consequence of obstruction of the return of blood, which can be
imitated at will, and which is not infrequently the result of
carelessness, as when an injured limb is bandaged too tightly.
Experiment shows that when such mechanical obstruction has taken
place there is temporary increase of intravenous pressure, which soon
returns to the normal standard, such readjustment meaning that blood
has found its way back by collateral circulation. Only when such
rearrangement is possible do we have anything like permanent passive
hyperemia. In organs with a single vein, such as the kidneys, the
question of obstruction may assume a very important aspect. Under these
circumstances the appearance of the involved part, when visible, is
spoken of as _cyanotic_, while its surface, instead of being abnormally
warm, is the reverse, due to impeded access of warm blood and more
rapid surface cooling. The blood under such conditions is often darker
than natural, because, remaining longer in the part, it absorbs more
carbonic dioxide, or at least gives up more of its oxygen. As long as
actual gangrene is not threatened, the blood column has a communicated
pulsation, at least in the large veins. Escape of corpuscular elements
may occur after the phenomena above noted have been present for some
time; but the corpuscles rarely, if ever, escape until there has
been more or less copious transudation of the fluid portion of the
blood--_i. e._, the serum. When anatomical changes can be grossly, yet
carefully, observed, as in the fundus of the eye, it is seen that under
these circumstances the arteries become smaller, although whether this
is a primary or secondary change is not to be determined. Discoloration
of the integument is the frequent result of leakage of blood corpuscles
and their pigmentary substance into the tissues, and is consequently a
frequent accompaniment of chronic passive edema. It is seen often in
connection with varicose veins of the legs.

Another form of passive congestion or hyperemia is that due to
enfeeblement of the heart’s action by serious injury or wasting
disease. When under these circumstances the lung has become more or
less infiltrated with fluid, with hemorrhagic extravasation, the
condition is known as _hypostatic pneumonia_--a misnomer, nevertheless
indicating a condition which is only too frequent in the aged and
feeble.


RESULTS OF HYPEREMIA AND CONGESTION.

These may be--

  1. Speedy subsidence of all hyperemic phenomena--resolution.

  2. Acute swelling.

  3. Chronic swelling.

  4. Gangrene.

  5. Nutritional changes--atrophy and hypertrophy.


1. =Resolution.=--The speedy subsidence of hyperemic phenomena is known
as _resolution_--a term which has also been applied to the retrograde
phenomena after a genuine inflammation. For present purposes it
implies, first, the subsidence into inactivity of the exciting cause
or its complete removal. This may include the passing of an emotion,
the removal of an irritant, the loosening of a bandage, the resort to
certain applications or to constringing or astringing measures by which
the effect is counteracted. A particle of dust in the conjunctiva may
within a few moments produce an active congestion of the conjunctival
vessels, which, ordinarily scarcely visible, becomes prominent and
easily noted. The removal of the offending substance permits a return
to their original size in perhaps a half-hour. This is an example of
the speedy subsidence of the hyperemia of dilatation after removal of
the cause. Should the hyperemia not subside promptly, it is well to use
cold applications, or in this instance an astringent collyrium, or some
agent whose physiological effect it is to produce vascular contraction,
as cocaine, adrenal extract, etc.


2. =Acute Swelling.=--When the effusion above referred to takes place
into loose connective tissues the condition is spoken of technically
as _edema_, while when it occurs into a previously existing cavity,
such as that of a joint, it is known as an _effusion_. The amount of
blood thus effused will be influenced by the anatomical and mechanical
conditions existing about the part. It may be presumed, as a general
rule, that when the extra vascular pressure equals the intravascular
pressure little or no more fluid may escape. As a matter of fact, it is
seldom that the former rises to the degree of the latter. Conversely,
one method of treating such edemas and effusions is by some device
which shall make the extravascular pressure exceed the intravascular,
when the fluid is, as it were, forced back into the vessels, and is
made to resume its proper place within the same. This is often done by
taking advantage of elastic compression, as when a rubber bandage is
applied about the part. In certain parts of the body it may be done by
pressure brought about by some other device. Pressure may be used for
two purposes:

_A._ To so increase extravascular pressure as to limit the possible
amount of an effusion, as when it is put on early after an injury; or,

_B._ When it is used as a later resort for the purpose of reducing
swelling which has already occurred.


3. =Chronic Swelling.=--This is something more than the swelling
alluded to under _Acute Swelling_. Chronic swelling implies either
a continuous passive hyperemia, or, what is more common, a positive
increase in tissue elements as the result of an oversupply of
nutrition brought by the blood, which itself was furnished to the part
in a degree far in excess of its needs. The result is a more rapid
reproduction of cell elements, with result in the shape of tissue
thickenings or tissue enlargements, known as _hypertrophy_, or, more
properly speaking, _hyperplasia_, of a part, and to the laity as
“overgrowth.” This chronic swelling or chronic enlargement is in some
degree also connected with the phenomena of escape of white corpuscles
from the bloodvessels and mitotic division of certain tissue cells,
which have up to this time been usually regarded as a feature of the
true inflammatory process.


4. =Gangrene.=--This may be the result of hyperemia--for the most part
the passive forms--though most instances of gangrene due to intrinsic
causes are inseparable from the presence of infectious microörganisms.
The gangrene which is spoken of here includes that due to the pressure
of tumors, tight dressings, or any natural or intrinsic agency, and
that due to pressure from without when not so pronounced as to produce
immediate and total loss of circulation in a part. It includes the
formation of many bed-sores and so-called _pressure-sores_, which may
be due to an enfeebled heart, to an obstructed pulmonary circulation,
or to external pressure in conjunction with cardiac debility. While
insisting, then, that gangrene should be recognized as a possible
result of hyperemia, it may be added that it is in effect a tissue
death, and that dead tissue is always and everywhere practically the
same thing, no matter by what causes brought about. Consequently, the
subject of gangrene will be considered under a separate heading.


5. =Nutritional Changes= will be considered later.

_The consequence of persistent hyperemia is transudation_--i. e.,
_escape of blood plasm from the vessels into body cavities and tissue
interspaces_. This leads to consideration under a distinct heading of--


TRANSUDATES AND EXUDATES.

Exudation may occur in vascular and non-vascular, in firm and soft
tissues, in, under, and upon membranes. With respect to location,
exudates are described as _free_, when found upon free surfaces or
within natural cavities; _interstitial_, when found between the tissues
or parts of tissues; and _parenchymatous_, when they are situated
within the tissues themselves, particularly in epithelial and glandular
cells of any kind.

Exudates are _serous_, _mucous_, _fibrinous_, or _mixed_, the mixed
forms including the so-called _seropurulent_, the _mucopurulent_, the
_croupous_, and the _diphtheritic_.

When any exudate contains red globules in sufficient quantity to stain
it, it is called _hemorrhagic_.

Serous transudates from free surfaces are sometimes spoken of as serous
_catarrhs_; when into cavities, as _dropsies_; when into tissues,
as _edema_; when occurring beneath the epidermis they form _serous
vesicles_ or _blebs_ or _bullæ_.

_Fibrinous_ exudation refers to the fluid which coagulates soon after
its exit from the vessels within those spaces into which it has
oozed. When flocculi of coagula float in serous fluid it is known as
a _serofibrinous_ exudate. Pure fibrinous exudate occurs rarely, save
in and upon mucous membranes. The extent to which exposure to the air
is responsible for the firm coagulation of the fibrin previously held
in solution is uncertain. The most potent factors in producing such
coagulation are bacteria, but it is not yet disproved that coagulation
may occur without their aid. When such coagulation occurs upon the
surface of a mucous membrane it has been spoken of as _croupous_. When
the epithelial covering as well as the basement membrane, and often
the submucous tissues, are involved, so that the membrane cannot be
stripped off without tearing across minute bloodvessels, the exudate
has been known as _diphtheritic_. These terms may possibly be still
retained in an adjective sense as implying the exact location of a
surface exudate, but are scarcely to be used in any other significance.

The following table illustrates significant differences whose full
importance cannot be impressed before a study of inflammation has been
carefully entered upon:


  _Hyperemic Transudates._          _Inflammatory Exudates._

  Poor in albumin.                  Rich in albumin.
  Rarely coagulate in the tissues.  Usually coagulate in the tissues.
  Contain few cells.                Contain numerous cells.
  Low specific gravity.             High specific gravity.
  Contain no peptone.               Contain peptone (product of cell
                                    disintegration).


TREATMENT OF CONGESTION AND HYPEREMIA.

These disturbances are to be combated, first of all, by insisting upon
_physiological rest_. This, perhaps, is the most important measure of
all. The profession is indebted to Hilton for the decided advance which
he made in the treatment of congestive and inflammatory affections
by insisting upon this principle in his celebrated work on _Rest and
Pain_, which every young practitioner should read. Aside from this
first and underlying principle, the treatment must, in some measure
at least, be based upon the time at which we are called upon to treat
the case. If seen at once, before exudation has been excessive or the
other disturbances marked, we may carry out a certain line of treatment
for the purpose of limiting all these unpleasant features. On the other
hand, if seen late, when exudation has been copious and when pain and
other disturbances are due to its presence, a distinctly different
course will be adopted.

Toward the end first mentioned--namely, the limitation of hyperemia--we
may adopt local and general measures. Local measures include graduated
pressure, providing this is not intolerable to the patient, so
equalized that outside of the vessels it shall equal that inside. This
may be done by careful bandaging, extreme care being taken that the
pressure be applied from the very extremity of the limb; otherwise,
passive exudation might be augmented and gangrene be precipitated.
Elevation of a limb will often accomplish the same purpose. Cold, which
is in effect an astringent and which tends to contract bloodvessels,
is another measure in the same direction, and if applied early will
do much to limit the degree of the attack. This may be applied as dry
or moist cold, and should be gradually mitigated as the congestion
subsides. It acts through the vasomotor system, and is a measure to be
resorted to with caution. An efficient way of applying dry cold can be
extemporized by a few yards of rubber tubing, held in place by wire
or sewed in place to a piece of cloth, through which a stream of cold
water is permitted to pass.

Heat is another efficient means, acting, however, in a rather different
way. Heat is a measure to be employed to hasten the disappearance of
exudation--in other words to quicken resorption, which it does by
equalizing blood pressure, dilating the capillaries, stimulating the
lymphatic current, and in every way helping to clear the tissues of
that which has left the bloodvessels.

It is necessary also, at least in extreme cases, to employ some
detergent or derivative measures, including _bloodletting_, to which we
do not resort sufficiently often. When used for this purpose, depletion
should be applied at the area involved, if possible. This may be done
either as venesection, by leeching, either with the natural or the
artificial leech, or by a series of minute punctures or incisions,
which give relief to tension, permit the rapid escape of fluid exudate,
and often save tissues from the disastrous effects of strangulation. In
some cases of deep-seated congestions these measures are inapplicable,
and venesection at the point of election--say the cephalic vein in the
arm--may be followed by great benefit. Another method of depletion
is by administration of cathartics, such intestinal activity being
stimulated as shall lead to copious watery evacuations. The salines
rank high as measures directed to this end, but in emergency much
stronger and more drastic drugs may be administered, such as jalap,
calomel, elaterium, etc. Diaphoretics and diuretics help to reduce
temperature and in some degree to deplete, but their action is usually
slow. When exudation is considerable in amount and confined to some one
of the body cavities, it is often best combated, if at all obstinate,
by the method of _aspiration_. This includes any suitable suction
apparatus by which the fluid may be withdrawn through a small needle
or cannula, the operation being trifling in difficulty, but one to be
performed under strictest aseptic precautions, lest infection of an
exudate already at hand be permitted.

Certain individuals, especially the neurotic, will need more or less
anodyne, particularly when local applications fail to give relief.
Sometimes a small dose of morphine administered hypodermically will
act magically in making efficient those measures which would otherwise
be inefficient. In little children some anodyne or hypnotic will be of
great service. Under all circumstances it is well to keep the lower
bowel empty, and certain elderly individuals with weak and enfeebled
hearts will need the stimulation to be afforded by digitalis, quinine,
and alcohol, or preferably strychnine administered subcutaneously.

In cases of chronic hyperemia and its consequent hyperplasias
(induration, thickening, etc.) there is no one measure so generally
applicable and effective as the continued use of cold-water dressings.
These are generally spoken of as “cold wet packs,” and may be
continued--constantly or intermittently--for many days.

Massage is also an invaluable agent in the reduction of swelling and
tissue overproduction. It promotes absorption, even of acute effusions,
by equalizing the blood and hastening the lymph circulation, and under
its scientific application it is surprising how firm exudates and old
adhesions seem to disappear.


ATROPHY AND HYPERTROPHY, AND THE CONSEQUENCES OF ALTERED, DIMINISHED,
AND PERVERTED NUTRITION.

As a consequence of increase of nutrition we have a condition
known commonly as _hypertrophy_, more accurately as _hyperplasia_.
Hypertrophy literally means overgrowth, whereas hyperplasia more
accurately describes that which constitutes hypertrophy--namely,
numerical increase of constituent cells. Common usage has made the
more inaccurate name “hypertrophy” cover nearly all these conditions.
_Hypertrophy_, or hyperplasia, _means enlargement of a part or of an
organ beyond its usual limits_, and as the result of increased function
or increased nutrition. It is to be distinguished from _gigantism_,
which means inordinate enlargement as the result of a congenital
tendency or condition. Hypertrophy is--

  A. _Physiological_ {1. Compensatory;
                     {2. From deficient use.

                     {3. Local;
  B. _Pathological_  {4. General;
                     {5. Senile;
                     {6. Congenital.

[Illustration: FIG. 1

Congenital hypertrophy: gigantism of both lower extremities. (Case of
Dr. Graefe [Sandusky].)]


A. =Physiological Hypertrophy.=--1. This includes many of the
compensatory enlargements of an organ or a part when extra work is
put upon it, owing to deficiency of some other organ or part. This
is spoken of as _compensatory_ enlargement. Illustrative examples
may be seen in the heart, which becomes larger and stronger when the
bloodvessel walls are diseased and their lumen narrowed, or when other
obstructions to circulation are brought about; again, in enlargement
of one kidney after extirpation of the other, or of the wall of the
stomach when the pylorus is constricted or obstructed; again, of the
fibula after weakening or more or less destruction of the tibia, or
of the shaft of any bone when it has been weakened at some point by
not too acute disease; or, again, of the walls of bursæ after constant
friction.

2. The best examples of physiological hypertrophy owing to deficient
use are perhaps seen in some of the lower animals; as, for instance,
in the teeth of such rodents as beavers when kept in captivity and
prevented from natural use.


B. =Pathological Hypertrophy.=--3, 4. Instances of this are
everywhere and every day are met in the results of so-called _chronic
inflammation_, a term which is a complete misnomer and should be
expunged from text-book use. So-called chronic inflammation simply
means increase of nutrition owing to a certain degree of hyperemia,
which may have been produced in the first place as the result of
traumatism, which may have come from chemical irritants circulating
in the fluids of the part--as, for example, uric acid, etc.--or which
is brought about as the result of perverted trophic-nerve influence.
Instances of local pathological hypertrophy may be seen in the
thickened periosteum after injury, in the enlargement of a phalanx
known as the “baseball finger,” and in numerous other places; or they
may be general, in which case they are brought about mainly by some
irritating material in the general circulation. The unknown poison of
syphilis generally provokes such nutritive disturbances.

5. _Senile hypertrophy_ is connected with nutritional disturbances
characteristic of old age, as to whose remote causes we are still
uncertain. Instances of senile hypertrophy, however, are common,
particularly in the prostates of elderly men, which are liable to
undergo extensive enlargement.

6. Of _congenital_ hypertrophy and that of unknown origin we see, for
instance, examples in certain rare cases of hypertrophy of the breast,
in leontiasis, perhaps even in acromegaly, etc.; and these are to
be distinguished from _gigantism_, because in most instances of the
former type the hypertrophic tendency is not manifested until youth or
adult life, whereas gigantism is a condition in which the tendency was
apparent even before the birth of the individual.


ATROPHY.

_Atrophy implies impaired nutrition, and means diminution in the
size of an organ or part_, and is the converse of hypertrophy. It is
necessary to make plain that in atrophy nutrition is only impaired and
not arrested, since complete arrest of nutrition means necrosis--_i.
e._, gangrene or disappearance of parts. It may be--

                     {1. From disuse without disease;
  A. _Physiological_ {2. Biological or developmental;
                     {3. Senile.

                     {4. Result of acute tissue losses;
  B. _Pathological_  {5. Result of phagocytic activity;
                     {6. Result of continuous pressure;
                     {7. Specific.


A. =Physiological Atrophy.=--1. This is always the result of disuse
or impaired function from any cause. Its evidences are generally seen
in the fatty structures and muscles--_i. e._, in the soft parts. It
is true, however, even of the bones, or, of greater interest, even in
the brain cells. We see evidences of it also in minute organs; as,
for example, in the digestive glands in certain cases where diet is
restricted. Again, we see it in the diminution of the size of the heart
after hip amputation, less being required of that organ, and also in
the entire structure of the rectum after colostomy.

2. Examples of the _developmental type_ are best seen in the natural
disappearance of the hypogastric arteries, the ductus arteriosus,
the vitelline duct, the Wolffian bodies, and in the various
generative ducts (Gärtner’s, etc.) shortly after the birth of the
human individual. We sometimes see it also in the prostate after
orchidectomy. Equally illustrative is the disappearance of the tail
and gills of the tadpole, the eyes of animals living in caverns, and,
in a general way, of organs which become useless owing to a different
environment.

3. _Senile_ atrophy is seen equally well in the hair follicles, the
teeth, the bones, and the sexual organs of elderly people--in fact, in
all their tissues, even in the brain.


B. =Pathological Atrophy.=--4. Acute atrophy of surrounding tissues
is the necessary accompaniment of destruction by suppurative or other
disturbances; that is, parts disappear by absorption which have not
been interfered with by pyogenic organisms. So complete may atrophy
occur under these circumstances as to cause disablement of an organ
or part. This kind of senile disappearance is merely an expression of
phagocytic activity, although not now a question of bacteria.

5. The same is true of that variety spoken of above as _biological_ or
_developmental_, since phagocytes are the active agents in producing
the disappearance of the tadpole’s tail.

6. A more slow form of pathological atrophy is seen in the _gradual
disappearance_ of tissues in the neighborhood of advancing tumors,
enlarging cysts, etc. This is perhaps but another expression of atrophy
from continuous pressure. But a still better illustration is the
atrophy which comes from immobilization of a part without pressure.
This is usually the case when splints or orthopedic apparatus have to
be kept in place for some time.

7. _Specific_ forms of pathological atrophy are largely connected with
disturbances in the central nervous system. They are often referred
to as _trophoneurotic_. Their exact mechanism is not yet understood,
and cases may be confused under this head whose remote causes are
widely different. Here should be included, for instance, the atrophy
of a deep bone which occurs after extensive burn of the surface; also
that peculiar form of atrophy of tissues in the stump which produces
the so-called _conical stump_. These cases are of a more complicated
character, for if pressure is removed from the bone end, especially
in young people, the bone tends to grow faster than it should, while
the soft parts disappear, partly as the result of mere disuse or loss
of function. In this way conicity is produced, which sometimes calls
for subsequent re-amputation. Under this head might also be included
the so-called “trophic inflammation” (misnomer) of some writers,
such, for example, as ulceration of the cornea after division of the
trigeminus. The general subject of _atrophic elongation_ also belongs
here, referring to the fact that as a result of disuse, or sometimes
of active disease, the bones, while showing atrophic changes in other
respects, actually increase in length. Should such increase occur in
one bone of those portions of the limbs which are supplied with two,
the result would be posture deformity and displacement of the terminal
portion.




CHAPTER II.

SURGICAL PATHOLOGY OF THE BLOOD.


The part played by the constituent elements of the blood in
inflammation, suppuration, and other still more disastrous conditions
is so great and so important that, before proceeding to discussion of
these lesions, it seems necessary to set forth a _resume_ of facts
illustrating the importance of accurate knowledge concerning this most
important fluid.

The total amount of blood in the human body has been variously
estimated at from one-eleventh to one-twenty-fifth of the body weight,
the average being about one-sixteenth. The amount which the body may
lose and still retain vitality is very vague and differs not only with
individuals, but very greatly under various conditions. Severe loss
of blood is one to be atoned for as quickly as possible, and is to be
prevented as far as it can be after accidents or during operation. For
this reason the so-called bloodless method of operating upon limbs, by
the use of the rubber bandage, constituted a great advance in surgery.
For the same reason the use of hemostatic forceps is of equal value
in operating upon other parts of the body; other things being equal
the quickest and most satisfactory recoveries follow the bloodless
operations, and it is an advantage to conserve this vital fluid as far
as possible.

It has been roughly estimated that the blood is divided about as
follows, between the different parts of the body: the heart, lungs,
and large vessels holding one-fourth, the skeletal muscles one-fourth,
the liver one-fourth, the remaining quarter being distributed over the
balance of the body.

The blood varies within wide limits in its coagulability, and this
variation occurs apparently even within conditions of health. In some
patients the blood may be seen to coagulate almost as rapidly as it
collects upon the surface, while in others the exposed parts continue
to ooze, and the checking of hemorrhage is a difficult, sometimes
almost impossible, matter. There are certain diseases in which the
blood is known to have reduced power in this direction; for example,
in the toxemias, especially those connected with biliary obstruction
and jaundice. There were not a few of these cases of slow bleeding to
death in days gone by, simply because the capillary hemorrhage could
not be controlled. Recently, it has been shown that calcium chloride
administered internally has a marked effect in favoring coagulation,
and when opportunity is afforded it should be given for several days
previous to operating and as part of the necessary preparation. It may
be administered in doses of from 1 to 2 Gm., and should be given three
or four times, at least, in twenty-four hours.

A test of the coagulation time, normally three to five minutes, but
lengthened under circumstances like those mentioned above, even to an
hour, will often prove of great value.

There are certain albumoses whose effect on coagulation of the blood
is very suggestive and very mysterious. A very minute dose of cobra
poison, for instance, will make the blood of an experimental animal
remain fluid for days, unless this animal has been previously immunized
against it, in which case coagulation takes place even more rapidly
than normally. A trace of serum from an immunized rabbit is enough
to prevent the fluidifying effect of the cobra poison, but quite
insufficient to neutralize its toxic effects. The surgeon practically
never desires to reduce coagulability of the blood, but frequently to
increase it. When it is increased by natural conditions or those not
easily controlled, then it may lead to thrombosis and produce trouble
in that way.


=Fibrin.=--Increase of fibrin, _hyperinosis_, accompanies the
leukocytosis of inflammation and suppuration. It may be approximately
estimated on the cover-glass by noting the closeness of the network
resulting after fifteen minutes’ exposure. The inflammatory indication
of leukocytosis may, therefore, be inferred from its determination,
while the leukocytosis of malignant disease will not be so accompanied.
Hyperinosis is most marked in pyogenic processes, pneumonia and
rheumatism. Its opposite, _hypinosis_, is met with in pernicious
anemia. There is no change in the percentage of fibrin in the ordinary
anemias or chlorosis. In hemophilia and purpura hemorrhagica the
coagulation time is greatly increased.


=The Formed Elements of the Blood.=--The specialized elements of the
blood which are of particular interest to the surgeon are the red and
the white corpuscles. These may both vary in relative size within
certain physiological limits. The red cells especially are not of
uniform size and vary from 6 to 9 microns in diameter. There are also
present in normal blood a small number of red cells having a diameter
of only 6 microns, which are known as microcytes. In infancy there
are present also so-called giant corpuscles, or megalocytes, with
a diameter of 10 microns or more. Considerable variation occurs in
disease, especially in the severe anemias. Red corpuscles ordinarily
stain with acid dyes, which facilitate their examination and a
computation of the number present. When present in unusually large
number the condition is spoken of as a _polycythemia_; when in reduced
number as _oligocythemia_. In several of the anemias variations in
size, shape, and color occur, and in certain of them many of the red
corpuscles are found to be nucleated. Red cells which are nucleated are
known as _erythroblasts_, and according to their size are spoken of as
_microblasts_, _normoblasts_, and _megaloblasts_. Again, under certain
diseased conditions the ordinary discoid form of the cells becomes
irregular and crenated, and to those which are thus altered is given
the name of _poikilocytes_.

There is another form of degeneration which consists in death or
necrobiosis of the cell, whereby it loses its capacity for staining,
or, at all events, stains irregularly and abnormally. This is seen also
in cases of severe anemia and in conditions where the blood has been
altered by the addition of toxic material, such as chloroform, etc.
Occasionally also the red cells show a tendency to a granular change,
which is probably entirely degenerative.

The red corpuscles have a certain degree of elasticity which helps
them to pass through capillaries which are smaller even than their
own diameter; after escaping from these the corpuscles regain their
original form. In the presence of carbon dioxide they lose this
elasticity and become distorted or crenate. The influence of high
altitudes in increasing the number of corpuscles is known, but
unexplained. For instance, a residence of less than a month in the
mountains will cause an increase of from 2,000,000 to 3,000,000
corpuscles per cubic millimeter. It has been surmised that under the
influence of oxygen red corpuscle formation is stimulated to greater
activity; in other words, that the red marrow becomes more active in
the production of the hematoblasts.

In general terms it may be said that the blood of a normal adult male
contains 5,000,000 red corpuscles per cubic millimeter, and that of an
adult female 4,500,000. These figures are, of course, approximate and
variable. When the number is reduced to 3,000,000 by common consent the
case will be regarded as oligocythemia, and when increased to 6,000,000
as one of polycythemia.

The latter condition is most evident in cases of newly born infants.
The excess rapidly diminishes during the first week of extrauterine
life. It is to be explained by the loss of fluid suffered by the
infant upon the establishment of respiration. The proportion of red
cells also varies according to the nutrition of the individual, the
season of the year, the altitude (as above), and climate, and varies
during menstruation, pregnancy, lactation, and at the climacteric.
With the loss of red cells the number is reduced in proportion to
the hemoglobin, although the change in one respect is not exactly
proportionate to that in the other.

That the _colorless corpuscles_, or leukocytes, are not all of one kind
has been recognized for nearly sixty years, and long ago they were
divided into granular and nucleated cells. A vast impetus to the study
of hemocytology was given by Ehrlich, in 1878, when he introduced the
use of aniline dyes. The reader must be reminded that some of these,
like eosin, are acid in reaction, and others, like methyl blue, are
basic; while a third group has been supposed to be neutral in reaction,
like a mixture of methyl blue and acid fuchsin; but it has been found
that the so-called neutral dyes have really a slightly acid reaction.
We may, therefore, divide the cells according to the reaction of the
dyes with which they usually are distinguished into the acid and basic,
or, more technically, into oxyphile, which includes neutrophile, and
basophile.

This is not the place in which to go into any minute discussion of
this subject nor further than should be of practical interest to the
surgeon; nevertheless an examination of the blood by some common and
routine procedure is so necessary in many surgical conditions that it
is impossible to entirely avoid the subject in a work like this. I have
accordingly condensed it and put the salient facts about leukocytes
into the following table:

_Classification of Leukocytes._

                                 _Granular._         _Non-granular._

           {               A. With fine granules C. Hyaline. Transiti-
           {Oxyphile.         (polynuclear) 60-     onal (large mono-
           {                  70 per cent.          nuclear) 4-8 per
           {Neutrophile.                            cent.
  Normal.  {The so-called  B. With coarse
           {neutral stain     granules (eosino-  D. Lymphocytes (small
           {being slight-     philes) 2-5 per       mononuclear) 20-30
           {ly acid.          cent.                 per cent.
           {

           {               E. Fine and coarse    G. Atypical hyaline
           {                  granules (baso-       (myelocytes).
  Patho-   {Basophile.        philes, mast-
  logical. {                  cells, etc.).
           {
           {Oxyphile.      F. Atypical (myelo-
           {                  cytes).

In normal blood by far the greater part of the leukocytes consists of
A and D. _Lymphocytosis_ means a relatively high percentage of C and
D. _Eosinophilia_ means an increase in the proportion of B. Basophile
cells are not absolutely pathological, for they may be present in very
small numbers in normal blood.

The number of leukocytes in normal blood will average about 7000 to
10,000 per cubic millimeter, the percentage of each variety being
given in the above table. Leukocytes are sometimes diminished in
number; under diseased conditions they are often increased, and these
are then included under the term leukocytosis. Variations occur daily
and almost hourly under normal conditions. Increase naturally occurs
after digestion, when the number of leukocytes may be almost doubled,
the same being due principally to lymphocytes which are washed into
the blood system from the lymph nodes by the flow of lymph or chyle.
In starvation, however, the number may be remarkably reduced and in
the case of the fasting man, Succi, the leukocytes were reduced at
the end of the first week to 860 per cubic millimeter. The rather
unusual condition of reduction of the number of corpuscles is called
_leukopenia_.

Leukocytosis is usually the rule in carcinoma, with increase in A and
F; the more rapid the growth, the greater this increase. In sarcoma
this is even more pronounced; when occurring without hyperinosis the
probability of malignancy is greater. Non-malignant tumors produce no
such changes.

The blood _platelets_ or _plaques_ first described by Bizzozero, in
1882, have no small interest for physiologists and pathologists, but
little for the practising surgeon. They number perhaps 5,000,000 per
cubic millimeter and sustain a fairly constant ratio to the red cells.
Their surgical interest is limited to the role which they may play in
the formation of thrombus.

The term _phagocytosis_ has to do in a general way with those
leukocytes which act as scavengers by removing from the blood its
noxious elements, presumably by a process of ingestion and digestion
(see Chapter III).

Examination and estimation of the various formed elements of the blood
are very valuable to the surgeon in the study of the anemias, of acute
inflammation when the presence of pus is suspected, in the presence of
suspected cancer, and in the presence of such conditions as Hodgkin’s
disease, the various disorders of the spleen, etc. The so-called
_primary anemias_ include only the pernicious anemias and chlorosis;
all others are designated as _secondary_. This distinction is not for
convenience only, but serves a useful purpose.

_Pernicious anemias_ produce a reduction both of the red corpuscles
and the hemoglobin, the former usually in a greater degree than the
latter, so that the _color index_ (see below) is usually plus. Many of
the cells become nucleated and, in general, their size is increased. In
chlorosis the reduction of the hemoglobin is relatively large and the
color index is extremely low. In the secondary anemias the red cells
and hemoglobin are reduced disproportionately, so that the color index
is minus. There may or may not be a relative increase of leukocytes and
of the nucleated red cells, but these latter are not so likely to be as
large as those seen in primary anemias. The _color index_ is obtained
by dividing the percentage of the hemoglobin present by the percentage
of the red cells.

Leukocytosis becomes pathological in conditions of acute inflammation
where the neutrophiles (A) show the greatest relative increase. The
degree of leukocytosis depends on two different factors: the intensity
or the virulence _of the infection_, and the _vitality_ or resisting
power _of the individual_. These vary within such wide limits that it
is hard to predicate anything definite in a given case. In general
the increase is supposed to be proportionate to the severity of the
infection, though the greater the reactionary ability of the patient
the larger the number of white cells. Where vitality is very low
leukocytosis is less pronounced. It is possible to have toxemia to such
a degree that the activity of the leukocytes seems to be destroyed. The
following summary from Cabot puts things in very distinct form.

Infection mild, vital reaction good--small leukocytosis.

Infection less mild, vital reaction less good--moderate leukocytosis.

Infection severe, vital reaction good--very marked leukocytosis.

Infection severe, vital reaction poor--no leukocytosis.

From this it will appear that the absence of leukocytosis in cases
where it naturally would be expected is a serious indication and
justifies an unfavorable prognosis; or else it may be interpreted in
evidently favorable cases as indicating infection of very mild grade.

There are but few diseases in which leukocytosis by itself (or for that
matter any other indication which the ordinary examination or blood
count may give) is wholly sufficient for diagnostic purposes. But a
blood count and estimate of the amount of hemoglobin present will often
be of such advantage to the surgeon that he may well afford to wait in
order to secure them. This is rarely necessary in acute cases, but in
chronic cases, and especially the anemias, he may gain great benefit by
such investigation. In _trichinosis_, for example, eosinophilia is most
pronounced, B forming even as high as 70 per cent. of the leukocytes
present.

The anemias which are of particular interest to the surgeon may be
classified as follows:

  1. _Anemias without marked leukocytosis._
     A. Characterized by oligocythemia.
     B. Characterized by diminution of hemoglobin.

  2. _Anemias with marked leukocytosis._
     A. Leukemia (leukocythemia).
     B. Pseudoleukemia (Hodgkin’s disease).

1. A. Anemias due to hemorrhage may assume one of two forms, that
resulting from sudden and extensive loss of blood or that resulting
from constant oozing. Example of the former is seen in hemorrhages
of the stomach or intestines after perforating ulcer, etc. Examples
of the latter are met with in hemophilia and in uterine hemorrhages,
or in excessive menstruation where the loss of blood extends over
a considerable length of time. It is known, moreover, that certain
entozoa in the intestines will produce a chronic anemia. Thus the
red corpuscles may be reduced to even less than 1,000,000 per cubic
millimeter. Immediately after acute hemorrhage the hemoglobin
percentage is still normal, but after a short time it becomes reduced.
If such cases do not speedily end fatally, nucleated red corpuscles
appear in the blood and the observer will recognize both normoblasts
and megaloblasts. At the same time the bone-marrow, which is normally
yellow, becomes red, vascular, and richly cellular, and seems to
furnish these cells just mentioned. Certain drugs, like potassium
chlorate and glycerin, affect also the number of red corpuscles,
but such poisons as these cause not only disintegration of the red
cells, but produce also jaundice and hemoglobinuria. Pernicious anemia
sometimes interferes with or fatally complicates surgical treatment.
It is characterized by the extreme changes already mentioned, with
which it marches steadily to a fatal termination. Quincke has reported
an instance in which their number was reduced to 43,000 per cubic
millimeter, while the hemoglobin was reduced to 20 or 25 per cent. of
the normal amount.

1. B. The best example of anemia which depends upon diminution of the
hemoglobin content of the red cells is that known as _chlorosis_. In
this there are few recognizable signs of destruction of corpuscles,
even under chemical microscopic examination; consequently the blood
picture is very simple. The color index is very low, yet similar
conditions may also be seen in syphilis, tuberculosis, and cancer. The
underlying feature of all of these cases is malnutrition.

Within a few years a peculiar form of intense anemia has been described
by Banti and others, and is often spoken of as _splenic anemia_ or
_Banti’s disease_. It is characterized by three stages: first, of
splenic enlargement and anemia; second, a transitional stage; third,
a stage of ascites which increases up to death. It is quite closely
allied to Hanot’s hypertrophic cirrhosis of the liver. It is quite
generally regarded as an example of an infection by some as yet
unknown organism. It is of interest to the surgeon because if the
spleen is removed early there are fair prospects of recovery.

2. A. _Anemias with marked leukocytosis_ include especially those
first spoken of by Virchow as _leukemia_. Originally he applied the
term to a particular alteration of the blood, but it is now made to
cover a group of diseases, all of which are characterized by peculiar
and more or less similar increase of white corpuscles. Sometimes these
are increased to such an extent as to make the blood grossly resemble
a mixture of blood and pus. This resemblance led some of the earlier
observers to speak of the condition as “suppuration of the blood.” The
number of leukocytes is sometimes enormously increased; 1 to 10 of the
red cells is quite common and 1 to 5 not exceedingly rare. Cases have
been known in which the white cells outnumbered the red. In well-marked
cases of leukemia, the red cells will be somewhat diminished, while
the white will number from 100,000 to 500,000 per cubic millimeter.
Accompanying this change in the blood there are alterations in
the spleen, the lymph nodes, and the bone-marrow, sometimes one
predominating, sometimes another. It has been customary in fact to
speak of splenic, lymphatic, and medullary leukemia, but these forms
are not sharply differentiated and a pure type of either form is rare.
In this country we speak mainly of _lymphatic_ and _splenomedullary_
forms, the latter being much more common. The latter is accompanied
by enlargement of the spleen, while in the lymphatic form the lymph
nodes are involved and may become as large as walnuts. In the lymphatic
form over 90 per cent. belong to C and D; in the splenomedullary or
splenomyelogenous form the increase of F and G is most marked, while
A will be reduced to 50 per cent. and D to about 10 per cent. The red
corpuscles are decreased in number, but not necessarily in an inverse
ratio; their number may be reduced even to 2,000,000 in extreme cases.

In these cases, besides the change in number and form of the leukocytes
already described, there are frequently found in the blood very minute
crystals first described by Charcot. These are small, often adherent
to the leukocytes, and most frequently found when eosinophile cells
predominate; their exact significance is not known. The pathology
of leukemia is too remote from the purpose of this work to receive
consideration here. Without asserting its germ character one may say
that it is under suspicion, and that various observers have described
appearances supposed to indicate a specific cause, probably a protozoön.

2. B. _Pseudoleukemia._--This has, in time past, gone under many
different names, of which the most common is _Hodgkin’s disease_ (_q.
v._). Many speak of it as _malignant lymphoma_. This is doubtless a
disease with a specific cause, as yet unrecognized, which produces
very significant changes in the blood, especially in the white
corpuscles. The spleen and lymph nodes are both involved, mainly the
latter. The general blood changes are quite variable and one may find
many types. As a rule, these comprise not so much an increase in the
number of leukocytes as a decrease in the number of red cells by
which an apparent leukocytosis is brought about; hence the expression
_pseudoleukemia_. Many cases, however, will present a certain degree
of actual leukocytosis, the proportion of the whites to the reds being
about 40 to 50.

_What interpretation in general is to be given to leukocytosis?_ A
condition deserving this name is, first of all, essentially temporary.
In acute infectious diseases it shows itself during the febrile stage
and the principal increase is in the finely granular oxyphile cells. In
such diseases as erysipelas, as well as pneumonia, it lasts but a short
time after the crisis has been reached and the temperature has fallen.
In diseases like acute appendicitis and acute peritonitis from any
cause a marked leukocytosis may be regarded as indicating the presence
of pus; it should be emphasized, however, that _pus may be present
without this indication_, and it has been previously stated that such
a fact is to be interpreted either as an example of a mild degree of
infection or an exceedingly reduced vitality.


=Differential Leukocyte Count.=--It seems to be now quite clearly
demonstrated that the mere establishment of a certain degree of
leukocytosis does not furnish the surgeon a reliable guide for
determining the presence of pus, it being an index of reaction rather
than of actual severity of any particular kind of infection. A much
more reliable guide is found in the proportion of polynuclear cells to
the total number of leukocytes counted, _i. e._, by what may be called
a differential count. In order to make this reliable, the normal ratio
should first be determined. This is put at a point between 68 and 80
per cent. by various writers. As Gibson (_Annals of Surgery_, April,
1906) says, 75 per cent. may be considered the best working average.
This average should be maintained as the total number of leukocytes
increases, or else there is a disproportion which becomes significant.
With a moderate leukocytosis there is a notable increase in polynuclear
cells, and it may be estimated that there is either a severe form of
lesion or less resistance to absorption, or both.

[Illustration: PLATE I

_Fig. I._

_Fig. II._

_Fig. III._

_Fig. IV._

_Fig. V._

_Fig. VI._

_Fig. VII._

_Fig. VIII._

_DRAWN BY J. N. Z. CHASE_]

  PLATE I.

  BLOOD.

  (Ehrlich triple stain.)

  (Prepared by DR. I. P. LYON.)

  Fig. I. TYPES OF LEUCOCYTES.

  _a._ Polymorphonuclear Neutrophile. _b._ Polymorphonuclear
  Eosinophile. _c._ Myelocyte (Neutrophilic). _d._ Eosinophilic
  Myelocyte. _e._ Large Lymphocyte (large Mononuclear). _f._ Small
  Lymphocyte (small Mononuclear).

  Fig. II. NORMAL BLOOD.

  Field contains one neutrophile. Reds are normal.

  Fig. III. ANÆMIA, POST-OPERATIVE (secondary).

  The reds are fewer than normal, and are deficient in hæmoglobin and
  somewhat irregular in form. One normoblast is seen in the field,
  and two neutrophiles and one small lymphocyte, showing a marked
  post-hæmorrhagic anæmia, with leucocytosis.

  Fig. IV. LEUCOCYTOSIS, INFLAMMATORY.

  The reds are normal. A marked leucocytosis is shown, with five
  neutrophiles and one small lymphocyte. This illustration may also
  serve the purpose of showing the leucocytosis of malignant tumor.

  Fig. V. TRICHINOSIS.

  A marked leucocytosis is shown, consisting of an eosinophilia.

  Fig. VI. LYMPHATIC LEUKÆMIA.

  Slight anæmia. A large relative and absolute increase of the
  lymphocytes (chiefly the small lymphocytes) is shown.

  Fig. VII. SPLENO-MYELOGENOUS LEUKÆMIA.

  The reds show a secondary anæmia. Two normoblasts are shown. The
  leucocytosis is massive. Twenty leucocytes are shown, consisting
  of nine neutrophiles, seven myelocytes, two small lymphocytes, one
  eosinophile (polymorphonuclear) and one eosinophilic myelocyte.
  Note the polymorphous condition of the leucocytes, _i. e._, their
  variations from the typical in size and form.

  Fig. VIII. VARIETIES OF RED CORPUSCLES.

  _a._ Normal Red Corpuscle (normocyte). _b, c._ Anæmic Red Corpuscles.
  _d-g._ Poikilocytes. _h._ Microcyte. _i._ Megalocyte. _j-n._
  Nucleated Red Corpuscles. _j, k._ Normoblasts. _l._ Microblast. _m,
  n._ Megaloblasts.

Gibson has suggested the formation of a chart where the number 10,000
of leukocytes shall appear upon the same line with 75 per cent. as the
average normal proportion of polynuclears. Then drawing a parallel
line, which shall indicate on one side each 1000 in increase of the
former and each advance of one in the percentage, it will be seen that
15,000 leukocytes will correspond to 80 per cent. of polynuclears,
20,000 to 85 per cent., etc. When upon this chart there is drawn a line
between that dot which represents the total leukocytosis on one side
and that on the other which indicates the percentage of polynuclears,
then the more horizontal this line the less the disproportion, while
the more marked the angle it makes with the base line the greater the
disproportion appears. It furnishes an admirable graphic record which
the eye appreciates at once.

It would appear, then, that a differential blood count made in this
way, and thus recorded, affords the most valuable diagnostic and
prognostic aid in acute surgical diseases, indicating especially the
presence of suppuration or of gangrene.


=Glycogen in the Blood and the Iodine Reaction.=--Glycogen occurs in
the blood especially in three classes of cases: those where there is
marked respiratory disturbance in certain of the anemias, and, what is
of especial interest to the surgeon, toxemias, either of chemical or
bacterial origin. It is usually present in the secondary and pernicious
anemias as well as in acute and late leukemias. It is considered
by some that in these cases it really indicates the occurrence of
some bacterial infection. Especially is glycogen present in cases
of suppuration and surgical sepsis, _i. e._, in those cases where
leukocytosis is usually, but not invariably, present; indeed, it would
seem to be a most significant indication. While the iodine test is
more easily carried out than is a blood count, the latter affords more
information. The reaction is reliable and its relative intensity gives
an idea of the intensity of the inflammatory process. In many cases
with obscure symptoms and without leukocytosis its presence will afford
much aid in diagnosis. It is of great assistance also in distinguishing
between a deep-seated pneumonia and serous pleurisy, since in the
latter there is no reaction, or in distinguishing between pleurisy with
effusion and empyema; again, in distinguishing gonorrheal arthritis
from true rheumatism. In a case of strangulated hernia the presence
of the iodine reaction would indicate that pressure had produced
gangrene, whereas its absence would indicate a relatively lesser degree
of destruction. It has been aptly said that the presence of iodine
reaction indicates that the patient is seriously sick.

It is easily obtained by staining a cover-glass with a blood smear in a
gummy solution of iodine and potassium iodide. When the blood is normal
all the cells take on a uniform, bright-yellow color, while the white
cells stain more lightly than does their protoplasm. When the glycogen
reaction is present, brown granules are seen in the protoplasm of the
polynuclear leukocytes, which may often take on a different brown tint.
Frequently brown particles are to be seen outside of the corpuscles,
while occasionally the other forms of leukocytes show also the reaction.

The value of a careful blood examination is well illustrated by
Plate I, prepared by Dr. Irving P. Lyon, in which are displayed the
alterations of greatest interest to the surgeon.


HEMOGLOBIN.

The principal interest of the red blood corpuscles for the surgeon,
aside from their relative number and shape, inheres in their relation
to hemoglobin, and hemoglobin is of particular interest here because
much can be learned by estimating the proportion in which it is
present. Hemoglobin has, furthermore, an interest which reaches
beyond the mere blood appearance, since it is considered to be the
apparent source from which both the urinary and biliary pigments are
produced. That the amount contained in the blood varies within wide
limits under different conditions has long been known. When notably
reduced in amount the condition is referred to as _oligochromemia_. The
ideal normal standard is present in but a small proportion of cases,
even in strong young men in the third decade of life. The average
is considerably lower and can scarcely be placed above 90 per cent.
Females show a smaller amount than males--3 or 4 per cent. less. In
anemia its reduction is not usually proportionate to that in the number
of red cells. After hemoglobin loss, as after surgical operations,
much can be gained in the matter of prognosis by estimating the speed
of its regeneration. With regard to how much actual hemoglobin loss
a patient can bear, it seems to be more important to determine how
much still remains in the body. The minimum is apparently 20 per
cent. In three cases dying of collapse after operation, Mikulicz
found only 15 per cent. remaining. The rapidity of regeneration is
a fairly accurate indication of improvement in every other respect.
Regeneration is interfered with by constitutional syphilis, and, on
the other hand, is often apparently favored in cases of tuberculosis.
In malignant tumors the average of hemoglobin is reduced to about 60
per cent., and in these cases also complete regeneration is materially
retarded. Incomplete removal or recurrence of cancer prevents typical
regeneration or restoration, while, after successful or radical
removal, complete restoration to the previous standard, often with
positive gain, is obtained. Thus, a woman who had gained thirty
pounds after resection of a cancerous pylorus, showed, after three
months, hemoglobin repair to the amount of 65 per cent. A prognostic
significance often attaches to the accurate estimation of hemoglobin at
intervals after removal of malignant tumors.

A very convenient method for the ready estimation of hemoglobin is
afforded by the Tallquist color scale. It can be practised at the
bedside and is sufficiently accurate for the surgeon’s general purposes.


THROMBOSIS.

Thrombosis is a term applied to the formation of a _thrombus_--_i. e._,
a clot within the cavity of the heart or one of the bloodvessels--the
term being limited to coagulation of blood within these natural
cavities, and without specifying the exciting cause of the same. A clot
so formed is called a thrombus. To be accurate, a distinction should
be made between a thrombus, which is caused always before death--or,
rather, during life--and the _clot_, which is essentially a postmortem
affair. Our application, then, of the terms “thrombosis” and “thrombus”
refers solely to that which takes place during life. In order to
appreciate the conditions which lead to thrombosis it is necessary
to fully appreciate the reciprocal conditions which must normally be
maintained between the circulating blood and the walls of the vessels
in which it flows. Fluidity of blood depends always upon integrity
of the vessel wall. As long as its lining membrane is absolutely
undisturbed and normal, moving blood will never coagulate within it,
and the only thrombi that may be met within it are those which are
propagated from a distance. Coagulation of blood is, for the main part,
associated with the peculiar properties of fibrin.

Fibrin is produced from _fibrinogen_, a globulin which is held in
solution under ordinary circumstances, which has certain peculiarities
of its own. When the change occurs it is entirely consumed and none
remains in the blood serum. Fibrinogen is split up by a peculiar
ferment called _thrombin_ into what we ordinarily speak of as fibrin
and a small amount of a soluble globulin, which remains in solution in
the serum. Thrombin is not a normal constituent of the blood, but is
formed when it escapes, as the result of the reaction between certain
calcium salts and a nucleoproteid, which has been called _prothrombin_.
The latter arises from the disintegration of the leukocytes, especially
the polynuclear, and the blood plaques, after the blood leaves the
bloodvessels. Calcium salts seem absolutely necessary for coagulation;
hence the value of the administration of calcium chloride in certain
cases previous to operation. Another essential feature seems to be
the absolute integrity of the endothelial lining of the bloodvessels,
although for this fact there is no satisfactory explanation. If a
portion of a vein is removed from the body after double ligation
its contained blood will not coagulate for a long time. Blood which
is kept circulating through the lungs and heart alone soon loses
its coagulability; hence the liver seems to be concerned in some
way in maintaining it. Certain other substances also seem to retard
coagulation, such as the albumoses of snake venom, and certain
synthetic, colloid, proteid-like substances, which can be introduced
very gradually. If, however, they are introduced rapidly, or in large
quantities, thrombosis occurs promptly. We have much to learn about the
coagulation of the blood, but the above facts are at least suggestive
to the surgeon.

[Illustration: PLATE II

FIG. 1

Small Vein showing Diapedesis of Leukocytes. (Engelmann.)

_a_, leukocyte escaping between endothelial cells; _b_, _c_, leukocytes
escaped; _f_, leukocytes migrating toward centre of attraction.

FIG. 2

Septic Thrombosis of Pulmonary Capillaries after Puerperal Septicemia,
showing Rapidly Increasing Colonies of Streptococci. (Klebs.)]


=Causes.=--The underlying _cause_ of all _thrombi_ is, then,
_alteration of the endothelium_. In consequence, when it is desirable
to produce coagulation artificially, advantage may be taken of this
fact, and mechanical injury to the vessel walls may be quickly followed
by the desired results. Advantage is also taken of this fact in
surgery, especially in certain methods of treating aneurysm, by rude
handling, by needling, by the introduction of horsehairs, fine wire,
etc. A venous thrombosis is certainly favored by the thinness of the
venous walls, by which poorer protection is afforded to their lining
endothelium, and infection more easily occurs. Arterial thrombosis is
favored when cardiac vigor is impaired and vessel walls are thickened
so as to obstruct the blood current. This occurs particularly in
syphilitic endarteritis, where the intima suffers most, and final
occlusion is due to the thrombus thus formed. Arteriosclerosis does
not, by itself, often produce this trouble; it comes rather with
atheromatous and calcareous degenerations. The local ischemia which
is occasioned by ergotism, by pellagra (due to use of certain kinds
of maize), by the vasomotor spasm of Raynaud’s disease (see under
_Gangrene_), by too long-continued constriction, or by frostbite,
causes results comparable to those produced experimentally in parts
supplied by a terminal artery, _e. g._, in the kidney after temporary
occlusion of its artery. All the tissues involved undergo profound
alterations, in which thrombosis figures very largely and may lead to
gangrene.

While such endothelial lesions are essential, there are, nevertheless,
numerous other accessory causes which should be mentioned. These
comprise:

A. _The presence of foreign bodies_, as, for example, needles, hooklets
of echinococci, parasites, particles of tumors, fragments from the
heart valves, and, most of all, that which is essentially a foreign
body, a clot which has come from some other point. Around such foreign
particles will quickly group themselves a relatively large number of
leukocytes, thus affording another example of phagocytosis, soon to be
described. Mere slowing of blood stream without some such mechanical
irritation is not sufficient to produce coagulation. If, for instance,
a section of vein is isolated between two ligatures, the ligation being
aseptically done and the surroundings of the vein wall disturbed as
little as possible, the blood thus shut up within the vein remains
fluid indefinitely. If, however, the vessel wall is separated from its
surroundings, so that its nourishment is compromised, the contained
fluid quickly coagulates.

B. _Necrosis_, _gangrene_, etc., lead to quick involvement of the
endothelium of the vessels contained within the involved part, and
consequently to quick coagulation of the blood which they contain.

C. _Temperature_ has also an influence in the same direction, and
extremes in either direction, or drying of vessels which may happen to
be exposed to the air for some time, lead to the same results.

D. _Inflammatory and degenerative processes_ occurring in and about the
vessel walls tend always to produce coagulation. This is well seen in
the influence exerted by the so-called _atheromatous ulcers_--_i. e._,
the degeneration of certain areas in the walls of large vessels.

E. _Microörganisms and their products_ are perhaps the most frequently
effective of all the accessory causes of thrombosis. In other words,
in all the surgical infectious diseases we may expect to find more or
less, sometimes extensive, thrombosis in the vessels of the affected
part. This may so far shut off circulation as to produce temporary or
permanent edema, or it may lead to gangrene, which may be local or may
terminate the life of the patient.

_Thrombi are classified_ as:

  1. _Primary_; and

  2. _Propagated_.

The _primary_ thrombus is one which has originated at the spot where
it has been first produced, and is usually co-extensive with its
cause. The propagated thrombus may be one which has been carried to
a considerable distance, and is met with at a point widely different
from that where it originated, or one which has extended along the
vascular channel in which it was first formed, but far beyond the
limits of its prime cause. When a thrombus attaches itself to a part
of the vessel wall it is called _parietal or valvular_, because it
does not completely occlude the vessel; when it involves the entire
circumference of the vessel, but does not completely occlude it, it
is spoken of as _annular_. The _obstructive_ thrombus is that which
completely fills a given vessel and shuts off all circulation through
it.

The _propagated_ thrombus extends usually in both directions, and
always much farther in veins than in arteries. Thus, thrombi may be
met with extending from the ankles even into the inferior vena cava.
The venous valves may on one hand excite coagulation, or on the other
tend to fix the coagula more firmly in their place. In arteries thrombi
usually extend only to the first collateral channel on the cardiac
side, but occasionally they spread farther. The _cause of a primary
thrombus_ is to be _sought at the site of its lodgement_; the _cause
of propagated thrombi_ is often observed _at a wide distance from the
effect_.

Thrombosis is, again, to be spoken of as--

  _a. Marasmic;_

  _b. Mechanical or traumatic;_

  _c. Infective._

_a._ The _marasmic_ forms are due to essential alterations in the
constituents of the blood, which are due mainly to starvation or
wasting disease. Marasmic thrombi seldom give rise to serious
disturbance during life until the condition is so complex and grave
that the patient is at death’s door. Postmortem evidences of marasmic
thrombi, however, are often found, and yet have but little surgical
significance. They are seen perhaps as often in the cranial sinuses as
anywhere.

_b._ Thrombi of _mechanical or traumatic_ origin are those, for
instance, which are due to the presence of foreign bodies, to
stagnation of blood as the result of ischemia or local anemia, to
compression by tumors, etc.

_c._ _Infective_ thrombi are those distinctly due to the injurious
effects of micro-organisms, and are those mainly concerned in the
various manifestations of sepsis which are of interest to surgeons.

While the ordinary evidences of thrombosis are most often looked for
in the veins of the extremities, in the lungs, and in the cranial
sinuses, it must not be forgotten that thrombosis may occur equally
easily in the portal system of vessels; in which case we find the most
marked expressions in this system and in the liver. In cases also of
pyemia proceeding from lesions in the rectum or in the bowels there are
evidences of infection, abscess, etc., in the liver, but not in the
lungs, to which point infective thrombi from other sources are promptly
carried.

The _ultimate fate of a thrombus_ depends entirely upon the presence or
absence of bacteria. If septic, it invariably breaks down. If aseptic,
it may undergo one or more of the following metamorphoses:

A. _Decolorization._--This is noted particularly in the red thrombi,
and is due to disintegration of the red corpuscles, their coloring
matter being diffused and resorbed or transformed into hematoidin. It
would be a mistake, however, to suppose that all light-colored thrombi
are those which, originally red, have been decolorized. The possibility
of white thrombi must always be remembered.

B. _Organization._--This is the result of time, and means a
metamorphosis into solid vascular connective tissue. Newly formed,
minute, vascular loops project from the vasa vasorum into the thrombus,
and it becomes thus vascularized, while the completion of the
organization is due, in the main, to spindle-cell connective tissue,
which is formed by wandering cells that penetrate into the thrombus
from without. This gives the organized thrombus a certain resemblance
to a sponge, and makes the original vein resemble a cranial sinus,
since its interior is spanned by bands of connective tissue. Typical
illustrations of this kind are seen, for instance, where the iliac
veins join to form the inferior cava, by which a certain amount of
obstruction to venous return is produced without its being total. The
length of time required for these changes is indefinite. They begin,
however, within a short time after ligature of a vein, and proceed with
a rapidity varying according to circumstances.

C. _Calcification._--Calcium salts are occasionally deposited in
thrombi, usually not until they have undergone considerable contraction
and alteration; as the result of which we have formation of small
masses, essentially minute calculi, to which the name of _phleboliths_
has been given. These phleboliths are not infrequently found in more or
less occluded and much distended varicose veins of the extremities, and
they prohibit the occurrence of softening.

D. _Softening._--This is the most serious termination of the thrombotic
accident, and is usually due to the agency of infecting organisms.
A non-infectious form is, however, recognized, by which there is a
metamorphosis of original clot into an oily or pulpy fluid, usually
dark colored, but in the white thrombi often yellowish white,
reminding one crudely of pus. The discovery of such material under
these circumstances has led in time past to the supposition that pus,
as such, was found floating in the blood--a condition that does not
exist except under extraordinary circumstances. It is with infection
of thrombi and consequent softening, however, that surgeons have most
to deal, and the paramount importance to them of such disturbances is
emphasized in the article under Pyemia.

A closely allied topic to that above considered is the subject of
_thrombophlebitis_. This means, in effect, inflammation of one or
more veins, which is directly due to the presence therein of thrombi.
Such a condition is, in its strict sense, an inflammation, since it
is always an infectious process. If in the veins of a non-infected
region simple thrombi form, they may be occluded by organization of the
included masses, but such a process never extends beyond the immediate
area involved. On the other hand, if the process is essentially an
infectious one, either from without or from within, then both vessel
and its contained thrombi succumb completely to the infectious process,
which is also essentially a spreading one; and this is limited only
by mechanical barriers, by conservative suppuration, or often only by
the life of the individual. Excellent examples of thrombophlebitis are
seen in the involved uterine sinuses in cases of puerperal septicemia,
and in the cranial sinuses after infected compound fractures, or
particularly after disease originating in the middle ear has extended
to them.

Thrombosis is, at times, a distinctly surgical condition, and often
a surgical complication of febrile and other diseases, especially
typhoid, in which it constitutes a serious complication and prolongs
convalescence for a period of several months. If foreseen it can
scarcely be prevented, and when present calls for treatment varying
with the location of the lesion and the exciting causes. In the earlier
stage anything like rude manipulation or massage is very unfortunate,
since soft clots might thus be broken up and distributed to other parts
of the body. Absolute physiological rest combined with the application
of silver ointment, of ichthyol-mercurial ointment, which should be
covered with some non-absorbent material, will probably give the best
results. If the lower limbs are affected it may be well to elevate the
feet so as to favor return of blood through vessels not yet obstructed.
After a certain length of time the thrombi may be regarded as at least
adherent if not organized, and massage will prove an important remedy,
since by it the lymphatics will be better enabled to take up the
fluids which have leaked from the bloodvessels and produced the edema
which always characterizes these cases. Sluggishness of circulation
is nearly always followed by more or less laxness of tissue, or
actual hypertrophy, and a limb thus involved may never regain its
original size or flexibility. Veins once compromised, if not occluded,
frequently become varicose, or varicosities develop in adjoining veins
and still further complicate the case. For such difficulty the measures
discussed in the chapter on the Veins may be later required.

In every fresh case of thrombosis or thrombophlebitis great care should
be taken in order that by no means shall the clots be disengaged and
float away. The dangers correspond to those existing in variocele and
nevi, often treated by the older methods of injection of coagulating
material. In one instance reported, a child died within half an hour
after the injection of an iron salt into a small nevus of the face.
Coagulation was excited to a point far beyond the limits intended.

_Thrombophlebitis is essentially a surgical condition_, occasionally
terminating favorably by suppuration and spontaneous evacuation,
but calling for surgical intervention whenever it can be recognized
and the parts are accessible. The principles of treatment of these
conditions are positive and unmistakable. They comprise evacuation
of the infective material and disinfection of the involved cavities
and tissues. Thus, in sinus phlebitis--_i. e._, thrombophlebitis of
the lateral sinus--it has been made practicable not only to open the
sinus in the mastoid region, but to expose the jugular vein in the
neck, to ligate it, and to wash through from one opening to the other,
effectually getting rid in this way of a long mass of infected thrombi.
Only by such bold and radical measures in many of these instances may
life be saved.


EMBOLISM.

Embolism means the _transportation of any material by which a
bloodvessel can be occluded or plugged_ from one part of the vascular
system to some other. The underlying idea is that of _transportation_
or carriage. An _embolus_ is anything so transported, without implying
its exact character. The name is even applied to so unsubstantial an
affair as a minute bubble of air, which, however, in a tube containing
a circulating fluid is a possible source of considerable disturbance.
A single bubble thus carried would, by itself, be a trifling affair,
but when numerous bubbles are thus transported the result is such local
disturbance as may lead to loss of function. Thus, _air embolism_,
so called, may provoke profound, even fatal, disturbances, as, when,
with the returning blood stream through the cranial sinuses or one of
the large veins in the neck, when opened by accident or operation,
air is sucked in, it is carried to the right side of the heart, whose
action is perhaps completely perverted because of the new and strange
substance which thus enters it, so different from that for which its
lining membrane is prepared and to which it reacts. The _entrance of
air into veins_, which constitutes in effect air embolism, has been
in time past a bugbear to surgeons, but nevertheless is a source of
probable danger when large venous trunks in proximity to the heart are
thus exposed. Air embolism is certainly a rarity. On the other hand,
those substances which figure most often as emboli are _vegetations
from the valves of the heart_; _drops of fat_; _fragments of tumors_;
_pieces of softened and disintegrated thrombi_; _foreign bodies_, as
hooklets of echinococcus cysts; and, perhaps most often of all, the
_microorganisms_ clinging to some minute fragment of thrombus which
has been dislodged. Embolism is also produced experimentally by the
artificial introduction into the circulating blood of cinnabar or
small particles of pith or other material. Emboli differ in number and
size from the smallest appreciable up to the largest, which may be
met with in the larger venous trunks. They are _dislodged_ from their
primary site sometimes by _accident_, as by rude manipulation, injury,
etc.; sometimes by _undue cardiac activity_, as when detached from a
valve wall; sometimes by the _process of softening_ of thrombus and
a subsequent introduction into the blood stream as a result of some
trifling motion; or even by _spontaneous processes_. Emboli also differ
in numbers according to the nature of the primary lesion. In cases of
so-called fat embolism fluidified fat is taken into the returning blood
stream, carried to the heart, churned up with the contained blood,
and distributed to the lungs in such a way that myriads of minute fat
masses are distributed throughout the capillaries of the lungs, and
free circulation of blood through them is thereby impeded.

It will thus be seen that the relations between thrombosis and embolism
are most intimate, but that either one may occur without the occurrence
of the other.

Among the viscera, with the exception possibly of the brain, the
disastrous consequences of such processes as those just described
are more apparent and indicative than in _thrombosis and embolism
of the mesenteric bloodvessels_--a condition not so rare as journal
articles would imply, yet, nevertheless, one seldom recognized either
during life or after death. Its principal symptoms consist of intense
abdominal pain, bloody diarrhea, subnormal temperature, sometimes with
vomiting, perhaps in the latter stages vomiting of blood. Shock is
usually also extremely marked. The consequence of this condition is
almost inevitably gangrene of the intestine supplied by that particular
portion of the mesenteric vessels. The pain comes on within a short
time after the occurrence, and under the peculiar circumstances
gangrene may be practically determined within a few hours. Some two
hundred and fifty cases of this kind are now on record, and the
condition is one well worth the prompt attention of the surgeon,
because only by surgical intervention--_i. e._, by resection of the
necrotic mass of intestine--can life possibly be saved. That when a
limited portion of the intestine is involved the gangrenous part may be
successfully removed has been proved by several operators. (See Chapter
LII.)

It will thus be seen that embolism constitutes often a distinctly
surgical condition for which unfortunately only radical measures are
suitable. Many cases of gangrene of the toes and feet, extending to the
legs, are produced by embolism of the femoral and popliteal arteries,
similar conditions being noted less often in the upper extremities.
Amputation offers the only resource in such instances, at the same
time affording no guarantee against any similar embolic disturbance
elsewhere. In only most exceptional instances is it possible, by
resorting to moist heat, position, etc., to encourage circulation to
such an extent as to obviate the necessity of amputation. (See Chapter
V.)


=Fat Embolism.=--Fat embolism as a distinct, sometimes fatal, surgical
condition has received of late so much study as to be entitled to
consideration by itself. By this term is meant a plugging of small
arteries by minute drops of fat, which, having been set free somewhere
about the periphery, are carried into the venous circulation and thence
distributed to various parts of the system. Inasmuch as the capillaries
of the lungs are often their first lodging place, fat embolism here
is most often met with, and consequently recognized and studied. But
it may occur in the brain, the choroid, the kidneys, or other parts,
provided only that there has been sufficient _ris a tergo_ on the
part of the heart to force the fat globules through the pulmonary
capillaries and into the systemic circulation.

[Illustration: FIG. 2

Fat embolism of lungs. Large branching pulmonary artery filled with
spherical, oval, cylindrical, and branching masses of fat. Fresh mashed
preparation in potassium hydrate. (Kaiserling.)]

Fat embolism occurs frequently, and to a slight extent in nearly every
case of fracture and laceration. So common is it, and so closely
allied are some of its most prominent symptoms to those of shock,
that as a matter of fact many cases heretofore considered shock are
to be regarded as instances of this condition. Indeed, even in a
miscellaneous series of 260 dead bodies fat embolism was found in 10
per cent. The injuries most likely to be followed by it are simple,
and particularly compound fractures of bones; laceration of soft
parts, especially of adipose tissues; certain surgical operations;
acute infections of bone and periosteum; rupture of fatty liver; and
certain pathological conditions where the phenomena are not so easily
explained, _e. g._, icterus gravis, diabetes, etc.

Drops of fat may be seen floating on fluid or semifluid blood after
many operations and compound injuries, and the possibility of escape of
fat--or, more accurately, its suction into the vessels from which this
blood has escaped--is easily appreciable. But it has also been shown
that absorption of fat is possible even from serous surfaces, and that
fat embolism may occur when fluid fat has been passed into the heart
through the thoracic duct, although more slowly. Oil drops are also
found in the interior of the tissues, while in a piece of lung spread
out in water in the visible vessels highly refracting fatty material
may be noted. _Fatty infarction_, particularly in the lower lobes, is
sometimes plainly visible to the naked eye. Under a low objective,
especially with osmic-acid staining, the presence of fat is easily
demonstrated.

The essential danger in case of fat embolism is of so clogging the
pulmonary capillaries that oxygenation shall become so imperfect as
to lead to absolute asphyxiation from carbonic dioxide poisoning.
When this fact is understood, the cyanosis, the rapid breathing, the
overaction of the heart, etc., are easily and correctly interpreted.

Fat embolism by itself cannot cause inflammation nor infection, nor
sepsis in any sense. It may, however, lead to ecchymoses in conjunction
with fatty infarcts in the organs most affected. The minute hemorrhages
are easily explained by the bursting of the capillaries in the attempt
to force blood through them. Fatty emboli, however, take the same
course as do septic--are carried first to the right side of the heart
and distributed over the lungs; are, if the patient lives, forced
through the lungs into the systemic circulation, and are then carried
to the brain, kidneys, etc. The first symptoms are referable to the
plugging of the pulmonary capillaries; the secondary symptoms to the
systemic disturbance.


=Symptoms.=--Pallor of countenance with facial expression of anxiety
and distress, followed by cyanosis and contracted pupils, are seen.
Patients are usually first excited, sometimes more or less disturbed,
then become somnolent, and, finally, comatose in the fatal cases. The
respiration rate increases from normal up to 50 or 60, and breathing is
sometimes stertorous. Dyspnea, increasing in intensity until it becomes
agonizing, sometimes marks these cases. Occasionally foam, possibly
blood, proceeds from the mouth, as in edema of the lungs. Sometimes
hemoptysis occurs. The pulse becomes weak, frequent, and irregular,
while toward the close it is fluttering. Temperature is not notably
disturbed, at least not typically.

These symptoms set in usually within thirty-six to seventy-two hours
after the lesion which has caused them. I have, however, known death
to occur in one or more cases within eighteen hours after reception of
injury.

After fat has been forced through the lungs and carried to the kidneys
it will be eliminated with the urine, and may be found floating upon it
in the shape of oil-like drops. Discovery of this condition is positive
evidence of fat embolism. It is to be distinguished from shock in that
by the time the symptoms of embolic disturbance are at their height,
all or nearly all symptoms of pure shock have subsided. Furthermore,
cyanosis and embarrassment of respiration are not indicative of shock;
and, finally, the discovery of fat in the urine will be corroborative.

A mild degree of fat embolism may be noted, if looked for, after almost
all serious fractures. It will give rise to slight embarrassment of
respiration and cyanosis and to the elimination of fat by the kidneys.


=Prognosis.=--Prognosis varies according to the extent of the injury
and the proximity of the lesion to the heart and lungs; also to the
possibility of continuous entrance of fat, _i. e._, from its continual
absorption. Prognosis really depends upon whether the heart can be
given sufficient vigor and endurance to continue pumping blood with its
burden of fat through the pulmonary circulation. A secondary danger
may come from the circulation of this fat-ladened blood through the
capillaries of the brain. Should the source of motive power thus become
paralyzed with resulting general enfeeblement, death may ensue. When
well-marked evidences of fat embolism are present, but are followed by
recovery, the worst of the trouble is usually over within forty-eight
hours after it begins.


=Treatment.=--Obviously treatment is mainly directed toward the
heart, so that we may stimulate it to carry its load of fat through
from the venous into the arterial system. If it can do this, the fat
is disposed of by oxidation or is saponified by the alkalies in the
blood. Physiological rest of the injured part is the first indication,
however, and if this occurs in a patient, say with delirium tremens,
powerful mechanical restraint may be necessary. The most effective
cardiac stimulants are called for--alcohol, adrenalin, strychnine. In
other respects treatment is largely symptomatic. Next to giving the
heart vigor in this way, inhalations of oxygen give the most promise,
because of the crying need of the system during this ordeal for this
life-giving gas.[1]

  [1] See paper by the author. New York Medical Journal, August 16,
  1884.


PHYSICAL PROPERTIES OF THE LEUKOCYTES.


=Phagocytosis.=--All leukocytes have the power of shifting their
location. The lymphocytes, so called, being the youngest of the white
corpuscles, show it less than the older forms. The eosinophile cells
are less able to manifest the peculiar activities of the other forms.
It is particularly the mononuclear and polynuclear corpuscles which
are endowed with most pronounced activity. These have the power,
like the ameba among the lowest forms of life, to not only spread
themselves around inert bodies, like granules of carmine or other
particles used for experiment, or the particles of coal-dust found in
certain conditions in the human body, but they also have the power to
englobe many living organisms, for the main part vegetable (bacteria).
Under the microscope it is possible to see living bacilli, performing
active movements, although enclosed in the nutritive vacuoles of
the leukocytes, in some of the lower animals. This _ameboid_ power
possessed by these cells of thus attacking and disposing of foreign
bodies or irritants has been demonstrated and proved, especially by
Metchnikoff, and has been called by him _phagocytosis_. His views
were for a long time disputed, and are perhaps not yet absolutely and
generally accepted. Nevertheless, they fulfil every demand made upon
them for explanation, and are susceptible of such demonstration under
the microscope that we now have practically a new and apparently a
correct theory of the inflammatory process. (See Chapter III.) Any
cell which has this property is known as a _phagocyte_. It is shared
by some of the leukocytes with certain other cells to be spoken of
later (wandering tissue cells). Cells which possess this power do not
attract all microbes indiscriminately, and it is often the case that
the leukocytes of an animal peculiarly susceptible to a certain kind
of bacteria do not attract them at all, even though they are directly
in contact. It is plausible that an explanation of the peculiar
susceptibility of certain animals to certain diseases is furnished by
this fact (Fig. 3).

[Illustration: FIG. 3

Phagocytosis in anthrax pustule. (Gaylord.)]

On the other hand, leukocytes may and do englobe virulent microbes.
In man the mononuclear forms do not take up either the streptococcus
of erysipelas or the gonococcus; whereas these two organisms are
readily attracted by the polynuclear neutrophile cells. The bacillus
of leprosy, on the other hand, is never attacked by the polynuclear
forms, but is speedily devoured by the mononuclear cells. This shows
that the various leukocytes may exercise a marked selective ability.
This inclusion of minute bodies within ameboid cells seems to be an
evidence of a peculiar tactile sensibility upon the part of the latter.
In fact, this is clearly established, and seems to be inseparable from
the peculiar attraction between leukocyte and bacterium, to which the
name _chemotaxis_ has been given, and which is described in an ensuing
chapter. If the included organism is, as is usually the case, killed,
it is disposed of by a true process of intracellular digestion in a
neutral or alkaline protoplasmic medium, and its inert portions are
again extruded. On the other hand, if the leukocyte is poisoned or die
in this phagocytic attempt, it presents usually as a so-called _pus
cell_ or _corpuscle_, and the solid part of pus is made up in large
measure of cells which have perished in this way. (See Inflammation and
Suppuration.)

_To regard phagocytosis as an affair mostly of certain tissue cells and
invading bacteria_ would be altogether too narrow a view to take of
it. It is really a process of the greatest importance and of constant
performance in our systems. By virtue of it disintegrated muscle
fibers and other tissue cells are disposed of, sloughs are separated,
certain absorbable foreign bodies (catgut, etc.) taken away--_i. e._,
absorbed--cellular tissue reduced in numerical strength (progressive
atrophy), and a great variety of changes, either normal, as those
pertaining to health and advancing years, or abnormal, like those
incident to many diseases, are actually the product of this kind of
phagocytic activity. The protective power, then, which the phagocytes
exert as against bacteria is only one part of their normal functions,
by virtue of which they become, in effect, perhaps the most important
cells within our bodies. Their powers are limited, however, as will be
seen when describing pus, for the so-called pus corpuscle is nothing
but a phagocyte which has perished in its self-assumed task. It is
known also that in certain instances phagocytes, which are incapable
of defence as against the mature bacterial organism, are nevertheless
capable of englobing its spores and preventing their development.
This is true, for instance, in case of anthrax in animals ordinarily
immune, as, for instance, the frog and fowl. If, however, in these very
animals the vitality of the phagocytes be affected--as by cooling in
fowls or heating in frogs--phagocytosis is so far interfered with that
the spores germinate within the enfeebled leukocytes and the entire
organism is infected.




CHAPTER III.

INFLAMMATION.


_Inflammation is an expression of the effort made by a given organism
to rid itself of or render inert noxious irritants, arising from within
or introduced from without_ (Sutton, modified).

After having duly considered hyperemia as a phenomenon having an
identity and termination of its own, we are prepared to study the more
complex processes included under the term _inflammation_, the first
of which is the hyperemia already considered. The characteristic of
the truly inflammatory process is that it does not stop with mere
congestion nor with any of its previously mentioned terminations, but
goes on to something more complex. It must be understood, therefore,
in this consideration that hyperemia is the first act of the vessels,
resulting from peculiar stimuli which will shortly be considered.
Even the hyperemia seems to be now more distinct than under other
circumstances, and, along with the dilatation of vessels and the
stagnation of blood current, the capillary vessels seem crowded with
blood corpuscles to an abnormal degree, the rapidity of their motion
is checked, and there occurs accumulation of blood cells along the
walls of the small veins, to which they seem to adhere as if by some
new cohesive property. The result is that before long the vessel wall
appears to have received a new coating of white corpuscles, this being
more marked in the veins than in the arterioles, while in the latter
the red are more numerously mingled with the white than in the veins,
in which the distinction between the two classes of cells is better
maintained.

Next comes the phenomenon whose clear recognition and description
is inseparably connected with Cohnheim’s name. This is known under
different names as _migration_ or _diapedesis of the leukocytes_. The
program is about as follows: A little protrusion of the vascular wall,
a marked alteration in the shape of a leukocyte, which yet adheres
to this point of its lumen, and then the curious fact so often seen
under the microscope--the gradual passage of this cell through the
vascular wall, from its inner to its outer side, by what is generally
known as its _ameboid movement_. This migration of the leukocyte is
not confined to its mere escape from the restriction of the vessel
lumen, but goes on to an indeterminate extent after it has detached
itself from the outer surface of the vessel. This seems to occur by
virtue of the same ameboid characteristic which it exhibited in passing
through between the cells of the vessel itself. If this occurs at one
point, it occurs at innumerable points, in consequence of which a large
number of leukocytes escape into the tissues of the part involved.
This diapedesis occurs most markedly from the smaller veins, to a
less extent from the capillaries. The cells which escape from the
latter are usually accompanied by red cells, the consequence being
that the exudate which necessarily occurs at the same time is more or
less tinged with the coloring matter of the blood, and is known as a
hemorrhagic exudate.

The above phenomenon, described in so few words, is in its minutiæ
a really complex one, depending on a variety of causes not easily
appreciated; but it is at least positive and well known, because it
can be observed at will in the mesentery or web or tongue of certain
animals which can be confined upon the stage of the microscope. The
_phenomena of inflammation_, therefore, comprise, first, _hyperemia_,
and then _escape_ from the bloodvessels of the _corpuscular_ and
_fluid_ elements of the blood. The former may be due, as already seen,
to various irritations of a non-specific character; while, as we shall
learn, the latter practically never take place save when the irritation
has been, as pathologists say, specific or infectious.

The phenomena of true inflammation comprise practically the roles
played by the three elements which conspire to produce those
changes--namely, the _tissues_, the _blood_, and the _specific
irritants_ which are the primary cause of the entire lesion. Each of
these should be considered separately.

All observers agree that in actively inflamed tissues the number of
cells is very greatly increased. A certain increase may be accounted
for by that which has already been described--namely, the escape into
the tissues of the wandering cells from the bloodvessels. But neither
this alone nor the products of their rapid proliferation are sufficient
to account for all the cells found in the truly inflammatory condition.
It is now well established that in connective tissue there are two
varieties of cells--the fixed and the wandering--the former concealed
in the trabeculæ of the intercellular substance, while the latter are
small, ordinarily round in shape, much resembling the white corpuscles,
possessed of ameboid characteristics, and having the power of changing
position. These are known as the wandering cells, which meander through
the lymph spaces of the tissues or back and forth into and out of
the blood-vascular system, their migration being regulated by causes
not yet known. Under natural conditions their number is relatively
small. Once given a true inflammatory disturbance they are reproduced
with amazing rapidity; and their numbers, added to those produced by
diapedesis of leukocytes, with the combined proliferative activity
of both forms, serve to account for the new cells whose presence
characterizes phlegmonous and other similar disturbances. That these
wandering connective-tissue cells have much to do with these changes
is shown by the unmistakable evidences of excessive activity known as
_karyokinesis_ (_i. e._, _nuclear activity_).

Karyokinesis is common not only in inflammatory disturbances, but in
new-growths of rapid formation, especially sarcomas, which are formed
from mesoblastic cells, the same which have to do with connective
tissue. Endothelial cells also undergo the same changes.

The peculiar characteristics of the leukocytes have already been
described at considerable length in the preceding chapter. It must
suffice, then, here to say that during the _inflammatory_ attack the
leukocytes are _increased in number_, _i. e._, there is a temporary
leukocytosis which is the usual accompaniment of suppuration. For
instance, this is regularly present in purulent, but not in catarrhal,
forms of appendicitis. The recognition of this fact may be of great
value in diagnosis. For instance, leukocytosis is rarely present in
tuberculous disease unless suppuration complicates the case. It is
met with in suppurative osteomyelitis and in all cases of pocketing
of pus. Moreover, when leukocytosis is present coagulability of the
blood is increased. Of the various leukocytes, it is the mononuclear
and polynuclear forms (see Chapter II) which are endowed with the
most pronounced activity and which play the principal role among the
blood cells or phagocytes. That phagocytosis plays a most important
part in the inflammatory process is a matter to be emphasized in more
than one way and in more than one place. The account of the process
already given should suffice for descriptive purposes; the importance
of the act, however, should be made most prominent in considering
inflammation and suppuration. That the phagocytic properties of these
cells are limited will be remembered when we recall that in certain
instances phagocytes, which are incapable of defence as against the
mature bacterial organism, are yet capable of englobing the spores and
preventing their development. Nevertheless, the activities of even the
most lively phagocytes are capable of being influenced and repressed
by extremes of heat and cold to which patients may be exposed, either
locally or generally.


CHEMOTAXIS AND OPSONINS.

Having considered briefly the cells which take prominent part in the
inflammatory process, and the escape along with them of the fluid
portions of the blood, whether these coagulate or not, it is necessary
before referring to specific factors to discuss that which induces
the above cells to act in this way. That there is a peculiar, even a
mysterious, attraction which brings specific irritant and phagocyte
together has been for some time recognized, but it remained for Pfeffer
to study it carefully and to give it the name by which it now passes,
_i. e._, _chemotaxis_, while others have widened our knowledge of
it, especially by a recognition of the _opsonins_ or material which
“prepares food,” _i. e._, prepare microbes for ingestion by the
phagocytes.

Chemotaxis is a term implying a peculiar property of _attraction and
repulsion between cells_, both animal and vegetable. It mainly pertains
to vegetable cells alone, and has been offered as the explanation of
the sporulation of ferns, for example; but as it interests us most in
this place it is manifested between the animal cells of the human body
and the bacteria, which are vegetable cells. As a result the former,
_i. e._, the phagocytes, having power of migration, are drawn toward
the latter. To be more accurate, this mutual or peculiar attraction
is known as _positive chemotaxis_, it being also known that exactly
the reverse prevails under certain circumstances, and that mobile
cells will move away as rapidly as possible from certain organisms or
substances for which they seem to have a repugnance, this being known
as _negative chemotaxis_.


SPECIFIC IRRITANTS.

These are essentially living organisms, bacteria, fungi, and the
protozoa, the first named being by far the most frequent. Before a
lesion can assume the type of inflammation as here understood some
one or more of these organisms must have secured an entrance into the
tissues, the circumstances determining such invasion being considered
a little farther on. It is these living organisms which, having once
invaded the tissues, determine that most active congregation and
proliferation of certain cells which we have just described under the
head of Phagocytosis. When once the irritants are present there begins
that very active conflict which Virchow has so graphically alluded to
as the _battle of the cells_. Now the mysterious chemotactic properties
of the component substances manifest themselves, and now phagocyte is
drawn toward bacterium, or the reverse, while the tiny war goes on
with sometimes varying results, it being a question which can prove
victor in the conquest. This is no fiction of the imagination, but is a
contest which may be seen under the microscope in certain of the lower
animals, while its results may be seen in the examination of pus from
any human source. In another place I have also likened this conflict
to that in which certain of the enemy resort to poisoned weapons,
because modern biological chemistry has now shown very evidently that
it is a part of the life history of many of these microörganisms to
produce, probably as excretory products, albuminoid or other substances
having sometimes extremely toxic properties. And so it comes about
that in many of the surgical infections, while the local destruction
is produced by the actual death of tissues which have been invaded by
microörganisms, the general or systemic symptoms, generally referred to
as the _toxic_ symptoms, are literally due to poisons generated in the
infected area, dispersed throughout the system, and often proving fatal.

The _local effect of these specific irritants_, when they are not
promptly attacked, devoured, and removed by phagocytes, is _pus_, which
means cellular death, or gangrene, which is death of masses of cells
which have not had time to separate from each other. Pus, then, is
the ordinary consequence of the contest above alluded to, and _each
pus cell represents the dead body of a phagocyte_ which has perished
in the attempt to protect the parent organism from harm. That it has
died valiantly can almost invariably be determined, because within its
dead body may be seen one or more of the minute invaders which it has
attacked. This, then, is the light in which inflammation and infection
should be viewed.

In other words, we may have escape of fluid portions of the blood,
which may or may not coagulate; we may even have some escape of
corpuscular elements with some activity in the extravascular cells,
which shall lead to temporary or even permanent enlargement of a part;
all of which may be provoked by injury or by the presence of certain
chemical irritants within the blood or tissues; for example, alcohol,
uric acid, etc. But the factors which provoke the greatest activity on
the part of intravascular and extravascular cells, and which determine
the richness in albumin of fluid exudates, or their prompt coagulation
as soon as blood serum has escaped from the vessels, and which
particularly determine the furious rush of phagocytes and that kind
of intercellular conflict which leads many of the contestants on both
sides to death, are living organisms which are introduced from without,
whose presence at the point of inflammation is abnormal and injurious,
which are offending substances in every respect, while the whole
phenomenon of inflammation is an expression of an effort to rid the
system thereof. Taking this view of the subject, there is an important
distinction between hyperemia and its consequences, which is absolutely
a non-infectious condition, and inflammation with its consequences,
which is always an infection and is always followed by more or less
death of cells, the same being often extruded in a semifluid mass known
as _pus_.


CIRCUMSTANCES WHICH FAVOR INFECTION.


1. =The Virulence of the Infecting Organisms and the Amount
Introduced.=--There is the widest difference between various forms of
microörganisms in the matter of virulence; and it is true that there
are very great differences between the same species under different
circumstances, these differences depending on conditions as yet
absolutely unknown. With certain organisms it is enough to infect an
animal with one alone in order to bring about a fatal result, this
meaning that the organism itself is extremely virulent and the animal
extremely susceptible.

In a guinea-pig, for instance, a single virulent anthrax bacillus
will produce death, whereas in a more resistant animal many are
required, and in still others there is absolute immunity against the
disease. Man is much more susceptible to the pyogenic organisms than
most of the lower animals, which is one reason why wrong deductions
have been drawn from many experiments, and why veterinary surgeons,
who are so careless of all antiseptic precautions, as a rule have
good results in work which, done after the same fashion on the human
being, would be inevitably fatal. It is one reason also why one may
draw false inferences from experimental work, for instance, upon dogs,
which survive many an operation which can scarcely be successfully
repeated upon a human being. The influences which affect the vitality
and virulence of microörganisms are most numerous and widespread.
Temperature, sunlight, moisture or dryness, association with other
bacteria, are but a few of the conditions known to be more or less
operative. Inoculation with a small number of certain bacteria may
be harmless; up to a certain number it may produce only a local
disturbance, like abscess, while a still larger dosage may produce
fatal results. This is not the case with all, however, but only with
some organisms. Bacteria which have been repeatedly passed through
the animal body become more virulent than those cultivated for many
generations in test-tubes in the laboratory. This variable virulence is
especially characteristic of the colon bacillus, the anthrax bacillus,
and the micrococcus of erysipelas. Nor does it always follow that the
most virulent organism is necessarily cultivated from the most toxic or
serous manifestation of its activity.


2. =Association.=--Bacteria are seldom found in pure cultures under
natural conditions. By mutual association remarkable changes are
produced, sometimes in the direction of enhanced virulence, sometimes
in the direction of attenuation of effect. Certain organisms, extremely
dangerous alone, lose their power when combined with others, while
still others have their virulence increased to a rapidly fatal degree.
In fact, these effects are so strange and so contradictory that no law
governing them has yet been formulated, it being necessary to establish
each case by experimental investigation. The virulence of the anthrax
bacillus under ordinary circumstances is well known, as is also that of
the streptococcus of erysipelas in man. Yet, when these two organisms
are introduced simultaneously, the mixture is apparently wellnigh
harmless. On the other hand, the simultaneous inoculation of certain
other species greatly increases the danger from either alone. The
diplococcus pneumoniæ when combined with the anthrax bacillus seems to
have a greatly augmented power.


3. =Hereditary Influences.=--The fact that immunity against certain
infections and susceptibility to other conditions are transmitted from
parent to offspring is one which admits of no dispute. The explanation,
however, is almost as remote from us today as it ever was. But the
recognition of the fact is of the greatest importance to all practising
surgeons. That bacteria frequently enter through wounds and bruises
is self-evident, but we all know that such wounds are more likely
to suppurate in some than in others, and the causes of infection in
some are, to a certain extent, connected with the hereditary habit of
tissues. The same causes influence not merely liability to infection,
but its severity and character. There are undoubtedly also local as
well as general variations, and it is very certain that among these
the results of bruising or contusion are by far the most prominent.
There is also undoubted experimental evidence that under certain
circumstances bacteria produce only local lesions, whereas under others
they produce general and even fatal infection.


4. =Local Predisposition.=--Local predisposition is a factor of almost
equal importance. Once given a distinct infection, and hyperemia
is sometimes a contributing cause of inflammation. _Per contra_,
anemia of tissues seems to be also a favoring condition. In parts
involved in chronic congestion the blood flows more slowly, while
the vessels are dilated and apparently susceptibility is increased.
Infection here produces a type of disease mentioned as _hypostatic
inflammation_. Conspicuous exception as to the occasional value of
an artificial passive hyperemia is seen, however, in the so-called
congestion treatment (Bier’s) of tuberculous joints, where the more
or less constant flooding of the tissues with venous blood seems to
render them uninhabitable for living bacilli, which apparently die
and disappear (by phagocytosis), thus permitting a slow return to the
normal condition. General anemia, again, is a predisposing cause, while
toxemias, including diabetes, etc., are still more so. The liability
of diabetic patients to suppurative and even gangrenous infection
is proverbial. The presence of foreign bodies has much to do also,
and, infection once having occurred along with its introduction, the
presence of a foreign body will nearly always excite suppuration;
otherwise it will ordinarily remain inert. The withdrawal of trophic
nerve influences also apparently permits infection, as is instanced by
the ease with which bed-sores form in paralytic patients. Obstruction
to the circulation or to escape of secretions more easily permits
infection; for example, in the appendix, in the kidney, in the
gall-bladder, the salivary glands, etc. Furthermore, one may formulate
a quite comprehensive statement and say that all such lesions as
solutions of continuity, hemorrhages, degenerations, vascular stasis
produced by strangulation, etc., and all perforations, increase more or
less the liability to infection.


5. =Pre-existing Disease.=--Here are reckoned, first, _previous and
long existent toxemias_, _e. g._, syphilis, diabetes, scurvy, etc.
Other conditions, like lithemia, cholemia, acetonemia, and the various
conditions represented by oxaluria, or in which acetone, peptone, and
excess of uric acid are found in the urine, also come under this head.
One need never be surprised to find suppuration occurring in those
cases in spite of due observance of all ordinary precautions, since by
their existence immunity is destroyed and vulnerability increased. (See
chapter on Auto-infections.)

_Recent toxemias_ also have important bearing in this same respect.
For instance, after typhoid fever and other acute wasting diseases,
including the exanthemas, surgical operations are sometimes followed
by failure, and should always be postponed until complete recovery,
except in cases of emergency. The condition to be hereafter described
as _enterosepsis_, and which has previously been known under many
different names, as fecal anemia, stercoremia, etc., is one which
makes the performance of all operations dangerous, and which certainly
predisposes to septic disturbances of all kinds. The postpuerperal
state is also one in which operations are to be avoided if possible.

Certain _anatomical changes peculiar to the various ages_ also belong
in this category. Old age, with its accompanying arterial sclerosis,
its cardiac debility, and other well-known tissue alterations, favors
sluggishness of wound repair and leads not infrequently to sloughing or
to bed-sores. Amyloid changes betoken impaired vitality. Children are
much more liable to acute osteomyelitis than adults. Nursing infants
are apparently exempt from many of the infectious diseases, but possess
relatively small power of vital resistance to surgical operations.
General anemia and impaired nutrition of the body predispose to most
infections and to acute starvation.


6. =Personal Habits and Environment.=--_Diet_ has much to do with
tissue resistance. Rats fed on bread are more susceptible to anthrax
than those fed on meat. Hunger makes pigeons highly susceptible to
the same disease, and artificial immunity induced in various animals
is quickly destroyed by starvation. Prolonged thirst seems to have
the same result. Excessive fatigue generally reduces immunity, as
already mentioned. The various drugs which destroy red corpuscles
impair immunity, and even by injection of water into the circulation
the bactericidal power of the blood is reduced. White mice fed
with phloridzin, which produces artificial diabetes, become highly
susceptible to glanders, from which they are ordinarily exempt. In this
connection may also be mentioned the various toxemias alluded to under
the previous heading, which may proceed from the intestine, from the
genito-urinary tract, and probably also from other sources. Climate
has more or less to do, as also extremes of weather, with power to
resist infection or to survive serious operations. Dark habitations,
poorly ventilated, constitute surroundings which manifestly predispose
to infection of all kinds. Rabbits inoculated with tuberculosis and
confined within a dark cell, badly ventilated, become rapidly diseased,
while others similarly inoculated, but allowed to roam at large,
present but slight evidences of the affection. Certain occupations
predispose to certain diseases. This is pre-eminently the case, for
example, with workers in mother-of-pearl, who are exceedingly liable to
a particular form of osteomyelitis; and with those who make phosphorus
matches, who are prone to suffer from a peculiar necrosis of the lower
jaw. Prolonged suppuration may produce such changes in the blood and
tissues that vital processes of repair, cell resistance, and chemotaxis
may be so far interfered with as to facilitate subsequent infection.

Finally, the _influence of local injury to tissues_, particularly of
contusions which cause tissues to lose their vitality, is strenuously
insisted upon by all, and is spoken of repeatedly in other places in
this work. Many tissues will succumb to inoculation after bruising,
ligature _en masse_, etc., which before such injury are not in the
least disturbed.


7. =Fetal Infection.=--It is only in a very limited class of cases
that infection can be transmitted from mother to fetus, but there are
instances of this kind in which the surgeon is deeply concerned. As
Welch has stated, syphilis is the only infection capable of direct
transmission through the ovum or spermatozoön; but intra-uterine
infection may occur in many ways, and many diseases may be thus
transmitted. The placenta is usually regarded as a perfect filter;
nevertheless, it is occasionally passable to microörganisms. These may
be caused by preëxisting lesions in the placenta or by the virulence
and activity of bacteria. It is known that in animals the bacilli
of chicken cholera (inoculated into the mammalia), of symptomatic
anthrax, and the pyogenic cocci, frequently traverse this barrier.
In mankind infection _in utero_ has been observed in smallpox,
measles, scarlatina, relapsing fever, syphilis, tuberculosis, croupous
pneumonia, typhoid fever, anthrax, and surgical sepsis.


SOURCES OF INFECTION.

That the effects of bacterial invasion may be anticipated and guarded
against most effectually it is necessary that the practitioner should
be thoroughly familiar with the sources from which they come, and the
localities in and about the body which they most commonly inhabit or
where they are met with in largest numbers.


=Skin and Mucous Membranes.=--Of all possible sources of infection,
the skin itself is probably the most fertile. It is exposed to
contamination by air and by everything which may come in contact with
the body, and there is perhaps no organism met with in disease which
may not be found upon its surface or within its recesses. In fact,
these recesses, such as the crevices beneath the nails, the spaces
between the toes, and the various pockets like the tonsils, the axillæ,
etc., are those most commonly inhabited by microörganisms.

Bacteria may penetrate the skin by means of three different routes,
namely, the sweat glands, the hair follicles, and the sebaceous glands,
by means of their regular openings. The hairy appendages of the skin
are even greater sources of danger than the skin itself, since a
direct path of infection into the depths of the skin is afforded by
their follicles. Experimentally it has been shown that when bacteria
are rubbed into the skin where there are no follicles, there is
freedom from infection, whereas the reverse is equally true, and it
is clinically generally recognized that furuncles and carbuncles form
almost exclusively in those parts provided with hair and sebaceous
glands.

The mucous membranes are in constant contact with microörganisms
and furnish conditions in many respects favorable for their rapid
development. Nevertheless, the latter is interfered with and often
inhibited by certain mechanical and chemical influences which afford
protection. The conjunctiva is an extremely exposed membrane, which
harbors, however, but a relatively small number of bacteria under
ordinary circumstances. The tears before escaping from the conjunctival
sac are sterile, and are probably saline enough to act as an antiseptic
bath for the cornea. Moreover, by free escape of secretion through
the nasal duct the conjunctival sac is kept constantly irrigated, to
which is mainly due its ordinary healthy condition, as it is well
known how commonly lesions follow obstruction to the lacrymal duct.
The horrible results of Egyptian ophthalmia, _i. e._, the pyogenic
form of conjunctivitis, are familiar to travellers in Egypt. Howe and
others have shown that this disturbance is due to flies, which are
carriers of infection, and are attracted toward the eyes of infants,
while the superstitious notions of the parents restrain their children
from instinctive protection of the eyes when thus irritated. There
is probably no greater common carrier of pyogenic infection than the
common house-fly, and nowhere is this agency more demonstrated than in
the hot climates of the Orient.

[Illustration: PLATE III

FIG. 1

Artificial Dental Caries in Cross-section. Tubules Filled with
Bacteria. (Miller.)

FIG. 2

Putrid Tooth Pulp. Infection of Dental Tissue. × 1000. (Miller.)

FIG. 3

Dental Caries. Disappearance of Dental Tissues as Result of Presence of
Bacteria. (Miller.)

FIG. 4

Dental Caries. Tubule Filled with Cocci. (Miller.)

FIG. 5

Dental Caries. × 500. (Miller.)

FIG. 6

Dental Caries. Tubules Plugged with Cocci. × 500. (Miller.)]


=Upper Respiratory Tract.=--The oral cavity and pharynx are seldom
free from bacteria. Miller has studied over one hundred species that
he has found under various circumstances in the human mouth. Some of
these are pathogenic; others are apparently absolutely innocent. Many
of the forms which grow in saliva will not grow in ordinary media.
(See Plate III, illustrating infection of the teeth.) Miller has
also shown that many forms of dental caries are but expressions of
bacterial invasion even of those apparently most solid structures,
the teeth; and of late we have been taught more fully that such
invasion may extend far beyond the confines of the teeth alone, and may
spread to various, even to distant parts, and produce possibly fatal
mischief. Abscesses in the brain and extensive septic infections have
been traced to invasion along the line of the dental tubules. One of
the most virulent of all the common inhabitants of the mouth is the
pneumococcus of Fränkel, known also as the micrococcus lanceolatus of
Stebernrg. In virulence it is a variable organism, but it is present in
a virulent state in only 12 or 15 per cent. of cases of infection due
to it. This is the organism which is the cause of lobar pneumonia, and
frequently of bronchopneumonia, as well as of numerous phlegmons and
other inflammations of the throat, and which, getting into the general
circulation through the tonsils or other possible ports of entry about
the mouth, causes serious septic and inflammatory disturbances in
widely distant regions. Aside from dental caries, a widely opened port
of entry is often afforded by those ulcerations around the margins of
the gums which are produced by accumulations of tartar. Disease in the
antrum of Highmore, for instance, and many other local destructions,
are frequently caused in this way.

The next most common port of entry is the _tonsils_, faucial, lingual,
and pharyngeal, which contain a variety of crypts which are often
filled with secretions or retentions loaded with bacteria. One of the
most common sources of an involvement of the cervical lymph nodes in
tuberculous disease is an infection springing first from the tonsils or
the teeth.

In spite of the fact that myriads of bacteria are swept into the
nasal cavities with the air we breathe, few are seen in the nose.
A peculiar capsule bacillus, closely allied to that described by
Friedländer, has been found in a number of cases of ozena, while the
pneumococcus of Fränkel is also often found there, and is known to
produce abscesses of the brain. One specific organism--namely, that of
_rhinoscleroma_--concerns the nose almost solely, its first ravages
being met with in this location.


=Alimentary Canal.=--Probably more microörganisms enter the alimentary
canal than gain access in any other way, these coming both from food
and drink as well as air. Once within its confines, few of them are
capable of prolonged existence. Welch states that the meconium of
newborn infants is sterile, but that within twenty-four hours it
usually contains abundant bacteria. That bacterial infection through
this passage-way is a fertile source of non-surgical lesions is well
known. The possibility of surgical infections being produced in
the same way is both more remote and less demonstrable. Naturally,
anaërobic organisms find here more favorable conditions, and even
extremely acid or extremely alkaline conditions do not serve to destroy
all such life. Pyogenic cocci are often present and are frequently
found in peritoneal exudates. In the intestines of herbivorous animals
the tetanus bacilli and those of malignant edema are regularly found.
The fungus of actinomycosis also finds its way into the bowel along
with ingested food. Under ordinary conditions the bile in its natural
reservoirs is free from bacteria, but the colon bacilli and pyogenic
cocci often invade these precincts.


=Genito-urinary Tract.=--Even the healthy urethra may contain bacteria.
While these may wander upward to an indefinite extent, it is believed
that the urine contained within the bladder in a condition of perfect
health is free from bacteria, and that if such gain entrance they do
not long remain. The same is true of the female bladder and urethra.
The vagina contains organisms of many species, some of which do not
grow on ordinary culture media, but are to be recognized by the
microscope. While it is generally acknowledged that the vaginal
secretion is, as a rule, possessed of bactericidal properties, there is
as yet no satisfactory nor comprehensive explanation of this fact, its
normal acidity not being sufficient to account for the fact.


=The Milk in the Lacteal Ducts.=--In a condition of perfect health milk
secreted from the ideal mammary gland is sterile, but may easily become
contaminated upon its exit from the nipple. Conversely, under many
favoring conditions organisms may travel into the lacteal ducts from
the skin without, and thus contaminate the milk. In all probability
the breast corresponds in behavior to other glands whose ducts open
upon the surface, and, while such openings invite entrance of bacteria,
their migrations do not extend far from the surface unless some of the
other conditions already mentioned predispose to further infection or
extension.

In summarizing the general topic of possible _sources_ and _paths of
infection_ bacteria may enter and exert deleterious action:

  A. _From within the system_; and

  B. _From without_.

A. _From within_ they may enter the tissues either through the
inspired air, through food and drink, _i. e._, ingesta, or by means
of more direct inoculation, _e. g._, by foreign bodies or by venereal
contact. The danger through infection by inspired air is very small,
and concerns probably a limited number of organisms, of which the
tubercle bacillus is the most important. Foul air and air which
emanates from sewers, cesspools, etc., while most unpleasant to breathe
and deleterious in many other ways, do not necessarily contain any
microörganisms which can be injurious. This fact, in opposition to
general belief, is, nevertheless, proved by recent investigations. The
ingesta furnish the most fertile source of contagion from within, but
the diseases thereby produced fall for the most part into the domain of
medicine rather than that of surgery.

B. _Infection from without_ the body may come by actual contact with
previous skin or mucous lesions, and particularly from noxious insects
and certain parasites. Among surgeons the principal sources of contact
infection to be enumerated and guarded against are:

  1. Skin and hair;

  2. Instruments;

  3. Sponges or their substitutes;

  4. Suture materials;

  5. The hands of the surgeon and his assistants;

  6. Drainage materials;

  7. Dressing materials;

  8. From miscellaneous sources, _e. g._, drops of perspiration,
  unclean irrigator nozzle, a contaminated nail-brush, the clothing of
  the operator, etc.

While insisting here upon the recognition of these sources of danger,
the precautions to be taken against them are to be considered under
another heading, to which the reader is referred.

One of the greatest sources of possible infection has of late been
shown to be the presence of flies and other noxious insects, which act
as carriers of infection. The Egyptian ophthalmia, which ruins the
sight of 30 per cent. of the inhabitants of Egypt, has been shown by
Howe and others to be due to infection by this mechanism; and a simple
bacteriological experiment will suffice to show that the foot-tracks
of a single fly across a wound furnish abundant opportunities for
infection with organisms which are presumably virulent. In fact, the
danger of carriage of infection by this means is greater than from
almost all other sources, except the use of improper materials during
surgical operations.


CLASSIFICATION OF INFECTIONS.

We speak of infections as _primary_, _secondary_, and _mixed_; and it
is necessary, for purposes of accuracy at least, to make a reasonably
clear distinction between them.


=Primary Infection.=--By primary infection is meant infection with a
single form of organism whose effects are prompt and speedy. Of this,
erysipelas or syphilis may serve as illustrations. Most of the acute
infections belong to the primary type.


=Secondary Infection.=--Secondary infection means that after certain
disturbances due to a primary infection, _i. e._, one of a given
type, there occurs at some later period and from a distinct source
another infection whose results may be more or less disastrous, and
cause the case, at least for the time being, to assume a different
aspect. We have an illustration of this in the case, for example, of
primary tuberculosis with distinct infection of a number of lymph
nodes, which, acting as filters, have caught in their tissue net a
large number of tubercle bacilli that, lodging there, have produced
the usual well-known results and have practically converted the
infected nodes into granulomata. In these infected masses well-known
changes, such as those which follow tuberculous infection--atrophy,
caseation, calcification, etc.--may be occurring, when suddenly
there comes infection of a _pyogenic_ type from another source, and
suppuration of the granuloma is the result. It is possible even to have
a _tertiary infection_, of which the following may be a hypothetical
instance: Primary infection with scarlatina or measles, by which vital
susceptibility is in some instances lowered; as the result of this,
secondary tuberculous infection in an individual previously resistant;
and, third, a suppurative infection, as above described.

In contradistinction to these distinct events, separated by an
appreciable, sometimes a considerable, length of time, we recognize
a _mixed infection_, where two or more organisms are implanted at
or about the same time. An illustration of this is seen in most
cases of gonorrhea in which there is a synchronous attack made by
the gonococcus, which is a specific microörganism, accompanied by
staphylococci or streptococci, whose effect will complicate the
case and make it assume a less particulate type of infection. Mixed
infections may often occur in other ways, as syphilis and chancroid,
chancroid and gonorrhea, etc. Most cases of mixed infection belong
rather to surgery than to general medicine, and constitute an apparent
violation of the rule to which physicians often point--that two
distinct infectious diseases are seldom communicated or acquired at the
same time. Nevertheless, the facts remain as above.


=Terminal Infections.=--Terminal infections constitute an apparent
paradox, perhaps oftener in medical than in surgical cases. Few people,
as Osler has shown, die of the diseases from which they suffer.
The final exitus is due to a more or less rapid infection which
terminates life. These terminal infections are mainly due to a few
well-known microbes, such as the streptococcus, staphylococcus aureus,
pneumococcus, bacillus proteus, gonococcus, bacillus pyocyaneus, and
the gas bacillus. In surgery such infections are, perhaps, most often
seen in malignant lymphoma, diabetes, tuberculosis, syphilis, cancer,
and in the so-called surgical kidney.


BACTERIA OF PUS FORMATION.

Bacteria which act as agents in the formation of pus are collectively
known as pyogenic organisms. These are divided into two groups:

  A. _The Obligate_; and

  B. _The Facultative._

_Obligate_ pyogenic organisms are those whose activity is manifested
in the direction of pus formation, which seem to produce it if they
produce any unpleasant action whatever. On the other hand, the
_facultative_ organisms are those which are known occasionally to be
active in this direction, and yet which are not always nor necessarily
so. The members of group A are fairly well known and catalogued, and
are not numerous. On the other hand, there is reason to believe that
many organisms may have the occasional effect of producing pus, as
it were, by accident or at least in a way not absolutely natural or
peculiar to themselves, but still are frequently found when there is no
pus present. A suitable list of the facultative organisms, therefore,
can hardly be made, and will not be here attempted, the effort being
only to mention the more common organisms which play this facultative
role. It may be mentioned also that even the adjectives “obligate” and
“facultative” are to be accepted with some mental reservation, since
staphylococci, for instance, may be met with even in the absence of
pus, although nearly all that we know about these organisms implies
that pus would be the result of their presence. Furthermore, there are
certain other organisms, not, strictly speaking, bacteria, which also
have the power of producing either pus or pyoid material. These also
will be mentioned in their place. Some of them belong not only to the
vegetable, but also to the animal kingdom.


=Obligate Pyogenic Organisms.=


A. =The Staphylococcus Pyogenes Aureus, Albus, Citreus, the
Staphylococcus Epidermidis, etc.=--One of the characteristics of the
staphylococci as a group is the powerful peptonizing action which they
exert. Moreover, the chemical products of their life changes seem
to be more potent in a local than a general way, leading to greater
destruction of tissue in their immediate vicinity, with greater
inhibition of the chemotactic powers of the leukocytes; that is, with
more interference with phagocytosis, by which their progress would
be interfered with. Their presence is recognized by a peculiar odor,
as of sour paste, which should lead to a prompt change of dressings
and disinfection of the wound (by irrigation, spraying with hydrogen
dioxide, etc.).


B. =Streptococcus Pyogenes and Streptococcus Erysipelatis.=--These two
organisms do not differ in morphology nor characteristics, and, while
for some time considered as distinct from each other, are now by most
observers regarded as identical. The streptococci grow in chains of
variable length, and individual cocci vary in size. They grow with
and without oxygen, in all media, at ordinary temperatures, do not
liquefy gelatin, stain readily, sometimes but not invariably coagulate
milk, and vary in longevity. They differ extraordinarily in virulence
according to their sources.

[Illustration: FIG. 4

Staphylococci in pus. × 1000. (Fränkel and Pfeiffer.)]

[Illustration: FIG. 5

Streptococci in pus. × 1000. (Fränkel and Pfeiffer.)]

There are many streptococci not included under the above head which
are indistinguishable morphologically and in other respects, and yet
which are partly or entirely free from pathogenic activity in man. A
biological study reveals remarkable and unexplainable transformation
between the different members of this species, a part of which may be
referable to conditions pertaining to the organisms infected, but part
of which apparently pertains to the bacteria. It is held by some that
scarlatina is an invasion by certain organisms of this class; this,
however, is not yet definitely established. When found in the stools
of children with summer diarrheas they are regarded as indicating
ulceration of the intestinal mucosa.

In contradistinction to the staphylococci, the streptococci manifest
a predilection for lymph vessels and lymph spaces, along which they
extend with great rapidity. They have less peptonizing power than the
staphylococci (except in the absence of oxygen); hence streptococcus
infection assumes usually the type of widespread infiltration rather
than of circumscribed and distinct edema. One sees remarkable instances
of this in cases of phlegmonous erysipelas. It is suggested also that
the peculiar manner of growth of the streptococci, in long chains which
may coil up and entangle blood corpuscles, has much to do with the
formation of fat emboli and with pyemic disturbances.

Both these bacterial forms have the power of producing lactic
fermentation in milk; and lactic-acid formation sometimes takes place
with suppuration in the human tissues, causing acidity of discharge,
sour odor, and watery pus. It appears also that these two pyogenic
forms have less power of ptomain or toxin formation than many others,
and, consequently, that the pyrexia attending suppuration or purulent
infiltration is not always to be ascribed to this cause alone, for
fever may in some measure be due to tissue metabolism attending their
growth, the metabolic products being pyretic. This is in a measure
substantiated by the fever attending trichinosis, where the question of
ptomain poisoning has not yet been raised.


C. =Micrococcus Lanceolatus.=--Micrococcus lanceolatus is also known
as the _diplococcus pneumoniæ_ or the pneumococcus of Fränkel and
Weichselbaum, and as the _micrococcus of sputum septicemia_ of Pasteur
and of Sternberg. It is of interest to surgeons because it causes many
localized inflammations and is a frequent factor in causing septicemia;
it is often present in the mouths of healthy individuals. It may
produce the various forms of exudates as the result of congestion set
up by its presence; also otitis media, meningitis, osteomyelitis, and
suppurative disturbance in the periosteum, the salivary glands, the
thyroid, the kidney, the endocardium, etc.

[Illustration: FIG. 6

Diplococcus pneumoniæ of Fränkel. (Karg and Schmorl.)]


D. =The Micrococcus Tetragenus.=--Suppurations produced by these
organisms are prolonged, mild in character, not painful, but
accompanied by much brawny induration of tissues.


E. =The Micrococcus Gonorrhœæ.=--The micrococcus gonorrhœæ, or
_gonococcus_, is found constantly in the pus of true gonorrhea, in
many cases the pus being a pure culture of this organism. These cocci
are generally seen in pairs (biscuit-shaped), while their inclusion
within the leukocytes or their attachment in or to epithelial cells
is characteristic. Unlike other pyogenic cocci, they do not stain
by Gram’s method, being decolorized by iodine, by which fact they
may be distinguished. They are cultivated with difficulty, and are
known rather by their clinical effects than by their laboratory
characteristics; are human parasites, other animals, so far as known,
being practically immune. The gonococcus may also produce abscesses,
and may be carried to distant parts of the body, where its effects are
commonly noted as pyarthrosis, although endocarditis, pericarditis,
pleurisy, etc., are known to be due to it, and fatal pyemia has been
produced in consequence. In some way it is probably the explanation
of the post _gonorrheal arthritis_, wrongly spoken of as gonorrheal
rheumatism.


F. =The Bacillus Coli Communis or Colon Bacillus.=--This is an
inhabitant of the intestinal canal; varies extremely in virulence
and somewhat in morphological appearances; coagulates milk; is often
associated with other organisms; migrates easily both along the
alimentary canal and from it into the surrounding tissues or channels.
It is a disturbing element in the production of kidney and hepatic
disease, also in the production of appendicitis and peritonitis.
Ordinarily its pyogenic properties are not virulent; occasionally,
however, it becomes extremely virulent.


G. =The Bacillus Pyocyaneus.=--The bacillus pyocyaneus, a widely
distributed organism, often observed in the skin and outside of the
body; a motile, liquefying bacillus, growing at ordinary temperatures,
seldom seen alone, but occasionally producing pus without association
with other organisms; it stains the discharges and dressings a
bluish-green and imparts sometimes an offensive odor. Suppuration
caused by this bacillus is usually prolonged, but characterized by
little constitutional disturbance.


=Facultative Pyogenic Organisms=--_i. e._, those which have the power
of provoking suppuration, but which have other and more distinct
pathogenic activities as well.


A. =Bacillus Typhi Abdominalis.=--This is found in many pus foci,
developing during or after typhoid fever. It is occasionally met with
alone, though most of these abscesses are really mixed infections.
It is generally found in the bone or beneath the periosteum. Such
abscesses are frequently seen in the ribs, and may not be noticed until
months after convalescence from the fever. The pus contained within
them is not always typical in appearance, but may be unduly thin or
unduly thick.


B. =Bacillus Proteus.=--Under this name are included three distinct
forms, which were originally described by Hauser as distinct species,
but which are now regarded as pleomorphic forms of the same organism.
It is a motile bacillus, met with in decomposing animal and vegetable
material, and occasionally found in the alimentary canal. It has been
known to produce pus, especially in the peritoneal cavity and about the
appendix. It may even cause general infection and peritonitis.


C. =Bacillus Diphtheriæ.=--A non-motile bacillus, varying considerably
in size and shape, changing the reaction in sweet bouillon from acid
to alkaline; produces a dangerous infective inflammation of exposed
surfaces, with tenacious exudate amounting to a distinct membrane. As
a part of its life history it also produces a toxalbumin, which is one
of the most powerful cell poisons known, the disintegration of the
cell constituents due to its action being rapid and pronounced. This
accounts for the heart failures which are often reported in connection
with the disease.


D. =Bacillus Tetani.=--More will be said about this organism when
considering tetanus, and to that subject the reader is referred. The
tetanus bacillus is occasionally found in pus which comes from the area
through which the original infection was produced. But these bacilli do
not travel to any distance in the human body, and are seldom found away
from the area involved. Under most circumstances the pus is the product
of a mixed infection.


E. =Bacillus Œdematis Maligni.=--This organism will be more fully
considered under a different heading. (See Malignant Edema.) It is a
long, anaërobic bacillus, widely distributed in the soil and the feces
of animals. It is believed that this, like the tetanus bacillus, may
occasionally lead to formation of pus.


F. =Bacillus Tuberculosis.=--This organism likewise will receive fuller
description in an ensuing chapter. (See Tuberculosis.) The pus of old
cold abscesses in which the more obligate pyogenic organisms have long
since died usually contains this organism in mildly virulent form.
On the other hand, fresh suppurations occurring in connection with
tuberculous disease are mixed infections. There is reason to believe,
however, that this organism is capable of producing pus even when
none of these are present; for example, in that form of acute miliary
tuberculosis which is occasionally met with as bone abscess it may be
found.


G. =Bacillus Anthracis.=--This is one of the most malignant and
resistant organisms known, being in the highest degree poisonous
for the smaller animals, man being less susceptible. One of its
characteristic lesions in the human body is a form of pustule commonly
known as _malignant pustule_, the pus in which is usually a pure
culture of this organism. (See Anthrax.)


H. =Bacillus Mallei.=--This is the organism which produces glanders in
the lower animals and in man. That form of the disease known as farcy,
in which the infected nodules rapidly break down, is likely to contain
pus which will be more or less a pure culture of this organism.


I. =Bacillus Lepræ.=--This is the microörganism which produces
leprosy, closely resembling the tubercle bacillus. It is constantly
and exclusively present in the lesions of leprosy, which are often of
the suppurative type, the bacilli being enclosed within pus cells; it
is also found in the fluid surrounding them. Although suppuration in
these cases may be in a large measure due to secondary infection, it is
positive that the leprous bacilli deserve to be grouped in this place.


J. =The Bacillus Pneumoniæ of Friedlander.=--The bacillus pneumoniæ
of Friedländer was at one time regarded as the cause of croupous
pneumonia, which is now known to be due to the micrococcus lanceolatus.
The Friedländer bacillus, however, is capable of producing
bronchopneumonia, and is occasionally met with in empyema, suppurative
meningitis, and inflammations about the nasopharyngeal cavity, of which
it is known to be an occasional inhabitant.


K. =The Bacillus of Rhinoscleroma.=--A distinctive organism has been
described for this disease and given this name. It has such wide
morphological differences, however, that it is possible that it is only
the bacillus of Friedländer above mentioned. At all events, an organism
of this general character is constantly found in this disease in the
thickened tissues from the nose (Fig. 8).


L. =The Bacillus of Bubonic Plague.=--This was recently discovered
by Kitasato, and, in view of the recent ravages of the disease in
the Orient, has assumed considerable importance. It grows upon most
media, and is found in the blood, in buboes, and in all internal
organs of patients suffering from this disease. The smaller animals
are susceptible upon inoculation. Animals fed with inoculated foods
die also, showing the possibility of infection through the intestine.
When exposed to direct sunlight for a few hours the bacillus dies. The
general symptoms of the disease are those of hemorrhagic septicemia and
its consequences.


M. =The Bacillus of Rauschbrand.=--This is seldom, if ever, seen
in this country. It is known in England as “the black-leg” or
“quarter-evil.” It is an anaërobic organism, frequently met with in
cattle, which causes a peculiar emphysema of subcutaneous tissue,
spreads deeply, and is followed by a copious exudate of dark serum with
gas formation. The smaller animals are not ordinarily inoculable; but
if to the culture material there is added 20 per cent. of lactic acid,
their insusceptibility is overcome and they succumb to the disease.
So, also, as in the case of the tetanus bacillus, by addition of the
bacillus prodigiosus or of proteus vulgaris the disease may be produced
in otherwise insusceptible animals.


N. =The Bacillus Aerogenes Capsulatus.=--The bacillus aërogenes
capsulatus seems capable sometimes of causing pyogenic and even fatal
infection. Its presence is associated with gas formation. It grows as
an anaërobe.


O. =The Bacillus of Chancroid.=--The bacillus of chancroid identified
by Ducrey, and briefly described in the chapter on that subject.

[Illustration: FIG. 7

Rhinoscleroma: infiltration of tissues about the nose. (Case reported
by Dr. Wende, Buffalo.)]

[Illustration: FIG. 8

Bacilli of rhinoscleroma. × 1000. (Fränkel and Pfeiffer.)]


YEASTS.

Busse was the first to call attention of clinicians and pathologists
to the role played by yeasts in certain infections. Since the original
observations of Busse in a case in which the organism produced a
general infection, the lesions of which were a combination of tumor
and abscess formation, various observers have noted the presence of
pathogenic yeasts, usually in skin lesions. Gilchrist and Stokes were
the first in this country to determine the nature of these organisms,
and their observations have been followed by the detection of a large
number of similar cases. In the skin lesions the organisms are found
in minute abscesses; in the subcutaneous tissue and in the infections
similar to those of Busse large abscesses surrounded by extensive
masses of granulation tissue characterize the infection. The organisms
can be detected in the pus by means of an examination of the fresh
unstained fluid (Fig. 9).


FUNGI.

Besides the micro-organisms everywhere grouped as bacteria, there are
other minute organisms which have also the power of engendering pus.
One of these is the ray fungus, known as the _actinomycis_, which
causes the disease known as lumpy jaw or actinomycosis. Suppuration
is always a concomitant of the advanced lesions of this disease,
and, while it may be in many instances a mixed infection, it is not
necessarily so. Moreover, the pus produced under these circumstances
contains minute calcareous particles which are pathognomonic, by which
a diagnosis can sometimes be made off-hand.

Besides these fungi, others, belonging rather to the class of vegetable
molds, which are yet pathogenic for human beings, may be occasionally
met with under these circumstances--_e. g._, _the fungus of Madura
foot_, the _leptothrix_, and other molds from the mouth, while the
different varieties of _aspergillus_ may be found in pus about the ear
or even in that from the brain.


PROTOZOA.

The protozoa have the power of producing, if not absolute ideal pus,
something so nearly resembling it that we may include them among the
facultative pyogenic organisms. The best known of these protozoa
are the _amebæ_, which are met with in the intestinal canal in some
countries, occasionally in the United States, especially as the
exciting causes of a peculiar type of dysentery often accompanied by
abscess of the liver. In these abscesses the amebæ are found, and no
other organisms. Another group of the protozoa, known to biologists
as the _coccidia_, are also capable of causing pus formation, more
particularly in some of the lower animals. Numerous other parasites,
belonging higher in the animal kingdom, are undoubted exciters of pus
formation, though it is not necessary to lengthen the list beyond those
already mentioned.

[Illustration: FIG. 9

Blastomycetic pus (fresh). × 1000. (Gaylord.)]

Protozoa have recently been established as the active agents in the
production of smallpox and probably also of scarlatina. They have been
seen so generally in and around cancer cells as to make it extremely
probable that cancer is a protozoan infection. In syphilis also they
are found as the _spirochetæ_, now regarded as its cause.

Protozoa are as ubiquitous as bacteria, but their recognition is as yet
more difficult, as but little is known of them. The numerous stages
through which they pass in completing their life cycles only complicate
the subject, while the difficulties encountered in cultivating them are
still to be overcome. As we become more familiar with them we shall
more frequently find them to be pathogenic organisms.


CLINICAL CHARACTERISTICS OF PUS FROM DIFFERENT AGENCIES.

_Staphylococcus._--Dirty white, moderately thick, with sour-paste odor.

_Streptococcus._--Thin, white, often with shreds of tissue.

_Colon Bacillus._--Thick, brownish, with fetid odor, or thin, dirty
white, with thicker masses.

_Micrococcus Lanceolatus._--Thin, watery, greenish, often copious.

_Bacillus Pyocyaneus._--Distinctly green or blue in tint.

_Bacillus Tuberculosis._--Thick, curdy, white paste, or thin, greenish,
with small, cheesy lumps or even with bone spicules.

_Actinomycis._--Thick, brownish white, with small, firm, gritty or
chalky nodules of yellow color.

_Ameba Coli._--Thick, brownish red.


BACTERIAL DETERMINATION AS AN INDICATION IN TREATMENT.

There is a practical side of great importance pertaining to the
recognition of the nature of the infectious organism in many cases
of suppuration and abscess. For instance, pus which is due to
streptococcus invasion indicates a collection which should be freely
evacuated and carefully drained. This is also true in essential
respects of staphylococcus pus, particularly that due to the
streptococcus aureus. Putrid pus from any source requires disinfection
and free drainage, the former preferably perhaps by hydrogen dioxide.
Pus which is due to the colon bacillus is not often extremely virulent,
which accounts for so many cases of appendicitis recovering with or
without operation. A collection of this pus needs little more than
mere drainage and opportunity for escape. Pus from a recognizable
tuberculous source may still contain living tubercle bacilli. This
means either that the cavity whence it came should be completely
destroyed and eradicated, or else that the margins of the incision
or opening through which it has escaped should be so cauterized that
infection of a fresh surface is impossible. The same is true of
abscesses due to glanders bacilli and to certain cases of suppurating
bubo following chancroid, where the whole course of events shows the
virulent character of the organisms at fault.


SUPPURATION.

Although it may be possible to produce in certain laboratory
experiments metamorphosed material which very closely simulates pus,
or, in fact, by injection of chemical irritants, to sometimes imitate
the suppurative processes, nevertheless, the student should be brought
face to face with the statement, to which for surgical purposes there
is no practical exception, that suppuration, _i. e._, _formation of
pus, is due to the presence in the tissues of the specific irritants
already catalogued and described, and of the peculiar peptonizing or
other biochemical changes which bacteria exert upon living animal
cells_.


=Coagulation Necrosis.=--Coagulation necrosis is the term applied
to the characteristic changes occurring in the tissue cells when
thus attacked, which may be summarized as a fading away of cell
outlines, diminution in reaction to reagents, and a merging of cells
and intercellular substance. Coagulation necrosis is not the only
result of bacterial activity, but may be produced by other causes.
Nevertheless, pyogenic bacteria do not exert their deleterious action
upon the tissues without occasioning changes included under this
term. In an area thus infected, as already described, leukocytes, _i.
e._, phagocytes, are present in increased number for purposes already
mentioned. As we approach the centre of activity phagocytes are more
numerous than cells, and intercellular barriers completely break
down. When bacteria are found in greatest number, there also occurs
the greatest phagocytic activity, and there also will be found the
evidence of suppuration, _i. e._, _pus_. As already indicated, the
_polynuclear leukocytes_ are most active in the process of defence.
Where coagulation necrosis is most marked there has been the greatest
activity of conflict with the greatest death of cells. Around these
areas bacteria and cells are found in indiscriminate arrangement.
Tissue vitality is impaired by intoxication of the cells by the
excretory products of the bacteria, _i. e._, the so-called ptomains,
toxins, etc., and their power of resistance is thus weakened. From the
mechanical results of pressure tension around the centre of activity is
increased, by which tension vitality is still more impaired and more
rapid tissue death occurs. Thus there occurs migration or burrowing of
pus; or, to state it more clearly, the tissues break down in front of
the advancing destruction, and in the direction of least resistance.
This is known as the _pointing of pus_, which brings it many times to
the surface, and often in other and less desirable directions.


=Abscess.=--An abscess is a _circumscribed collection of pus_. The term
is used in contradistinction to _purulent infiltration_, in which the
collection is not circumscribed, but is exceedingly diffuse and extends
itself in various directions, the amount at any spot being almost
inappreciable. Purulent infiltration is regarded as the more serious
of the two conditions, as it is more difficult for pus to escape under
these circumstances than when it can be evacuated through a single
opening. The term _phlegmon_ is one now generally used to indicate
a suppurative process, usually of the general character of purulent
infiltration rather than of abrupt abscess, but generally employed to
include both conditions. The adjective _phlegmonous_ is coupled with
the names of other surgical infectious diseases to indicate that it
is complicated by suppuration, _e. g._, phlegmonous erysipelas. _Pus_
is a product of bacterial activity usually formed rapidly rather than
otherwise, and abscess formation or phlegmonous activity of any kind is
a question of but a few days. _Empyema_ means a collection of pus in a
preëxisting cavity.

The significance of this condition is well described in the story of
inflammation and suppuration, to paraphrase Sutton, read zoölogically,
as though it were the story of a battle: The leukocytes (phagocytes)
are the defending army, the vessels its lines of communication, the
leukocytes being, in effect, the standing army maintained by every
composite organism. When this body is invaded by bacteria or other
irritants, information of the invasion is telegraphed by means
of the vasomotor nerves, and leukocytes are pushed to the front,
reinforcements being rapidly furnished, so that the standing army of
white corpuscles may be increased to thirty or forty times the normal
standard. In this conflict cells die, and often are eaten by their
companions. Frequently the slaughter is so great that the tissues
become burdened by the dead bodies of the soldiers in the form of
pus, the activity of the cells being proved by the fact that their
protoplasm often contains bacilli in various stages of destruction.
These dead cells, like the corpses of soldiers who fall in battle,
later become hurtful to the organism which, during their lives, it was
their duty to protect, for they are fertile sources of septicemia and
pyemia. This illustration may seem romantic, but is warranted by the
facts.

Around the margin of the site of an acute abscess a barrier is formed
by condensation and cell infiltration of the surrounding tissues. This
is not a distinct wall nor membrane, yet, nevertheless, serves as a
sanitary cordon to confine the mimic conflict within reasonable bounds.
This is the zone of real inflammation; within it there are tissue
destruction and coagulation necrosis. By virtue of the peptonizing
power of the pyogenic organisms the parts involved in this necrosis
gradually liquefy the intercellular substance dissolving first. It is
this which in the main forms the fluid portion of the pus. Various
tissues show widely differing resistance to this softening process. In
true glands the interlobular septa seem to break down first, and in
this way suppuration extends around the acini or gland lobules, and
thus pus may contain masses of easily recognizable size. These masses
are ordinarily known as _sloughs_.

It is by virtue of the so-called lymphoid cells, which are those
principally involved in producing the barrier or boundary of the
acute abscess as above described, that granulation tissue is formed,
which takes up the effort of repair as soon as pus is evacuated. This
boundary has no sharp limit, but shades off into healthy surrounding
tissues.

Under the term “abscess” is meant that which is described as _acute
abscess_. Under certain circumstances, especially when they are
produced by the facultative pyogenic organisms rather than the
obligate, abscesses form more slowly, and may be spoken of as
_subacute_. These are terms used in contradistinction to the so-called
_cold abscesses_, which, although clinically bearing a certain
resemblance to the acute, are in almost every pathological respect
different from it. Cold abscesses will be considered under the head of
Tuberculosis. It is possible to have an acute pyogenic infection of a
cold abscess; in such case we have acute manifestations. _Gravitation
abscesses_ are those where pus forming in one part tends to migrate,
usually in the direction in which gravity would take it, extending
into portions deeper or lower. Perhaps the best illustration of
this is the pointing of a psoas abscess below Poupart’s ligament.
_Metastatic abscesses_ are those which are formed as the result of
embolic processes, each one being in miniature a repetition of a lesion
which has occurred at some other part of the body. The underlying
fact concerning metastatic abscesses is that the primary process
has occurred in some other portion of the body, whence it has been
distributed as above. These will be considered in the chapter treating
of Pyemia.

The product of all acute suppurative lesions is _pus_. This is an
opaque fluid of creamy consistence and whitish or grayish appearance,
varying in density, met with in amounts from a minute drop to half a
gallon or more. Under ordinary circumstances it is odorless, and its
reaction, either acid or alkaline, is very faint. It is, like the
blood, composed of a fluid and a solid portion. The solid portion
consists of so-called _pus corpuscles_ and other debris of tissue,
which vary with the site of the disease and the parts involved. The
source of the pus corpuscles has been cited and the statement made that
they are in effect the bodies of phagocytes which have perished in
the biochemical fight for existence of the parent organism. Cocci or
bacilli are found in pus corpuscles and also in the surrounding fluid.

Pus should be without odor, but under certain circumstances it
possesses an odor which will vary in character according to the source
of the pus or the nature of its principal bacterial excitant. Pus from
the upper end of the alimentary canal frequently has the sour smell
of gastric contents; that from the neighborhood of the lower end,
the fetid odor which is for the most part due to the action of the
colon bacillus. Inasmuch as colon bacilli are found in widely distant
parts of the body, they may also give an unpleasant odor to pus even
from a brain abscess. When the pus has become contaminated with the
ordinary saprophytic organisms, it may smell like any other decomposing
material. The older writers called it _ichorous pus_, while _sanious
pus_ was supposed to be that more or less mixed with blood, undergoing
ammoniacal decomposition or else strongly acid. Pus sometimes has a
well-marked _blue_ or _bluish-green tint_. This is due to the presence
of the _bacillus pyocyaneus_, already described. An orange tint is
sometimes given by the presence of hematoidin crystals, due to the
original hemorrhagic character of the infected exudate. The former
appearance indicates usually a slow course to the suppurative lesion,
while the latter has been regarded by some as affording an unfavorable
prognosis. Distinctly red pus, whose tint is due to the presence of a
bacillus giving bright-red cultures on blood serum, has been noted in
other instances. This can readily be distinguished from blood, because
upon dressings it does not change color.

Pus may form superficially, when it is called subcutaneous suppuration,
in which case there is a minimum of pain, because tension is not
great and the distance to the surface is short. Collections which
form beneath the fasciæ, especially the deeper fasciæ of the limbs
and trunk, give rise to much more extensive disturbance, both locally
and generally, and frequently do not point for many days; or, instead
of pointing, burrow deeply and find their outlet at some undesirable
point. These are known as _subfascial_ collections. _Subperiosteal_
abscesses give rise to still more pain, because of the unyielding
character of their limiting structures, and the symptoms caused by them
are acute and distressing.

An illustration of the pain which may follow deep suppuration may also
be seen in the ordinary panaritium, or bone felon, where the path of
infection is from without, but the destructive lesion is confined
within absolutely unyielding tissues, at least at first. Along certain
tissues infection spreads with rapidity. This is particularly true of
the delicate areolar tissue seen between tendons and tendon sheaths,
and the infectious process may follow this tissue wherever it shall
lead, even along complex courses.

The question often arises, _Can pus be resorbed?_ There is no question
but that small amounts of pus are disposed of by phagocytic activity,
and the disappearance of purulent infiltration, under the influence of
favoring remedies, or even when let alone, is not infrequently noted.
True pus resorption is a question of phagocytic possibilities, and
can occur only in very limited degree, as a result upon which it is
not safe to count, and which is capable of encouragement only up to a
certain point.

One inevitable law seems to govern collections of pus, that when
they _advance_ or migrate in any direction it is in that of _least
resistance_. This causes them to take peculiar and sometimes disastrous
courses, but it is a law which is never violated. It leads to the
bursting of abscesses into the brain, into the pleural cavity, into the
peritoneal cavity, the bowel, and elsewhere; it leads to a condition
where pus may travel along a path even a foot or more in length,
rather than come to the surface, a distance of perhaps an inch, and
affords one of the best reasons for early operative interference so
that the disastrous effects of burrowing may be obviated. When the
pus is limited to a drop or fraction thereof the abscess is called a
_furuncle_, especially when in the skin. The average “boil” of the
layman is a subcutaneous or subfascial abscess. When the infiltration
is pronounced, and when there has been more or less extensive
destruction of tissue, with perhaps formation of numerous outlets for
the escape of pus and detritus, it is known as a _carbuncle_. (See
Chapter XXVI.) In certain conditions small superficial furuncles or
boils form, sometimes in great number and almost synchronously, or, as
it were, in crops. This condition is known as _general furunculosis_.


=Signs and Symptoms of Abscesses.=--The appearances by which pus may
be suspected or detected are those of congestion and hyperemia, more
or less abruptly circumscribed and markedly accentuated. Along with
these there is more or less edema or edematous infiltration of the skin
and overlying tissue, which permits of that peculiar appearance known
as “pitting on pressure.” Often, too, there is a distinctly edematous
swelling of the parts, especially around the margin, with brawny
infiltration of the centre of the infected area. Numerous vesicles
occasionally are noted upon the skin, which may be filled with reddish
serum. When softening and pus formation occur, there is a condition
which to the palpating fingers gives the characteristic sensation known
as _fluctuation_. Fluctuation simply points out the presence of fluid
beneath; but when in an area marked as thus described fluctuation is
noted, it means the presence of pus. It is detected by manipulating in
a direction parallel to and concentric with the axis of the limb or
part. The pain is also in most instances significant; patients speak
of it as having an intense and throbbing character. With these local
signs occur symptoms indicating some degree of septic intoxication, _i.
e._, pyrexia, chills, malaise, sweats, etc., which are corroborative
indications, their intensity being a reasonably correct index of the
severity and gravity of the local infection.

When a deep-seated abscess is suspected a careful blood count will
often permit a diagnosis to be made. This is conspicuously true of
cases of appendicitis. If leukocytosis is established there should be
immediate operation. (See Chapter II.)

It is seldom that a superficial collection of pus can be mistaken for
anything else. In small and superficial abscesses (boils, furuncles)
as pus approaches the superficial layer (epidermis) of the skin it
may be discovered through its thin covering. In deep lesions there is
often a doubt, even on the part of the most experienced. The measure
now usually resorted to for purposes of diagnosis and exact recognition
is the exploring or aspirating needle. The old exploring needle was
one of good size, having a groove along which, after introduction, pus
might pass. Since the almost universal use of the hypodermic syringe, a
small aspirating needle attached to the ordinary syringe is the measure
commonly adopted. Such a needle may be introduced into the brain, into
the liver, or into almost any and every soft tissue without danger, and
if properly manipulated is almost sure to facilitate detection of pus.
Exploration done with either of these means and for this purpose should
always be conducted as an aseptic, even if a minor operation, in order
that no extra infection may be added from without. The skin should be
carefully washed, the needle sterilized, etc.

It is good surgery to resort to the knife either for the above purpose
or in order that by a longer incision or by opening the cavity deep
exploration may be made. Such explorations are of benefit even though
a circumscribed collection of pus is not found, since by relief of
tension and local abstraction of blood they act in a revulsive way and
do much good. Acting upon the same principle the trephine or the bone
chisel may be used for the purpose of opening the cranium and exploring
for pus, or of opening into the medullary canal of the long bones and
hunting there for that which is suspected.


=Treatment.=--As soon as suppuration threatens speedy measures should
be adopted, either for the purpose of bringing about resorption, or of
favoring and hastening suppuration. In theory antiseptic applications
are demanded; in practice they are sometimes of benefit. These may
consist of mere soothing applications, as a lead and opium wash, or
some other wet or dry astringent applied upon the surface; or they
may consist of cold applications, which by their astringent action
will limit the amount of exudate and prevent its further infection.
Or advantage may be taken of the properties of moist heat, and the
application of hot poultices or fomentations may encourage exudation,
but particularly quicken superficial breaking down, and thus hasten
the time when the phlegmon shall point, or come sufficiently close
to the surface to show that its contents are pus and permit of
evacuation. Such local applications, therefore, give relief from pain
and hasten favorably the suppurative process. In cases of phlegmonous
infiltration, the application of an ointment composed of resorcin 5,
ichthyol 10, mercurial ointment 35, and lanolin 50 parts, or else the
Credé silver ointment, is beneficial. Under the influence of these
antiseptic and sorbefacient preparations, and of moist heat, many
phlegmonous infiltrations assume a kindlier type, and may secure the
actual resorption of pus.

Finally in almost every case pus must be evacuated. Here the universal
rule may be applied, to which there are practically no exceptions,
and which should be stamped on the mind of every student and young
practitioner. It is--that _pus left to itself will do more harm than
will the knife of the surgeon if judiciously used for its evacuation_.
Action taken in accordance with this rule may be considered wise and
timely. The operation of evacuation may at one time be a mere puncture,
or possibly the aspirating needle alone will be enough; at other
times it requires extensive and careful dissection and entails no
little responsibility. This is particularly true in such deep-seated
suppurations as those around the appendix and in the brain, while in
the deep-seated bone lesions of this character the use of the bone
chisel or the cutting forceps may be of use. But the rule holds good,
no matter where the pus may be, and as long as good judgment is shown
in the operative procedure nothing but good can come from recognition
of this law. After the evacuation of pus the cavity should be cleansed
and disinfected with hydrogen dioxide, perhaps even with caustic
pyrozone, or, if these are not at hand, with other suitable antiseptic
solutions.

Ordinary judgment should be exercised in evacuating every abscess, in
order that opening be made at that point which in the common position
of the body shall be most favorable to drainage by mere gravity alone.
If circumstances compel opening when advantage cannot be taken of
gravity, then one or more _counteropenings_ should be made at points
selected where drainage may be best effected, and where anatomical
conditions do not make it injudicious to incise. Drainage should be
favored by the introduction of a drainage tube or of other aids, such
as gauze, strands of catgut, bundles of horse-hair, etc. Finally, a
dressing should be applied which is both protective and absorbent, and
in quantity sufficient to make compression of the walls of the abscess
cavity--not sufficient to obstruct drainage, but enough to favor prompt
adhesion of surfaces, which by speedy granulation shall ensure prompt
healing.

Abscesses are found in proximity to large vessels or dangerous
anatomical regions, when care must be exercised in opening them. Here
careful dissection should be made under an anesthetic. This is true of
abscesses in the neck and of those around the appendix, for example,
where the general peritoneal cavity is shut off only by more or less
delicate adhesions, and where the surgeon must literally feel his
way with great precaution lest adhesions be torn and the previously
protected cavity infected. At other times, especially in abdominal
abscesses, it is necessary to pack sponges or absorbent gauze in and
about the parts, so that any fluid which may escape may be absorbed by
these dressings.


=Accompanying Disturbances.=--The disturbance of function which
accompanies all congestion and exudation, whether provoked by specific
irritants or not, has been alluded to; but in cases of surgical
infections, especially those which produce local suppuration,
disturbance of function is much greater, while there are other
disturbances which sometimes constitute the worst feature of these
cases. The _presence of pus_ is often indicated, especially when
deeply seated, by one or more _chills_, and the occurrence of a chill
is always marked to varying degree by _pyrexia_. It is conceded that
the chill is an expression of a general septic disturbance; but it
is necessary also not to forget that general septic disturbance is a
frequent accompaniment of pus which is not evacuated as soon as formed.
Moreover in certain cases suppuration and septic infection seem to
occur synchronously, one being local, the other general.

Pus may also be suspected beneath a surface which is red, tender,
swollen, edematous, and pitting on pressure. When fluctuation is added
to these indications any element of doubt is thereby dissipated.

Other indications of the presence of pus are a well-marked
leukocytosis, coupled with the iodine reaction indicating the existence
of glycogen in the blood, the presence of indican in the urine, and
the positive results frequently obtained by making cultures from the
blood. When pyogenic bacteria are found in the blood the inference
is very plain, and both treatment and prognosis are influenced. In
such a case the introduction into the blood of an antiseptic such as
Credé’s soluble metallic silver or of the antistreptococcus serum,
is plainly indicated. The absence of bacteria from the blood, under
these circumstances, does not disprove the presence of pus, but their
presence gives a very serious character to the disease, and should lead
to a most guarded prognosis. Invasion of the blood by staphylococci is
nearly twice as serious as when streptococci gain entrance. Suppuration
of the bones and of the tendon sheaths is liable to produce such
invasion.

The other disturbance with which suppuration is so often complicated
is _septic infection_. In fact it may be questioned whether pyrexia is
not an expression of this condition. Any collection of pus, no matter
how small, may show signs of septic infection; and, on the other hand,
large collections may be formed without serious septic symptoms--in
other words, suppuration and expressions of septic infection may be
blended in almost every conceivable way. Sepsis as a distinct condition
will be described in another chapter.

It is important to summarize what may become of pus when once it has
formed and is not promptly evacuated. Pus when long present may be--

  A. _Absorbed_;

  B. _Encapsulated_; and

  C. _Undergo various degenerations or chemical alterations_.

A. _The possibility of the absorption of pus_, or, what is equivalent
to it, its spontaneous disappearance, has been mentioned. While it
does not usually take this course, it may thus disappear; as, for
instance, in the anterior chamber of the eye in cases of _hypopyon_, or
in various other localities, particularly when present only in small
amounts. The absorption of pus is purely a matter, as far as we know,
of phagocytic activity plus the power of the tissues to take up various
fluids.

B. _Encapsulation._--This occurs only when pus has been present for
some time and when the virulence of the pyogenic organisms is not
intense. We may get encapsulation of pus in any part of the body, the
most typical illustration naturally being within the bones. Around
the purulent focus, as around any other irritating foreign body, the
capsule is formed by condensation of surrounding tissue. This is the
way in which most cold abscesses with their limiting membranes are
produced, those produced by tubercle bacilli having slight irritating
properties. Inasmuch, then, as the biological activity in such a focus
is small, there is time for such encapsulation; while by the membrane
thus formed, or the sanitary cordon, already referred to, protection
is afforded to the surrounding tissues. In such a collection fresh
infection may incite acute disturbances again, and many abscesses
which thus lie latent for a considerable length of time are fanned, as
it were, into a conflagration, when a new and acute inflammation is
produced.

C. _Of the various metamorphoses and chemical changes_ that occur in
that which was originally pus, the caseous and the calcific are the
most common. These also are connected largely with the tuberculous
process, although calcareous particles are found in the pus of
actinomycosis. Under their respective heads these degenerations will be
more particularly described.

Certain names have been given to collections of pus in different
localities or under peculiar circumstances. A collection of pus in
the anterior chamber of the eye is known as _hypopyon_; when in any
preëxisting cavity, it is known as _empyema_ of that cavity, the
_distinction between empyema and abscess_ being that “abscess” means a
circumscribed collection where previously there was no cavity, while
“empyema” implies a normal cavity, without respect to size or location,
filled with this abnormal fluid. The term _empyema_, when not used
in connection with some particular cavity, is understood to refer
to a collection of pus in the pleural cavity. Other names also are
used which are particulate and distinctive; in these the prefix _pyo_
is used while the suffix indicates the part involved; thus we have
_pyothorax_, _pyopericardium_, _pyarthrosis_, etc.


SINUS AND FISTULA.

These are terms applied to more or less _tubular channels abnormally
connecting various parts of the body, or connecting some cavity
with the surface of the body in a way anatomically quite abnormal_.
Or they may be regarded as _tubular ulcers_, or ulcerated tunnels,
connecting as above. A more exact distinction between the two terms
would imply that a _sinus_ connects the surface with some deeper
portion where a cavity is not normally present--_i. e._, with a focus
of disease--whereas a _fistula_ properly refers to a tubular passage
connecting natural or preëxisting cavities in an abnormal manner. Thus
we speak of buccal, rectal, vesicovaginal fistulas, etc., whereas
a passage leading down to an old abscess or to a focus of disease
in bone, for instance, is properly referred to as a sinus. It is
possible for the margins of a fistula to become more or less cicatrized
and cease to be ulcerous, whereas the entire track of a sinus is
practically a continuous ulcer, only tubular in arrangement.


=Causes.= A. =Congenital.=--There are numerous points about the
body where, as the result of arrest of development or failure to
grow, fistulous passages which are comprised within the normal fetal
arrangements, but which should close later, either before or at birth,
fail to do so. Thus we have congenital fistulas of the neck, persistent
urachus, persistent omphalomesenteric duct, etc. These are in no
sense primarily connected with diseased conditions, but may become so
secondarily.


B. =Pre-existing Abscess with Unhealed Channel of Escape=--_e. g._,
rectal, fecal, and other fistulas and sinuses which connect with
tuberculous foci in any part of the body.


C. =Previous Traumatic or other Destruction of Normal Tissues=--_e.
g._, vesicovaginal fistulas due to tissue death from pressure, buccal
fistulas from gangrene of the cheek, as in noma.


D. =Foreign Bodies=--bullets, ligatures, etc.--which prove irritating
or infectious enough to prevent absolute healing. More or less tortuous
sinuses will generally be found leading down to the irritating material.


E. =The Presence of Necrosed or Necrotic Material=--_e. g._, a
sequestrum in bone, which is usually evidenced by the presence of one
or more sinuses.


=Treatment.=--If the determining cause is still acting, the treatment
is to remove the cause. Consequently, when the sinus leads down to
diseased bone or other dead or dying tissue, the complete evacuation of
the cavity is necessary before the sinus may heal. If the cause is a
foreign body, its removal should be at once insisted upon.

An excellent suggestion is to stain all fistulous tracks with
methylene-blue; the blue trail after doing this may be followed, no
matter how irregular its course (Fergusson). If the color is mixed
with a little hydrogen dioxide, and this forced into a sinus mouth or
a fistulous opening, it will carry the dye to all parts of the cavity.
This may be used even in dealing with fecal fistulas or those extending
deeply into the interior of the body or among the viscera.

Fistulas of congenital origin and those which connect two normal
cavities of the human body are usually due to a cause which has ceased
to act. Consequently we should endeavor solely to atone for the result.
The direction and the course of a sinus may be learned by the use of
a probe curved to suit and manipulated by a gentle hand, force never
being required. Or sometimes, when the silver instrument fails to
pass, a flexible bougie or catheter may be introduced. The character
of the passage can be judged for the most part by the appearance of
the discharges. With sinuses of recent origin leading down to recent
suppurative foci it may be sufficient to enlarge the opening and to
wash the cavity thoroughly. If a particle of gauze, tube, or sponge has
been left therein, its removal is necessary to secure prompt healing.
In cases of long standing antiseptic and stimulating substances should
be injected or the interior should be cauterized with strong solutions
of zinc chloride or silver nitrate, or with these melted upon the end
of a probe. The _chronic_ sinus, as well as the chronic rectal fistula,
is usually an expression of _local tuberculous disease_. Accordingly
these passages may be found lined with the same dense, fungating
membrane which lines a cold abscess cavity--the membrane, protective in
its purpose, to which I have given the name _pyophylactic_. Whenever
such tissue and such membrane are met with they should both be
extirpated thoroughly, since in this way only can absolute eradication
of the tuberculous infection be relied upon. After such complete
excision--which means usually laying open the entire sinus--the parts
may be brought together with sutures (this, at least, is usually
possible about the rectum) to secure primary union; otherwise, the
whole sinus, as well as the cavity to which it has led, must heal by
the granulating process, both being kept packed with gauze or some
other desirable foreign body acting as an irritant, thereby provoking
more rapid formation of granulation tissue. When it is necessary
thus to pack a cavity, or when it is desired to keep its upper exit
open lest it heal before the lower part, ordinary white beeswax, as
suggested by Gunn, makes a serviceable material. This can be molded in
hot water to fit the cavity; can be tunnelled or bored for drainage;
can be diminished in size as the cavity heals, and is absolutely
non-absorbent.

Finally there are numerous plastic methods which have been resorted
to in various parts of the body, most of which are made to comprise,
first, the absolute eradication of the diseased tract, and, later, the
closure of the wound thus made by transplantation or sliding of flaps,
or any other plastic expedient which may be considered best. These, as
well as the special treatment made necessary for particular forms of
sinus and fistula, will be dealt with under their proper headings.




CHAPTER IV.

ULCER AND ULCERATION.


The term _ulcer_ pertains to surfaces, and should be defined as a
_surface which is or ought to be granulating_, _i. e._, _healing_.

While an ulcer may be the result of ulceration, it is not necessarily
so, the term _ulceration_ being one of very loose significance and
applied to many different processes. The idea underlying ulceration is
_infection_, and, when limited to its proper significance, the term
should never be used for a process in which infection and consequent
breaking down of tissue do not virtually comprise the whole process.
Therefore, it is to be distinguished from certain disappearances of
tissue alluded to under the head of Atrophy or Interstitial Absorption.
It is not correct to say that the sternum ulcerates away, making room
for a growing aortic aneurysm, the question of infection here not
being raised. These distinctions should be accurately maintained and
constantly borne in mind.


ULCERS.

The causes of ulcers may be--

  A. _Traumatic_;

  B. _Local_; or,

  C. _Constitutional_.


A. =Traumatic.=--This includes all surfaces which are granulating
and healing more or less rapidly, or are displaying a disposition
toward healing, and which may have been produced by _wounds_, _burns_,
_frostbites_, etc. These include also ulcers due to _pressure_, as from
splints, bandages, orthopedic apparatus, or from _external friction_.
Ulcers which form around _foreign bodies_ may also be included under
this head, their essential cause being traumatic. It should include
also destruction of the surface by various _chemical agencies_, such
as strong caustics, and the consequences of intense _heat_ or _cold_,
including burns and frostbites.


B. =Local.=--1. Among local causes may be mentioned _local infections_,
with tissue death in consequence, such as occur in tuberculous,
cancerous, leprous, syphilitic, and other specific manifestations where
surfaces are involved.

2. _Tumors_, either benign or malignant, whose blood supply is cut off
and whose surface is thereby predisposed to infection.

3. _Perverted surface nutrition_, for example, in connection with
varicose veins of the extremities, where, aside from any perverted
trophoneurotic influence, there is stagnation of blood, saturation of
tissues with serum, and final leakage of the same, even to the surface.
Varicose veins of the leg which lie near or underlie ulcerating
surfaces become thrombosed and obliterated, so that such ulcers rarely
bleed. On the other hand, a passive hyperemia here leads to edema,
perversion of nutrition, failure to repair trifling surface injury, and
a surface is left which of itself rarely, if ever, heals.

4. So-called _pressure sores_ or _bed-sores_, which in some cases may
be regarded as having a traumatic origin, but which, nevertheless,
would not occur from purely traumatic influences without predisposing
tissue changes. The bed-sore is probably the best illustration of this.
Simple ulcer is known as bed-sore, while a sloughing ulcer of this kind
is frequently alluded to as _decubitus_. Such ulcers are usually found
over those regions of the body made most prominent by bony projections,
upon which undue pressure is made when debilitated patients have lain
for a long time in bed.

5. Ulcer is the frequent result of numerous _skin diseases_, into whose
etiology as yet bacteria have not been introduced--_e. g._, pemphigus,
eczema, etc.

6. Ulcer is the occasional result of _embolic_ or other _disturbance_
of the principal artery of the part, by which nutrition is cut off and
tissue death results.

7. _Bites of insects_ or other _parasites_ or of noxious animals
frequently lead to ulceration.

8. Certain more specific forms of ulcer are described by some writers,
apparently with more or less reason, among them being _chancroid_,
_perforating ulcer of the foot_, etc. (Chancroid is described in
Chapter X.) Trophic ulcers of the fingers or hand are also seen,
particularly after injury to or division of nerve trunks in the arm
or forearm. Perforating ulcer of the foot is a circumscribed circular
ulcer with thickened edges, often nearly concealed by overhanging skin.
It may be found in any part of the sole of the foot, but is most common
near the first joint of the great toe. The borders of the ulcer are
usually anesthetic. It is frequently seen in diabetics. By some it is
associated with trophic nerve disturbance; by others it is regarded as
having a specific etiology of its own. The probability, however, is
that it is simply a subvariety of pressure sore.

9. Since the introduction of the _Röntgen_ or _x-rays_ into surgical
therapeutics a new local cause of painful and intractable ulcers should
be enumerated. A too prolonged or injudicious exposure of a part to
this peculiar influence induces first a dermatitis, which is not always
immediate, but may be tardy in appearance, and which may be followed
by desquamation or exfoliation that may proceed to absolute surface
destruction and sloughing. These lesions are popularly spoken of as
_x-ray burns_. The superficial ulcers thus produced may be extensive
and are nearly always excessively sensitive and painful. The very
structure of the surface vessels is affected and they undergo a species
of sclerosis. A strong preparation of _radium_ has been known to
produce a similar effect.


C. =Constitutional.=--1. Ulcers are frequently met with in certain
constitutional conditions which are characterized by tendency to
local manifestation at points of least resistance. Among these may be
mentioned _scurvy_.

2. There are ulcers of apparently distinctive _trophoneurotic_ origin,
of which that mentioned above as B, 8--perforating ulcer of the
foot--may possibly be one. These accompany certain nervous disorders of
central origin, prominent among which are locomotor ataxia and tabetic
disease of all forms.

3. Ulcers are produced sometimes as the result of _specific_ or
selective _action of certain drugs_, among them mercury and phosphorus
being the most prominent. These manifestations are usually perceived
in the mouth, and may be regarded as infections at points of least
resistance. Nevertheless, they are commonly associated with the
tendency of these drugs.

4. There are many constitutional conditions in which vitality is so
lowered that a special liability to ulcer--_i. e._, infection and
production of ulcer at many points--is noted. It is well, however, to
mention that the common diseases in which this tendency is most often
noted are typhoid, diphtheria, diabetes, and syphilis.

With this summary of the common causes of ulcer it is again stated
that ulcers may be due to direct consequence of traumatic loss of
substance or to the process of ulceration--_i. e._, as a consequence of
previous infection, or as permitted by trophoneurotic disturbance and
ischemia. Ulceration is a process of _molecular death_, in which cells
die successively and more slowly, as _distinguished from gangrene_, in
which there is simultaneous death of large aggregations of cells, by
which a slough or its equivalent is produced.

Ulcers are referred to as _healthy_ when the process of granulation
is proceeding with average rapidity; _indolent_, when the reverse
prevails; _sloughing_, when there is actual visible tissue death
in connection with the ulcerative process; _phagedenic_, when the
gangrenous tendency is well marked and the process exceedingly rapid;
_irritable_ or _erethistic_, when the surface is exquisitely sensitive;
_hemorrhagic_, when bleeding easily; _fungous_ or _fungoid_, when the
granulations have risen above the surface and are increasing at too
rapid a rate. There is a peculiar form of ulcer, seen mostly upon the
face, to which the name _rodent ulcer_ (also lupus exedens) has been
given. This is now known to be a slowly growing form of epithelioma,
and is described in Chapter XXV.

The best examples of the indolent ulcer are seen in connection with
varicose veins of the extremities; of the phagedenic ulcer, in certain
cases of chancroid; of the irritable ulcer, in ulceration of the
cornea, when the pain and photophobia are intense; or in fissured ulcer
of the anus, where the pain and sphincter spasm are sometimes agonizing.

Ulcers are described according to their _shape_ as _regular_ or
_irregular_; as _fissured_, when they extend more or less deeply and
abruptly into the surface involved; as _fistulous_ when they have a
tubular arrangement; as _rodent_, when they spare nothing in their
course.

The _borders_ of ulcers are described as _healthy_, _indurated_,
_tumid_, _edematous_, _undermined_, _livid_, _inflamed_, etc., these
adjectives explaining themselves.

The _surfaces_ of ulcers are described as _healthy_ when they have
normal color and appearance, _inflamed_, _excavated_, _covered with
sloughs_, _callous_, etc. The _callous_ ulcer is one which exhibits
little change from month to month; its surface is dirty, and its
secretion thin and mucopurulent. It is usually sunk considerably below
the surrounding level, while its border is firm and nodular. The best
examples of this form are those accompanying varicose veins.

In size or area ulcers may vary from the slightest local destruction of
tissue to an area covering an entire limb or a large part of the trunk.
In depth they vary within lesser limits; while an external ulcer may
connect with some deep lesion by means of a tubular passage or _sinus_.
It thus appears that the term ulcer may be applied to the result of
a natural effort to repair loss of substance without introducing
the element of disease, or that it may be the consequence of local
infection with local tissue disaster.

The character of the material discharged from an ulcer will vary
according to the category in which it belongs. The healthy, healing, or
granulating surface, often spoken of as ulcer, discharges a material
in gross appearance much resembling pus from an acute abscess; in
consistency, color, and other appearances it is the same. Nevertheless,
its origin is essentially distinct. This material represents simply the
waste of reparative material, sent up to the surface for the purpose
of hurrying the process. Its fluid, like that of pus, comes from the
serum of the blood; its corpuscular elements, like those of pus, are
leukocytes or wandering tissue cells, which have been furnished in
great numbers--in fact, in excess. As it comes to the surface--or
as, rather, it is rejected from the surface, being superfluous in
amount--it is likely to become contaminated with bacteria by contact
infection, and consequently may be seen under the microscope to
contain various microörganisms. This contamination, however, has been
final, accidental, and irrelevant. This material is _not pus_; has no
infectious properties, except those which may accidentally be conveyed
to it; represents no warfare of cells, only excess of supply or
overdemand; and should be spoken of as _pyoid_ or _puruloid_ material,
and never confused with pus. In amount it will vary according to the
activity of the reparative endeavor, and somewhat according to the
amount of irritation of the surface by dressings which may be applied.
If a granulating surface is absolutely protected from possibility of
contact infection, it will never contain microörganisms; while this
_pyoid_, if allowed to remain too long, especially when infection is
permitted, may decompose and become irritating, and is a material to be
gently dislodged by a spray or an irrigating stream with each dressing,
which dressing should be made once in twenty-four to sixty hours.


PROCESSES OF REPAIR.

An ulcer having been defined as a surface which is or ought to be
granulating, it becomes necessary to define the granulation process
and to show how healing is thereby achieved. _Granulation tissue_
is a name applied to a new and temporary tissue of embryonic type,
which acts as a scaffolding or temporary structure, permitting the
construction of more permanent tissue. It is produced entirely by the
activity of cells, which are the mononuclear and polynuclear leukocytes
and the wandering cells already mentioned. They are frequently known
as _embryonal cells_ when performing this function; sometimes as
_formative cells_. They have a distinct nucleus, which stains readily,
and, having this resemblance to epithelial cells, they are often
referred to as _epithelioid cells_--sometimes as _fibroblasts_, because
they may later assume the dignity of connective-tissue cells. They
assume a multitude of shapes. Between these cells as they are drawn
toward the point at which they are most needed, perhaps by chemotactic
activity, there is an _intercellular substance_ which later becomes
fibrillated. As these fibers develop the remaining cells become
entangled between them, and in this way a new connective tissue is
formed of cells of originally mesoblastic origin. Of such tissue the
solid part of granulation tissue is built. This tissue is essentially
different from the epithelium which it is expected will subsequently
cover it. If a normal granulating surface is scanned with a magnifying
glass of small magnifying power, it will be seen to consist of
numerous minute projections, each of which is known as a granulation,
consisting of the tissue above described, formed as a minute eminence
around a budding capillary bloodvessel, from which a projection has
arisen upon the exposed surface. This capillary bud is the result of
karyokinetic activity on the part of the endothelium--namely, the
hypoblastic cells of which it is essentially composed. In each of these
cells, under certain circumstances, the karyokinetic threads already
mentioned develop and become loosely coiled, while the chromatin in the
nucleus increases in amount and the nucleolus disappears. The chromatin
threads become thicker, arrange themselves equatorially around the
poles of the nucleus, and gradually turn so as to point toward it,
while a new membrane forms around each separate coil, and two nuclei
are thus made out of one. While this is taking place within the
nucleus the cell protoplasm undergoes active rotary motion, is finally
segmented, and by the time the nucleus is divided is nearly ready
for complete division of the cell. While nuclear division is usually
bipolar, it may be multipolar; if a rearrangement of the protoplasm
is delayed, the result becomes a multinuclear cell, known as a _giant
cell_.

The consequence of this endothelial activity is new cell formation and
the construction of a projection from the capillary which soon attains
the dignity of its parent vessel, and, as connective-tissue cells form
around it, soon becomes a granulation by itself, each granulation being
marked by a capillary loop of its own. Healing by granulation or the
granulation process, no matter how set up or caused, is essentially
the formation of hundreds or thousands of these tiny structures, a
new one being formed on top of those which precede it, while those
first formed and deeper down undergo condensation and metamorphosis
of tissues, by which they are converted into something higher in
the tissue scale. Under ideal conditions true granulation building
proceeds _pari passu_ with epithelial reproduction around the margin
of the granulating surface, so that by the time granulation tissue
has completely filled the defect, no matter how caused, epithelial
covering has been completely constructed and the healing process thus
completed. These two processes, however, do not necessarily keep pace
with each other. Should surface repair take place relatively early,
we may have a depressed scar; while, on the other hand, should it not
proceed rapidly enough, or, to state it in another way, should the
granulating process be too rapid, we have such excess of granulations
as shall rise considerably above the surrounding level, and may, under
certain circumstances, become so exuberant that nutritive material
cannot be formed rapidly enough, and those granulations farthest away
from the centre of supply may die. Such exuberant granulation is often
spoken of as _fungoid_, and constitutes that great bugbear in the eyes
of the laity which is termed by them _proud flesh_. It has no further
significance than that the supply has exceeded the demand and that the
granulating process has been overdone. Such luxuriant granulations may
be cut away with scissors or knife, may be burned away with caustic
agents or the actual cautery, or may be disposed of in any other manner
without harm and only with benefit; in fact, it is often necessary to
suppress this exuberant tendency by caustics and pressure, in order
that the desired epithelial covering may be properly formed.

Epithelium, being an epiblastic structure and capable of no other
origin save from its kind, can only be supplied from those regions
where it has preëxisted. Consequently, ulcers involving the external
surface of the body demand a lively epithelial reproduction in order
that they may have a normal covering. Epithelial activity sometimes
becomes retarded, and is much slower toward the termination of the
healing process than at the beginning. The epithelial covering of a
healing ulcer is always marked by a delicate whitish or pinkish film,
which proceeds from the periphery as well as from any little island
of original epithelial structure left. It is well known that after a
certain amount of this repair the process sometimes comes to a complete
halt, and the various expedients for stimulating and promoting it, as
sponge grafting and the different methods of skin grafting, have been
devised solely to atone for such sluggishness or inability.

Ulcers of small size, which are more or less exposed to the air in
healthy individuals, while also exposed to possibility of infection,
nevertheless seem to escape it, owing to the defensive power of the
blood serum and the active cells. Such discharge as naturally comes
from them, when not excessive, undergoes evaporation until a point
is reached where a _dry crust_ or _scab_ is formed. Under this scab
granulation proceeds to a point where the pressure of the scab itself,
presumably on the level of the surrounding parts, checks its activity,
while at the same time epithelial reproduction goes on until it has
been completed. Then the scab, being no longer of use, drops off or is
detached by slight friction.

_Such is granulation tissue_: at first a mere trelliswork of
temporary and delicate cell structure, traced in a certain amount of
intercellular, homogeneous substance, into which the budding vessels
project, the whole mounting, nearer and nearer to the surface, day by
day, with variable rapidity, diminishing in this regard as the days go
by, so that frequently the granulation process comes to an apparent
halt before enough new tissue has been formed. While the superficial
granulations preserve the characteristics above noted, those deeper
down undergo firmer and more complete organization, and the delicate
embryonic structures show the same tendency which they do in the
growing embryo, by virtue of what Virchow has called _metaplasia_,
to become converted into something higher and more dignified in the
tissue scale. These cells do not specialize themselves to the extent
of permitting complete repair of organs of special sense. Thus, while
a wound in the cornea or retina may be completely healed, it heals
by cicatricial tissue, and not by repair of the special structures
involved. On the other hand, tissues of more common connective
type--fibrous, bone, cartilage, etc.--are capable of regeneration;
and it seems to be a part of the privilege of these new granulations
to merge themselves into that kind of tissue necessary for filling
the gap. Nevertheless the most _common result of granulation is its
metablastic conversion_ into fibrous tissue, which has the special
characteristic of contractility without elasticity. As a result the
_scars contract_, in consequence of which disfiguring results are
sometimes the almost inevitable consequence of healing of extensive
losses of substance. In certain instances it is possible by constant
effort to overcome the unpleasant effect of this cicatricial
contraction. For example, after extensive burn of the anterior part of
the arm, the forearm will be gradually and permanently flexed upon the
arm by virtue of contraction of the scar in front of the elbow unless
some forcible means is practised for maintaining extension of the limb
for at least a part of the time. So with many other injuries and the
various mechanical or other expedients required to prevent the untoward
result. Nowhere are the after-effects more disfiguring or serious than
about the face, where the eyelids are drawn out of shape, the contour
of the mouth altered, and where, sometimes, there are other extensive
manifestations (Figs. 10 and 11).

[Illustration: FIG. 10

Cicatricial deformity following burn. (Original.)]

[Illustration: FIG. 11

Cicatricial deformity following burn: side view of same case.]

[Illustration: FIG. 12

Epitheliomatous degeneration of chronic ulcer, necessitating
amputation. (Original.)]

As a result of healing of the granulating surface there is what is
known as a _cicatrix_ or _scar_. This is composed of fibrous tissue,
probably more or less distorted by virtue of its contractility, and
of epithelial covering furnished from the margin of the original
ulcer, constituting a thin, glistening membrane, applied closely to
the scar tissue beneath, without intervening fat or tissue which
permits of the play of the one upon the other. When this epithelial
surface is abraded it is repaired with difficulty, and a raw or
ulcerating scar is difficult to heal. Manifestation of perverted
epithelial outgrowth is frequently provoked at these points by the
action of continuous irritation. In consequence there is what is
generally recognized as the _transformation of a chronic ulcer_,
or the site of one, _into an epithelioma_, or possibly, by similar
irritation of the connective-tissue elements, into a sarcoma. This is
the so-called cancerous degeneration of previous ulcers, and is noted
occasionally. The lesion is one which often requires disfiguring,
or even mutilating operations in order to get rid of the malignant
disease (Fig. 12.) All the scars thus resulting are liable to undergo a
fibrous and degenerative change to which is given the name _cicatricial
keloid_. It is marked by increase in size and density, by reddening
which denotes increased vascularity, and extension into surrounding
previously healthy tissue. By these changes a given scar is made much
more prominent and disfiguring. It cannot be prevented by any ordinary
treatment, and is often the _bête noir_ of surgeons. (See also under
Fibroma, and chapter on Diseases of the Skin.)

The surface of a superficial scar while thus covered with epithelium
shows a complete lack of all the other skin elements. No hair grows
upon such a surface, because the original hair follicles are destroyed;
neither is it moistened by perspiration nor anointed by sebaceous
material, because the secretory glands have also disappeared. It is a
surface which often needs more or less protection, especially when in
exposed situations.


=Treatment.=--Here, as in all other instances, the first effort of the
surgeon should be to remove the cause. This may be done by _local_, or
may require _constitutional_ measures. If a definite local cause can be
established, its removal may be a slight or may entail a more or less
serious surgical operation. Aside from this disposal of the exciting
agent, treatment should be divided into the general and the local.
General treatment is scarcely called for when dealing with healthy
ulcers; but in all those instances where the constitutional condition
of the patient is below par, or where there is a general poisoning
or infection underlying the ulcer itself, prompt and energetic
constitutional treatment should be at once instituted. In scurvy, for
instance, the diet and hygienic surroundings of the patient should
be rectified immediately. In syphilis no lasting nor deep impression
can be made on local manifestations without general constitutional
treatment. In tuberculosis and the other surgical infections much will
be accomplished by internal medication, by proper hygiene, as well as
by local applications or operation. The importance of these general
measures is likely to be underestimated, and many fail to realize the
advantage of combining suitable internal and external therapeutic
measures.


=Local Treatment.=--First of all may be mentioned the insistence upon
repose which induces _physiological rest_. The ulcer may then show a
tendency to heal. This may necessitate wearing a splint or restraining
apparatus, or confinement in bed, depending upon the location of the
ulcer. Physiological rest will be enforced sometimes by stretching a
sphincter in order to temporarily paralyze it in cases of irritable
rectal ulcer, where the principal pain is produced by the reflex spasm
of its fibers. Again, the eye with irritable ulcer of the cornea is
sometimes kept so tightly closed by the same kind of spasm there that
it may be necessary to divide the lids, or the orbicularis muscle at
the angle of the lids, in order to make access to the part. This is
carrying out the principle of physiological rest, because it permits
proper exposure and treatment.

The healthy and healing ulcer needs no treatment except protection.
Epithelial covering will probably keep pace with filling of the
depression by granulations, and all that is necessary to do is to
prevent external irritation. Should there be excess of discharge, the
simplest absorbent dressing, with enough antiseptic material to prevent
putrefaction by contamination with the bacteria of the surrounding
air, should be employed. The ulcer which is becoming tardy in its
repair may be stimulated by silver nitrate, zinc chloride, or other
caustic applications, which act as a spur to the sluggish granulations,
destroying those with which it comes in contact, but stimulating those
below to do their duty more promptly.

The conventional applications to ulcers fall usually under two
categories--the _watery solutions_ and the _unguents_.

[Illustration: FIG. 13

Cicatricial deformity following specific ulcer. (Original.)]

Investigations in the laboratory have led to the employment of
peptonized preparations, among which are peptonized cod-liver oil and
some of the partially or predigested foods, such as _bovinine_, etc.
These appear to have the power of digesting sloughs and of causing a
speedy separation or disposal of everything necessary in the endeavor
to secure a healthy condition of the ulcerating surface and give most
satisfactory results. When sloughs are present it is an advantage to
dust over them papoid, caroid, etc., which have the power of catalytic
disposition of decomposing material without reference to the action of
bacteria. Under their use there seems to be a solution and disposition
of these dead products. With a foul ulcer--one from which the discharge
is more or less offensive, due usually to decomposition of sloughing
masses, not yet separated--the method of _continuous immersion in hot
water_, when it can be performed, is always valuable. But nothing
seems to equal _brewers’ yeast_ for this purpose. It may be applied on
absorbent cotton (which should be soaked in it) and covered with oiled
silk. Its curative property may be ascribed to the nuclein which it
contains in a nascent state. It will, when fresh, clean off a sloughing
surface better than anything I ever used.

Many ulcers are surrounded with such firm, indurated borders that it
seems impossible that any active regenerative process can arise from
such source. Hence, incisions have been practised for centuries. These
have been made radially from the centre or have been made parallel to
the margin of the ulcer, or sometimes the firm, dense tissues have
been minced or chopped by a series of cross-cut stabs or incisions;
as the result of which renewed activity has arisen, and an impetus
given to the healing process. These methods, however, have yielded
to that alluded to above. The ulcer in which granulation has come to
a standstill is often treated with the _sharp spoon_ or _curette_.
The result of this has been to provoke again a speedy renewal of
granulation efforts, and treatment by curetting is standard and
often useful. Actual cauterization of the ulcer with a view to such
complete destruction of its covering and border as shall lead to their
separation by the sloughing process is occasionally practised. This
is perhaps best performed with the actual cautery. It lacks, however,
the valuable features of the operative method, to be described below.
Modern methods have made it plain that it is often an absolute waste
of valuable time to resort to the older expedients of stimulation,
incising the edges, etc., and that one can accomplish by an operation
in perhaps three weeks what ten times that length of time would fail
to do by older methods. The _most effective method_, therefore, in
dealing _with old and chronic ulcers_ is to anesthetize the patient, to
_excise the entire affected area_--_i. e._, the surface which ought to
be granulating and the firm border and tissue in its neighborhood--and
then to cover the surface either with _skin grafts_, pared off with a
razor according to the Thiersch method, or with a strip of skin whose
full thickness is raised, which is taken from surrounding parts by
some autoplastic or heteroplastic method. This line of treatment is so
far preferable to all others that, except in case of refusal of the
patient to submit to it, it is the one which must hereafter commend
itself. It may afford opportunity for extensive plastic operations or
for the exercise of the best discretion and knowledge of experienced
men; yet cases are rare in which it cannot be successfully performed.
These methods of skin grafting have so far supplanted the older method
of sponge grafting that the latter is now seldom practised. It may
possibly have a sphere of usefulness in certain ulcerated cavities, but
under all other circumstances it must take a position far below the
plastic methods in practical value.

Finally, ulcers of specific type--syphilitic, tuberculous, leprous,
glanderous, etc.--need methods in which the first effort should be not
so much to arrange for healing as to dispose of infectious material.
The knife, the scissors, the sharp spoon come first into use here,
the surgeon bearing in mind that almost all this material is more or
less infectious, and that inoculation of his own hands is possible as
the result of carelessness. After taking away with instruments all
the granulation tissue, with its surroundings, which seems to expose
to danger, it is well to cauterize the part with the actual cautery,
nitric acid, bromine, or zinc chloride.

The markedly _hemorrhagic ulcer_, whose surface bleeds on the
slightest contact or disturbance, is often a cancerous ulcer, though
not necessarily so. This ready bleeding is usually the effect of
the fragility of the walls of the new-formed bloodvessels. In many
instances it is sufficient to scrape until harder or more resisting
tissue is encountered. Hemorrhage may be profuse for the moment, but it
is easily controlled. Caustics may then be applied or not, according to
the judgment of the surgeon.

Another method is to treat such a surface with the actual cautery.
Another is to operate, even in the presence of incurable disease, in
order to check a tendency to fatal hemorrhage before the disease has
expended itself. In a general way, in regard to small, ulcerating,
cancerous surfaces, it may be said that if they bleed excessively or
are unduly irritable, it is preferable to attack them by operative
measures in spite of the impossibility of effecting a cure.

There are other methods of treating ulcers, but they have mainly been
abandoned for those mentioned.




CHAPTER V.

GANGRENE.


Gangrene is known also as _necrosis_, although this term is usually
limited to gangrene of bone. It is known also as _mortification_, and
to the older writers, especially when soft parts die and separate in
sloughs, as _sphacelus_. _Gangrene means death of tissue in visible and
more or less circumscribed masses._ It is distinguished from ulceration
not on account of molecular disintegration, particle by particle,
but because of death _in toto and synchronously_ of a large, perhaps
innumerable, number of cells. Gangrene is described as due to causes
which may be:


A. =Traumatic=, including the so-called thermal causes as essentially
mechanical injuries. Under this head are included cases where _injury_
is the primary cause, whether this injury is the crushing of a limb,
the separation or occlusion of its main bloodvessels, the division of
its main nerves, or the crushing or pulpefying of its entire structure
by machinery or accident; also those so-called _thermal_ cases which
are due to intense heat or intense cold. To these might be added the
_chemical_ causes, comprising injuries by powerful caustics, alkalies,
or acids, which are known to cause speedy death of every living tissue
with which they come in contact.

Gangrene from _frostbite_ is often of the moist type. There is scarcely
a limit to its extent, either in area or depth. It is due primarily to
thrombosis, which is followed by a purplish color of the skin, by loss
of local warmth, and numbness. Naturally it involves the ears, nose,
fingers, and toes. But after alcoholism and exposure one or more entire
limbs may be involved. With moist gangrene there is danger of septic
infection (_q. v._). After formation of a line of demarcation the line
of amputation may be made to follow it closely, but the best results
are obtained by higher division, at points of election, where tissues
are less sensitive and less infiltrated.


B. =Local Causes.=--These are largely connected with _ischemia_.
_Gangrene from edema_--itself the result of passive hyperemia and
exudation--is not infrequent, the most common expression of this
condition being seen perhaps in the external genitals of the male.
_Embolism_ due to valvular heart disease, _thrombosis_ due usually to
a preceding phlebitis, but possibly to marasmic origin, especially
met with after confinement, with disturbance in the uterine sinuses,
shutting off the circulation by endarteritis, which thus assumes the
form _obliterans_, are some of the local causes which concern the
bloodvessels alone. In fact, the majority of cases of spontaneous
gangrene are probably due to changes in the vessels, endarteritis
being the cause of a condition known as atheroma of vessels, in which
fungoid outgrowths, or, rather, ingrowths into the vessel lumen, are
common. Any one of these, if detached, may serve as an embolus. The
degenerative excavations in the thickened walls of the bloodvessels,
which discharge more or less cholesterin and other debris, and which
have been known as _atheromatous abscesses_ (misnomer), are frequently
the precursors of the disease under consideration. As the result of
these changes alone, without reference to formation of emboli, vessels
may become completely occluded, especially when slightly injured.[2]

  [2] Intermittent claudication, when recognized, may be regarded as a
  precursor of that arteriosclerosis which may proceed to gangrene. The
  term implies temporary anemia of one or more of the extremities, with
  numbness, burning, or prickling sensations in the skin, occasional
  cramps in the muscles, with loss of power, tenderness of the nerve
  trunks, weakening or loss of pulse in the affected part. When these
  symptoms occur in the feet they are not infrequently followed by
  terminal gangrene or other evidences of angioneurotic necrosis,
  including even those forms known as erythromelalgia and Raynaud’s
  disease. Its treatment, of course, is relaxation of vasomotor
  spasm, best accomplished by the use of the nitrites, among which
  nitroglycerin is perhaps most valuable.

_Extravasation_ of blood is another cause connected with the
bloodvessels, this coming usually from traumatic rupture, possibly from
idiopathic causes. At any rate, the tension in the part may threaten
its life because of the pressure which overcomes the circulation of
blood. _Ligation_ of the main trunk of an artery is sometimes followed
by gangrene, no matter how carefully done, collateral circulation
being insufficient to sustain the nourishment of the part. In certain
fractures, simple as well as compound, the blood supply of a part is
rudely broken off by injury to a bloodvessel in such a way as to cause
local or general death, either of a bone or of the entire limb. Flaps
made for plastic purposes, arranged without sufficient regard to their
proper blood supply, or so dressed after operation as to sustain undue
pressure, are often so shut off from the heart as to die for want
of blood. Finally, gangrene may be the result of _pressure_ either
from splints, bandages, etc., or from _tumors_ increasing in size, or
possibly, as in certain pressure sores, etc., from the mere weight of
the body. Here, too, _chemical agents_ must be mentioned, referring
now to the peculiar action of certain _foods or drugs_, particularly
ergot. Thus antiseptic solutions, particularly carbolic acid, may be
made strong enough to destroy the vitality of certain tissues. Carbolic
gangrene (Warren) is a possibility not to be forgotten.

Extravasation of urine, unless promptly recognized and appropriately
treated, or especially as occurring when the urine is peculiarly toxic
(ammoniacal) and the patient’s vitality reduced, as in confirmed
alcoholics, is almost sure to produce gangrene which may easily
terminate fatally.

[Illustration: FIG. 14

Raynaud’s disease: digiti mortui. (Original.)]

[Illustration: FIG. 15

Raynaud’s disease: perforating ulcer of foot. (Original.)]


C. =Constitutional Causes.=--Among these are to be mentioned
particularly that symptom-complex ordinarily known as _diabetes_ or
_glycosuria_. This means a depraved condition of the system in which
gangrene is threatened or permitted under circumstances which otherwise
would have little or no disastrous effect. Thus _diabetic gangrene_
has come to be one of the recognized manifestations of the general
disease. That the trophic nerves have a more or less pronounced effect
in determining gangrene in certain cases seems to be now quite well
established. It is well known how quickly _bed-sores_ form after
injuries to the spine, while in certain nervous affections a minimum of
friction of the skin may determine its death, particularly about the
labia or scrotum. It is said that the insane, when made to sleep by
chloral, may develop decubitus from pressure in a single night. There
is also a well-known form of _symmetrical gangrene_, known sometimes
as _Raynaud’s disease_, which is characterized by symmetry of lesions
and absence of definite pathological changes (Figs. 14 and 15). The
so-called _digiti mortui_, or _dead fingers_, and _erythromelalgia_ are
examples of this character. A condition almost leading up to gangrene,
but perhaps not absolutely terminating in such a way, has been known
as _local asphyxia_, which seems to be a condition of arterial spasm
with venous congestion and slight edema. While the aged will often
recover from a legitimate surgical operation without disturbance, it
is, nevertheless, true that senile gangrene commencing in the toes has
for its cause some very trifling injury or lesion, such, _e. g._, as
paring of a corn, or the like. This shows a weakened local and general
resistance, as well as the wisdom of redoubling aseptic precautions in
operations upon such patients.

As constitutional causes also should be included the deleterious
effects of certain drugs, particularly ergot, mercury, and phosphorus.


D. =Infectious Causes.=--In the instances already mentioned reference
to the infectious microörganisms has been avoided. There remain
to be considered types of gangrene due to the activity of certain
microörganisms--_hospital gangrene_, _phlegmonous erysipelas_,
_malignant edema_, _gangrenous emphysema_, _noma_, _ainhum_, etc.

Gangrene as the result of infectious processes is seen in phlegmonous
erysipelas, where death of tissue seems to be due to the combined
influence of the invading organisms and of mechanical agencies--_i.
e._, tension produced by stasis and exudation, with such stretching
of tissues or overcrowding with inflammatory products as to virtually
strangle them, in consequence of all of which they die. Gangrene of an
entire hand may thus result, or, more commonly, the gangrene is limited
in extent to the more superficial parts, so that sloughs separate. A
specific form of gangrenous inflammation known as _malignant edema_,
due to a peculiar anaërobic bacillus, will be treated of separately
under a distinct heading. Quite like it in several respects is the
gangrenous emphysema of certain writers, known also as the fulminating
form, or, as the French call it, the “_gangrène foudroyante_.” More
or less emphysematous condition may accompany malignant edema; yet
that we do have gaseous forms of gangrene without the specific
bacillus of malignant edema is established. At least sixteen cases of
so-called gaseous gangrene due to infection by the _bacillus aërogenes
capsulatus_ are on record, of which twelve were fatal. Most of them
followed surgical injuries--_e. g._, compound fracture.

[Illustration: FIG. 16

Noma. (Original.)]

_Hospital gangrene_, so called, has been in years past the terror
of military surgeons and camp hospitals. As a type it has almost
completely disappeared from observation, and, in its old manifestations
at least, is now practically never seen.

_Noma_, known also as _gangrenous stomatitis_, _cancrum oris_, and
_gangræna oris_, is a term applied to a form of tissue necrosis
affecting the cheeks or parts about the face of young children,
occurring frequently as a complication of the exanthemata. A similar
condition occasionally involves the external genitals. From the fact
that it seldom passes across the middle line, it has been regarded
by some as of neurotic origin. Naturally bacteria are always found
in the decomposing tissues; but whether there as cause or as result
is not yet established. The probability is, however, that we have
to deal with a specific form of infection. The loss of substance is
usually so great as to determine complete perforation of the cheek, so
that the jaw bones may be laid bare. The gums and alveolar processes
also frequently share in the process, and the teeth occasionally drop
out. Death of tissue is rapid, and septic infection may accompany
it to such an extent as to cause the death of the patient in a few
days. While most vigorous measures are necessary for combating it,
the patients are often so reduced as to preclude the possibility of
doing much, and death is the termination of noma. Free incision, even
complete excision, is called for, perhaps with combined resort to
the actual cautery or such remedies as bromine (strong or diluted).
Antistreptococcic serum has also been used with success. Obviously it
must be used early if success is expected. Should patients recover,
there is extensive deformity as the result of cicatricial contraction.

Along the coast of Africa and in the West Indies there occurs among the
negroes a peculiar gangrenous affection of the toes known as _ainhum_.
This may assume either the moist or the dry type of gangrene, but the
result is gradual separation of the part, usually by the dry process,
as if it had been strangulated by a ligature. The disease is slow and
may extend over ten years. The cause is unknown.

Finally, gangrene is the termination of the infectious process in
several other zymotic diseases, among the best illustrations being that
afforded by _diphtheria_. The formation of diphtheritic ulcers in the
mouth and the vulva, about the eyes and elsewhere, as the result of
separation of sloughs, is too frequent to pass unnoticed, yet at the
same time does not essentially differ from the separation of sloughs
due to any other specific cause. All these acute zymotic diseases,
therefore, need to be regarded as among the possible causes of gangrene
by infection of tissues.

The _symmetrical gangrene_, often paroxysmal, affecting the fingers
and toes, described by Raynaud and often called by his name, is due
to vasomotor spasm, and is accompanied by neuralgia and sensory
disturbances, with coldness of the part and discoloration suggestive of
impending gangrene. (See above.)

Billroth and others have also described a _spontaneous_ or
_angioneurotic gangrene_ of the extremities, occurring during youth,
in abrupt distinction to senile gangrene, whose course is tedious
and painful, which will usually necessitate amputation. The cause of
this condition has been found to be a well-marked arteriosclerosis
and thrombosis, both in the arteries and veins. This form of gangrene
occurs most often in the frigid zone--_e. g._, in Northern Russia.

There are also forms of _visceral gangrene_, traumatic and
non-traumatic, which often constitute fatal maladies. The latter are
mainly due to thrombotic or embolic lesions, for example, the gangrene
of the mesentery, already alluded to when discussing thrombosis (_q.
v._), clinically described under Surgical Diseases of the Mesentery.


=Gross Appearances.=--In a general way tissue death, known as
_gangrene_, assumes two opposite types--_the moist_ and _the dry_.
In _moist gangrene_, aside from those appearances which indicate
commencing putrefaction of tissues, and the loss of heat due to
stoppage of the blood supply, one of the most characteristic features
is the formation of a so-called _line of demarcation_, _i. e._, a
line which separates the dead from the living tissues. While this is
usually plainly indicated by a red line which abruptly separates the
discolored, usually dark, dead portion from the bright red, congested
appearance of the living tissues, it is noted that this area of redness
shades out into a more and more natural appearance as we pass upward,
while below the line is seen a surface, usually covered with blisters,
from which exudes a foul-smelling, altered serum, while the gangrenous
portion assumes a dark, finally an almost black appearance, retaining
only the crude outlines of its original shape. Along with this the
objective evidences of putrefaction are unmistakable, appearances
and odor being characteristic. With all there are more or less
constitutional disturbances, and a recognizable, often a profound,
condition of septic infection, due to the fact that along the line
of demarcation absorbents are still active and that the poisonous
products of putrefaction are being absorbed into the general system.
Consequently _collapse_, _profuse perspiration_, _septic diarrhea_,
etc., are noted. In gangrene from frostbite the process is slower than
in the traumatic forms. In _gangrene from extravasation of urine_ the
separation of sloughs is extensive, and sloughing of the scrotum with
exposure of the testicles is a frequent result. In _decubitus_, or
_bed-sore_, the process is still more slow, but always of the moist
type. After a variable length of time there is separation of slough and
a resulting large, often foul, ulcer.

_Dry_ or _senile gangrene_ presents a very distinct contrast to
the moist type. It occurs generally in patients over fifty, often
as the result of causes which are slow of action. As a result of
the shrinking and corrugation of the tissues, with the dryness of
the same by evaporation, there is a peculiar appearance known as
_mummification_, the foot, for instance--the feet are usually first
involved--resembling the foot of a person who has been embalmed, except
that it is discolored. It is possible sometimes to have a combination
of moist and senile gangrene, especially when there has been infection
by which putrefaction is permitted. When from the outset putrefactive
processes are prevented, the gangrene of this type is almost invariably
dry. In practically all of the cases of this character there will be
found evidences of vascular disease, usually in the femoral artery
and its branches. Gangrene of the foot alone is most commonly due to
endarteritis, while gangrene of the foot and leg together are usually
due to embolism or thrombosis.

While disease of the vessel walls is usually of the type either of
endarteritis or arterial sclerosis, peculiar to the closing years of
life, and commonly affecting the lower extremities, gangrene due to
embolism of arteries or thrombosis, or both, may occur in the young,
and in the upper extremities as well, in the latter case the emboli
being detached from the heart, while thrombosis may be caused by a
tight splint or bandage, or even the use of crutches. I have repeatedly
amputated the arm as well as the leg for gangrene of this type.


=Signs and Symptoms.=--The appearance and the odor of a part will
indicate impending or actual traumatic gangrene. The pallor, the
coldness, the dryness of senile gangrene are also characteristic.
In the latter form constitutional symptoms are not indicative nor
essentially of septic type. As soon, however, as a process of
spontaneous separation begins putrefaction is inevitable and sepsis
unavoidable. In moist gangrene there is seldom acute pain. This is
one of the predominating subjective features of the senile form.
Hemorrhages occur, sometimes terminating fatally, in the moist forms
when large vessels are eroded. This is particularly true of the
_phagedenic_ or _hospital_ form. A recognition of their possibility may
enable us to avoid sudden death from this source.


=Treatment.=--_Threatening gangrene_ should be attacked and the cause
removed. Threatening bed-sores may be avoided by equalizing surface
pressure, which can be done with the water-bed; by protecting the skin
or by stimulating and toughening it with alcoholic and astringent
lotions; by frequent changes of position; by attention to the heart,
which should be stimulated to a point that may make it capable of
forcing or distributing blood equally over the entire body. So,
too, with limbs which are enveloped in dressings or splints; it is
well to leave exposed the tips of the toes or fingers in order that
discoloration of the same may be recognized and the threatening
disasters averted. Local gangrene as the result of pressure by tumors,
aneurysms, etc., cannot always be averted.

For gangrene there is but one relief, the _removal of the dead and
dying tissue_. The method and location of the operation must be
determined by the general character of the cause. For a case of acute
traumatic gangrene amputation at the nearest point of election above
the injury will often suffice. In case of gangrene from frostbite the
tissues in the neighborhood of the line of demarcation are so affected
or their vitality so compromised that to separate the tissues along
the lines at which nature is endeavoring to remove them is not enough,
and to go an inch or so above this line is to operate in tissues which
bleed readily and heal badly. Consequently it is often advisable to
select a point at some distance above. It is especially in diabetic
and senile gangrene that surgeons have laid down the rule that if
_amputation_ is done at all it must be _high_. For gangrene of the toe,
as the result of disease of the vessels, it is best to amputate above
the ankle; whereas if any greater portion of the foot is threatened,
amputation should take place above the knee. The tibial arteries have
been found so brittle as to snap under a ligature, and the femorals
so disorganized as to require handling and ligating with the greatest
caution. These high amputations are therefore necessitated by the
condition of the vessel walls. While amputation for traumatic and
acute cases is, in the majority of instances, if not too long delayed,
successful in saving life, in the senile and particularly in the
diabetic forms it is, in the majority of cases, a disappointment.




PART II.

SURGICAL DISEASES.




CHAPTER VI.

AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS.


One of the greatest advances made in pathology has been the
establishment of the fact that a great many of the morbid conditions
from which the human race suffer are those due to causes arising
entirely from within their own systems and in consequence of
deficiencies of elimination or of perverted physiological processes
which, in large degree, are themselves the result of errors and
indiscretions in diet, in manner of life, in habits, etc. That these
general facts have been recognized for centuries is perhaps a credit
to the powers of observation of practitioners of past generations.
Exact knowledge, however, has come only with exact laboratory
methods of research and most painstaking study of the secretions and
excretions, both under normal and morbid conditions. The subject of
_auto-intoxication_ has been too commonly relegated to the domain of
internal medicine, and has been supposed to be one in which the surgeon
need take only passing interest.

The _alkaloids_ are by no means the only poisonous products which the
human body may produce and retain. That most important excrementitious
material of all--_i. e._, _carbon dioxide_--could not be retained
in the organism for more than a few moments without death as the
inevitable consequence. The various _soluble ferments_ elaborated
by certain glands may exert deleterious influence, both local and
general; and in the saliva are also found products which are not
ferments. The _biliary acids_ also, if they do not find free escape,
may produce fatal poisoning. So also _leucin_, _tyrosin_, and all the
excrementitious products which arise from insufficient liver activity,
are capable of producing forms of intoxication--such, for example, as
_eclampsia_, etc. The character of the solvent has much to do with
toxicity. Thus aqueous extract of putrid matter is more poisonous than
that of fecal matter, while alcoholic extract of fecal material is
more toxic than that of putrid. All the alkaloids produced within the
body are not poisonous. Some are found in the normal tissues, and they
are, perhaps, only one of the results of the disassimilation of animal
cells. Nor are all these poisons of bacterial origin, although many are
formed only in the presence of microbes.

From these constantly menacing sources of intoxication man escapes by
virtue of his intestinal, cutaneous, pulmonary, and renal emunctories.
For instance, the usefulness of the perspiration is shown by the odor
which it assumes under the influence of certain disorders. Among
hypochondriacs and the inactive fatty acids are eliminated by the skin.
Hence the odors of hospital wards, asylums, prisons, etc. So, too, in
the case of many who suffer from deep-seated, indolent ulcers, the odor
of the skin is suggestive of the presence of pus. During twenty-four
hours there is eliminated from the lungs 1100 grams of carbon dioxide,
water, etc., which sometimes contain ammonia and various volatile
fatty acids; all of which will explain fetor of breath when it is the
result of incomplete nutrition and destruction of food. Of the _organs
of elimination_, the most important is the _kidney_, which does not
reabsorb a part of its own products, as does the intestine. The kidneys
eliminate fluids and solids, not gases. The most important of the toxic
principles contained in the urine are:

1. _Urea_, which plays an important and useful role in the economy,
since it possesses the property of forcing the renal barrier and
removing along with itself the water in which it is dissolved and other
toxic matters. Urea is toxic, but only in the sense that any other
substance, even water, may be--_i. e._, it is toxic only in large
doses, less than sugar, and no more than the most inoffensive salts.
This is contrary to generally received views, but is established by the
researches of Bouchard.

2. A _narcotic_ substance, and

3. A _sialagogue_ substance, whose composition is unknown;

4, 5. Two substances having the property of causing _convulsions_, one
having the power of _contracting the pupils_. The composition of both
is unknown.

6. A substance which _produces heat_ by diminishing heat
production--possibly a coloring matter. That coloring matters are
absorbed by charcoal and that urine thus decolorized is rendered less
toxic are no proof that the coloring matters themselves are responsible
for this toxic action. There is no doubt that numerous alkaloidal
bodies possessing a high molecular weight are precipitated by means of
carbon or charcoal, and to these bodies may be attributed a portion of
that toxic action previously considered as due to coloring matters.

7. _Potassium salts_, which are really convulsing agencies, are the
most toxic perhaps of any of the poisons contained in the urine.
Chloride of potassium, for instance, is toxic at 18 Gm. for every kilo
of animal.

_Salivation_ and _myosis_, as well as diarrhea, are often noticed in
so-called _uremia_. In that form known as hepatic uremia, when the
liver no longer forms urea, the kidneys scarcely act. In other words,
if urea is no longer present in the body, the kidneys are deprived of
their principal stimulation to physiological activity. Consequently
urea, for so long a time the bugbear of physicians, is shown to be
most dangerous when absent. When urea is deficient, blood serum or
water in which the other toxic substances are dissolved should be
withdrawn. This is best done by _venesection_, whose value in so-called
uremia experience amply corroborates. When kidney activity ceases,
intoxication is likely to be produced by potassium salts. Ptomains,
amido bases, etc., are proved to be present in normal urine and are
known to produce toxic effect. These ptomains increase enormously in
pathological urines, and to this increase, rather than to that of
potassium and coloring matters (which remain fairly constant), may be
attributed the higher toxicity of pathological urine. In certain cases,
however, as in that of jaundice, the toxicity of the urine is partly
due to decomposition of tissue cells, whereby potassium salts and
organic decomposition products are liberated and excreted in the urine.
The toxicity of the urine also increases with the increase of indican,
which is indirectly a product of intestinal fermentation.

The _osmotic pressure_ of the blood has much to do with the general
subject of auto-intoxication, since it surrounds and permeates all
the organs of the body, which are necessarily in equilibrium with it.
Their individual cells functionate, then, in accordance with it, and
variations in such pressure must affect their activities. It is a
special function of the kidneys to eliminate enough of the accumulated
metabolic products in the blood to keep this osmotic pressure at
its normal. Should investigation or symptoms of disease show a wide
divergence from this standard, the inference is plain, _i. e._, that
there is renal insufficiency from impairment.

This test may be made with a small amount of blood by _cryoscopy_
(determination of freezing point). So, too, a determination of
_electrical conductivity_ may, in a similar way and for a similar
purpose, be made of clinical value. Unfortunately, these investigations
are not exactly simple in character, and are not available outside of
well-equipped hospitals.

Correct performance of _hepatic function_ is also necessary that
surgical cases may progress without disturbance. Bile escapes direct
absorption by the blood, but not all contact with it, since in the
intestine it is in contact with mesenteric capillaries, but must pass
again through the liver, which takes it up again and pours it once more
into the intestine.

Bile in the blood is always dangerous, although its toxicity is much
smaller than has been supposed. Of all the bile thrown out into the
duodenum, we are only able to account for about one-half. Its coloring
matter and biliary salts are metamorphosed. Yet in certain morbid
conditions bile, as such, may be reabsorbed in the liver along the
margin of the hepatic cells. In these cases, if the kidneys remain
permeable, auto-intoxication is simply threatened; if they have ceased
to be permeable, actual auto-intoxication is the result.

_Putrefaction of intestinal contents_ affords another source of
auto-intoxication. This comes both from imperfect metamorphosis of food
and from bacterial infection. Here the conditions are most favorable.
Nitrogenous substances become peptonized, and peptones form the best
culture media for microbes. Water is present in sufficient quantities,
and a constant temperature of 37° C. is maintained. The digestive tube
is always open, and invaded at frequent intervals. By such mechanism
are formed those products whose effects are revealed in the so-called
_putrid fever of Gaspard_. Brieger has shown that alkaloids are
developed during the act of peptonization. Fecal matter contains also
_excretin_, whose toxicity has been amply proved, and several other
alkaloidal substances, soluble in various media, varying in toxicity.
The potassium and ammonium salts contribute largely to the toxicity
of feces; bile also, but in lesser degree. It has been shown that the
aqueous extract of putrid matter is very toxic, while that of fecal
matter is otherwise.

The most serious features of the conditions grouped under the heading
of _Bright’s disease_ are their _so-called uremic_ features. These
happen at the period when retention of toxic products is peculiarly
harmful. As long as the urine is ample in amount and density--_i. e._,
containing enough toxic materials in solution--there is no danger
of intoxication. But when it no longer eliminates in twenty-four
hours what it should, then we see the chronic and paroxysmal nervous
accidents, the edemas, fluctuations of temperature, etc. Oliguria
with urine of increasing density and general edema of the tissues may
be noticed, although the other secretions continue natural and the
tongue moist. As long as the normal amount of solids is eliminated,
this form of “uremia” may be due to mere accumulation of water and may
not be serious. _Ordinarily, uremic patients are those whose urine
has lost its toxicity._ Usually on the day in which so-called uremic
accidents happen the urine quite ceases to be toxic and is scarcely
more so than distilled water. Urea alone is not to be held guilty for
this condition. In order to kill a man with urea it would require the
quantity which he makes in sixteen days. Nevertheless, it may become
harmful after undergoing transformation into ammonium carbonate or
other substances.

Among the most poisonous substances in the urine are the _extractive_
and _coloring materials_. Normal urine loses one-half of its toxicity
by decoloration; bile acts in the same way. _Urea_ alone represents
about one-eighth of the total toxicity of urine. _Ammonia_ is toxic,
but present in small amounts. The _coloring matters of the urine cause
two-thirds of its toxicity_, the remainder of which is to be ascribed
to its mineral salts, which it contains in the following proportion:
A liter of urine ordinarily contains 44 Gm. of solid matter, of which
32 are organic, 12 mineral. Of the latter, potassium salts constitute
3 Gm., sodium salts 7.5 Gm., and other earthy salts constitute the
remainder.

In these conditions physicians have relied largely upon purgatives,
hoping thereby to remove urea from the blood. But intestinal
elimination has no elective affinity for it, and removes it only in its
normal proportion with the balance of the blood. Purgatives, however,
help, first, by dehydrating the tissues--_i. e._, removing water with
toxic material in solution. But they should be followed by restoring
to the tissues pure water. By bleeding more extractives are removed
than by any other channel, except by the kidneys. A bleeding of 32 Gm.
removes from the body as much toxic matter as would 280 Gm. of a liquid
diarrhea or 100 liters of perspiration. This much may be removed by two
leeches. It is especially in the _subacute nephritis of scarlatina_,
etc., _that bleeding finds its greatest indication_. If the kidneys
are chronically diseased, the utility of bleeding is doubtful. Between
the arterial capillaries of the bowels, however, and the liver is
found a mass of blood accumulated in the _portal_ vessels. This may be
regarded as a reserve which can be thrown into the general circulation
when needed, in order that thereby arterial tension may be augmented
and the function of the kidney increased. _Cold injections_ into the
bowels will often accomplish this, and serious _anuria frequently
disappears after their use_. It is advisable, also, to make use of
urea by subcutaneous administration, as the most powerful diuretic
known, surface friction, caffeine, digitalis, etc., being far behind it
in efficiency. In the form of intoxication noted in the eclampsia of
puerperal patients _inhalations of chloroform_ are valuable. Potassium
salts should, under these circumstances, _never_ be employed. An
exposure of urine in compressed air will diminish its toxicity, on
account of contact with the oxygen; the most toxic bacteria are those
which grow without oxygen. Consequently patients inhaling this gas may
overcome this kind of auto-intoxication.

The value of an active liver is not appreciated by most surgeons to the
full extent. The blood of the _portal vein_ is so much more toxic than
that of the _hepatic vein_ that it is evident that the function of the
liver is to purify and remove the toxic material from the blood that
comes from the intestines. This has been called by Flint and others the
_depurative action_ of the liver. The activity of the liver also may be
proved by grinding up a freshly removed liver with alkaloids, whereby
the latter are chemically changed.

That the facts above stated, or others related thereto, have not been
lost sight of by surgeons is shown by such expressions as _septic
enteritis_, _enterosepsis_, etc., which are used by various writers. In
previous publications the writer has made a separate topic of so-called
_intestinal toxemia_, which he has preferred to introduce here as
one of the many possible auto-intoxications. It is a condition not
always permitting of exact definition, nor, still less, can the exact
toxic agency be indicated in a given case. Nevertheless, it has been
made plain that there is perhaps no condition which so _predisposes
to sapremia_, _septicemia_, or even _pyemia_ as this vague condition
of intestinal toxemia, which, notwithstanding, is so often present.
Many surgical patients present forms of blood poisoning in which the
poison has _not_ proceeded from the wound, for which the surgeon is
not responsible, except that he may have neglected to avail himself of
certain precautions.

The auto-intoxications, then, which have peculiar interest for the
surgeon may be conveniently classified as follows:

1. Those caused by failure in the function of particular organs; _e.
g._, myxedema, cretinism, and cachexia strumipriva from thyroidal
failure; pancreatic diabetes, where the islands of Langerhans are
invaded (interstitial pancreatitis, _q. v._); Addison’s disease from
adrenal failure (this being at present the prevailing belief).

2. Those caused by general disturbance of metabolism, where its
incomplete or abnormal products reach the general circulation, _e. g._,
oxaluria, gout, diabetes. (See Diabetic Gangrene.)

3. Those caused by retention in particular organs or tissues of
disturbed metabolic products, _e. g._, the toxemias following serious
burns and many septic conditions.

4. Those due to excessive formation of more or less normal products,
_e. g._:

(_a_) _Hydrothionemia_, _i. e._, the presence of hydrogen sulphide in
the blood. This results from one form of gastro-intestinal putrefaction
and causes violent symptoms with evidences of hydrogen sulphide
poisoning. It is seen in some cases of gastric dilatation, especially
those caused by pyloric obstruction (_q. v._).

(_b_) _Acetonuria and Acetonemia._--The former sometimes follows
chloroform anesthesia, and occurs especially in diabetes (particularly
after removal of the pancreas in experimental animals). Acetone
_per se_ is nearly or quite harmless, but its congeners, diacetic
and beta-oxybutyric acids, are very toxic. The danger in so-called
acetonuria is from acid intoxication by these acids, which has been
described as “excessive acidosis,” and its co-existence with glycosuria
makes diabetes certain, while prognosis is grave in proportion to its
presence. Prominent among the symptoms produced by it are delirium and
coma.

When either or all of these three substances are present in the blood
its alkalinity is reduced and its ability to absorb carbon dioxide
impaired; hence, acetonemia is evidenced by carbon dioxide poisoning.
To the brain symptoms above noted is added a peculiar odor in the
breath--sweetish or ethereal. This has been noted in pyemia. This
condition may set in after various operations, but whether due to
disease, the traumatism itself, or to chloroform may not always be
determined.[3]

  [3] See paper by Brewer, Annals of Surgery, 1902, vol. xxxvi, No. 4,
  p. 481.

(_c_) _Cystinuria._

(_d_) _Coma of cancerous cachexia_ (coma carcinomatosum).

(_e_) _Exophthalmic goitre_, from excess of thyroidal activity
(thyroidism).

Besides the above there is auto-intoxication proceeding especially from
the gastro-intestinal and hepatic systems. Of the former, the best
surgical examples are seen in the tetany which occasionally takes its
rise from a dilated stomach, and which may be cured by a pyloroplasty
or a gastro-enterostomy; in the nephritis which follows stercoremia of
intestinal obstruction; and in oxaluria, with its painful, serious, and
often deforming or crippling joint affections. Of the latter we have
examples in the cholemia of acute atrophy or of biliary obstruction,
and in the uremia of hepatic origin which occasionally terminates a
surgical case.

In addition to the above there should also be mentioned the
auto-intoxications of pregnancy, with the consequent salivation,
peripheral neuritis, pigmentations of the skin, icterus, and pruritus,
which are mainly attributed to perverted action of the liver or kidneys.

The practice of preparing patients for operation by a course
of purgatives, emetics, etc., is based upon the recognition of
certain principles. The general symptoms included under the name
_enterosepsis_, _stercoremia_, _copremia_, are due to the activity of
the colon bacillus, which seems to be made more virulent by certain
conditions of diet or retained fecal excretions, and to such an extent
that it wanders widely from its normal habitat and may be found in
distant parts of the body. _Enterosepsis may be mistaken for surgical
fever_, and is to be distinguished from it, perhaps, only by the study
of the excretions of a case and establishing the fact that they are
free, and that consequently pyrexia, etc., cannot be due to diminished
elimination. Aside from the migrations of the colon bacillus, it is
also possible for auto-intoxication to occur. Thus that which is
stercoremia one day may later become a genuine septicemia, vital
resistance being so lowered as to permit of local infection. The
various conditions are so often merged that it is difficult to separate
and identify them. Nevertheless, enterosepsis differs from sapremia in
that in the one instance the putrefying material is contained within a
normal cavity, whereas in sapremia it is contained within an abnormal
cavity, in either case corresponding to a _septic suppository_,
varying, however, in the place of insertion, also in the nature of
the surrounding tissues, which in the latter case are more capable of
absorption and of becoming infected than in the former.

A determination of indol and indican is often of the greatest value,
both in determining the extent of infection and the presence of pus.
Indol is set free under the following circumstances: (_a_) Suppuration
in a closed cavity. (_b_) Continued suppuration in a cavity with
an outlet. (_c_) Ulceration or necrosis of tissue. The degree of
indicanuria will depend on the length of time pus has been present,
the possibility of absorption from the tissues surrounding it, and its
degree. When pus is fully formed in a serous sac the indican reaction
becomes intense according to the length of time pus has been present.
This is particularly true in the empyemas of childhood. In continued
suppuration with a free outlet the production of indol will be great;
but the amount finally eliminated will depend upon the character of the
surrounding tissue. When solid tissue, like bone, becomes affected,
the elimination of indol is intense. Rapid biogenic degeneration of
tissue causes an increased amount of indol to be deposited in the
liver, and it is possible at postmortem, by simple extraction with
absolute alcohol, to take from the liver this excess deposit in the
shape of its oxidation product, indigo blue. Lardaceous degeneration
is characterized by marked and persistent elimination of indol, which
seems to be a product of tyrosin. It occurs frequently in the liver, in
which indol is notably deposited. Its primary factor is deposited by
the blood, in which latter indol circulates and is oxidized. Lardaceous
material gives a red or blue color with oxidizing agents, which latter
yield with indol an indigo red or blue.

The practical outcome of such a chapter as this is, then, to insist
as strongly as possible on the preparation of patients, whenever this
is feasible, for an ordeal which comprises the combined effect of
anesthesia and consequent disturbance of secretion and elimination,
with loss of blood and of strength, and subsequent confinement in
bed, with, moreover, all that this entails in further impairment of
activities of important organs. It is not always possible, practically
rarely so in emergency cases, to adopt these precautions; in which
cases they must be atoned for, as far as possible, by extra attention
in the same directions after the emergency is passed or has been
met. In the former case, however, the functions of the skin, the
kidneys, and the abdominal viscera should be regulated, the first by
hot-air baths; the second by this same measure in conjunction with
copious draughts of pure water, the correction of hyperacidity of the
urine, and the administration of whatever drugs may be of benefit as
diuretics, etc.; and the third by a course, perhaps covering several
days, of gentle or active purgation, by which the alimentary canal
will be entirely emptied of all that may serve to act as a source of
poisoning. In addition to this, in certain cases careful massage will
dislodge from the muscles and other tissues material which they ought
not to retain, and which will be washed away, as it were, by the
extra amount of fluid which this preparation, necessitates. Again,
the activity of the heart should be stimulated, perhaps by digitalis,
but preferably by that best of all tonics, strychnine, which is to
be administered hypodermically in average doses of a thirtieth or
twenty-fifth of a grain, morning and night. When these precautions are
taken, patients will successfully pass through trying ordeals without
anything which may give rise to alarm. When they are not possible, the
risk of operating, even in a small way, is materially enhanced. So,
too, after operations when these precautions have not been taken, it is
necessary to give careful attention to atoning for their lack by such
active purgation as a now reduced patient may bear--by hot-air baths,
if feasible, and by the administration of such intestinal antiseptics
as charcoal, naphthalin, corrosive sublimate, bismuth salicylate,
salol, etc., for the purpose of reducing to the lowest possible minimum
the opportunity for formation of poisons which will disturb the proper
repair of injury.




CHAPTER VII.

THE SURGICAL FEVERS AND SEPTIC INFECTIONS.


SURGICAL FEVER, KNOWN ALSO AS TRAUMATIC FEVER, OR ASEPTIC WOUND FEVER.

Formerly the surgical fevers were all grouped together, and a certain
amount of febrile disturbance was looked for after any injury. But
with the introduction of antiseptic methods and the healing of wounds
by primary union, with absence of all septic phenomena, and the use
of the clinical thermometer, it is noted that there is a certain rise
of temperature more or less quickly after an operation or reception
of a wound, with fever of mild grade, persisting for several hours or
two or three days, and with other accompaniments. This phenomenon has
been carefully studied, and so separated from the septic fevers as to
deserve a distinct recognition under the names above given, of which
the most common in this country is _surgical fever_.

As long as this fever is free from indications of septic character it
is without significance and needs only symptomatic treatment. It begins
usually within the first twenty-four or thirty-six hours, after which
the temperature may rise, progressively or with a morning remission,
to a height of 102° or possibly 103°. In children we are more likely
to get extremes in this regard than in healthy adults. It will be
followed by some disturbance of alimentary function, glazing or drying
of the tongue, deficiency in urinary secretion, and subside generally
spontaneously--invariably so if cathartics, diuretics, cool sponge
baths, etc., are used. It is usually due to the retention of blood
clot, ligatures, etc., or tissues which have been ligated and whose
stumps remain; in all instances there is some foreign material to be
removed. This means unusual phagocytic activity, perhaps temporary
leukocytosis, with active metamorphosis of clot and other material,
of all of which the elevated temperature is an accompaniment and
expression. It is not unlikely that the antiseptic materials used may
sometimes occasion this pyrexia.

Iodoform and carbolic acid are among the drugs in common use which are
known to be irritating and capable of producing toxic symptoms. Often
after the use of the latter the urine will be discolored and will
furnish the clue to the fever. In young children particularly, and not
infrequently in adults, mental disturbance, even active delirium, may
characterize the case. This is not always to be explained by cerebral
anemia due to loss of blood during the operation or accident, but
is probably due to drug toxemia or to intoxication from materials
furnished by the altered tissues.

_Surgical fever of strict type may merge into a more or less continuous
fever as the result of intestinal toxemia_ permitted by failure to
evacuate the bowels, and this _intestinal toxemia may be a predisposing
cause of genuine septic infection_. Consequently a surgical fever which
does not disappear within two days is to be viewed with suspicion,
especially if it does not subside after the administration of
cathartics.

Some surgical fevers are accompanied by eruptions, a number of which
may be due to drugs and some to intrinsic poisons. Thus carbolic
acid and iodoform give rise occasionally to erythematous eruptions,
and the concomitant administration of drugs like potassium iodide,
quinine, antipyrine, and copaiba may produce urticarial or other
manifestations. Again, it is known that certain toxins--produced, _e.
g._, by the bacillus pyocyaneus--are capable of causing dilatation of
the superficial vessels and various flushes or eruptions. To one of
these, which dilates the capillaries, Bouchard has given the name of
_ectasine_. Consequently it by no means follows that every eruption or
rash following operations or injuries is of a specific character. On
the other hand it seems to be established by numerous observers--among
whom Paget is perhaps the most prominent--that surgical patients,
particularly the young, are particularly liable to infection by
scarlatina; and in the experience of Thomas Smith, of forty-three
children whom he cut for stone, ten had scarlet fever. Therefore, in
spite of the fact that a certain number of cases of eruption may
have been mistaken for scarlet fever, it is undoubtedly true that in
surgical and puerperal cases patients are more than usually liable to
this invasion. The use of antitoxins or serums is also occasionally
followed by intense urticaria.

The subject of surgical fever may then be epitomized as consisting of
elevation of temperature with certain accompanying disturbances, which
appear to be essentially due to the results of tissue metabolism,
including also metabolism of blood clot, ligatures, etc. It is not a
necessary nor conspicuous accompaniment of all surgical cases, and in
some individuals, even after grave operations, it will scarcely be
noted. It is more likely to be extreme in children than in adults.
As a result of excessive loss of blood it may be postponed. It may
be complicated and prolonged by any one of the auto-infections,
particularly that already mentioned in the preceding chapter as
intestinal toxemia, as a result of which septic infection may ensue,
and that which was at first a legitimate surgical fever may thus become
merged into a septic condition. In the absence of auto-infection, and
with appropriate treatment, surgical fever should quickly subside until
it becomes indistinguishable about the second or third day.

Proceeding then in the order of pathological complexities, the first of
the surgical infectious fevers to be considered is sapremia.


SAPREMIA.

The term _sapremia_ will be used here as indicating a condition which
is often likened to an _intoxication produced by a supposititious
septic suppository_. The term was first used by Duncan, and was largely
confined to puerperal cases. Some of the most ideal cases of sapremia
are those of puerperal origin.

In each of the three conditions comprised under the general term of
_septic infection_ it is not now a question of particular organisms,
but of intoxication by products which are more or less common to at
least several of them. In a general way, they are mainly _due to the
activity of the organisms already grouped as pyogenic_. Those which
produce pus are capable of causing septic infection. In addition to
these, it is probable that certain of the saprophytes or ordinary
putrefactive organisms may produce the same effect.


=Symptoms.=--In sapremia the symptoms begin promptly, depend for
their intensity upon the dosage of poison, and recede quickly as
soon as the source of poisoning is removed or its activity subdued.
An instance of the possible causes of sapremia will perhaps best
illustrate its pathology. Take, for example, the act of delivery of
the full-term fetus. At the completion of this operation there is left
a fresh, bleeding wound of large area which is more or less exposed
to putrefactive agencies. This is reduced with the contraction of the
uterine walls to a comparatively small cavity containing more or less
freshly coagulated blood. As long as this clot does not putrefy it
is disintegrated inoffensively, to be discharged in large part with
the lochia. If germs of putrefaction enter, either during the act of
labor or afterward, and linger, putrefactive processes are set up in
the clot with the prompt production of certain toxins and ptomains.
There is here then a _septic suppository_ with conditions favorable
for absorption by the containing tissues. How quickly the poisoning
may show itself, and how soon it may subside after removal of the
putrefying clot, daily experience may tell.

_Sapremia then is intoxication produced by absorption of the results
of putrefaction of a contained material within a more or less closed
cavity_, whose walls are capable of absorption of noxious products
as they form. _As long as putrefaction is essentially limited to the
contained mass_, and does not spread to and involve the containing
or surrounding tissues the case is one of sapremia. _As soon as the
process spreads from the containing tissues the case merges from one
of sapremia into one of septicemia._ That this may occur in any case
without prompt intervention will be readily understood. Sometimes
patients may die of sapremia, though rarely, and in such case
ordinarily as the result of gross neglect. Once the septicemic process
is begun, however, its spread cannot always be checked, and the case
which one day is sapremic and redeemable may later become septicemic
and practically lost.

The symptoms of sapremia are not essentially different from those
common to septic infection, save that ordinarily they are, at least
at first, milder. There are flushing of the face, dry tongue, mental
disturbance, pyrexia, while usually all the symptoms are ushered in by
a chill, which may have been preceded only by slight malaise. These
are followed by nausea and vomiting, with headache, and often, later,
by diarrhea or active purging. Later delirium may occur, possibly even
fatal coma. On postmortem examination there are few changes revealed;
alterations in the blood, a failure to coagulate, and some softening of
the spleen and liver would probably be the only ones.


=Treatment.=--The treatment should be prompt and the cause removed. In
puerperal sapremia the uterus should be emptied, antiseptic douches
given, irrigating as often as necessary to prevent offensive odor to
the discharge, and combating general signs of poisoning by plainly
indicated measures. Heart depression should be overcome by diffusible
stimulants and hypodermic injections of strychnine in doses of ¹⁄₂₅
grain or more. The _bowels should be unloaded_ by a mercurial followed
by a saline cathartic; suppression of urine treated by venesection
and hot-air baths or sweats; diuretics should also be prescribed, and
fluids administered copiously. If the patient is restless, an opiate
should be given; if delirious, necessary restraint should be resorted
to.

Essentially the same measures should be pursued in a surgical wound or
in a case of compound fracture, or any injury where retained material
may be undergoing changes already alluded to. General measures should
be the same. _Purgatives_ are advisable in these cases.


=Chronic Sapremia.=--Chronic sapremia is a better name for what used
to be known as _hectic fever_. It is characterized by rapid, feeble
pulse, a temperature but little elevated in the morning and rising to
102° or 103° in the latter part of the day, with profuse perspiration,
or sometimes colliquative sweats that leave patients exhausted. There
is usually a distinctive flushing of the cheeks. Emaciation is a marked
feature in most instances. Hectic means simply _habitual_ fever. It is
met with particularly in tuberculous cases, whether of lungs or bones
or joints, in empyema, psoas abscess, and most all chronic pyogenic
infections. It is frequently followed by or associated with amyloid
or waxy degeneration of the liver, kidneys, and spleen. This process
commences in the walls of the bloodvessels and by its spread to the
surrounding connective tissue leads to notable enlargement of these
organs, with albuminuria, edema, ascites, and the usual associated
phenomena.


=Treatment.=--Treatment, in addition to that already indicated above,
should be addressed to removal of the cause. In all instances it should
comprise attention to elimination, digestion, nutrition, and fresh air.
By such measures even distinct amyloid changes may be arrested, or
possibly improved.


=Cryptogenetic or Spontaneous Septicemia.=--Cryptogenetic or
spontaneous septicemia is a term applied to those cases in which the
port of entry of the germs is no longer visible--_e. g._, a hypodermic
puncture--or cannot be positively determined. On careful study this may
be found to consist of a small focus where pus is forming within narrow
confines and under great pressure. Under these circumstances, as Kocher
has shown, toxic virulence is rapidly augmented. This is doubtless
one reason why the septic features of many cases of osteomyelitis and
appendicitis are so pronounced.


SEPTICEMIA.

According to the views thus enunciated, the difference between sapremia
and septicemia is not one of character as much as of location. _In
septicemia the putrefactive action is no longer confined to material
enclosed by_ (_yet not of_) _the tissues themselves, but has spread
from this to the surrounding living cells_, which are being attacked by
bacterial enemies; in other words, we deal with _infection of living
tissues rather than with mere intoxication_. This is a _progressive
invasion_ of tissues by continuity, _with_ a constantly proceeding
systemic _intoxication_ by poisons produced in larger quantities. So
rapid may this action be--as may be seen in malignant diphtheria--that
the individual speedily succumbs before evidences of abscess or local
gangrene appear. On the other hand, providing that the toxic action is
less pronounced or the patient’s vitality more enduring,--_i. e._, his
tissues more resistant--abscess, phlegmon, or local gangrene may result
in the destruction of tissue being limited to the environs of the parts
first involved. Bacteria are also found in the blood.

While septicemia then may be a direct continuance of an original
sapremia, it is not intended to intimate that it may not originate _de
novo_; that is, _many cases may begin as a pronounced septicemia from a
local infection_. This is the case, for instance, with the majority of
dissecting wounds, etc.


=Symptoms.=--In septicemia there is a period of incubation, usually two
or three days, often longer. If this follows an operation, the mild
fever which would indicate the slumbering fire is usually regarded as
surgical fever. But when this rises and is followed by prostration,
with alimentary disturbance, loss of appetite, headache, etc., followed
by typhoidal symptoms, the alarm is sounded and should be quickly
heeded. Usually, but not always, there is a preliminary or _premonitory
chill_, after which prostration will be more marked than before. The
severity of the symptoms cannot be foretold from the size, location,
or character of the wound. The character of the fever is essentially
continued, usually with morning remissions. Gussenbauer has called
attention to a class of cases in which subnormal temperature is caused
by the absorption of ammonia compounds. To these he has given the name
_ammoniemia_. This condition may be seen in connection with gangrenous
hernia, and has even been mistaken for shock (Warren). (See also
_acetonemia_, in previous chapter.)

In septicemia from infection of a visible portion of the body there
are usually seen evidences of _lymphangitis_ and _perilymphangitis_
of septic character. These will be evidenced by tender and purplish
lines, extending subcutaneously along the course of the known
lymphatics or in connection with the more prominent subcutaneous veins.
The _lymph nodes_, into which these visible vessels as well as the
deeper ones empty, become _enlarged and tender_; the whole lymphatic
system participates; the _spleen_ in aggravated cases becomes notably
enlarged, and even the bone-marrow more or less involved. _Diarrhea_ is
commonly an early but controllable symptom. A hematogenous icterus of
mild degree is another frequent accompaniment. The conjunctiva becomes
discolored and the skin slightly so. Should the blood be examined
marked _leukocytosis_ will be noted, and should cultures be made from
it, in many instances at least, the organisms at fault can be detected
and recovered from it. The vigor of the heart muscle is seriously
impaired; the _pulse_ becomes _rapid_ and _weak_. In scarcely any form
of septic infection is this more prominent than in diphtheria; and
microscopic examination shows the rapid disintegration of the cells
of the heart muscle, as well as those of other parts of the body,
even to the almost complete molecular disintegration of the nuclei.
Erythematoid, pustular, and even hemorrhagic _eruptions_ are met with
upon the skin, some of which are probably to be explained by thrombosis
of the dermal capillaries. Certain _complications_ are not infrequent,
among which inflammations of the pericardium and endocardium--_e. g._,
ulcerative endocarditis--are frequent. As the case becomes aggravated
the temperature rises irregularly; the hot, dry skin becomes cold
and clammy; prostration and indifference more marked; diarrhea more
colliquative; icterus more pronounced; urine more reduced in quantity
or suppressed; and these symptoms are succeeded by indifference, mental
apathy, stupor or delirium, and finally death, the patients being
comatose and collapsed.

While these are the general indications of septicemia, the _wound_ or
site of injury has undergone _changes_ which are also _characteristic_.
They comprise the _edema and redness of wound margins_, which may be
seen even in sapremia, followed by increasing _tumefaction_, escape
of _foul-smelling discharge_, and finally by _sloughing and gangrene_
of the parts involved. On microscopic examination the capillaries
are filled with infective thrombi and vessel walls infiltrated with
microörganisms, which abound also in the lymph spaces. Bacterial
infection can be traced in microscopic sections from the infected area,
from the point in the neighborhood of the wound where microbes infest
the tissues to points remote from it, where they are sparsely found,
if at all. The same evidences of infection may be traced along the
lymphatic vessels, and often the veins.


=Postmortem Evidences.=--The postmortem evidences of septicemia are
indicative on first sight: the blood is of the consistency of tar
and does not coagulate; evidences of putrefaction are plain to sight
and smell; the serous membranes, particularly the pia mater, are
often extravasated; the muscles are discolored and of a darker hue
than natural, edema of the lung is frequent; the intestines reveal a
gastro-intestinal catarrh, the duodenum and rectum showing punctate
hemorrhages; the spleen is darkened, enlarged, and softened; the
liver shows similar signs, less marked, and at times an emphysematous
condition due to putrefactive gases. Cultures can be made from the
fluids and tissues of organs thus affected. It is also of importance
to emphasize that such material is _powerfully_ and often fatally
_infectious_; some of the worst forms of dissecting wounds and
instances of _fatal infection_ have come from carelessness in making
these _postmortem examinations_.

So far as concerns the character of the wound, which is most likely
to be followed by septicemia, there is but little to be said. Wounds
made by infected tools, the butcher’s knife, the anatomist’s scalpel,
etc., are the most dangerous. All forms of phlegmonous erysipelas,
many cases of gangrene following frostbite, nearly all instances of
traumatic gangrene, most cases of carbuncle, and, in fact, all similar
lesions, are likely to be followed by septicemia. The so-called
spontaneous cases have an equally infectious origin, though one which
is concealed. In unrecognized instances of appendicitis, for instance,
and in many other conditions, although the path of infection may not be
easily traced, it is, nevertheless, always present, and can be found
if diligent search is made. The nasal cavity, the tonsils, the teeth,
the middle ear, the deep urethra, and the rectum are often overlooked
as offering possibilities for septic infection which may follow this
general type.


=Treatment.=--This should be both local and general. Local treatment
should consist in complete and absolute removal of the active cause.
This comprises the reopening of wounds, evacuation of clot, cutting or
scraping away of sloughs and gangrenous tissue, with cauterization of
the exposed living tissue, in order that absorption may be prevented,
and will often include amputation or extirpation of a part. For
tissues which are not too completely riddled by disease, and lost
beyond possibility of redemption, _continuous immersion in hot water_
offers the best possible prospect. By it putrefaction seems checked,
the separation of dead from living tissues is accelerated, relief of
pain or discomfort is afforded, and disinfection of material which is
foul and infectious is guaranteed. An excellent local application is
the mixture of resorcin 5 parts, ichthyol 10 parts, ung. hydrarg. 40
parts, and lanolin 45 parts, already mentioned in Chapter IV, or the
application of _brewers’ yeast_. (See chapter on Ulcers.) Of great
value also will be found the silver ointment of Credé (_Unguentum
Credé_). This permits of absorption of silver through the unbroken skin
(as in the case of ung. hydrarg.), and the dissemination throughout
the system of the antiseptic virtues of the silver itself. To ensure
its greatest efficiency this ointment should be thoroughly rubbed
in, especially over parts which are not too tender. Many cases of
septic infection promptly yield under the influence of the argentine
preparations which Credé has lately introduced.

In suitable cases also the subcutaneous injections of
_antistreptococcic serum_ will be followed by beneficial effects. The
earlier the injection is given the better the prospect of benefit.
Evidence is strongly in favor of this serum as a prophylactic measure,
especially before operations, when septic pneumonia or other septic
accidents are feared.

Another measure of great utility in selected cases is the intravenous
infusion of a solution of Credé’s soluble silver, made with 1 gram
of silver in 1000 Cc. of sterilized water at a temperature of 105°
to 110°. In cases of profound toxemia a small amount of blood may
be withdrawn (50 to 400 Cc.), for reasons stated in Chapter VI. No
hesitation need be felt in introducing 500 Cc. or even 1000 Cc. of
this solution. It is the ideal way of bringing a powerful non-toxic
antiseptic into immediate contact with pathogenic microbes.

There have been recent suggestions as to the intravenous injection
of very dilute _formalin solution_, in order to take advantage of
its remarkable germicidal activity; it has been employed in a few
cases, especially of puerperal sepsis, with success, 1 Cc. of standard
formalin solution is mixed with 800 Cc. of sterilized salt solution. It
has been shown that if 50 Cc. of this is thrown into the veins of an
average adult it will form with the 5000 Cc. of blood a mixture of 1
to 200,000, in which strength it may be expected to prove an efficient
bactericidal agent. Indeed, a smaller amount or a weaker preparation
would probably suffice. Barrows has reported success following two
infusions, two days apart, of first 500 Cc., then 750 Cc. of a 1 to
5000 formalin solution. Still, these injections may be followed by
cramps in the arms, cardiac discomfort or distress, and blood (or blood
cells) in the urine. It would probably be well to limit this use of
formalin to those cases at least in which the presence of cocci in the
blood can be demonstrated by culture or other method.

An excellent method in the local treatment of parts which admit of it
(hands and feet) is their exposure to dry hot air in the Kelly heater
or some similar apparatus. Hot air will be borne at a temperature of
210° to 220°, which may be destructive to germs while still tolerable
for a short time by the tissues. Clinton, of Buffalo, with whom this
method is original, reports that the temperature within the tissues
thus treated is raised to about 107°, which is above the thermal death
point of the ordinary pyogenic organisms, and that this method gives
better results than any other of treatment of septic infection of those
parts which can be subjected to it.

The _general treatment_ of septicemia is, in the main, _stimulant_ and
_tonic_. Fever is not to be treated with arterial sedatives nor often
with antipyretics. It is a symptom of poisoning, and its too prompt
suppression prevents both the recognition of the intoxication and the
measure of its degree. Pyrexia then is best combated with cool sponge
baths and stimulant measures of a general character. The principal
reliance must be upon _nutrition_ and _stimulants_. Assimilation
may be impaired when gastro-intestinal catarrh is as prominent a
feature as it is in many of these cases. Consequently the simplest
and most assimilable food, often that which is predigested, should be
administered. Milk, eggs, beef peptonoids, and fruits are among the
most appropriate. The best stimulants and tonics are _alcohol_ and
_strychnine_. Strychnine is preferably administered hypodermically in
doses of ¹⁄₂₅ grain from two to four times a day. Heart depression is
best combated by this measure, or by _quinine_ in large doses, while
digitalis and atropine may be added. For internal use _alcohol_ is,
_par excellence_, _the remedy_. This is administered in doses only to
be measured by their effect. In fact, the administration of alcohol
in these cases is a matter of _effect_, and _not of dosage_. Aside
from these measures the intestinal antiseptics should be administered,
among these being corrosive sublimate, ¹⁄₁₀₀ grain, every three or four
hours, salol in large doses, bismuth salicylate, or naphthalin--any
or all of these in connection with powdered charcoal. Intestinal pain
and frequency of stool can be more or less controlled by opium, while
disinfection of the alimentary canal is only to be accomplished by the
above remedies, in connection with flushing of the colon with saturated
boric acid solution or something of that kind. Pain is to be controlled
by morphine administered subcutaneously.

No special attention need be given to the so-called _septicopyemia_. It
represents a mixed condition of septic intoxication, local infection,
and destruction, with metastatic abscess, and is a term appropriately
applied to cases which combine the significant features of each type.


PYEMIA.

The derivation of the term pyemia, which came into general use in 1828,
is misleading. Although septic fever always accompanies suppuration, it
is not certain that pus as such circulates in the blood, as the term
pyemia implies, the error having arisen originally from mistaking the
contents of breaking-down thrombi for pus from ordinary sources. While
a recognition of the etiology of the disease is new, the disease itself
has been recognized for many centuries.

Pyemia is only met with in connection with suppuration, as far as
known, never without it. In those cases which appear to be free
from suppuration pus will be found. _Pyemia may be described as
septicemia plus thrombotic and embolic accidents, which lead to
distribution of infectious material to all parts of the body._ This
distribution is made by the bloodvessels, although to some extent
the lymphatics undoubtedly participate. When pyogenic organisms
reach bloodvessel walls they tend to set up a _mycotic phlebitis_,
which, by virtue of the coagulating blood, becomes soon what is
known as _thrombophlebitis_. Infection proceeding through the vessel
walls, the endothelial lining is loosened, while to these rotting
spots leukocytes adhere and coalesce into a more or less homogeneous
mass. This so-called _white thrombus_ becomes also infected with
bacteria; portions of it, loosened and dislodged, are carried by the
returning blood stream to the right side of the heart, whence they are
distributed through the lungs. Dislodgement may be made by mere force
of the blood stream, or may be assisted by movements of the part or
handling of the same. These particles of thrombi are loaded with the
infectious organisms which began the disease, and wherever one settles
a reproduction of the original thrombophlebitis is rapidly produced.
In this way numerous infected thrombi are formed within the vessels
of the lungs, which, again, loosen, and are now swept into the left
side of the heart, whence they are distributed with arterial blood in
all directions. While it is true that they are equably distributed, it
is also positive that certain tissues seem more capable of lodging
and being attacked by the contained organisms than are others. When
it is once appreciated that each particle of infected clot is capable
of setting up, either in the lungs or in the other tissues, upon the
second distribution, other abscess formations analogous in etiology
to that from which came the first disturbance, then the fundamental
idea of _metastatic abscess_ is fully impressed. The term _metastasis_
may be regarded as _synonymous with transportation_, and metastatic
abscesses are those produced by transportation of infected particles
from one part of the body to another. Wherever they lodge similar
trouble will result. Contiguous minute metastatic abscesses quickly
_coalesce_, and in this way large collections of pus are formed. The
blood also contains organisms not attached to thrombi, and from the
blood of the pyemic patient cultures can at almost any time be made.
Until this is done it will be virtually impossible to incriminate
any particular organism as the one at fault. _Thrombo-arteritis_ is
the equivalent in the arteries of thrombophlebitis in the veins, and
is accompanied by the same detachment of endothelium, adhesion of
leukocytes, etc. Whenever such a lesion occurs in artery or vein,
coagulation necrosis takes place and suppuration occurs around it.
The metastatic abscess is thus the result of breaking down of this
affected tissue, and is often called _miliary abscess_. Particles of
infective thrombi cling also to the valves of the heart and a _septic
endocarditis_ may result.

The possibility of _so-called spontaneous_ or _idiopathic pyemia_ is
occasionally discussed. This means a pyemia whose cause is concealed.
The explanation will be found sometimes in an acute infectious
osteomyelitis, sometimes in ulcerative endocarditis, or inflamed
appendix or other portion of the peritoneal cavity. Again, it may
proceed from middle-ear disease, in which there is so little discharge
as scarcely to attract attention. Thus causes which predispose to
suppuration (see Chapter III) come into play here, and the influence of
exposure, fatigue, starvation, etc., is not to be ignored in furnishing
an explanation for the so-called idiopathic cases.

In the majority of instances, however, pyemia follows surgical
operations and injuries, among which are compound fractures, deep
injuries with small superficial evidence thereof, compound injuries of
the skull, and injuries by which veins are exposed. Inasmuch as the
typical pyemic manifestations require a certain length of time for
their development, the onset of this disease is more delayed than in
the case of septicemia. While the case may be manifestly one of septic
infection of unrecognizable type, the characteristic indications of
pyemia seldom appear in less than ten days, and frequently not for
several days longer.


=Symptoms.=--The symptoms of pyemia do not essentially differ from
those of other septic infections. The principal difference is in the
_frequency of chill_ and _range of temperature_. _Chills_ are more
_common_ at the _inception_ of the condition, and more _frequent_
throughout its continuance than in other septic conditions. The chill
may be slight or assume the proportions of a rigor, and each chill is
followed by colliquative sweat and exhaustion. In other words, chills
which are infrequent in septicemia are common in pyemia. There is
reason to believe that with each fresh distribution of emboli we have
one or more chills as the objective evidence thereof. Distinctive also
of pyemia is the _temperature curve_, which much resembles that of
intermittent fever, without the regularity of change characteristic
of malarial fevers. It is without regular remissions, and has been
referred to as irregularly intermittent. The first rise is abrupt and
usually excessive, while with each fresh chill or series of chills
similar abrupt alterations will be noted. These occur so frequently
and fluctuate so irregularly that in order to note them accurately the
temperature should be taken at least every two hours. The temperature
seldom drops to normal.

As the lungs fill with the first crop of infected emboli, and the
first series of metastatic abscesses form there, there is more or
less _dyspnea_ and sense of oppression; there may be also _pulmonary
complications_--pleurisy, bronchitis, etc., even pulmonary edema.
Frequently there is expectoration of frothy and discolored sputum;
occasionally there is blood in the sputum. A peculiar _sweetish odor
of the breath_ has been noted by many observers in this disease, and
is supposed to be idiopathic and characteristic. (See _acetonemia_
in previous chapter.) With the dispersion of the second crop of
emboli from the lungs there is apt to be _icterus_, with evidence of
_metastatic abscess in the liver_, and collection of pus as the result
of coalescence of small abscesses. The sensorium is not so affected in
pyemia as in septicemia, and in the former disease patients are more
likely to be alert and active in mind. General _hyperesthesia_ and
_restlessness_ are common. Colliquative sweats are also a feature of
pyemia. There is the same liability to _eruptions_, etc., which may
mislead or complicate the diagnosis. A dermatitis is seen sometimes in
pyemia, the lesions assuming a papular or pustular form, due to local
infections of the skin. Purpuric spots are also seen, and vesication is
not infrequent. Within the mouth _sordes_ collect upon the _teeth or
gums_; the _tongue_ becomes dry and brown and heavily coated. Diarrhea
is less common in pyemia. The urine is usually scanty and high colored,
containing solids in excess; albumin is sometimes found therein, as
well as peptone. The presence of _peptone in the urine_ is probably an
indication of the breaking down of pus corpuscles in various parts of
the tissues.

A significant objective evidence of pyemia is met with in the
_metastatic collections of pus within the joints_, which occur
relatively early, and which, if multiple, may lead to a correct
diagnosis. One of the earliest joints to be involved is the
sternoclavicular, although none of the joints are free from the
possibility of invasion. The articular serous membranes seem to have
the property of carrying and holding the infective thrombi better
than any other tissue in the body. The _pyarthrosis of pyemia_ is for
the most part painless, yet implies loss of function of the affected
joints. The distention of these is usually evident to the eye, the
fluctuation pronounced, tenderness not extreme, but the swollen part
merges into tissues which are edematous and reddened. When pain in the
limb is extreme, it is usually because of metastatic abscess within
the bone-marrow cavity. In other words, we now have a _metastatic
osteomyelitis_.

In all cases of pyemia prostration is marked, yet the pulse is seldom
weak, at least until toward the close of life. As cases progress from
bad to worse _subsultus tendinum_ is often noted.

The _appearance of the wound_ or site of operation does not differ
essentially from that already described under Septicemia. There is
usually, however, _less discharge_, granulations are _smoother and
dryer_, and if tissues are gangrenous they are not as wet and nauseous
as in the other case. _Evidences of thrombophlebitis and lymphangitis_
will proceed from the wound toward the body, as in other instances of
septic infection.


=Prognosis.=--Prognosis is usually _bad_. While recovery may follow
where metastatic infiltration has not been too general, the ordinary
case of pyemia will die within twelve to fourteen days after diagnosis.
Sometimes the entire process is much slower, and isolated cases occur
which can be designated as _so-called chronic pyemia_, which differs
but little from the acute form. A case of pyemia should not fail of
recognition because there is no evidence of infection from without.
A fatal case of pyemia has been known to occur from a suppurating
soft corn which was not discovered during life; also from _peridental
abscess_, etc., which had been overlooked. Death is the result of
tissue destruction and septic intoxication.


=Postmortem Appearances.=--In the vessels these consist essentially
of _thrombosis_, examples of which may be seen, for instance, in the
cranial sinuses and in the large veins. Aside from these, with the
_enlargement and softening of the spleen_, the _liver_, and _lymphatic
structures_, already described under Septicemia, the principal
objective evidences consist in the discovery of metastatic abscesses in
many or all parts of the body. As stated above, there is no tissue or
organ in which they may not be found. The mechanism of their production
has been already described. _Infarcts_ may also be met with, in the
kidneys especially, the liver and spleen as well, and indicate areas
already cut off from blood supply by thrombo-arteritis, in which
abscess formation would have occurred had time been given. In the
liver large abscesses may be found; joint cavities may be filled with
pus; the lungs are usually the site of innumerable small abscesses.
The other postmortem changes commonly noted are not difficult of
explanation, but are not so characteristic or pathognomonic as to
call for further mention. In a joint which has become filled with pus
there usually has been loosening of the cartilage and more or less
disorganization of all the joint structures, which appear to have
undergone rapid ulcerative destruction and putrefaction.


=Treatment.=--Treatment of pyemia is in large degree unsatisfactory.
That which used to be the terror of surgeons in the pre-antiseptic era
is now, thanks to Lister and others, almost abolished. Pyemia is a rare
disease in modern surgical practice. Its possibility should be borne
constantly in mind, however, and the necessity for careful antiseptic
or for a rigid aseptic technique is in large degree based upon fear of
pyemic consequences.

When once established, the disease is to be treated on lines nearly
similar to those laid down for septicemia, including resort to the
ichthyol or silver ointments, and to intravenous infusion of silver
solution. (See p. 89.) Amputation or extirpation of the part from
which infection has first proceeded may be of avail. Among the most
successful measures for surgical treatment of this disease is to expose
the infected area, open the involved veins, and either excise them or
scrape them out and disinfect them. This treatment has been successful
in cases of cranial infection following middle-ear disease, etc. (See
chapter on Cranial Surgery.)

Disinfection of the infected area and immersion in hot water should
be practised. Metastatic abscesses should be opened and drained, and
every accessible collection of pus evacuated, either by the knife or
aspirator needle--_e. g._, in the liver.

The medicinal treatment is practically the same as in septicemia,
while the surgeon’s mainstays are alcohol and strychnine. These, with
cathartics and intestinal antiseptics, will practically sum up the drug
treatment, the surgeon meantime not neglecting the matter of nutrition,
crowding it in every assimilable form.


ERYSIPELAS.

Erysipelas is an _acute infectious disease characterized by its
tendency to involve the skin and cellular structures, to extend along
the lymphatic vessels, to involve wounds and injuries under certain
conditions, accompanied by more or less fever of septic type, leading
frequently to septic disturbances of profoundest character, yet tending
in the majority of instances to spontaneous recovery_. It has been
observed probably from prehistoric times, but has not found a proper
description nor appreciation until perhaps within the past century. It
occurs in so-called _traumatic_ and _idiopathic_ form--which latter
means that the site of infection is not discovered--and also in a
_virulent_ and _contagious_ type, which leads to the appearance of
a number of cases over a large territory; it often appears in the
_epidemic_ form. On account of the reddening of the skin it goes by the
name of _the rose_ among the German laity. It may assume the type of
an infectious dermatitis, subsiding without suppuration, or a similar
lesion of exposed mucous membrane may be noted, or, occasionally, its
virulence seeming greater, its lesions are met with in more deeply
seated parts, accompanied by suppuration or even gangrene, and it
is then called _phlegmonous_. In a small proportion of cases the
infectious organism appears to be transported from one part of the body
to another, and thus we have _metastatic_ expressions of this disease.
The most common examples of this are seen in erysipelatous meningitis
after erysipelas of the face or scalp, and erysipelatous peritonitis
after the disease has manifested itself on the truncal surface. It is
of a type which makes itself almost interchangeable with puerperal
fever; and when epidemics of erysipelas have involved certain states
or areas, it has been noted also that nearly every obstetrical case
developed puerperal septicemia.


=Etiology.=--There is more than passing interest connected with this
last statement. It is now definitely established that the infectious
organism is a _streptococcus_ which is allied to, if not identical
with, the streptococcus pyogenes, the ordinary pyogenic organism
of this form. This specific organism has been separated, studied,
and its role assigned by Fehleisen, and the organism is frequently
called _Fehleisen’s coccus_. Preserving always its morphological
characteristics, it acts, as do many other pathogenic organisms, within
wide limits in virulence. Cultivated from some cases, it scarcely seems
infectious, while from others it is fatal.


=Pathology.=--The disease manifests a tendency to travel _via lymphatic
routes_. As long as it is confined to the skin and superficial tissues
it has the appearance of an acute dermatitis. When it migrates deeper
it generally leads to suppuration, another reason for believing that
the streptococci of erysipelas and of pus production are the same. In
the affected and infected area the minute lymphatics will be found
crowded with the cocci, which are seen much less often in the small
bloodvessels; also in the tissues beyond the apparently infected area
they may be found dispersed less freely. The bacterial activity seems
most active along the advancing border of the superficial lesion. Here
the phenomena of hyperemia and phagocytosis are most active. Even in
the vesicles that are characteristic of the disease the organisms may
be found.

The _discharges_ from this region are _infectious_, and caution should
be observed in dressing such cases. A finger pricked by a pin from a
dressing may subject the individual to loss of life. The _dressings_
containing the discharges should be _burned_ immediately.

The path of infection is usually through a wound, and as soon as
discovered a case of erysipelas should be separated from all surgical
cases, or if the erysipelatous patient cannot be isolated, he should be
removed from proximity of other wounded individuals.

Erysipelas which follows injury, however slight, is termed _traumatic_.
The terms “idiopathic” or “spontaneous” should be restricted to those
cases in which the path of infection is not discovered.


=Symptoms.=--With the exception of the local appearances, they
are essentially the same in both of the above-mentioned forms.
The characteristic feature of the disease is a _dermatitis_ with
its peculiar _roseate_ hue, which it is impossible to describe in
words. In tint it differs slightly from that noted in certain cases
of erythema. It is, however, accompanied by an infiltration of the
structures of the skin, so that the area which is reddened is at the
same time elevated above the surrounding surface. Its edges are often
irregular. As exudate takes the place of blood in the tissues, the
red tint merges into a yellow. At this time there is more induration
of the skin and tendency to pit on pressure. Vesication of this
involved area is now frequent, the vesicles often coalescing and
forming large blebs and bullæ, which fill with serum that may become
discolored or purulent. When exposed to the air, unless the tissues
become gangrenous, this serum usually evaporates and forms scabs. This
disturbance of the skin is always followed after a number of days by
desquamation. This infectious dermatitis shows a constant tendency
to spread in all directions. Its most characteristic appearances are
limited to the margin of the enlarging zone, while in its centre there
may be evidences of recession of the disease. If it commences in the
vicinity of a wound it will probably spread in all directions from it.
Beginning in the face, it usually spreads upward; in the trunk, in all
directions; if on the extremities it tends to migrate toward the trunk.
_Wandering erysipelas_ is a term often applied to these phenomena. The
_metastatic_ expressions of the disease have been described.

When this affection attacks a recent wound the local appearances are
not essentially distinct from those mentioned under Septicemia. The
wound margins separate to a greater or less extent, the surfaces
slough, and a characteristic seropurulent discharge occurs. Granulating
surfaces usually become glazed--often covered with a membrane
resembling that of diphtheria; deep sloughs may occur, undermining of
wound edges, even hemorrhages from destruction of vessel walls. In rare
instances, however, under the influence of the microbic stimulation
granulations proceed faster than normal.

Whether the disease proceeds from an injury or not, the
_constitutional_ symptoms vary but little. There is usually a period of
_malaise_ with _nausea_, followed by alimentary disturbance, coating
of the tongue, elevation of _temperature_, sometimes with occurrence
of _chill_. Complaint of pain or unpleasant sensation will lead to
examination of the area involved, when the above symptoms will be
noted, with evidences of _lymphangitis_ and enlargement of lymph nodes.
When chill occurs it is followed by pyrexia. Temperature fluctuates,
with a tendency to assume the remittent type. When the disease subsides
spontaneously it is by a gradual process of betterment and subsidence
of temperature. In other instances the constitutional symptoms assume
more or less of the _septicemic_ or _typhoid_ type, and it is seen that
the patient’s condition is practically one of mild septicemia, which
often proves fatal.

When the disease assumes the _phlegmonous_ type the constitutional
symptoms become more and more typhoidal and the septicemia becomes most
pronounced. Locally exudation goes on to the point of threatening,
even of actual, gangrene, unless tension is relieved by incisions.
Pain is usually intense, partly because of confined exudates beneath
resisting structures. More or less rapidly the local and constitutional
signs of pus formation are noted, and unless these are observed and
acted upon early there will not only be suppuration, but more or less
actual gangrene, so that not only pus, but sloughs of tissue will be
discharged through the incision, or will, when this is delayed, make
their escape by death of overlying textures.

In all _phlegmonous_ cases there is practically coincidence of
septicemia, already described, and of the local appearances above
noted. In proportion to the extent of the lesion in these phlegmonous
cases, and failure to afford relief, will be the opportunity for septic
intoxication.

The mucous membrane does not always escape, and even in the nose, the
pharynx, the vagina, and the rectum a distinctive erysipelatous lesion
may be found. The disease may travel from the pharynx through the nose
and involve the face, or through the Eustachian tube to the ear and
thence to the scalp, or _vice versa_. _Erysipelatous laryngitis_ is to
be feared on account of edema of the glottis, which would soon be fatal
unless overcome by intubation or tracheotomy. An infectious exudation
into the lungs is also known to follow erysipelas, and has been
considered an _erysipelatous pneumonia_. The cellular tissue of the
orbits may also be involved, when abscesses will occur, which should
be opened early; the parotid and other salivary glands may become
involved, usually in suppuration.

Many cases are accompanied by much _gastric irritation_, which it is
difficult to explain. Ulcers are sometimes found in the intestines,
as after burns. These usually give rise to bloody diarrhea. The
cerebral symptoms may be simply those of delirium from irritation
or of meningitis from infection. Strange phenomena have followed
the disease in certain instances--cessation of neuralgic and of
vague, unexplainable pain, improvement in deranged mental condition,
spontaneous disappearance of tumors, etc. Advantage has been taken of
this last in the treatment of these cases. (See Cancer.)

It is quite likely that some of the worst forms of phlegmonous
erysipelas are due to _mixed infection_. To inject the bacillus
prodigiosus together with the streptococcus of erysipelas will greatly
enhance the virulence of the latter, so that reaction may proceed even
to gangrene.


=Postmortem Appearances.=--These are not distinctive, but are a
combination of local evidences of suppuration and gangrene, with the
deterioration of the blood, the softening of the spleen, etc., which
are characteristic of septic poisoning. Only in the skin, and then
under microscopic examination, can any pathognomonic appearance be
discovered. This will consist in the crowding of the lymphatic vessels
and connective-tissue spaces with cocci, in the evidences of rapid cell
proliferation, in the quantity of exudate, in vesication, sloughs, etc.


=Diagnosis.=--Diagnosis of erysipelas should be made mainly from
various forms of erythema, from certain drug eruptions, and from other
forms of septic infection which do not assume the clinical type of
erysipelas. The gastric symptoms of this disease are sometimes produced
by certain poisonous foods or the distress which is produced by
medicines, such as quinine, antipyrine, etc.


=Prognosis.=--The majority of instances of idiopathic erysipelas run
a certain limited course, although the eruption may spread to almost
any distance upon the body. When the disease attacks surgical cases,
and especially when it involves wound areas, the prognosis is not so
good. When the disease assumes an _epidemic_ type and involves cases
of all kinds, it will be found to have a _virulence_ that may make it
a most serious affair. In proportion to the extent to which it assumes
the phlegmonous type it will be found locally, if not generally,
destructive. The ordinary case of facial erysipelas will recover with
almost any treatment. Nevertheless meningitis may develop, and even a
mild case is to be treated with care and caution.


=Treatment.=--Danger comes from two sources--_septic intoxication_ and
_local phlegmons_ or gangrenous destruction. Each is therefore to be
combated. Treatment should consist of isolation. There is _no specific
internal treatment_ for this disease. Tincture of iron, which was long
vaunted as such, has proved unsatisfactory, and is of benefit only as
a supporting measure in a limited class of cases. _Constitutional_
measures should be employed: First, for the purpose of maintaining
_free excretion_ by bowels and kidneys; second, for the purpose of
_supporting_ and maintaining strength; third, for tonic and _stimulant_
measures in prostrated and debilitated patients; and, fourth, for the
purpose of _combating intestinal sepsis or intoxication_ from any other
source. The robust patients with this disease need no particular tonic.
The aged, the enfeebled, the dissipated, the prostrated individuals,
and the confirmed alcoholics are those who need vigorous stimulation,
partly by alcohol and quinine, and partly by strychnine, preferably
given hypodermically, and by the other diffusible stimulants by which
they may be kept alive. Pilocarpine, given subcutaneously and pushed
to the physiological limit, has been praised by some. If along with
prostration there occur restlessness and delirium, then anodynes and
hypnotics are serviceable, and should be administered to meet the
indication--morphine hypodermically and any of the agents which produce
sleep are now most beneficial. Finally, if there is any drug which
can be administered in doses sufficient to saturate the system with
an antiseptic which shall at the same time not prove fatal because
of toxicity, this is the ideal medicament for constitutional use
only. Such a drug is not known, but it will be well to give some near
approach to it internally, as by administering corrosive sublimate,
salol, naphthalin, or something else of this character in doses as
large as can be tolerated.

Should patients become violent it may be necessary to resort to
_mechanical restraint_--a strait-jacket, a restraining sheet, a
camisole, etc.

_Nourishment_ must be kept up by the administration of the easily
assimilable and predigested foods.

_Locally_ the number of remedies that have been resorted to is legion.
In a mild case of spontaneous erysipelas--_i. e._, where no infection
can be traced--it will sometimes be sufficient to put on a soothing
application, like a lead-and-opium wash. It often gives relief to have
the part protected from air contact, which may be done by a soothing
ointment or by dusting the part with a powder, such as bismuth oleate
or subnitrate, zinc oxide, etc., these being rubbed up with powdered
starch; or by a film of rubber tissue or of oiled silk. Brewers’ yeast
applied on compresses and covered with oiled silk is efficacious.

Even before the bacterial origin of the disease was accepted it had
been suggested to use _antiseptic applications_, either in watery
solution or combined with oil or some unguent; this is now the ideal
method of local treatment, the difficulty being only to find that
which shall be efficacious as an antiseptic, yet not injurious in
other ways. Compresses wrung in solutions of various antiseptics are
often serviceable. The following preparation has given satisfaction:
Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin
50. The proportions of these ingredients may be varied, and the amount
of ichthyol sometimes increased, especially when the skin is not too
tender. The affected parts are anointed with this, and then covered
with oiled silk or other impermeable material, simply to prevent
its absorption by the dressings; the parts are then enveloped in a
light dressing and bandaged. Credé’s silver ointment has also proved
useful. As the disease becomes mitigated the ointment may be reduced
with simple lard, and discontinued when local signs have disappeared.
Absorption of any of these preparations may be hastened by scratches
over the affected area with the sharp point of a knife.

Treatment of _threatening phlegmon_, or phlegmonous erysipelas, must
be more radical, and consists of free incision down to the depth of
the deepest tissues involved. In treating dissecting and other septic
wounds of the fingers incision should be made to the tendon sheaths,
even to the bone. It is only by such radical measures that worse
disaster may be avoided. Some aggravated local cases are treated by a
series of deep incisions with the use of the curette, the surface after
careful clearing being kept buried under an antiseptic solution (silver
lactate 1 to 500) or ointment.


RELATION OF LYMPH NODES AND GRANULATION TISSUE TO INFECTION.

In connection with erysipelas and the _role_ of the lymphatics, it is
advisable to consider the relation and behavior of the lymph nodes and
granulation tissue to infecting agents. Depending on the virulence of
the infectious material, the site of infection, and the variety of the
microbe will be its arrival in these protective filters. Then follows a
series of cycles of maximum and minimum activity in the nodes, during
the former the bacteria almost disappearing. The more pathogenic the
microörganism the more certain the destruction of the lymph node, or
perhaps of the individual. The well-known enlargement of the nodes is
due almost solely to an increase in their lymphoid elements. Halban,
who demonstrated these cyclic variations in the contents of the lymph
nodes, is inclined to insist on an intimate relation between them and
the temperature variations noted in cases of septic infection.

When _granulations_ are present the lymph sacs are closed, as by a
sanitary cordon. Unless this tissue is broken they are proof against
ordinary infection. It is well known that erysipelas will appear about
an old wound or sinus that has been rudely probed. Even virulent
organisms spread upon healthy granulating surfaces fail to infect.
Strong carbolic and other toxic agents can be used in and about such
granulating cavities with an exemption from poisoning that otherwise
would produce dangerous effects.




CHAPTER VIII.

SURGICAL DISEASES COMMON TO MAN AND DOMESTIC ANIMALS.


TETANUS.

Synonyms: _Trismus_, _Lockjaw_.

Tetanus is an _acute infectious disease_, of relatively infrequent
occurrence, _invariably of microbic origin, characterized by more or
less tonic muscle spasm with clonic exacerbations_, which, for the
most part, occurs first in the muscles of the jaw and neck, involving
progressively, in fatal cases, nearly the entire musculature of the
body. Certain _races_ of people seem predisposed, and in certain
climates and geographical areas the disease is exceedingly prevalent.
Negroes, Hindoos, and many of the South Sea Islanders show a peculiar
racial predisposition, and, in a general way, inhabitants of warm
countries are less resistant. This is shown partly by the fact that
in various European wars the Italians and French have suffered more
than the soldiers of more northern climes. Tetanus is by no means
confined to adult life, since infants are far from exempt, and in
the _tropics_ the _trismus of the newborn_ is the cause of a high
mortality rate. In Jamaica one-fourth of the newborn negroes succumb
within eight days after birth, and in various other hot countries the
proportion is at times equally great. One plantation owner states that
fully three-fourths of the colored children born upon his plantation
succumbed to the disease. The peculiar reason for this infection will
appear later when speaking of _tetanus neonatorum_. Men seem more
commonly affected than women, probably because of their occupations,
by which they are more exposed. Military surgeons have had to contend
with the disease in its most virulent form, and it has been noted
that soldiers when worn out by fatigue or suffering from the disaster
of defeat seemed more liable to the disease. In 1813 the English
soldiers in Spain suffered from tetanus in the proportion of 1 case
to 80 wounded men. In the East Indies, in 1782, this proportion was
doubled. Quick variations of heat and cold, such as warm days and cold
nights, coupled with the other exposures incidental to military life,
seem to exert a great effect. Curiously enough, the wounded in many
campaigns who have been cared for in churches have suffered more from
the disease than those cared for in any other way. Tetanus, however,
is by no means necessarily confined to any one clime or race, but may
be met with anywhere, at any time, providing only that infection has
occurred. A celebrated Belgian surgeon lost by tetanus ten cases of
major operations before he discovered that the source of the infection
was his hemostatic forceps. As soon as these were thoroughly sterilized
by heat he had no further undesirable complications. If the disease can
be conveyed by the instruments of a careful surgeon, how much more so
by the dirty scissors of a careless midwife, etc.

It is true, also, that the popular notions of the laity concerning the
liability to tetanus after certain forms of injury are not ill-founded.
Small, ragged wounds of the hands and feet are those which ordinarily
receive little or no attention, and are among those most likely to be
followed by this disease. The _toy pistol_, which, a few years ago,
was such a prevalent and widely sold children’s toy, was the cause
of many a small laceration of the hand, due to careless handling and
the peculiar injury produced by the explosion of a small charge of
fulminating powder in a paper or other cap. It was not the character
of the laceration or injury thereby produced, but the fact that such
injuries occurred in the dirty hands of dirty children, which were most
likely to become infected, that has caused the so-called _toy-pistol
tetanus_ to be raised almost to the dignity of a special form of this
disease. During the month of July, 1881, in Chicago alone, there were
over 60 deaths from tetanus among children who had been injured in this
way by these little toys. This led to their sale being suppressed by
law.


=Etiology.=--Two theories have had strong advocates, one being that
which would account for the disease by irritation of nerves; while
the second, the humoral, would explain the disease by alterations in
the blood. Each has had its most ardent defenders, but both have now
completely yielded to the investigations of a few observers, among whom
Kitasato and Nicolaier are the most prominent. These ardent workers
were, in 1885, able to clearly establish the _parasitic_ nature of this
disease, and to isolate and investigate the organisms by which it is
produced.

[Illustration: FIG. 17

Tetanus bacilli, showing spore formation. (Kitasato.)]

The bacillus of tetanus is a somewhat slender, rod-shaped organism,
with a peculiar tendency to spore formation at one end, which gives
it a drumstick appearance. It is essentially an anaërobic organism,
and can never be cultivated in contact with the air. In laboratory
experiments it is grown in the depths of a solid culture medium or
else in fluids and on surfaces in an atmosphere of hydrogen gas. It is
one of the apparent contradictions of bacteriology that this organism,
which can only be grown as an anaërobe, nevertheless abounds in earth,
particularly the rich, black loam which best supports luxuriant
vegetable life, and that it practically inhabits the upper layers of
the soil, which accounts for the fact that so many contaminations and
infections have occurred from stepping upon planks or boards with nails
projecting, or from introduction of splinters, or from lacerations of
the hands and feet which are so often followed by contact with such
materials. There is nothing about a rusty nail wound which, by itself,
predisposes to tetanus, but the rusty nail upon which a person steps
is either itself infected or leaves a rent or wound which may become
infected within the next few moments, and which is not likely to
receive the careful attention which it should. Verneuil has of late
laid stress upon the fact that in localities where horses are kept
tetanus is more prevalent, and that the infectious organism abounds in
and upon stable floors, about barn-yards, and wherever the excretions
of a horse may be found. Bacteriologists are aware that in the
intestines of herbivorous animals the bacilli (anaërobic) of tetanus
and malignant edema are often found. Verneuil has further shown that
almost the only instances of tetanus which occur on shipboard are upon
those ships which are used for transportation of horses and cattle. His
statements are at least interesting, if not absolutely well-founded. At
all events, tetanus is certainly of telluric origin.

A French veterinary surgeon of twenty-five years’ experience had not
seen a single case of tetanus until 1884, when he “removed a tumefied
testicle from a horse, with the _ecraseur_, and it died of tetanus;
in the following six months he castrated five, and all died; another
castrated fifteen in one day, and all died but one; another in ten
days castrated six bulls and operated on three fillies for umbilical
hernia, when five of the bulls and one of the fillies died.” This will
illustrate how the infectious agent may be conveyed by instruments, etc.

The tetanus bacillus manifests other peculiar properties, for some of
which it is most difficult to account. Upon susceptible animals it is
violently infectious, but is rarely found at any distance from the
tissues in which it has first lodged. In laboratory investigations the
period of incubation is seldom longer than forty-eight hours. Another
peculiarity of the organism is that it generates certain poisons of
active properties which may be separated from pure cultures, by whose
injection the peculiar spasms of the disease itself may be reproduced.
These have been isolated, especially by Brieger, who has given to them
the names of _tetanin_, _tetanotoxin_, _spasmotoxin_, etc. It has been
estimated that about ¹⁄₃₀₀ Gm. of the pure toxin of tetanus would be a
fatal dose for a man. This toxin seems to have a specific affinity for
the ganglion cells of the anterior horn of the spinal cord, with which
it unites with great force. Herein lies the secret of its disturbing
power.

It is peculiar that some time may elapse after its injection before the
appearance of the first symptoms. Diphtheria toxins appear to be prompt
in their action, and thus display quite opposite characteristics.
Experiment would seem to show, moreover, that the tetanus toxins do not
reach the cord through the blood stream, but appear to slowly pass
along the axis cylinders. Sensory nerves do not transport the toxins
to the cord. The toxin enters the nerve termination, first of all, at
the site of the infection, where it is most concentrated, which will
explain why the spasms most frequently begin in the vicinity of the
infection, or are the most marked there. Most of the toxin is taken
up by the blood and lymph and distributed all over the body, and
then passing along the motor fibers it enters the cord and leads to
general convulsion. When the toxin is injected directly into the cord
the symptoms begin at once. Therefore, for protective purposes, much
may be expected from the administration of the antitoxin in cases of
suspicious injury or those where experiment has shown there is reason
to fear the development of tetanus. There does not appear to be on
record a single instance in which a person who had been given antitoxin
soon after receiving such a wound has developed tetanus, nor does the
antitoxin by itself seem to have done any harm. Obviously, then, the
earlier antitoxin is used in the case the better. It may be recalled
that there are no diagnostic symptoms of tetanus until the first spasm
develops, usually after the expiration of from five to twelve days. By
this time the nerve cells are thoroughly saturated with the poison and
considerable time may elapse before the antitoxin can reach these cells
by a more indirect route.


=Tetanus Neonatorum.=--Tetanus neonatorum, or _tetanus of the newborn_,
a condition already alluded to, is a remarkably fatal affection,
very prevalent among the negro race, especially in hot climates. It
nowise differs from traumatic tetanus, but is such in effect, since
the infection in these instances always follows the _division of the
umbilical cord_, which is usually effected with dirty scissors in the
hands of a dirty midwife, while the thread with which the cord is tied
is itself a possible source of infection, as well as the rags which
are used to cover the umbilicus in the first dressing. It is generally
fatal, because of the weakness and lack of resistance of these little
patients. It occurs usually within a week after birth, if at all.


=Tetanus Cephalicus.=--Tetanus cephalicus, called also _tetanus
hydrophobicus_ and _head tetanus_, is only a peculiar manifestation of
this same affection, confined mainly to the head and usually following
injuries to this region. The muscle spasms are mostly confined to
the facial, pharyngeal, and cervical muscles, sometimes extending to
the abdominal. These manifestations may be reproduced in animals by
inoculating them on the head rather than upon the extremities. It is
the least fatal form of the disease.


=Symptoms.=--There is always a _period of incubation_, usually three or
four days, occasionally a week in length, but rarely longer.

It is generally held that the longer the period of incubation the more
hopeful the prognosis. While for the great part the disease assumes
an acute type, a chronic tetanus is described and occasionally seen.
The _first warning_ of the disease usually comes as more or less
_stiffness_ of the _cervical_ and maxillary _muscles_, which is likely
to be referred to by the patient as a “sore throat,” because of the
consequent difficulty in deglutition. A complaint to this effect should
be regarded as a warning, especially if on inspection no visible reason
for it can be detected in the pharynx. This complaint is usually made
in the morning after an ordinary night’s rest. This muscle stiffness
will be followed by increasing _tonic spasm_ in the _muscles of the
jaw_, making it difficult to open the mouth, while the head and neck
gradually become stiffened and fixed by spasm of the cervical muscles.
These muscles may now be felt more or less rigidly contracted, as
if by voluntary effort, and the condition, which is at first not
painful, becomes after some hours a source of discomfort, perhaps of
actual pain, to the patient. If the disease pursues the usual course,
the other muscles of the body become gradually affected, usually in
the order of their proximity, but not necessarily so. The _abdominal
muscles_ are _firm_ and board-like, and the dorsal muscles more or less
contracted, sometimes to an extent which causes arching of the spine.
Should the original wound or port of entry for infectious germs have
been in the hand or foot, the muscles of this limb become contracted,
more or less rigidly, holding it in a position which is not easily
changed, even by efforts of the attendant. Sensation is also often more
or less perverted. In this condition of tonic rigidity the muscles
remain, to relax usually only with death.

The most _characteristic features_ of the disease, however, are the
peculiar _clonic exacerbations_, which _convert spastic rigidity_
into _violent and convulsive muscle activity_, so that the limbs and
even the frame of the patient are more or less contorted, the muscle
exertion being sometimes painful to witness. Notable effects are thus
produced; the mouth is peculiarly puckered, and its corners drawn
upward and backward by the risorius muscles, giving to the face that
peculiar expression known as the “_sardonic grin_.” When the abdominal
and flexor muscles of the thighs are involved, and the body is more
or less curved forward, this condition is known as _emprosthotonos_;
when the muscles of the back especially are involved, with the extensor
muscles of the thighs, as _opisthotonos_; and when the body is bent to
one side or to the other it is called _pleurosthotonos_. It is said
that opisthotonic convulsions occur to such an extent in some instances
that the heels touch the head. At all events, the patient’s body is
frequently raised from the bed, so that he rests upon the head and feet.

Another characteristic feature of the disease is the _reflex
irritability_, or _hyperesthesia_, by which these convulsive attacks
apparently are produced. Into this condition the patient falls more or
less rapidly within the first day after the inception of the disease,
and to such a height may it be augmented that the slightest movement in
the room, jarring of the bed, or displacement of clothing, even noise
or a flash of light, may immediately bring on a convulsion. Rupture of
muscles has been reported during some of these violent convulsions.

[Illustration: FIG. 18

Characteristic tetanic spasm in a rabbit twenty-six hours after
inoculation with pure culture of tetanus bacilli. (Tizzoni and
Cattani.)]

During the course of this disease the jaws are so fixed that patients
speak with extreme difficulty and the tongue cannot be protruded. The
mind is clear until the end. The pain is rather the acute soreness due
to intense muscle strain. There is spasm of the sphincters, by which
urine and feces are often retained. There is nothing characteristic
about the temperature, which is seldom much augmented. Attempts to
swallow give pain, and are resisted because of the renewed muscle
spasm which is likely to follow the irritation inseparable from the
act itself. As the result of spasm of the glottis peculiar respiratory
sounds may be noted.

Until the last only the voluntary muscles are involved. Finally,
however, there are spasms of the accessory respiratory muscles and
of the diaphragm. Death is usually produced by involvement of these
muscles analogous to those of the others, and results usually from
_apnea_ or _suffocation_. During the last hour or two perspiration may
be copious and the temperature may rise.

_Chronic tetanus_ is characterized throughout by a milder and much more
prolonged series of symptoms. The period of incubation is much longer,
and, while the general program of the acute form is adhered to, it
is of less severe degree and is spread over a longer time; in fact,
cases covering two months or more are reported. In chronic tetanus the
prognosis is much more hopeful than in the acute form.

The wound is but slightly, if at all, affected. In some cases it will
be found to have healed before the onset of the disease. If suppurating
or open, its evidences of repair will be found unsatisfactory and
some indications of septic infection may be noted. Pricking or needle
sensations may be subjective phenomena.


=Prognosis.=--Prognosis is almost invariably bad; if patients live more
than five or six days it is thereby improved.


=Postmortem Appearances.=--These are rarely distinctive. In most
instances there are evidences at least of hyperemia, if not of more
active changes, in the upper portions of the cord. Less often slight
changes have been noted in the brain, consisting, in some measure, of
disintegration and softening. Evidences of ascending neuritis in the
nerve trunks leading to the injured area have been claimed in some
instances. Few if any distinctive postmortem changes can be described
as due to this disease.


=Diagnosis.=--The diagnosis should be made as between _strychnine
poisoning_, _hysteria_, _hydrophobia_, _tetany_, and, in the beginning,
from pharyngitis, tonsillitis, etc. When the disease is fully developed
it is not likely to be mistaken for anything else.

Tetanus may be simulated by _hysteria_, but in this event the phenomena
will be so uncertain, and the evidences of organic disease so
essentially lacking, that it is not likely that mistake can occur.


=Treatment.=--If any case can be imagined in which efficient treatment
is most urgently demanded it is one of tetanus. In scarcely any
disease, however, is drug treatment so unsatisfactory. In the rare
instances in which patients have recovered it is questionable whether
it is not due to individual resistance rather than to medication.
Treatment may be subdivided into _local_, _constitutional_, and
_specific_. If there is still an _open suppurating or discharging
wound_, it is, of course, essential to cleanse this out, basing this
advice in some measure upon general principles--largely upon the fact,
already stated, that ordinarily only the immediate surroundings of such
a wound are found infected by the bacilli themselves. Consequently
thorough _scraping_, _excising_, and _cauterization_, either with
powerful caustics or the actual cautery, are indicated. Since the
specific germ is an anaërobe, hydrogen dioxide may be used locally with
great advantage, mainly because it oxidizes the albuminous material
upon which the bacilli thrive. If it is in a finger or toe, amputation
may be the simplest method of eradicating the local lesions.

_Constitutional treatment_ may be divided into _nutrition_ and
medication. The tendency too often in these cases is to be careless
or indefinite with regard to the excretions and the nutrition of the
patient. If, for instance, each attempt at catheterization throws him
into convulsions, the bladder may become overdistended and burst. So,
too, there is apprehension usually in regard to fecal evacuations. At
the same time these patients are allowed to almost starve because of
the difficulty of feeding them. It is advisable to resort to chloroform
to permit the introduction of the stomach tube--through the nostrils,
if necessary--by which nutrition may be introduced into the stomach
without causing the violent convulsions that would occur without an
anesthetic. At the same time the catheter may be used.

In the way of _active medication_ there is no agent so efficacious
for controlling the tetanic spasms as _chloroform_, which may be
administered occasionally, or more or less continuously, according to
the wishes of the attendant. By its use the severest spasms can be
kept in abeyance, and the horrible character of the disease somewhat
mitigated. Of the other medicaments used, most of them are of the
nature of nerve sedatives, such as _chloral_, the _bromides_, _Calabar
bean_, _cannabis indica_, _opium_, etc. Hot-air baths or diaphoretics,
by which copious perspiration may be induced, have yielded good results.

_Specific treatment_ means in these instances taking advantage of the
well-known properties which the _blood serum of an animal artificially
immunized_ against the disease possesses. This is in accordance with
experimental labors with a number of different diseases, of which
tetanus is one. It is, in effect, similar to the serum therapy of
diphtheria.

The most hopeful of remedies is _antitoxin_. More lives can be saved by
this preparation, if used _early_ and freely, than by any other known
remedy. Moschcowitz, in 1900, collected 338 cases, with a mortality
of 40 per cent. In many of these cases it was not used early. It is
of importance, however, to use it at the very outset, and to repeat
its use as soon or as often as may be indicated by any exacerbation of
symptoms. In one instance under my observation twenty-three phials of
antitoxin were used before muscle rigidity subsided; in another case
double this amount was used. Without quoting figures it is safe to
say that the former great mortality rate of tetanus has been _reduced
at least 50 per cent._ by its use, and that further reduction can be
effected by its early and prolonged use.

The use of antitoxin nowise takes away the necessity for proper
physical care of the laceration or the wound. Every particle of
affected tissue should be cut away, all the principles of physical
cleanliness adhered to, and proper antiseptics used.

When the antitoxin is used in the presence of the disease it should be
injected into the spinal canal, as it is known that the cerebrospinal
fluid may contain a considerable amount of the toxin and is of itself
highly poisonous. Therefore after inserting the needle into the canal
it is well to withdraw a considerable amount of the fluid before
injecting the antitoxin. If this method is pursued the material is
brought into more immediate contact with the anterior horns of the
cord than could be effected in any other way. After withdrawing all
the fluid that will run through the needle without applying the
syringe--probably 150 to 200 Gm.--10 to 15 Cc. of the antitoxin may
be slowly injected, the process consuming from three to five minutes.
Then a further injection should be made along some of the large nerve
trunks, preferably those leading to the part involved. This injection
should be made with a finer needle, such as that with which cocaine
solution is injected during anesthesia for the prevention of shock.
This is a more effective and less serious matter than trephining the
skull for the injection of fluid upon the surface of the brain. This
may be done while the patient is under the influence of the anesthetic
administered for the purpose of giving proper attention to the wound.
The antitoxin should be injected into the nerve trunks after their
exposure. At the same time it is well to make intravenous saline
injections at more than one point. After from twelve to fifteen hours
the injection of antitoxin and perhaps of saline solution should be
repeated, if necessary, under such light anesthesia as can be produced
by ethyl chloride. Recently a substitute for antitoxin has been
suggested in an emulsion of brain tissue which has been shown to have
a specific affinity for the tetanus toxin. It has been seen that when
these two substances have been thoroughly shaken together the toxin
is removed from the fluid and confined in harmless form within the
brain-tissue cells.

In injecting the antitoxin into the spinal canal no harm will ensue if
a little blood flow through the needle, showing that the cord itself
has been touched.

When there is need to employ this material the brain of a freshly
killed small animal should be removed under antiseptic precautions.
10 Gm. or 15 Gm. should be emulsified in about 30 Cc. of sterile salt
solution, which should then be strained through a sterile cloth under
light pressure. This is then injected as near the wound as possible
and the procedure repeated every day as long as indicated. This method
can only be expected to neutralize toxin that has not yet entered the
nerve cells. Nevertheless, Russian observers have reported thirteen
recoveries out of sixteen instances in which the method was practised.

When no other means are at hand a 1 per cent. carbolic acid solution
may be injected after the same fashion, using such an amount that about
five grains are administered during twenty-four hours to an adult. This
is the method especially favored by the Italians, and is due especially
to Baccelli.

Matthews has devised a method which seems quite effective in
experimental animals. It consists of the use of a solution of the
following: Sodium chloride 4 Gm., sodium sulphate 10 Gm., sodium
nitrate 3 Gm., calcium chloride 14 Cgm., water 1000 Cc. This is
intended for intravenous injection, and must be introduced very slowly.
The performance should be repeated twice during the first twenty-four
hours and once each succeeding twenty-four hours. It produces profound
diuresis, _i. e._, a washing out of tissue cells, as he calls it.


HYDROPHOBIA.

Hydrophobia is _an acute specific or infectious disease_, as far as
known _never originating in man, but transmitted to him, usually
through the bite_ or by inoculation from the saliva of a _rabid
animal_--in this country usually the dog, although the wolf, the cat,
the skunk, and even certain of the domestic poultry, are capable of
conveying the disease. Chickens are said to be immune save when their
vital resistance is lowered by starvation. Chicken blood injected
into other animals seems to antidote the virulence of the virus. It
can also be inoculated in other animals, like rabbits. The _virus_
is ordinarily conveyed in the _saliva_ of the rabid animal. This may
be wiped off as the teeth of the animal pass through the clothing of
the injured individual; consequently, infection does not certainly
follow such bites. But those upon exposed portions of the body, where
animals generally bite, are almost invariably followed by infection.
Hydrophobia is frequently spoken of as _rabies_, sometimes as _lyssa_.
While rare in this country, it is by no means uncommon in Central
Europe, especially perhaps in Russia, where bites from infuriated
wolves are common. In the United States infection comes almost
invariably from the rabid dog, in which this disease presents two types.

The so-called _furious form_ is that which is marked by frenzy and
canine madness, the objective symptoms being more pronounced and
alarming, though not less dangerous than the other variety. After
the period of incubation, which varies considerably, these animals
show depression and uneasiness, and even thus early their saliva is
infectious. Their sense of hunger becomes perverted; they exhibit
unusual tastes, secrete saliva abundantly, which becomes very tenacious
and even frothy, exhibit a dry and edematous condition of the faucial
mucous membranes; the character of the bark is altered, while they are
usually infuriated at the sight of other dogs. In this stage there is
usually insensibility to pain. Finally, come more or less paralysis
of deglutition, quickened respiration, dilated pupils, and frenzy and
madness of manner, by which they attack indiscriminately men and other
animals. To this stage of furious excitation succeeds one of paralysis,
and death follows from exhaustion. These manifestations usually last
about a week.

_Dumb hydrophobia_ is the more common form. Here paralysis appears much
earlier and involves especially the lower jaw; the tongue falls out of
the mouth; and the posterior extremities are quickly paralyzed. This
form is much more quickly fatal than the other.

Animals thought to have hydrophobia should be kept by themselves in a
secure enclosure and carefully watched, especially those known to have
bitten men or other animals. If a suspected dog have been killed before
the suspicion has been confirmed, the head and upper part of the neck
should be removed for examination. Veterinarians claim that what they
call the plexiform ganglion permits an almost certain diagnosis to be
made. The presence of foreign bodies in the stomach of the animal is a
corroborative feature. Diagnosis by subdural inoculation requires two
or three weeks, and in at least one case a human patient died while
waiting for diagnosis to be thus established.

_Hydrophobia in man_ is rare in this country, yet is occasionally
observed. Its etiology is as yet obscure. That a _contagion vivum_ is
present is positive, but its nature is uncertain. Negri, of Pavia, has
recently described certain bodies observed in the nervous system of
animals dead of hydrophobia which may offer the solution of the problem
that has so long been sought. They are found in the protoplasm of nerve
cells, but not in their nuclei. They are round or oval in shape, vary
in size from 25 microns down to those which can be barely seen with the
highest powers. They take ordinary stains.

Negri maintains that these bodies are parasites and he has invariably
failed to find them in animals which did not have rabies. His work has
been confirmed by a number of his colleagues, and bids fair to furnish
a reliable and rapid means of diagnosis. The fact that the virus of
hydrophobia will pass through a porcelain filter nowise contradicts the
view that these bodies may be parasitic, for it is quite possible that
they undergo different stages of development, in some of which they are
small enough to pass even barriers of porcelain.

In fact it seems to have been positively demonstrated that these bodies
described by Negri, in 1903, are diagnostic for rabies. They are most
likely to be found in the horns of Ammon or the cerebellum. When found
here, careful examination must be made of the Gasserian ganglion, where
may be found the lesions first described by Van Gehuchten and Nelis,
which consist of a proliferation of the endothelial cells to such an
extent that the ganglion cells are first invaded and then destroyed,
their places being taken by the new cells.

The Negri bodies have been generally regarded as protozoa and the
specific cause of the disease. At all events, it seems possible always
to successfully reproduce the disease in rabbits or guinea-pigs by
inoculation with these bodies.

If examination shows neither the Negri bodies nor the lesions in the
ganglion the presence of the disease can scarcely be suspected, and
could only be proved by animal inoculations, which, however, would be
advisable in doubtful cases where human beings have been bitten.


=Symptoms.=--The _period of incubation_ in man is variable, ten weeks
being perhaps the average. It is shorter in children, as also when
the bites are numerous. It is even stated that it may be as long as a
year or more, during which time the poison seems to lie latent. When
the active symptoms supervene there are, locally, discomfort about
the wound, itching, heat, and peculiar unpleasant sensations. It is
said also that vesicles may make their appearance in the neighborhood
of the original lesion. _As in animals, so in man_, the disease may
assume either the _furious_ or the _paralytic_ type. These cases are
nearly all marked by mental depression and apathy, with complete
loss of courage. The earlier symptoms are connected perhaps with the
respiration, which is infrequent, while inspiration is halting and
speech is interfered with. The facial appearance is often changed
to one of anxiety, even despair. The muscles of deglutition are
next involved in a combination of spasm and paralysis, and the act
of swallowing is interfered with, sometimes made almost impossible.
Although patients can swallow their own saliva, they find it difficult
to swallow any foreign substances, such as water, etc. This is _not
due to the fear of water_, as the term “hydrophobia” would imply--this
being an absolute misnomer--but is due to reflex spasm excited by
the attempt. It is accompanied by more or less sense of suffocation
and palpitation of the heart. Indeed, a paroxysm of this kind may
be precipitated by the attempt to swallow, so that the patient
instinctively refuses water or any other fluid. _Reflex excitability_
is also very great, and a breath of air or a trifling disturbance may
precipitate a paroxysm, almost as in extreme cases of tetanus. As the
case progresses the saliva becomes more tenacious and viscid, faucial
irritation more marked, and the attempts to expel the secretion, along
with the disturbed respiratory efforts, have given rise to the foolish
lay notion that these patients bark like dogs. The paroxysms, as the
case progresses, become more marked, the patient more restless, until,
later, furious mania or muttering delirium is present, to be followed
by prostration and paralytic phenomena, muscle tremor, etc., and death.

The _paralytic form in man_, as in dogs, is marked by the much
earlier paretic phenomena, anesthesia, and, finally, respiratory
paralysis which terminates the case. Curtis and others have insisted
that the hydrophobic paroxysms are not convulsions in the ordinary
sense of the term, but are due to temporary inhibitions of the most
important respiratory and cardiac centres as the result of peripheral
impressions. He likens them to the shock of a shower bath.


=Postmortem Changes.=--Postmortem changes are indistinct and only
suggestive. They consist for the greater part of a sort of vacuolous
degeneration of the ganglion cells of the nerve centres--most
prominently in the medulla, next in the hemispheres, and then in
the spinal cord. There is hyperemia, with minute ecchymoses, with
infiltration of the adventitia of the vessels and perivascular
extravasation. The changes met with in the other viscera bear no
constant relation to symptoms. Nevertheless, Gowers holds that because
of the location of the lesions and their intensity in the neighborhood
of certain nerve nuclei we have here a distinguishing anatomical
character of the disease.

The toxin (as we may call it for the lack of a better term) seems to be
transmitted much as is that of tetanus (_q. v._), along the afferent
nerves to the cells of the anterior horns of the cord.


=Diagnosis.=--As between hydrophobia and tetanus diagnosis is not
difficult, as already described. In certain hysterical individuals
nervous paroxysms, largely due to fright, may be precipitated by
dog-bites and other incidents or accidents. In these cases there is
rarely such a period of incubation, and in a true hysterical case there
will be no such mimicry of this awful disease. A condition known as
_lyssophobia_ (fear of hydrophobia) has been described. It is seen in
hysterical subjects. It is said to have even been fatal, but this must
have been from other complications.


=Treatment.=--There is no authenticated case on record of recovery
after medication by drugs. It is probable that recovery has never
followed anything but the modern inoculation treatment.

The only successful treatment for this disease has been elaborated
as the result of the labors of that indefatigable French savant,
Pasteur, and is among the glorious triumphs of laboratory research,
against which it is so often charged that it is not practical in its
results. It is in some respects a curious commentary on the study of
infectious disease that we can secure and work with the peculiar virus
of hydrophobia, and at the same time be utterly unacquainted with its
true character. To this fact is due the modern cure. It is based upon
the fact that the virus is not only in the saliva, but also in the
nervous system of animals suffering from this disease, and that its
effects are intensified and hastened by inoculation directly into the
cerebral substance. Accordingly, when a diagnosis of hydrophobia can
be reasonably well established, no time should be lost in sending the
patient to one of the “Pasteur Institutes,” to be found now in most of
the great centres, there to undergo a regular course of treatment. It
was reported that in the Institute in Paris, between the years 1886
to 1894, there were treated a total of 13,817 cases, and that the
mortality was 0.05 per cent. Of course but a small proportion of these
really had or would have developed the disease.

Virus obtained from the brain or cord and inoculated into the dura
of another animal quickly precipitates the disease. It is, moreover,
modified in virulence as it passes through successive animals of
certain species--for example, monkeys. It is increased by passage
through rabbits, and the period of incubation thereby shortened.
The weakest virus can by proper handling and manipulation in this
way be so intensified as to produce disease within seven days after
inoculation. Desiccation reduces the virulence, and preparations from
the cord of an infected animal may be attenuated to almost any desired
extent by drying. By inoculating a dog or a rabbit with virus prepared
from this weakened source, and daily making injections from stronger
and stronger preparations, it is in the course of a couple of weeks
rendered practically immune to the disease. Animals thus made immune
are trephined and the virus injected beneath the dura, by which more
certain results are obtained. The treatment consists in using a section
of a rabbit’s spinal cord, 0.5 Cm. in length, rubbed up in 6 Cc. of
sterile salt solution. Half of this amount is injected each day into
the flank of the patient. The cord first used is one that is thirteen
or fourteen days old, which has been kept suspended in a sterile flask,
over caustic potash, in order to assist in its desiccation. The next
day a cord one day younger is used, and so on until by the twelfth day
of treatment the cord is one only two days old, and at the end of two
weeks a fresh cord can be used which would convey the disease had it
been used first. If this course of treatment can be carried through
before the first symptoms of the disease appear, the antidote has
gained complete mastery over the infecting agent and the patient is
saved.


GLANDERS AND FARCY.

Glanders as it is known in man is a _specific infectious disease,
transmitted usually from the horse, characterized by rapid formation of
specific granulomas_, particularly in the skin and mucous membranes,
_which quickly break down into ulcers_, and by the general toxemia
characteristic of any acute infection. In German it is known as _Rotz_,
in French as _morve_, while its old Latin name was “malleus” (hence
we speak of the _bacillus mallei_). It was also known in former days
as _equinia_. In horses the disease has also been known as _farcy_,
because of the peculiar subcutaneous nodules which farriers and
hostlers, almost from time immemorial, have called “farcy buds.” The
disease, while capable of transmission from man to man, is generally
produced by contagion from some of the domestic animals, most commonly
the horse, although sheep and goats are known to occasionally have it,
and dogs are susceptible, though seldom showing manifestations of it.

Like some of the other infectious diseases glanders appears to be
variable in its manifestations. While infection occurs probably through
some superficial abrasion, it is almost certain that it may also occur
through the unbroken mucous membrane of the respiratory organs. It
is said to be also capable of transmission from mother to fetus _in
utero_. So far as known in man, infection occurs practically invariably
through some slight abrasion, either of the skin or the mucous membrane
of the nose, the eye, or the mouth. The discharges from the nostrils of
affected animals are extremely virulent, and infection comes usually
from this source. It is said to have been communicated from one patient
to another by eating from the same dish or by drinking from a pail used
by a diseased horse.

Glanders is due to the specific bacillus known as the _bacillus
mallei_. It is shorter and plumper than the tubercle bacillus, in
length about one-third the diameter of a red corpuscle. It is a
non-motile organism, occasionally spore-bearing, not very resistant,
belonging to the facultative anaërobic forms, growing best at blood
temperature, taking stains easily, and losing them in the same way.


=Symptoms.=--Glanders is seen usually in workers and hangers-on in
stables. The _acute_--the common--form has a _period of incubation_
of from three to seven or eight days, after which both local and
general symptoms supervene. About the infected region a form of
cellulitis appears, assuming often a more or less phlegmonous type,
with implication of the adjacent lymphatic nodes and evidences of
periphlebitis and perilymphangitis. Over the affected area vesicles
appear, which become hemorrhagic and later suppurate. A wound which has
healed may reopen. Almost always there are accompanying constitutional
disturbances of septic type, occasionally chills, pyrexia, etc. It is
rather characteristic of glanders to have severe pain in the muscles
and extremities, with epistaxis and formation of metastatic tumors and
edematous swellings in various parts of the body. Frequently, later
in the disease, appears a somewhat distinctive eruption, papular in
character, merging into pustular. Hemorrhagic bullæ are also often
seen. Pustulation and edema of the face change its appearance. There
are also edema of the eyelids and _mucopurulent discharge from the
conjunctivæ and the nose_. This latter discharge is often ozenous in
character. Upon inspection of the nasopharynx and oropharynx a similar
condition will be noted. In connection with these local signs more or
less general furunculosis also will be observed. Obviously, as these
local conditions intensify and multiply, septic disturbance will be
increased, and the patient dying of acute glanders dies generally of
septicemia or intoxication and exhaustion combined.

A chronic form is known, distinguished mainly by slowness or tardiness
of lesions, though the local changes are not particularly different in
character. There is perhaps more tendency to suppuration and less to
lymphatic complications. The nodule which breaks down will leave a foul
ulcer, the _discharge_ from these lesions being _extremely infectious_.


=Diagnosis.=--This is not always easy, but may be based in suspicious
cases to some extent upon the occupation of the patient. The presence
of multiple lymphatic lesions and subcutaneous nodes, especially when
breaking down as above described, and accompanied by ozenous discharge
from the nose, should at least be suggestive, and will serve to
distinguish between this disease and, for instance, typhoid fever. The
chronic type of glanders might be mistaken for syphilis, and here is
where the real difficulty of diagnosis will probably occur. In doubtful
cases the crucial tests are the microscopic examination of discharges,
after staining for bacilli, and the cultivation test.


=Prognosis.=--A generalized attack of glanders is a matter of gravest
import, especially when acute. Scarcely more than 10 or 15 per cent. of
such cases recover. In the more chronic manifestations the prognosis is
more favorable, half of the patients making a final recovery.


=Treatment.=--All infected animals should be isolated and destroyed,
their carcasses being _burned_. If possible, the infected wound or
abrasion should be induced to bleed freely, and then cauterized with an
active caustic. By prompt interference with the first manifestations
it may be possible to cut short the disease. This would necessarily
be done by _excision_, _cauterization_, _packing_, etc. Bayard Holmes
has reported a case in which, during two and a half years of chronic
manifestations of this disease, he anesthetized the patient twenty
times for the purpose of opening new foci or scraping out old ones,
finally obtaining a permanent cure. There is no specific treatment, but
the septic symptoms should be combated as indicated in the chapter on
Septicemia.

By making a _glycerin extract_ from the filtered and evaporated culture
of the glanders bacillus it is possible to prepare a toxalbumin
analogous to tuberculin, which reacts in a similar way. By it animals
may be fortified against inoculation, and by its use a peculiar
reaction is produced in those affected by the disease. It is known as
_mallein_, and by it are tested all horses used for the preparation of
the diphtheria antitoxin, in order that all possibility of glanders
may be eliminated. It is probable that it might be made of therapeutic
value in treating the disease when actively present in man.


ANTHRAX.

Anthrax is more commonly known as _splenic fever_, _malignant pustule_,
or _woolsorters’ disease_; in Germany as _Milzbrand_, and in France as
_charbon_. It is an infectious disease of cattle, which has devastated
many parts of Central Europe, and has been frequently met with on
the Continent among men, though but rarely in the United States. All
the domestic and nearly all the experimental animals are subject to
it. Gronin has stated that in the district of Novgorod, in Russia,
during four years more than 56,000 cattle and 528 men perished from
anthrax. Poultry and dogs are not strictly immune, but possess a low
susceptibility to the disease. It generally prevails in low districts
and in marshy grounds.

The disease is the result of the invasion of the _bacillus anthracis_,
which is a relatively large-sized bacillus, varying in breadth from 1
to 1¹⁄₂ and in length from 5 to 20 microns. It is easily cultivated
outside the body, and multiplies with great rapidity in the bodies
of susceptible animals; it is the type of spore-bearing bacilli, and
is so readily recognized and worked with that it is commonly used in
laboratory investigations. The demonstration of its specificity we owe
to Davaine, in 1873, although he had described it in 1850.

[Illustration: PLATE IV

FIG. 1

Anthrax Bacilli. Spore Formation. (Karg and Schmorl.)

From an agar culture twenty-four hours old. About the margin of the
photograph are a number of free spores, × 600.

FIG. 2

Anthrax Pustule. Removed from Arm of Man. (Karg and Schmorl.)

Marked edema of the skin, causing elevation and separation of the
papillæ. In the edematous exudate a large number of anthrax bacilli and
leukocytes. × 50.]

_Anthrax bacilli_ may enter the body through the _respiratory
organs_, through any _abraded surface_, and possibly even through the
_alimentary canal_. They may also pass through the placenta and affect
the fetus _in utero_. They are too large to pass through the walls
of the capillaries of ordinary size; consequently they plug them and
produce a mechanical stasis which is rapidly followed by gangrene. From
the kidney structures and capillaries, however, they may escape, as
bacilli are found in the urine in certain cases of anthrax. (See Plate
IV.)

In _man_ the disease occurs usually as the so-called _malignant
pustule_, or _woolsorters’ disease_, the latter name being given
because of the liability of those individuals who come in contact
with the carcasses and hides of diseased animals or their immediate
products. The _period of incubation is brief_--on the average two
or three days. The first lesion appears usually on the face, hands,
or arms, and is characterized by local discomfort with formation
of a small papule, which rapidly becomes a vesicle with an areola
of cellulitis about it. This is rapidly followed by induration and
infiltration, and these by local gangrene, the result being the
separation of a core-like mass, similar to that of carbuncle. The
affected area is usually discolored, often quite black. The process
is not usually accompanied by suppuration, nor is there the pain of
true carbuncle. The lesions tend to spread peripherally, but there is
more or less vesication of the surrounding skin. On account of the
local ischemia there will always be edema of the affected region,
and sometimes the swelling and local disturbance become extreme.
These peculiar lesions have given rise to the common name _malignant
pustule_, which is well deserved. At last a line of demarcation becomes
manifest, and if the disease progresses favorably the included area
is sloughed out, leaving a surface which it is hoped will soon become
covered with reasonably healthy granulations.

Absence of pain, and usually of pus, are significant features of
anthrax. Should mixed infection occur, however, we are likely to see
pus formation. When the disease partakes less of the characteristics of
malignant pustule and more of a general infection, the local symptoms
may not predominate, but, on the contrary, septic indications may
become serious and even fatal. The evidence of more or less toxemia
is usually at hand, however, and the toxin of anthrax is almost as
destructive of muscle cell integrity as is that of diphtheria.

The local lesions may be single or multiple, but will be met with
almost always upon exposed areas of the body.


=Postmortem Appearances.=--These will depend upon the clinical course
of the disease. In the sloughing tissues the bacilli are very numerous,
while around the margin more than one bacterial form will probably be
met--_i. e._, mixed infection. Should saprophytic organisms complicate
the case, they may have replaced the anthrax bacilli by the time the
examination is made. The latter abound, however, in the blood, and
may usually be found occluding the capillaries of the liver, spleen,
kidney, etc. In intestinal infection, particularly in animals, the
mesenteric nodes are involved. Inasmuch as septic features accompany
all fatal cases, putrefaction will be found to begin early, and the
changes in the blood and the gross changes in the other organs will
resemble sepsis rather than anthrax.


=Prognosis.=--Prognosis for man is not usually unfavorable, the
majority of cases recovering with more or less local destruction of
tissue. Should, however, infection become generalized, the case will
probably terminate fatally. Cases assuming the type of splenic fever
are of much more serious character, and their prognosis graver.


=Treatment.=--This should be both local and constitutional. The
former should consist of the most radical possible attack and include
complete excision of the infected area, with the use of active caustics
or the actual cautery. In fact, the latter instrument offers a most
valuable means for combating the destructive tendency of the disease.
Sloughing and separation of the cauterized mass may be hastened by
warm antiseptic poultices. Subcutaneous injections of 5 per cent.
carbolic solution have been given, with apparent benefit, in a number
of cases, but should only be relied upon in the treatment of the milder
manifestations.

Benefit will accrue from the use of the ichthyol-mercurial ointment
whose formula was given under treatment of Erysipelas. It has been
suggested to treat these cases by the employment of the bacillus
pyocyaneus, since it is known that this organism when injected with the
anthrax bacillus materially attenuates its effect.


=Prophylaxis.=--Prophylaxis is most important. The bodies of all
infected animals should be burned, not buried, since the resistant
bacilli are often brought to the surface of the soil by earth-worms.
Every discoverable source or medium of infection should be destroyed or
sterilized.


MALIGNANT EDEMA.

This disease has been recognized for some time, mainly by French
and Continental clinicians, and under such names as _gangrène
foudroyante_, _gangrène gazeuse_, _gangrenous septicemia_, and
_gangrenous emphysema_. The name _malignant edema_ was given by Koch,
who identified the infecting organism. It is one of the most dangerous
forms of gangrenous inflammation, and occurs sometimes after serious
injuries, and, again, after most trifling lesions, such as those
inflicted by the dirty pointed implements of the gardener, etc., or
even the stings of insects. Two cases are on record where the disease
followed a puncture of the hypodermic needle for the administration of
morphine. In one of these the organism was found in the solution; in
the other it probably had been deposited upon the skin.

Malignant edema is essentially a specific form of _gangrene_ (see
Chapter V), and is mentioned here rather because of its specific
character. It is characterized by rapidity of spread and the specific
nature of the exudate, as well as by the speedy destruction of the
tissue involved, and by more or less gas formation. It is not the
same as the gaseous phlegmons described by some German surgeons, yet
partakes of their general character. _Gas phlegmons_ have been rarely
noted, their peculiarity being formation not only of pus, but of more
or less offensive gases, which escape when the phlegmon is incised.
The gases are mainly due to the presence of _bacillus aërogenes
capsulatus_, and gas phlegmons, as such, are to be regarded as
instances of mixed or rarely pure infection.

Malignant edema is known by the brownish discoloration of the overlying
skin, which is streaked with blue where the overfilled veins show
through it, while the underlying tissues are sodden with fluid and
more or less inflated by the gaseous products of decomposition, so
that the finger detects a firm crepitus, as is common in subcutaneous
emphysema. From the wound, if there is one, flows a thin, foul-smelling
secretion, which may also be expressed from the deeper layers. That the
neighboring lymph spaces and nodes are actively involved is evident
from the enormous swelling of the latter, as well as from the general
condition of the patient. The rapid elevation of temperature with
but trifling remissions remains constant until shortly before death.
The tongue early becomes dry and cleaves to the palate, its surface
being covered with a thick, foul fur. Patients early become apathetic,
complaining only of pain and burning thirst. Delirium and coma usually
precede death, which may occur in fifteen to thirty hours. After death
the cadaver bloats quickly and putrefaction goes on with amazing
rapidity.


=Postmortem Appearances.=--At the seat of the lesion even muscles
and tendons will be found macerated, bone denuded and surrounded by
a putrid fluid, the entire region presenting a notable swelling and
infiltration of soft parts with reddish fluids and stinking gases. The
overlying skin will be stretched, and superficial blisters may deepen
the intensity of the process. The veins are clogged with decomposed
blood and broken-down thrombi, and in the heart and large vessels will
be found putrid liquid as well as gas, to whose presence early and
sudden death is probably due.


=Prognosis.=--This is unsatisfactory, especially when the bacillus
of malignant edema is alone at fault. Patients may escape with their
lives, but always at the expense of more or less tissue destruction.


=Treatment.=--This should consist of extensive incision to permit
escape of fluids and gases and relieve tension; of such antiseptic
applications as can be made available; of immersion of the affected
part in a hot antiseptic bath; and of such vigorous stimulation by the
most powerful measures--strychnine, alcohol, etc.--in order to support
the patient through the period of profound depression characteristic of
the disease.

[Illustration: PLATE V

Actinomycosis. Ray Fungus in Man. (Gaylord.)]


ACTINOMYCOSIS.

This also is a _subacute_ but always _destructive infection by a
specific microörganism, though not a bacterium_. Known always as
_actinomycosis_ in man, the disease, which is most common in cattle,
is called _lumpy jaw_ or _swelled head_, and years ago was usually
regarded as cancer or as a malignant affection.

Many museum specimens labelled as cancer of the tongue, jaw, etc.,
have been shown to be instances of actinomycosis of these parts. It
is occasionally met with in man, so that there are at least four
hundred cases on record in this country and in Europe. The organism
was recognized a half-century ago by Langenbeck and Lebert, but was
not scientifically described until many years later. The names of
Bollinger, Israel, and Ponfick will always be connected with these
researches.

The organism belongs among the _ray fungi_, is known as the
_actinomycis_, and occupies an uncertain place in classification.
It is large enough, when entire, to be perceived by the naked eye,
has ordinarily a yellowish tint, a tallowy consistence, and may
be seen under the microscope to consist of a cluster of branching
prolongations, club-shaped at the end, radiating from a common centre.
They give it a sunflower appearance. It is stained with difficulty,
the best stain being a combination of picrocarmine and an aniline dye.
In tissue sections the Gram stain is the best. It is cultivated with
difficulty, but can be grown upon solid media and may be inoculated.
(See Plate V.)

As met with in tissue or in pus these fungi constitute small
granulations, giving usually a gritty sensation to the finger, which
is due to the presence of calcium salts. The recognition of this
calcareous material is of importance, since it may enable a diagnosis
to be made offhand, in a case which otherwise might puzzle one.

The disease is very common among cattle in certain regions, and causes
the condemnation of many animals in every large stockyard establishment
where inspection is careful and scientific. It occurs oftener in
young than in old animals, and most frequently in those which come
from valley regions and marshes. In animals infection occurs almost
invariably through the mouth, which is easily explained by the fact
that, in grazing, the lips, tongue, and gums are likely to be irritated
and infected at any time from soil containing these fungi along with
growing grain. The path of infection is usually by the mouth, while
accident seems to determine whether the infection shall manifest itself
mainly in the intestinal canal or the respiratory tract. In animals
there is less tendency to suppuration than in man, the infection in man
being usually a mixed one. The name _lumpy jaw_, so generally given
to the affection, is indicative of the most conspicuous lesion in
cattle, for the organism, having once invaded the gum, for instance,
passes quickly to the bone, or, having involved the tongue, is not
slow to infect the lymphatics of that region. In consequence we have
tumors, often of inordinate size, which may involve the bones or the
soft parts and cause great disfigurement, along with necrosis, leading
eventually to the death of the animal. These tumors are essentially
_granulation tumors_ due to the presence of a specific irritant--the
_actinomycis_--which acts here as do the tubercle bacillus, the lepra
bacillus, etc., in other infectious granulomata.

In man the disease is generally accompanied by abscess formation,
the pus containing the distinctive yellow gritty particles which are
found in no other disease. The strong resemblance between the lymphoid
cells of this form of granuloma and the embryonal cells of sarcoma has
permitted the perpetuation of confusion between these two neoplasms.

[Illustration: FIG. 19

Actinomycosis in man. (Lexer.)]

Large abscesses form as the result of the coalescence of small ones,
and by the time the disease is recognized extensive destruction and
loss of substance may have taken place. In man it is not alone about
the mouth that the disease is noted, although primary lesion here is
by no means infrequent. It leads to affections similar to that already
spoken of in cattle, with a progressive infiltration and breaking down,
including actual necrosis of bone, etc. The pus will escape at various
points, and may give to the surface an appearance as of many craters
with a central cause. When the disease has involved the lung, either
directly or indirectly, the fungi and the calcareous particles may be
found in the sputum. Should there be suspicion of this involvement, the
sputum should always be examined. Even in the heart substance tumors of
this same character have been found. The first case noted in man had
undergone extensive vertebral caries. Intestinal infection is possible,
in which case multiple lesions will form in the intestinal walls,
which may contract adhesions to the abdominal parietes and discharge
externally through them. The appendix has been found involved in such
lesions. Infection of the skin has also been described, though this
occurs more rarely.


=Diagnosis.=--Actinomycotic lesions have been _mistaken for cancer_,
_sarcoma_, _tuberculosis_, _syphilis_, etc. In man it will always
be characterized by more or less suppuration, and in the purulent
discharge from the infected focus the yellow calcareous particles
should enable recognition of this disease at once.


=Prognosis.=--As long as the focus is accessible it is a purely local
matter, and prognosis is as favorable as in local tuberculosis; but,
inasmuch as in many cases infection has proceeded to a point where
the surgeon cannot safely follow it, prognosis must be guarded.
Actinomycosis is free from acute manifestations, for the main part free
from pain, pursues a chronic course, and is characterized, as are the
other slow infections, by progressive emaciation, prostration, etc. As
it is essentially a chronic condition, time is afforded for careful
study in doubtful cases, for microscopic examination, etc.


=Treatment.=--This must consist of extirpation of all infected tissues
and areas. If this can be done thoroughly there is a prospect of
positive cure. Free incision, wide dissection, the use of the actual
cautery, etc., are always called for in these cases. If it involves
the tongue alone, there is an excellent prospect; if but a portion of
the jaw is involved, a complete excision of one-half or more may be
followed by excellent results. If, however, the lung, liver, vertebrae,
or other vital and inaccessible parts are involved, surgical measures
may afford amelioration, but can hardly be expected to cure.

Iodine, alone or in combination, has been found efficacious in the
therapy of actinomycosis. In diluted solutions used locally, or as
potassium iodide given internally or injected into tumors, it doubtless
has a beneficial effect during the period of its administration.
Recent reports and experiences show that great value attaches to the
use, as suggested by Bevan, of copper sulphate in the treatment of
actinomycosis, its use having been suggested by the fact that copper
is used to destroy rusts (fungi) on grain. One-half grain (3 Cg.) may
be given internally three times a day, while the sinuses are irrigated
with a 1 per cent. solution. I have seen apparently complete cure of
an aggravated case follow its use. Incidentally it may be stated that
Bevan advises its use also in cases of blastomycosis.


MADURA FOOT.

While _madura foot_ is not a disease from which domestic animals
suffer, its general characteristics make it a proper subject for
brief consideration. It is essentially a disease of the tropics and
subtropics, and is often seen in some of our new possessions.

It commences as a painless swelling upon either aspect of the foot, in
which hard nodules form, which later soften, ulcerate, and discharge
puruloid material containing granules in which the microscope reveals
mycelia of the peculiar fungus that produces the disease. In some cases
these particles are black, in others colorless. The disease is of slow
progress, and the lower limbs become weak, atrophied, and finally
useless Death results from exhaustion or some terminal infection.

The principal lesion is the slowly growing gumma or granuloma, whose
presence is unmistakable. This is due to the presence of a fungus,
called by Vincent the _streptothrix maduræ_. Thus in its pathology the
disease much resembles actinomycosis. The habitually bare feet of most
of the inhabitants of the tropics and the habitat of the fungus explain
the site of the primary lesion.


=Treatment.=--The only _treatment_ is extirpation of the growth--_i.
e._, amputation.

[Illustration: PLATE VI

Tuberculosis of Testicle.

Miliary Tubercle with Caseation and Giant Cells. (Gaylord and Aschoff.)

_a_, seminal tubules; _b_, giant cells; _c_, caseated tubercles.]




CHAPTER IX.

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS (CONTINUED).


TUBERCULOSIS.

The most important and frequent of the infectious diseases common to
animals and man is _tuberculosis_. This appears usually as a subacute
or chronic affection, although in a small proportion of cases it
assumes an acuteness of type which may make it fatal within as short
a time as fourteen or fifteen days, or even less, from the first
recognizable symptom. Tuberculosis is more prevalent than any other
form of disease, and is the cause of death of a proportion variously
estimated at from 20 to 30 per cent. of mankind. It is a disease which
perhaps concerns the surgeon more than the physician, inasmuch as it is
also the most common of the so-called surgical diseases. Its frequency
varies in different parts of the country. In the average surgical
clinic of the United States probably 20 to 25 per cent. of cases are
manifestations of this affection.

Surgical tuberculosis covers the entire range of diseases formerly
described as _scrofula_. The term scrofula is now expurgated from
medical terminology. All of the active manifestations formerly regarded
as scrofulous are known to be due to tuberculosis.

To the presence of tubercle bacilli in the tissues is due that
distinctive aggregation of cells which constitutes the so-called
_miliary tubercle_. Its presence and arrangement are apparently the
direct outcome of the irritation produced by these minute foreign
bodies, and its method of grouping is so characteristic that it may
be everywhere and usually easily recognized. Its centre is composed
of one, possibly several, _giant cells_, whose nuclei are generally
arranged around its margin, with perhaps degenerative changes going
on in the interior of the cell itself. In this giant cell, as well
as outside of it, may be seen one or several _tubercle bacilli_.
Around this centre are clustered a number of large cells known as
_epithelioid_, which may also contain bacilli. These cells are probably
derived from epithelium when at hand, or from the endothelium of the
vessel walls, or from the fixed tissue cells. Outside of these are
other, usually spindle-shaped, cells, contained in a connective-tissue
network and regarded mostly as _lymphoid cells_. When tubercle is
experimentally produced the bacilli seem more numerous than they do
in instances of spontaneous disease. This little aggregation of cells
constitutes a mass which may be recognized by the naked eye--a minute,
usually white point or nodule, which is known as a _miliary tubercle_.
It is subject to any one of several changes to be presently considered,
and it is usually found in large numbers. The punctate appearance
of miliary tuberculosis is perhaps best seen upon the cerebral
membranes or the peritoneum in cases of acute miliary tuberculosis. By
coalescence of a number of these nodules larger tubercles are formed,
and by combination of coalescence and caseous degeneration are produced
the large cheesy masses which were formerly called _yellow tubercle_.
(See Plate VI.)

The epithelioid cells are by some regarded as modified leukocytes; by
others as the product of division of the fixed cells. The giant cell is
probably the result of irritation in one of these cells, the stimulus
being sufficient to provoke division of the nucleus, but not of the
entire cell. As the principal cellular activity occurs in the interior
of this nodule the result is a condensation about the periphery which
furnishes eventually a sort of capsule, the tissues being hardened and
condensed as if for this special purpose. The effect of this is to
interfere with vascular supply and finally to shut it off completely.
As long as no pyogenic infection occurs, the original tubercle may
gradually shrivel down and disappear or caseous degeneration may
occur, and it may persist as a cheesy nodule for an indefinite time.
As such a tubercle grows old the cells lose their identity, refuse
to take stains, and a slow or quiet coagulation necrosis results. In
this nest sometimes calcium salts are precipitated, the result being
a _calcareous nodule_. On the other hand, during the active stage of
this tubercle formation cell resistance may be lowered, either from
general or constitutional causes; the original focus disintegrates;
tubercle bacilli are liberated, and are now carried hither and thither,
_metastatic tubercles_ being the result of their dissemination.

Spontaneous healing of tubercle is possible, and may be due to three
different causes:

  (_a_) Necrosis and exfoliation of diseased tissue (_e. g._, in lupus);

  (_b_) Cicatricial formation;

  (_c_) Retrograde metamorphosis.

Looked at from another point of view, the possible fates awaiting the
miliary tubercle are the following:

  (_a_) _Absorption_;

  (_b_) _Encapsulation_;

  (_c_) _Cheesy degeneration_;

  (_d_) _Calcareous degeneration_;

  (_e_) _Suppuration_.


=Absorption.=--Absorption of tubercle undoubtedly is possible under
favorable circumstances, but just what constitute these favoring
circumstances no one knows, since they occur in cases which do not
terminate fatally. To be able to describe them would be to detail
minutely the changes which permit of recovery after non-traumatic
tuberculous infection, which clinical fact is amply demonstrated by the
experience of the profession. Absorption is probably largely a matter
of phagocytosis.


=Encapsulation.=--Encapsulation has already been spoken of, the
capsule being formed by the condensation of the original cells of the
tuberculous agglomeration, the infectious organisms being thereby
imprisoned as long that they are practically starved and finally die.
The tubercle bacilli, however, may long lie latent in such a cellular
prison, and should anything occur to break the prison wall they may
escape and still prove actively infectious. In this way are to be
accounted for the fresh eruptions from old miliary or other deposits.


=Caseation.=--Caseation comprises a series of changes in the chemical
constitution of the cells by which an albuminoid mass much resembling
casein in composition and appearance is produced. The English
equivalent _cheesy_ well describes many of these masses, which both cut
and appear very much like domestic cheese. They have a yellowish color,
and are met with in masses in size from a pin’s head up to a robin’s
egg. These are the yellow tubercles of the older writers, and such a
cheesy tumor has been called _tyroma_.


=Calcification.=--Calcification refers to a peculiar deposition
of calcium salts within the interior of these nodules, the first
precipitation occurring usually in the centre of the giant cell, which
is itself the topographical centre of the miliary tubercle. It may
spread from this until a mass easily recognizable by the naked eye and
detectable by the finger is produced. Such calcareous particles are
frequently found in sputa, and are always an index of the tuberculous
character of the case. They differ markedly from the yellow calcareous
nodules found in the pus of actinomycosis, the circumstances under
which they are likely to be confused being met in pulmonary disease.


COLD ABSCESSES.


=Suppuration=, as indicated, is the result of a mixed or secondary
infection with pyogenic organisms. In the previous chapter tubercle
bacilli were grouped as among the facultative pyogenic bacteria, yet
pus is not formed in this disease except in consequence of coincident
activity of other bacterial organisms. Suppuration of tuberculous foci
is of importance to the surgeon, because thereby is produced a distinct
class of so-called abscesses--namely, the _cold_ or _congestion
abscesses_. These are of the chronic type, and are generally free from
the ordinary signs of abscess formation. They are invariably the result
of local infection, sometimes perhaps by the tubercle bacilli alone,
but frequently by the combined action of these with pyogenic forms. For
their formation a previous tuberculous lesion is essential. Wherever
old tuberculous lesions are encountered cold abscesses also may form.
No tissue or organ is exempt: they are found in the brain, in the
bones, viscera, joints, skin--in fact, in all parts of the body.

Cold abscesses have not only a significance of their own, but for the
most part an identity. Their distinguishing feature is a _limiting
membrane_, which forms whenever sufficient time has elapsed. Much has
been written about it, and much error has been perpetuated with regard
to it. This is the membrane formerly considered and called _pyogenic_,
under the misapprehension that by it the pus or contents of the abscess
were produced. I desire to emphasize in every possible way that this is
a mistake. This membrane does not act to produce pus, but is rather the
result of condensation of cells around the margin of the tuberculous
lesion, forming, as it were, a sanitary cordon, for the absolute and
definite purpose of protection against further ravages. I would suggest
that the term pyogenic membrane be abolished, there being no such
membrane under any circumstances, and that, this be known as that which
in effect it is--namely, a _pyophylactic membrane_. _It is a protection
against pus_, and were it not for its presence there would be no limit
to the spread of tuberculous invasion. A lesion thus surrounded is
shut off from most possibilities of harm, rarely encroaches, except
by the most gradual processes, and, on the contrary, often contracts
and reduces its dimensions, the watery portion of its contents being
gradually absorbed and the more solid and cellular portions becoming
condensed into matter which undergoes caseous degeneration, so that
eventually recovery may ensue as the consequence of a metamorphosis of
an original cold abscess into a caseous nodule surrounded by the old
pyophylactic membrane, which is now serving as a capsule.

The contents of the cold abscess are, in some instances at least, of
acute origin, and consequently may have been originally pus or its near
ally. On the other hand, in cases which have occurred very slowly this
material is not real pus, but is a semifluid debris having certain
properties which remind one of pus. It has been my effort hitherto to
devise for this material a name which should distinguish it from pus
and indicate what it really is. Inasmuch as most of it has been of a
puruloid character, at least at one time, I have suggested that it
be called _archepyon_ (_i. e._, originally pus or puruloid). As this
flows from such a cold abscess, it is more or less watery and contains
caseous, sometimes calcareous, nodules in masses of considerable
size, and not infrequently sloughs of tissue and old shreds of white
fibrous tissue which resist decomposition for a long time. This
material has been thus imprisoned, sometimes for months or even years,
and consequently has lost most of its resemblance to what it was
originally. The organisms which first produced it have long since died,
and it is practically sterile. If any organisms survive, they are the
tubercle bacilli, which are more resistant and tenacious of life than
the ordinary pyogenic organisms. This is why most culture experiments
fail, and why even inoculation with the contents of an old cold abscess
is often without effect even on most susceptible animals. _Nevertheless
the bacilli which the semifluid contents do not contain may yet linger
in the meshes of the pyophylactic membrane; and here lurks the greatest
danger in dealing with these lesions._

In old cases the pyophylactic membrane is very tough and very adherent
by its outer surface. It can sometimes be peeled off in strips of
considerable extent, at other times cannot even be separated, or
sometimes is so placed as to render it impossible to follow it to its
termination. There must be _complete extirpation of this membrane_, or
at least destruction; and when its removal is impracticable, failure to
remove it should be atoned for by some powerful caustic, such as zinc
chloride, nitric acid, caustic pyrozone or the actual cautery, which
should be made to follow it to its ultimate ramification. The membrane
and the tissues underlying, when thus cauterized, will separate as
sloughs, and these will be replaced by presumably healthy granulations,
which should be encouraged until the original cavity is filled or the
surface healed.

Acute abscesses, as indicated in the previous chapter, have no real
limiting membrane, although there is more or less condensation of
tissues about the focus of infection. A typical membrane is distinctive
of tuberculous abscesses, and is to be regarded always as their
natural protection and a barrier against their further encroachment--a
membrane whose inner surface may harbor active organisms which cannot
escape through its outer texture. Consequently, to simply incise it or
inefficiently scrape it is to do a worse than useless thing; and one
should never attack it unless he is prepared to extirpate it or destroy
its integrity, and in this way dispose of it.

Cold abscesses when near the surface cause a bluish or dusky
discoloration of the overlying skin, while the superficial and
subcutaneous veins of this region are usually enlarged. Fluctuation
is also a prominent phenomena in connection with them when they
can be palpated. Deep collections of this kind may be mistaken for
cysts or tumors, in which case the aspirator needle may be used to
facilitate diagnosis. They vary in size from the smallest possible
collection of fluid to abscesses which may contain a gallon or more of
puruloid material or archepyon. They are known often as _gravitation
abscesses_, because by the weight of the contained fluid they tend to
elongate or spread themselves in the direction in which gravity would
naturally carry a collection of fluid. Thus cold abscesses originating
from tuberculous disease of the lower spine frequently work their way
along the psoas muscle and present below Poupart’s ligament as _psoas
abscesses_, or elsewhere about the thigh, while those which come from
similar disease of the uppermost cervical vertebrae may present behind
the pharynx, as the so-called _retropharyngeal abscesses_, and those
from the dorsal spine present not infrequently as _lumbar abscesses_.
These are but two or three familiar examples of what may occur in any
part of the body.


=Treatment.=--Aside from the treatment of cold abscesses, already
indicated by radical measures, other means have been suggested, and
particularly for the treatment of those in which such extreme measures
are impracticable or impossible. It is sometimes efficacious to simply
tap or remove by aspiration the contents of such a cavity. It may never
refill, or but slowly, and after repeated tapping alone a very small
percentage of such cases will subside into inactivity and the lesion be
subdued, if not absolutely cured. Treatment by injection of emulsions
of iodoform has found favor with many surgeons. I have never been able
to secure the good results reported by others, and consequently have
abandoned it; yet it deserves mention here because of the repute it has
enjoyed.

This is based upon the alleged specific properties of iodoform as
being peculiarly fatal to tubercle bacilli, presumably by liberation
of free iodine. A cavity to be thus treated should be first emptied as
completely as possible, after which may be thrown into it a glycerin
emulsion or an ethereal solution, or a suspension in sterilized oil
of 5 to 10 per cent. of iodoform. From 25 to 200 Cc. of some such
preparation is introduced, while the walls of the abscess are more or
less manipulated in the endeavor to completely disseminate the mixture.
The cannula through which it has been introduced is then withdrawn; and
this can usually be done with but little unpleasant iodoform effect.
This is due to the pyophylactic membrane, which limits the activity of
the drug as it has done that of the previous contents of the abscess.
Such cavities have also been treated by washing out through a trocar
with an injection of various antiseptic or stimulating solutions, among
which may be mentioned hydrogen peroxide, weak iodine solutions, etc.
My own advice is to treat all tuberculous lesions radically when such
measures are not contra-indicated by their multiplicity or by too great
depression of the patient, and so long as lesions are accessible to
ordinary operative procedures. This same advice pertains also to those
which have already spontaneously evacuated themselves, or where the
overlying skin is threatening to break and permit escape of contents.
Almost any case where this is imminent is one in which the surgeon, as
such, ought to interfere. On the other hand, in deep collections and in
debilitated individuals the treatment by injection may be tried.

The best way to treat accessible tuberculous lesions is by extirpation,
as this hastens convalescence and leads to more permanent results.


THE GUMMAS OF TUBERCULOSIS.

The other and essential characteristic of tuberculous disease is the
_infectious granuloma_ to which it gives rise. This is a term first
applied by Virchow to new formations of granulation tissue which are
the result of the presence of invading and specific irritants. This
tissue varies little in type from that already described under Ulcers,
and is common to the neoplasms which are found in tuberculosis,
syphilis, leprosy, glanders, and other local infections. So little does
the tissue type vary in these different instances that it is difficult
to distinguish by microscopic sections of the unstained tissues, or
at least those unstained for bacteria, to which class of lesions they
belong.

[Illustration: PLATE VII

Lupus of Skin. (Gaylord.)

_a_, fresh tubercles containing numerous plasma cells; _b_, mature
tubercle with giant cells. Below are accumulations of plasma cells
about the vessels. Low power.

Unna’s polychrome methylene blue.]

This tissue may be met with in any of the tissues of the body, but
is less seen upon the serous membranes of the cranial and peritoneal
cavities, whereas in the joint cavities it is common. It is provoked,
as just stated, by the presence of tubercle, and has the power of
penetration into and substitution for almost all the other tissues
of the body. Thus in a primary tuberculous focus within the bone a
granuloma will form and extend its limits, while the surrounding bony
tissue melts away before it; and it is by the growth of this tissue
in a particular direction that tuberculous products from within the
bone cavity are finally carried to the surface. When this material
has escaped from bone, or from tissues without the bone, toward the
surface its presence is marked by induration, by livid discoloration of
a limited area of skin, with elevation of the surface, which finally
breaks down and shows discolored, bleeding, and pouting granulations,
which in the absence of restraint now proliferate more rapidly, and
often to the point where they loose their former blood supply, and
consequently necrose upon the surface. This is the _fungous granulation
tissue_, especially of the German writers, and may be met with upon
the surface, or is frequently seen in opening into joint cavities and
other tissues infected by tubercle. The appearances of this fungous
tissue are modified somewhat by environment and pressure: in joints
flat and radiating masses of it will be found, extending along the
synovial surfaces and into the articular crevices. This fungous tissue
may grow in any direction, but apparently advances in the direction of
least resistance. It leads to complete perforations of the flat bones,
like those of the skull, while tuberculous masses from the dura may
cause multiple perforations, the granulation tissue finally escaping
through the overlying skin. In tuberculosis of synovial sheaths and
bursæ it extends along and may completely fill and even distend them.
It will separate tissues which were united together, and it may lead
to disintegration and disorganization of the firmest textures in
the body. So long as it is not exposed to the air nor to pyogenic
infection, it will preserve its characteristics for a considerable
length of time. Immediately upon exposure it is likely to break down,
and infection will travel speedily along it into the deeper cavity
whence it has sprung. A mass of this tissue contained within the normal
tissues, condensed more or less by pressure, uninfected, and not freely
supplied with blood, is entitled to the name of _tuberculous gumma_,
whose tendency, however, is too often to break down and suppurate.
Such gummas may be found in any part of the body, and differ only in
unessential respects from the diffuse and more or less infiltrated
masses of granulation tissue which occupy serous cavities or which
extend in various directions.

The lesions of surgical tuberculosis, except those already spoken of
as constituting cold abscess, are so essentially connected with the
presence of granulation tissue, just described, or of this form of
the infectious granulomas, that no student can appreciate the subject
until he is familiar with this tissue in its various phases and in
various locations. Of such great importance is it that this be realized
that some of the local manifestations of this new tissue must here be
considered, although they may be rehearsed in other form in succeeding
chapters.

_In the skin and subcutaneous tissues_ and _in and under mucous
membranes_ this granulation tissue may be studied at places where
it is free from most mechanical restraints to growth, and where, in
other respects, its appearances are typical. The most characteristic
manifestations in the skin occur as _lupus_, a disease considered
cancerous or of uncertain etiology. Lupus is always a cutaneous
manifestation of this protean disease. (See Plate VII.)

In its incipient stages lupus consists of multiple minute nodules
of granulation tissue just beneath the surface, containing all the
elements of true miliary tubercle, with infiltration of the surrounding
skin, even into the subcutaneous fat. The most common location of these
lesions is on exposed surfaces. Bacilli are not numerous in them, yet
may be demonstrated. The tendency is more or less rapidly to break
down, the result being a tuberculous ulcer, which, as it extends,
manifests usually a disposition to cicatrize in the centre while
enlarging around its periphery. The dermatologists describe several
different forms of lupus under the names _hypertrophicus_, _vulgaris_,
_maculosus_, etc., all of which are essentially the same in character,
the differences being largely constituted by the rapidity or slowness
with which the granuloma of the skin breaks down. From the surface
these growths may extend and involve parts at considerable depth, even
the periosteum. This name should also include the lesions described as
_scrofuloderma_ or scrofulous ulcers of the skin, they being all of the
same character.

A variety known as _anatomical tubercle_ has been described by some
writers, found especially upon the hands of those who frequent
dissecting-rooms or handle dead bodies, and is supposed to be the
result of local inoculation. It appears usually as a warty growth,
which ulcerates and becomes covered with a scab--is usually indolent
in character, but is followed by lymphatic involvement, and in rare
instances by death from tuberculous disease.

[Illustration: FIG. 20

Tuberculosis of cervical lymph nodes.]

_In the lymphatic structures and lymph nodes_ tuberculosis is a most
frequent affection. In these localities it may occasionally be primary,
but is almost always a secondary lesion. It is in separating from the
lymph stream the tubercle bacilli, which would otherwise be passed
into the general circulation, that the lymph nodes, acting as filters,
render us the greatest possible service. These filters themselves,
however, almost always become infected, and, enlarging, they assume
the appearances known to the laity as _scrofula_, which have been
generally referred to as _scrofulous glands_. These lesions abound
rather about the axilla and the cervical and bronchial nodes than about
the lower extremities. Nevertheless, the retroperitoneal, mesenteric,
and inguinal nodes are occasionally infected. In these nodes will be
found giant cells surrounded with epithelioid cells, containing bacilli
and undergoing cheesy degeneration or suppuration. Infection often
proceeds from centre to periphery, and then to the surrounding tissues,
the filter, as such, having become so choked that nothing seems to pass
it. By virtue of this surrounding infiltration (which used to be known
as _peri-adenitis_, when lymph nodes were spoken of as _lymph glands_)
generalized infection is in some measure prevented, while the natural
barriers are altered and natural distinctions between tissues are
lost. This makes complete extirpation of these tuberculous foci often
very difficult, while the adhesions which they contract, for instance
in the neck, are often to the large vessels and nerve sheaths, by all
of which their operative treatment is naturally complicated. When
infection from the superficial nodes extends toward the surface it is
easily recognized by the dusky hue of the overlying skin, the hardness,
infiltration, and, later, the fixation, of these masses, accompanied
usually by evidences of suppuration.

_In and on the serous membranes_ we find tuberculous lesions, either
primary or metastatic, usually miliary in type. In the _pleural cavity_
they produce effusion (hydrothorax), which may necessitate repeated
paracentesis, or by a mixed or secondary infection may cause empyema,
for which much more radical and even extensive operations are demanded.
(See Thoracoplasty.)

In the case of the _peritoneum_ we find (_a_) miliary tuberculosis,
(_b_) a slower non-exudative form with firm, sometimes pigmented
nodules, and (_c_) a form characterized by small gummas which become
caseous, coalesce, and ulcerate, binding together intestinal coils
and producing extensive and irregular adhesions, with seropurulent
exudation, often enclosed in walled-off sacs. In all of these cases
surgical intervention should be considered, while in the more acute
miliary forms abdominal section, with flushing, has in many instances
afforded relief.

Tuberculous _meningitis_, cerebral or spinal, is in surgical cases
practically always of miliary type, accompanied by the inevitable
increase of fluid, and, in the cerebrospinal canal, of consequent
tension. Inasmuch as the latter constitutes the most formidable feature
of these cases, its possible relief by puncture may be considered.
And so lumbar puncture (_q. v._) may be practised, and even tapping
the cerebral ventricles after making the small trephine opening has
been done a few times, though not with encouraging success. (See
Hydrocephalus.) Too often tuberculous meningitis is the terminal
infection which ends many a case of local tuberculous disease in other
parts of the body.

In general the more acute and miliary the lesions presented in
tuberculous disease of serous membranes the greater the tendency to
profuse watery (serous) exudate, whose volume may demand operative
measures for relief.

_In the bones_ we often find indications of tuberculous disease. It
is not much more than sixty years since Nélaton called attention to
the frequency of these intra-osseous lesions, and demonstrated the
essentially tuberculous character of much that had hitherto been
overlooked or considered under that vague term scrofula. All those
forms of bone disease comprehended under the names _Pott’s disease_,
_spina ventosa_, _tumor albus_, etc., are now known to be distinctly
tuberculous lesions. In many instances these follow the slight
circulatory disturbances brought about by contusions sprains, etc. This
is especially the case in those who are predisposed to this disease.

[Illustration: FIG. 21

Tuberculous spondylitis (caries): _a_, osteogenesis and osteosclerosis;
_c_, cavity formed by degeneration of tuberculous focus. (Krause.)]

Tuberculosis of bone always assumes the phase of miliary lesions,
followed by the formation of a granuloma, which may gradually encroach
upon surrounding tissues or may assume a more fulminating type and
spread rapidly. Apparently because of the circulatory conditions
these lesions generally occur near the epiphyseal lines of the long
bones, apparently seeking the ends of the bones, as pulmonary lesions
seek the terminations of the lungs. These lesions may be solitary or
multiple. Beginning always minutely, they spread so as to produce foci
perhaps two inches in diameter. As the result of the formation of
granulation tissue, the surrounding bone melts away and disappears,
the result being a great weakening of its structure and expansion of
its dimensions in order to make room for the growing mass within.
The tendency of this granulation tissue thus imprisoned is always
to escape in the direction of least resistance. This carries it
sometimes into the joint, sometimes out through epiphyseal junctions,
and sometimes through channels in the bone made by its own pressure,
with external escape and appearance of the dusky distinctive tissue,
felt beneath and then upon the skin. Where bone is so weakened in
one direction it is usually strengthened by compensatory deposition
of calcium salts at other points, and the result frequently is a
striking _combination of osteoporosis_ in the immediate presence of
the disease, with _osteosclerosis_, sometimes to a remarkable degree,
even to _eburnation_, of an adjoining portion. When this mass undergoes
caseous degeneration the progress of the disease is much slower and
the pain less. When it undergoes suppuration there are more evidences
of inflammation, with more pain and systemic disturbance, as well as
local swelling, tenderness, etc. The surrounding musculature is rarely
involved, although the periosteum is nearly always so. In fact, it
is stated that in an inflamed and suppurating bone lesion, if the
muscles are extensively invaded, it may be regarded as of syphilitic
rather than of tuberculous origin. The _pyophylactic_ membrane already
alluded to is seen in almost every instance of tuberculous disease.
The spina ventosa of some writers refers to the expansion of the shaft
and medullary cavity of a long bone whose interior is occupied by
a mass of tuberculous gumma, which is perforated at one point, and
through which opening it escapes as does lava from a crater, to involve
the structures on the outer side. The appearance of this granulation
tissue in joints as _fungous tissue_ has already been mentioned. In a
general way it preserves its fungoid characteristics until attacked by
pyogenic or saprogenic organisms, when it quickly breaks down, forming
an ulcer if upon the surface, or a cold abscess if not externally open.
Tuberculous disease of the bone is most common in the young, and in
them the majority of tuberculous joints are those whose bony structures
have been first involved. In other words, the majority of cases of
tuberculous pyarthrosis are due to primary bone disease. As the result
of the tuberculous infection the bones become distorted, which is best
illustrated in Pott’s disease of the spine; while, as the result of
the constant irritation, joint ends become displaced by chronic muscle
spasm, and joint contours entirely altered by expansion of the affected
bone and thickening and infiltration of the overlying soft parts.

I have often, for the sake of illustration to medical students,
drawn a certain analogy (following Savory) of the gross resemblances
between lungs and bones in their behavior when involved in tuberculous
disease. In either case the structure is in a measure spongy and
contains cavities and networks of tissue; in each case the structures
are invested by a resisting membrane--in the one instance pleura,
in the other periosteum. Again, each is closely related to a serous
cavity--the lungs to the pleural cavity, the bones to the serous
cavities of the joints. Tuberculous disease manifests a predilection
for the extremities of both organs. Perforation into the adjoining
serous cavity is frequent, and previous to perforation collections
of serous fluid are frequently noted--in one instance pleurisy, in
the other hydrarthrosis. Moreover, these fluids may frequently become
contaminated, and then become purulent, constituting empyema or
pyarthrosis as the condition may be. One sees, too, in each place the
same striking combinations of weakening of tissue and strengthening in
order to atone for the undermining of the disease. These are not all of
the similarities that might be adduced, but are perhaps sufficient for
the purpose of showing that tuberculous disease is essentially one and
the same thing, no matter what tissue is invaded.

_In the tendon sheaths and bursæ_ we frequently find manifestations
of tuberculosis. When seen early these are always in the direction
either of miliary affection, or, most commonly, of tuberculous gumma,
while when seen late the disease has usually advanced to the point of
suppuration, and we now have cold abscess of the affected part.

In many joints and tendon sheaths, particularly the latter, we find
certain detached, usually colorless, firmly resistant masses, of
smooth and polished surface, lying in a collection of fluid, in size
from a minute particle up to that of a melon-seed. These have been
known at various times as _rice grains_, _melon-seed bodies_, _corpora
oryzoidea_, etc., and for a long time their explanation was a mystery.
It is now well established that in the majority of instances these
are the result of fungous granulations which have become detached in
small pieces, which then, in the absence of infection, have shrunken
and become rounded and polished by attrition. The bursal enlargement
and distention with fluid in which they are usually found is commonly
spoken of as _hygroma_ of that particular bursa. Tuberculosis of these
bursæ, however, does not always result so harmlessly as the formation
of these bodies, but, on the contrary, tuberculous infiltration may
extend beyond the serous limits to the surrounding soft parts, with
a tendency finally to external escape, just as in the case of bone
lesions. These constitute affections of the soft parts which are more
or less destructive, and are difficult, often impossible, to deal with,
because of the mutilation which a thorough extirpation of the disease
would necessitate.

_In the testicles and ovaries_, particularly in the former, tuberculous
disease is frequently met with. In the testicles it begins usually in
the _epididymis_, forming a somewhat dense nodule and a distinct tumor,
easily observed from the outside, although its minute character may be
still concealed. The tendency here is almost invariably to progressive
infiltration and breaking down, either into a caseous mass or, more
commonly, into puruloid material, while sometimes acute infection
supervenes.

It is not always easy to distinguish between syphilis and tuberculosis
of the testicle, though the latter is usually characterized by the same
tendency to effusion into the adjoining serous cavity, _i. e._, that
of the tunica vaginalis, as is manifested in disease of the lungs or
bones. When the disease is extensive the overlying skin is involved,
and frequently the surgeon is called to deal with cases of perforation
and escape of fungoid tissue on the outside.

_In the kidneys, in the ureters, as also in the bladder_, tuberculous
lesions are noted, the miliary form being particularly frequent in
the former. Tuberculous disease of the kidney leads sooner or later
to caseation and a condition of pyonephrosis or its equivalent, which
calls practically always for extirpation of the affected organ.
Tubercle bacilli are sometimes recognized in the urine, but only when
the lesion has an opportunity of discharging into one of the urinary
passages.

_In the peritoneum_ tubercle appears usually in the miliary form,
leading sometimes to such extensive involvement of and interference
with visceral functions as to produce anasarca or more general
disturbance prior to death. Acute miliary disease here is as rapid
and as essentially fatal as the same affection of the dura or pia,
while the more chronic forms are followed by degenerations that may
involve the intestines either in agglutinated masses or in ulcerations
and possible perforations. The indication in all tuberculous lesions
of serous membranes is for exposure by operation, disinfection of the
surface, and evacuation of retained fluids. Recovery from tuberculous
peritonitis, even of acute type, after abdominal section, is now
definitely established as a possibility. The same would probably
be true of tuberculous meningitis were we permitted to expose the
membranes and attack them or drain them in the same way.

Although a few distinct organs or tissues have here been specifically
considered in their relations to tuberculous disease, there is no organ
or tissue in the body which is exempt from its ravages and in which
evidences of tuberculous disease may not be found. Even the _mammary
gland_ occasionally presents tumors composed of tuberculous granuloma
which more or less simulate malignant disease, while calling for the
same radical treatment (Fig. 22).

[Illustration: FIG. 22

Gross appearance in tuberculosis of the mamma. (Dubar.)]


=Paths of Infection.=--The tuberculous virus may enter the body
through various channels. Probably in the majority of instances it
gains entrance through the _respiratory tract_, less often by the
_alimentary canal_, and _occasionally by air contact of open wounds or
direct infection by local agencies_. It is now well established that
tuberculous disease is easily inherited, although a predisposition to
its ravages is transmitted from parent to children.

In what this predisposition consists is not always easy to say. As
the tubercle bacillus grows in the tissues, it is by preference an
anaërobe, and it seems to be lowered in activity or banished by access
of oxygen. It has been shown that in those individuals in whose pallid
skin, long bones, flabby muscles, and pale conjunctivæ we recognize
a predisposition to this disease, the heart is disproportionately
small as compared with the weight and size of the lungs. This means a
relatively feeble pumping power, and is perhaps the best explanation
for what is accepted as a fact. The _mucous membranes of the nose_ and
_throat_ are usually the first lodging places for germs carried by the
air, they finding here the warmth and moisture necessary for their
detention, development, and growth. As long as these membranes are
unbroken and healthy, infection is rarely possible; but let tubercle
bacilli become caught in the crypts of the tonsils or in adenoid tissue
in the nasopharynx, and the other disturbance, set up by irritant
organisms of various species, will usually bring about conditions
favoring their growth and incorporation into the living tissues. This
lymphadenoid tissue is often the port of entry for these organisms.
The explanation for local and surgical tuberculosis in bones and other
accessible tissues probably is connected with causes determining at
these points an area of least resistance, in which the germs find
tissues more susceptible than elsewhere, and in which they may live and
thrive.

Not the least interesting and important of the considerations
regarding tuberculous disease is the possibility of an _acute outbreak
of tuberculosis after long latent or chronic manifestations of the
disease_. This means, in effect, the onset of _general miliary
tuberculosis_ which soon terminates fatally, and death is not the
infrequent result of such extremely rapid outbreaks from tuberculous
disease of joints, bones, ovaries, etc. For the disease when it has
assumed this extremely rapid type there is, so far as known, no relief.


=Diagnosis.=--So far as the general recognition of tuberculous
disease is concerned, it is not often difficult. It is accompanied
usually by more or less marked cachexia (at least this is the case
when infection is serious and widespread), one of whose principal
characteristics is the so-called _hectic_ (habitual) fever of old
writers. This was a fever of a remittent type, accompanied also by more
or less colliquative night sweats, with dryness of the skin during
the daytime, and flushing of the face. Hectic fever, as a matter of
fact, often accompanies tuberculous disease, but is seldom encountered
until pyogenic infection has occurred and suppuration is taking or
has taken place. There is now much reason to consider hectic fever as
an auto-intoxication from absorption of morbid products. In advanced
cases we may find evidence of _amyloid_ changes, although these are
seldom recognized prior to autopsy. It is seldom difficult to recognize
tuberculous disease except when at a considerable depth. Here, as long
as there is no suppuration, there is little tendency to _leukocytosis_,
by which diagnosis as between _sarcoma_ and _tuberculous_ infection
may perhaps be made. Sometimes when in doubt the exploring trocar or
an exploratory incision may be resorted to, it being always best to be
prepared at the same time to proceed with whatever further operative
procedure the findings may indicate.


=Treatment.=--It is well to emphasize, first of all, that _tuberculous
disease when circumscribed and accessible is a distinctly curable
affection_. If this is accepted, it puts a much more hopeful aspect
upon the condition than it formerly bore. It moreover justifies
operations of a more radical nature than were formerly practised.
Treatment should be divided into the hygienic and constitutional and
the local and operative.

Of all the natural remedies, _oxygen_ undoubtedly ranks first. This
means the best of _ventilation_, an outdoor life if possible, and
preferably in localities and at altitudes free from dust and well
supplied with ozone. When this is impossible inhalations of dilute
oxygen are capable of doing much good. The two canons of successful
treatment of pulmonary tuberculosis are equally of value in surgical
tuberculosis, viz., _abundance of oxygen and hypernutrition_. The diet
should be rich and nutritious, at the same time capable of complete
digestion. The emunctories should be stimulated and elimination favored
in every possible way. Undoubtedly the old standard remedies--cod-liver
oil, compound syrup of hypophosphites, etc.--are beneficial, and much
good may be accomplished by their proper use.

Certain remedies have been at various times supposed to be endowed with
specific properties, and for many years clinicians have endeavored to
find that substance with which the system could be safely saturated
and prove inimical to the parasite causing this disease. Such agent
has not yet been discovered; nevertheless, much has been done in
this direction. Of the remedies highly spoken of for this purpose,
_creosote_ and _guaiacol_ are considered the best. These are somewhat
difficult of administration, but if the latter is given in the form of
the carbonate, generally known as _benzosol_, it comes the nearest to
the ideal for which we are striving. _Benzosol_ should be given to the
adult in doses of at least a gram a day, perhaps more. It is better
tolerated and less offensive than the guaiacol from which it is made. I
have never seen anything but benefit result from its use, and yet would
not extol it as a positive cure. Nevertheless in conjunction with other
local and constitutional measures its administration may be followed by
complete recovery.

Of the various _local measures_, _physiological rest_ should be placed
first, and can be achieved in some places better than in others. The
various forms of apparatus resorted to by orthopedists are simply
mechanical measures in furtherance of this purpose. Some surgeons have
faith in _iodoform_, used locally in solution or suspension in some
menstruum like glycerin, oil, etc. The benefit which has been claimed
in some cases is not duplicated in the experience of all surgeons;
nevertheless, it has undoubtedly been of service. A recent and most
promising method of treating tuberculous disease of the extremities
has been suggested by Bier, and consists in the establishment of a
_permanent hyperemia_ by the application of a rubber tourniquet on the
proximal side of the lesion. (See chapter on the Joints.)

It would appear that the access of more blood which is thus permitted
is inimical, presumably by the presence of the oxygen which it brings,
to the development of the disease germ. The method depends for its
rationale upon the fact that the congested lung does not become
tuberculous. Lannelongue has suggested what he calls the _sclerogenic
treatment_ of tuberculous lesions, by injection of a very dilute
solution of zinc chloride, which serves as an irritant and produces a
tissue sclerosis that serves the purpose of a prophylactic membrane,
while at the same time the solution is fatal to those germs with which
it comes in contact. This treatment is painful and has not proved
acceptable.

The astute surgeon, who gains the confidence of his patients and
retains it, will not hesitate to remove by a suitable operation the
tuberculous focus which he feels confident that he can reach and
extirpate. The resulting tissue defects may be in many instances
atoned for by plastic operations. At other times this procedure
means _excision of some joint_, which leaves usually a much better
functionating member than would the disease if permitted to go on
to spontaneous recovery--_i. e._, ankylosis--and at the same time
removes a focus of disease which is a menace if left to the future
welfare of the patient. It may mean at other times _amputation_, but
the artificial limbmaker now supplies a member vastly more useful than
a natural one crippled by this infectious disease. In a general way,
then, time may be saved and recovery ensured by early and judicious
operation, while later in the course of this protean malady it may be
absolutely necessitated in the endeavor to save life.

After operations where clean extirpation and reunion of the parts
with primary healing is impossible a local dressing of balsam of Peru
containing 10 per cent. of guaiacol is recommended. Gauze saturated
with this dressing and packed into the cavity best accomplishes the
purposes of a surgical dressing for such cases.

The superficial and ulcerative (skin) lesions due to tuberculosis often
yield very readily to exposure to the Röntgen rays and the ultraviolet
rays. Recrudescences appear not infrequently, and the treatment should
be administered at intervals long after the apparent subsidence of the
lesion.

Deep pain of tuberculous lesions, especially in bone, is often relieved
by _ignipuncture_, meaning thereby a perforation into the depth even of
the bone-marrow by the actual cautery (Paquelin’s), which may be thrust
directly through the skin or which may be used after exposing the bone
by incision. The use of the actual cautery is indicated in eradicating
and destroying tuberculous tissue when a neat dissection or extirpation
is impossible.


=Tuberculin.=--Finally the treatment of tuberculosis cannot be
dismissed without a reference to the glycerin extract made from a
filtered culture of the tubercle bacillus, containing the peculiar
toxalbumin first prepared by Koch, forever associated with his name,
and first given to the world in 1890, when its announcement created
a furore and aroused hopes that have never been completely realized.
Yet in spite of disappointments which have often followed its use, it
is a remedy of great value when judiciously used in selected cases.
The diagnostic value of the material should also not be forgotten,
as by its use one may possibly decide in doubtful cases as between
tuberculous or some other disease. The best preparation for use
today is that made by Koch’s new process, by which the possibility
of the presence of microörganisms is eliminated. It contains those
constituents of the bacilli which are insoluble in glycerin, and
which have distinct immunizing power. On the market it is known as
_tuberculin rest_, indicated simply as T. R. The initial dose is ¹⁄₅₀₀
Mg., to be increased with each injection. Its effect, _e. g._, on
lupus, is very marked.




CHAPTER X.

SYPHILIS.


The younger generation, when studying the subject of syphilis,
should be referred back one hundred years or more to the time when
the opinions held by John Hunter generally prevailed--when venereal
diseases were grouped under one heading, and considered to be but three
manifestations of the same morbid condition. It took years for the
profession to break away from this mistaken teaching, and a generation
had passed before gonorrhea was separated from the others. This left
chancroid and syphilis still more or less confused in the minds of
many, and until the middle of the previous century they were considered
as different types of the same disease by some of the most experienced
observers. Thus it happened that those who made a special study of
this subject were grouped into two classes, the _unicists_ and the
_dualists_, according as they held to the unity or duality of syphilis
and chancroid. It was a question of importance, and differences of
opinions led to bitter antagonisms. Its importance inhered in this:
either all venereal sores were to be subjected to constitutional
treatment, or else differences in treatment were to be made according
to the local or constitutional nature of the malady. Men sacrificed
their own health, even their own lives, in their willingness to make
experiments upon themselves, and auto-inoculability was proved by one
observer through some 1700 inoculations produced upon his own body.
Such devotion to medical science has been rarely eclipsed. In the
latter half of the eighteenth century came clearer distinctions, and
toward its close there were none who ranked as authorities who held to
the old view of the unity of these diseases.

Syphilis is a disease of ancient if not of respectable origin. We read
much of the possibility of so-called pre-Columbian syphilis, implying
by that term that the Spaniards who came over to this country found
it here and carried it with them back to Europe. This is probably
the case, and yet the disease antedates the Christian era, as may be
established by familiarity with ancient literature, whether Arabian,
Egyptian, or Hebraic. No one can read the Psalms of David, for
instance, without finding therein intrinsic evidence that the writer
thereof, whoever he may have been, suffered from this disease. Of
its antiquity, however, as well as of its universal distribution, we
need not speak. History has shown that whenever it has appeared in
a community previously unaffected by it, it has assumed malignant
and epidemic features, and has spread rapidly while claiming many
victims; on the other hand, in those communities where it has long been
domesticated, it assumes usually a milder type, as though a racial
immunity were being gradually established.

_Syphilis is an infectious chronic disease, acquired either by
inheritance or by contagion, mediate or immediate_, with a certain
period of incubation, characterized by an initial lesion at the site
of infection, which is followed in time by a series of systemic
disturbances, usually quite characteristic, in a commonly determinate
order. A large proportion of these consist of neoplastic lesions of
the general type of the infectious granulomas. In the majority of
instances it is of distinctly venereal origin, although not always. It
is known among the common people as _pox_, while a frequent synonym for
it in foreign literature is _lues venerea_, or often _lues_ alone, the
adjective being _luetic_.

_Syphilis is always transmitted as such_ and is not interchangeable
with leprosy, tuberculosis, or anything else, although it is not
unfrequently complicated with them as well as with cancer. It has
certain resemblances to the exanthemas in its periods of incubation,
and in the fact that one attack is supposed to confer immunity, as well
as that many of the typical symptoms of syphilis pertain to the skin
and mucous membrane; further resemblances may also be found in each
case.

Within certain limits the specific infection of syphilis, or, as it is
frequently spoken of, the specific disease, passes through a somewhat
regular program in which periods of activity and latency seem to
alternate. The first visible lesion is at the point of entrance of the
virus, in acquired cases, after a certain period of incubation, and
is known always as the _chancre_. Of course, in inherited syphilis
no chancre or primary sore is found. Then occurs a second period of
incubation, during which there is a still more widespread general
infection of the body, in which at first the lymphatic system seems
to suffer most. This is characterized by a certain degree of fever,
progressive anemia, malaise, tenderness and pain in bones and joints,
all of which indicate a _progressive toxemia_.


=Manner of Contagion.=--The manner of contagion in acquired cases is
naturally most often that of the sexual act, although contagion may
come from many sources, including unclean utensils, pipes, etc., as
well as the instruments of the dentist or the surgeon. Some abrasion
of the infected surface is almost invariably presupposed, since it
is not established that the virus of syphilis will enter an unbroken
surface, though it may lurk thereon; but the abrasion may be trifling
and occur in such situation, especially on the female genitalia, as to
be undiscoverable or unnoticed. It is then possible that patients may
speak truthfully when denying the existence in the past of any venereal
sores. The transmission of infection from parent to offspring in the
uterus will be discussed later.


=Nature of the Virus.=--That syphilis is a disease of parasitic
character, _i. e._, _contagious_, there can, of course, be no question.
The nature of the _contagium vivum_ which produces these changes, long
unknown, is now believed to be revealed in the _spirochæta pallida_
recently described by Schaudinn and others; an organism 4 to 10 μ in
length, ¹⁄₂ μ in width, possessing several curves like those of a
corkscrew, with sharpened poles, mobile, its motions consisting of
rotations and bendings. It has been demonstrated that primary lesions
contain the organism, either constantly or in the majority of cases,
while in skin and nearly all other lesions it can be also shown (Fig.
23).

[Illustration: FIG. 23

Spirochæta pallida (syphilis) in adrenal of child with congenital
syphilis. (Gaylord.)]


=Evolution of the Disease.=--Ever since the days of Ricord’s writings
on the subject it has been customary to group the manifestations of
syphilis into three groups or stages: _the primary_, _the secondary_,
_and the tertiary_. Less stress is laid upon these stages than
previously, yet it is convenient to retain them for descriptive
purposes. It should be emphasized, however, that between them there are
no arbitrary limits of time or tissue. _Primary_ syphilis under this
classification includes the first period of incubation and the symptoms
and appearances of the initial lesions. _Secondary_ syphilis may be
made to include the earlier constitutional symptoms which involve or
at least become apparent upon the more superficial portions of the
body, _i. e._, skin, mucous membrane, lymphatics, etc. Later comes
the so-called _tertiary_ period, in which the body surfaces are not
necessarily spared, but in which also deep lesions of the viscera, the
bones, the brain, etc., are noted. Between the first and the second
stages comes the so-called second period of incubation. The second and
third stages are characterized by frequent neoplastic formations, which
assume the type of the infectious granulomas and are commonly spoken of
as gummas; these lesions are destructive in their tendency, and will so
prove unless dissipated or aborted by suitable treatment.

_In the first and second stages of the disease it can be conveyed by
inheritance and inoculation_; in the later stage such an occurrence is
exceptional.

That syphilis is, _per se_, an infection is proved by the
constitutional symptoms which accompany its earlier manifestations; the
fever, usually mild, though sometimes well marked, which comes early
in the course of the disease, the general lymphatic involvement, the
malaise and depression, all indicate the systemic disturbances of a
true toxemia.

The periods of quiescence between successive outbreaks of the disease
are, moreover, characteristic, although they sometimes lull the patient
and his physician into an inactive state, during which medication is
too often suspended, so that when fresh disturbance arises vigorous
treatment must be renewed.

_The infection of syphilis occurs on the instant of inoculation_, as in
the case of tetanus. This is important, as upon it depends the question
of early local treatment. While excision of the primary sore, or even
of an area which might have become infected during exposure, and before
the actual formation of the chancre, has been often practised and urged
by some, experience has shown that it has little to commend it, since
the general experience is that it does not prevent the development of
the disease.

In its tendency syphilis is constantly progressive and destructive,
although it often behaves in a capricious manner, sometimes when under
efficient treatment and generally when treatment is inefficient. It
is usually more virulent in the dissipated and those who are weakened
by inheritance or poor constitutions, or by other disease. One reads
in literature on the subject about the malignancy of some cases and
the benignancy of others. Some cases seem to have a malignant aspect,
while others run an unusually mild course, so much so as to raise the
question whether the patient had syphilis. As far as the nature of the
parasitic cause is understood, this would depend on differences in the
make-up of the individual rather than in the actual virulence of the
germ. In the extremes of life individuals are more susceptible. When
implanted upon a tuberculous constitution it sometimes renders the
tuberculous lesions more active; whether it acts as a mixed infection
is not definitely known. Tuberculous lymph nodes frequently break down
during the course of secondary syphilis, and consumptive patients grow
rapidly worse. Syphilis, like alcohol, tends to play havoc with the
bloodvessel walls, and their combined effects in this direction are
greatly to be deprecated and should be prevented.


=The Lesions and Secretions which Convey Infection.=--As far as
acquired syphilis is concerned _absolute contact_ is necessary between
the infecting material and the infected area, while upon the latter
must exist some abrasion of the surface. Chancres and the early
eruptions or mixed lesions have been proved to be absolutely virulent.
The genitalia of both sexes are frequently the site of wart-like
lesions referred to as condylomas, which are usually kept more or less
moistened by the secretion of the parts, and are fruitful sources of
contagion. _The discharging lesion of those suffering from syphilitic
disease should be regarded as capable of transmitting it_, while during
the primary and secondary stages the blood and lymph should be regarded
as probable sources of danger.

Inoculation with the blood of patients during these stages has been
known to be successful. How long the blood retains its power of
infection is uncertain; it is usually regarded as free from it when the
disease is latent.

The _natural and physiological secretions of various organs_, _e.
g._, saliva, milk, perspiration, tears, and urine, are not generally
believed to _be capable of transmitting the disease_. The semen of
syphilitic men may reproduce the disease by heredity but not by direct
inoculation. It is possible under these circumstances for the father
to transmit the disease to the ovum without previously infecting the
mother; such infection of the ovum by diseased spermatozoa is quite
different from the infection of the ovum by the mother who has acquired
the disease, the father having escaped it.

In a general way it may be held that secretions of organs, or even of
lesions, which are non-specific, are not contagious except as they
happen to be mixed with blood or with disintegrated portions of actual
syphilitic lesions; thus, for instance, vaccinal lymph might be safely
taken from a syphilitic subject if there were absolutely no admixture
of blood. _But the difficulty of securing pure lymph is such as to
make its use inadvisable because of its danger._

_Suppuration frequently complicates syphilitic_ lesions. This is to be
regarded as in the nature of a secondary and pyogenic infection. It has
not been established that the germ of syphilis is by itself a pyogenic
organism.

_Gonorrhea or chancroid is often simultaneously contracted with
syphilis_, with resulting clinical complications that are perplexing as
well as difficult to treat. The contagion of chancroid acts promptly,
as will be stated in the chapter on Chancroid; and so it may happen
that the sore which begins as a chancroid is gradually converted
into a true chancre, the change taking place so gradually that it is
difficult to state when it begins or is completed. In this way result
the so-called _mixed sores_, which may give rise to so much doubt that
the surgeon feels it wise to wait for some secondary manifestations
before deciding that syphilis has been acquired. Confusion is often
created by preliminary treatment which the local lesion has received
previous to its examination by the surgeon. Patients, especially in the
lower walks of life, frequently go to a druggist or to someone who will
cauterize the sore and thus mask its characteristics to a degree which
makes prompt diagnosis impossible. Again, patients are often uncertain
regarding the matter of time, which is of great importance; thus the
sore which appears within a few days after exposure may be chancroidal,
while one which comes on twenty or thirty days afterward may be
syphilitic. These periods, however, afford little help when there have
been repeated exposures, by which confusion may be caused; but an
accurate and complete personal history will be helpful toward a correct
diagnosis.


=Location of Primary Lesions.=--Owing to the greater delicacy of the
mucous membranes they are more frequently the site of primary lesions
than the skin: 85 to 90 per cent. of all primary sores occur about
the genitalia; in men, especially on the inner side of the prepuce,
the glands, and the sulcus behind it; externally, chancre may occur
upon any part of the surrounding skin; in women, the tissues about the
vulva are most frequently its seat. Occasionally it is found within the
vagina, but rarely upon the os. The so-called extragenital chancres
are met with anywhere, especially on the most exposed parts, as the
lips, tongue, tonsils, eyelids, and nipples. Syphilis is occasionally
conveyed to a wet-nurse by the infected mouth of an infant suffering
from hereditary disease; even multiple chancres sometimes occurring.
Conversely, children have been infected by wet-nurses with syphilitic
lesions about the nipple. The disease has been conveyed by bites, as
upon the face and fingers. Surgeons and obstetricians are peculiarly
exposed, as are also nurses, to this disease, especially occurring
upon the fingers and hands. Infants have been known to be inoculated
during parturition. These are all examples of _direct_ or _immediate_
contagion. On the other hand, the disease may be positively conveyed
by utensils in common use between different individuals, as table-ware
or tobacco-pipes; by tools of trade which are passed from one person
to another, as, for instance, the blowpipe in glass factories; and by
cigars as they are made in some places, the wrapper being moistened
from the mouth of the cigarmaker. These are examples of its _indirect_
transmission. Physicians are familiar as well with instances where the
disease has been conveyed by instruments, either surgical or those of
the dentist. So possible is this last form of contagion that dentists
are trained to sterilize their instruments as carefully as does the
surgeon.

Possibility of conveying syphilis by vaccinal lymph has been alluded to
as occurring only in those instances where the blood of the syphilitic
patient is mingled with the lymph. The production of vaccinal virus
is now, however, so well regulated that it is rare that the surgeon
employs humanized lymph. Some cases considered vaccinal have been due
to the _use of infected instruments_; hence the necessity for extreme
caution in this regard. When the disease is acquired in a non-venereal
manner it is called _syphilis insontium_, or syphilis of the innocent;
this, however, is an unfortunate expression, as it tends to cast
reflections upon other cases which may be, in effect, just as innocent.


=Symptoms of the Ulcer.=--In all probability the initial sore and the
ensuing lymphatic involvement are due to the parasite and to its toxic
products. These latter are quickly taken into the general circulation
and are held to confer the immunity which syphilitics enjoy before
the outbreak of the general eruption. Anemia, malaise, and other like
symptoms are evidences of a progressive intoxication or toxemia, while
the earlier eruptions, which tend to evince the contagious element in
a rather virulent form, may be due to the germs alone, or combined
with their toxins. On this hypothesis can be explained the partial or
complete immunity evinced by mothers who bear syphilitic children, the
infection coming from the father.

From the first evidence of infection the whole syphilitic process gives
evidence of its infectious character. The bloodvessel walls undergo a
thickening of their coats and more or less obliteration of their lumen,
and this, of course, causes a disturbance in the nutrition of the parts
supplied by them. This vascular change can be recognized even in the
minute vessels of the initial lesion, and thereafter pertains to most
if not all specific manifestations of the disease.

Our knowledge of the nature of this disease would be more complete were
it possible to convey it to animals, but these are practically exempt
from it, for the few and rare instances where, it is said, the disease
has been inoculated upon the higher quadrumana furnish insufficient
data. In this respect the disease is like the exanthemas, of whose
parasitic origin there can be no question.

_The First Period of Incubation and the Chancre._--The time which
elapses between the exposure and the first appearance of the initial
lesion is known as the _first period of incubation_. _This varies,
within wide limits, from ten days to forty or fifty_; some writers have
made it even seventy days. The average period varies from three to four
weeks. There is often uncertainty as to when the induration began, and
patients, women especially, may easily make a mistake of several days
in fixing this date.

_Every case of acquired syphilis begins with an initial sore_, though
this may be so located or so complicated with some other lesion as to
be overlooked. The character of the induration varies somewhat with the
location, _i. e._, whether upon the skin or mucous membrane. The amount
of moisture or maceration to which it is exposed will also influence
its appearance. It may be minute, so as to almost elude observation
even on visible parts, or it may spread and involve an area 1 Cm. in
diameter. The lesion is _usually solitary_, but when several abraded
spots are infected at the same time there may be multiple sores. When
a surgeon sees a lesion of this character it has usually changed its
original appearance--perhaps by some previous treatment, perhaps by
maceration. There is one invariable feature upon varying expressions
of which diagnosis is based, and that is _induration_. The instances
in which this fails are very rare; on the other hand, it is possible
that it may be the result of treatment already undergone, and for this
reason the recent history of the case should be obtained; in other
words, _the typical chancroid is always indurated_, but an indurated
sore does not of itself necessarily indicate syphilis if it can be
satisfactorily accounted for in other ways. The presence of an active
primary lesion seems to confer immunity to subsequent infection for a
period co-equal with the active manifestations of the disease, although
even in this respect exceptions are occasionally to be noted.

The induration of syphilis develops beyond and beneath the limits of
the superficial lesion, and gives the sensation, when grasped between
the fingers, of a piece of firm material embedded in the skin or
membrane. It is firm, slightly elastic, with usually well-defined
boundaries, which accounts for the expression, _parchment induration_.
Ordinarily no pain or other sensations accompany its formation
or attract attention; hence the frequency with which it escapes
observation for some time and the uncertainty which the patient feels
regarding the dates. The surface of the induration usually becomes
moist or abraded and frequently ulcerated; but these surface lesions
tend eventually to heal, even if let alone, except in those parts, _e.
g._, the lips, where they are constantly bathed by discharge.

The characteristic induration disappears slowly in a few weeks or
months, leaving ordinarily no trace of its existence, although
sometimes a small scar, occasionally pigmented, is left to mark its
site.

There are two or three classical varieties of chancre which deserve
more minute description. As ordinarily seen upon the genitalia, a
chancre may assume the following types:

  A. Dry, scaly papule.

  B. Superficial erosion.

  C. Hunterian, or ulcerating chancre.


A. =Dry Papule.=--The _dry papule_ commences as a small rounded area of
redness, becoming infiltrated and rising above the surface, gradually
developing into a nodule the size of a pea or larger, over which the
superficial skin seems to be thickened. Should the summit of this
nodule become abraded there will escape a serous fluid, which dries
and forms a thin scab. This papule may disappear more slowly than it
came, or may become more infiltrated, while its surface breaks down
into an ulcer, whose area will be dropped a little below that of the
surrounding tissue. In this case the induration is produced almost
entirely by new round-cell infiltration, as in the other varieties;
when it ulcerates these cells are the ones mainly to suffer, so that
there is not much destruction of the original elements, and but little
scar remains.


B. =Superficial Erosion.=--The superficial erosion is the most common
of the primitive sores, but is not often seen so early as to have its
first appearance noted. It begins as a well-defined, dark-red area,
which loses its epithelium and exposes a raw surface, with a trifling
depression whose edges are usually on a level with the surrounding
skin, while in the previous case the edges are generally characterized
by an elevated margin. The base of this sore is also indurated, and
partakes usually of the parchment-like character already described.


C. =Hunterian Chancre.=--The Hunterian chancre, so named after John
Hunter’s description of it, is the most distinct and typical of these
primary lesions. It begins as a papule, with some erosion, increasing
slowly in size, sharply outlined, with a somewhat flat top. As it grows
larger it increases in firmness until its base is extremely dense.
In color it is greenish or bluish red, and this color appearance is
more distinctive than in the other forms. In from one to three weeks
its surface epithelium is usually loosened by maceration, and serous
discharge is the consequence, or else it becomes covered with a grayish
exudate, which, by its location, is rarely allowed to form a scab. The
centre of the ulcer becomes deeper, its edges more elevated, and in
typical cases a minute crater is formed by a characteristic destructive
process. While the Hunterian chancre tends in ordinary cases to slowly
disappear of itself, this involution can be materially hastened by
local and constitutional treatment, and usually heals, when properly
treated, with but slight local evidence of its previous existence.


=The Mixed Chancre.=--Chancroid will now be described, and its
consideration will include the statement that it may be followed by
true syphilitic chancre. Such a lesion is known as _mixed chancre_ or
_mixed sore_, and indicates a simultaneous infection by two distinct
infecting agencies; it may easily cause confusion, for if seen early
it will lack the characteristic induration of syphilis. This latter
will only appear about the time that the chancroidal ulcers should be
healed, if promptly and properly treated. Supposing this treatment
to consist at least in part of caustics, the surgeon may be in doubt
as to whether the induration is due to this agency or to developing
syphilis. It seems justifiable to imagine causes of this kind while
awaiting the further developments of the case, and to postpone vigorous
antisyphilitic remedies until the diagnosis is established. It is a
serious thing to condemn to a long course of mercurials a patient who
perhaps does not need such drastic drugs. Instances arise where the
situation is to be carefully considered in view of these possibilities.
Should the healing and apparently healthy ulcer, however, take on an
indurated base and develop the typical scleroses of chancre, it may be
supposed that all doubt has been removed. The possibility of syphilitic
infection being implanted upon a chancroidal base by subsequent
exposure should also be taken into consideration. This will require an
accurate history and a faithful narration of the same by the patient.

There are, also, the _extragenital chancres_, which may be met with
upon the hands, upon the breasts, in the oropharynx, as well as about
the eyelids. Chancres on those surfaces of the body where tissues are
loose may attain considerable size and ulcerate early, the discharge
drying into scabs or crusts, which mask the underlying ulcer. Around
the margins of the nails these lesions show but slight induration.
Sometimes suppuration and granulation are profuse. When appearing
upon the tonsils there is nearly always ulceration, with considerable
swelling and often a false membrane. A patient with this lesion will
complain of sore throat, and involvement of the surrounding lymphatics
is usually extensive.

When _chancre appears upon the lips_ there is usually extensive
induration; the lesion attains considerable size, with protrusion,
unless recognized and treated, and ulceration takes place early and
deeply. It may be confused here with _epithelioma_. The latter occurs
during the later period of life, is slower in its evolution, and its
involvement of the neighboring lymph nodes. The local changes which
often precede cancer, _e. g._, hyperkeratosis and papilloma, will be
lacking in chancre of the lip.

Sometimes at the site of the original chancre, which may have healed,
there will be found one of the later lesions of the disease, which may
be mistaken for another primary sore occupying the site of the first
one. It may be distinguished by its central ulceration, its tendency to
extend, and by the absence of the lymphatic involvement which is met
with in the early stages of the disease.


=Pathology of the Chancre.=--The chancre should be regarded as
the first neoplastic evidence of a disease which is throughout
characterized by its tendency toward new-cell formation. In the
developed chancre there is a well-defined cell proliferation in the
skin or mucous membrane, whose bloodvessels show the same character
of change already mentioned, since in the walls, both of the minute
arteries and veins, are found many new cells, some of which were
originally leukocytes, but most of which are products of cell division,
as shown by their numerous mitoses. All the coats of the vessels are
involved and even the perivascular spaces are involved and obliterated.
Essentially, then, the chancre consists of a local infiltration of the
superficial tissues by cells, most of which are of the round type;
the whole constitutes what may be spoken of as the initial sclerosis,
which remains or disappears as such unless infected secondarily. This
sclerosis should be carefully sought in every suspected region when
the patient is first examined. It may range in bulk from a millet-seed
to that of a good-sized grape; it is usually movable upon the tissues
beneath; it may ulcerate deeply, and, should it persist for a long
time, it may seem unusually active just before the outbreak of the
so-called secondary symptoms.

But little can be predicted with regard to the future course of the
disease from the size, number, or appearance of the primary sores. The
nature of the tissues upon which the virus has been implanted is a
more important feature in the evolution of the disease than anything
pertaining to its primary lesions, so far as appearances go. In
patients of depraved habits or vitiated constitutions the chancre may
often become gangrenous or phagedenic.


=Lymphatic Involvement.=--Soon after the appearance of the primary
sore, or coincident with it, the enlargement of the adjoining
lymphvessels and nodes begins. This is noted first in those which
are in closest communication with the site of the chancre, usually
in the groin. Occasionally thickened lymphvessels may be felt as
cords extending along the dorsum of the penis. There may be enough
involvement of the perivascular spaces to produce this appearance and
sensation even around the bloodvessels. This lymphatic involvement is
exceedingly significant, and yet may be found to some degree after
chancroid and even after herpes of the genitals. It is, of course, an
expression of a travelling infection--in the first case produced by the
syphilitic virus; in the second, by the chancroidal virus; and in the
third, by ordinary pyogenic organisms which enter through the pathway
afforded by the herpes.

The involved lymph nodes of syphilis suppurate much less often than
do those of chancroid, and suppurating bubo is, therefore, not common
in syphilis. The term _bubo_ generally means an involvement of the
lymphatics in the groin, although, strictly speaking, it implies
a similar condition in any part of the body. _Syphilitic bubo_,
therefore, is to be distinguished from chancroidal as well as from
non-specific bubo. These lymphatic lesions are sometimes spoken of as
constituting the characteristic _adenopathy_ of the disease, but this
is an unfortunate expression, as it implies _glandular_ involvement,
and the term lymph gland should never be used, since the structures are
not glandular in any respect. The enlargement and persistence of these
lymph nodes constitute peculiar features of the disease, and may be
noted long after the subsidence of active manifestations.


=Treatment.=--With the earliest possible recognition of a syphilitic
chancre or sore there is need for active and prolonged constitutional
treatment, in addition to whatever may be required locally. If the
diagnosis can be made, _constitutional treatment should commence at
once_; only in cases of doubt is it advisable to wait. The local
treatment is a matter of ordinarily small importance; the sores tend
to heal spontaneously and quickly when the system is brought under
the influence of mercurials. There are few authorities who recommend
excision of the primary lesion or believe it is possible to abort
syphilis by anything that can be done to the chancre. It is advisable
to make mild antiseptic applications only. A chancre, however, in a
location which makes it difficult to keep the parts clean, should
be exposed to treatment by a minor operation, as an incision of the
prepuce, circumcision, or a dilatation or incision of the hymen.
Aside from such operation the indication is for surgical cleanliness;
soap and water followed by hydrogen peroxide, which may be continued
as an application, or dusting with calomel, will usually prove
sufficient. Various antiseptic solutions may be used. Dry applications,
however, are the most convenient and usually the most serviceable;
iodoform should be avoided on account of its penetrating odor; and
pure, dry calomel will sometimes prove a mild caustic, and is best
reduced with one to three parts by weight of bismuth subnitrate. The
stronger applications, especially caustic, are only employed when
there is unhealthy ulceration. If the sore is gangrenous it should be
cocainized, then the surface thoroughly treated with some powerful
caustic like nitric acid, and thereafter kept moist with aqueous
antiseptic solutions. When the surface is practically healthy, dry
preparations or unguents may be employed, preferably the mercurial
ointments. There is greater difficulty in preserving cleanliness about
the female genitalia, and here the use of antiseptic cotton or gauze
will probably be necessary in addition to the other precautions.
Surfaces should be kept apart by their aid, and it is well to use
frequent antiseptic douches or occasionally to insert a suppository
containing an antiseptic drug. Of the various preparations used those
containing mercury in some form are doubly serviceable. The inguinal
lymphatics should be kept anointed with a mercurial ointment, which
should be thoroughly rubbed in, and the parts afterward protected with
oiled silk.

While these local measures are being employed vigorous general
treatment should be promptly instituted. This will be discussed when
dealing with treatment of the constitutional features of the disease.

There are locations in which chancre gives rise to considerable
distress, as, for instance, upon the lip and tonsils. Great improvement
and relief of pain in these lesions is afforded by proper use of
auxiliary drugs.

In regard to local precautions, the patient should be impressed with
the virulent and infectious character of the discharge from every
primary lesion, and given minute and cautious directions so that
its transmission to others can be prevented. This will mean the use
of separate utensils, as well as soap, towels, etc., possibly the
temporary isolation of the patient.


CONSTITUTIONAL SYPHILIS.

Between the time of appearance of the primary sore and the development
of widespread constitutional symptoms there intervenes a period of
latency, the _second period of incubation_. This is more variable
in duration than the first. The shortest time on record is about
two weeks, and the longest about two hundred days, the average
time being six or seven weeks. The _secondary symptoms_ indicate
complete generalization of the syphilitic poison, and follow the
early manifestations in almost every case; nevertheless, there are
instances in which they are either wanting or are so trifling as to
escape observation. A careful examination during the second period will
usually show, however, that the lymph nodes throughout the body are
gradually becoming enlarged, especially those in the neck, along the
border of the sternomastoid, the occipital nodes, those in the axilla
and groin, and particularly one or two small ones above the inner
condyle of the humerus, known as the _supracondyloid_ or _epitrochlear_
nodes. When these latter become involved without evident and local
cause, syphilis is always to be suspected or even diagnosticated. This
node is to be found by bending the patient’s elbow and feeling for
it on the inner side, above the condyle, in the interval between the
biceps and the triceps. The other lymph nodes of the body might also
be found involved if they could be as easily palpated. This lymphatic
involvement is quite independent of skin or other lesions, and does not
yield as readily to mercurial treatment. The enlargements are usually
movable, distinct in outline, and never suppurate unless locally and
secondarily infected. In tuberculous patients, however, they may
break down. This generalized involvement of the lymphatics is also of
importance in diagnosticating old syphilitic infections.

During the second period of incubation there is generally a certain
degree of malaise and progressive anemia. Examination of the blood
will show diminution of hemoglobin, and a relative if not actual
leukocytosis, due to reduction in the number of the red corpuscles.
Occasionally the anemic features become pronounced; the patient may
complain of weakness, lassitude, sleeplessness, failure of appetite,
and of pain and discomfort in the bones and joints, more pronounced
at night, and often regarded by patients as “rheumatic.” The painful
joints may also show a slight swelling due to increase of the joint
serum.

Sometimes intermittent fever accompanies these cases, especially
during the early eruptive period. The rise of temperature is noted
mainly in the evening, when it may reach 104° or even 105° F. It does
not last long, and often precedes the appearance of a well-marked and
characteristic eruption. It is a peculiar feature of the syphilitic
poison that it seems to attack points of least resistance in each
patient, as is the case with that of influenza. In one patient fibrous
tissues will suffer most; in another, joints; in others there will
be headache or expressions of perverted nerve activity, as vertigo,
convulsions, disturbances of sensation, temporary paralysis; again
there occur disturbances like mild pleurisy, splenic enlargement, or
jaundice. Occasionally there will be a typhoidal condition, during
which the kidneys are seriously compromised. Morbid conditions are
intensified by an attack of syphilis. During rheumatism and the various
forms of neuritis, and during almost all affections of the central
nervous system, symptoms are, under these circumstances, frequently
aggravated. In malarial countries it is said that latent syphilis
sometimes becomes active when malaria is present. Lesions of the bones
and joints are occasionally influenced, while some claim that fractures
occur more readily in syphilitic subjects, and it is generally conceded
that delayed union of fractures is often due to this cause. I have seen
fracture, apparently spontaneous, of both tibiæ, one after the other,
in a patient with syphilitic disease of the cord and bones. I have also
seen exuberant callus form around a fracture in a syphilitic subject,
as it never does under ordinary circumstances. Injury seems sometimes
to localize the manifestations of the disease; thus chronic irritation
at the site of old syphilitic lesions frequently becomes a point of
development for epithelioma, or some other expression of malignant
growth. This is seen particularly in cancer of the tongue, which
sometimes follows the change in the epithelium known as _leukoplakia_.

The _influence of an attack of erysipelas_ upon certain specific
lesions is remarkable. In many instances eruptions and ulcerations have
been known to subside, and gummas and exostoses to disappear, after an
attack of erysipelas involving their site, but these lesions are likely
to reappear after the disappearance of the acute infectious process.
The temporary effect of the toxins of erysipelas upon syphilitic
lesions is similar to their influence upon some malignant growths.


=Syphilis of the Skin.=--Passing now to the lesions of early
constitutional syphilis as manifested in particular regions or organs
of the body, we take, first, the skin. When syphilis seems to have
ended its existence during the primary stage (Fordyce) no further
disturbances are expected, and only by waiting can the termination of
the disease be determined.

The malignancy of the disease may be estimated by noting the rapidity
with which the destructive lesions appear; thus gummas which appear
early in the skin or mucous membranes, or elsewhere, indicate a serious
type of the disease. So also does profound cachexia, including in this
term more than mere anemia. The devastations of the disease in Europe
during the fifteenth century show that it presented at that time a
severe type.

The eruptions of syphilis have been grouped under distinctive terms,
and are usually referred to as _syphilides_ or _syphilodermas_. It has
been already stated that among the new formations of syphilis are those
known as syphilodermas; any of the former which are distinctly due to
syphilis may be syphilomas. Thus, we may have syphiloma in the skin,
in the bones, in the viscera, etc. It has been customary to speak of
the syphilides as simulating the non-specific eruptions and identify
them by placing before them the adjective syphilitic. Thus writers
formerly described syphilitic psoriasis, syphilitic erythema, etc.;
but these terms have been abandoned, because it is recognized that the
skin lesions of syphilis while imitating most of the features of the
non-specific diseases are yet distinctly different from them. We speak,
therefore, now of a macular, vesicular, papular, squamous syphilide,
etc., implying thereby that it is vesicular, scaly, or otherwise, as
the case may be, and at the same time that it is a cutaneous expression
of syphilis.

[Illustration: PLATE VIII

Grouped Miliary Papular Syphilide.]

[Illustration: PLATE IX

Mixed Papular and Papulopustular Syphilide.]

[Illustration: PLATE X

Tuberculous Ulcerating Syphilide, showing Lesions in Different
Stages.]

The _syphilodermas have certain peculiarities_ which are striking
and distinctive; they are symmetrically distributed; their color is
characteristic, and is due to the disease of the bloodvessel walls,
which has been referred to, by which stasis is favored and exudation
encouraged. The pigmentation is often striking, and, whatever it
may be at first, it assumes a tint described by the terms “raw ham”
or “coppery.” Dark pigmentation may take the place of the lighter
colored, as the sole evidence of the existence of the previous lesion.
Occasionally, however, the normal pigment of the skin disappears and a
bleached-out area marks the site of the previous lesion. This is often
irregular in shape and considerable in size. Such a spot is spoken of
as _leukoderma_. Again, the syphilodermas are generally _polymorphous_,
and seem to be capable of imitating almost every known non-specific
skin affection; so close is the resemblance that it often requires
careful study of the case to permit of diagnosis. The absence of
itching is also a feature of most of these cases.

The early syphilides are superficial, distributed generally and
symmetrically, and disappear spontaneously.

When skin lesions are clustered, as in the macular and papular forms,
they usually group themselves symmetrically and in more or less
circular outline. When, however, they are too regularly arranged, it
may be taken as evidence of their older and more relapsing character.

The later skin lesions of syphilis differ in several respects from the
earlier. They are less regularly grouped; they involve a greater depth
of tissue; they tend to ulcerate and to leave permanent scars; and they
have around them a more infiltrated area, probably because they are
deeper. They are, however, not so infectious as the earlier lesions,
and it is rare that they are of serious menace to others. (See Plates
VIII, IX, X.)

Fordyce and others have pointed out that the prompt and specific
influence of mercury and even of iodine upon these eruptions is an
instance of the selective action of certain drugs, and nothing could be
more conspicuous in demonstrating it.

Certain types of syphilide are common in the earlier stages and others
in the later; there may be a well-defined limit between the two, since
in not a few instances all types seem to be combined.

The first eruption of so-called secondary syphilis assumes the
erythematous or macular type, and has been referred to as _roseola
syphilitica_. It appears as a generalized eruption, in spots varying
from 0.5 to 1 Cm. in size, which are of a vivid color and scarcely
elevated above the surface. It commences usually upon the abdomen,
proceeds to the chest, and then to the extremities. It does not often
appear upon the face. Two or three weeks may be consumed in its
generalization over the entire body. If let alone it has a duration of
a few days to several weeks, and may then fade away, leaving nothing to
indicate its presence save a slight pigmentation.

Of more pronounced character is the _papular_ eruption, which commences
as a small papule, and is described as _lenticulopapular_ and _miliary
papular_. At first these are generalized, then become circumscribed,
and exhibit transition forms from the early to the later type of
lesions. The papules vary in size from that of a millet-seed to that
of a split pea; even this type may disappear without ulceration or
suppuration.

Lichen planus may be mistaken for papular syphilide, but may be
distinguished from it by intense itching and by lack of the pigment
changes which characterize the syphilide.

The _squamous syphilide_ is sometimes a continuance of the papular,
and sometimes it begins as such. It is characterized by a variety of
scaly macules and papules, which strikingly resemble the lesions of
psoriasis. The latter are seldom seen on the palms and soles, while
the squamous syphilide is very frequently seen in these locations.
Moreover, along with the squamous lesions are frequently associated
other skin lesions, which give the case a complex type, resembling
at one point one of the non-specific affections, and others at other
points. Such changes are mainly expressions of various stages in the
involution or degeneration of the papule, but they may give the case a
variegated appearance, in which pigmentation may be prominent.

Some years ago Biett described a form of syphilide which he claimed
was unmistakable and indicative. Since he described the lesion it has
been known as _Biett’s collarette_. It appears in from ten to twenty
weeks after the secondary symptoms are fully declared, is superficial,
usually situated upon the trunk and extremities, but never upon the
palms or soles. It consists of a flat papule almost level with the
skin, 1 to 2 Cm. in diameter, rounded in contour, while around it there
is seen a zone of white epidermal scales pretty sharply defined and
giving it the name of collarette. The area within is dry and painless,
and the ring itself narrow. There is little or no itching. It may be
followed by some other skin lesion. The lesion is often so mild as to
pass unnoticed.

At other times _pustulocrustaceous syphilides_ will appear above the
level of the skin, surrounded by a series of narrow concentric rings,
not scaly, but composed of a number of small pustules, the first ring
being perhaps an inch from the centre of the inner lesion. This is seen
more often in males than in females, and it seems as though the smaller
pustules were the result of an auto-infection of ordinary pyogenic
character. In the presence of either of these lesions a positive
diagnosis of syphilis can be made.

The _pustular syphilide_ may give rise to large or small pustules,
which soon become superficial ulcers, often irregular in shape, with
an unhealthy floor which may be livid or gangrenous, or may resemble a
diphtheritic lesion, while from its surface exudes a mixture of blood,
debris, and pus, which dries into dark-colored crusts and constitutes
the lesion known as _ecthyma_. These lesions are often deceptive, since
while scabbing seems to be occurring over the surface the ulceration
may be extending beneath. This is an intermediate or earlier tertiary
rather than a secondary lesion.

Another type of pustular syphilide is that known as _rupia_, where
the ulcers are larger and are covered with concentric layers of crust
resembling an oyster-shell. These lesions begin as papules and undergo
changes which make them bullæ or pustules and then open ulcers. The
peculiar scabs are somewhat conical in shape when not disturbed, and
are greenish or brownish in color. If they are dislodged, irregular,
indolent, and often sensitive ulcerated areas will be found beneath
them. Even when these ulcers heal they are irregular in outline and
show a white scar often surrounded by an areola of pigment. This rupia
is the most visible lesion of syphilis, as no other skin disease
assumes any such type.

In the last-described and ulcerative forms of syphilide there is a
possibility of septic infection, or at least of septic intoxication by
absorption; hence the need for care in this direction. In fact, into
the treatment of every pustular indication of syphilis the elements of
local protection and local antisepsis should enter.


=The Mucous Membranes.=--Here the manifestations of syphilis are of
great importance because of their extreme infectiousness. The earlier
manifestations are seen mainly about the mouth. When an eruption
appears upon the skin a condition corresponding to it may often be
recognized in the pharynx and upon the uvula and soft palate. This will
be accompanied by discomfort, and the patient complains of “soreness
of the throat.” These throat lesions are chronic, liable to recur,
and disappear slowly, unless the patient is vigorously treated; they
sometimes cause dryness of the fauces, followed by a free flow of
mucus. The dusky discoloration of the rash is quite distinctive.

The congested areas have a dusky hue on the skin and are spoken of as
“coppery” or “raw-ham” in tint. They are usually well outlined; should
the disease progress they become eroded. “Syphilitic sore throat,” as
this condition is often called, may be aggravated by the use of tobacco
and by unclean mouths. The involvement of the cervical lymphatics will
be proportionate to the vividness of the lesion.


TERTIARY OR CONSTITUTIONAL SYPHILIS.

There is no distinctive time limit between the so-called secondary and
the tertiary symptoms of syphilis. Generally the lesions disappear with
but little treatment; in many instances they will fade away without
any. In most cases, however, the patient, even under poor management,
takes enough medicine to disperse the lesions more quickly than they
would spontaneously subside. If he discontinues medicine for several
weeks, sometimes many months will elapse before there are any active
manifestations of the disease. During this period, however, the
lymphatic enlargements will not decrease perceptibly, and there may be
evidence of advance in this direction. The so-called tertiary symptoms
appear usually without fever or other symptoms, and not often in less
than five or six months after the commencement of the disease. On the
other hand, their advent may be delayed for years, even when the early
treatment of the case has been but partially effective.

No organ or tissue in the body is exempt from the ravages of tertiary
syphilis. Even the finger-nails and the hair may suffer, while the
teeth are affected in the hereditary manifestations. Affections of the
skin occur, according to Haslund, in about 12 per cent. of the cases.

The _mucous membranes_ are liable to exhibit those lesions above
described, known as _mucous patches_, usually regarded as late
secondary symptoms. The description applies equally well to the
tertiary lesions. They occur about the oropharynx, upon the tongue,
the lips, the nostrils, and the eyelids. They are frequently found
also about the rectum, anus, and genitalia of either sex. In general
they present about the same appearance. They commence usually with
a slight elevation of the surface and at several points, sometimes
simultaneously and successively. These surfaces ulcerate superficially,
and thus are produced irregular but rounded patches, with uneven edges,
of grayish-yellow surface, which ordinarily are not sensitive, but
occasionally extremely so. They may disappear under local treatment,
but in that case tend to recur at frequent intervals. If unnoticed
or not properly cared for the ulcers may become deeper and assume
an unhealthy appearance. In the mucus-lined cavities affected the
condition of these ulcers will depend upon the personal habits of the
patient. In mouths where tartar has accumulated upon the teeth, or
where the toothbrush is seldom used, the patches may become large and
foul.

_These lesions are extremely infectious_ and the disease may be
conveyed by kissing, by the common use of small domestic utensils,
by the pipe, by dentists’ instruments, etc. Patches occurring at the
junction of the skin and mucous membrane may extend over onto the
latter and become deep, specific ulcers. Lesions of this character
need judicious local as well as constitutional treatment. They will
often disappear under the latter alone, but it should be combined
with local measures. These consist in cleanliness and the use of
various antiseptic solutions or applications. An antiseptic mouth
wash, as diluted hydrogen dioxide, or of water given a mahogany color
by tincture of iodine, should be frequently used. There should be an
application of a 5 per cent. solution of silver nitrate, or some other
astringent, stimulating, or mild caustic.

[Illustration: FIG. 24

Grouped papulopustular syphilide and numerous pigmented spots from
former lesions. (Fordyce.)]


=The Skin.=--The late syphilides of syphilis belong to the _gummatous_
or _tuberculous_ types (_i. e._, tuberculous in the anatomical sense,
or nodular). The latter may occupy the entire thickness of the skin or
lie even deeper. Such lesions may begin as papules and develop into
distinct and circumscribed nodules, while these may coalesce into
considerable masses. These tend to break down and leave scars after
they have disappeared. There is little difference, microscopically,
between the nodule and the gumma. Clinically, the tuberculous lesions
spread usually in a serpiginous manner, producing a more or less
curvilinear outline. (See Figs. 24 to 27.) These ulcerations undermine
the tissues to a greater or less extent, and pus and debris will be
formed in consequence. In this way they imitate considerably the
lesions of lupus, and it may require a careful study of the case and of
its history to make a diagnosis. Some of these lesions are extremely
slow in their course and long in duration. When scars form they are
usually white and smooth, with irregular borders, but sometimes are
surrounded by pigment that makes them characteristic. The extent of
the scar is no criterion as to the size of the originating lesion, the
former being always smaller than the latter.

[Illustration: FIG. 25

Ulcers resulting from deep ecthymatous syphilide. (Fordyce.)]


=The Gumma of Syphilis.=--This is as characteristic of late syphilis
as is the _condyloma_ of the earlier stage. By this term is meant a
new formation which may vary in size from a millet-seed to a large
mass. Sometimes it is diffuse, or it may be circumscribed. It seems
to originate from connective tissue, and may be met in all parts of
the body. Microscopically it consists of a delicate stroma filled with
small, round cells, the mass being furnished usually with bloodvessels,
also of new formation. Such a gumma may pass through various stages
of integration and disintegration. The cells sometimes undergo fatty
changes by which the entire mass is softened, and its interior contains
a puruloid material resembling pus. The gumma, as it increases, will
replace other tissues and cause them to disappear, and thus it happens
that when it disappears the region previously occupied by it seems
to have diminished in size. Sometimes, however, cicatricial tissue
takes its place and not only distorts an organ or part but impairs its
function. Thus softening and melting may occur at one time and a dense
scar or mass at another.

The degree of infectiousness of gummatous and other late syphilitic
ulcerations is uncertain. The later they occur, the less infectious. It
would be safe, however, to assume that they are all dangerous.


=The Gummatous Syphilide.=--This begins, as a rule, as a subcutaneous
gumma which quickly proceeds to and involves the skin. At first it
appears as an induration, developing into a distinct tumor, becoming
more indurated and firmly implanted as it grows, the overlying skin
becoming reddened and swollen. After a time there occurs softening in
the interior of the mass, and upon incision there will escape not pus
but viscid, puruloid fluid, yellowish gray in color, which may contain
corpuscles resembling those of pus. It is the content of such a tumor
as this which has given it its peculiar name, _gumma_. Should proper
treatment be rapidly pushed, it is possible for a softened gumma to
disappear by absorption, but if ulceration or evacuation has taken
place, there remains usually a permanent disfigurement at the site of
the mass; like tuberculous gummas these growths may undergo caseous or
even calcareous degeneration.

A gumma of the skin will open at one or several points, and, becoming
thus secondarily infected, may give exit to sloughing tissue and foul
discharge. If the skin directly overlies the bone, then the tumor may
involve the latter as well; and when it ulcerates, the bone will be
exposed. In the healing process, however brought about, deformity from
cicatricial contraction may cause much disfigurement. When a gumma
appears beneath the true skin and then disappears it may leave areas
of depression, with more or less adherent, bleached-out scars, perhaps
with a pigmented margin. The appearance of such scars is suggestive of
the disease even without a definite history.

The gummas form the most important features of syphilis, at least from
a surgical standpoint, since they frequently appear in the depths
as well as on the surface of the body, without any other symptoms,
and they often cause no little perplexity in diagnosis. Syphilomas,
tuberculous gummas, phlegmons, innocent and benign tumors, as
occurring especially in and upon the bone, in the muscles, tongue, the
breast, the testicle, and elsewhere, may be difficult of diagnosis.
Of course, a history of syphilis is a great help. Doubt frequently
arises when such a history cannot be obtained. Scarcely any other
disease will produce multiple lesions such as are seen in syphilis,
and when multiple they are usually distributed, with some appearance
of symmetry. Ulcers formed by their breaking down are often extremely
sensitive, but do not bleed easily, nor show a tendency to exuberant
granulation. In cases of doubt the most successful test is perhaps the
therapeutic, and consists in giving mercurial or mixed treatment to the
point of toleration and noting its effect.

[Illustration: FIG. 26

Tuberculous serpiginous syphilide resembling lupus vulgaris. (Fordyce.)]

[Illustration: FIG. 27

An ulcerating gumma of the leg. (Fordyce.)]

In many patients, especially of the hospital class, scars, which
are strongly suggestive, will be visible upon the legs. It does not
follow, however, that an old scar upon the legs, even if surrounded
by a pigmented area, is necessarily of syphilitic origin. Old ulcers
of the limbs are frequently seen in connection with varicose veins,
and may show exceedingly chronic tendencies; moreover, it is possible
for chronic and non-specific ulcers to occur in old syphilitic
subjects when the course of the local lesions may be influenced by
the old affection, although they are not specific ulcers. Benefit,
however, will in such cases accrue by the reasonable administration of
antispecific treatment, but it should be combined with suitable local
measures.


=The Vascular System.=--The lesions which are encountered in the
bloodvessel walls in chancre and early syphilis have been described.
The heart and vessels are liable to suffer, as they contain connective
tissue. Gummas have been noted in the heart, while the poison also may
produce thickening of the valves, and disease of the coronary arteries,
the endocardium and the myocardial structure.

The arteries often suffer from _arteriosclerosis_, which is either
diffuse or nodular. Endarteritis is a common manifestation of syphilis
and leads frequently to the formation of aneurysm. Sometimes this
appears as a single and large lesion; at other times hundreds of small
aneurysms will form in the arterial system of the brain, so that the
arteries are studded with them. The explanation of aneurysm under these
circumstances is that the arterial walls, being weakened, dilate under
the influence of blood pressure. Thus the arteries, from the largest
to the smallest, also may suffer. The veins likewise are subject to
syphilitic phlebitis, which is frequent in the superficial veins of the
extremities.


=Bones and Joints.=--Syphilitic manifestations in bones are frequent,
but are not so common in the joints. While early syphilitic periostitis
is not infrequent the actual lesions of the bone are mostly expressions
of late syphilis. Nearly all of them are painful. The pain is worse
at night, and is called the osteocopic pain of syphilis. At first
these bone lesions are hyperplastic, because of the connective tissue
in the bone. Periostitis is a common manifestation, and here, again,
the neoplastic tendency of the disease is manifested, in that the
periosteum is thickened as well as the bone beneath, and swellings
called _nodes_ are thus formed. Nodes are met with more often on the
tibia and the sternum than elsewhere, but are frequent upon the skull
and clavicles. No bone is exempt from these lesions. They often form
at points where there has been previous injury. These swellings are
ill-defined, and usually quite tender, while the skin over them is
easily movable unless secondary infection has occurred and suppuration
is present. The nocturnal pains in these lesions, of which patients
often complain, are sometimes excruciating. Should suppuration occur,
with subsequent formation of ulcer, there may be necrosis of the
exposed bone. Another bone lesion of syphilis assumes the type of
_ostitis_. Physiologically this consists essentially of gummatous
involvement of the connective tissue, which may be either localized or
diffuse. When this undergoes retrocession there occurs a rarefaction of
the bone, by which it is weakened and easily broken, so easily in fact
that we have to deal sometimes with what is referred to as _spontaneous
fracture_. There is frequently a thickening and condensation of
the entire bone, with some distortion, so that the actual weight
of the bone may be nearly doubled. _Dactylitis_ is the name given
to syphilitic ostitis of the phalanges, which increase in size and
become tender and useless, while the skin becomes glazed. Occasionally
the disturbance appears to involve the extra-osseous tissues rather
than the bones themselves. Bones which are spongy are liable to this
disease. Some of the bones in the face are peculiarly susceptible;
hence the loss of the bridge of the nose, or of a portion of the hard
palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring
in tuberculous disease. There may be either a gummatous synovitis
or an arthritis, or else destruction of articular surfaces. These
joint lesions of syphilis are all slow in their course, and sometimes
difficult of distinction from tuberculous and other lesions. They have
so much in common with the joint expressions of tabes that some writers
believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint
these cases are usually amenable to treatment, but for the actual
destructions caused here or elsewhere by syphilis there is no repair
possible, and the harm once done cannot be undone. Plastic operations
and injections of paraffin may have to be practised for cosmetic
purposes and relief of disfigurement.


=Muscles and Tendons.=--It is the connective tissue of muscles which
suffers most in the luetic affection of these structures. It may be
met with as a diffuse process or as a gumma. In the former cases the
muscle becomes irregular in shape and size, and in the latter distinct
tumors are formed. As such growths advance and contract adhesions to
surrounding structures, there is interference with muscle play.

_Syphilitic myositis_ causes little pain, and patients with gummas in
muscles are often not seen until ulceration has begun.

The dense fibrous structure of _tendons_ and _aponeuroses_ is
frequently involved in late syphilis, causing pain and disability.
Little is discovered on physical examination, but considerable loss of
function may result. Points of tenderness sometimes are noted along
junctions with the adjoining periosteum. Such a _tendoperiostitis_ may
be painful, and even crippling.


=Bursæ.=--Bursæ are prone to be involved in syphilis, especially those
in front of the patella. A gumma frequently develops at this point,
where it constitutes a painless, somewhat tender enlargement, which
may be dense or elastic. After it has become adherent to the skin it
is usually infected, and a chronic ulcer results at this point, which
may often manifest gangrenous tendencies. This constitutes one form of
so-called _housemaid’s knee_.


=The Eye.=--Of the manifestations of syphilis in particular organs the
eye sometimes suffers severely. _Iritis_ is the most common and serious
manifestations of constitutional syphilis. It has been estimated that
nearly 60 per cent. of all cases of iritis are due to this cause. It
may occur in two months after the primary sore; it is usually acute,
and rarely begins in both eyes at the same time, but may involve one
after the other. The ciliary body is frequently associated in the
lesion, and _iridocyclitis_ occurs. It commences with congestion of
the conjunctiva, photophobia, and lacrymation. The pain is not always
severe. Inspection of the iris will show beads of lymph, a small pupil,
with loss of contractility, or the dull iris may appear infiltrated and
inflexible. The pain in some cases is extreme. Where treatment has been
only partially effective relapses are common. The greatest danger to be
feared is formation of adhesions between the anterior surface of the
lens and the margin of the pupil, _i. e._, anterior synechiæ. These are
detrimental, and serve as the cause of many irritations.

The treatment of these affections is constitutional; locally solutions
of atropine of sufficient strength to ensure dilatation of the pupil
should be used, not only to relieve the pain, but to carry the
margin of the pupil from the central portion of the lens and prevent
adhesions. The patients should be kept in the dark because of their
photophobia. Atropine may be substituted by duboisine if the former
tends to produce congestion. Leeches applied to the temples will also
give relief from pain.

The _cornea_ is often affected by a deposit on its posterior surface
of particles of debris, which give it a punctate appearance known
as keratitis punctata. It also becomes the seat of opacities which
materially interfere with vision, and prove only partially amenable to
treatment. Lesions of the cornea are frequent in hereditary syphilis.

_Retinitis_ and _choroiditis_, of either acute or chronic type, are
the most common syphilitic lesions of the fundus. They are usually
associated and involve both eyes. They come on so insidiously that they
are often far advanced when first discovered. The lesions consist of
patches of exudation and areas of atrophy, accompanied by some haziness
in the vitreous. Vision is affected in proportion to the area involved.

The _movements of the eyes_ are interfered with by lesions which
pertain, however, rather to the brain and the ocular nerves than to
the eye itself. The sixth nerve, lying on the floor of the skull, is
affected by syphilitic disease at the base of the bone. As a result of
these nerve lesions paralysis is often seen, or at least disturbances
of motility from which _diplopia_ results. _Ptosis_ occurs from
affection of the third nerve. In lesions situated below the aqueduct
of Sylvius, the paralytic condition which Hutchinson has spoken of as
_ophthalmoplegia_ is likely to appear. _Optic neuritis_ is also a late
manifestation of syphilis, and may be either chronic and mild, with a
small disturbance of vision, or acute, with rapid loss of eyesight.


=The Ear.=--The ear may suffer in various ways. The external ear may
participate in affections of the adjoining skin. The middle ear may
be affected as a result of extension of trouble from the nasopharynx,
while in the late stages of the disease patients may suffer from
labyrinthine disease, with partial or almost total deafness.


=The Nose.=--The lesions of syphilis in the nose are numerous and
offensive. Ulceration is frequent and followed by perforation through
the septum or into the mouth. When the vomer is involved the bridge of
the nose falls in. In neglected cases the whole substance of the nose
may be involved and subsequently lost. The bone is often exfoliated.
These ulcerations of the mucous membrane and periosteum give rise to
a characteristic condition known as _ozena_, with its characteristic
discharge.


=The Oropharynx.=--The tongue may be the site of intermediate and late
syphilitic lesions. Men suffer more than women, apparently because of
their use of tobacco. Mucous patches, deep ulcers, and even gummas,
single or multiple, are seen here. Gummas in the tongue are inclined to
undergo superficial ulcerative infection and become abscesses. In these
lesions there will be notable involvement of the adjoining lymphatics.
The appearance of smooth, bluish-gray patches upon the mucous membrane
of the tongue and cheeks is known as _leukoplakia_ or _leukokeratosis_.
These lesions do not respond readily to treatment; they give rise to
little or no complaint, and are often followed by malignant disease.

It is difficult to distinguish between gumma of the tongue and
epithelioma. Usually the latter is a single lesion; the former often
multiple. In epithelioma the ulcer is superficially painful, with more
elevated and indurated edges, while the pain is sometimes intense and
radiates toward the ears.

_Interstitial glossitis_ is a late manifestation of a sclerosis
beginning in the connective tissue and involving the muscle fibers,
leading to enlargement of the tongue and later to atrophy and
inflexibility.


=The Larynx.=--Syphilis of the larynx appears either as one or more
ulcers, as gumma, or as _chondritis_ or _perichondritis_, often
with necrosis of cartilage. When ulcers form they are deep and
destructive, involving even the intrinsic muscles of the larynx, and
causing harshness or loss of voice, with dyspnea. Subsequently they
lead to cicatrization, often leaving a stricture which may call for
tracheotomy. The epiglottis is also liable to ulceration and gummatous
lesions.

In these cases, aside from the general treatment, there is need also
for local applications of combined antiseptic and anodyne character.
Cocaine or one of its less toxic substitutes may be used in spray or
by insufflation, in connection with an antiseptic powder, morphine
or heroine. Edema of the glottis may be subdued by the local use of
adrenalin.


=The Alimentary Tract.=--Between the mouth and the rectum the
intestinal canal is rarely involved in syphilitic disease. In the
_rectum_, however, ulcers, as well as gummatous infiltrations, are
frequently encountered. If the ulcers are low, within two inches of
the anus, they will cause great pain. Higher up the rectum is not so
well supplied with sensory nerves. Ulceration may involve the entire
circumference of the anus.

In the rectum chronic ulcers are liable to be followed by stricture,
which will call for surgical relief. (See chapter on the Rectum.)

In the _colon_ chronic ulcers have been so serious as to lead to
dysentery, followed by stricture formation. It has been suggested to
make an artificial anus at the cecum and allow the large intestine to
rest, treating it at the same time with irrigation through the opening.


=The Viscera.=--Of the solid viscera the _liver_ is more commonly
affected than the spleen or kidneys. Chronic _interstitial hepatitis_
may lead to cirrhosis, the new tissue being less distinctly distributed
than when due to alcohol, the liver consequently becoming irregular,
with a deep separation between its lobes. The pain is sometimes intense.

On the other hand isolated _gummas_, or confluent masses of smaller
gummas, may be found beneath the capsule or in the substance of the
liver. From one or both of these cases combined this viscus may attain
an enormous size, with acute pain. Under these conditions there may
occur albuminuria and evidences of amyloid disease.

Likewise in the _spleen_ there may be diffuse or localized trouble.
Here the lesions cause but slight distress.

The mercurials are of greater importance than the iodides in treatment
of these lesions. The kidneys suffer less often than the spleen.
Syphilitic patients do not lose their liability to renal disorders, but
there seems to be but small, direct connection between syphilis and the
common changes in these organs.


=The Genitalia.=--In both sexes the genitalia are subject to gummatous
involvement during the later stages; in the male more frequently in the
_corpora cavernosa_ and _testicle_. In the latter a chronic induration,
with some enlargement of the epididymis, is one of the manifestations
of constitutional disease. Most of the enlargements of the testicle
are slow and painless, and occasionally some fluid will collect.
The _prostate_ and the _seminal vesicles_ are rarely involved in
syphilis, but frequently in a tuberculous process. This is an important
diagnostic point.

In the ovaries there may occur a diffuse cirrhotic process.


=The Nervous System.=--Here the manifestations of syphilis are often
serious and widespread. They are produced by the same new tissue
to which we have so often alluded, with its tendency at first to
degeneration and later to sclerosis. They are always insidious.
Gummatous thickening may occur at any point, springing often from
the pia of the brain and cord. The arterial walls are frequently so
affected, and at many points, that multiple minute aneurysms are
produced, any one of which may give way and produce the fatal results
of a cerebral hemorrhage. In diffuse gumma of the membranes or
cortex the process is slow, and likely to involve areas which may be
recognized by cerebral localization. Many cases presenting the features
of brain tumor will yield to antisyphilitic treatment, and thus show
themselves to be syphilomas.

In the _spinal canal_ implication of the membranes is more likely to
occur than in the vessels. In the _cord_ these sclerotic changes are
also quite common and produce symptoms strongly suggestive of tabes;
in fact, there are those who hold that tabes is of specific origin.

In the motor and sensory nerves much connective tissue is present, and
consequently these nerves are not exempt from sclerotic changes with
pressure symptoms, which will give the clinical picture of a _neuritis_.


SYPHILIS IN CHILDREN.

Syphilis appears in young children under the following circumstances:

_A._ The disease may have been transmitted from the father to the ovum,
at the time of conception, by infected spermatozoa.

_B._ From the mother, who may have acquired it before impregnation
or during the early part of her pregnancy. In the latter case the
infecting influence is transmitted through the placental circulation.

_C._ From the mother at the time of its birth, from a recently infected
puerperal tract.

_D._ From some possible extrinsic source, a short time after its birth,
as, _e. g._, through the umbilicus.

The later the mother acquires the disease after conception, the less
likelihood that the child will be infected. If infection takes place
from the placenta, then it also will be found to be diseased.


=Profeta’s “Law.”=--Profeta first made the statement that the child of
an infected mother who acquired the disease late in her pregnancy may
not only be born healthy, but may be immune to subsequent infection,
as are other healthy children of syphilitic parents. But, on the other
hand, such a child may be anemic, puny, with small resisting power, or
it may develop a late hereditary syphilis. When the ovum is infected
by the father the healthy mother may escape, or she may acquire the
disease through the placenta in her own uterus, or she may suffer from
a mitigated form of syphilis whose principal features will appear as
late manifestations of the disease.


=Colles’ “Law.”=--Colles, in 1837, made the statement that such a
mother may remain healthy with an acquired immunity to subsequent
infection. The statements above made have often been alluded to as
Profeta’s and Colles’ “laws.” These should, however, be regarded simply
as statements of what usually occurs, and too much dependence should
not be placed upon them. In fact, the immunity which the mother or the
child may enjoy under conditions mentioned above is not likely to be
permanent, though it may last for a varying period of time. There is
no limit to the time when a parent may transmit syphilis to the child.
The five-year limit given for the father is often overstepped, and the
longer the man waits before marrying after acquiring the disease, and
the more thoroughly he submits to judicious treatment, the less likely
he is to convey it to offspring. This is the strongest kind of argument
that can be used to _delay marriage of syphilitics_.

_The indication of syphilis on the part of the mother_ is, in addition
to those already given above, a tendency to miscarriage or abortion.
The earlier she acquires the disease the earlier will the mishap occur.
Should she escape the child may go on to full term, or it may die and
be expelled as a dead fetus two or three months before the expiration
of term. Should a child be born alive with hereditary syphilis, the
evidences may appear at birth or within three months. Should a child
apparently escape for six months it may grow up to be puny or develop
some form of late hereditary disease, or it may possibly remain well.
These children usually show developmental defect in some direction, and
manifest a much weakened resisting power to other diseases; moreover,
the spleen will usually be found enlarged.

Among the changes which may occur are the following: The _skin_ becomes
loose and resembles that of an old person. This is partly because
it grows even faster than the tissues beneath it, so pronounced
is the emaciation. _Snuffles_, or _nasal catarrh_, is one of the
earliest features. This is due to specific swelling of portions of
the Schneiderian membrane. Snuffles _may_ occur in children without
syphilis, but syphilis will nearly always produce snuffles, which may
last for some time, and cause a widening at the root of the nose which
will persist through life. Following the snuffles there usually appears
a rash over the trunk and thighs and about the anus, accompanied by
mucous patches. This will have the same bright, coppery tint as roseola
syphilitica, already mentioned, which it much resembles. Sometimes
it assumes the mixed type of eruption, while upon the palms and soles
appears the so-called pemphigus syphiliticus. Should the child live
nodular or gummatous syphilides may develop.

In the bone and cartilage characteristic changes are met at the
lower end of the femur and at the costochondral junctions. This
consists of an _osteochondritis syphilitica_. At the affected points
enlargements take place, which may disappear under treatment or may
go on to ulceration and necrosis. In the fingers and toes there are
manifestations already described as syphilitic _dactylitis_.

The bones of the skull are likely to be involved in thickenings,
especially about the anterior fontanelle, where they form the so-called
Parrot’s nodes. These may disappear, with or without treatment, and the
affected bone may undergo atrophy or may entirely disappear.

Among the viscera the _spleen_ generally becomes affected first and
then the liver. Syphilitic iritis may occur early, but is rather
rare; ocular changes occur more often in the choroid. In the brain
distinctive lesions may occur to such an extent as to lead to
considerable thickening of the dura, with or without hydrocephalus, and
subsequent imbecility or idiocy.

_Deafness_ is not infrequent in hereditary syphilis. It may begin
suddenly and at any age, even during infancy. It is produced by deep
lesions which do not yield readily to treatment, and sometimes leads to
deaf-mutism, especially when it occurs before the child has learned to
talk.

Among the later manifestations of hereditary syphilis are opacities
of the cornea from _interstitial keratitis_. This may occur in
children who are apparently in good health and free from other signs
of hereditary disease. The condition is rather obstinate, but it can
be made to disappear under suitable treatment. _Retinitis_ occurs
frequently in young women, and is likely to lead to atrophy or
detachment.


=The Teeth.=--The permanent teeth often show peculiar changes that
are distinctive, especially in those who have shown signs of corneal
involvement, which, having been first described by Hutchinson, are
frequently alluded to as _Hutchinson’s teeth_. When they first appear
they are smaller than natural and irregular. Later they become notched.
The crescentic notches show best upon the incisor teeth. Sometimes the
canines are also affected, being narrow, rounded, and peg-like, with
jagged edges. These teeth are usually so formed that they do not meet
properly, and so small that they scarcely touch each other. The most
characteristic changes are met with in the upper incisors, which may
be affected when all the others are fairly normal. In such cases they
will be found narrow and short, with a single broad notch at the edge,
with perhaps a furrow passing from it upward and on both anterior and
posterior aspects. Notching is usually symmetrical. No conclusions can
be drawn from the teeth if they are normal, as they may be, but when
they present the above-described features they prove a very important
indication.

The relations between syphilis and rickets have attracted much
attention, and there is little doubt but that rachitic changes are
prone to occur in subjects with inherited syphilis. The two conditions
are sometimes blended in various degrees and ways, and yet it is not
safe to say that rickets is always an expression of inherited syphilis.


TREATMENT OF SYPHILIS.

There is no question but that some of the above-described lesions
constitute as disgusting and repelling diseased conditions as the
physician or surgeon is ever called upon to treat. In spite of these
circumstances, however, it is generally believed that syphilis is a
most satisfactory disease to treat. This is because of the almost
mathematical certainty with which results can be predicted and
estimated. There is nothing more satisfactory in therapeutics than
the rapidity with which many pronounced and serious manifestations of
syphilis will disappear under the influence of proper treatment. These
statements, however, should be modified to make room for exceptional
cases, where the disease assumes a malignant type, owing probably to
some defect in the patient’s constitution, or where patients show
peculiar idiosyncrasies and susceptibilities to the influence of
mercury and iodine. Such cases happen occasionally and prove difficult
of solution, while they sorely try the surgeon’s ingenuity and
resources.

_In the majority of instances syphilis is a curable disease._ A patient
should be first impressed with the necessity of faithfully following
the directions of his physician, and continuing under treatment for
a period of at least three years after the disappearance of the last
manifestation of the disease. The disease is curable, but only by the
judicious combination of two principal remedies, _i. e._, _mercury_ and
_iodine_. Those rare instances in which cure seems to have followed
lines of treatment which do not include the use of these two drugs
are so exceptional and misleading that they should not be considered
criteria. Mercury and iodine are powerful remedies, needing to be
administered with caution and judgment. Unfortunately there is no
arbitrary limit of time for any given case. The time stated above
is that usually considered requisite. While syphilis may be curable
in some cases in less than the stated time, it is better to give it
longer treatment than is absolutely required rather than the reverse.
The treatment entails no unpleasant consequences. Warnings as to the
approach of toxic symptoms from the drugs can be easily recognized.

Of the two drugs the preparations of mercury are the more important.
The surgeon may adopt as his motto, _mercury, more mercury, and again
mercury_, and if he begins with this measure early in the disease he
may be able to conduct it to a successful termination with but little
resort to iodine. Iodine is effective rather in those cases where
treatment has been begun relatively late, and where it seems necessary
to make a double impression upon the disease.

When the nature of the primary lesion is positive treatment should
begin with the first visit of the patient to the surgeon. When there
is uncertainty regarding the character of the venereal sore, treatment
_may_ be postponed until the appearance of the first eruption. As
soon as this has appeared the treatment should be hastened. It is
necessary to begin with mercury. The patient’s mouth should be examined
by a dentist and all tartar removed from the teeth, especially from
the gingival borders, at which lines the gums are likely to become
sore when mercury is too freely used. All diseased teeth should be
extracted or filled, and the mouth and its contents should be put in
normal condition. The dentist should be informed as to the reason
for the visit. Smoking should be discontinued, especially when there
are mucous patches, since it is apt to irritate and make subsequent
lesions of the mucous membrane more likely to occur. The habits of the
patient should be regulated as to alcohol and other indulgences, and he
should be warned as to the infectious nature of the disease, _in order
that others may be protected_. In many instances tonic, even roborant
treatment may be advantageously combined with the antispecific. It will
be found that the anemia so characteristic of well-marked secondary
syphilis will improve materially under the influence of mercury alone.

Should the disease occur in a married person, or develop after
marriage, caution should be given as to the danger to offspring, and to
the other associate in the marriage relation, which might follow the
occurrence of pregnancy.

Mercury may be given by the _mouth_, by _inunction_, by _hypodermic
injection_, or by _fumigation_. The intent should be to get the
patient under its influence as rapidly as is consistent with safety.
The most effective of these methods to which patients will ordinarily
submit is that by _inunction_. This consists essentially in the use
of _mercurial ointment_ (blue ointment), of which 15 Gm. may be used
daily or nightly, which should be thoroughly rubbed into some area
of the body; the areas selected being changed at perhaps three-day
intervals, in order that irritation, which its prolonged use produces,
may be avoided. It takes considerable effort to so completely rub this
in as to make most of it disappear, and it can be done more easily
upon those parts of the body which are free from hair. It can be best
done by employing someone for the purpose, but patients can be easily
taught to use it themselves. There are upon the market, ointments
containing mercury made with other excipients than lard, which are less
uncomfortable to the skin and seem to be absorbed better; among these
is a preparation made with a petroleum compound called vasogen, which
may be procured in different strengths; that containing 33 per cent. or
50 per cent. is the best.

Inunction should be practised at least once every twenty-four hours,
until either the gums become tender or swollen, with an offensive odor
of the breath, or until the skin is irritated. The mouth should be
protected by use of an astringent antiseptic mouth-wash, such as the
following: Carbolic acid 10 parts, oil of wintergreen 1 part, tincture
of myrrh 50 parts. A little of this solution in a tablespoonful or more
of water makes a serviceable wash, which should be used several times
a day. There are sanitaria and springs, or health resorts, in this
country where a specialty is made of this manner of treatment. At these
resorts inunction is practised freely and thoroughly, but the benefit
which is obtained comes rather from the attention which patients give
to the treatment, and their abstention from business or dissipation,
than from any inherent medicinal features either in the mineral water
or climate.

Under the influence of mercurial ointment alone, if a patient is
willing to persist in its use, many cases of syphilis may be conducted
to a successful termination; but its use is disagreeable to some
people, and it may be impossible to resort to it for any great length
of time. It has its inconveniences and disadvantages, but it should be
applied in at least the first stages of the disease.

When mercurial ointment is seen to have made a distinctive impression
upon the constitution of the patient it may be discarded and the
treatment changed to the internal administration of the drug.

Mercurials may be given internally in any one of several different
preparations. Hutchinson has recommended _gray powder_, in doses of
¹⁄₄ to ¹⁄₃ Gm. three or four times a day. _Corrosive sublimate_ is a
reliable form in which to administer mercury in doses which can be
tolerated, from 1 to 2 Mg., three or four times a day. The red iodide
may be given in similar doses, or the green iodide may be administered
in doses of 0.15 to 2 Cg. These preparations sometimes irritate the
intestinal tract and produce a certain amount of colic or looseness
of the bowel. For the latter some astringent may be combined with the
mercury, while intestinal pain may be checked by the use of extract of
conium.

The _hypodermic use of mercury_ can be made effective, but there are
but few preparations which can be used that do not cause pain and
subsequent irritation. Perhaps that which gives least pain is the
sozoiodolate of mercury. This is sparingly soluble in water, dissolving
in about 500 parts by weight. As the dose is 9 or 10 Cg., the amount
of water necessary for this solution is so bulky that the dose should
be injected into the gluteal region. Corrosive sublimate is also
used in 1 per cent. solution, made up in common salt solution of the
usual strength of 9 to 1000. Of this 10 minims represent a suitable
dose to commence with, which may be increased to 30 or 40 minims when
necessary. This should be given in the same region, the needle being
driven in its full length perpendicularly to the surface. When this is
done an injection is made into the muscle, where it seems to be more
effective than in the subcutaneous fat. When the dose is increased to
more than 20 minims a 2 per cent. solution may be used and the amount
of fluid correspondingly reduced.

_Fumigation_ is a method now not often adopted, calomel being used for
the purpose, an ordinary cabinet hot-air bath confining the vapor about
the patient. One treatment a day by either of these methods is usually
sufficient.

About the _initial sore_ dry calomel, pure or reduced with bismuth
subnitrate, may be used. The condylomas met with about the
perineum will often shrink and disappear under the influence of
this application. _Mucous patches_ should be treated with absolute
cleanliness; in the mouth a wash of diluted hydrogen dioxide may be
used, and the patches touched with a strong nitrate of silver solution,
pure carbolic acid, or camphophenol. This will not prevent contagion
from such a source, but will reduce it to a minimum beneficial in every
respect.

The various eruptions of syphilis will disappear gradually under the
influence of a local application of one of the mercurial preparations,
either the ordinary mercurial ointment or ammoniated mercury.

In cases of _inherited syphilis_, especially in young children, a
reduced mercurial ointment, or the use of gray powder (mercury with
chalk) will give the best results. The dose should be regulated by
the age of the patient; for instance, of the latter 1 to 2 Cg. for an
infant. The iodides have also proved successful.

_Iodine_ and its preparations have by many authorities been held to
be useful in the later and especially in the gummatous lesions of
syphilis. There are patients who cannot take iodine to any extent
without suffering from such disturbance of mucous membranes, especially
in the nose and intestines, as to make it an exceedingly unpleasant
remedy.

The iodides have not proved as successful as the mercurials;
nevertheless, the combination is a popular one and sometimes of
peculiar value. The potassium salt is the one generally used, as it
is cheaper than the sodium compound. The latter, however, is less
irritating and often more available. The lithium compound is ideal
in some respects, but very expensive. The iodides may be given in
large doses, to the extent of 30 Gm. or more (an ounce or more) in
twenty-four hours. Large doses are sometimes necessary in the treatment
of late syphilis of the nervous system. When it is necessary to put
the patient rapidly under the influence of antispecific medication the
combined use of these two drugs, as for example by mercurial inunction
and the use of one of the iodides internally, will most speedily
bring about the desired result. This result may be overreached, and
sore mouth or other toxic manifestations may appear suddenly and
unexpectedly.

The mercuric salts are soluble in solutions of the iodides, and what is
known as _mixed treatment_ is often employed. The salts may be combined
in any desired preparation. Donovan’s solution is exceedingly valuable,
the arsenic which it contains seeming to reinforce both the mercury and
the iodine.

The iodides produce eruptions or rashes which strongly simulate both
syphilitic and non-syphilitic skin diseases, and confusion may arise
from their use. In those who are sensitive to the iodides, and in whom
catarrh of the mucous membranes is easily produced, it is best to begin
with small doses, increasing them as circumstances may warrant. Some
patients cannot take iodine in any form. When iodides irritate the
stomach they should be given in essence of pepsin.

Of the various vegetable remedies some are unreliable and of little
value. Certain combinations can, however, be effected in some cases by
which the value of the effective agents may be enhanced. _Zittmann’s
decoction_ or _McDade’s formula_ will occasionally prove of service. In
aggravated cases the former is believed to be the most effective of all
methods of administering mercury. Tonics or any other medicines which
may be called for in particular cases should be given judiciously.
There is nothing in antisyphilitic treatment which precludes other
treatment when needed.




CHAPTER XI.

CHANCROID OR VENEREAL ULCER.


Since the time of John Hunter and his pupils, who confused the three
totally different and so-called venereal diseases, pathologists have
drawn a distinct line between _chancre_, which is simply the initial
sore of syphilis, and _chancroid_ or _venereal ulcer_, which is a
distinctly local lesion, often destructive, but never followed by
constitutional disease, except of septicemic or pyemic type. It is
usually found upon the _genitals_, about the foreskin, glans, and
vulva, but may be met anywhere upon the body where infection has
occurred. It is distinctly _auto-inoculable_, in which respect it
differs from chancre.

Varying views have been held as to the minute agency concerned in
the production of this lesion. The bacillus discovered and studied
by Ducrey, in 1889, is now accepted as the exciting cause. This
is 1.5 μ long and 1 μ thick, with rounded deep-staining ends and
fainter-staining central portion, occurring with great constancy in
chancroidal pus, less often in buboes than in ulcers, in and outside of
the cells, and in chains. It is cultivated with difficulty, grows best
on human blood, takes basic aniline stains, but is easily decolorized
by alcohol or by Gram’s method. Characteristic ulcers can be produced
by inoculating it, even in monkeys.

Chancroid begins, in twenty-four hours, as a red point or papule,
which is quickly converted into a pustule and then into an _ulcer_.
The borders of this ulcer enlarge, its depth increases, until after a
few days it forms a more or less deep, often undermined excavation,
irregular in contour, discharging grayish purulent material. In this
respect it differs also from chancre, whose natural discharge is more
like serum. In other words, _chancroid is essentially destructive,
chancre constructive_, since the latter forms a new-growth which
ordinarily has little or no discharge. When the necrosis of chancroid
becomes extensive and tends to spread rapidly the ulcer is spoken
of as _phagedenic_. This tendency to rapid local gangrene is the
combined result, probably, of virulence of virus and lowered local or
constitutional tissue resistance. It is consequently most often seen
in alcoholics and prostitutes. In rare instances a surface larger than
the hand may be rapidly destroyed, every particle of material sloughed
being infectious.

In chancroids of the mild variety the discharge may dry upon their
surfaces and scabs or crusts result, beneath which, when detached, the
characteristic ulcer is present.

Under proper treatment this foul ulcer is soon converted into an
ordinary granulating surface, which heals by cicatrization.


CHANCROIDAL BUBO.

Infection, by propagation along the lymphatics, of the inguinal nodes
is frequent, and, since the infection is almost always a mixed one,
suppuration is frequent.

The pus of a suppurating chancroidal bubo is as infectious as the
discharge from the original sore; hence the need of great caution. The
edges of the local incision should be promptly cauterized so that they
may not become linear chancroids. Phagedena shows itself here as well
as about the genitals proper, and differs only in that it makes the
case more serious. A chancroidal bubo may, however, subside without
abscess formation. The signs of suppuration are those incident to pus
formation anywhere near the surface. When pus is present its early
evacuation is demanded.


=Diagnosis.=--Chancroid is likely to be confounded with _chancre_ and
_herpes preputialis_. It has no period of incubation. Destruction
commences after infection, so that within twenty-four hours macroscopic
evidence may be observed, and within two or three days the sore has
attained distinct size and shape.

      _Chancroid._             _Chancre._             _Herpes._

  Local ulcer.           First local sign of a  Local neurosis.
                         constitutional
                         disease.

  A distinctly venereal  Usually a venereal     May be non-venereal,
  infection.             infection.             from friction, irri-
                                                tation, uncleanliness,
                                                etc.

  No incubation; lesion  Incubation from ten to No incubation.
  noticed within a few   seventy days before
  days.                  first lymphatic in-
                         duration.

  Commences and remains  Commences as a papule, Commences as a crop
  as an ulcer.           or occasionally as an  of vesicles.
                         erosion. This _may_
                         ulcerate later.

  Usually multiple.      Usually single.        Multiple and occurring
                                                in crops or series.

  Secretion purulent     Secretion slight and   Little or no secretion.
  and abundant.          serous or bloody.

  May occur again and    As a rule, it only     Patients who once have
  again.                 occurs once in the     it are frequently
                         same patient.          subject to it.

  Auto-inoculable.       Not auto-inoculable.   Not inoculable.

  Phagedena frequent.    Phagedenic action very Never.
                         rare.

  Buboes in about 65     Bubonic enlargement    Lymphatics rarely
  per cent. of cases.    nearly always.         involved.

  Buboes usually         Buboes as a rule do
  suppurate.             not suppurate.


=Prognosis.=--Except in the most debilitated and dissipated, in whom
phagedena may prove fatal, recovery always occurs, but often with the
loss of tissue and disfiguring scars.


=Treatment.=--In mild cases--_i. e._, those showing but little
destructive tendency--cleanliness and the use of hydrogen peroxide,
followed by local use of any of the ordinary antiseptic powders, or
even of calomel, will usually prove sufficient. Sodium sozoiodolate
makes an excellent application. It is odorless and non-toxic. At first
its use may be preceded by morphine or cocaine, but after a few days it
will prove a painless application. If the ulcer manifest any tendency
to spread, it should be cleansed, cocainized, and then cauterized with
nitric acid or the actual cautery, after which it should be so treated
as to encourage granulation. This plan should be followed in phagedenic
cases, which may call for general anesthesia, with the use of scissors
and a sharp spoon, followed by cauterization of every particle of raw
or diseased surface.

Widespread phagedena is more rare now than formerly. Cases which are
extensive do best when submitted to continuous immersion of the hips
in a sitz-bath as hot as can be tolerated. All aggravated cases call
for invigorating and tonic measures, laxatives, improved nutrition, and
stimulants.

_Suppurating buboes_ should be incised, usually curetted, and
thoroughly swabbed with pure carbolic acid, followed by pure alcohol
to neutralize the acid, then packed lightly with antiseptic gauze, and
allowed to close by granulation. Virulent cases will be accompanied by
sloughing of so much tissue that it is best to remove all sloughs with
scissors. Here even stronger caustics will be called for. _Phimosis_
often complicates chancroid, and will necessitate circumcision or
incision along the dorsum of the prepuce, with such attention to the
parts thus exposed as their condition may require.


=Mixed Chancre.=--Mixed chancre, or the combination of the two lesions,
has been already discussed.


=Extragenital Chancroid.=--Extragenital chancroid may occur upon any
portion of the body, but is more rare than extragenital chancre. It
is characterized by the same peculiarities as pertain to the venereal
sores already described, and is amenable to similar treatment.




CHAPTER XII.

GONORRHEA.


Gonorrhea is an acute infectious process, involving especially
the mucous membranes of the genito-urinary organs, but met with
elsewhere about the body, in both superficial and deep tissues. The
name itself is a misnomer, since it implies a flow of semen, whereas
the discharge which issues from the male urethra is simply mucopus,
and is the product of a severe inflammation of the mucous membrane.
A less inaccurate name for it is _blennorrhea_, although this is
usually limited rather to a discharge from the vagina, and indicates
a whitish and copious fluid exudate, mingled with pus corpuscles and
bacteria. It is stated that probably 80 per cent. of men have at some
time contracted this disease. Neisser claims that it is a more common
affection than measles.

True gonorrhea is the result of an infection by a specific organism
universally recognized as the _gonococcus_ of Neisser, though the
discharge, when studied in the clinical laboratory, may give evidence
of being the product of a mixed infection and contain the ordinary
pyogenic or other organisms. The common name for the disease is _clap_.

The gonococcus is a diplococcus which seems to be injurious only to the
tissues of the human being, as inoculations in animals have produced
no definite or reliable result. Like syphilis, it is spread by direct
or indirect contagion, and usually in the same way. It is generally
found in the genito-urinary mucosa of both sexes, but it has been
accidentally and even innocently conveyed by immediate and mediate
transfer to the mucous membranes of the _eye_, the _rectum_, and even
to the _mouth_, although here, as in the nose, the mucous membrane is
but little susceptible to its activity. It is generally stated that 20
per cent. of the blindness occurring in the young is due to gonorrheal
conjunctivitis. Those membranes covered with cylindrical epithelium
are more liable to succumb to infection by this parasite than are
those covered with squamous epithelium. The more the epithelial cells
conform to the former type, the more difficult it is to get rid of the
infection; hence the disease lingers in the cervical canal longer than
in the vagina.

The disease always commences as a contagious catarrhal discharge from
the mucous membrane. It may spread much farther than this, invading
deeper tissues by continuity, or tissues at a distance by the lymph
stream, or producing even metastatic expressions of infection in
distant tissues and organs. Under these circumstances the serous
membranes are likely to suffer, and the peritoneum, the endocardium,
the pericardium, the pleuræ, the meninges, and particularly the serous
linings of some of the joints, as the elbow and knee, show unmistakable
evidences of infection; while through the medium of the venous and
then the arterial systems typical representations of pyemia following
gonorrhea may occur.

The disease as it usually appears is seriously and often obstinately
complicated by the structure of the membranes which it involves.
The mucous membranes throughout the body are more than mere mucous
surfaces; they are dotted with openings for the escape of glandular
secretions, and nowhere is this more conspicuous than in the urethra,
where many minute follicles, so called, empty tiny drops of secretion
into the mucous canal. Infection may easily travel along these routes
and lurk within such minute recesses long after it has apparently
disappeared from the surface; and so it often happens that in the male
not only the urethral follicles but the ducts leading to Cowper’s
glands and prostate become involved, while in the female the follicles
around the meatus, the urethra, and the vulva rarely escape. The
clinical importance of this statement is of interest, as by it may be
explained many of those cases where an old infection seems to have been
lighted up, or where the contagion has been conveyed to another after
an attack which was supposed to have been entirely cured. Nothing seems
to favor outbreaks of this kind as do alcoholic and sexual excesses.

The gonococcus may be scarcely regarded as an obligate pyogenic
organism by itself, but the parts most often involved in this disease
may be regarded as never free from the presence of other germs
of greater or less activity, and by association, if not by actual
symbiosis, such an intense reaction is provoked that the resulting
products do not differ from true pus, save by the added presence of the
specific organism most at fault. Under these circumstances abscesses
may form in any tissue infected. Another expression of this fact would
be the establishment of a pyarthrosis after involvement of one or
more joints. Gonococci may be found in almost every abscess of truly
gonorrheal origin; on the other hand, in some of the serous cavities it
is possible, at least for a time, that gonococci may be present in the
serous fluid without producing in it more than a disturbing effect, the
fluid now appearing turbid rather than puruloid.

The amount of toxemia which may be produced by gonococci without
reference to formation of pus has not yet been established. It is,
moreover, a difficult thing to estimate in cases of mixed infection.
Occasionally there are cases of metastasis and gonorrheal invasion
which are free from evidences of suppuration, and yet there may be
anemia and cachexia of profound type; these can only be explained on
the theory of an intoxication.

Besides the serous tissues of the body the _fibrous_ structures may
suffer seriously, not only in an acute manner, but also in a chronic
and obstinate form.

It has been the custom to speak of _urethritis_ as a synonym for
gonorrhea, and to divide it into the specific and non-specific forms,
including under the former expression cases where the gonococcus can
be demonstrated, and under the latter term those which do not seem
to show it. There is no doubt but that urethritis may be set up by
the introduction of a foreign body, such as a sound or catheter, as
well as by some irritating discharge from the vagina, and also as the
result of excess of uric acid in the system, perhaps even of alcohol.
These, if occurring in a previously uninfected urethra, may be regarded
as distinctly non-specific lesions. It is also supposed that under
certain circumstances inflammation may be set up by other organisms
than the gonococcus; nevertheless almost all cases of so-called clap
are positively gonococcus infections, simple or mixed, and have but one
origin.


=Diagnosis.=--_Diagnosis can be made positive only with the
microscope._ A recognition of the gonococci by staining them and then
watching the effect of iodine in their decolorization will be of
great importance and reliable. The affinity of these germs for basic
aniline dyes, and the fact that they do not take the iodine stain
of Gram, will serve to differentiate them from the numerous other
organisms with which they may be found mixed. By staining a cover-glass
preparation first with methyl blue or other basic color, then placing
it in Gram’s solution, and finally in a solution of Bismarck brown,
the true gonococci which have been made visible by the methyl blue
will have disappeared under the influence of the iodine, while other
bacteria will be stained by it. It has been mentioned that the germ
is a diplococcus of rather ovoid form, met in clusters but not in
chains, and in groups of four or multiples of four; it may be attached
to epithelium and pus corpuscles, or found within them, and is rarely
found free in fluid except when present in large numbers. These
organisms are capable of cultivation, growing best upon a mixture of
human serum and neutral agar, at a temperature of 36° C.

_The urethra may be infected from without and from within_, and this
infection may be either of a truly specific type (gonococcus) or of the
pyogenic type; as between these forms information may be gained by the
history and the clinical course, but the minute diagnosis is only to
be made with the microscope. This is of more than theoretical value,
inasmuch as it substitutes a certainty for a working hypothesis. It is,
moreover, sometimes of great value, as when the question of infection
of one of the opposite sex comes up, or it may have at times even an
important medicolegal value, as in cases of rape.

_Infection from without_, so far as the male urethra is concerned,
is a question of the venereal origin of the disease. _Infection from
within_, in the specific form, is a matter of recrudescence of a
formerly active lesion supposed to have disappeared. Infection of
_non-specific type from without_ affects the introduction of germs
either by venereal contact or by the medium of an unclean catheter,
sound, or some other instrument, or _from within_ by the extension
forward of an inflammation higher up in the genito-urinary tract, such
as may be due to stone in the bladder, cystitis, enlarged prostate, or
uric acid or oxalic acid crystals. Urethritis, usually of mild type,
is not infrequent in old men from either of these causes. It may also
be produced by the infection of a too strong or irritant injection,
whether used either for prophylaxis or for ordinary treatment.

Classifying them we may then have urethritis of the following four
types:

  _A._ Gonorrheal of extrinsic origin.

  _B._ Gonorrheal of intrinsic origin (originally extrinsic).

  _C._ Non-specific urethritis of extrinsic origin.

  _D._ Non-specific urethritis of intrinsic origin.

_A._ The period of incubation is short, usually two to six days, and
the resulting inflammation is severe; the consequences are often remote
and sometimes disastrous. Gonococci will be found in the pus and
epithelial debris.

_B._ This has been described as “_bastard clap_.” It is really an
auto-infection, with an incubation period of a few hours, and is
practically the reawakening of a quiescent stage of _A_. It is
characterized by abundant purulent discharge; this latter is thin and
mucilaginous, more like that of so-called gleet, with an abundance of
pus threads, or “clap threads,” in the urine. In this form gonococci
are also found, but less frequently.

_C._ Much like _A_ in its clinical course, but less violent, and with
less widespread reaction. Its period of incubation is rarely over
thirty-six hours. This type is most common after alcoholic and sexual
excesses; the latter especially with one already suffering from vaginal
discharge, particularly so when near the time of menstruation. Here
the microscope will show few if any true gonococci, but a profusion of
pyogenic organisms.

_D._ This form of disease is of non-venereal origin, and is susceptible
of easy explanation and of satisfactory treatment if the cause be
properly treated. No case of urethral discharge which does not seem to
fall easily into one of the above categories should be treated without
a search of the anterior urethra, especially the fossa navicularis, for
possible _chancre_ or _chancroid_, as well as for stricture.

Among the laity the idea is prevalent that gonorrhea is a disease of
more or less trifling import, while many of the profession regard it as
rarely worthy of serious consideration. This is an unfortunate notion
regarding this disease, and those who have had largest experience
unite in expressing the opinion that gonorrhea reckons more victims
in the death list than does syphilis--not because it is more common,
but because of its complications and the ravages, especially in the
kidneys, resulting therefrom. It has been shown that the specific
organism producing it may linger for years in the follicles of the
urethra, whence it may issue forth, unexpectedly, to produce vaginitis,
perhaps in the most innocent of women, and thus bring on a train of
pelvic disorders which may involve the ovaries, the tubes, and the
peritoneum. Doubtless _gonorrhea has made_ in this indirect way _many
more victims than syphilis_.

Regarding gonorrhea thus seriously, it is well to treat it cautiously
and to inculcate vigilance in the daily life and habits of the patient.
There are no arbitrary limits during which danger exists and then
passes; peril lurks about such a case for an almost indefinite time.
There is danger not alone to the individual, but to all with whom he
may have sexual or even other relations. This advice pertains not alone
to the urethral discharge and the care of the urethra, but especially
to the avoidance of all possible contamination of the conjunctiva.
One of the saddest spectacles in the domain of medicine is to see one
or both eyes of an innocent victim injured or ruined by gonorrheal
infection.

There is no denying the clinical fact that individuals vary
considerably in their susceptibility to this disease; moreover,
individual susceptibility varies at different times. Alcoholic and
sexual indulgence seem to materially lower this susceptibility. Thus
from the same individual, and within twenty-four hours, one may acquire
the disease while others escape. In some instances immunity seems to
be afforded by repeated attacks; in other individuals repeated attacks
seem only to enhance the liability to the disease. The gonococcus
grows best in alkaline media. Prolonged sexual excitement diminishes
the acidity of the urethral fluids, and this favors the growth and
development of the germ. No credence should be given to popular notions
concerning the possible avoidance of infection after exposure. Even a
careful _toilet_ is usually inefficient for this purpose, while the use
of prophylactic injections is to be reprehended. They do more harm than
good. If strong enough to be bactericidal, they should be extremely
irritant; if weak enough to be tolerated, they will prove useless.
The patient should also be warned concerning possible transfer of the
disease without sexual contact, and all toilet utensils, towels, etc.,
should be kept by themselves, and all syringes and instruments used in
the treatment of the case should be carefully sterilized.


=Course.=--The period of incubation generally varies within wide
limits, as mentioned above under classification of the various
types; it may be as short as a few hours or may extend to ten days,
or possibly even longer. Usually it is from two to five days. The
early symptoms consist of discomfort along the course of the urethra,
chemosis or edema, and swelling of the meatus. Within a short time
after these symptoms the characteristic discharge appears. It may at
first be viscid, but soon becomes purulent, and then more or less
profuse, while urination gives rise to great discomfort. By the end
of the first week the discharge is usually grayish in color, thick,
continuous, and so profuse as to equal in volume 20 to 50 Cc. in
twenty-four hours. The lesion is not confined to the urethra, and soon
spreads to the peri-urethral tissues and thence to the lymphatics. A
peri-urethritis with venous engorgement is added to the urethritis, and
there is such an obstruction of the return circulation as to produce
swelling and edema of the prepuce; this not only makes access to the
urethra difficult, but conceals any excoriation and ulceration which
may be going on beneath it. Sometimes this tumefaction proceeds to a
degree where gangrene results.

All these local disturbances will be accompanied by more or less
lymphatic involvement in the groins and in the perineum, with great
soreness and tenderness throughout the entire genital tract. _Chordee_
(painful erection) is a common and painful complication of this stage
of the disease. Finally a well-marked degree of _auto-intoxication_,
with its ordinary febrile and septic manifestations, may ensue. As
the disease spreads farther back into the deep urethra there is
irritability of the bladder, while in severe cases the frequent
attempts at urination thus excited, with the accompanying pain during
the act of expelling a few drops of urine, are distressing features
of the disease. The pains are not limited to the organs involved, but
are often referred to the back, to the perineum, and down the thighs.
The symptoms above referred to belong to a well-marked case of acute
specific type. There may be milder manifestations of each kind, and
occasionally a case will run its course with but a minimum of the
difficulties and discomforts above mentioned. Sometimes by the end
of the third week, usually before, the disease will show a tendency
to subside, even if inadequately treated. The inflammatory symptoms
become less marked, the discharge thinner and less voluminous, until
perhaps by the end of the seventh week there is noticed only a small
amount when the patient rises in the morning. With all this apparent
and spontaneous improvement there may be present, nevertheless, a
serious and distressing amount of peri-urethral infiltration, which
will soon be followed by cicatricial contraction and the formation of a
_stricture_, the most frequent sequel of gonorrhea.


=Complications.=--Complications may occur along any portion of the
genito-urinary tract. These will be considered in their anatomical
order.


=Balanitis.=--Balanitis signifies an inflammation of the mucosa
covering the glans. When the mucous surface of the prepuce is also
involved, as it usually is when the orifice is contracted, then the
condition is known as _balanoposthitis_. In the absence of ordinary
cleanliness of the parts this may go on to erosion or extensive
ulceration. It is sometimes complicated with chancroid or chancre. When
such a condition exists, and the glans cannot be sufficiently exposed
for purposes of cleanliness, the dorsum of the prepuce should be slit
up sufficiently to permit of complete exposure, while in some cases the
edema and the infiltration will be such as to justify circumcision.
When needed these operations should be practised even if raw surfaces
are thereby left exposed to infection. Such possibility may be usually
obviated by cauterizing a fresh surface, as soon as exposed, with pure
carbolic acid or one of the stronger caustics, or operation may be made
with the thermocautery.


=Folliculitis.=--Folliculitis implies the extension of the infection
to the follicles and lacunæ which abound within the urethral canal. As
long as their orifices do not become occluded they easily discharge
their contents into the urethra, but when so swollen as to become
occluded they lead to the formation of abscesses, which, beginning in a
minute way, may sometimes give relatively extensive disturbance. These
discharge internally; sometimes they so present that they may be opened
externally, as they should be under these circumstances. They form a
communication between the urethra and the exterior, and in this manner
the majority of the ordinary urinary fistulæ are produced. These often
occur in the perineum, but sometimes even in the pendulous portion.


=Peri-urethritis.=--Inflammation frequently extends beyond the
anatomical confines of the urethra, and produces a degree of
infiltration which is often well marked and disastrous. The site of
such a lesion is marked by a nodule, more or less tender, which may
subsequently break down into an abscess. The pus from these abscesses
will usually escape into the urethra. Sometimes it burrows into
the tissues of the corpus spongiosum, or travels even farther, and
produces locally extensive destruction of tissue, with its possibility
of urinary infiltration as a sequel, and all the septic disturbances
which can be imagined as resulting therefrom. Thus fistulas often
follow abscess formation, and these may be succeeded by phlebitis of
the peri-urethral and prostatic plexuses, extensive destruction or
multiple abscesses, or even gangrene and pyemia. Peri-urethritis is the
essential factor in the production of strictures of the urethra, which
constitute an exceedingly common condition.

While urethral stricture is a common result of gonorrhea it constitutes
by itself a special lesion. (See chapter on the Genito-urinary Tract.)
These peri-urethral infiltrations may occur in irregular patches, so
variously placed as to encroach upon the urethra at different points
without completely surrounding it, or they may form tubular lesions
by which very serious annular constriction is produced. The degree
of infiltration is, to some extent, a measure of the violence of the
inflammation and of the virulence of the infection. This is true,
however, only up to a certain point. One object of properly directed
treatment should be to guard against the deep extension of a gonorrheal
infection, in order to limit the tendency to the formation of stricture.

Between the folds of the triangular ligament are situated two racemose
follicles known as Cowper’s glands. These occasionally become infected
in the same way as the anterior follicles of the urethra and give rise
to a painful swelling in the perineum, which gives most discomfort
to the patient in the sitting posture. This condition is known as
_Cowperitis_. It may proceed to abscess formation, in which case
incision in the perineum should be made for its relief.


=Prostatitis.=--The prostate consists of a collection of follicles
embedded in a mass of involuntary muscle fiber. The largest of these
follicles is known as the _utricle_, or, under the old anatomical
name, _uterus masculinus_. These are liable to invasion when the
infection has reached the deep urethra. The reaction which follows in
this tissue after such invasion gives rise to _prostatitis_ and causes
much pain and general reaction. The prostate, being embedded within a
fibrous capsule, cannot expand easily when it becomes inflamed, and the
pressure thus made not only causes intense pain, but will also obstruct
the urethra and occasion great difficulty in urination, sometimes
retention of urine. In proportion to the other disturbance will be
the general reaction, and fever may run high, with early expressions
of septic intoxication or of septicemia. The prostate becomes tender,
and pain is felt not only in the pelvic region, but in the back and
in the thighs, as well as along the urethra. Prostatic abscess is a
frequent sequel to this condition; it sometimes evacuates spontaneously
into the urethra, or bursts through the capsule and burrows along the
structures in the perineum and lower pelvis; occasionally it empties
into the rectum. Intensity of symptoms should give rise to a suspicion
of prostatic abscess, and a perineal incision should be made early and
the abscess evacuated. Occasionally these abscesses present toward the
rectum, when they should be tapped or incised through the bowel.

From the prostatic urethra inflammation may extend on one side or both
along the vas deferens to the seminal vesicles. The production in
this way of a _vesiculitis_ is made known by the reference of pain to
the rectum and by the appearance of blood, sometimes with pus, in the
seminal discharge. By a digital examination of the rectum the enlarged
and tender vesicles can be recognized above the prostate.

When the deep urethra has become seriously involved the condition
of the patient is unpromising. Belfield calls attention to the
triple function of the deep urethra, in that the impulse to urinate
originates therein, that it is a sphincter for the bladder, and that
it is intimately concerned with the sexual act. When it is disturbed
by gonorrheal infection all of these functions are disturbed, the
most serious symptoms being increased desire to urinate, amounting to
almost constant vesical tenesmus; marked difficulty in expulsion of
urine, which may increase to complete retention, and frequent bloody
emissions, with chordee. The pain, the heat, and the sense of tension
in the perineum and in the parts around it are distressing, as well as
pain during and after urination, which is usually referred to the end
of the urethra. The last few drops of urine will often be bloody.


=Cystitis.=--Cystitis is the not infrequent result of the further
migration of the infectious process from the deep urethra to the
bladder. The process is usually acute and serves to further complicate
the case and to harass the patient. Except in the nature of the
exciting causes cystitis differs but little from the other varieties
to be considered in their appropriate place (_q. v._). Cystitis of
gonorrheal origin is likely to travel along the ureters and lead to
involvement of the kidneys. Ascending infection is most commonly of
gonorrheal origin. In proportion to the extent and rapidity with
which the disease travels upward the case is marked by expressions of
septic intoxication and infection, such as chills, fever, pain in the
loins, along the ureters, and in the testicles. The kidneys may become
enlarged. A more minute appreciation of the condition of affairs can
be obtained by microscopic examination of the urine. In proportion as
the kidney is involved, there is a preponderance of albumin, _i. e._,
more than pus alone would produce. One of the numerous ways in which
gonorrhea kills its victims is by the production of a _pyelonephritis_
of the type known as “_surgical kidney_.”


=Lymphangitis.=--No such invasion of mucous membrane by septic
organisms can take place without active participation of the lymphatics
in the region involved. In cases of gonorrheal or even non-gonorrheal
urethritis, not merely enlargement of the lymph nodes in the groin may
occur, but an active lymphangitis, manifested as a tender, sensitive
cord beneath the skin, especially along the dorsum of the penis. The
lymph nodes thus become involved and sometimes suppurate, and these
abscesses are referred to as _suppurating gonorrheal buboes_. The
suppurative feature is probably caused by contamination with the
ordinary pyogenic organisms.


=The Testicles.=--Gonorrheal infection seems often to extend along the
vas and thus invades the epididymis, where evidences of activity are
more frequent than in the vas itself. _Epididymitis_ complicates cases
of clap usually after the second week. It is characterized by pain,
tenderness, and swelling of the epididymis, which occupies the same
position relative to the testis proper that the heel does to the rest
of the foot when a person stands in the ordinary military position, _i.
e._, to the rear and inner side. The swelling becomes pronounced, and
it is not unusual for a certain degree of swelling to be manifested in
the testis proper, with the accumulation of a small amount of fluid in
the sac of the tunica vaginalis, thus constituting a mild degree of
acute hydrocele. While the inflammation is confined to the epididymis
the pain is not intense, but of a dull, heavy character; but when the
testis proper is involved there is a true _orchitis_, the inflammation
being confined within the inelastic sclerotic tunic, and the pain then
may be severe. Considerable fever accompanies many of these cases, with
occasionally some edema of the scrotum and congestion of the testicular
coverings. The weight of such a “swelled testicle,” as this condition
is called by the laity, is irksome, and occasionally causes extreme
discomfort. Under these circumstances physiological rest, _i. e._, in
bed, and the use of a suitable suspensory apparatus are essential.

While resolution of this swelling ordinarily begins early and proceeds
satisfactorily, the latter portion of the process is often slow and
tedious, and the epididymis thus once involved will for months contain
nodules and irregularities of contour. Usually the affection is limited
to one side; but both testicles may be involved. If the infection be
violent and the treatment inefficient abscesses may result.

This condition calls for early and effective treatment. If seen at the
very outset, progress of the lesion may be checked by embedding the
affected part in cold, wet compresses, and keeping them cold with ice.
Relief later is more likely to be afforded by hot applications, and a
hot poultice containing a small amount of fine-cut tobacco has been
popular as a local application--the tobacco apparently being anodyne
in its effect, although perhaps no more so than belladonna leaves.
This may be regarded as a good emergency dressing when it affords
the only means of treatment. The greatest relief will be obtained by
the application of guaiacol, diluted with three volumes of olive oil
or castor oil, well applied over the scrotum, and covered with oiled
silk or rubber tissue. This application should be made twice a day.
Later, in the more chronic and less painful stages, a reduced mercurial
ointment containing a little guaiacol or ichthyol may be used to
advantage, resolution being thereby assisted. In quite tedious cases
the flying application of the actual cautery is serviceable. Internally
tincture of pulsatilla has proved beneficial. It should be given in 1
Cc. doses every two hours. While the benefits accruing from its use are
questionable, it has helped to allay fever and subdue pain.

Much has been said about the _sterility_ which results from
epididymitis, especially when both sides have been involved. It is easy
to understand how the vas may become occluded in many cases, either
temporarily or permanently, and yet within my own observation men have
suffered from the double lesion and yet begotten children.


=Gonococcus Septicemia and Pyemia. Postgonorrheal Arthritis=
(=Gonorrheal Rheumatism=).--Considering the extent of the mucous tract
involved, the open port of entry for germs, and the virulence of these
organisms in many cases, it is remarkable that there are not more
conspicuous illustrations of septic absorption in cases of gonorrheal
urethritis. That these do occur and have a widespread, sometimes
disastrous, effect has long been recognized. The severe forms are
usually the more acute, and if they assume the septicemic type, go on
to abscess formation, and in parts which are not always accessible. In
rare instances septic disturbance assumes the pyemic type. The writer
believes that he was the first to report a case of typical pyemia
following gonorrhea, and to recognize it as such.

Aside from these acute manifestations, more chronic and mild
affections, especially of the serous membranes, are well known. The
most common of these exhibitions occur in the joints, mostly in the
knee. A gonococcus peritonitis, pericarditis, or endocarditis are,
however, well known. Because of the similarity of the discomfort and
the disability resulting from the joint complications of clap to the
ordinary joint manifestations of rheumatism, these lesions have long
been popularly called _gonorrheal rheumatism_. The name, however,
should be discarded as being incorrect, and for it the best substitute
would be _postgonorrheal arthritis_.

These lesions may be sudden in their onset or may come slowly. They
may occur at any time during the acute stage or after its apparent
subsidence. The first manifestations involve the serous membranes
proper; the fibrous tissues participate sooner or later, and the
infiltration resulting from the inflammation thus set up will often
permanently compromise their integrity and cause an impairment of
their function for the rest of the patient’s life. They are usually
confined to one of the larger joints, but may involve several,
either simultaneously or consecutively. In acute cases the swelling
is somewhat pronounced and the pain and soreness intense. The local
symptoms simulate those of acute articular rheumatism. In the
fluid drawn from these joints the gonococcus can be occasionally
demonstrated. The course of the disease is usually slow, and
convalescence may be protracted. Nor is the disability acute only
and temporary, but it is often made permanent by the formation of
adhesions resulting from the condensation of exudates. Partial or
complete ankylosis may result, with considerable deformity. The muscle
spasm provoked by the acute joint inflammation will occasion the same
distortions and subluxations as are produced by tuberculous and other
forms of arthritis, and operations varying in severity from forced
motion to joint exsection may later be necessary. (See pp. 392 and 393.)

The writer has seen cases of postgonorrheal toxemia of extremely
chronic and even fatal type, where the joints were conspicuously
involved and where they did not constitute the most serious features
of the disease. These cases proved most intractable to treatment and
illustrate the possible complications of gonorrhea.

In addition to the joints various _bursæ_ and _tendon sheaths_ may
suffer in the same way as do the joint membranes. Such lesions are seen
about the hands and feet, especially about the tendo Achillis, and are
also seen in the muscles of the neck and of the orbit.

The treatment of these gonorrheal complications should be effected
largely by improving elimination and getting rid of the general
toxemia; thus hot-air baths, diuretics, and cathartics are advisable.
These eliminants, with free massage, are useful in dislodging the toxic
products.


=Treatment.=--The treatment of gonorrhea is directed not alone toward
the mere alleviation of symptoms, but to the destruction of the
invading germs. The patient should abstain from much exercise, and in
cases of severity should be kept in bed, avoid alcohol and tobacco, and
eat sparingly of meats and of richly seasoned foods. He should wear a
“gonorrhea bag,” or large condom, and there should be no obstruction
to the outflow of pus. His hands should be washed immediately after
contact with the parts involved, and all dressings and linen which may
have been contaminated should be promptly burned.

The actual treatment of gonorrhea should be both internal and local.
_Internal treatment_ should consist (1) of the administration of
laxatives; (2) of such amount of alkali as may be necessary to
overcome hyperacidity of the urine and mitigate the distress caused
during its passage; (3) of remedies which, being eliminated by the
kidneys, serve to medicate the urine and give it the effect of a
retrojection; (4) of such anodynes and sedatives as may be necessary to
give comfort, allay distress, and produce sleep or relieve and prevent
chordee.

Of the drugs which are supposed to be eliminated by the kidneys, the
balsams have sustained a high reputation. Among these is cubebs,
of which 2 or 3 Gm. may be taken every two or three hours, as this
remedy favorably influences the amount of discharge, though sometimes
disturbing the stomach. Of the oleoresin of copaiba a ¹⁄₂ Gm. capsule,
taken several times a day, is more pleasantly borne by the stomach,
and with nearly as good effect as cubebs. Copaiba is known to produce
a vivid scarlatiniform rash. The oil of sandal-wood, or santal oil, is
the most efficient of these remedies, and may be given in the same dose
as copaiba. That these drugs are eliminated by the kidneys is shown
by the odor which they impart to the urine. It must be said, however,
that these remedies are of but trifling benefit until the bladder is
involved; when this occurs, they may prove of great value.

The urine should be diluted that it may be less irritating, and also
to overcome its acidity. Fluids should be administered in profusion
and alkaline diuretics in considerable doses. Hyperacidity is readily
controlled by the administration of liquor potassæ, or the common
sodium bicarbonate.

Sedatives may be necessary even from the first. The stronger anodynes
are rarely needed during the first day or two, but by the end of the
first week vesical tenesmus and chordee may be so marked that remedies
such as cannabis indica, lactucarium, chloral, and the bromides may
prove insufficient, and an opiate should then be administered. When
required, morphine or heroine subcutaneously and in doses sufficient to
promptly bring about the effect desired are preferable.

The _local treatment_ of urethritis is directed to the alleviation
of discomfort and distress and the cure of the local disease. Much
has been said about _abortive_ treatment. There is no such thing
as aborting the disease. Much may, however, be done in the way of
mitigating and shortening its course, and mild cases, especially of the
non-specific form, may be considerably relieved within a few days.

The local treatment is carried out by injections into the urethra,
which must be made with a syringe, preferably of hard rubber, with
a blunt tip and without a nozzle, or by a douche bag connected with
a soft catheter, all of which should be kept constantly sterilized.
During the first days of an attack, when only the anterior part of the
urethra is affected, treatment can be made more readily and effectively
with a small “P” syringe, and at this time only 15 to 20 Cc. of
fluid will be required, which should be held in the urethra for some
time. When irrigation is decided upon a douche should be employed.
Accurate directions should be given the patient as to how to make the
injections, and he should be cautioned to first empty the bladder
before using the syringe. The patient’s comfort may be increased by
injections of water up to a temperature of 115° F. Antiseptics, _i.
e._, potassium permanganate, boric acid, or one of the new preparations
of the silver salts, may be added to the water. The parts may be
advantageously immersed in hot water at intervals during the day,
and for fifteen or twenty minutes at a time. There are many ways of
conducting local treatment in these cases. Those mentioned below have
given the best results in the practice of the writer.

A very satisfactory method would be to commence the local treatment
with the use of hot water, as above, every two to six hours, and to
follow it with a small injection of an emulsion of bismuth subnitrate,
with sufficient cocaine and a little morphine to blunt sensibility
and diminish tenderness and pain. The following formula, which may be
varied, will accomplish this purpose: Morphine sulphate 0.3, cocaine
muriate 2, bismuth subnitrate 20, cherry-laurel water 150, mucilage of
acacia 50.

The injection should be retained for a few moments and no effort made
to expel it. The bismuth salt is not only antiseptic, but is soothing,
slightly astringent, and non-irritating.

Belfield has recommended the use of the yellow hydrastia muriate in
connection with protargol. His formula is as follows: Yellow hydrastia
muriate 2.50, protargol 1.50, glycerin 15, water 500. After using
this for a few days the proportion of protargol may be doubled. Of
this preparation 15 to 20 Cc. should be injected several times a day.
The silver salts are the least irritating of all the stronger and
more reliable antiseptics, and drug manufacturers are putting upon
the market at frequent intervals new preparations for which much is
claimed. Among the latest of these is argyrol, a combination of silver
with albumen (vitellin), in such form as to make it antiseptic and
non-irritating. In solution it is of a dark mahogany color and stains
whatever it comes in contact with; these stains, however, are readily
washed out. Argyrol in solutions of 2 to 5 per cent. strength has
proved reliable, and if such a solution be retained in the urethra
for five minutes at a time a pronounced effect may be made upon the
disease. It is my custom to alternate the use of the bismuth formula
with a solution of argyrol as above, and in this way give the greatest
relief in the shortest time. It has been demonstrated that under the
influence of this preparation all gonococci which are reached by it
are destroyed; therefore the earlier it is employed the better. Before
using either of these formulas the anterior urethra should be washed
with hot water or with hot normal salt solution. No harm need be feared
should either of the above injections reach the deep urethra, and the
effort should be to make them reach at least as deeply as the disease
has gone.

When the discharge has reached what Finger has called “the mucous
terminal stage,” then the argyrol may be used two or three times a day
only, and one of the following solutions substituted for it part of
the time: Zinc sulphate 0.75, bismuth subnitrate 8, colorless liquor
hydrastis 15, cherry-laurel water 60. Of this solution 10 Cc. may be
used three or four times a day.

Belfield strongly recommends the use at this time of a solution of
muriate of berberine, in strength of ¹⁄₂ to 1 per cent., or the yellow
hydrastia muriate in about the same strength. He also recommends zinc
chloride 0.25, zinc iodide 0.50, water 500. Either of the above salts
may be added to this.

When nothing remains of the discharge but the so-called “morning” or
“military drop,” and the urine is almost clear, argyrol solution at
night and one of the above formulas once or twice through the day
will be sufficient. This, in brief, is a description of how a case of
urethritis may be satisfactorily treated.

The systematic use of potassium permanganate solutions was introduced
by Janet, and has been enthusiastically described and prescribed by
Valentine. The treatment is more complicated and less satisfactory than
that advised above.

With deep extension of the disease and its added symptoms of tenesmus,
pain local and referred, etc., the limit of the injection should be
extended and the entire urethra should now be treated. The bladder
being empty, the patient should make a strong effort to empty it
again at the moment when fluid is being injected into the urethra;
the compressor muscle being thus relaxed, the fluid passes into the
deep urethra. It will take a little practice to enable him to do this,
but when once learned the procedure is simple, and those who cannot
accomplish it in the standing position will succeed if they lie down
before making the attempt. In this way the entire urethra may be
traversed.

In the treatment of deep urethritis it is not necessary to change the
formulas or drugs above advised.

Under this line of treatment it may be possible to cure the majority of
cases of gonorrhea in from two to five or six weeks. This by no means
indicates that the lesion is actually cured, for trifling evidences,
such as adhesion of the lips of the meatus, with the retention of a
drop or so of mucopus, and the presence in the urine of the so-called
“clap threads,” _i. e._, threads of flocculent material that consist
of mucus and epithelial debris loaded with bacteria, will for a long
time be noted. These appearances indicate that there are still areas
along the urinary tract which are infected, and are sources of possible
danger.

The _vesiculitis_ which often follows deep urethritis, as shown by the
enlargement of the vesicles, detected by rectal examination, requires
physiological rest, hot sitz baths, hot enemas, and opiates, the latter
usually by suppository. After a short time the vesicles should be
“milked” with a finger in the rectum, gentle pressure being made toward
the prostate in the direction of their outlet. This will frequently
cause an outflow into the urethra of pus and debris and give great
relief. Should the infection persist and the above manipulation prove
insufficient, the vesicles may be opened through the rectum, washed
out, and packed with gauze.


CHRONIC GONORRHEA, OR GLEET.

Gleet is the name given to gonorrhea which persists, being only partly
influenced by treatment, and which has extended over an arbitrary
period placed usually at six weeks to two months. Strictly speaking
the term _gleet_ should be restricted to cases where there is a
mucopurulent discharge from the meatus, often complicated by formation
of strictures in the _anterior_ urethra; on the other hand, a _chronic
gonorrhea_ may for a long time persist in the _deep_ urethra and
the glands and ducts adjoining, whence will issue a discharge which
appears anteriorly, but, nevertheless, comes from the depths of the
genito-urinary tract.

It is possible to have a chronic gonorrhea with little or no true
gleet, the infection being latent, but nevertheless persisting. In
gleet the discharge varies from a thin watery flow to one which is
profuse and purulent, most noticeable in the morning on rising,
when the meatus may be occluded by adhesion of the surfaces and
there appears the so-called “morning drop.” Careful investigation
of the urethra will generally disclose at least some constriction,
with tender areas along the anterior urethra. To successfully treat
the disease these areas and constrictions should be determined and
suitably medicated. For this purpose two instruments especially are
necessary--the _bulbous bougie_, for which a sound of the same size is
an unsatisfactory substitute, and the _endoscope_, through which the
lesions may be not only viewed but suitably treated.

The peculiar discharge comes from a lesion of one of the following
varieties--either from isolated areas of inflamed mucous membrane
with underlying exudate, from follicles and vesicles which fail to
completely empty themselves, or from preëxisting strictures. The
endoscope will easily reveal the first and second of these; the bulbous
bougie the first and third, while further examination by the rectum may
be necessary to decide in regard to the seminal vesicles.

[Illustration: FIG. 28

Bulbous sound.]

The bulbous _bougie_ is an instrument of great importance in urethral
work. It should be carefully sterilized before introduction, and the
urethra should be cleansed before its use. The instrument should be
gently passed into the urethra; its course will be obstructed by any
constriction which will give rise to stricture of smaller caliber than
the bougie itself, while the discomfort or pain which it will excite
as it passes over a tender or ulcerated area will be significant. The
urethra is most distensible at its bulbous portion, while its caliber
varies in different individuals, ranging ordinarily from 30 to 35 of
the French scale, while the urethral diameter is about four-tenths of
the circumference of the penis. We owe more to the studies of Otis in
this matter than to any other investigator. He also showed that the
size of the meatal opening is not a criterion as to the size of the
urethra; that the contracted meatus often produced a certain degree
of reflex and spasmodic stricture behind it, and that when the meatus
is too small to permit the introduction of such an instrument as the
urethra should take it should be enlarged, the operation for its
enlargement being known as _meatotomy_, which may be easily effected
with a blunt bistoury under the local use of cocaine. The meatus having
been enlarged to suitable size, any consistent and organic constriction
which then prevents the passage of the bougie should be considered a
stricture and treated accordingly. Such a constriction may be of recent
origin, when it will be found easily dilatable, or it may be old,
resillient, and tough. Otis also devised an instrument known as the
_urethrometer_, which is of value in the accurate estimation but not
necessary in the treatment of many cases.

[Illustration: FIG. 29

Urethrometer.]

These instruments may be passed down to the bulbous portion of the
urethra; beyond this further investigation should be made with the
ordinary sounds. By their use much may be determined in regard to
prostatic tenderness, and the combined use of the sound in the
deep urethra with the finger in the rectum will give more accurate
information regarding the size of the prostate than can easily be
obtained in any other way. Much reaction, however, may occur from the
use of the sounds in this way, and it is a good rule never to introduce
an instrument into the deep urethra without having ample reason
therefor, and then doing it under antiseptic precautions; while, as a
formal measure after it, the patient should be placed at absolute rest.
This serious reaction, which occasionally follows instrumentation of
the deep urethral passage, is commonly known as _urethral fever_. It is
characterized by chills, elevation of temperature, and often by local
indications, the constitutional features being sometimes pronounced,
and in rare cases terminating fatally. Such serious symptoms are
difficult to explain. Doubtless the use of the instrument opens up
paths of fresh infection, and absorption rapidly follows, which may be
limited to the surrounding tissues or cause widespread trouble. This
may ensue after every precaution has been adopted, although doubtless
many of these cases have been the result of carelessness and failure
in antisepsis. Much may be done in the way of prevention when this
condition is feared, for these cases are rarely so urgent but that the
urine can be medicated and its quality improved, while a part of the
procedure may consist in having the patient empty the bladder and then
carefully washing it, or filling it with an antiseptic solution, which
may be expelled before any instrument is used except the catheter,
through which it may be necessary to introduce the bladder wash. The
administration of 2 or 3 Gm. doses of urotropin, with or without
quinine, previous to the exploration, may also be of great service. The
surgeon perhaps does not always take these precautions, but he should
when the history of the case shows that patients have already suffered
in this way. In the presence of such a history the urethra should be
explored with great caution.

When the rectal examination is made the intent should be to discover
any enlargement, irregularity, or undue sensitiveness of the prostate,
and then to pass the finger still farther and ascertain if there is
involvement of the seminal vesicles. At the same time a species of
manipulation described as “milking” may be conducted, by which the
contents of the vesicles as well as of the prostatic utricle may be
incited by gentle pressure, directed from above downward, to empty
into the deep urethra, whence they may be promptly expelled or may be
carried out by the urinary stream, or removed through the endoscope.
The discharge of pus or catarrhal debris in any visible amount is
suggestive, and indicates that these passages have participated in
the infectious process. This act may be repeated at three or four day
intervals; it should be so gently done as not to cause much pain, and
will be found of great value in cases calling for it.


=Treatment.=--The treatment of gleet is essentially treatment of the
causes which produce it, and these should be carefully determined. In
the urethra, as in all other tubular channels of the body, an abnormal
constriction is accompanied by an area of excitement behind it, from
which will issue more than the normal mucous discharge. We see this
in stricture of the esophagus, intestine, or any of the ducts. This
discharge is not to be subdued by mere applications nor by astringent
and antiseptic injections, but the stricture itself, being the most
important factor, must be suitably managed. In recent cases its gradual
distention by the use of conical sounds will usually suffice.

In long-existing strictures more radical measures should be adopted,
and they should be divided with one of the numerous urethrotomes
in general use. Mere division, however, is not sufficient, but the
patient should be impressed with the fact that cicatricial tissue
tends invariably to contract, and that persistent dilatation is to be
practised lest the stricture recur. The old saying used to be, “Once
a stricture, always a stricture.” If this is to be disproved, it can
only be by the frequent and long-continued use of sounds. Ignorance
or indifference impel many a patient to return for further treatment,
sometimes in a condition worse than at first, while occasionally the
penalty paid for carelessness is life itself.

No routine in the treatment of gleet will give satisfactory results
beyond this fact, that patients should be instructed to regulate their
lives by absolute rules as regards indulgence of every description,
and avoidance of intestinal inactivity and constipation. The urine
will be found concentrated and irritating in many of these cases, and
this should be overcome by the free use of water and diluent drinks.
Hyperacidity should be corrected by suitable alkaline medication,
and remedies administered, already mentioned, which are supposed
to medicate the urine. Capsules may be procured containing salol,
oleoresin of cubebs, balsam of copaiba, and pepsin, and except in cases
where there is already great irritation of the urinary tract, these
serve their purpose admirably.

When the anterior urethra alone seems to be involved, one of the
milder injections already mentioned in describing the treatment of
acute cases may be employed. When the deep urethra appears to be the
site of continued irritation, it should then be treated extensively
with deep irrigations and injections of suitable medicaments. The deep
irrigations can be practised with or without the use of a catheter.
The deep urethra may be flushed through a smaller catheter than the
urethra will comfortably take, allowing the fluid to return through the
urethral channel outside of the catheter itself. When this practice
is adopted, hot water which has been made antiseptic should be used,
preferably with one of the silver salts. The nitrate may be used in
proportion of 1 to 500, and the citrate or lactate in strength of 1 to
300 or 1 to 400. Protargol is effective in 1 per cent. solution, or
argyrol in 1 to 3 per cent. strength.

In the employment of irrigation in these cases a shield should be
used, by which the end of the penis may be covered and all danger of
spattering avoided. The simplest expedient for this purpose is one-half
of an old atomizer bulb, which may be punctured and slipped over the
catheter or irrigator tube.

Apart from mere irrigation it is well to deposit within the depths of
the urethra, in the membranous portion, by means of a deep urethral
syringe, a drop or two of a fresh solution of silver nitrate in
distilled water, in strength of ¹⁄₂ to 1 per cent. This should be
deposited behind the “cut-off” muscle, where it will cause a burning
sensation for a short time. The strength of the solution is to be
regulated by this complaint, as no benefit is derived from using it too
strong.

Of all the medication that has been suggested, nothing gives better
results for this purpose than this silver nitrate.

For ordinary urethral injections, besides those already mentioned,
formalin may be used, but in weak solution (1 to 2000, or stronger if
the patient can tolerate it); while picric acid has been recommended by
Belfield and others in strength of 1 to 1000 or 1 to 2000.

Some surgeons believe that patients can learn to flush the deep
urethra, or even the bladder itself, without the use of the catheter
or internal tubing of any kind. The procedure may have to be learned
in the sitz bath, the pelvis being immersed in warm water; the nozzle
of the irrigator tube is inserted into the urethra and the patient is
told to make an effort as if to void his urine. This will so relax the
“cut-off” muscle as to permit the passage of fluid into the bladder,
and this, which is most desirable in many cases of cystitis, where
the bladder washing is an essential feature of the case, is to be
avoided when the gonorrheal infection has travelled backward beyond
the prostate; no attempt should be made to pass the solution into the
bladder, but simply to wash out the urethra. The better plan is to
teach the patient the proper use of a small soft catheter, which may
also be used in the sitz bath, inserted to the proper extent.

Recent strictures should be treated by sounds after the urethra has
been thoroughly cleansed. For this purpose a conical cylindrical
sound should be selected, whose urethral end will comfortably enter
the stricture. Gentle force should then be brought to bear to pass it
beyond the stricture. If gradual dilatation be aimed at, it is well
not to go beyond the point of drawing a drop or two of blood; even
this may be avoided. On the other hand, should it be decided to use
sufficient force, the dilatation should be done thoroughly and at one
sitting, in order to avoid repetition of the irritation. The instrument
generally in use in this country for this purpose is the _Otis dilating
urethrotome_, by which the degree of dilatation and the size of the
cicatricial ring can be estimated and the extent of the division
and the effect gained also regulated. (See Operative Surgery of the
Urethral Canal.)

The _divulsion of strictures_, formerly in vogue, is now abandoned for
the more accurate division performed by this instrument. The strictures
having been thus divided, sounds should be passed at intervals of from
three to five days, by which the urethra is distended to its full
caliber and the divided surfaces not allowed to contract. This is an
important part of the treatment, and gives opportunity for widest
discretion in their employment. Ordinarily they should not be carried
farther back than the lesion calls for, as the deep urethra is best
let alone. On the other hand, there are many cases where the stimulus
of the cold metal passing the entire length of the urethra and the
effect which it seems to have in expressing from the various follicles
any retained contents seem beneficial. It has been stated that
instrumentation sometimes leads to epididymitis or “swelled testicle;”
should this take place in a case undergoing treatment for gleet it may
necessitate a temporary cessation of the mechanical treatment. It is
not good surgery to introduce any instrument into the urethra when one
or both testicles present this complication.

In the local treatment of these lesions, cocaine or one of its
substitutes should be employed. It is questionable whether the
full benefit of applications is obtained when the surfaces are so
anesthetized; on the other hand, the treatment can be made more
endurable by its use.

This is true, also, of the use of the _endoscope_, and applications
which may be made through it to inflamed or hypersensitive patches.
When these are recognized or exposed, they are best treated by a
probang moistened with silver nitrate solution, in 5 to 10 per cent.
strength, or by the solid stick or crystal of copper sulphate, pure or
mitigated, as used by the oculists.

One of the most important features in the consideration of gonorrhea is
to determine, if possible, when a given case has ceased to be dangerous
to others. In theory the danger passes with the disappearance of the
gonococci, but it is so difficult to determine when this has occurred
that it is almost impossible to fix a time limit in any given case. An
excellent method of determining the matter in a reasonably accurate
way is by having the patient void urine in two different glasses; a
small quantity in the first, which will contain, then, the washings
of the urethra. In this glass will be found those chains of gonococci
clustering around masses of epithelial cells or debris which have been
especially described as “clap threads” (tripper-faden of the Germans),
upon which, by careful examination, gonococci can often be recognized.
As long as these threads are in evidence it may be held that the
infection still persists, and might be either brought into activity
again by excitement or convey the disease in the sexual act.

Gonococci have been found in clap threads years after the last known
infection, and this will illustrate why they are such a source of
danger, and how an innocent woman has been made to suffer when it was
supposed that all danger of infection had passed away.


GONORRHEA IN WOMEN.

This naturally assumes the type of a _specific vaginitis_, usually
with active participation of the mucous membrane of the _vulva_ and
of the _vulvovaginal glands_, the urethra and bladder being sometimes
secondarily involved, while the role of the lymphatics is about as
described in the male. In the young, especially in young girls upon
whom rape has been attempted, the mucosa is extremely susceptible. In
adults, particularly in those who have borne children, the vaginal
walls offer more resistance. The nature of the parts permits of more
violent chemosis of the mucous membrane, while in serious cases there
will be well-marked edema of the labia. The urethral orifice is usually
inflamed and chemotic, even though the infection travel no farther in
this direction.

It has been stated that 80 per cent. of deaths from pelvic disease in
women are due directly or indirectly to gonorrhea, as well as one-half
of the cases of involuntary sterility.

As in the male, there may be different types of so-called gonorrheal
infection of the vagina, varying from the pure gonococcus type to that
in which the preponderating bacteria are of the ordinary pyogenic
varieties. The detection of gonococci in the discharges sometimes
assumes medicolegal importance, and upon it has depended the guilt or
innocence of more than one individual.

The intensity of the vaginitis will vary with that of the infection. In
the worst cases the discharge is profuse and acrid. It may amount to
50 Cc. or even 100 Cc. in twenty-four hours. The burning pain will be
extreme, while backache and pelvic soreness will be bitterly complained
of. In mild cases the disease assumes the clinical form of a low-grade
vaginitis with abnormal discharge, such as may be characterized as a
severe case of “whites.”

In these cases of either type the question is, whether infection has
already travelled upward beyond the vagina into the uterine cavity or
through it into the tubes.

Gonorrhea is the most common, and some believe almost the sole, cause
of _pyosalpinx_ with its attendant complications and dangers. Even when
not severe, vaginitis may permit of such extension, and so not only
induce sterility, but compromise the physical welfare of the patient;
while in acute cases the activity is so great that it occasionally
terminates in peritonitis, primarily of gonorrheal origin. When both
tubes have become involved, the patient is almost invariably sterile.

In nearly all of these cases strings of mucopus will be found hanging
out, or beads of it presenting at the external os, and when examined
this exudation will afford a fair test as to the character and degree
of the infection. Here, as in the male, there are so many follicles
difficult of access, and so many recesses in which germs may lurk, that
a complete disinfection of the parts is almost impossible. For this
reason, then, latent gonorrhea is a frequent outcome of the disease
when once it has existed, and a possible and more or less constant
source of danger to others.


=Treatment.=--A case of acute gonorrheal vaginitis with its
accompaniments will present a difficult problem. The discharge is
so great that the danger to others, and especially to the eyes, is
pronounced, while the exquisite tenderness of the parts makes radical
treatment difficult. The treatment should consist of antiseptic
douches, which in serious cases should be made as nearly continuous
as possible. The water used for the purpose should be as warm as
the patient can tolerate, and contain an antiseptic, of which
corrosive sublimate, in strength of 1 to 2000, silver nitrate in the
same strength, or formalin in double this strength, are the most
serviceable. The irrigating tube should be carried to the upper end
of the vagina and the stream made to flow outward. In milder cases a
douche at intervals through the day may suffice. The vaginal surface
should later be exposed through a speculum and the entire mucous
surface treated with nitrate of silver solution in from 6 to 10 per
cent. strength. Should the surface be tender, this will be painful, and
might justify the use of an anesthetic, especially of nitrous oxide.

If the disease extend upward and there is an _endometritis_ or a
_salpingitis_, external applications of ice may be used to lull the
pain; but probably hot poultices or some application of external heat
might afford greater comfort to the patient. Byford has used succinic
dioxide in the treatment of specific vaginitis with great satisfaction.
It is sold in the open market under the trade name “Alphozone.”

The edema of the vulva will subside with the general improvement of the
case. Abscesses in the vulvovaginal glands are not uncommon. These are
easily recognized, are often painful, and should be incised early or as
soon as recognized, cleaned out thoroughly, the interior of the cavity
cauterized to prevent the result of fresh infection, and then packed
and left to heal by granulation.

Urethritis and cystitis may be treated as when they occur in the
male. There is the same liability in women as in men to lymphatic
involvement, with the consequent bubo, which may perhaps suppurate.
They are less liable to the widespread manifestations of postgonorrheal
infections of the joints, etc., although they are even more liable
to infection of the endocardium, and, as will be readily understood,
more so to infection of the peritoneum. It will then be seen that the
treatment of the disease is essentially the same in either sex, certain
differences in method rather than in principle having to be made in
accordance with anatomical requirements.

As to the rectal mucous membrane participating in gonorrheal infection,
under ordinary circumstances it would escape. In the treatment of any
of these cases by the sitz bath, the question might arise whether there
would be danger of extending the contagion in this direction. It does
not appear that much fear need be felt, for two reasons: the grasp
of the sphincter is usually sufficient to prevent entrance of fluid,
and, furthermore, the rectal mucosa is itself extremely resistant to
the gonococcus. _Gonorrheal proctitis_ is an exceedingly uncommon
infection, and one rarely seen, except in extreme cases of sexual
perversion. It should be treated in about the same manner as gonorrheal
vaginitis, _i. e._, by continuous irrigation with hot water, and
stretching the sphincter in order to overcome the spasm into which it
would be thrown by reflex activity.

_Gonorrheal urethritis_ in women is best treated with local
applications of argyrol or one of the other silver compounds. These
can be made with a syringe or with a small swab. _Cystitis_ is to be
treated in the same manner as when it occurs in the male.




CHAPTER XIII.

SCURVY AND RICKETS.


SCURVY.

Scurvy is placed among the so-called surgical diseases, since it
manifests many distinctly surgical features and is possibly of
parasitic character, although this feature of its existence has not
been incontrovertibly established. It is a _starvation_ disease, its
principal characteristic being that of _malassimilation_, accompanied
by profound _anemia_. Well-marked cases are seen during long sieges,
like that of Paris, in 1871, or during long imprisonment, as in
Andersonville prison. It has certain points of resemblance to that
condition of multiple neuritis met with in warm climates, and known
usually as _beriberi_. The former is apparently due to the absence of
a vegetable regimen, while beriberi is largely due to the absence of
an animal regimen, nature having intended that man’s diet should be
mixed, and having ordained that suffering and disease always follow
confinement to one or the other.


=Pathology.=--The pathology of scurvy is obscure. It has been shown
that gastric digestion is seriously at fault, that there is much
intestinal putrefaction, that the urine shows great absorption of
toxins, that the hematopoietic function is incomplete: that scurvy is
a toxemic or chronic ptomain poisoning, which may in part or at times
be due to the use of tainted food. Morphological changes are, however,
neither distinct nor pathognomonic. It has been described as a disease
of diet and occupation rather than of race, age, sex, or season. The
ease with which hemorrhagic effusions occur, the degeneration of
muscles and other tissues, the frequent detachment of cartilages, can
be accounted for by conditions thus summarized, for which, however,
we have no minute explanation. Scurvy may so complicate various other
diseases, and usually does when occurring in large bodies of men--as in
armies, prisons, among convicts, etc.--that it is hard to dissociate
morbid phenomena and assign to each its proper place.


=Symptoms.=--The disease begins by a condition of generalized
prostration, with an icteric tint of the skin, malaise, mental torpor,
loss of appetite, insomnia, etc. The first recognizable or distinctive
local appearances occur about the margins of the gums. Here, in the
intervals between the teeth, the gums become livid, friable, and bleed
easily, while the breath assumes a characteristic fetid odor. The
skin becomes dry and brittle, and covered with minute prominences,
which give it the popular name “goose-flesh.” These appearances are
followed by local pains, diversified and sometimes excessive, and
extravasations of blood in the skin and under the visible mucous
membranes, causing small ecchymoses, which by themselves would be
considered as simple purpura hæmorrhagica. These pass through the usual
phases of extravasations, while it is made evident by pain, nodular
masses, etc., and by postmortem examination, that similar hæmorrhages
occur in the deeper tissues, especially in the muscles, even in the
bones and epiphyses. So easily do hemorrhages occur in advanced stages
that there is often external bleeding, particularly from the gums and
mucous membranes, while from points thus involved pyogenic infection
may proceed internally. Near the close the victim presents a picture
apparently of an animated corpse, with surface discolored and mottled,
often appearing bruised, with ulcerations where extravasations have
failed to resolve, and where infection has occurred, possibly with
epiphyses loosened, and necrosis of the bones of the extremities. In
such cases death results from marasmus and sepsis.


=Treatment.=--As long as the patient is not in the desperate condition
just described the prognosis and outlook for treatment are promising,
as all the milder manifestations of scurvy can be dispersed by suitable
feeding and medication. Loss of teeth and cicatrices of ulcers leave
permanent traces, but function can be restored. The _purpura_ is but
one expression of the scorbutic condition. Nearly all cases of scurvy
will present purpuric manifestations, but all cases of purpura are not
necessarily scorbutic. The course of treatment may be summed up in
proper diet and in the administration of certain drugs. _Proper diet_
should be prescribed at once, but administered, especially in severe
cases, _with extreme caution_. The food selected should be given in
small quantities, but frequently. It should consist in large measure of
fresh fruits and vegetables, while cranberries and lime-juice figure
largely among the former. Buttermilk is excellent, and cider may be
allowed; also lemonade, with but little sugar.

[Illustration: PLATE XI

FIG. 1

Rickets. Rib. Very low power. (Gaylord and Aschoff.)

FIG. 2

Rickets. Flat Bone of Skull (Craniotabes). (Karg and Schmorl.)]

For the local condition in the mouth an antiseptic mouth-wash
containing a fair proportion of hydrogen dioxide is advisable.
Alcoholic stimulants are called for, at least up to a certain point.
Strychnine and cinchona preparations will give force to the heart’s
action, and the horizontal position, for a time at least, will prevent
sudden heart failure. Compound syrup of the hypophosphites, with meat
preparations, will supply lacking material, while the hemorrhagic
manifestations are best controlled by the fluid extract of ergot and
aromatic sulphuric acid, separately or combined. Particular attention
should be given to cleanliness and fresh air.


=Infantile Scorbutus.=--Infantile scorbutus sometimes furnishes the
surgeon with very young patients who are brought to him especially
for disability of the limbs, with pain and fretfulness, leading to
immobility, followed by enlargement of the lower ends of the femurs
(due to subperiosteal hemorrhages) with fixation by muscle spasm; this
may be followed by “spontaneous” fractures. The gums will show the
same changes as are seen in adults, while subcutaneous hemorrhages
and infiltrated muscles, with foul breath, ashen pallor, listlessness
and apathy, and perhaps several swollen joints, will complete an
unmistakable picture.

Fresh milk with orange-juice in small amounts between feedings,
combined with more strictly surgical measures if needed, will secure
good results in these little patients.


RICKETS.

Rickets, or _rachitis_, is another of the diathetic conditions, in
this instance not yet considered of parasitic origin, most commonly
occurring in infancy and early childhood, although its resulting
lesions may persist throughout life. It is characterized by nutritional
disturbances and organic irregularities.


=Pathology.=--Rickets is generally referred to as “fetal” or
“congenital,” according to whether the infant presents characteristic
markings at birth or whether they develop later. The most marked
constitutional defect seems to be in the supply of calcium salts, which
leads apparently to formation of bone which has not sufficient compact
tissue to make it strong. Especially along the line of junction between
bone and cartilage do we see the most marked expressions of rachitic
lesions. Here the cartilage is evidently actively growing, while the
bone formation proceeds with difficulty, and the proportion of vascular
tissue is excessive. The result is prolongations of soft vascular into
the cartilaginous tissue, by which the latter becomes more or less
absorbed, and this essentially interferes with _ossification_. In
severe cases it may be lacking. At epiphyseal lines one may see a layer
of osteoid tissue which is not cartilage and will not become bone.
Because of its yielding nature it warps under the mechanical strain to
which the bones of the extremities in young children are constantly
subjected.

The obscure but unmistakable relations existing _between rickets and
the status lymphaticus_ will be referred to in Chapter XIV.

The osseous lesions of rickets differ from those seen in osteomalacia,
since in the latter the softened tissue is practically decalcified
bone, while in the former case most of the affected tissue has never
gone so far as genuine bone formation, but is arrested in its perverted
state.

The result of rickety changes in the skeleton is a thickening of
the shafts of the long bones, of the outer table of flat ones, of
the epiphyseal extremities of shafts, and frequently a stunting of
their development, so that they do not attain their normal length.
The periosteum is also affected in rickets, with the result that
when the changes occur, mostly subperiosteally, there are warpings
and curvings of the bone shafts, while so long as the disturbance is
epiphyseal more or less abrupt curvatures and angular deformities will
be produced as the result of muscle action. So marked are the changes
in some instances that it has been stated that bones may even lose
three-fourths of their calcium salts. When rachitic bones are so soft
as to be easily cut with a knife, marked deformities occur as the
result of muscular activity. (See Plate XI.)

In the extremities we see _bow-legs_, _knock-knees_, _clubbing of the
ends of the long bones_, bending of the neck of the femur, _flat-foot_,
_club-foot_, etc.; while the clubbing of the bone ends also may be well
marked in the bones of the upper extremity, where, however, marked
deformity is less common, because the upper extremity does not bear
the weight of the growing body. In the skull the bones remain soft
and yielding to pressure, with a tendency to return to their original
membranous condition, and this is the condition comprised under the
term _craniotabes rachitica_. The _fontanelles always remain open_ for
an undue time; the sutures are broad and membranous. The _bones of the
face grow less rapidly_, giving to the face a disproportionately small
size; _dentition is delayed_ and the _teeth decay easily_. The upper
incisors often project far over the lower.

In the thorax there are enlargements of the sternal ends of the ribs,
causing a row of nodules referred to as the _rachitic rosary_. The ribs
tend to sink in, the sternum to be protruded forward, and the deformity
known as _pigeon-breast_ becomes often pronounced. Curvatures of the
spinal column, especially _kyphosis_, are common, and distinct degrees
of _lateral curvature_ are frequently begun as rachitic deformities, to
be magnified by perverted muscle action as the child grows older. In
the pelvis the innominate bones approach each other, causing the pelvic
cavity to become contracted, or the sacral promontory projects too
far, or in various other ways the normal pelvic diameters are so far
compromised that _rachitic deformities of the pelvis_ constitute the
most common and serious obstacles to normal labor in adult women, and
are frequently the cause of major obstetric operations.

While the rachitic changes in the osseous system are the most
distinctive and easily recognized, numerous other organs and tissues
of the body are more or less seriously compromised. _Ventricular
dilatation_, leading to chronic _hydrocephalus_, is one of the common
results of rachitis of the skull, which may be followed by convulsions
and terminate fatally. _Porencephalon_ and _cerebral sclerosis_
may also ensue. Disturbances of digestion are common in rickety
children--the _liver_ may decrease in size or become much enlarged;
the _spleen_ often enlarges, sometimes to enormous dimensions. In
various other parts of the body there are the same expressions of
malnutrition as are met with in tuberculous disease. Rickety children
_perspire easily_, particularly at night, when the head will often
be found bathed in perspiration. They are fretful and irritable, as
a rule, and difficult to control. A child with protuberant belly,
due to enlargement of liver and spleen, as well as to crowding of
pelvic organs, with relaxation of abdominal walls, and a contracted
and distorted thorax, the skull flattened on the top, clubbed bone
ends, a history of resting badly at night and sweating profusely,
constitute a clinical picture of rachitis so marked that it can be
recognized at a glance. Between this picture in its worst forms and the
slightest deviation from the ideal type there may be met all degrees
in manifestations of rickets in the children of the rich or the poor,
while in adults may often be seen evidences of that which prevailed
during early childhood. In order that all these features may be made
out the child should be stripped and examined from head to foot.

_Laryngismus stridulus_ is a frequent accompaniment. It may be followed
by general convulsions and tetany. (See Chapter XIV.) While rickets
may be a very acute disease, it is as a rule chronic, and children
dying essentially from this disease die rather from cerebral or other
manifestations which may be regarded as in some degree accidental.
_Scurvy_ and other nutritive disturbances may be associated with
rickets.


=Treatment.=--The treatment for the condition consists mainly in
_proper nutrition_. Mothers’ milk is certainly preferable to any other,
and should be demanded. If feeding must be artificial, it should be in
accordance with the best precepts of modern therapeutics. Cod-liver-oil
emulsions are of advantage; compound syrup of the hypophosphites is
a remedy of great virtue. Minute doses of phosphorus seem to be of
value--1 Mg. _pro die_. It is a mistake to let rickety children begin
to walk or even to creep too early. They should be kept upon the back
in their cribs.

The modern opotherapy of rickets includes the employment of _thyroid_
and _pituitary extracts_. The dose should be graduated to the age of
the patient, based upon 30 Cg. for an adult, and given thrice daily.
This will not preclude the necessity for a careful regulation of diet,
etc., but will constitute a valuable adjunct in treatment.

The deformities due to rickets are so numerous as to constitute a large
part of those to which special or orthopedic surgery is addressed. The
mechanical and operative treatment of these cases will be referred to
in their appropriate place.




CHAPTER XIV.

THE STATUS LYMPHATICUS.


Under the term _status lymphaticus_ has been described a condition
which is of interest to the surgeon, as it includes not only minor
complications, and even those which are serious, which follow surgical
procedure, but it also has reference to the cases of sudden death
during or after operation, some of which have been attributed to the
anesthetic, while others have been considered absolutely unexplainable.
The condition is so easily described or defined that it should be
recognized during life, but it has often been discovered only after
sudden death.

The essential feature of the condition is _enlargement of the
lymphatic tissue and apparatus_, perhaps throughout the entire body,
more frequently through its internal portions. It usually occurs
in children. It is accompanied by much lowering of the power of
resistance, and results in sudden death from cardiac failure, as
the result of causes which seem disproportionately trivial; as, for
instance, such deaths as occur not merely during anesthesia, but during
bathing, convalescence from the exanthemas, etc. It stands in close
relation to diphtheria, perhaps because of its peculiarly depressing
toxins, and probably accounts for cases of sudden demise in that
disease, even when mild.

The status lymphaticus is also designated by other names, as
_lymphatism_, _lymphatic constitution_, and _status thymicus_, the
latter because of the active participation of the thymus. Enlargement
of this body has been noted at autopsy, but its relation to the other
features of status lymphaticus were unknown until Rokitansky, in 1842,
first recognized the condition in its entirety, but confused it with
the tuberculosis of the lymphatics formerly called scrofula.

The death of a son of a German professor, a few years ago, shortly
after an injection of antitoxin to protect him from diphtheria, and the
subsequent discovery that the boy was the victim of this condition,
caused a widespread interest in and a most careful study of the
problems involved. They occur in the thymus more frequently than in
any other organ of the body. Normally the thymus begins its involution
within a few months after birth, and this process should be completed
at puberty. In the status lymphaticus this involution does not occur,
but enlargement persists or increases even into adult life, varying in
different cases, the weight of the thymus varying from 20 to 135 grams.

While the thymus may for some purposes be grouped among the lymphatic
tissues of the body, little is known as to its function. Its juice
contains leukocytes, which find their way into the general circulation,
and it is supposed to have an internal secretion correlated with that
of other ductless glands.

Injections into dogs of thymus extract produce a fall in the blood
pressure, with acceleration of the heart, and, in fatal doses, dyspnea
and collapse. While enlargement of the thymus may cause death by
pressure on important structures other than the trachea, it produces
a type of asthma known as _thymic asthma_, in which death sometimes
occurs unexpectedly and rapidly by strangulation.

An examination of the thymus rarely shows anything more abnormal
than the enlargement of its natural structure, with perhaps acute
hyperemia, while occasionally the cut surfaces will exude a milky
fluid; there will be found, in addition to these changes in the thymus,
a general hyperplasia of the lymphatic system, with enlargement of
the superficial and deep nodes, especially the cervical and axillary,
the inguinal and those in the abdomen. The spleen enlarges and the
Malpighian bodies seem to be packed with lymphoid cells. There may be
enlargement of the heart and increase in the thickness of the arterial
walls. This is so marked that Virchow suggested the name _lymphatic
chlorotic constitution_. It has been suggested that the narrowing of
the aortic valve in these cases is due to this lymphoid infiltration.

_The relations between rickets and the status lymphaticus_ are so
frequent and so conspicuous as to make one suspect a more than casual
connection between them. Nearly all cases of lymphatism show the
ordinary clinical evidences of rickets. By some such relation may be
explained the benefit which accrues in rickets from the administration
of the extract of thymus, as well as of the thyroid and the pituitary
body.

Enlargement of the lymphoid tissue in the wall of the alimentary canal
also occurs, and in those rings of adenoid tissue which mark the site
of the embryonic canals. This tissue may be seen around the origin
of the appendix, while its most conspicuous illustrations are seen
about the pharynx, where not only the faucial, but the lingual and the
pharyngeal tonsils are enlarged. In many of these cases there are the
so-called “adenoids” of the throat specialists, while, of still greater
interest to the surgeon, the deaths that have occurred from the status
lymphaticus have happened repeatedly in operations for these growths
within the nasopharynx. Furthermore, the yellow marrow of the bones
seems to be replaced by red marrow, but whether this is due to the
anemia which always accompanies the condition is not known.

Kaposi some years ago described under the name _lymphodermia
perniciosa_ a rare condition characterized by a scaly and itching
skin, exuding fluid, with later a diffuse and doughy condition of the
affected parts, and then by nodules which sometimes ulcerate, lymph
nodes and spleen being also enlarged, and the general health impaired.
While some have held that this is a variety of mycosis fungoides, it is
supposed that it is only another expression of lymphatism.

Another variety of this condition occurs in young people, in which
coma comes on suddenly, followed by death in twelve to eighteen hours.
Vomiting may occur during the coma, but it is convulsions and spasm of
the glottis that cause the death of the patient.

_Thymic asthma_ has been called _laryngismus stridulus_. Whether the
latter can ever occur without the former is not definitely known, but
doubtless the asthma is very frequently the cause of the obstruction
and the difficulty in breathing.

Medicolegal questions arise in this connection which are of interest.
Death occurs, except under anesthesia, after a series of convulsions,
yet it may happen almost instantly. Some claim that death may take
place as the result of pressure of an enlarged thymus upon the vessels,
and especially upon the nerves, while others claim it to be due to a
sudden arrest of heart action by reflex activity.

Convulsions of any character in adolescent individuals and young
children should raise a suspicion of this condition, and, of greater
importance for the surgeon, all possibility of existence of the
condition should be eliminated before operation is undertaken. Deaths
occurring during anesthesia are often attributable to the anesthetist;
nevertheless there are instances where he is absolutely blameless, and
where death may occur as by a flash of lightning.

It does not follow that chloroform is the agent at fault in these
cases, and opinion seems to trend in the direction of ascribing the
censure to the status itself rather than to the anesthetic used.
Deaths may occur at any stage of anesthesia, or some minutes after
the anesthetic has been stopped. It is significant that the most
conspicuous illustrations of the relations between the condition and
sudden death have occurred during operations upon the throat and nose.
This seems to show the role played by the adenoid tissue.

Another interesting question is why individuals with well-marked status
lymphaticus should live, apparently comfortable for years, and then
suddenly succumb from apparently trifling causes.

The relations between the thymus and the thyroid are unmistakable, yet
obscure. In perhaps one-half of the cases where the thymus is enlarged
the thyroid is also increased in size. When one is removed the other
seems to undergo more or less compensatory enlargement. This would seem
to indicate a species of interchangeable function. Much less has been
ascertained between the relations of either of these bodies and the
pituitary, while nothing has as yet appeared concerning any sympathetic
involvement of the coccygeal body or Luschka’s gland.


=Diagnosis.=--Recognition of the status lymphaticus during life is
somewhat difficult, nevertheless there are certain suggestive features
which should arouse suspicion. Of these the close relation between the
status lymphaticus and rickets, already alluded to, furnishes a hint,
and, when recognized, a positive warning. Widespread enlargement of the
lymph nodes may furnish another. Adenoid growths in the nasopharynx
accompanied by enlargement of the spleen should be regarded as a
suspicious combination; and when an area of dulness is discovered over
the thymus, or when it can be detected by palpation, the diagnosis
may be regarded as established. Moreover, children who are subject to
this condition usually have a pasty complexion and an anxious facies.
Besides showing evidences of rickets they are anemic, with liability
to spasm of the glottis. The thyroid is often enlarged. In young
adults the condition may simulate cretinism, in that they are retarded
in growth and infantile in appearance, while sexual development is
incomplete.


=Treatment.=--In well-marked instances of status lymphaticus there
should be ordinarily no operative intervention; yet when the nose
and pharynx are obstructed it is advisable to give free channels for
breathing purposes.

Assuming that the result of experimental injection of thymic juice
shows it to have a depressing and pressure-lowering effect, an effort
should be made to ward off danger by the use of adrenalin, which should
be given previous to the commencement of the anesthesia. These are
cases where it is best to treat the surfaces to be operated with a
spray of mild cocaine solution, in order to deaden liability to those
impressions which may produce secondary and reflex cardiac disturbances
if conveyed to the brain. When operation is necessary for glottic
spasm or laryngismus stridulus it may be commenced with a tracheotomy,
with the use of a long trachea tube. When operation is required for
the relief of thymic enlargement, a preliminary tracheotomy should be
made, with the use of a long tube. The improvement which results after
the completion of the surgical treatment, for instance after removing
adenoids from the nasopharynx, is gratifying.

The most reliable measures have proved to be adrenalin and artificial
respiration, used as described in the chapters on Blood Pressure and
Shock and Anesthetics.




CHAPTER XV.

SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND DISEASES.


As a result of the conditions which two centuries ago and more so
distinctly separated the barber surgeon from the practitioner of
medicine, there has been evolved an artificial separation of surgery
from so-called internal medicine. The consequence has been a more
or less deep-rooted feeling that medical cases were to be treated
exclusively by non-operative measures, and that surgical cases could
scarcely be expected to present any perplexities that were not to
be solved by an operating surgeon. It has been no small part of
the benefit resulting from modern teachings that these imaginary
boundaries and limitations have been swept away; and one of the
lessons which this text-book is intended to inculcate is that broad
principles underlie disease conditions, and that their bearings must be
appreciated thoroughly in order to practise either medicine or surgery
successfully. In order better to inculcate this teaching a chapter with
the above general heading has been inserted, in order to impress the
statement that any of the so-called internal diseases may present at
almost any time indications for distinctly surgical intervention.

Some of the surgical sequels of the exanthematous and continued
fevers are well known and commonly recognized: for example, _orchitis
following mumps_, _suppurative inflammation of the middle ear after
scarlatina_, _and bed-sores after typhus and typhoid_. These are easily
recognized. Moreover, scarlatiniform eruptions occasionally follow
various operations and give rise to great perplexity.[4]

  [4] Medical News, February 20, 1897, p. 234.


DYSENTERY.

Joint complications in this disease have been recognized from the
earliest times. One hundred and fifty years ago Strack expressed
himself thus: “If the dysenteric poison affect only the chest, it
causes asthma; if the limbs, it produces arthritis; if both, abscess.”

Joint pains and swellings, with other suppurations, have been noted in
several of the epidemics of this disease which have ravaged various
parts of the world at different times. Postdysenteric arthritis
may assume noticeable and even pyemic aspects, and is occasionally
fatal. The bones and joints may become involved in painful and even
suppurative swellings, not alone during the active stage of the
disease, but during the period of convalescence; while mildness of
the primary attack does not necessarily provide immunity from later
complications. Here thrombosis of large veins or thrombophlebitis are
also observed. When the joints are involved it is usually in irregular
order and not simultaneously. Joint lesion does not necessarily proceed
to suppuration, but perhaps only to the point of edema and fluid
exudation or hydrops. In the Cuban and South African campaigns, during
which dysentery prevailed, joint complications were noted.


CHOLERA.

Cholera is usually too rapid and too violent in its course to be
followed by secondary infections. Nevertheless, Poulet reports from
Val-de-Grace several instances of articular and osseous lesions, some
of these characterized by effusion of fluid which was sometimes very
thick and resembled balsam, while at other times pus was present.


PNEUMONIA.

Pneumonia having now taken its place as a distinct germ disease, and
the micrococcus of Fränkel and the capsule coccus of Friedländer
being well established as the active agents in the two principal
forms of this disease, pus may be found in other parts of the body.
The most common surgical sequels of pneumonia occur as postpneumonic
pyarthrosis, which has been wrongly considered a rheumatic affection.
These lesions are of embolic or of metastatic origin.


INFLUENZA, OR LA GRIPPE.

This disease has assumed prominence in medical literature, and not
a few instances have been reported of surgical sequels--abscesses,
purulent ear disease, pyarthrosis, bone lesions, etc. Even necrosis has
been repeatedly observed.


MEASLES AND SCARLATINA.

The infectious agent in these affections is not yet recognized and
their surgical sequels should be regarded as due to secondary pyogenic
infections.

Surgical tuberculosis appears often as a sequel of the exanthemas.
In the lymphatics, periosteum, bones, and joint cavities, and in and
about the eye and ear, manifestations of suppurative disease are often
found. It is believed that these sequels are likely to appear when the
eruption has been incomplete. Hyperplastic thickening of periosteum and
neuralgic pains of the affected parts occur without suppuration, hence
the rheumatic character which Bonnet and others have wrongly ascribed
to these manifestations.

While the absence of pus takes these out of the category of pyogenic
infections, it nevertheless leaves them still as surgical complications
which have often to be dealt with by mechanical measures, such as
orthopedic apparatus, etc.; while more or less formidable operations,
as for relief of ankylosis, have to be performed. Postscarlatinal
arthralgia may be explained as a local ischemia; so may acute swelling
or chronic thickening. But pus is an expression of infection, and
cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar
necrosis of the alveolar process of the jaws, described by Salter,
are among the various serious surgical complications of scarlatina.
Epiphyseal separations and purulent destruction of ribs have also been
noted.


TYPHOID FEVER.

Although in elaborate treatises, as by Liebermeister and Murchison,
there is no mention of bone and joint complications as sequels of
typhoid, they have, nevertheless, been recognized by surgeons.
Post-typhoid hip dislocations have been reported by several German
surgeons. Boyer observed spontaneous dislocation of both thighs after
what he called “essential fever,” and the general topic of spontaneous
luxations subsequent to typhoid has been frequently discussed.

Those affections of joints formerly considered rheumatic occur
much less often after typhoid than after dysentery. Nevertheless,
post-typhoidal arthralgia and myodynia have been recognized by several
French writers. Some with affected joints, supposed to be rheumatic,
have later been discovered to be suffering from genuine typhoid
fever, and it has been afterward recognized that the joint lesion was
a bizarre expression of the typhoid poisoning. The works on general
practice call attention to the frequent complications of the pleural
and pericardial serous membranes in this disease. They say little,
however, about the implications of the articular serous membranes,
though one is as easy to explain as the other. Post-typhoidal
polyarticular serous arthritis has been described by more than one
writer. Multiple joint abscesses have been rarely seen. Pus has been
known to collect not only in the joints, but also in the tendon sheaths
and bursæ. The lymph nodes are also frequently affected, and cervical,
axillary, and inguinal abscesses are not rare. Post-typhoidal
pyarthrosis, as leading to spontaneous luxation, has had a medicolegal
interest, for luxation has been known to occur while raising or lifting
a patient, the question of violence being subsequently brought into
court. When the joint disease assumes the mono-articular form it is
likely to terminate in suppuration; when polyarticular, pyarthrosis is
less common. In the pus from many of these abscesses typhoid bacilli
may be recognized, but by no means in all. The writer has found them in
a case of abscess in the abdominal wall occurring during convalescence
from typhoid in a young woman. A non-suppurative but painful form of
periostitis is occasionally observed. I have never seen more exquisite
tenderness nor expressions of suffering than I met in a case of this
kind in a boy in whom the bones of both lower extremities, of the
pelvis, and the lower spine were involved. The slightest jar upon the
floor would make him exclaim with pain, and to minister to his ordinary
wants was a distressing task. He eventually recovered without any pus
formation. Deep suppuration in bones occasionally occurs, and even
necrosis with separation of sequestra.

Thrombosis and thrombophlebitis are also well-known sequels of typhoid,
which may lead to unpleasant complications. Typhoid fever appears
to bear a peculiar relation to the growth of bones, as it has been
noticed that during its course, or during convalescence, they show an
extraordinarily rapid growth in length, even to the extent of 1 Mm. a
day. This is probably caused by the irritation of the typhoid toxin
upon the osteogenic tissue, since hyperemic areas have been found in
the bone-marrow of those dying of the disease, and bone pains are a
frequent accompaniment of the disease. Typhoid bacilli have the power
of remaining latent in the tissues for a long time after cessation of
active symptoms, and have been found alive and capable of active growth
seven months after cessation of the fever. Remembering the multiple
ulcers of the lymphoid tissue which characterize the intestinal lesions
of typhoid, it is difficult to explain pyogenic or other septic
infection by absorption through these open ports of entry; and the
typhoid bacilli themselves, entering the circulation through these
paths, may be carried to all parts of the body, and have been found in
the pia.

A large amount of interest has attached to the so-called “_surgery of
typhoid fever_,” which, however, has been permitted to include only
abdominal section for perforation of intestinal ulcers. The mortality
due to this accident is nearly 70 per cent.--_i. e._, is formidable.
It occurs generally during the third week. It is usually preceded by
leukocytosis, and is followed by profound shock. Operation offers
almost the only hope. It has been successful in about one out of five
cases. (See Surgery of the Intestines.)

Post-typhoidal infections of the _biliary and pancreatic ducts_, with
their resulting complications, play a conspicuous part in the etiology
of biliary obstruction. They are regarded as among the most common
causes of acute and chronic or latent disease in these passages.


DIPHTHERIA.

This also belongs to the diseases frequently complicated by lesions,
aside from those of laryngeal obstruction calling for surgical relief.
Abscess occurs so frequently as to scarcely call for comment. Here,
as in the cases of scarlatina, the location of the throat lesions
and the absorbing powers of the lymphadenoid tissue so completely
involved will readily account for all septic or pyogenic manifestations
at a distance. Multiple abscesses have been found in the liver, the
spleen, and lungs, in and around bones, betokening thereby a pyemic
manifestation. Infectious nephritis is also common.

Mann, of Denver, has communicated to me personally cases of embolus of
the femoral artery with resulting gangrene as sequels of diphtheria,
as well as instances of true diphtheria of the penis, established by
bacteriological diagnosis.


MUMPS.

The infectious character of this disease is not questioned, although
not definitely established. Orchitis, ovaritis, stomatitis, enlargement
of the tonsils and spleen, and albuminuria are frequent accompaniments
of the disease, while articular and peri-articular complications have
been noted. Bursal abscesses and pyarthroses have also been reported.
These surgical complications have been regarded as rheumatoid or
rheumatic, their essential significance not being recognized until
recently.


VARIOLA.

The writers of the earlier part of this century allude frequently to
the rheumatoid complications of smallpox, among which pyarthrosis
seemed the most common and most serious. The various arthropathies are
the most interesting of the surgical complications of this disease. The
joints become swollen, red, and painful, one joint after another being
involved.


INFECTIOUS ENDOCARDITIS.

The individuality of this condition has been recognized only within
the last thirty years. That it deserves the characterization of
“malignant” often given to it is well known. It is an infectious
disease with a special localization in the heart, the term _cardiac
typhus_ being very expressive. Although so apparently spontaneous,
it is usually a secondary lesion, sometimes a primary infection. The
arthritic manifestations often assume a pyemic character, and even at
the beginning of the affection, as Trousseau pointed out, there are
frequently severe joint pains.


DENTAL CARIES.

Nearly one hundred species of microörganisms from the mouth have been
studied and identified by W. D. Miller, who has clearly established
that dental caries is due to the specific action of some of these
parasites, which, gaining entrance into the dental tubules, determine
fermentation and acid production, with erosion of the dental structure
of the teeth and an increase in softening and destruction. In this
way the teeth, as already indicated in Chapter IV, become paths of
infection for germs which may travel but a short distance, causing only
local disturbance, or which may be carried to other points about the
head, producing disturbance in the antrum, in the neighboring bones,
in the middle ear, and not infrequently in the brain. Abscess in the
brain has been distinctly traced to caries of the teeth. Tuberculous
infection is also common through this channel, and its most common
expression is probably the invasion of the cervical lymphatics,
superficial and deep, constituting those lymphatic tumors of the neck,
formerly known as scrofulous, with their disastrous train of adhesions,
suppuration, erosion, etc.


SYPHILIS AND GONORRHEA.

These are surgical affections whose secondary complications in the way
of abscesses, infarcts, tumors, etc., have been dealt with in other
parts of this work. It will be well to group all of these infections
with anthrax, glanders, etc., into a class of infections which may be
followed by tardy or late surgical sequels that may call for more or
less radical operation. In the case of gonorrhea this is best seen,
perhaps, in the so-called pus tubes of the female pelvis, which often
require removal years after the date of the primary invasion.

Endocarditis and pyemia are occasionally of solely gonorrheal origin,
as well as peritonitis by extension from infected pelvic viscera.


THE PUERPERAL STATE.

This is seldom followed by surgical sequels, save in the instance
of mechanical lacerations demanding plastic repair, or of septic
infections, which, when life is saved, sometimes lead to disastrous
consequences. Puerperal septicemia is in no respect different,
pathologically speaking, from septicemia due to any other presumably
streptococcus invasion; and the predilection which streptococci
manifest for serous membranes, and especially joints, is well known.
Consequently after puerperal fever one may meet with articular or
peri-articular abscesses, affections of tendon sheaths, lymphatics,
etc., or the complication may assume a different type, the veins and
their contents being mainly involved, with thrombosis, infarct, etc.,
for its immediate results.

There is probably no disease of known or suspected germ origin which
may not be followed by disastrous or unexpected surgical complications,
while even degenerative changes, for which as yet no theory of
parasitism has been invoked, are followed by conditions which may
call for serious surgical measures. _In other words, the surgical
complications of any so-called non-surgical disease may loom up at any
moment in any case._




CHAPTER XVI.

POISONING BY ANIMALS AND PLANTS.


Certain poisons or deleterious substances are introduced in various
ways into the human system from without, some of which produce
only symptoms of moderate intensity, while others are fatal. It is
authentically stated that in India many thousands of individuals lose
their lives every year as the result of the bites of poisonous snakes.
In 1903 there were officially reported 23,164 deaths from this cause.
Nothing approaching such injuries in frequency or intensity can be
found in any other part of the world. Animal poisons may be introduced
by animals of many species. The poison of hydrophobia has been
described. The bites of the mammalia may be serious and may be followed
by septic symptoms, but are not ordinarily regarded as due to any
special toxin secreted by the animal. A number of reptiles, however,
possess special _poison glands_ which are connected, in most of them,
with a tooth on either side of the upper jaw which is canaliculated,
and serves as a duct through which the poison is injected when the
animal inflicts its bite.


SNAKE BITES.

The principal poisonous serpents in North America are the
_rattlesnakes_--of which there are several species, usually placed at
eighteen--the _copperheads_, the _moccasins_, and the _vipers_. Some
of these have movable poison fangs, some fixed. In other parts of the
world others equally or even more poisonous are known.

The poison gland is analogous to the parotid in location and structure.
The duct which runs through it is so dilated as to contain a small
amount of the peculiar poison. The amount of poison contained in these
reservoirs varies from eight to twelve minims, and is secreted somewhat
slowly. It seems to be, in some cases at least, a _glucoside_; in
others, a _toxalbumin_. It is capable of being preserved either dry
or in alcohol or in glycerin. The active poisonous principle seems to
pertain to a _globulin_ or to a _peptone_. Almost all of these venoms
are innocuous if swallowed, and like septic infections seem inoculable
only through the tissues and the circulating fluids. According to
Mitchell, the venom of the rattlesnake renders the blood incoagulable,
paralyzes the walls of the capillaries, and facilitates escape of
leukocytes into the tissues, thus making actual hemorrhagic swelling
occur; while the red corpuscles rapidly lose shape and fuse into
irregular masses and their hemoglobin is dissolved or disappears. This
poison seems to paralyze both the respiratory centre and the heart.
Cobra poison, not containing globulin, at least to a great extent, does
not produce the rapid changes of rattlesnake poison.


=Symptoms.=--A snake bite is like a hypodermic injection of a deadly
poison, and symptoms set in promptly. These are both local and general.
There is more or less local pain, with swelling and discoloration,
which are due to effusion of blood. They increase in intensity, and are
followed by vesication and necrosis of tissues--that is, gangrene--if
the patient survive for some time. Constitutional symptoms are not long
delayed, and are characterized by severe prostration, including cold,
clammy sweat; feeble and rapid pulse, irregular respiration, etc. When
patients succumb they usually die in collapse. The pathological changes
are not well-marked or characteristic.


=Treatment.=--Treatment of snake bite must be prompt if it is to be
successful. It should consist of incision and drainage of blood from
the part, in order to prevent diffusion into the rest of the body by
means of the returning blood and lymph. Bleeding should be facilitated
by cups or by sucking the wound. An elastic tourniquet should be
applied around the limb near the trunk, the site of the wound freely
incised, and the blood worked both ways toward the wound by “stripping”
the member. If there be any known antidote to snake poison it consists
of potassium permanganate or calcium hypochlorite (chloride of lime),
applied locally in solution, the former sufficiently strong to have a
marked color and capable of producing local irritation (1 per cent.).
With these local measures, constitutional stimulation should be
indulged by means of volatile and other stimulants. There is a popular
fallacy in favor of inducing alcoholic intoxication. To do this is
a mistake. Nevertheless, alcohol may be given freely, dosage being
limited not by amount but by effect. Strychnine, digitalis, atropine,
etc., will often prove serviceable. The tourniquet should be gradually
released after being in use for two or three hours, and an assistant
ready to antidote the poison which may then enter the system with
the necessary doses of stimulants above mentioned. One-half grain of
strychnine may be administered in divided doses, it apparently being
an antidote to the snake venom. There is much reason from recent
experimentation to expect benefit from serum therapy--_i. e._, by
injection of serum from immunized animals who have been fortified by
increasing doses of the snake poison. Calmette advises the use of 20
Cc. of serum from a horse which has been immunized by cobra poison. He
believes the active poison of all venomous serpents to be essentially
identical. Good results have been reported even after an interval of an
hour. In this country, however, such treatment will be called for so
seldom that there is not the hopeful outlook for the serum therapy of
snake bite that there is in India.


POISONING BY LIZARDS.

A large lizard found in the southwestern part of this country and in
Northern Mexico, known as the _Gila Monster_ (_Heloderma suspectum_),
is credited with being a poisonous animal. The probability is that the
bite is fatal to some of the lower animals and may produce more or less
serious disturbances in man. Nevertheless there is little real evidence
that this is to be considered in the same category with the venomous
serpents above mentioned.


POISONING BY SPIDERS AND SCORPIONS.

Certain species of _spiders_ are venomous, the _tarantula_ being
the best known. Certain _scorpions_ also inflict poisonous stings,
and _centipedes_ and other animals occasion at least serious local
disturbance by bites or stings. These insects and animals seldom
attack unless irritated or disturbed. Tarantula bites are occasionally
inflicted in the Northern States by spiders which have concealed
themselves in shipments of fruit, bunches of bananas being especially
likely to be their hiding places. The injuries inflicted by these
animal organisms cause local pain, considerable swelling, with remote
effects on the nervous system, prostration, restlessness, etc. They are
seldom fatal, but may cause annoyance and serious disturbance. These
cases are to be treated in the same way as bites of poisonous serpents,
adapting the measures and the energy of the treatment to the severity
of the symptoms.


POISONING BY WASPS, HORNETS, AND BEES.

_Wasps_, _hornets_, and _bees_ are capable of inflicting severe stings;
domestic insects, like _mosquitoes_, _bed-bugs_, etc., inflict minute
wounds which sometimes occasion excessive annoyance. Their sting is
followed by pain, burning sensation, sometimes intense itching, and
more or less swelling. Enough poison is deposited to produce local
vasomotor paralysis, as the result of which wheals resembling those
of urticaria, or more extensive swellings, quickly result. If the
sting of an insect has been broken off in the flesh it may remain and
intensify the disturbance. Two or three injuries of this kind create
local disturbance, but there are some instances on record where men
and animals have been stung to death when attacked by swarms of these
insects, death apparently being due to intensification of effect owing
to increased dosage of poison. If a sting occur upon loose tissues,
like the eyelid, or upon the tongue or lips, swelling and suffering may
be extreme. If symptoms of depression present, they should be combated
by stimulants, diffusible or other, and by hypodermic medication _pro
re nata_. Local discomfort may be alleviated by ice, by menthol, by
chloral camphor, etc.[5]

  [5] Oil of lavender is a pleasant means of local protection against
  mosquitoes, etc. Oil of tar is also in common use. A mixture of equal
  parts of camphor and chloral, with menthol dissolved in the mixture
  (camphor and chloral when mixed without other ingredients quickly
  form a dense fluid like glycerin), gives great local relief from the
  itching and pain of insect bites.

_Many of the lower forms of marine animals_ are capable of inflicting
stings by their rays, or minute injuries in other ways, which give
rise to great temporary annoyance. The _stinging nettle_, etc., is an
instance of this kind. The lesions produced in this way partake of the
nature of a more or less acute dermatitis.


ARROW POISON.

The _arrow poison_ of various Indian and savage tribes is a composition
of variable and usually unknown nature. It is compounded, for the
most part, from vegetable substances, and, if one may judge from the
specimens of _curare_ sold by importing houses, their strength is
unreliable.

While some of these preparations are made by the natives from a species
of Strychnos growing in the northern part of South America, this tree
is not in universal use for this purpose: in the East Indies they are
made from a species of Upas (the deadly Upas of song and story). Some
of the poisoned arrows are dipped in putrefying blood. A wound made
by these is not necessarily promptly fatal, but would tend to kill by
setting up septic disturbance. The vegetable poisons have the property
of paralyzing the motor nerves and the circulation to such an extent
that death may occur within a few moments after injury. All of these
poisons are innocuous when swallowed, and game killed by their agency
may be eaten without fear of ill results. Arrow poison of the vegetable
variety which is not fatal within a few hours may be recovered from if
stimulation be vigorous. Artificial respiration is a factor in keeping
such patients alive.


IVY POISONING.

_In the vegetable kingdom_ there is one kind of plant, the so-called
_poison ivy_ (_Rhus toxicodendron_), which is capable of producing
intense dermatitis. All persons are not susceptible to this
poison--least so those of thick skin and dark hair. It is generally
those of blonde type and thin skin who seem most liable to its
irritation.

The active agent is _toxicodendric acid_, and it is capable of setting
up an intense irritation of the eczematous type, with a large amount
of hyperemia and edema, especially of soft tissues. When the face is
involved the eyelids become puffed so as to make it almost impossible
to separate them for purposes of vision. _Ivy poisoning_ is usually
contracted by contact with the plant. Symptoms supervene generally
within twenty-four hours, and in well-marked cases do not subside for
three or four days. The itching is intolerable, and is best combated by
strong alkaline solutions or brine. A dilute bromine solution sometimes
proves beneficial. Salt and soda in strong solution and vigorous
catharsis are also useful. Hypodermic injections may be necessary to
induce sleep.

Certain species of _sumach_, particularly the genus Cypripedium, may
produce similar symptoms, usually less severe.




CHAPTER XVII.

ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS.


DELIRIUM TREMENS.

Delirium tremens as an expression of acute or subacute alcoholic
poisoning is in no essential degree a surgical condition. This form
of toxic delirium may occur while the individual is still drinking
inordinately, or not until several days have elapsed after active
drinking has ceased. It is precipitated in many cases, where otherwise
it would simply remain imminent, by surgical injuries and operations.
In one in whom it is feared, the surgeon should become apprehensive in
proportion as the muscular system becomes unsteady and tremulous, the
mind disturbed, and the individual sleepless.

Patients in a well-marked condition of delirium tremens may become
so uncontrollable and so lost to sensation of pain that it may be
practically impossible to enforce the physiological rest which their
surgical condition demands. The restraining sheet will answer for
general purposes, but the strait-jacket and even the most carefully
applied plaster splint or mechanical restraint will not always be
sufficient to carry out the indication.

Ingenuity may be taxed beyond its limit to enforce the needed rest, for
patients will tear off bandages and injure themselves in various ways.


=Treatment.=--The _local indications_ are in the direction of
_physiological rest_. _Constitutionally_ the indications are in two
directions: First, _to keep up nutrition_ and _excretion_; secondly,
_to properly medicate_. Nutrition is difficult unless excretion is
maintained. Hot-air baths, laxative enemas, preferably of cold water,
when necessary, and administration of a fluid and easily assimilable
diet are measures of the utmost importance. Should the case present
features of an acute alcoholic gastritis, stomach feeding may be
abandoned and the rectum utilized for this purpose. _Medication_
should consist mostly of stimulants, with such sedatives, laxatives,
diuretics, etc., as may be necessary. In surgical cases it is not wise
to abruptly deprive these patients of the alcohol which they have so
abused. Consequently in many instances a mild degree of alcoholic
stimulation, at least for a time, should be continued. Two stimulants
rank higher than all others as substitutes for alcohol, and in some
degree antidotes to its effect. These are _strychnine_ and _digitalis_.
The former should be given preferably subcutaneously; the latter by the
stomach if tolerated, otherwise by the rectum or beneath the skin. My
own preference for the use of digitalis is in the direction of large
and few doses. I have not hesitated in many instances to give 15 Cc.
of ordinary tincture, repeated once or twice at intervals of a few
hours, and then to discontinue it. The effect is to brace up the heart
and to equalize the circulation, while at the same time it acts as an
efficient diuretic. _Adrenalin_ may be necessary, but should be used
with discrimination.

Of the sedatives, bromides, chloral, and remedies of that class are
those most often resorted to, and should be given in doses sufficient
to meet the symptoms. They are all more or less depressant, and
stimulation by strychnine, etc., is necessary even while they are being
administered, in spite of the apparent physiological antagonism between
them. Opium is the remedy of choice, and is best given in the form of
morphine introduced beneath the skin.

The first indication is in the direction of ensuring rest and sleep,
even at the expense of inconvenience or misfortune in other directions.
I write this with a realizing sense of its significance, yet with
positive conviction as to its truth.

Upon the assumption that this form of delirium is a toxemia of
complicated type, only benefit can accrue, in aggravated cases, from a
free venesection, followed by intravenous infusion of a pint or more of
saline solution, at a temperature of 105° F.


TRAUMATIC OR POSTOPERATIVE MANIA.

It is difficult to distinguish this form of mania from that known
as _puerperal mania_, the two conditions being essentially similar.
This, too, is to be regarded as a complicated toxemia, in which
products of defective metabolism, of insufficient elimination, and of
phagocytic activity mingle in a blood whose corpuscular elements are
already much disturbed by injury or hemorrhage. Regarding these cases
from a surgeon’s standpoint, and carefully avoiding any attempt at
minute explanation of the phenomena, such cases are met with in the
practice of operating surgeons, as in the experience of obstetricians,
presenting themselves either as mild forms of harmless mental
aberration, or assuming almost any of the types of insanity as made
out and classified by experts in that subject. From the mildest mental
alienation up to intense and even homicidal or suicidal mania, one may
meet with all degrees of departure from the normal standard. Bowel
washing, hot-air baths, hepatic stimulants, and carefully regulated
nutrition will usually restore to the brain its natural food supply,
and hence its normal function. I have repeatedly seen much good result
from the exhibition of small doses (0.30 to 0.50) of potassium iodide.


TOXIC ANTISEPTICS.

As stated above, it is generally recognized that in people of peculiar
idiosyncrasies the administration of certain drugs ordinarily
considered harmless is followed by more or less toxic symptoms.
Obviously if this were universally the case, or true in the majority of
instances, the use of these drugs would speedily be abandoned. As it
is, it is well to have in mind the consequences which are occasionally
known to ensue, and perhaps to weigh in every case the chances as to
whether it is worth while to use a given substance of known occasional
toxic power as against another which is not known to possess it.

Of the less active antiseptic agents, _boric acid_ is considered
absolutely innocuous, yet is known sometimes to cause intestinal
disturbance, while in one instance serious toxic effects followed its
use. _Naphthalin_ will sometimes produce vertigo or vasomotor symptoms,
especially when administered internally. Many of the antiseptic
materials used are more or less irritating to the skin, and such local
expressions as _eczema_, etc., provoke little comment.

_Iodine_ is a drug whose activity should be borne in mind. Applied
upon the surface, it tans the skin and does no good. Injected in
solutions of varying strength into serous cavities (for example,
hydroceles, etc.) it gives rise to symptoms which may be alarming.
Fatal poisoning following its injection into an ovarian cyst has been
reported, and alarming symptoms have been produced by injection of the
ordinary solution into a hydrocele sac. Much of the virtue ascribed
to _iodoform_ is credited to the liberation of free iodine by its
decomposition. Whether or not this be true, iodoform is one of the
most frequently toxic of the antiseptic agents in ordinary use. In
mild cases it produces headache, restlessness, wakefulness, and often
a distinct taste of iodoform in the mouth. In more pronounced degrees
of poisoning there is fever, often with mental derangement which may
amount to delirium or even to acute mania, and may cause well-founded
suspicion of meningitis. Death after its use has repeatedly occurred
from syncope or in coma.

_Carbolic acid_ produces unpleasant effects, both upon patient and
operator, or with whoever it may come in contact. Aside from its local
effect upon the skin, which is most unpleasant, but which usually
passes away within a few hours, it seems to affect especially the
kidneys, causing often temporary albuminuria with discolored urine,
deranged secretion, and sometimes more acute forms of disturbance,
similar to those met with after its internal use. Carbolic poisoning
was observed most frequently during the era when Lister’s original
directions were scrupulously followed, and at a time before it was
learned that it is much better to remove dirt than to try to antagonize
its action. Eminent surgeons were compelled to discontinue its use
because of its unpleasant effect upon themselves as well as upon their
patients.

Among the powerful antiseptic agents in common use are the soluble
preparations of _mercury_, ordinarily _corrosive sublimate_, in
solutions of varying strength, which are used for irrigation,
douching, etc., and for preparation of dressings. An intense eczema
may follow its local use, and symptoms of mercurial poisoning may
appear in individuals of peculiar susceptibility to this drug.
Salivation, intestinal irritation, and other phenomena of mercurial
poisoning have been produced, with the result that the solutions and
preparations of corrosive sublimate are much weaker than those which
were used at first. The drug eczema produced by _corrosive sublimate_
interferes with one of the essentials of ideal wound healing--_i.
e._, physiological rest. The area involved should be protected with a
sterilized powder or by anointing it with sterilized ointment.




PART III.

SURGICAL PRINCIPLES, METHODS AND MINOR PROCEDURES.




CHAPTER XVIII.

DISTURBANCES OF BLOOD PRESSURE; SHOCK AND COLLAPSE.


The maintenance of the normal pressure of the blood is a material
factor in the welfare of surgical cases. Deviations in the direction of
lowered pressure constitute the most important features of _shock_ and
_collapse_. Prevention of loss of blood is but one of several complex
indications in prophylaxis and after-treatment.

Blood pressure is maintained in large part by the vasomotor system
of nerves, whose prime centre is in the gray matter of the fourth
ventricle, with subsidiary centres in the spinal cord and great
ganglia. Stimulation of these centres causes contraction of the
peripheral arterioles and increases intravascular pressure. If,
however, it be long-continued or excessive, these centres become
exhausted, vasomotor paralysis results, the arterioles dilate, and
pressure is lowered.

Three factors coöperate to maintain this pressure:

  1. Regular and normal rhythmic heart action;

  2. Normal vascular contractility;

  3. Normal quantity of suitable fluid in the vascular system.

Departure from the normal in any one of these factors causes
perceptible disturbance, but when in all three of them it may prove
fatal. Whether this be caused by emotion, accidental injury, or
deliberate operation is of slight concern, as the effect is essentially
the same.

The pulse will usually tell its own story to the experienced observer,
but scientific accuracy in measuring blood pressure can only be
obtained by certain instruments of precision, such as the _tonometer_
or the _sphygmomanometer_, consisting of an air-containing armlet
which encircles the arm, a bulb by which the pressure of air can be
regulated, and the whole connected with a manometric gauge and mercury
tube. These instruments can be procured of the dealers, and their
employment during an operation gives the operator a continuous record
of the blood pressure, by which he may judge at any moment of the
degree of shock.

The normal blood pressure in healthy adults is 130 to 140 Mm. of
mercury in the tube. In children it ranges from 90 to 110 Mm. Females
have an average lower pressure of 10 Mm.

Excitement or slight stimuli will send the pressure up thirty or forty
points. It is also higher than the above average in arteriosclerosis.
In uremia it is always high. In cases of intracranial tension it is
also high, as the brain alone of all the organs of the body has no
complete vasomotor apparatus of its own; when it needs more blood this
has to be contributed from the general supply. When pressed upon by a
clot, depressed bone, or foreign body it becomes anemic, and on effort
to furnish the needed blood from other parts the vascular tonus is
increased. Cushing has shown the value of these estimations in cases
of _head injury_, for the rise of blood pressure may be regarded as an
indication for operation. In typhoid fever a sudden rise of pressure is
associated with perforation, or perhaps with the peritonitis which is
its immediate result. On the other hand, in this disease a sudden fall
of pressure is an indication of hemorrhage.

The course of events in surgical shock is about as follows: Injury to
afferent sensory nerves acts as a vasomotor stimulus after it reaches
the centre in the fourth ventricle; a reflex impulse is then sent out
which produces arterial contraction and raises the blood pressure.
When the abdomen is concerned the opening and handling of its contents
produce the same result through the splanchnic centres. If, however,
the stimulus is excessive, too often repeated, or too prolonged the
vasomotor grip is lost, the arterioles dilate, and the blood pressure
is reduced. A severe injury to any part of the body may produce this
effect without the preliminary rise. The popular impression that a
patient “bleeds to death into his own veins” has this to justify
itself, that the arterial tonus is lost and the blood is pumped through
the arterioles to accumulate in the capillaries and veins, especially
the abdominal, thus overloading the right side of the heart and giving
it a disproportionate amount of work.

Accompanying these circulatory disturbances are others, secondary and
unavoidable, as of respiration, which becomes rapid and enfeebled in
proportion to the degree of shock.

Any factor which tends to weaken the heart’s force favors both
phenomena. So important is the respiratory action that patients die
from cessation of respiration rather than from impairment of the
circulation. This shows the importance of maintaining artificial
respiration in cases of severe shock.

Cushing and Crile have studied the subject exhaustively in animals.
They have shown that certain injuries are likely to be followed by
well-marked reduction of blood pressure; for example, those of the
brain, the interior of the larynx, the abdomen and testicle, are often
followed by a marked reduction of pressure without any preliminary
rise. In other words, vasomotor paralysis is sometimes an almost
instantaneous effect of certain injuries. When most of the blood is
collected in the venous system and the central nervous system fails,
because of lack of blood supply, to respond to those normal stimuli
which are essential to heart action and respiration, the heart weakness
or heart failure is due, not alone to failure of its innervation, but
to its reduced output and its diminished content of blood on the left
side.

Crile has shown that the more abundant the blood supply to a given part
the more it contributes to production of shock; hence, the value of
cocainizing the interior of the larynx and the nerve trunks.

Aside from emotional causes--which are sometimes inseparable from even
surgical cases--the principal agencies in the production of surgical
shock and collapse are those which make a sudden and deep impression
through the medium of the sensory nerves upon the central nervous
system or the large sympathetic ganglia; ultimately upon the latter in
all serious cases. _Loss of blood, then, need not play a very important
role._

Weakened, anemic, or neurotic patients are predisposed by virtue
of these conditions, and also the young and aged. Fright combined
with injury increases the degree of the effect. Crile has shown that
trifling lesions of the interior of the larynx will cause symptoms
which do not occur in animals if the superior laryngeal nerves be
divided or if the parts be cocainized.

The upper portions of the abdomen are more sensitive in this respect
than are the lower, testicles particularly. The skin is more
impressible than the muscles or tissues beneath, save the nerve trunks,
which are very sensitive; the bones and large joints slightly so. After
shock has been once produced further injury causes a disproportionate
lowering of blood pressure.

So-called “concussion of the brain” is essentially a condition of
shock following injury to this particular part of the body. (See Head
Injuries.)

_Shock and hemorrhage are often closely associated_, and loss of
blood is doubtless a powerful factor in the production of the former,
especially in those already reduced or whose blood contains a lowered
percentage of hemoglobin. There are, therefore, great advantages in
entrusting an assistant with the duty of watching blood pressure during
serious operations.

The terms _shock_ and _collapse_ are nearly interchangeable, but, by
common consent, the latter is usually the name given to conditions that
are more sudden and overwhelming. Shock may be of all degrees--from
temporary faintness, from which the patient recovers within a few
moments, up to a condition of vital depression which terminates
fatally, there being no reaction in spite of all efforts to produce it.


=Symptoms.=--These vary to a considerable extent according as the
patient is or is not under a general anesthetic. The description of
_types_ and _symptoms_ includes an expressionless face, pallor of the
skin and mucous membranes, with corresponding coldness of the same,
_i. e._, reduction of surface circulation and heat; dilated pupils,
reacting slowly to light; irregularity of the heart’s action, with a
weak, irregular, thready, or almost imperceptible pulse; irregular
respiration, _i. e._, irregular both in rate and depth; mental
inactivity and apathy; loss of voluntary muscle movement; impairment of
superficial sensibility; reduction of body temperature; and nausea or
actual vomiting. These at least constitute the symptoms and form the
apathetic or torpid type of shock.

In the so-called erethistic type (Travers) the patients are restless
and excited, uncontrollable, with irregular pulse and breathing, often
with dilated pupils.

In a third type, described by Travers as the _delayed_, the symptoms
are as above detailed, but do not appear until some hours after the
cause which has produced them, which may be a concealed (internal)
hemorrhage. The delayed type is also seen in those who escape serious
accident with a minimum of physical harm.

As shock becomes more pronounced, mental depression deepens into coma,
or mental excitement subsides into it; the surface becomes colder and
bathed with perspiration, and death follows. These symptoms are those
generally noted, whether following injury to the head and denoting
so-called concussion of the brain, loss of blood, wound of the
abdomen with injury to the viscera, blows upon the testicles, gunshot
wounds or other accidents which are causes of shock. They follow also
after perforation of the bowel, as in typhoid fever or appendicitis;
depression following the receipt of bad news, or fright, etc.; in other
words, the physical condition is practically the same no matter what
the exciting cause.


=Diagnosis.=--Shock is mainly to be diagnosticated from fat embolism;
concealed hemorrhage as well as pulmonary edema and suppression of
urine are to be suspected. It is unquestionable that many patients have
died of fat embolism in whom the actual cause of death has not been
ascertained, yet has been ascribed to shock. (See Fat Embolism, Chapter
II.)


=Treatment.=--The treatment of shock consists essentially in measures
directed toward raising the lowered blood pressure. At the outset
reaction should not be established too quickly, lest it be succeeded
by overaction, with attendant disasters in the shape of secondary
hemorrhage, etc. Patients should not be expected to swallow nor act
as they would under other circumstances. They should not drink strong
liquors, for the irritating fluid may escape into the larynx and induce
coughing, which might prove fatal. The same is true of inhalations of
strong volatile stimulants, like ammonia. These measures, therefore,
should all be resorted to with great care and discretion. Warm,
stimulating drinks, if they can be swallowed, are useful; and whisky,
brandy, etc., should be given dilute and warm rather than strong and
cold. External heat is advisable, and can be supplied by immersing
the patient in a bath-tub of warm water, care being taken to keep the
face out of the water. When this is not at hand, bottles and other
receptacles for warm water may be used, but with caution, since too
much heat has been the cause of serious burns.

Numerous drugs have been recommended in the treatment of shock.
There are but two or three which are worthy of confidence. Crile, of
Cleveland, subjected a large number of animals to tests in regard to
the effect of various drugs in influencing blood pressure. He found,
for example, that alcohol apparently produces more depression, and
in deep shock is dangerous. Nitroglycerin and amyl nitrite seem to
increase shock and lower pressure. Digitalis may produce a temporary
rise in pressure, but in considerable doses impairs or arrests
respiration, and it seemed to him that cases of severe shock treated
with it did not live as long as the control animals. Strychnine has
been one of the main reliances in these conditions. Crile found that if
enough were given to cause increased excitability of the spinal cord it
raised the blood pressure, while small doses had little or no effect.
Pressure was raised by doses large enough to produce convulsions;
repeated smaller doses had little effect, tending rather to increase
shock.

These were the experimental results in the treatment of shock, and are
to be distinguished from what may be done with the same drugs in the
way of fortification and preparation as against shock. Thus strychnine
always exalts susceptibility of the cord of the medulla and digitalis
may temporarily supplement its use; together they may help to sustain
pressure or to fortify as against depressing agencies. They are like
whip or spur to a jaded horse.

Morphine alone, or in combination with ether as a general anesthetic,
reduces susceptibility to shock, and appears to be an equalizer of
pressure and a tranquillizer of an excited heart. Nitroglycerin and
the nitrites usually fail to raise or even sustain pressure. _Saline
infusion_ and _adrenalin_ are the _reliable and efficient means_ to
be used in combating shock and collapse; _they always raise blood
pressure_, and the latter is the most powerful of all known vasomotor
constrictors. Adrenalin always produces rise of blood pressure,
even after cocainization of the medulla and cord or destruction of
the medulla, division of the splanchnics, or arrest of the heart by
powerful electrical currents (2300 volts, alternating). Even after
death by decapitation and an interval of fifteen minutes, adrenalin
salt solution thrown into the veins causes a rise of blood pressure.
If this be combined with artificial respiration and rhythmic pressure
over the heart, resuscitation is possible in most extreme cases. In one
case, reported by Crile, a human heart which had stopped beating for
nine minutes was made to resume its pulsation for thirty-two minutes.
From all this it will appear that the heart stimulants, so called, have
a very limited applicability.

Crile further experimented by raising the atmospheric pressure
surrounding the animal, and found that blood pressure was somewhat
exalted. The reverse was also found to be true. When he so arranged his
experiment that an animal inhaled air under increased pressure he found
the tendency was rather to impairment of heart action, blocking the
circulation and reducing pressure. Changing the experiment and causing
the animal to breathe air at normal pressure while the body was under
increased atmospheric pressure, blood pressure was notably raised, but
respiration became labored and the heart’s action impaired. After death
the heart and the pulmonary vessels were found engorged.

This has its practical interest because it concerns not alone the
general treatment of shock, but the management of those cases where
the thorax must be opened, as in the surgery of the heart, the lungs,
the esophagus, etc., and the mechanical devices recently suggested
for maintaining differences of atmospheric pressure, and preventing a
traumatic collapse of the lungs.

These experiments also suggested the so-called “_pneumatic suit_”
devised by Dr. Crile, which is in effect a double-layered garment
of rubber cloth. The patient is enveloped in the suit, which can be
inflated with an ordinary bicycle pump, so that pressure is made upon
the surface of the body, and at the same time evenly distributed.
By such pressure accumulation of blood in the venous reservoirs is
prevented, and the emptying of the arteries, especially those in the
brain, is prevented. This is a more perfect and ideal application of
the idea underlying the practice of _bandaging the extremities_ or
raising them, in extreme conditions of shock; the former requires an
elaborate and expensive outfit, while for the latter purpose cotton
bandages or rubber may suffice. The latter, however, must be used with
great caution lest pressure be overdone. When the bandages are removed
they should be taken off slowly, and from one limb at a time, lest the
change be too abrupt.

Two other expedients are of the greatest value in conditions of
this kind; the first is _artificial respiration_. This cannot be
carried out, as is done on experimental animals, in a well-furnished
laboratory, by opening the trachea and making connection with a pump;
it must be effected by the usual methods, coupled with the aid afforded
by the improved Fell apparatus. If oxygen can be administered at the
same time it will enhance the effect.

The second expedient is _rhythmic pressure_ made over the lower part
of the thorax, or beneath the ribs, by which is produced a stimulus to
contraction of the heart. This may be made slowly at first, but may
approximate a rate corresponding to a slow pulse.

The temptation is to use the adrenalin solution too strong or in too
large doses. It may be administered in doses of 4 or 5 minims in a
small syringeful of salt solution, but when the symptoms are profound
and the case urgent, 300 to 500 Cc. of sterilized salt solution,
containing the same amount, should be injected beneath the skin into
the subcutaneous cellular tissue about the shoulder-blade, the buttock,
behind the breast, or into a convenient vein. Much larger amounts, even
up to 1000 Cc., may be used, but the adrenalin should never be mixed
until just before using it, as it is quickly oxidized and changed, and
should be used in the freshest possible condition. With salt solution
containing 1 to 50,000 of adrenalin and continuously administered,
Crile has kept a decapitated dog alive for over ten hours--that is,
the heart continued its action. One may agree with him, then, in the
statement that “_control of blood pressure is the control of life
itself_.”

Mathews, after a careful study of the osmotic behavior of blood plasma
and saline solutions, has shown that the ordinary salt solution, which
has been usually made in proportion of 6 to 1000, is not the best which
can be used for purposes of saline infusion. Many observers have added
potassium and calcium salts to such a mixture, the latter, especially,
because of its property of increasing the coagulability of the blood.

The following mixture meets the indications for what may be called
the “balanced” physiological solution: Sodium chloride 0.9, potassium
chloride 0.03, calcium chloride 0.02, water 100.[6]

  [6] To the fluid for hypodermoclysis (salt solution) there may be
  added a proportion of grape sugar, by which much is gained of true
  nutritive value, which may be enhanced by the addition of pure
  pepsin peptone free from albumose. Thus if every four hours there
  be injected beneath the skin 100 Cc. of water containing 2 grams
  each of grape sugar and table salt to 4 grams of pepsin peptone,
  the necessity for further nourishment may be almost obviated, at
  least for a period of two or three days at a time; as for instance
  when intense nausea of severe peritonitis prevents the ingestion of
  anything possessing food value. Credé recommends for the same purpose
  a preparation containing soluble albumin in the strength of 95 per
  cent., with traces of iron and salt. This preparation is called by
  him kalodol, and much resembles blood albumin, which is why it is so
  easily assimilated. According to Credé, four injections of kalodol a
  day will suffice for ordinary needs.

It must not be forgotten that indiscriminate resort to intravenous
infusion may do great harm. It is a minor procedure which requires
skill. When the lungs are congested from the irritating effect of
ether, and the right heart is embarrassed, a too sudden flushing with
saline solution may further embarrass it or even check its activity. So
with a patient in the Trendelenburg posture, the intestines are crowded
up against the diaphragm and its natural downward play impeded, though
the brain is better supplied with blood in this than in any other
position.

Much may be done in the way of _prevention_ when shock can be foreseen.
This includes the general fortification of the patient by overcoming
any auto-intoxication which may have been previously noticed, by
improving elimination, and by stimulating the heart’s action with
strychnine, digitalis, cactus, etc. Atropine is especially a stimulant
to the respiratory centres.

Once the operation is begun, and remembering that the depressing
influences which tend to reduce blood pressure are transmitted through
the afferent nerves, we may take advantage of Crile’s suggestions and
temporarily paralyze them, by exposing them and injecting directly
into the nerve trunks two or three drops of 1 per cent. cocaine
solution. This should be done before division of the main trunks
and at a point above the line of section. It is possible during an
amputation, by taking a little extra time and pains, to “block off,” as
it is called, the nerves in this way and prevent their conveying any
depressing sensation. At other times, as in operations on the mouth,
and especially the larynx, cocaine solution may be used locally, as
by the spray, and the same effect produced. Cocaine seems to be a
protoplasmatic poison which inhibits nerve action.

In the description of the treatment of shock there has been little
reference made to the result of loss of blood as such. In cases where
this has already occurred, or cannot be prevented, it should be
atoned for by the infusion of saline solution, either by intravenous
introduction or by hypodermoclysis, _i. e._, its injection into the
loose connective tissues in various parts of the body. While a special
apparatus has been devised for this purpose, a sterile fountain syringe
with an ordinary aspirator needle will be found to be sufficient for
nearly all purposes.

The erethistic, or extremely restless type of shock, may be profitably
treated by small doses of morphine given subcutaneously.

The _question of immediate operation or delay_ should be carefully
considered. Shock is often alleviated by prompt removal of mutilated
limbs or parts whose fragments, while still connected with the trunk,
seem rather to perpetuate the condition, especially if the principal
nerve trunks are cocainized. In serious cases intravenous infusion
should be practised.

After commencing with the anesthetic, while scrubbing and cleansing
the field of operation it is advisable to scrub an arm where it may
be necessary to expose a vein, or the skin at several points, where a
needle may be entered, so that there may be no delay for this purpose
should infusion or hypodermoclysis be suddenly required.




CHAPTER XIX.

ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS; TRANSFUSION;
CATHETERIZATION; SKIN GRAFTING; BANDAGING.


Abstraction of blood, usually of venous blood, known as venesection,
was a practice frequently indulged in years ago. At one time in the
history of medicine it seemed to be the measure regarded as a panacea
for all ills. The reaction from the period of excessive bloodletting
came during the previous century, and was so strong that the practice
was for a generation or so almost abandoned. The eminent surgeon S. D.
Gross wrote a paper entitled “Bleeding as a Lost Art.” Bloodletting is
an expedient of great value in a somewhat restricted class of cases,
but is capable of affording such relief in certain emergencies that
practitioners should be ready to resort to it at any moment when it may
be required.

After removal of a certain amount of fluid blood pressure is naturally
reduced and at the same time equalized, while when the right side of
the heart is overburdened with its task it is thus made to beat more
easily and regularly; thus indirectly there may be brought about a
subsidence of violent heart effort, a reduction of the respiration
rate, a lowering of temperature, and sometimes a diminution in the
activity of morbid processes which may be beneficial, and even
life-saving. Even after moderate bleeding, say a half-pint, the amount
of urine is increased and the proportion of solids raised. More air is
taken into the lungs, and oxygenation is thereby much improved.

The indications for venesection are:

  Excessive vascular tension.

  Intensity of pathological tissue activity which is leading to serious
  disturbances.

  The removal of a certain proportion of toxic material from the blood.

There may be added later the introduction of balanced physiological
salt solution as recommended in the treatment of shock, and of some of
the acute toxemias, _e. g._, delirium tremens.

The effect on an embarrassed and overfilled right heart of the
abstraction of blood is prompt. Nowhere is this more conspicuous than
in the early stages of pneumonia, and in some cases of heart failure
during administration of an anesthetic where a dilated heart seems
to become so overfilled as to be unable to empty itself. In profound
uremia, especially in puerperal eclampsia, the relief afforded by it is
usually immediate and permanent.


VENESECTION.

The question of the amount of blood to be withdrawn must be settled
at the time and for each individual case. The pulse is watched, as
well as the patient’s face; the best indications when to cease being
noted in this way. From 500 to 1000 Cc. may be removed according to
the condition of the patient and the degree of emergency. While the
operation is a trifling one, it should, nevertheless, be performed
with strict aseptic precautions. One of the veins at the bend of the
elbow, usually in the left arm, is commonly chosen, although in rare
instances, when there is intense cerebral venous congestion, the
external jugular may be selected. At the elbow the median basilic vein
crosses the brachial artery, being separated from it only by a thin
prolongation of the biceps tendon. It was especially in opening this
vein at this point with the old-fashioned lancet, which was plunged
perpendicularly to the surface and directly into the vein, that injury
to the artery occasionally occurred, thus leading to varicose aneurysms
and aneurysmal varices.

The skin should be thoroughly cleansed; a reasonably tight constriction
is made about the middle of the arm by a bandage, not so tight as
to completely occlude the radial pulse; the arm is allowed to hang
downward and the patient encouraged to grip some object in order to
better fill the vein. This soon becomes prominent, after which an
oblique incision is made through the skin above it, so that the vessel
itself is exposed. Then with a sharp bistoury the external surface
of the vein is pricked with the point, and a cut made outward. The
opening in the skin should be free; the skin may be frozen, or in very
sensitive patients local anesthesia may be first produced with cocaine.
By tightening and releasing the grasp, that is by closing and opening
the hand, the flow of blood may be hastened. When it is time to cease,
the bandage should be removed and an aseptic pad be applied over the
site of the wound, suitable pressure being made, and the arm kept at
rest for two or three days.

When the jugular or some other vein is selected the procedure is
essentially the same.


=Arteriotomy.=--Arteriotomy, or the opening of an artery for
bloodletting purposes, is resorted to only in rare instances, and
in an emergency. The temporal artery is the one usually selected
because of its accessibility and the ease with which its outflow can
be controlled. Its position is determined by its pulsation; it should
then be exposed by incision through the skin, and opened exactly as is
a vein, _not cut through_, lest it retract and furnish an insufficient
amount of blood. It should, however, be divided and tied before
application of the dressings.


=Cupping.=--By the application of “cups,” blood is drawn to the
surface, but ordinarily not abstracted, unless the surfaces have
been previously scarified or incised. _Dry cupping_ has the effect
of attracting blood to one portion of the body, thus drawing it
from another and congested part. It has the temporary effect of a
venesection. Cupping glasses are small tumblers which are rinsed in
alcohol; their edges are wiped and the remaining film within the
glass is ignited from a candle or flame. The glass is then instantly
applied to the affected area. The oxygen within the contained air is
sufficiently consumed to create a slight vacuum and the skin quickly
becomes congested, being sucked upward into the glass. These cups may
be allowed to remain for a few moments, or until they drop off. Care
should be exercised with alcohol and a lighted lamp around a patient
who may be unconscious or excitable, as serious burns have followed
carelessness in this regard. Small vacuum pumps, like the Allen
surgical pump, have been provided for this purpose, and give very
satisfactory results.

There was formerly employed for the purpose of _wet cupping_ a small
spring instrument, containing several sharp knives, by which a series
of incisions were made in order that blood might be drawn. This
instrument cannot be kept clean and is not used at present. When wet
cupping is desired the part should be scarified with a sharp knife and
the cup applied as above.


=Leeching.=--Leeches figure largely in literature of the past, but are
not often used, although they may be made effective, especially when
applied behind the ears in cases of cerebral congestion. The American
leech can be relied on only to abstract about a teaspoonful of blood,
while the Swedish will draw three or four times that amount. The region
to which they are applied must be washed, and, if necessary, shaved.
The part should then be smeared with milk, blood, or sugar-water. The
leeches should be put in a basin of fresh water, after which they are
placed upon a dry towel for two or three minutes. Each one is then
taken up in a small glass or test-tube and inverted over the spot
chosen. As soon as the animal fastens itself upon the skin the glass
may be removed. Leeches are often capricious and will sometimes wait
considerable time before attaching themselves. When full of blood
they usually relax and drop. If it be desired to remove them a little
salt will make them relax. Leeches should never be applied over loose
cellular tissue nor over superficial vessels or nerves. If used in the
interior of a cavity they should be prevented from passing too far.


COUNTERIRRITATION.

Counterirritation is a valuable means of accomplishing that which
is sometimes induced by leeches--namely, attracting blood to the
surface for the relief of deep congestion. In fact it comprises more
than this, since there is some deep influence exerted through the
medium of the nervous system; it not only equalizes the circulation,
but tranquillizes a disturbed innervation. The milder and more
domestic means include the use of the so-called rubefacients--hot
water, mustard, and turpentine. These are of little use in surgical
conditions which call for counterirritation; their use should be
controlled with caution lest mere counterirritation be converted into
actual burning.

By the use of _vesicants_ a blister is produced, _i. e._, an effusion
of serum and lymph beneath the superficial and outside of the deeper
layer of the skin. Mustard and cantharis are the principal vesicants in
common use. The former may be used in full strength, in which case it
is active, or it may be reduced with wheat flour or linseed meal. To
bring out the full strength of mustard, hot water should not be used in
its preparation, as it renders it almost valueless. A mustard paste or
plaster should be watched at intervals, and it should be removed when
the desired effect has been obtained--at all events, when the surface
to which it has been applied is covered with vesicles.

Cantharis, or Spanish fly, is used either in the form of the
cantharidal cerate or mixed with collodion, the latter being the
neatest and most pleasant preparation. Several layers are painted on
the surface where its effect is desired. This is then protected, and
vesication will be found to have been produced within an hour or two,
except where the skin is most resistant. The stronger chemicals, like
ammonia, chloroform, strong iodine, and nitrate of silver solutions,
will be found to be active blistering agents, but should be used with
caution.

Two other methods of irritation were at one time in favor--namely, the
_seton_ and the _issue_. The former consisted of a bundle of threads
or a wick, drawn into a large needle with a lancet-shaped point; the
skin was picked up into a fold, the needle made to traverse it, and the
wick was thus drawn through and cut off, so as to be left in place. The
issue was made by drawing a blister with a powerful agent, and then
preventing it from healing by the use of an irritating foreign body.
These procedures have been abandoned by the medical profession, but are
still in vogue among veterinary surgeons.


=The Actual Cautery.=--In some one of its improved forms the Paquelin
cautery has replaced all the old cruder methods of cauterization.
When properly employed its counterirritant effect can be made most
serviceable for the relief of pain, or for any desired form or
degree of counterirritation. Applied over the upper abdomen, with
the lightest possible touch, in such a way as to deserve the term
“_flying cautery_,” it will sometimes afford great relief in nausea and
vomiting, especially when these symptoms are purely reflex.

Used over the course of the larger nerves it does much to relieve the
pain of neuritis; while over swollen joints and swollen testicles it
affords great relief from the pain of chronic arthritis and chronic
or acute epididymitis. In deep-seated congestions and inflammations
_ignipuncture_ may be made with a small cautery point, by plunging it
through the skin into the underlying tissues, and into bone. The relief
of tension as well as the counterirritation will give great relief.
When practised in this manner local or general anesthesia may be used.
Except when thus used it will rarely be necessary to do more with it
than to disturb the exterior of the skin. When skilfully used this can
be done with the production of very little pain.


PARACENTESIS.

Paracentesis is the technical name given to the act of tapping, or the
withdrawal of fluid from any of the closed cavities of the body. It
includes _aspiration_, _tapping_, and _incision_.


=Aspiration.=--By aspiration is meant the removal of fluid without the
admission of air; it comprises the use of a suction apparatus, usually
known as an aspirator, which may be had in various forms and sizes. A
small so-called _exploring syringe_ will answer for small cavities,
while for large collections of fluid, such as may be met with in the
thorax, more elaborate apparatus is used, consisting of a suction pump
connected by tubing with a bottle in which the vacuum is produced. By
another tube this bottle is connected with a hollow needle used for
the withdrawal of the fluid. Absolute asepsis should be observed, even
in this minor procedure. The skin should be cleansed, and the needle,
instrument, and hands should be sterilized. The pain of puncture may be
prevented by use of the freezing spray, of cocaine injected locally,
or by touching the skin with a drop of pure carbolic acid. The vacuum
is commonly resorted to in the removal of fluid from the thorax,
the spinal and the cranial cavities, and from joints; also in small
collections of pus in any part of the body.


=Tapping.=--Tapping means a somewhat similar procedure with a larger
instrument known as a _trocar_ and a surrounding _cannula_, without the
aid of the vacuum. Precaution should be taken in every regard that the
instruments and the parts should be sterilized.

The trocar, inserted in the cannula, should be plunged quickly into the
cavity at the site selected. Considerable resistance will be offered
by the skin. If the trocar be small it is enough to anesthetize the
skin; if large, a small incision will permit of its better use. The
instrument makers have provided cannulas of various descriptions, to
which tubing may be attached, so that the fluid may be conducted into
a suitable receptacle, and wetting the patient avoided. It is well to
draw the skin aside and not to make the instrument pass directly into
the cavity to be tapped unless it contain pus and it be desired to
keep it open. If this precaution is taken the skin will cover the deep
opening after it slips back into its position, and will act as a valve
to prevent leakage. In this way infection may be avoided.

When fluid has ceased to be serous and has become purulent, as in
empyema, it is often so thick that it will not flow through any hollow
instrument. In such an event free incision should be made. When the
thorax is involved incision is made between the ribs, and in order to
maintain drainage a good-sized drainage tube should be inserted. This
at times may be so compressed between the ribs that an inch or more of
one rib should be exsected to provide against this possibility.


TRANSFUSION AND INFUSION.

Though much has been said concerning the indications for these
procedures no explicit directions have been given. While they are often
emergency measures they are, nevertheless, frequently practised. In
well-regulated institutions the conveniences are always at hand for
instant resort when needed; but it would be well for every general
practitioner to have ready at all times the few things that are
required, for at least hypodermoclysis. In country practice, however,
a clean fountain syringe, a suitable aspirator needle (both carefully
sterilized), some boiled water, table salt (when nothing else is at
hand), and soap and water for sterilization of the operator’s hands
and the patient’s skin are all that are necessary. In every outfit
there should be a needle which may be used for this purpose. It may
be carried in a glass tube, always sterilized, and ready for use. No
fountain syringe should be used which has not been freshly boiled,
except in an emergency. Tablets containing common salt in definite
amount, so that a solution of given strength can be made by adding them
to a definite amount of water, can be procured. With such a needle, a
few tablets, and a fountain syringe the surgeon is prepared for any
emergency.

For intravenous infusion for which no pressure is required, an ordinary
funnel, with rubber tubing attached, will be sufficient without the use
of a rubber bag.

The use of salt solution has supplanted the _transfusion of blood_.
This requires a source of blood which is not always at hand and an
amount of attention which can rarely be given in emergencies; moreover,
it has been shown that the injection even of defibrinated blood
is a dangerous procedure, because of liberation of hemoglobin and
destruction of white corpuscles, with the liability to coagulation of
the blood from increase of fibrin ferment, and the possible death of
the patient. Direct transfusion from another person into the veins of
the patient is also difficult, and has rarely been of service.

As already stated in the chapter on Shock, the best solution for
infusion is composed of calcium chloride 2 parts, potassium chloride 3
parts, sodium chloride 9 parts, sterile water, 1000 parts. The addition
of one part of sodium bicarbonate will sometimes prove of advantage,
while in diabetic cases this may be increased to three parts to a
thousand. It has also been suggested to add a small proportion of
sugar, even up to thirty parts, to this solution, in order to increase
osmotic action and better preserve the red corpuscles from injury. It
is supposed also to give a certain nutritive value.

When the fluid is injected into the venous system all that is desired
is that it barely enter; consequently the receptacle containing the
fluid should be held but a few inches above the level of the opening.
When hypodermoclysis is practised more pressure will be needed and a
greater difference of level should be maintained. In the veins the
amount injected should not exceed 100 Cc. each minute. From 500 to 1500
Cc. may be used altogether. There need be no hesitation in introducing
it at a temperature considerably above the body normal, and in cases of
shock it may be introduced even at 115° F. The character of the pulse
will afford the indication as to the amount of fluid to be used as well
as the wisdom of repeating the measure after an interval.

For _intravenous infusion_ a vein in the arm is usually exposed and the
needle point carefully inserted. It is an advantage to have for this
purpose a special needle, made with a blunted extremity, enlarged a
little, so that by the use of a temporary ligature the vein may be held
tightly around the cannula, for such it really is, and the escape of
fluid be prevented. After withdrawal of the needle a double ligature
should be placed for purposes of security. The limb should also be kept
at rest for a few days.

For _hypodermoclysis_ from 500 to 1000 Cc. may be employed; the
anterior abdominal wall, the flank, the thigh, and the retromammary
tissues are the best regions in which to inject the solution.
Absorption will be assisted by gentle massage. Local anesthesia by
the freezing spray, or by cocaine, will rob the procedure of its
discomfort. Adrenalin may be added to the solution, whose formula is
given above, in emergency cases where it seems to be especially needed.
In instances where infusion is practised for the purpose of washing out
the blood, _i. e._, in the acute toxemia of uremia, alcoholism, etc.,
nothing of the kind will be required; but in conditions of lowered
blood pressure, _i. e._, shock, it will prove of great value, as
already indicated.


CATHETERIZATION.

Catheters, as such, are intended for the withdrawal of urine from the
urinary bladder, or for the introduction and withdrawal of cleansing
fluids. They are made of metal, glass, gum, and silk, or other similar
material, in various sizes, while some are specially formed or bent
in order to pass more easily over the obstruction offered by a median
prostatic enlargement. Various forms are sold in the surgical depots,
from which the purchaser may make a choice. Next to the simple tubular
forms the elbowed or Coudé catheters are of the greatest value.

Catheters should be sterilized before use. Those used occasionally
should be cleaned after use and dried, while those in daily use may
be kept in an antiseptic solution after cleansing. The cleansing of a
catheter should include not only attention to the exterior, but also
removal from its bore of all clots, debris, etc. Some pressure behind
the fluid used for this purpose is advisable. A clean metal or glass
catheter may be sterilized in a flame just before use. All flexible
catheters should be boiled just prior to their insertion, or they
should be taken out of an air-tight receptacle in which they have been
kept in contact with some antiseptic, or in an antiseptic vapor. For
the latter purpose _paraform_ offers an excellent material, as there is
given off from it formaldehyde vapor, which is a powerful bactericide.
It comes in crystals and in tablets. Rubber catheters should be boiled
in a 5 to 10 per cent. solution of ammonium sulphate.

The urethra should also be cleansed, especially the meatus, in either
sex. Cases of cystitis may be directly traced to infection introduced
by a catheter, the result being the same whether the germs be not
removed from the instrument or are carried in by it from the anterior
urethra. This is particularly true in paralytics who have no power of
expelling the urine, and in prostatics who need regular catheterization.

The technique of using the metal catheter in the male is the same as
that of introducing a sound. A lubricant is necessary for the easy
introduction of the instrument, and a sterilized ointment or oil will
serve the purpose. Olive oil, mixed with iodoform, as often used, is
not sterile. The hands of the operator should also be clean, and no
part of a clean instrument should be allowed to come into contact with
any portion of the patient’s surface. On this account the parts exposed
should be covered with sterile towels.

The catheter being intended to afford relief with the least amount of
discomfort, a smaller instrument may be used than would be inserted
were it meant for the dilatation of a stricture. Occasionally, and in a
sensitive patient or hyperesthetic urethra, a little cocaine solution
may be used to advantage, especially if force or pressure need be made
in order to overcome spasm of the cut-off muscle. The metal instrument
is too rigid in some cases, while the gum catheter is too flexible.
Under these circumstances, the silk instrument may be used.

If the tip of the instrument be kept close to the floor of the urethra
it will rarely catch in any fossa or lacuna, particularly if the
size has been correctly chosen. When apparent obstruction occurs at
the triangular ligament the instrument should be withdrawn a little,
tilted differently, or lifted a little so that it is made to hug the
roof of the urethra rather than to press upon its floor. By a little
manipulation of the end of the instrument any obstruction at the neck
of the bladder may also be overcome. A sudden depression of the outer
end as the catheter reaches this part, or a little pressure by the
finger of the disengaged hand in the perineum, will give much help. It
is well, occasionally, to introduce one finger into the rectum in order
that by it the instrument may be better guided along its course. Only
in cases where there has been previous disease or where unsuccessful
attempts have already been made to pass an instrument will much real
difficulty be found; that is, only in those already suffering from
stricture, or from enlarged prostate with the difficulties which it
affords, will one have to resort to manipulation requiring more than
ordinary dexterity. In some of these cases even the expert is likely to
meet with difficulty, rarely with absolute disappointment. Should it
be impossible to empty a distended bladder with a catheter _suprapubic
puncture_ with the _aspirator needle_ should be made.

When difficulty is experienced it is enhanced by spasm of the deep
muscles, as a reflex from the soreness produced by repeated efforts and
by hemorrhage.

Hemorrhage from this source is rarely of serious character and quickly
ceases. In certain instances where it is aggravated much can be
accomplished by leaving the catheter _in situ_ for a few hours, or even
for two or three days.

False passages will occur sometimes in spite of at least ordinary care,
and are always serious in their nature. Extravasation of urine may
result, with more or less disastrous consequences, or speedy septic
infection may quickly terminate the life of the individual. They
are to be avoided, as far as possible, by the use of instruments of
large rather than of small size, with blunt tips, and by delicacy of
manipulation. For this purpose it is well to avoid the use of catheters
which require a wire stylet for the maintenance of their proper curve,
lest during manipulation the point of the wire may work injury. The
various accidents due to or connected with catheterization will be
dealt with in their proper places in connection with the surgery of the
urethra and bladder.

There are certain constitutional complications, however, which deserve
mention. One of these is known as _urethral fever_, which comes on
usually with a chill, followed by more or less rise in temperature,
and with general disturbance of the system. It is to be regarded
as a manifestation of septic intoxication, the hope being that the
disturbance may not go beyond this degree. In cases that have once
suffered from this intoxication precautions should be doubled. The deep
urethra should be irrigated before and after the withdrawal of the
urine, the patient should be kept in bed, and urotropin and quinine
may be administered before and after the discharge of urine. Much may
be done in the prevention of this as of other unpleasant occurrences,
such as pain, excitement, suppression of urine, syncope, etc., by the
previous use of cocaine and by due regard for gentleness. Should a
septic process be set up in the deep urethra it may lead to sapremia
of urethral origin, and to septicemia and pyemia. Septic complications
accompanied by any local indications, such as swelling, should make the
surgeon watchful for the time when an incision must be made for relief
of tension or escape of pus.

Postoperative suppression of urine, which may occur even after
catheterization, may be treated by giving 0.08 to 0.15 Cg. of sulphate
of sparteine every three or four hours (McGuire).


SKIN GRAFTING.

The whole method of skin grafting is based on the fact that if
epithelium be removed from any portion of the body and planted on
favorable soil elsewhere it will take root and grow, reproducing only
itself and no other kind of tissue. It is closely analogous to sewing
seed upon a favorable soil, or even to sodding. Furthermore it is not
necessary that epithelium be furnished from the individual upon whom
it is to be implanted; it may come from another of the same species or
even from a different species. Thus the skin of the frog has been used
for grafting upon human beings, and even the lining membrane of the
egg. Nor is it necessary that the epithelial cells should be apparently
alive when thus employed. Very thin shavings of human skin which have
been dried, or have been kept from decomposing by some antiseptic,
have been successfully used; nevertheless the ideal method consists in
taking what is needed from the individual who needs it.

The term skin grafting is now applied to the employment of very thin
layers of the epidermis, _i. e._, as thin as can be shaved off with a
sharp razor, and it does not apply to the autoplastic methods of skin
transplantation.

Hamilton, of Buffalo, and Reverdin, of Geneva, a number of years ago
independently discovered that minute particles of healthy skin might
be implanted upon healthy granulations and that from such minute
grafts epithelium would be produced and a fresh epidermal covering be
afforded. This method was in use for years and was a great advance on
what had previously been done. Then Hamilton, of Edinburgh, suggested
the use of thin slices of clean sponge, in order that thereby a trellis
might be offered for the growing and climbing granulation tissue; this
served a good purpose in many cavities. But the greatest advance came
when Thiersch demonstrated that large areas might be covered with skin
shavings, and that thus in a few days there would be accomplished
that which took weeks or months by older methods. His original plan
comprehended only the use of these grafts upon granulation tissue;
later it was found that they might be applied to fresh raw tissue, even
to denuded bone. Thus originated the so-called _Thiersch method of skin
grafting_.

The surface to which these grafts are applied must be thoroughly
cleansed as well as the surface from which they are removed. If an
ulcerated surface is to be prepared for grafting it should be scraped
thoroughly with a sharp spoon; all sloughing or suspicious tissue
should be carefully removed, and all oozing allowed to subside. Not
until the surface is prepared is it advisable to remove the grafts.
These are best removed by putting upon the stretch the skin of the
selected area, so as to render it taut and as nearly flat as possible.
The razor used for the purpose should be sterilized and sharp. Salt
solution may be allowed to drip upon the razor while the surgeon is
using it. It is rarely practicable to remove a strip over 5 Cm. wide
or 25 Cm. long. The endeavor should be to remove only the superficial
layer of the skin, and when properly done this removal should be
followed by but a trifling oozing of blood. If bleeding be profuse
the layer removed has been too thick. Grafts of sufficient number and
size are removed to nearly cover the desired area. The more completely
it is covered the more acceptable will be the final appearance of the
surface. If the grafts adhere, we may confidently rely upon their
furnishing enough fresh epithelium to fill in the irregular defects
between the edges. The grafts when cut should be raised with a razor
and a spatula and gently spread out upon the prepared surface, and so
pressed and treated that no air bubbles are retained beneath them. If
the surface be dry enough they will adhere to the very thin coagulum of
blood which glazes it, and after a few moments it will take friction to
disturb them.

Should the margin of the surface to be grafted be old and indurated it
is best to trim off any depression that exists, so that the new skin
may not be let in below the surface of the surrounding skin.

The _dressing_ should consist of a layer of sterilized oiled silk,
gutta-percha tissue, or green protective, laid on in strips, in order
that excessive fluid may escape between them. A little antiseptic
powder may be dusted upon the grafts, if such be the choice of the
surgeon, but if the operation has been properly managed this will
hardly be necessary. Careful regulated pressure should be made outside
of the protective, by cotton and a suitable dressing, and then the
part, if a limb, may be bound upon a splint in order to ensure
physiological rest. _Silver, tin, or aluminum foil_ also make a good
protective, and, on theoretical principles, are even better than the
textile materials.

Some surgeons leave these dressings for several days. I have found it
an advantage to remove them within thirty-six hours, as sometimes the
grafts appear to be macerated in the fluids and to lose their first
cohesion to the prepared surface. The main thing about the dressing
is that it should be non-adhesive and restful. After three or four
days, when the grafts have completely adhered, any ointment dressing
may be used. It may happen that only a portion of the entire number
of grafts serve their purpose, and that others fail to do their work.
Even when the failure has been apparently considerable it will often
be seen that individual epithelial cells have adhered and later will
grow. The unhealed portions of such a surface now fall within the
definition given earlier of an ulcer, and should be subjected to the
same treatment.

Grafting may be repeated as often as seems to be necessary. The best
surfaces from which to take the grafts are usually the outer aspects
of the arms and thighs. The places from which they are removed need
only the simplest antiseptic dressings. If the grafts have been of
sufficient thinness the scars left by their removal are scarcely
permanent and rarely disfiguring.

Wight, of Brooklyn, has suggested that advantage be taken of the
properties of high-frequency discharges from a suitable apparatus to
secure their hemostatic and coagulant effect. He has shown that such
electrical discharge will clot blood and coagulate albumin, this effect
being partly due to the formation of nitric acid from the air. In this
way it is theoretically possible to so seal the surfaces as to fix
grafts firmly in place. The apparatus calls for a pointed electrode,
passed at a distance of about 1 Cm. above the entire surface, until the
clot is firm and reasonably dry, all serum that is expressed in the
process being removed with sponges. Where the apparatus can be employed
this affords an effective way of fixing the grafts and preventing their
displacement.

Surface epithelium from an animal source may be used when necessary--as
from a young pig after it has left the packing-house, a young calf, or
some smaller animal. All that is required is _epithelium_. That from
a negro will reproduce only pigmented cells like the original. At the
time when amputating a limb about which there is still left healthy
unbroken skin, shavings may be removed from it and preserved for a week
or two between dry sterilized towels or in a weak antiseptic solution;
these may then be utilized for skin grafting during the ensuing few
days.

[Illustration: FIG. 30

Figure-of-8 bandage of leg.]

[Illustration: FIG. 31

Velpeau’s bandage.]

[Illustration: FIG. 32

Ascending spica bandage of the groin.]


BANDAGING.

Bandaging is a subject now taught so generally by actual demonstration,
and so simplified, that it scarcely seems necessary to more than
present a few illustrations showing how simple bandages can be applied
in the most effective manner.

The purposes of a bandage are either to afford means of retaining
splints and dressings, to exert pressure, or to afford physiological
rest. After every operation of importance it is necessary to apply and
retain an occlusive and aseptic dressing, under which the wound may
heal or into which wound discharges may be received; but the ideal
dressing affords more than this--it furnishes _support and rest._

[Illustration:

FIG. 33

FIG. 34

Spica bandage of shoulder.]

[Illustration:

FIG. 35

FIG. 36

Third roller of Desault’s bandage.]

There is danger in the injudicious use of any bandage, as by the
exertion of undue pressure it may interfere with wound healing, or may
even lead to gangrene. If applied loosely at the extremity and too
tightly above it will lead to venous obstruction and possibly secondary
hemorrhage. Moreover a bandage which seems properly arranged may become
so tight as to be painful and even unbearable after swelling has
occurred. There is but one safe rule, and that is to take note of the
appearance of the part as well as of the sensations of the patient. An
abdominal bandage may have been placed with a proper degree of snugness
at the conclusion of an operation, and yet be altogether too tight when
the abdomen becomes distended with a little gas. There is then always
room for discretion and good judgment in the matter of bandaging. It
may be necessary to apply a bandage quite firmly at first in order to
repress hemorrhage, with the intention to relax it after a few hours.

A splint may be a necessary feature in a surgical dressing; after
amputating at the lower part of the leg it is advisable to bind the
limb upon a splint in order that the necessary physiological rest
may be thus afforded. The first requisite of a bandage is not its
appearance but its effectiveness; a due regard for the esthetic in
surgery will, however, dictate that it be made as presentable as
possible.

[Illustration: FIG. 37

T-bandage.]

[Illustration: FIG. 38

Kelly’s bandage with perineal straps.]

For the roller bandages of cotton cloth, universally in use twenty-five
years ago, there have been substituted bandages of thin gauze or
crinoline, which have scarcely body enough to be applied, as was the
roller, or else of flannel, made wider and necessarily thicker, which
are more flexible, comfortable, and applicable.

[Illustration: FIG. 39

Barton’s head bandage as employed for suspension in applying
plaster-of-Paris bandage.]

Crinoline impregnated with starch is also in general use and makes a
serviceable bandage for head injuries. When prepared with plaster of
Paris it is capable of affording absolute support and even rigidity.




CHAPTER XX.

ANESTHESIA AND ANESTHETICS, GENERAL AND LOCAL.


To Oliver Wendell Holmes we owe the term _anesthesia_, as generally
employed and made to mean insensibility to pain, no matter how
produced. A more strict definition would limit the term to conditions
comprising not only insensibility to pain but loss of consciousness.
For mere loss of sensation we should, strictly speaking, use the word
_analgesia_. This is a distinction with a difference. Thus I have on
rare occasions seen a patient under chloroform absolutely oblivious to
pain but perfectly conscious, and chatting intelligently throughout
the operation. This is a rare phenomenon, but has been noted by
various observers. So after intraspinal cocaine injections we secure
complete analgesia of the lower portion of the body, but not complete
anesthesia, the former being what we are most anxious to produce.

The discovery of anesthesia is essentially to America’s credit. Long,
of Georgia, had produced anesthesia by ether as early as 1842; Jackson,
of Boston, also claims credit for the discovery; but to Morton, a
dentist of Boston, is undoubtedly due the honor of having introduced it
for surgical purposes. The first public demonstration of its properties
was made by Morton and Warren, October 16, 1846, in the Massachusetts
General Hospital. Chloroform seems to have been exploited independently
by Guthrie, of Sackett’s Harbor, N. Y., and Simpson, of Edinburgh, in
1847. It is a curious historical fact that the patient to whom Simpson
meant first to administer chloroform in his clinic did not receive it
because of some failure to have it on hand; she took ether instead and
died, presumably of the anesthetic. Had she died under the influence
of chloroform it would have been a serious setback to any general
appreciation of its merits. Nitrous oxide is also an anesthetic for
which America may take the credit. These are the three drugs in common
use today, although there are others which are coming into general
favor.

It can be stated as an axiom that when a surgeon tries to abolish
human sensibility, or pass an instrument through the human skin,
he introduces elements of danger which can never be certainly and
completely controlled--that is to say, the administration of an
anesthetic is never to be undertaken as a trifling matter, but should
be entered upon as carefully for a minor procedure as for a dangerous
and prolonged operation.

Anesthetics are sources of danger, not only for the moment while
they are in use, but because of the disturbances which may follow in
their train. These drugs should never be administered carelessly nor
thoughtlessly, nor by inexperienced individuals, but entrusted to the
wisest and the most discreet. More is expected of the anesthetizer
than that he shall barely keep the patient alive; he should be so
expert as to keep the patient safely on the side of complete anesthesia
and muscle relaxation. Nor should he be willing to yield to the
importunities of an impatient operator who may be continually appealing
to him to crowd the anesthetic. When thus given, and by an expert,
such postanesthetic distress as nausea, vomiting, coughing, etc., may
be avoided. So generally are these facts now realized and appreciated,
that in many of the large hospitals a regular anesthetizer is employed,
whose sole duty it is to administer the anesthetic for the attending
surgeons. The management of an anesthetic has much to do with the
allied subjects of the _preparation of the patient_, the _management of
shock or reduced blood pressure_, and the _status lymphaticus_, which
have already been considered.

Fatal accidents from anesthetics are the appalling ones which have
generally occurred in cases where it has been assumed that the patient
is in good condition, and where neither preliminary examination nor
preparation has been made. In the presence of unmistakable cardiac
disease, or of great arterial tension, the surgeon may, by foreseeing
the possibility of trouble, do much to prevent it; but when an
apparently healthy individual is placed upon the operating table
without attention to these matters it may happen that his heart will
stop as suddenly and unexpectedly as though it had been transfixed.
In other words, the accidents of anesthesia usually occur when least
expected; on the other hand, accidents will be few and far between when
all cases are handled as though promising to be severe ones.

The odor of most anesthetics is so distasteful to patients that they
inhale at first with difficulty and with signs of irritation. Much of
this can be guarded against by spraying the nasopharynx with a 1 or
2 per cent. solution of cocaine. This expedient will make anesthesia
much easier for them. The mouth should be examined; all false teeth or
foreign bodies, such as pins, chewing-gum, etc., should be removed.
Unpleasant burning of the sensitive mucosa of the nose and lips may be
avoided by anointing these parts with cold cream. Attention should be
given to the avoidance of irritation of the eyes or the careless escape
of an anesthetic into the conjunctival sac; with a struggling patient,
or a careless administrator, this may easily happen.

Circumstances which would justify the administration of an anesthetic
without the consent of the patient, or the friends or parents, occur
but rarely; still in an emergency case, with a patient incompetent to
decide for himself, the surgeon must assume the responsibility, in
which in all probability the law will sustain him.

The anesthetizer should always be accompanied by an assistant;
preferably in the case of a female patient, by a female nurse, who may
not only be of assistance to him at the time, but an actual protection
should the patient experience any erotic delusions during or after her
period of anesthesia. This applies equally well to dentists giving
nitrous oxide for the extraction of teeth, or physicians attending
cases of accident, convulsions, and the like.

The anesthetics in general use are ether and chloroform. If statistics
alone are appealed to it can be easily shown that ether is the safer
of the two by a large ratio. But the recovery of consciousness by no
means indicates the conclusion of the period of danger. The harm which
chloroform does is largely done promptly, whereas the unpleasant effect
of ether lasts through a much greater period, and the statistics which
give ether an advantage are in many respects fallacious. Chloroform is
doubtless the stronger and the more subtle agent of the two, and in
careless hands would, in all probability, become the more dangerous.
_But no anesthetic should be given carelessly_, and no one should
give it who cannot give it properly. There may be emergency cases,
especially in the rural districts, in which the surgeon may have to act
in the capacity of anesthetizer and operator as well, and where he may
have to transfer the inhaler to some lay assistant who knows nothing
of the action of these drugs. If this happen it would be safer to use
ether.

_When administered by a thoroughly competent person_ chloroform is the
safer anesthetic of the two, and is usually to be preferred. So largely
does the personal equation figure in this consideration that it seems
unnecessary to reproduce here statistical tables in regard to its
efficiency.


ETHER.

The writer’s intention is to confine his views on anesthesia to the
practical application of certain drugs whose chemistry, materia medica,
and ordinary therapeutic properties are appropriately treated of in
other works.

Ether anesthesia has by some been considered to be simply one form of
carbon dioxide poisoning; that it may be all of this, in certain cases,
may be granted; but it is certainly something more, as is shown, among
other things, by the peculiar odor which persists in the breath of
the patient for hours or even for days after its use. Various ways of
administering it have been recommended. Some give it well diluted with
air, and some give it as strong as a patient can possibly bear it, and
from the outset. Some keep mixing air with the vapor, while others have
devised inhalers, by which the same ether-ladened air is breathed over
and over again. These latter produce a certain degree of the carbon
dioxide poisoning above alluded to, and are not ideal even if effective.

Even when well diluted with air the vapor of ether causes irritation of
the air passages, in both the nose and throat, and leads quickly to a
sensation at first of oppression and then almost of suffocation, which
is trying to the self-control of intelligent patients and disturbing to
those having little or none. An inhaler saturated with ether should not
be pressed tightly over the patient’s face, as it is likely to produce
struggling to such an extent that weakened bloodvessels may give way
and by their rupture produce serious disturbance.

The first momentary period of irritation having subsided, there will
likely follow a few deep inspirations, and then perhaps a fixation
and immobility of the chest, so that for half a minute or a minute it
would seem as though the patient had _forgotten to breathe_ (Hare).
But deep respiration is quickly reëstablished, or may be stimulated by
slapping the chest, by a few movements at artificial respiration, or at
least by compressing the thorax. Then follows the period of “primary
anesthesia,” so called, or a period of excitement, during which the
patient may rave or become quite disturbed, and in a manner sometimes
quite at variance with his ordinary temperament. As this period
subsides the state of complete anesthesia begins, and when muscular
relaxation is complete, or even before, the surgeon may commence his
work. The respiration under complete anesthesia is usually deeper and
sometimes more rapid than in health, while as the muscles become more
relaxed a positively stertorous breathing is noted, along with an
increase in flow of saliva, due to the irritation of the ether vapor.
As anesthesia passes into complete narcosis, and this into asphyxia,
the color of the surface, especially of the face, changes to a cyanotic
hue, the skin becomes moist and clammy, and the pulse, which had been
accelerated, fails. The blood also becomes exceedingly dark from lack
of oxygen. Under these circumstances the heart may continue to beat
feebly for a short time after respiration has ceased. As Hare puts
it: “In producing its effects ether first attacks the perceptive and
intellectual cerebral centres, next the sensory side of the spinal
cord, next the motor side of the cord, then the medulla, and with this
last depression death ensues.”

Ether is more pungent and less agreeable to breathe than chloroform,
but the chief advantage usually connected with its use is its supposed
factor of safety.

On the other hand, the accidents which are due to ether are in a large
measure those common to the use of any anesthetic agent. Among the
most prominent is _arrest of respiration_, which may be caused either
by mucus or some foreign body in the air passages, or by the tongue
dropping back in the pharynx, and the impediment to respiration thereby
offered. When the cause of the difficulty is ascertained it is usually
easily removed. Should great pallor accompany these symptoms, then,
it is usually because the heart as well is at fault, and vigorous
stimulation of this organ should be promptly instituted.

Another disadvantage pertaining to ether results from the irritation
which its vapor produces in the bronchi and lungs, or in the kidneys
during its elimination. From the former may result bronchitis,
congestion, or even pneumonia; the latter more often of the catarrhal
type than of the croupous. As the result of renal irritation there may
be temporary albuminuria, or the congestion resulting may assume so
serious a type as to produce absolute suppression (_anuria_), which is
practically always fatal. Ether is said to be particularly undesirable
in cases of diabetes, because of the resulting acetonuria. Patients
have even been known to pass from anesthesia into diabetic coma.

It has been found that complications are more common in males than in
females, but more severe in the latter. Vomiting following the use of
ether is a frequent and most unpleasant sequel. It is to be prevented
by previous lavage, as well as by the same measure at the conclusion
of the operation. It will rarely subside when present until the ether
vapor has been eliminated. So far as it is possible to suppress it with
drugs probably 2 Gm. doses of chloral and one of the bromides, with
a little laudanum, given by the rectum in salt solution or a little
starch-water, will give the best results.

As already stated, it was formerly held that anesthesia was carbon
dioxide poisoning, plus something else which was vaguely described by
different authorities; much clearer notions now prevail regarding the
mechanism of anesthesia. A few years ago Meyer and Overton concluded
that anesthesia is produced by solution of the fatty constituents
of the cells by the anesthetic absorbed, this being true at least
with chloroform and ether, both of which are solvents of fat. The
absorbability of the anesthetic varies with the blood temperature,
this varying widely between the cold-blooded and warm-blooded animals.
They estimate that 1 part of ether to 400 parts of serum is necessary
for complete anesthesia in man, while one part in 4500 to 6000 parts
is a sufficient proportion of chloroform. According to these views
the dissolved fat is not removed from the cells, and no satisfactory
explanation yet accompanies this theory, even assuming its accuracy.

Of no small importance are the experiences of Snel, who found that
anesthetics decrease the bactericidal properties both of the blood and
of the tissues, but that this power is quickly recovered after the
elimination of the anesthetic. He furnishes reason for the theory that
the thus lowered resistance of the lungs is an important factor in the
production of the pneumonia which occasionally follows operations.

There is a belief that ether is more irritating to the kidneys than
chloroform. This, however, does not seem to be justified by evidence,
neither is the prejudice against the use of ether during the existence
of albuminuria or in the presence of casts. In the presence of a high
degree of albuminuria any anesthetic is dangerous, and here ether
would be the less desirable of the two. Nevertheless in ordinary mild
albuminuria one need not fear to give ether.

About twenty years ago it was suggested that ether anesthesia could
be induced by passing its _vapor into the colon through an ordinary
rectal tube_. There are many obvious reasons why it would be of great
advantage if anesthesia could be safely practised in this way, not only
in operations about the face and head, but because of the avoidance of
pulmonary and gastric irritation.

The method was to thoroughly empty the colon and then connect a rectal
tube with a receptacle containing ether, which was placed in warm water
and the vapor passed into the intestine. It was found that patients
could be readily anesthetized in this manner, but unfortunately it was
also found that a considerable degree of intestinal irritation was
produced.

The writer recalls one case in which this method was practised, which
terminated fatally within twenty-four hours after the operation, where
the autopsy disclosed a violent degree of acute colitis.[7]

  [7] _Ether Narcosis by the Rectum._--Cunningham and Lahey have
  revived the almost abandoned method of rectal ether narcosis, after
  improving the technique. The rectal tube is introduced for ten to
  fifteen inches and ether vapor is then forced in until considerable
  gas is pressed around the rectal tube, keeping the forefinger in
  the rectum opposite the tube until it causes pain and hastens the
  expulsion of the rectal gases. It is essential that the rectum be
  distended to the point of keeping closed around the tube, since
  unless the gas normally in the bowel be first removed the patient
  absorbs the ether much more slowly, presumably because of its
  dilution. At the first introduction of the ether vapor the patient
  may feel a natural discomfort and desire to defecate, but in a short
  time this sensation disappears; the breath becomes ether-ladened
  in from one to five minutes, he becomes drowsy, the breathing
  stertorous, and he passes into complete surgical narcosis without any
  excitement.

  The apparatus used consists of a bottle seven inches in height, of
  which five inches are used for ether space and the balance for vapor.
  The afferent tube which leads to the bottom of the ether ends in a
  bulb, with small perforations, so that the air escapes in several
  bubbles. This bottle is placed in a water-bath at a temperature
  between 80° and 90°. By keeping the ether warm, without boiling, the
  air forced through it is more easily saturated.

  The same care must be given to see that the tongue does not fall
  over the larynx as when ether is given by the mouth. Should narcosis
  be too pronounced the tube should be disconnected and ether gas
  forced out of the bowel by abdominal massage. Oxygen may be given
  through the same tube if desired, while artificial respiration and
  stimulation are practised as usual when needed. After completion
  of the operation the ether vapor should be completely expelled by
  pressure.

  The advantages of the method are that but a small amount of ether is
  used, there is no stage of excitement, vomiting is rare, bronchial
  secretion is prevented, and recovery is rapid. It has been shown that
  six volumes per cent. of ether are required in the blood for the
  production of complete anesthesia. The rapidity with which the latter
  can be produced depends upon the rapid production of this percentage.
  This result is attained more readily by the rectum than by the lungs.
  For the production of narcosis by this method the rectum should be
  previously and thoroughly emptied.


CHLOROFORM.

It is important that pure chloroform should be secured for anesthetic
purposes. It should be kept in dark bottles, and in the dark, as it is
liable to undergo decomposition in the presence of sunlight. It is less
volatile than ether, and mixtures of the two drugs are not stabile,
since the ether is likely to evaporate first. In its anesthetic effects
it resembles ether, acting first upon the perceptive and last upon the
motor centres.

The British Chloroform Committee estimate that from 1 to 2 per cent. of
chloroform in the inspired air is sufficient for anesthetic purposes,
and may be safely used; that 5 per cent. is more than adequate, and
that anything stronger than 2.5 per cent. is dangerous.

The _effect of chloroform upon the heart_ is to quicken and then
slacken it. The former action is due to a depression of the vagus
centre, while subsequent slowing is due partly to vagus stimulation
and partly to direct weakening of the heart muscle. While chloroform
does not materially affect the excitability either of the vagus or
accelerator nerves its main effect is on the strength of the heart
action, and is less marked on the auricles than on the ventricles.
Ether has a more marked tendency to raise blood pressure than
chloroform, while the latter is likely to be more responsible for
sudden falls in blood pressure even after its administration has ceased.

The question of the _relative dangers_ of the two drugs has engaged
the attention of investigators the world over, and one of the side
questions to be discussed is whether chloroform kills by arresting the
circulation or the respiration. Chloroform produces a fall in blood
pressure (see Chapter XVII) but as long as the blood pressure within
the brain, and especially the medulla, is maintained this effect is
of secondary importance; but when the respiratory centres lack their
natural stimulus, and respiration becomes irregular, then, as it
were, the patient “bleeds into his own vessels.” It is under these
circumstances that adrenalin produces its most marked and prompt effect.

The first effect of chloroform inhalations is to _raise blood
pressure_, but this is soon followed by lowered tension. The _pupils_
may dilate slightly at first, but usually contract and remain
contracted during anesthesia. _When they dilate suddenly means should
be adopted to avert the danger threatened_, as the relaxation of the
iris is the first visible relaxation of death. While the pupils react
to light there is little danger.[8]

  [8] Lehmann believes it is a bad sign when a patient who is taking an
  anesthetic keeps the eyes partially or completely open, or frequently
  reopens them after being under the influence of the drug. He holds it
  to be a premonitory symptom of more or less serious complications.

Death from chloroform usually occurs when it is assumed that no
accident is likely to happen, as when it is given to an athlete, or to
drunkards who are supposed to be secure from any reflex influences.
Patients with weak hearts can be conducted safely through a prolonged
anesthesia if there be time to prepare them. (See chapter on the
Preparation of Patients.)

The after-dangers of chloroform are smaller than those of ether, due in
part to the fact that a much smaller amount of the drug suffices; in
other words--that it is the stronger.

After anesthesia has been produced and the patient is unconscious it
requires but small additional amounts to maintain unconsciousness, as
it is necessary to add only as much as may be required to replace what
is lost by evaporation and exhalation. It is sometimes advantageous
to commence with nitrous oxide gas, for there are fewer unpleasant
reflexes, less salivation, and less disturbance of every kind. _Shallow
breathing may be improved at almost any time with a few drops of ether._

Many anesthetizers have a habit of testing the degree of anesthesia by
touching the cornea with their fingers. A piece of sterile gauze will
prove equally effective and less irritating.

When the mask upon which chloroform or ether is given is held over the
face free salivation will frequently be excited, and the patient will
be tempted to swallow as well as inhale. In this way the vapor of the
anesthetic is taken into the stomach as well as into the air passages,
and when the stomach is empty this comes into direct contact with the
gastric mucosa. This may produce not only irritation, but, in extreme
cases, gastritis. It has been suggested that to allow the patient to
drink a quantity of water at intervals before taking the anesthetic,
and especially a half-pint or more immediately before beginning it,
will be to permit of absorption and dilution of the anesthetic vapor
without their causing this irritation.

[Illustration: FIG. 40

Harcourt inhaler.]

The simplest method of administering chloroform is upon an ordinary
mask, the covering of which should be thin in order to permit of easy
play of air. By this method a patient can always be anesthetized, but
with a waste of the anesthetic and with absolute uncertainty as to
the proportion of chloroform vapor in the inspired air. A variety of
expedients have been suggested in time past, and chloroform inhalers of
various patterns are constantly upon the market. The Junker inhaler,
introduced some twenty-five years ago, was a great improvement upon
its predecessors, but only recently has a really scientific measuring
inhaler been placed before the profession. This is the one devised for
and introduced by a committee of the British Medical Association, and
is the result of the study and ingenuity of Prof. Vernon Harcourt. It
has already been stated that more than 2 per cent. of chloroform vapor
in the inhaled air is dangerous. The Harcourt apparatus consists of
a two-necked bottle, nearly filled with chloroform, into which are
dropped two colored glass beads, which serve to indicate when the
temperature is between 55° and 59° F. If the temperature be below 55°
F., both beads will float; if it be above 50° F. both will sink. If
the former, the proportion of chloroform will be below that indicated
by the pointer; if the latter, it will be greater. Inasmuch as during
inhalation the chloroform is cooled by evaporation, it is necessary to
occasionally place the warm hand over the bottle until the blue bead
has sunk and the red bead is beginning to sink, indicating that the
temperature is again approaching 59° F. A stopcock is so constructed
that when the pointer is at one end of the arc the maximum amount of
chloroform which may be taken up is 2 per cent.; when the pointer is at
the opposite end, the patient breathes only pure air. There are valves
which prevent the entrance of expired air into the apparatus, and which
show whether the stopcock is working. They also show the character of
the respiration. Administration is begun with the pointer at 0.2, and
while it may require 2 per cent. of vapor to produce narcosis; _i. e._,
the complete and final stage of anesthesia, it will take scarcely more
than 1 per cent. to maintain it. The mouth-piece has an expiratory
valve, and the apparatus can be held in any position, but should be
kept nearly vertical. The mask is fitted with an air cushion, which can
be molded in hot water so as to fit the patient’s face. Buxton, who is
the leading authority on anesthetics in London, has abandoned all other
apparatus for this. While he is a most skilled expert, he has shown
that by means of this apparatus chloroform can be given with almost
absolute safety.

Aside from the danger and discomfort pertaining to the use of
chloroform in apartments lighted or heated with natural gas, there is
another similar danger in connection with ordinary city illuminating
gas. In the presence of a flame produced by the latter the vapor of
chloroform is broken up not only into chlorine and hydrochloric acid,
but into a carbon oxychloride, known also as _phosgene_, which is
toxic and produces a sense of suffocation by producing decomposition
within the blood. A fatal occurrence of this kind led to experiments
on animals by an Italian observer, which showed that the substance
produced rapid disintegration of hemoglobin, which fell rapidly to 40
per cent., and that accompanying this there was suppression of urine
with convulsions.

Unless chloroform be given by one familiar with its use, it is best
given from a dropping bottle. If this be so arranged that it will
discharge but one drop at a time, and the anesthetizer so administer
it as to allow perhaps one drop to fall each second, the patient will
at no time get an overdose, nor will there be struggling or choking.
Irregularity of breathing is usually the result of insufficient air,
and the mask should be at once removed, so that the patient may take
one or two deep inspirations. When the cornea is insensitive the
patient will stand almost any manipulation except, perhaps, stretching
of the sphincters. When the sphincter can be stretched without
provoking any effect except a prolonged inspiration, then the patient
is, in all probability, completely relaxed and ready for any procedure.
When the breath becomes stertorous the mask should be removed even
though the cornea be sensitive. It will quickly lose its sensitiveness
again within a few seconds. _Proper breathing must be maintained._ Free
supply of air is important above all other things, and it is better
that the surgeon should wait rather than the anesthetizer.

Additional safety in the use of chloroform may be afforded by the
simultaneous use of oxygen gas, by which cyanosis is usually avoided
and vomiting often prevented. It may be safely used with chloroform,
but not with ether. If ozonized air be conducted into anhydrous ether
it forms a thick liquid, probably ethyl peroxide, which explodes if
heated (Hare). It is a mistake to so manage the administration of
chloroform with oxygen that the patient receives no pure air. Oxygen
is of great value, but it is not physiologically breathed in its
pure state. When the gas is allowed to bubble through a bottle of
chloroform, carrying with it the vapor, no idea can be formed as to
relative percentages. A better way is to administer the chloroform upon
a mask, and the oxygen by a tube from a wash-bottle filled with water
and passed into the nostril under the edge of the inhaler (Hare).

Gwathmey has introduced a modification of the well-known standard
Junker inhaler, by which oxygen and chloroform, or nitrous oxide and
ether, may be given together, or by which any desired combination
can be effected. Its special advantage is the same as the Harcourt
apparatus, that the percentage of chloroform or ether vapor can be
estimated or controlled. So far as the administration of chloroform
with oxygen is concerned, Roth has shown that oxygen does not decompose
the chloroform, but diminishes the danger of its administration.

Gwathmey refers to the advantage of keeping an open airway by turning
the head a little to one side and pressing the jaw well forward; he
also advises that when the anesthetic is removed from the face it
is well to replace its odor by some other perfume, such as cologne
or smelling salts, as it is presumed that the olfactory nerve is
responsible for the initial symptoms of nausea and gastric distress.

In some States natural gas is used as fuel, usually in open fireplaces
or stoves. When chloroform is administered in a room thus heated, or
even lighted by natural gas, formaldehyde gas is the result of a mutual
decomposition, and this is exceedingly pungent and irritating, and
will soon produce violent coughing in all who are present in the room.
It may be impossible to avoid this, but natural gas flames should be
extinguished and some other source of illumination should be depended
upon when practicable.


A. C. E. MIXTURE.

Under this term are known various mixtures of alcohol, chloroform,
and ether, the intent being to counteract the depressing influence
of chloroform by alcohol and ether. It may be said of every mixture
of anesthetics that it is no less dangerous than its strongest
constituent. Thus a mixture of chloroform and ether should be given
with as much precaution as pure chloroform.

Mixtures of this kind should be made fresh for each administration, as
the most volatile ingredient may evaporate in unknown amount and thus
change the proportions. This is true of the mixture even after it is
poured upon the inhaler, and the patient will thus be subjected to a
chloroform mixture of varying strength.

The administration of ether for a few seconds during chloroform
anesthesia will often prove beneficial in regulating or deepening
inspiration, but it would be best to have the two drugs separate, and
use the ether as it may seem called for, rather than to rely upon any
such mixture. Moreover the vapor of alcohol is of itself irritating and
undesirable.


ETHYL BROMIDE.

For operations of but short duration ethyl bromide offers some
advantages, in that its effects quickly pass away and that there are
few unpleasant sequels. Indeed, patients may take it for a few minutes
with almost as little disturbance as is produced by nitrous oxide;
nevertheless it cannot be regarded as being as free from danger as was
originally claimed. Only a pure preparation should be used. When given
as ether is usually given, upon a cone or mask, complete anesthesia may
often be produced within one minute. It can hardly be relied upon to
produce muscular relaxation and it frequently causes great congestion
of the face and head, consequently it is not as convenient for short
operations on the nasopharynx as its other good qualities might render
it. It is not unpleasant to take, and ordinary ether anesthesia may
well be begun with it.


METHYLENE BICHLORIDE.

For a number of years this anesthetic agent was in favor, especially
in Great Britain, where it was warmly advocated by Spencer Wells. Its
odor is agreeable, its action rapid, and recovery from its effects is
usually prompt. But it proved to be unsafe, since it was found that
the substance commonly used under this name was really chloroform
diluted with one-fifth of methyl alcohol, while the genuine methylene
bichloride was found by experiment to be a dangerous substance, and its
use has been discarded.


ETHYL CHLORIDE.

This, like every other drug used for the purpose, should be used in
perfectly pure form. While this can be obtained from manufacturers in
this country, there seems to be a tendency to rely upon the imported
preparation sold here under the name of Kelene. For certain short
operations, such as those upon the eye, nose, and throat, and for
children, it has many advantages and appears to be a reasonably safe
drug for the purpose. Consciousness is quickly recovered after its use,
and the after-effects are slight. It is in general use preparatory
to one of the stronger anesthetics, like ether or chloroform, and
affords a means of putting patients under the relaxing effect of either
of these drugs. It should be administered upon a cone or mask, from
which evaporation should not occur too easily, because it is extremely
volatile. In the hands of one accustomed to its use, operations of
considerable magnitude and duration may be successfully maintained.
A special valveless mask has been devised for its use, consisting of
a rubber mouth-piece which can be snugly fitted to the face, and a
movable tube over which two or three layers of gauze may be stretched,
upon which the ethyl chloride is allowed to drop or is ejected from the
tube in which it is sold. Sometimes the expired air will freeze upon
this gauze. This is of no disadvantage.


=Local Use.=--On account of its extreme volatility, chloride of ethyl
affords a ready means of producing local anesthesia. It boils at 50°
F., and when the tube containing it is held in the hands and its
capillary tip is opened it issues in the form of a fine spray, which
being directed upon the part to be desensitized first chills and then
freezes it. Whether this part be skin or mucous membrane the effect
is the same. As soon as the desired area is covered with a thin layer
of small frozen crystals, looking like hoar-frost, the surface is
anesthetized and the necessary instruments may be used. Blowing on the
part to be anesthetized will favor evaporation and shorten the time
necessary for the purpose.

The purposes to which this drug may thus be used are numerous and
obvious. For instance, in dentistry it will do much to allay the pain
of tooth extraction; in genito-urinary surgery such operations as
incision of the prepuce, the cauterization of venereal ulcers, and
circumcision may be done with little or no pain. The small operations
required in various skin diseases, the incision of small abscesses, the
use of caustics wherever they may be needed, may all be made easy under
its effect; while in cases of neuralgia, stings, bites, etc., it will
often alleviate the symptoms. The skin may also be anesthetized in this
way before the introduction of the needle through which antitoxins are
injected or hypodermoclysis practised. Before venesection or before
exploratory puncture it may also be used.


=Somnoform.=--This agent, composed of ethyl bromide 5 parts methyl
chloride 35 parts, and ethyl chloride 60 parts, was introduced by
Rowland, of Bordeaux, as a convenient means of producing an analgesic
condition, _i. e._, something between complete anesthesia and conscious
sensibility. The dose is about 5 Cc., to be sprayed upon a tightly
fitting mask. The patient should be told to breathe and swallow as
naturally as possible, and the effect is obtained within a few seconds.
The agent is so speedy in producing its effects that it is sometimes
difficult to tell when the proper degree of unconsciousness has been
secured. A patient may be directed to hold up an arm in order that
when it drops the surgeon may proceed. There is neither cyanosis nor
corneal reflex, and nausea does not usually occur. The essential
point of administration is the exclusion of air. Twenty seconds of
administration will give from one to two minutes of anesthetic effect,
during which various brief operations can be performed. By proper
management this period can be lengthened many times.


=Petroleum Ether.=--Petroleum ether was introduced by Schleich for the
purpose of diluting chloroform. By itself it has a weak anesthetic
power, and seems to possess some dangers of its own in the way of
depressing the heart’s action and producing convulsions.


OTHER VOLATILE ANESTHETICS.

Schleich was among the first to demonstrate that the retention of
an anesthetic within the body depends upon its boiling point. W.
Meyer carried Schleich’s views still farther and showed the at least
theoretical value of an anesthetic mixture whose boiling point was
that of the normal blood temperature. If the evaporating point be much
higher than the blood it is volatilized too easily, while if it be
lower it reduces body temperature as it evaporates. After considerable
experimentation Meyer recommended a mixture by volume of chloroform 3
parts, ether 2 parts, and ethyl chloride 1 part, and introduced this
mixture under the name of _anesthol_. This composition does not seem
to have met with great favor as yet, although it has theoretically
much to commend it, as it seems slower in action and but little more
satisfactory in other respects.


NITROUS OXIDE GAS.

This is by all means the most rapid general anesthetic in use. Patients
can be placed under its influence in from twenty-five to sixty seconds.
For a long time its employment was confined to dental practice, but
it is now in general use by surgeons, as a preliminary to the use of
ether or as the sole anesthetic agent. When managed properly patients
can be kept for a half-hour or even an hour under its influence.
Two disadvantages attend its administration: (1) It is difficult to
completely relax the muscles and so maintain them that no difficulties
are placed in the operator’s way, _e. g._, in certain operations upon
the abdomen where muscle rigidity delays and makes difficult the
operation. (2) The use of nitrous oxide alone so far impairs proper
oxygenation of the blood that this fluid becomes dark or almost black
and frequently obscures the field of operation. These difficulties,
especially the latter, can be overcome by the skilful _simultaneous
use of oxygen gas_, by which the blood is kept well oxygenated, and by
which the deep stupor of nitrous oxide poisoning can be made so safe
that it can be prolonged to the degree necessary to afford relaxation.

Nitrous oxide anesthesia is thus proved to be something more than mere
asphyxia, or it would be completely counteracted by oxygen. Suitable
apparatus can now be procured by which both gases can be blended
together as desired; considerable experience, however, is necessary
for their successful use. It is generally stated that nitrous oxide
alone should not be given to persons with fatty hearts or atheromatous
vessels. From a brief period of nitrous oxide anesthesia patients
usually recover within a few minutes and without after-effects; still,
relaxation of the sphincters may occur. After its prolonged use there
may be considerable headache and vertigo.


THE CHOICE OF AN ANESTHETIC.

This will depend upon who is to be the anesthetizer as well as upon
the actual condition of the patient. If an inexperienced person is
to administer the anesthetic, ether is safer than chloroform, though
slower. On the other hand, when given by an expert, and after due
preparation of the patient, chloroform is ordinarily preferable. The
latter is especially indicated in the young and aged, as well as in
those who have bronchitis or chronic cough, and those who have advanced
renal diseases or atheroma, because it is not likely to produce such
high arterial tension.

Ether should never be given near an unprotected flame, and lamps or
gas-jets should be held above the level of the operating table, as
the vapor of ether is heavier than air and will tend to sink. The
disadvantages of chloroform where natural gas is in use have already
been mentioned.

Efforts should be made to prevent struggling, as in the violence of
this unconscious act an overtaxed heart might yield, or at least
undergo dilatation. Chloroform is notably less likely to be followed
by nausea and vomiting than ether, and yet nausea cannot always be
prevented. There can be no doubt that morphine, alone or with atropine,
may be given with advantage to most patients before administration
of a general anesthetic. The treatment of postanesthetic nausea has
been referred to in the chapter on the Preparation and After-care of
Patients. By general consent, chloroform is the anesthetic of choice
during labor.


THE DANGERS OF AND ACCIDENTS FROM ANESTHETICS.

The principal dangers from any of the volatile anesthetics come
from interference with circulation and with respiration. The heart
may give rise to alarm by gradual _failure in strength_, while the
pulse becomes more rapid and irregular, or by sudden and apparently
complete _cessation of activity_. _When the pupils suddenly dilate_
and do not react to light danger is close at hand, if it have not
already manifested itself, and then is the time to discontinue the
anesthetic and resort to vigorous methods, which may include artificial
respiration, but must include attention to the heart. It is customary
to use injections of strychnine, which are often too weak or too small
to be of service, nothing less than ¹⁄₂₀ Gr., which may be repeated
in a few moments, will be of any service. If ¹⁄₁₅₀ to ¹⁄₁₀₀ Gr. of
atropine be given with the strychnine it will prove a much more
effective stimulus. It is right and proper to administer these drugs in
this emergency, but still more reliable measures are at hand.

_Sudden stoppage of the heart_, being the most disastrous accident
during or after anesthesia, has attracted no small amount of attention
on the part of experimenters. An active _massage of the heart_ seems
to furnish the basis for all the newer methods of treating it, all of
which are accompanied by artificial respiration. Some of Crile’s work
in this connection was alluded to in the chapter on Blood Pressure and
Shock.

[Illustration: FIG. 41

Showing how proper traction on the tongue pulls on the epiglottis.
(Hare.)]

Numerous investigators have revived the hearts of experimental animals
by massage and saline injections, and Crile has shown the advantage of
adding adrenalin to the latter. It is better to begin the efforts while
the heart is still feebly beating than to wait until it has ceased.
Ordinarily this massage should be made through the intact thorax, but
the time is coming when it will be esteemed life-saving either to open
the abdomen and massage the heart through the diaphragm, or to open
the thorax and do it directly. The former can be done during almost
any abdominal operation. The greatest obstacle to success has been the
formation of clots in the cardiac cavities. These are formed within a
few moments after the heart has ceased to act.

_Massage of the heart, coupled with the use of adrenalin_, will prove
of service.

_Approaching cardiac weakness_ is always indicated by failure of
capillary circulation, which may be easily and instantly estimated
by making pressure upon the finger-nails. The rapidity with which
the blood will return to give them a natural appearance, after such
pressure is made, will be the index as to whether or no stimulation
is necessary. Tardiness in return of color, or absence, is a better
indication of the approach of shock than is coldness of the nose or
moisture of the skin. It often precedes acceleration of the pulse.

_Respiration may be interfered with by a variety of causes._ Not
infrequently the tongue is allowed to drop backward into the pharynx
as the patient lies upon his back, which, by its pressure, causes the
epiglottis to fall backward upon and close the glottis. The indication
here is to lift the tongue forward and carry the epiglottis upward so
as to restore the air channel. Extension of the head and neck will
accomplish much in this direction, as well as holding the lower jaw
forward and upward by well-regulated pressure exerted behind the angle
and at the same time by upward and forward traction upon the hyoid
bone. But when it is necessary in cases of emergency to carry out this
maneuver forcibly and extensively, then the _tongue should be drawn
upward and forward_ in the direction indicated in Figs. 41 and 42.

Tongue forceps are often resorted to for this purpose, and can be
procured in various forms and shapes. To the writer their employment
has always seemed far more barbarous than the much simpler expedient
of passing a curved needle, armed with silk, through the tongue in
either direction, 3 to 5 Cm. back of its tip. The suture thus drawn
through is knotted and made into a loop, and may be employed through
a long operation to make all the traction that will be required. This
really makes the tongue less sore and produces _less swelling and
after-discomfort_ than does the use of forceps.

[Illustration: FIG. 42

Showing how dragging the tongue over the teeth fails to pull on the
epiglottis. (Hare.)]

Respiration may also be impeded or suddenly checked by the presence of
a foreign body. This may possibly be a plate which the anesthetizer
has failed to require the patient to remove, or it may be material
ejected from the stomach; this latter is especially likely to happen
when emergency has required anesthesia without due preparation. When
this happens the fingers should be passed behind the epiglottis and
the obstructing body removed. In rare instances some portion of food
may have been so impacted in the glottis as to completely obstruct it.
If such an emergency arise the trachea should be opened and relief
thus afforded. Only in this way can life be saved. Embarrassment
of respiration is caused at other times by the patient apparently
“forgetting to breathe” or by his taking such shallow inspirations
that nothing is accomplished. This may be combated in several ways. In
the former instance the use of ether or injections of atropine will
frequently afford the necessary stimulus to the respiratory centres.
In the latter class of cases especially the most valuable expedient is
the _dilatation of the sphincter ani_, which may be stretched with a
speculum, or with the fingers. Long-drawn, even gasping inspirations
may follow this expedient.

Finally in certain cases artificial respiration will be required,
combined with rhythmical traction upon the tongue. The tongue should
be grasped, or controlled by a suture, and _retracted from the mouth
at the rate of at least sixteen times a minute, while the chest is
compressed at the same rate_, the traction being made at the moment
of relaxation of chest pressure. Tongue traction alone will sometimes
renew respiratory movements in extreme cases.[9] Figs. 43 and 44 from
Hare, show the combined manipulation of inverting the patient in
order that the brain may not lack for blood supply, and carrying out
artificial respiration.

  [9] Freudenthal has called attention to the extreme irritability of
  both surfaces of the epiglottis, and advises to pass the index finger
  down upon it, irritating it by friction. This causes a powerful
  reflex effect, as the glossopharyngeal supplies its anterior surface
  and the inner branch of the superior laryngeal its posterior surface.

While these measures are to be regarded as emergency expedients, they
will often need to be supplemented by others, the use of adrenalin and
of salt solution, either beneath the skin or in the veins, and the use
of the Crile pneumatic rubber suit described in the chapter on Shock.

[Illustration: FIG. 43

Showing inversion of patient and method of performing artificial
respiration simultaneously. (Hare.)]

[Illustration: FIG. 44

Same as Fig. 43.]

There is a delay in the management of the patient after the conclusion
of an operation which is too often neglected--namely, prevention of
such exposure as shall produce a sudden checking of perspiration. The
patient should be wrapped in several thicknesses of blanket, leaving
only the face exposed; and only when fully conscious should he be
uncovered gradually and well dried with a bath towel. Such procedure
takes away much of the danger of congestion of the lungs, or of the
kidneys, which may cause serious disturbance should they occur.[10]

  [10] The following is quoted from a recent journal article by an
  unknown writer:

  _Acid Intoxication after Anesthetics._--Occasionally some surgeon
  reports a case of peculiar rapid fatal toxemia after a prolonged
  operation, the cause of which is obscure. We have also heard of this
  trouble after parturition, during which chloroform was given for a
  prolonged period, and the ultimate cause of the violent symptoms
  has been unknown. Now we are beginning to believe that anesthetics,
  especially chloroform, can produce a destructive effect on the liver
  and kidney cells very similar to phosphorus poisoning. In many cases
  a peculiar idiosyncrasy seems necessary to explain the toxic effect,
  but certain predisposing causes have been noted, _e. g._, hemorrhage.
  The symptom-complex makes its appearance from a few hours to a few
  days after the anesthesia, and consists of vomiting, restlessness,
  delirium, convulsions, coma, irregular breathing, cyanosis, and
  icterus in varying degree. The disease as described by Bevan and
  Favill is a hepatic toxemia, resulting from acute fatty degeneration
  of the liver, and seems to be a clinical entity. It is characterized
  by an acid intoxication, acetone, diacetic acid, and beta-oxybutyric
  acid being found in the blood and urine. Several clinical varieties
  must receive renewed interest in the light of this investigation.
  First is acute yellow atrophy of the liver, many cases of which occur
  after chloroform anesthesia. Next, the rapid death after abdominal
  operations, which have hitherto been attributed to intestinal
  toxemia; and lastly, certain fatal cases of nephritis after operation
  need a more careful study.


ARTIFICIAL RESPIRATION.

All foreign bodies should be removed from the mouth and pharynx. If
the patient have been in water he should be suspended head downward,
in order that the water may escape by gravity from the lungs. In all
of these methods _rhythmical traction_ upon the tongue will be found a
valuable aid in the procedure.

_Sylvester’s method_ utilizes the arms as levers by which to expand
the thorax, by means of the muscles which pass between them and the
chest. The patient is laid on his back, the shoulders somewhat elevated
and the head thrown backward. The forearms are seized just below the
elbows and carried upward over his head, by which movement the chest
is expanded; here they are held about two seconds, and then brought
down to the side of the chest and actual compression of the thorax made
with them, for the same period of time. When the chest is compressed,
an assistant may also press the liver upward and thus help to empty
the lungs. The intent is to make from sixteen to eighteen of these
movements in a minute. In children the movements are made more rapidly,
and in infants considerably more. It is usually necessary that traction
be made upon the feet to prevent pulling the body upward when the arms
are moved to expand the thorax. If the manipulations can be carried out
upon a table whose feet can be somewhat elevated this will also help,
as the blood is thereby induced to enter the cranium.

_Marshall Hall’s method_ is to roll the patient from his back on to his
side, the uppermost arm being utilized to make pressure upon the side
of the thorax in order to expel air. Then the body is rolled over on to
the back, by which movement the chest is expanded. This method is not
nearly as efficient as that mentioned above.

[Illustration: FIG. 45

Fell’s apparatus for forced or artificial respiration.]

In case of drowning _Howard’s method_ is quite applicable. The
maneuvers are as follows:

1. Turning the patient upon the face, with a large firm roll under the
stomach and chest, and protecting his mouth from the surface upon which
he is lying, press with full weight two or three times, for four or
five seconds, each time upon his back, so that the water is expelled
from his lungs and stomach.

2. Then quickly turn him face upward with the roll beneath his back,
with his head hanging downward and his hands above his head. The
operator then kneels astride over the patient, with the hips between
his knees, and grasps the lower part of the patient’s chest firmly,
bracing his own hands with his elbows firmly against his own hips.
With his full weight he then makes pressure upon the patient’s chest,
compressing it laterally for two or three seconds, gradually leaning
forward while doing this, and then with a sudden jerk pushing himself
backward. The intent here is to imitate the ordinary respiration rate
as above, or perhaps a little less often. This may be continued for a
half-hour or even for an hour, sometimes with eventual success.

There should be also massage of the heart, in addition to traction
upon the tongue. Artificial assistance should not be discontinued
until the patient is breathing regularly and sufficiently without
help. In Fig. 45 is represented the Fell apparatus for making forced
artificial respiration, this being a great improvement on the so-called
mouth-to-mouth inflation. The essential feature of it is a bellows, by
which the air is forced into the lungs, through a mouth-piece made to
fit tightly over the face, or through a tracheotomy tube. In accident
cases other measures, such as artificial warmth, etc., should be
employed.


MORPHINE AND SCOPOLAMINE.

Morphine offers no little aid in the production of anesthesia in many
cases. Those patients who are terrified by the thought of operation,
and who are in a semihysterical state when anesthesia is begun, may
be greatly tranquillized by a hypodermic injection of 0.01 to 0.015
of morphine, fifteen or twenty minutes previously. Given in this way
it acts as a heart tonic and general equalizer to the circulation.
If a small dose of atropine be added the effect upon the respiratory
centres is much enhanced. Again, in those cases where anesthesia is
begun without it, and patients prove very rebellious, it will have the
same happy effect. The only objection to its use is the nausea which
may thereby be produced. There is no way by which to dissociate this
from the nausea due to the anesthetic, elsewhere considered under the
heading of the After-care of Patients.

Patients can rarely be so completely put under the influence of
morphine as to justify its use alone.


=Scopolamine.=--The Germans sell under this name an alkaloid made from
the Solanaceæ, which seems to be identical with the _hyoscyamine_ of
the U.S. Pharmacopœia. Schneiderlin, in 1900, published a method of
producing anesthesia with little discomfort by using it combined with
morphine. The mixture seems more effective than either alkaloid alone,
but is rather slow in action. On the day preceding the operation a
trial dose of 0.02 of morphine and 0.008 to 0.01 of scopolamine may
be given. This will demonstrate the susceptibility of the patient to
the mixture. One hour and a half before the operation this dose, or a
larger one, should be administered, and, if necessary, another one of
smaller size fifteen minutes before the time of operation.

According to this method an interval of sixty to eighty minutes should
elapse between the first dose and the operation itself. When anesthesia
is thus produced it lasts from three to several hours. Others have
advised to divide the dose into three injections, giving the first
about two and one-half hours, the second one and one-half hours, and
the third one-half hour before operating. In some cases this has
produced complete and satisfactory anesthesia; in some it has not
been complete, while in others serious symptoms have been produced.
The statement that each alkaloid counteracts the dangerous effects
of the other is not substantiated; it is probable that the combined
effect is greater than would be that of either used alone. This mixture
should rarely be used, save in those cases where general anesthesia
is inadvisable, and where there are difficulties, even about the
employment of local anesthetics.


LOCAL ANESTHESIA.

The use of ethyl chloride, as the most volatile of the ordinary drugs,
by which chilling or freezing of the skin may be produced, has been
already mentioned. Other agents which chill or freeze may be used, _e.
g._, a spray of common ether or of rhigolene, or the local application
of ice and salt.


=Liquid Air.=--Liquid air, when available, affords an excellent means
of benumbing sensibility, since one or two very light applications, two
or three minutes apart, admirably serve the purpose. It is, however,
rarely available and should be used with great caution.


=Cocaine.=--Of the local anesthetics _cocaine_, or some of its
compounds or substitutes, will give the best results; although it
is said that injections of pure water, if sufficiently bulky, will
also answer the purpose of a local anesthetic. Cocaine has marvellous
properties upon mucous surfaces or in the tissues, but none upon the
unbroken skin. Where the parts to be operated are covered with skin
it is necessary to inject the drug with a hypodermic syringe, as in
the case of all deeper tissues. About the eye, the drug is used in
from 1 to 4 per cent. strength; in the nasopharynx, from 2 to 4 for
ordinary purposes; about the genitals, 2 to 5 per cent.; beneath the
skin, ordinarily in strength of 1 to 2 per cent. In operations upon
the nasopharynx and larynx it is often advisable to make a local
application of a small amount of an almost saturated solution, by which
a more complete effect is gained.

_Cocaine is not without dangerous toxic properties_, to which some
persons are peculiarly susceptible. It will seriously disturb heart
action in some; in others produce vertigo and mild delirium, and in
still others peculiar erotic symptoms. Warm solutions are more quickly
absorbed than cold ones. The use of more than 0.06 (1 grain) should be
avoided.

When the skin alone is to be anesthetized the injection should be made
into and not beneath. The nearer the cocaine solution is deposited to
the principal nerve trunk or branches the more promising will be its
effect.

The use of cocaine in operations, under general anesthesia, for the
prevention of those depressing influences which cause lowered blood
pressure and shock, has been alluded to in the chapter on Shock. For
instance, it is well to spray the larynx after opening it and before
making further operation upon it; while in all major operations in
which large nerve trunks are exposed or divided, _e. g._, amputations,
etc., the injection into the nerve trunks of a few drops of 2 or 3 per
cent. cocaine solution prevents this kind of disturbance.

For small and localized operations the direct injection of cocaine
into and around the area involved will prove sufficient. It is rarely
necessary to use for this purpose a solution stronger than 1 or 2 per
cent., especially if it is deposited drop by drop around the entire
margin of the area and if the part have been previously made bloodless
by pressure, as by the Esmarch rubber bandage. But when extensive
operations are to be undertaken the method of “_blocking_,” so called,
should be carried out. This consists in cocainizing the principal nerve
trunks which supply the part, for which purpose an accurate knowledge
of regional neural anatomy is necessary, with the intent to inject into
or closely around the nerve trunks a few drops of a 1 or 2 per cent.
solution. Working in this way by combination of injection, then of
incision, by which the nerve trunks are better exposed and more fully
protected in order to be more completely injected, and then proceeding
farther with the operative part, extensive operations have been and may
be done; such for instance as amputations, not alone of the limbs but
even of the shoulder girdle, removal of large tumors, etc. In this way,
for example, Kocher now removes most of the goitres which he attacks.
The essential feature of this work is to first get the cocaine inside
of the nerve sheaths. In this way a minimum of the drug is used with a
maximum of effect. Nevertheless when a large nerve trunk is thus to be
paralyzed temporarily it is best to inject the solution directly _into
it as well as around it inside the sheath_. Cocaine is a temporary
protoplasmic poison, and for the time being shuts off the afferent
power of the nerve. One advantage of this method is the avoidance of
shock as well as of pain. Another method, devised by Schleich, is to be
preferred. He uses three different solutions, of which the second is
commonly used. Tablets for making these solutions can now be obtained.
In order to secure the best effect with them the parts should be made
bloodless. The solution is deposited subcutaneously in a series of
drops around the margin of the area, and then massage may be made to
distribute the fluid more uniformly in the tissues. When the tissue to
be operated upon is inflamed the injections should be made first into
the healthy area on the proximal side.

Schleich’s formulas are as follows:

                          No. 1.
  Cocainæ hydrochloridi            .200 (gr. iij).
  Morphinæ hydrochloridi           .025 (gr. ²⁄₅).
  Sodii chloridi                   .200 (gr. iij).
  Aquæ destillatæ            ad 100.000 (f ℥ iiiss).

                          No. 2.
  Cocainæ hydrochloridi            .100 (gr. iss).
  Morphinæ hydrochloridi           .025 (gr. ²⁄₅).
  Sodii chloridi                   .200 (gr. iij).
  Aquæ destillatæ            ad 100.000 (f ℥ iiiss).

                          No. 3.
  Cocainæ hydrochloridi            .010 (gr. ¹⁄₆).
  Morphinæ hydrochloridi           .005 (gr. ²⁄₅).
  Sodii chloridi                   .200 (gr. iij).
  Aquæ destillatæ            ad 100.000 (f ℥ iiiss).

Various substitutes for cocaine are now on the market. Some of these
are soluble and some insoluble. _Eucaine_ is most commonly used,
especially in form known as _eucaine B._, or _beta-eucaine_. It is
weaker than cocaine, especially so in toxic properties, and solutions
of twice the strength can be used, often with satisfaction, and almost
always without danger. For urethral and eye work, _e. g._, it answers
the purpose; nevertheless, it will sometimes prove disappointing.
_Orthoform_ is a crystalline, sparingly soluble artificial product,
which is too light and too coherent to be generally serviceable. It
often gives satisfaction mixed with other powders or in ointments,
and it is usually free from toxic properties. _Nervanin_ is another
laboratory product, not equal in activity to cocaine, but almost free
from unpleasant properties. _Anesthesin_ is another similar product,
which is practically free from physiological properties save that it
acts as a local anesthetic. The latter may be employed for infiltration
anesthesia in the following proportion, recommended by Dunbar:

  Anesthesin hydrochloride     0.250
  Sodium chloride              0.150
  Morphine hydrochloride       0.005 to 0.015
  Water                      100.000 Cc.

_Stovaine_ and _alypin_ are among the latest synthetic substitutes for
cocaine. The latter seems to offer promise of usefulness.

Adrenalin may be added to any of these solutions in proportion of 1 per
cent. of a 1 to 1000 solution, and will have a beneficial effect in all
cases.


INTRASPINAL COCAINIZATION.

The intraspinal injection of remedies was first suggested by Corning,
of New York, in 1885; it remained, however, for Bier to perfect the
technique in 1899, and to make it so popular that the same maneuver
has been practised for various other purposes; as, for instance, for
withdrawal of cerebrospinal fluid in cases of hydrocephalus, etc., or
the injection of tetanus antitoxin. (See chapter on Tetanus.)

The intent in this use of cocaine is to spread the solution over the
surface of the cord and beneath the arachnoid. For this purpose a
needle about 4 inches in length, with a point not too sharp, preferably
gold or platinum plated, is used; with this also a syringe which will
hold 2 to 4 Cc., which can be firmly, yet easily, attached to the
needle. The accompanying illustration (Fig. 46) will give an idea of
the technique. The patient should be seated leaning forward so as to
curve the back and open the intervertebral spaces. A sterilized towel
is stretched tightly across the back from one iliac crest to the other;
its upper edge should then pass just over the spinous process of the
fourth lumbar vertebra. The injection is usually practised between
the second and third lumbar spines, or between the third and fourth;
the latter having been identified, the former are easily made out.
The needle is entered about 1 Cm. to the right of the middle line and
passed forward, inward, and upward, to a depth of 7 or 8 Cm. in the
ordinary adult, until the resistance offered by the tissues is felt to
have been passed and the point to have entered a cavity. If the needle
has been passed alone the escape of a drop or two of cerebrospinal
fluid will indicate that the spinal canal has been entered; if the
syringe is attached to the needle the piston should be withdrawn
in order to show the same result. It is possible to practise this
operation with a patient in the recumbent position, but it is done more
easily as above outlined. The skin may be frozen by the freezing spray,
or may be anesthetized by the local injection of cocaine solution with
the ordinary hypodermic syringe.

It is astonishing what beneficial effects can be gained from the use of
a small amount of cocaine. It is rarely necessary to use more than 0.03
(¹⁄₂ grain) of pure cocaine in order to procure analgesia of the entire
lower part of the body.

_Beta-cocaine_ or _tropacocaine_ may be used for the same purpose, in
double this amount, but they do not give as reliable results. Morton,
of San Francisco, has suggested that ¹⁄₂ Gr. powders of cocaine be
wrapped in such a way that they can be repeatedly sterilized by a
heat of 200° F., and that one of these be dropped into the syringe
barrel, that this be attached to the needle, and the cocaine itself
be dissolved in the cerebrospinal fluid withdrawn through the latter,
and then thrown back again. This is probably the neatest and most
serviceable method yet devised, and its originator has assured the
writer that with 1 Gr. of tropacocaine used in this way, thrown into
the spinal canal with considerable force, _i. e._, in such a way as to
more completely distribute it, he has been able to practise operations
even upon the tongue with little or no pain to the patient. The
solution used for this purpose should be sterilized, also the needle,
the syringe, the patient’s skin, and the operator’s hands. The water
with which the cocaine solution is made should be first pure, then
measured, and the solution made in such strength that not more than
the amount indicated above will be used. This should then be again
heated, but not quite to the boiling point, since cocaine solutions are
impaired by too much heat.

[Illustration: FIG. 46

Technique of intraspinal injection.]

The advantages of intraspinal anesthesia are many and obvious, and
were it not for disadvantages this method would have supplanted all
others for certain work. It is, however, by no means free from danger,
both from the maneuver and from the drug itself. Carelessness in its
introduction may lead to septic meningitis, while the drug itself may
produce considerable and even serious or fatal disturbance, though
these cases are rare. It has been claimed that 2 per cent. of the
cases in which this method has been employed have, in consequence,
terminated fatally. The immediate effects are largely confined to the
stomach and the nervous system, and include nausea, intense headache,
and profound depression. The remote effects are less positive, but
have been stated to include serious changes in the cord itself. It is
often a disadvantage to have the patient mentally conscious of what is
going on, even though oblivious to pain. Inasmuch as cocaine produces
analgesia rather than anesthesia, nervous patients will be likely to
mistake the general sensation of lifting a limb, or manipulating it,
for actual pain. There are not a few cases where chloroform and ether
are so plainly contra-indicated that if it were possible to use any
other agent with safety this would offer a valuable substitute.

The effect desired is not produced immediately, but comes on slowly,
after the expiration of ten to twelve minutes. As ordinarily used,
anesthesia of the surface will be produced up to the height of about
the waist. Should it be desired, however, to increase or enhance
the effect the solution might be injected between some of the dorsal
vertebræ, although at this point it will require more skill to
introduce the needle, and the operator should be cautious not to injure
the cord. Below the second lumbar vertebra the cord breaks up into its
segments and the patient would be almost exempt from this danger. It
is occasionally necessary to tranquillize the patient’s fear by using
morphine subcutaneously at the same time. It is a question whether this
can be safely combined with cocaine for the subarachnoid injection.
Failing in this it may be necessary to supplement the use of cocaine
with ether or chloroform.

The intraspinal injection of normal saline solution, or even of pure
water, has been shown by Eden to be almost as effective in some cases
as the cocaine solutions. Bier has largely modified his statements
about the value of intraspinal cocaine injections, and speaks of them
as more dangerous than he had first appreciated.[11]

  [11] _Magnesium Salts as Local Anesthetics._--Six years ago Meltzer
  discovered that magnesium salts have the property of inhibiting
  functional activity in nerve tissue, and in December, 1899, he
  announced that the intracerebral injection of magnesium sulphate
  in a rabbit caused paralysis without previous convulsions. He has
  recently announced the local anesthetic effect of small doses of a
  25 per cent. solution of magnesium sulphate, an effect which lasts
  from one to two hours. It is the magnesium “ion” which possesses the
  anesthetic property, since the chloride and the bromides give the
  same effects.

  These salts have this advantage over other local anesthetics that
  there is no primary period of excitation. Moreover, applied locally
  to nerve trunks they have the effect of “blocking” them; and when
  applied to the sciatic, pneumogastric, and other nerves, temporarily
  abolish their power of conducting influences, either motor or
  sensory. This effect is apparently due to the fact that the magnesium
  normally present in the tissues constantly exercises an inhibitory
  power over them, and that when thus applied from without they merely
  exaggerate the condition already present; thus, if this be true,
  affording an ideal anesthetic.

  In December, 1905, Meltzer read a paper before the New York Academy
  of Medicine, announcing success with intraspinal injection of
  magnesium sulphate in 25 per cent. strength. Blake, of New York,
  promptly made use of the suggestion in a child with tetanus. Two
  injections of antitoxin had been made into the cervical cord on
  successive days, with apparently no effect. He then made lumbar
  puncture and a subdural injection of magnesium sulphate, giving 1 Cc.
  of 25 per cent. solution for every twenty-five pounds of body weight,
  administering it every thirty-six hours, employing four doses. The
  effect was marked, in immediate control of convulsions, which,
  however, was not permanent; hence the repetition of the doses. How
  much influence the previous antitoxin had produced does not appear.

  Meltzer suggests that the best time for an operation is three or
  four hours after a spinal injection. He reports four cases thus
  operated, in one of which, after the operation, the patient passed
  into a period of deep general anesthesia, in which he remained for
  five hours, the pulse keeping up, the respirations falling to ten
  per minute. In this case another spinal puncture was made, some of
  the spinal fluid let out, and the spinal cavity treated by repeated
  irrigations with sterile salt solution.

  Meltzer’s few but important experiences indicate that at least three
  or four hours should be allowed to elapse after the introduction of
  the magnesium solution. He advises 1 Cc. for every twenty-five pounds
  of body weight, for intraspinal injection, which causes not only
  _analgesia_ but temporary paralysis of the legs, sensation and motion
  returning in from eight to fourteen hours, with possible retention of
  urine for a day or two, requiring the use of the catheter.

  Doses a little larger than the above, he thinks, would permit the
  performance of extensive operations in the abdominal cavity, or even
  higher up, without the aid of a general anesthesia. He is inclined
  to think that it would be preferable not to wait four hours, but
  to operate within about two hours after injection, with the aid
  of a small amount of chloroform, the operation to be followed by
  another puncture, with the removal of at least as much fluid as
  was introduced, and irrigation with sterile salt solution, finally
  leaving some of it within the canal.




PART IV.

INJURY AND REPAIR.




CHAPTER XXI.

WOUNDS AND THEIR REPAIR.


The old classification of wounds divides them into _contused_,
_lacerated_, _punctured_, and _incised_. For descriptive purposes these
adjectives are self-sufficient; they can be criticised only in case
the injuries differ in character. The adjectives thus employed allude
to the character of the injury as well as to its cause, but no meaning
should be conveyed by any of them other than to indicate a severance
of continuity in tissues. In either case cells are rudely torn apart.
But whether the injury be subcutaneous and the tearing make a ragged
surface; or whether the wound be an open one, with the possibility of
introduction of germ-laden air and grosser impurities, even though the
surfaces separated present an even plane, as in an incised wound; or a
channel or tunnel, as when made by a pointed instrument or a gunshot
missile, the principle is the same, and the same processes of repair
are brought to work to undo the harm. There is but one natural method
of repair, and that includes the exudate, or the utilization of the
fluid portion of the blood already poured out, and the activity of
cells, those which lie in the vicinity and those which are furnished
from a distance, _i. e._, leukocytes and wandering corpuscles. It is of
advantage to have the injury subcutaneous and protected from contact
with the air, yet extensive injuries of this kind are often much longer
in healing than those inflicted by the surgeon’s knife, when the parts
can be brought into complete apposition with each other by sutures.

It is the writer’s intent to simplify the description of the healing
processes and to insist that it is always the same, not modified in
character but in duration and extent, according to the nature of the
injury.


CONTUSION.

The term contusion implies a subcutaneous injury of varied extent,
in which laceration cannot be left out of consideration. Even in
the mildest contusion mechanical harm has been done, permitting a
dilatation of the vessels and the escape of fluid. Should this occur in
linear form, as by a whip-lash, there may be what is called a _wheal_.
In loose tissues swelling occurs more easily, as in the eyelid, the
scrotum, etc. Injuries of severity will produce laceration, at least
of capillaries if not of arterioles, and the result is the escape of
an amount of blood which will infiltrate the surrounding tissues and
discolor them and produce an _extravasation_ or _ecchymosis_. The blood
barely escapes and coagulates before its absorption begins. The fluid
portion disappears before the solid, and the pigment is usually the
last. There results a _black and blue spot_; the color when near the
surface is at first indigo or purple, and fades out through bluish and
greenish tints into a yellow, which may not disappear for two or three
weeks. Should blood collect in a cavity or in large amount the mass is
called a _hematoma_; this is especially common in the pelvis and in the
cranial cavity. Should a vessel wall give way from weakness caused by
disease instead of by accident the result is the same.

Contused wounds of the surface often cover excessive and even fatal
injuries within, as when a heavy object falls upon or injures the
abdomen or a limb. The skin is resistant, and the writer has seen a
limb pulpified by being run over by a heavy car, the skin being but
slightly torn. In such accidents exploratory incisions are imperative.
Better results will follow opening the abdomen in cases of severe
contusion, for the purpose of exploring the viscera, than will follow
the “let-alone” policy of waiting for something serious to appear.

An outpour of blood should be expected in every contusion, save the
most trifling, while clot formation may ensue. Whether the clot will be
absorbed or require the aid of the surgeon will depend upon its size,
its location, and its liability to infection. Clot in some locations,
_e. g._, pressing upon the brain or spinal cord, may justify extensive
operation for its removal.

_Pain produced by contusion_ is variable. When nerve trunks of
considerable size have been injured pain is frequently aggravated. In
general it is proportionate to the amount of swelling, _i. e._, to the
density or laxity of the injured tissue. When exudate occurs beneath
unyielding membranes, for instance the periosteum and the capsules of
certain organs, the pain may be severe. The appearance of discoloration
is proportionate to the depth of the injury and the amount of
hemorrhage. The time of its appearance will depend upon the distance
from the surface; after fracture of the neck of the femur it may not be
observed for several days. The general condition of the patient will
depend greatly upon his temperament. When there has been considerable
extravasation the release of the fibrin ferment may produce a mild rise
in temperature.


=Treatment.=--So long as air or other infection can be excluded the
treatment of contusions is simple. Cleanliness of the injured parts
should be enjoined; also physiological rest, by their confinement
within dressings or splints, or by placing the patient in bed. An
antiseptic application, dry, watery, or in ointment form, should be
applied upon a surface which has been abraded. Differences of opinion
exist as to the respective values of heat and cold. When the case is
seen early, before much swelling has occurred, the exudate may be
limited by the application of cold dressings; whereas if seen after
the swelling is at its height the use of moist heat may favor a more
speedy re-absorption. The effect of extremes, either of heat or cold,
is sedative, although hot applications afford more relief than do those
of ice. Of domestic remedies in use among the laity it may be said that
those which have any value owe it to the alcohol which they contain.
Elastic constriction will reduce the amount of exudate and assist in
the absorption of that already present. It is a measure, however, to be
used with great caution lest venous return be interfered with and edema
or gangrene be the consequence. A joint tensely distended with fluid as
a result of combined contusion and laceration, called a _sprain_, may
be emptied by aspiration, but this should be used only under antiseptic
precautions. Finally any collection of blood which fails to disappear
may be incised and cleaned, its cavity mopped out with compresses, and
its surface made to come in contact by pressure. In hematomas and large
extravasations of blood, sometimes in joints, but rarely in the pleural
or peritoneal cavities, this method may also be used.


LACERATED WOUNDS.

Lacerated wounds differ from contused in the character of the tears
in the tissues affected and in the exposure to infection by contact.
They vary in extent and severity. Not infrequently tissues or organs
of the greatest importance are lacerated, _e. g._, the globe of the
eye, the liver, the intestines. The term laceration itself implies
such open injury that part of it may be exposed to infection. The
first danger is from hemorrhage. This may subside spontaneously, or
may have been checked by some first aid, or may prove nearly fatal by
the time the patient is seen by the surgeon. The first measure will be
_hemostasis_ by the readiest and most effective measures at hand. This
may mean the application of compresses or of a tourniquet, or even of
manual pressure, until surgical procedures can be instituted. Shock
should be treated by lowering the head and raising the extremities, or
bandaging the latter, and the subcutaneous administration of morphine
or atropine. Emergency treatment of these cases should include removal
of foreign bodies, and such cleanliness and attention to antisepsis
as may be possible at the time. Support of the injured part should be
effected temporarily until dressings can be scientifically applied. If
cane sugar will keep fruit and meat from decomposition it will have the
same effect in human tissues, and a laceration with or without compound
fracture of bone may be filled with granulated sugar until a suitable
dressing can be applied.

The surgical treatment of laceration should include the following
measures: _Hemostasis_; the _removal of foreign bodies_, as well as
of tissue which is so injured as to make repair impossible or even
questionable; a careful _study of nerve supply_, in order to be sure
that no nerve suture should be made; a similar _study of muscles and
tendons_, in order that tendon suture may be promptly made; careful
_antisepsis_ throughout, asepsis being impossible; closure of the
wound by buried and superficial sutures, and such drainage tubes or
outlets as may permit free escape of whatever products of inflammation
or disintegration may result. There should also be provision for
physiological rest of the injured parts as well as of the patient’s
mind and body.

When large areas of skin or deep tissues are destroyed or torn away,
as in scalp wounds, avulsion of limbs or parts of limbs, it may be
necessary to retain that which can be saved and to remove that which
would slough if left to itself, thereby providing for flaps of skin by
which the wound may subsequently be covered, or leaving them in case
removal of a part must be made.

Everything which has vitality should be spared; on the other hand, that
which has lost its vitality should be removed at once. Thus amputations
may be sometimes called for because of extensive lacerations with
destruction of vascular and nerve supply, even though the bones be
uninjured.

In cases where the question of viability of tissues cannot be promptly
decided it is best to keep the injured part immersed in water as warm
as can be borne. In hospitals the entire body may be kept immersed for
days. By the use of warm water parts which have been seriously injured
may be restored. Ulcerations which are seen after the sloughing process
has begun can be best treated by immersion or by the application
of brewers’ yeast upon compresses or cotton. No other substance,
perhaps, will so quickly clear up an indolent or foul surface as this;
it hastens the time of separation of all that is dead or dying and
restores healthful activity to the surrounding tissues.

Extensive lacerations leave frequent opportunity for operations by
which function may be restored or improvement affected.


PUNCTURED WOUNDS.

The essential features of punctured wounds are sufficiently indicated
by the descriptive name; but harm may be done through a small external
opening. An important subvariety of punctured wounds is inflicted by
_gunshot_ missiles, which will receive consideration by themselves.
Injury to important vessels may lead to serious hemorrhage; while
injuries to nerve trunks may be followed by paralysis of sensation and
motion, or, as in the case of a sympathetic trunk, by the well-known
consequences of division of vasomotor nerves, _e. g._, in the neck.
When the punctured wound bleeds freely and externally it may be assumed
that some large vessel has been injured. When it bleeds into one of the
cavities of the body delay in recognition may occur. This is true of a
puncture of the skull by which the middle meningeal artery or one of
the sinuses is wounded, when the symptoms of brain pressure may tardily
or rapidly appear. In the chest the intercostal or internal mammary
artery may be so injured as to bleed into the pleural cavity and cause
death. A puncture of the heart frequently leads to fatal hemorrhage
into the pericardial cavity, and in the abdomen puncture of the various
viscera has led to consequences beyond help save when prompt relief
could be afforded.

The dangers attending punctures pertain to the introduction of
infectious material which may produce sepsis or may slowly produce
tetanus. No ordinary weapon or tool is clean in a surgical sense, while
a rusty nail is even less so. It will be seen, therefore, that the
danger inherent in such a case is not to be measured by either the size
or the depth of the wound.

In dealing with these cases the first attention is to be given to
_hemorrhage_. Obviously punctures in certain regions are much more
likely to be followed by hemorrhage, and any puncture in the vicinity
of one of the large vessels should be managed with caution, especially
if the surgeon ascertain that it had bled profusely when first
inflicted. Such a puncture, when seen a few hours later, may have
become occluded by clot, or a considerable hematoma may have formed
beneath the skin. It is safe to presume that there is more danger of
septic infection than can accrue from later attention, and it would be
advisable in such cases to anesthetize the patient and lay open the
parts freely under full aseptic precautions, in order that the clot be
turned out and any bleeding vessel secured. A brief study of such a
case will decide the question of injury to the principal nerve trunks.
A principal nerve which has been injured or divided should be carefully
sought for and its ends freshened and sutured. This is true also of
any tendon whose function is evidently lost. If the thorax have been
punctured and the physical signs indicate the presence of fluid, _i.
e._, blood in the pleural cavity, it should be incised and the blood
withdrawn. This method should also be applied to punctures of the
heart. These measures will be more completely dealt with in treating of
the surgery of the chest and its contents.

_Punctured wounds of the abdomen_ may give rise to great anxiety. If
none of the viscera have been injured they may be let alone, but if
doubt exists as to the safety or injury of any of them the abdomen
should be opened. (See Surgery of the Abdomen.)


=Treatment.=--For emergency purposes antiseptic occlusion is the
best procedure, and all punctures inflicted by ragged and infectious
materials, as rusty nails, should be treated by free incision, with
thorough cleansing and packing with antiseptic material, that the
wounds may heal by granulation.


INCISED WOUNDS.

Incised wounds are those inflicted by a sharp object which divides
the tissues abruptly and with a minimum amount of disruption. They
invariably bleed, sometimes seriously, even to a fatal degree, the
hemorrhage in such cases being due to severance of large vascular
trunks. Like contused wounds they vary as infinitely in extent as
in locality. According to their locality and dimensions important
structures may be severed, _e. g._, the trachea, the large nerve trunks
of the body, the tendons, etc., while visceral and joint cavities may
be more or less widely opened. When death occurs soon after injury it
is generally from hemorrhage. They are attended by the same dangers of
septic infection as are punctures, especially when there is neglect in
the emergency dressing. Should the pleural cavity be opened there may
be collapse of the lung.

_Hemostasis_ is the paramount indication in all incised wounds which
bleed seriously. Hemorrhage is to be controlled temporarily by any
expedient, later by ligation or suture, or both. The remarks above in
relation to possible injury to vessels and nerves are of equal force in
this consideration. Every divided nerve trunk, as well as every severed
tendon, should be reunited by suture. If a joint have been opened it
should be cleansed and drained, even though the incision be closed.
Should there be injury to any of the viscera, the wound may be enlarged
in order that exploration may be made and suitable remedies applied.
This is true of every punctured or incised wound. No hesitation need be
felt about enlarging it so as to permit of investigation. Hemorrhage
having been checked and all required attention having been given, the
closure of an incised wound may be made partial or complete according
to its condition. If fresh and clean it may be almost completely
reunited, using deep and buried sutures in order to bring into contact
its deeper portions, while superficial sutures will suffice for the
skin. Drainage may be by tubes or gauze or by loose suturing of the
surface; but no incised wound whose surfaces have become contaminated
should be completely closed by primary suture until all such surfaces
have been freely cut away and appear healthy and uninfected. An old
infected and gaping incised wound may be cleaned by the application of
brewers’ yeast, and when granulating it may be closed secondarily with
sutures, by which granulating surfaces are brought into close contact.

_Of wounds in general_ it may be said that there are mixed types as
well as illustrative examples. Thus a wound made by a hatchet or axe
may partake of the nature of contusion and of incision. In instances
where personal violence has been applied multiple wounds of varied
character may complicate the case. The statements made above pertain to
their conventional and common characteristics. Treatment which would
be proper in one case may be impossible in another. There is always
room for discretion and good judgment, though there are fundamental
rules which apply to all cases, and include exact hemostasis, surgical
cleanliness, repair of severed nerves and tendons, removal of foreign
bodies and involved tissue, and the enforcement of physiological rest.


REPAIR OF WOUNDS.

The process of repair is _essentially the same_, being modified
only by the needs of the wound and the tissues involved, and by
their environment. Whether soft tissues or bones are being repaired
the differences are apparent rather than real, as bony tissue is
temporarily decalcified, and then, as soon as the process permits, is
once more stiffened by deposition of calcium salts.

The process of repair should be begun immediately after the cessation
of the disturbance which has produced the wound, and as soon as the
bleeding is checked. It may be materially influenced and retarded by
the presence of bacteria or other foreign bodies, but its character
remains unchanged. Healing has been described as occurring by _primary
union_, or by “_the first intention_,” and by _granulation_, or the
“_second intention_.”

Wounds which have been permitted to remain clean, with their edges
brought together so that the surfaces are in contact, are healed
with a minimum of waste of reparative material, the process being
as follows: The small vessels are occluded with thrombi up to the
first collateral branches; the leukocytes begin to penetrate the
film of blood, which, having coagulated, serves as a cement to help
hold the surfaces together. By their proliferation and more complete
organization the gap between the surfaces is bridged with both fibrous
and capillary bloodvessels, and within sixty or seventy hours the clot
has become largely replaced by organized cells. Meantime from the
endothelial cells of the vessels and vascular spaces, as well as from
the fixed cells of the connective tissue, the so-called _fibroblasts_
are formed, which are later converted into connective tissue. Many of
the cells which have wandered to the scene of activity, or have been
there reproduced in unnecessary numbers, disappear again, either into
the circulation or they serve as food for the fibroblasts. Branching
cells attach themselves more intimately, and thus the original clot is
completely converted into _fibrous and connective tissue_, and this
becomes a _scar_, which extends as deeply as did the original injury.
New capillaries are rapidly formed by a budding process, and supply
the pabulum required for nourishment of the new cells. By fusion or
amalgamation of neighboring vascular buds complete new vessels are
formed, extending through the new tissue from one side to the other,
while around them the fibroblasts or connective-tissue elements arrange
themselves. From this it will appear that the coagulum which forms
within a wound is desirable as a scaffolding upon which the process
of repair may be begun. But it is desirable that this coagulum should
be small in amount, in order that these processes may not be too long
delayed; hence the advisability of removing all clots within a wound
when closing it, and preventing the formation or leaving of _dead
spaces_ in the tissues in which blood clots may collect.

_The process of granulation_ is not dissimilar to that described above,
save only in its gross appearances. Granulations consist of vascular
buds surrounded by leukocytes and lightly covered by them, while around
the base of each bud epithelioid and spindle cells arrange themselves,
these fixed cells organizing themselves more and more, as the wound
fills up, with the more superficial layers of granulations. In time
they are converted into a dense fibrous tissue which forms later what
is known as the _scar_. As before, also, the spaces between the young
capillary loops are filled with large nucleated cells derived from
the fixed cells of the tissue, and from the endothelial lining of the
newly formed vessels. Thus fibroblasts are produced in each case, and
are often more or less mingled with giant cells, especially if some
foreign body, such as a silk ligature, be embodied in the tissues. The
particular function of the leukocytes seems to be the removal of red
corpuscles and fibrin from the original clot.

The _granulation tissue_ thus constituted by capillary loops and
proliferating cells constitutes the basis of all wound repair. Later
this tissue assumes more of the fibrous and less of the cellular
character, while the fibroblasts arrange themselves in accordance with
the mechanical requirements of the tissues and the stress or strain
placed upon them. This tissue is at first vascular, but as it condenses
its capillaries become less numerous and smaller, and the final white
fibrous scar is usually almost bloodless.

When there has been loss of skin, or when skin edges are not brought
together, the deeper process of granulation needs an epithelial
covering, which cannot be afforded by mesoblastic or endothelial cells.
The formation of an epithelial or epidermal covering is a process
peculiar to epithelial tissue alone, and takes place mainly from the
cells of the rete Malpighii.

Epithelial elements of the skin will afford a large amount of covering,
and yet even their activity sometimes is insufficient and has to be
atoned for by _skin grafting_. Should the granulating surface be small,
and so situated that the fluid upon its surface may dry by evaporation,
there will result a crust or scab, which, while it conceals from
observation what is going on beneath, serves as an admirable
protection, beneath which proliferation of epithelium takes place. A
spontaneous detachment of the scab may take place when this process
is complete, and with the loosening of the crust it is apparent that
repair has become complete. This is known as _healing under a scab or
under a crust_.

Two clean and healthy granulating surfaces may be so placed in contact
with each other as to blend together by exactly the same process as
that by which granulations are first formed. This is called _secondary
adhesion_, or by the older writers the “_third intention_.” Advantage
is taken of this possibility in the application of what are called
_secondary sutures_, which may be placed some days before they are
utilized, with the intent to bring together surfaces so soon as they
shall present granulations.

One of the most interesting of all healing processes is that by which
_severed tissues_, when promptly replaced, often reëstablish vascular
communication and grow again in a satisfactory manner. Thus a severed
ear, nose, or finger-tip may be replaced, and, if carefully held _in
situ_, the parts being kept at rest, will prevent disfigurement and the
loss of important tissues. In these cases the severed tissue remains
passive several days until it has become vascularized. Meantime its
nutrition seems to be maintained through the medium of the living
tissues to which it has been affixed, probably by absorption of their
blood plasma.

Two human tissues are essentially non-vascular, the _cornea_ and
_cartilage_. The former appears to be nourished by cellular interspaces
which may admit leukocytes from the surrounding tissues, and through
these proliferation and vascularization occur; while a scar in the
cornea remains permanent, and the new tissue by which repair is brought
about never becomes transparent like the cells composing the cornea
proper. In cartilage scar tissue is produced, as in other tissues, by
a similar process, in spite of the extent of the cartilaginous layer
and its non-vascularity. In general the more specialized a tissue the
less completely does it heal, and the specialized tissues, like the
retina, etc., seem to be incapable of reproducing themselves. Low down
in the animal scale some parts can be more or less reproduced. In the
ascending forms there is less tendency in this direction; in man there
is little reproduction of an original tissue, scar tissue taking the
place of most of that which has been lost. An apparent exception to
this is seen in the osseous system, where a large amount of bone may
often be reproduced. Epithelium, also, whether on the external or
internal surfaces of the body, can regenerate itself in large degree
and amount. From every small island or mass of epithelial cells which
can be retained new cells may thus be reproduced; hence accrues the
advantage of leaving such epithelial collections whenever possible,
and wherever they may be beneficial. If upon a burnt area it happens
that epithelium has not been completely destroyed, new skin may be
confidently looked for from each clump of epidermal cells. It should
be remembered, however, that with the epidermization of a surface
under these circumstances merely an epithelial covering is secured.
The distinctively dermal appendages, such as hair, sweat glands, and
sebaceous glands, are not reproduced. If the highest ideal results are
to be secured in any case the parts must be put in the most favorable
condition, which means early surgical attention to every wound.


INJURIES TO VESSELS.

Bloodvessels are subject to contusion, to laceration, and to incision.
They may be contused by superficial blows, compressed against
underlying bone, torn in the replacement of old dislocations, or
punctured or incised by accidental or homicidal injuries. A vessel
which is not abruptly divided but is seriously injured will usually
sustain a separation of its internal and middle coats, which curl
up within the external coat, occlude the channel, and lead to
_thrombosis_. A vessel thus occluded may tend to gangrene of the parts
supplied by it or to a temporary ischemia, with numbness and pallor
if an artery, or to passive edema if a vein. In cases of such injury
it is always hoped that the blood supply will be provided through
the collateral circulation. If a vessel be torn or cut across there
may result a hematoma which may lead to immediate prostration, from
hemorrhage, and to gangrene by stopping the blood supply. Such blood
tumor rarely pulsates, but may cause extreme pain. The character and
the size of the swelling will depend upon the tissues which surround
the injured vessel. Cessation of the pulse on the distal side of an
injury nearly always implies temporary occlusion. _Traumatic aneurysm_
may be produced by lateral injury to an arterial trunk, by which its
continuity as such is yet not completely disrupted.

If a large outpour of blood has occurred it will be safer to incise
and turn out the clot and secure the injured vessel. In milder cases
the surgeon should do all that he can by rest and by position to
favor restoration of blood circulation. After the subsidence of acute
symptoms massage and gentle motion will serve to promote absorption of
the escaped blood. Cases will occasionally occur in which the principal
arterial trunk of a limb should be tied, hoping thereby to save the
member. Amputation may be the last resort when gangrene is impending.

_Injury to the veins_ is of a less serious nature in so far as
immediate consequences are concerned; nevertheless a punctured wound
or a large vein is always a serious matter. The pressure of the blood
may produce gangrene, or cause so large a hematoma that it should be
incised.

Fine silk sutures may be applied to wounded vessels, arteries or veins,
when they have been partially severed.

The healing process in all these cases is essentially the same. It
may mean the formation of a clot in or around a vessel, followed by
absorption of its principal portion and organization of what remains.
A vessel itself which has once been occluded by thrombus will usually
remain closed, a cord of fibrous tissue taking its place. Only in rare
instances is continuity of the blood channel preserved or regained. In
such cases the collateral circulation affords the life-saving feature.
The granulations which intrude themselves into the clot gradually
substitute tissue for coagulum, the conversion beginning promptly, but
often occupying weeks for its completion.

_Lymph vessels_ may be lacerated in almost any injuries and more or
less lymph escape with the blood. When the skin is torn from the
underlying parts lymph collects in the cavity thus made, while its wall
may undergo more or less organization, and formation of a _lymph cyst_
results. Should one of these connect with a good-sized lymph duct,
as, for instance, in the neck the thoracic duct, then lymph cysts of
considerable size might form. Should these rupture or be opened lymph
fistulæ might result.


INJURIES OF NERVES.

By small hemorrhages into a nerve sheath nerve function may be either
temporarily or permanently disturbed. A compression too long-continued
may lead to degeneration within the nerve fibers. Providing this do
not occur there may be complete restoration of function, or there may
result chronic neuritis, with pain and irritation. A later consequence
of all nerve injuries is more or less serious disturbance of sensation,
while still later parts supplied by the affected nerves may undergo
more or less atrophy as well as spastic contraction, by which loss of
function and deformity are produced.

There is a form of nerve injury which is due to the temporary pressure
of the elastic tourniquet, frequently applied around limbs previous
to operations, or to pressure which is made by crutch handles upon
the axillary plexus, and called _crutch paralysis_. _Limbs carelessly
allowed to hang over the edge of the operating table_ during prolonged
operations also have suffered in the same way. Such lesions are of the
character of a contusion, but are often followed by paresis, paralysis,
and by various sensory disturbances.

Injury to a nerve trunk having been recognized by a study of the
local features of a given case requires special treatment in case
laceration or more localized division can be assumed. The nerve known
to be lacerated and torn across should have its ends freshened and
be reunited by fine catgut sutures; also a nerve trunk known to be
punctured or divided. Such injury is not necessarily inflicted from
without, as it may be produced by a fragment of bone; in this case
the operation should be directed toward the bone as well as toward the
nerve trunk itself. A divided nerve trunk, if neatly sutured, heals by
the organization of blood clot, as in other instances, actual nerve
communication being made across the intervening clot by a process
of regeneration or reduplication of the true nerve elements, the
peripheral neurilemma playing an important part. Autogenetic power
decreases with the age of the individual. By careful nerve suturing
disability may be prevented.

Even months after injury much can be accomplished by nerve suture
properly performed. Symptoms similar to those of division may occur
when a nerve trunk is surrounded and compressed by bone callus after
fracture, as when the ulnar nerve is thus caught. If too long a time
have intervened it may be necessary to exsect the injured portion
and then bring the ends into apposition by sutures. Other methods of
atoning for these nerve injuries by nerve grafting, etc., will be
described in the chapter on Surgery of the Peripheral Nerves.

Neuritis may be overcome by counterirritation, preferably with the
_actual cautery_, _i. e._, the “flying cautery,” by massage, and by
galvanization. The pain in many of these cases can be mitigated, if not
completely relieved, by the x-rays, or by the high-frequency current.
In some cases nerve elongation may be brought to bear and a tender and
irritable nerve be thus brought under subjection.


INJURIES TO MUSCLES AND TENDONS.

Lacerations or divisions of muscles are usually repaired at first by
fibrous tissue, the result of organization of a clot. Later a true
muscle regeneration takes place and muscle scar finally disappears.
Atrophy of a muscle is not a sign of injury directly to itself, but
often results from injury to the nerve which supplies it; for example,
the circumflex nerve may be injured in shoulder dislocations, while the
deltoid muscle, which is supplied by it, speedily undergoes atrophy.

Muscle fibers may be torn by violent exertion. Such an accident may be
followed by pain and loss of function. An interval can often be felt,
even from the outside, between the torn muscle ends. The injury will
produce considerable hemorrhage. The amount of function regained in a
muscle will depend to some degree on the extent of its injury. If it
have been injured by an incised wound it will depend upon the way in
which it is brought together after an open incision. The origin and
insertion of such a muscle should be approximated by proper position,
and so maintained by the dressings, in order that perfect rest may be
more easily maintained. When a portion of the fascia or aponeurosis is
torn the muscle fiber may protrude and form a _hernia of muscle_.

_Tendons_ often suffer from _contusion_, in consequence of which
they may become adherent within their tendon sheaths; this leads to
stiffness of the part and more or less loss of function. Sometimes they
calcify, as does the adductor magnus tendon in the formation of the
so-called _rider’s bone_. The tendon most frequently injured is that of
the quadriceps, near the knee.

If it can be decided that a tendon has been divided or torn across its
prompt reunion by suture should be always practised. Also a divided
muscle, if exposed, should be drawn together with sutures, chromic
or hardened, so as to make them more reliable. Tears of aponeuroses
and fasciæ should also be sutured. Tendon suturing is nearly always
successful, especially if it can be done in a cleanly manner; while
tendon grafting is a measure which may be reserved to overcome the
consequences of injuries to muscles and tendons not disposed to repair.


INJURIES TO BONES.

Aside from simple and compound fractures, which are essentially bone
wounds, there may be seen hemorrhages beneath the periosteum or in the
immediate vicinity of bones, which are usually small in amount, yet may
cause considerable disturbance. The _traumatic hematoma of the scalp_
which often follows delivery is an illustration of an injury of this
class, the periosteum itself being sometimes separated. Collections of
blood under these circumstances which fail to disappear by absorption
may be incised and the contained clot turned out.

[Illustration: PLATE XII

FIG. 1

Young Granulation Tissue Following Bur., _a_, _aa_, thin-walled
capillaries. Large nuclei, fibroblasts horseshoe nuclei, leukocytes. ×
250.

FIG. 2

Young Scar. Numerous capillaries perpendicular to surface. Spindle
elements, fibroblasts considerably smaller than in Fig. 1. × 250.

FIG. 3

Mature Scar. Dense fibrous connective tissue with a few fibroblasts. At
_a_, a small bloodvessel. × 250.

Granulation Tissue organizing into Cicatricial Tissue. (Karg and
Schmorl.)

Illustrating statements made on several of the foregoing pages.]


CONTUSIONS OF THE VISCERA.

Contusions of the viscera may be followed by many and disastrous
consequences. They compromise such lesions as rupture of the liver,
kidney, spleen, laceration of the bowel, bladder, or gall-bladder,
and may occur by blows which do not break the surface; or any of the
viscera may be lacerated, punctured, or gashed by gunshot, punctured,
or incised wounds. These will be more completely considered in Chapter
XLV.




CHAPTER XXII.

GUNSHOT WOUNDS.


Gunshot wounds are usually considered with the special subject of
military surgery. Military surgery as such, however, consists in the
application of general surgical principles. Nevertheless a gunshot
wound is essentially the same whether it be received upon the
battle-field or in civil life, and the injury inflicted by a piece of
flying shell is in no sense different from that which may be received
in a blasting accident.

A gunshot wound is always contused and lacerated, and often punctured.
According to its size and shape, its location, the nature and velocity
of the missile, the distance at which the weapon was discharged will
depend its severity and prognosis.

Shot vary in size from those which weigh but a fraction of a grain
to buckshot which weigh nearly one-third of an ounce. Revolver and
pistol bullets vary in diameter from 0.22″ to 0.45″, and in weight
from twenty-five grains to ten times that amount, and nearly always
of conical form. They are usually made of compressed lead, sometimes
hardened by the addition of tin or antimony.

The old military weapons, such as the Springfield rifle, have been
entirely abandoned, and for them have been substituted rifles of
smaller bore, projecting bullets of from 0.25″ to 0.31″, varying
in weight from one-fourth to one-half ounce and attaining a muzzle
velocity of nearly 2500 feet per second. They have, therefore, a
much increased range and may kill at two miles. Their trajectory is
flatter and the character of the wound caused by these modern weapons
is different from those inflicted, for instance, during the Civil
War. The bullets now in use in the armies and navies of the world are
nearly all encased in a thin covering of steel, copper, etc., which
is known as the _jacket_ or _mantle_. They are from 3.5″ to 4″ in
length, possessing a much greater range than a shell bullet, while the
rifling of the weapon is so made as to give them a more rapid rotation.
In active service, moreover, these are usually fired with smokeless
powder. The so-called “dangerous zone,” _i. e._, that where mounted men
or infantry can be injured, is much wider than formerly.

In India the practice has been introduced of leaving the point of
the bullet uncovered by the mantle, so that when it strikes it would
“mushroom”--especially in the bone. These “Dumdum bullets,” as they
are called, from the place of manufacture, inflict much more serious
injuries than do the relatively smooth perforations made by the others,
and have been considered so cruel that they are excluded from use in
civilized warfare.

During the Russo-Japanese war, in which nearly all previous records
were broken, the deaths from gunshot wounds constituted but a small
proportion of the entire loss in camp and warfare, a larger number of
soldiers dying from disease and exposure. Statistics also show that out
of every 100 cases of gunshot wounds 12 per cent. have been produced by
bullets, the remaining portion being caused by shell, etc. De Nancrède
has epitomized some interesting figures which may be here quoted:
In the United States army during the Spanish war 4750 casualties
were accurately studied; of these wounds of the lower extremities
constituted nearly 33 per cent., those of the upper extremities nearly
30 per cent., those of the trunk a little over 22 per cent., and those
of the head and neck a little over 15 per cent. During the South
African campaign the mortality among the wounded was 5.7 per cent.,
essentially the same as that during our Cuban and Filipino campaigns,
and in marked contrast to the 14 per cent. mortality of the Civil War.
Considering that with our Mauser weapons the trajectory is practically
flat up to 500 yards, and they may kill up to a distance of two miles,
it will be seen that this difference in figures is important. The
British discovered in their campaign against the Afghans, who were
using antiquated weapons, that their own Lee-Metford bullets would
pass through their enemies without disabling them, while the British
soldiers who were once struck by the large, soft-lead bullets of their
antagonists were far more seriously injured or absolutely disabled.

As one explanation of the injury inflicted by modern projectiles there
has been advanced the theory that a bullet with a high-muzzle velocity,
striking an object while it still retains most of its original speed,
compresses and forces ahead of it into the wounded tissues a small
column of air, which, exercising an expansive force, produces more or
less explosive effect, that may be seen along the bullet track or at
the point of exit. These explosive effects are proportionate to the
size of the bullet, its bluntness, and its velocity. This theory was
more tenable in the days of large and blunt projectiles than today,
for in time past experiments have shown that when a bullet is dropped
into water from a height there is forced into the water along with it a
certain amount of air, estimated by Longmore at twenty times the actual
volume of the bullet itself. It may be doubted, however, whether the
rifle projectiles of today can produce sufficient air pressure to cause
the destructive effects thus attributed to it.

[Illustration: FIG. 47

_a_, completely shattered after perforating a horse’s thigh-bone at
220 yards; steel mantle stripped; _b_, ball with mantle torn off and
rolled up, core deformed, after shattering human tibia at 60 yards;
_c_, wholly disorganized ball, which destroyed middle metatarsal bone
of horse at 660 yards, steel-mantled; _d_, ball which shattered a human
femur at about 750 yards, steel-mantled; _e_, remains of steel mantle
and part of core lodged in human femur, wound inflicted at about 1100
yards; _f_, _g_, fragments of mantle found near the orifice of the
wound of exit at about 1100 yards’ range, steel-mantled; _h_, piece
of steel mantle split off by striking a dried horse’s metatarsal at
over 1300 yards; _i_, steel-mantled ball which perforated the internal
femoral condyle and lodged beneath the skin at nearly 2200 yards.
(Recent foreign report.) (De Nancrède.)]

Another method of accounting for shattering effects noted in many
of these wounds is hydrodynamic pressure, depending upon the
incompressibility of fluid and of tissue containing it, and the
narrowing of the space occupied by fluid as a result of the transfer
of pressure in all directions. Other things being equal, the most
marked effects would be manifest in organs containing the most fluid,
the effect increasing with the amount of fluid, the speed of the
bullet, its size, and any alteration of shape which it has undergone
in transit. It has been shown that the hydrodynamic pressure of
steel-jacketed modern bullets varies from six to eight atmospheres.
This theory accounts for the peculiar destructive effects seen in the
brain, the heart, the stomach, and intestines when struck at short
range.

Another method of accounting for the results of a bullet wound takes
account of the peculiar effect due to the rapid rotation of the bullet,
the movement given it by the rifling of the barrel from which it is
fired. It appears that a bullet travelling at the rate of 620 meters
per second will average about four rotations per meter. Even in passing
through a human body this would scarcely give it but two rotations in
transit, while in passing through any given bone the force would be too
slight to be appreciable.

While the theories mentioned above, the _hydraulic_ and _hydrodynamic_,
are attractive, yet they are unsatisfactory; we can do little more than
sum up the damage done by a rifle ball as due to arrest and divergence
of its energy, penetration depending upon its remaining velocity, its
preservation of its original shape, and the resistance offered by the
part injured. If the latter be great, and its shape be but slightly
changed, there are pronounced explosive effects. Moreover, one end of
the bullet is a little heavier than the other, and this will tend to
produce a certain amount of tilting, by which a key-hole wound may be
also produced. Fig. 47, from De Nancrède, shows the many alterations
in shape which may be produced under various circumstances. Again,
hard-metal jackets or mantles may be stripped off bullets before the
latter reach the body, or in passing through it, as has been shown.

Bruns has shown that with the ordinary small arms the size of the
wounds of entrance and exit diminishes with the decrease in velocity
or increase of the distance, although allowance should be made for
the manner and angle at which the bullet strikes the surface, the
wound being circular or oval according to these conditions. The wound
of exit will depend upon the direction of the axis of the bullet at
the instant it leaves it; thus it may be oval or irregular. When the
bullet in transit shatters or comminutes a bone the wound of exit may
be made much larger and more ragged than otherwise. In a general way
Bruns makes the statement that, other things being equal, the damage
inflicted by the escape of a projectile from the body varies according
to distance from the weapon. Thus up to fifty meters a considerable
amount of destruction of muscle, etc., may be produced. The area is
small and the track of the bullet is smooth and little larger than
the caliber of the projectile. Between 100 and 300 meters there is
little destruction of muscle, and the wound of exit is smooth and may
contain some bone debris. Thus Bruns would make it appear that the
distinguishable characteristics of near and distant shots appear in the
variations to be noted between the wounds of entrance and exit.

After a careful study of the alterations in the shape of the bullets
themselves, Coler and Schjerning reported at the Twelfth International
Medical Congress that only in 4.5 per cent. of all hits does deforming
of the bullet occur; if hits in the bones only are considered, the
percentage would be much greater. In wounds of the other parts alone
there is rarely any deforming effect upon the projectile. They also
show that careful distinction must be made between the deformity of
the bullet caused by the body and that resulting from impact upon some
object before reaching the body. Thus if a bullet have first struck a
branch of a tree, or some object upon the ground, it may have become so
altered in shape as to correspond almost to a Dumdum bullet. The harm
done by such a ricochet shot depends upon its unexpended energy and its
altered shape, but will always be greater than if it had struck in the
direction of its long axis.

The question of the heat imparted to a projectile in its course and the
possibility of its being sterilized by such heating are questions which
have been carefully investigated. The heat of a bullet produced by
penetration into a hard material will depend upon the striking distance
and the density of the material. In the human tissues the heat attained
by a bullet, even when penetrating a bone at short range, is rarely
100°C., while at long range it will scarcely amount to half of that.
There is no accurate measure of the heat that may be engendered in its
passage through the atmosphere, but the question is one of interest,
in that it brings up the possible sterilization of the bullet and its
capacity for destroying such septic material as it may carry in with
it. A series of experiments made in Baltimore and elsewhere permit the
following conclusions to be drawn:

1. The majority of cartridges in their original packages are free from
septic germs, this freedom being due to the precautions observed during
their manufacture.

2. As a result of this cleanliness the majority of gunshot wounds are
not septic.

3. Such resistant germs as those of anthrax, when applied to the small
bullet of a hand weapon, are rarely completely destroyed by the act of
firing, and it is possible to infect an experimental animal with such a
projectile.

4. The ordinary germs of suppuration are not always destroyed, and may
also cause infection.

These conclusions may be epitomized in these two statements: that
bullets from small hand weapons are not necessarily sterilized by the
act of firing, and that they also may infect.

The principal features to be noted in a case of gunshot wound are the
following:

  1. Hemorrhage.

  2. Shock.

  3. Pain.

  4. Powder burn.

  5. Localizing symptoms.

  6. Multiplicity of wounds.

  7. Entrance of foreign material.

  8. Explosive effects.

  9. Perforation of large vessels and the viscera.


1. =Hemorrhage.=--Hemorrhage may be internal or external. When internal
it is rarely so accessible as to permit of the saving of life, yet
the effort should be made to ascertain the source of the hemorrhage,
as only in this way can life be saved. For example: A patient may
bleed to death from injury to an intercostal artery, an epigastric,
etc., while in either case a very simple expedient would tend to
save life. External hemorrhage is generally due to injury of main
vessels, and may end fatally unless first help be instantly rendered.
Since the introduction into the army of a trained hospital corps,
and a widespread diffusion of a knowledge of “first-aid dressings,”
this is much less likely to occur than in the days previous to the
use of the emergency packet. Recent military experiences have been
that hemorrhages from limb vessels are much more likely to subside
spontaneously than those of the viscera.


2. =Shock.=--Shock is present in a large proportion of gunshot
injuries, especially those of the viscera and the region of the spine.
Experienced army surgeons speak of the peculiar facial expression in
those cases of shock which demand immediate attention.


3. =Pain.=--The symptom of pain is exceedingly variable. It is
rarely complained of at the time of infliction, especially when the
individual is laboring under stress of excitement. The pain of a
wound will be increased by every movement of the body. When momentary
pain is followed by local anesthesia, and especially if the latter be
permanent, it will indicate the division of a nerve trunk, which will
justify an operation for exposure of the site of the injury and nerve
suture.


4. =Powder Burn.=--Powder burn is met with only as one of the
complications of a short range and injury of an exposed part. Its
degree is modified by the distance of the injured part from the muzzle,
by the character of the powder, and the dimensions of the barrel.
Fish has shown that in a pistol wound at short range the burning or
scorching effects, which he calls the “_brand_,” are always found on
the hammer side of the weapon which inflicted the wound, _i. e._, if
the hammer were held up the brand would be above the entrance wound.
The bullet wound in such a case shows the direction of the aim, but the
recoil will so far change the direction of the barrel as to divert the
stream of gases of combustion, so that they follow the new direction
of the barrel, which is always toward the side of the hammer. This is
a point in medical jurisprudence which has been testified to in the
courts. The use of smokeless powder minimizes any effect of this kind.
It has been claimed that a homicide has been recognized in the dark
by the flash of the old-fashioned gunpowder used in the weapon, but
the use of smokeless powder would obviate this possibility. The most
distinctive part of a powder burn is the appearance of the tattooing
caused by the lodgement under the skin of grains of unconsumed
powder. Such grains, when accidentally or purposely contaminated with
germs, are not purified by the act of firing. This is less true of
certain brands of smokeless powder. Nevertheless the opinion prevails
that gunpowder may serve for conveyance of infection. The so-called
_smokeless powders_ are of secret composition, although it is known
that in a general way they are composed of gun-cotton, dynamite (_i.
e._, nitroglycerin), or picric acid. Melinite is composed of picric
acid and collodium--_i. e._, gun-cotton. There are many of the modern
explosives which depend for their final effect upon the combination of
two or more substances. In the smokeless powers there is usually enough
nitroglycerin to have a very noticeable effect should they be touched
to the tongue, while even the fumes might be disagreeable or disabling.


5. =Localizing Symptoms Due to the Presence of the Bullet.=--The
greater the distance and the smaller the velocity the more likely is
a bullet to lodge within some portion of the body instead of passing
through it. In the Cuban campaign the proportion of cases of lodgement
was less than 10 per cent. of the entire number of bullet wounds. A
bullet which rests within the body either will or will not produce
disturbances which may be more or less lasting. In a large proportion
of cases the latter will prevail. The number of pensioned soldiers who
are carrying unremoved bullets in some portions of their body is by
no means small. A rifle bullet may remain in certain portions of the
cranium without producing much disturbance. _Bullets which cause no
trouble are best left undisturbed. Those which produce serious symptoms
should be removed._ To Esmarch is attributed the dictum that the harm
produced by a bullet is usually done during its passage, and after it
has found lodgement it ceases to be a source of trouble. While not
invariably true, this is so generally the case that acceptance of this
statement has revolutionized the previously prevailing view, _i. e._,
that a bullet should be always removed if it be possible to locate
and extract it. In some instances it may be located by a study of the
symptoms; as, for instance, in certain areas of the brain, or when
lying in close proximity to joint surfaces it interferes with their
function; although a bullet embedded in bone often does not seriously
interfere with the use of the affected part. The bullet which divides a
nerve trunk rarely lodges in such position as to be considered when the
repair of the nerve injury is undertaken; such wounds will generally be
found to be perforating.

[Illustration: FIG. 48

Multiple shot wounds of arms and back. The ulcer over the spine was
produced by pressure, not by the ball (case in Cincinnati Hospital,
1884). (Conner, Dennis’ System of Surgery.)]


6. =Multiple Wounds.=--The same bullet may sometimes inflict _multiple
wounds_, and, with modern projectiles, these are now more common, as
many as six wounds having been made by one missile in its passage, _e.
g._, wounds of the arm and body. Thus multiplicity of wounds may not
indicate that the patient has really been shot more than once. In cases
of perforation, for each wound of entrance there should be found one
of exit, and at the first examination of the patient the discovery and
consideration of each of these injuries should be part of the routine.
If on examination but one wound be discovered, then the inference is
natural and unavoidable that the bullet is still within the patient’s
body (Fig. 48).


7. =Entrance of Foreign Material.=--The entrance of fragments of
cloth or other extraneous matter is now less frequent, for bullets of
tremendous velocity rarely carry in any perceptible material, their
diameter being small and their surfaces polished. A ricochet bullet may
carry tetanus or other spores from the earth, and lockjaw may be the
result. In other words, gunshot wounds now are less likely to become
infected wounds than they were years ago.


8. =Explosive Effects.=--The shattering and explosive effects of the
impact of bullets upon certain of the viscera are sometimes disastrous,
and yet not easily seen from the outside. This is especially true in
the brain, heart, liver, spleen, kidneys, and bones. Almost complete
pulpification of the semisolid viscera may occur as the result of
perforation by a small missile, and the general condition of the
patient should be relied upon to indicate this fact.


9. =Perforation of the Large Cavities of the Body= usually implies
perforation of at least a portion of their contained viscera. Thus if a
man be shot through the chest it may be assumed that perforation of the
lung has occurred, while in a case of bullet wound of the abdomen it
will rarely be found that the viscera, especially the intestines, have
escaped perforation. Still, remarkable cases are occasionally recorded.
Thus I have seen a man who had been shot through the abdomen from
front to back, the bullet entering just above the pubis and escaping
near the lumbar spine, who never seemed to have suffered seriously
from his injury, although the bullet was a large soft one from the old
Springfield musket.


=Diagnosis.=--More or less characteristic appearances pertain to most
wounds of entrance and of exit, which render them reasonably distinct
and recognizable, even though no history be obtained. Nevertheless much
depends upon distance, velocity, and any deformation of the bullet
due to its impact upon some other substance previous to its entering
the body. An elongated wound may suggest that the direction of the
bullet was at an angle with the surface struck. Such wounds are known
as “key-hole” wounds. A bullet already deformed may inflict a wound
that will baffle speculation. The wound of exit is usually a little
larger than that of entrance. When much larger a bone lesion should be
expected. Trifling punctures, perhaps made by particles of the bullet,
may be found around the principal wound or in the bone which it has
shattered.

Diagnosis may include a recognition not merely of the general character
of the injury, but whether it was inflicted by one or more bullets;
whether these bullets have escaped; and if not, in what part they are
probably lodged. In the preantiseptic days much of this information
was gathered by the use of the probe, and the porcelain-tipped probe
devised by Nélaton was relied on for much more than it could possibly
safely tell. In those days probing was indiscriminately practised, and
accomplished more harm than good. Now the probe is rarely used, at
least at first, and when used, it is connected with some electrical
device by which results are attained with a minimum of handling. For
this purpose the telephone probe of Girdner was formerly a popular and
ingenious device, which has been more recently supplanted by a simpler
mechanism by which, when the end of the probe comes in contact with
metal, a little bell, or buzzer, is rung. No probe or other instrument
should be introduced into a gunshot wound, for diagnostic or other
purposes, without observing aseptic precautions.

The most valuable expedient for the detection and location of bullets,
as of other foreign bodies, is the Röntgen ray. With a suitable
apparatus of this kind the surgeon can not only decide as to the
location of the missile, but whether it is best to attempt an operation
for its removal.


=Prognosis.=--In gunshot wounds not speedily fatal the prognosis
depends upon the part injured, the size and shape of the missile, its
velocity, the distance from the weapon, the amount of blood lost before
attention was given, the character of the attention first received, and
the absence of such complications as exposure, rough handling, etc. The
dictum that the _fate of a wounded man is in the hands of the surgeon
who first attends him_ made its author, Esmarch, famous. The patient
having escaped the dangers of hemorrhage and shock is to be carefully
guarded from sepsis, and if thus guarded can be protected against most
of the other visible dangers save those due to perforations of large
cavities. If, therefore, a gunshot wound can be promptly provided with
a primary aseptic or antiseptic dressing, and in other respects be let
alone, the outlook for the patient will be encouraging. The prognosis
often depends upon how completely the patient is let alone after the
application of occlusive dressing.


=Treatment.=--_Hemorrhage_ is the first consideration, and should be
the first care of the surgeon. Digital pressure may be resorted to,
which may suffice until a temporary expedient has been supplied. Next
in importance is disinfection of the area surrounding the wound and
the application of a sterilized absorbent dressing, with pressure to
prevent loss of blood. The use of the probe, or any attempt to at once
ascertain the location of the bullet, is not advisable. The question
is not, “Where is the bullet?” but, “_How much harm has it already
done?_” And the first attention should be addressed to atoning for any
harm that may have been done. Even though the intestines have been
perforated, or the heart wounded, there is no need in doing anything
more than meeting the immediate emergency. If shock be extreme it may
be atoned for in some measure by lowering the head and bandaging the
extremities; while in extreme cases hypodermoclysis or venous infusion
of saline solution, often with the addition of a little adrenalin, will
be of service.

Again, physiological rest of the part injured, _i. e._,
_immobilization_, as well as absolute rest of the patient’s body and
mind, must not be neglected.

Primary laparotomy has been done upon the battle-field, and is of
itself a testimony to the intrepidity and zeal of those who have done
it; yet, as a practice, it is to be condemned. All operations upon
gunshot wounds should be done in a well-equipped hospital.

[Illustration: FIG. 49

Gunshot wound of forearm. Bullet _in situ_ in bone.]

The probing of bullet wounds is so unwise that it may be well to state
the reasons for its general condemnation:

1. As it used to be practised, neither probe nor skin nor the
operator’s hands were sterilized.

2. Even when carefully done it is often absolutely disappointing, the
probe failing to reveal the presence of the bullet.

3. By the time the probe is introduced the wound will be usually more
or less filled with blood clot. To stir this with a probe is to invite
a secondary hemorrhage or annoying oozing.

4. Even when properly used the probe may carry in infectious material
from the surface.

5. Most wounds made by modern bullets, even pistol bullets, are of such
a character that it is difficult to follow their track without using
force.

6. I have known a wound on the anterior surface of the body to be
probed for a bullet that had escaped, as shown by an examination of the
other side of the body, which the attendants had failed to search.

7. If there be good reason for exploration of a wound let it be
postponed until the surgeon is prepared to follow a bullet and extract
it. _When it does not call for extraction, it does not call for
probing._

8. The best probe is the surgeon’s finger, and for its use the patient
generally requires an anesthetic and free incision.

When muscle is torn and needs suturing, or when tendons or nerves
are divided and need the same resource; when bones are shattered and
fragments need to be removed; when the skull has been fractured and
portions of bone driven into or upon the brain; when the intestines
have been perforated; when even the heart has been wounded and the
pericardium is filling with blood so that the heart’s action is
becoming impeded; in any or all of these emergencies the patient
needs surgical relief. But this should be of a kind that, save in
an emergency, should be postponed until suitable preparation can be
afforded.

[Illustration: FIG. 50

Wound inflicted at 1300 yards by steel-mantled ball (from a recent
foreign report). (De Nancrède.)]

[Illustration: FIG. 51

Shattering of humerus at long range with modern projectile; fusible
metal cast showing extent and character of laceration of soft parts
(from a recent foreign report).]

In regard to _regional indications_ in the treatment of gunshot wounds
it will only be possible here to give some brief general hints, the
reader being referred to the chapters on Regional Surgery for more
specific instructions. Nearly all gunshot wounds of bones are compound
fractures, and are comminuted as well. The best treatment is primary
aseptic occlusion and immobilization, without effort in the direction
of exploration. In an open wound the vessels should be secured, loose
pieces of bone removed, and jagged bone ends trimmed; while in some
instances a wire suture or other mechanical expedient may be resorted
to with advantage. Provision should also be made for drainage.

In the regions of the _large joints_ the same general principles are
applicable. Under the old _regime_ a gunshot wound of the knee would
condemn a person to amputation in the middle of the thigh. Now, if such
a limb be promptly provided with suitable antiseptic dressing, and
placed at rest, the patient may save not only the limb, but the use of
the joint. Extensive comminution may call for excision. Amputation is
seldom necessary, except when important bloodvessels have been divided.

[Illustration: FIG. 52

Perforating bullet wound of head, wound of exit showing brain
protrusion. Sloughing pressure-sore of scalp. Complete paralysis of
motion and loss of speech. Battle of Mukden. (Major Charles Lynch.)]

[Illustration: FIG. 53

Perforating bullet wound of head, with prolapse of brain at wound of
entrance. Operation done in Russian Red Cross Hospital at Mukden. Left
hemiplegia; mind clear. (Major Charles Lynch.)]

[Illustration: PLATE XIII

Radiograph of Head viewed from the Left Side, showing Mauser Bullet
Lodged in Brain. (Surgeon-General’s Report on Use of Röntgen Ray,
1900.)]

[Illustration: FIG. 54

Perforating gunshot wound of head; two wounds converted into one by
removal of comminuted bone. From Russian Red Cross Hospital, Mukden.
(Major Charles Lynch.)]

[Illustration: FIG. 55

Result of accidental explosion of hand grenade, in a Chinese coolie
with Fourth Division of Japanese Army, near Mukden. (Major Lynch.)]

[Illustration: FIG. 56

Shrapnel wound of leg necessitating amputation. Japanese soldier at
battle of Mukden. (Major Lynch.)]

_About the head_ may be seen all varieties of gunshot wounds and their
complications. The bullets from small weapons may not penetrate, but
those from larger ones usually penetrate and sometimes perforate.
Infection is not an uncommon sequel to all of these injuries, even
if involving the skin alone; the skull, especially the diploë;
the membranes, or the brain itself. (See Chapter XXXVI.) Septic
complications are more likely to occur in proportion to disregard of
antiseptic precautions in the first treatment. Usually the most serious
head injuries are those connected with penetrating bullets. Sometimes
the skull undergoes extensive shattering, and occasionally the base
is fractured. Instantaneous death, such as occurs when a soldier is
beheaded by a cannon ball, sometimes causes a peculiar cataleptic
rigidity, which is a species of immediate postmortem rigidity, by which
a body may be maintained in the position it occupied when struck.
Obviously, lesions at the base are still more serious than those of
the vertex, and wounds of the cerebrum are nearly always fatal. I have
seen a number of men who had been shot entirely through the head--by
Mauser or smaller bullets--who, nevertheless, recovered more or less
completely. In one soldier, I recall, the bullet traversed an orbit in
such a way as to divide the optic nerve. He was blinded, but recovered
most of his other functions; he remained well for some years, and
then developed symptoms of insanity. Epilepsy and other psychical
disturbances are all more or less frequent after head injuries. Plate
XIII illustrates how a bullet may be, apparently, harmlessly embedded
in the interior of the cranium. Sometimes years after such injuries
active symptoms make their first appearance. There can be no question
as to the value of the information usually afforded in such cases by
the aid of the _x_-rays.

The same necessity exists here as elsewhere for primary antiseptic
occlusion, including careful shaving and cleansing of the scalp.
Inasmuch as nearly every gunshot wound of the skull calls for
subsequent operation--just as does almost every compound fracture--the
parts should be prepared for it early, and everything else should
be left until the time when the surgeon is ready to make a complete
operation and meet all the indications. In such a case hemorrhage may
be temporarily checked by tampon. The surgeon should not omit to take
advantage of all the information which a study of cerebral localization
may afford him, since localizing symptoms may reveal not only the
course of a bullet, but something regarding its location.

_Penetrating wounds of the face_ are less serious than those of the
cranium proper. Occasionally a bullet striking a tooth will displace it
and drive it in some other portion of the face, _e. g._, the tongue.
Bullets and loose pieces of bone should be removed in wounds of the
face. Hemorrhage can usually be controlled by tampons. Interdental
splints may often be used to advantage, and in every case where the
mouth has been injured antiseptic mouth-washes should be frequently
used; in the case of the nose, an antiseptic spray should be employed.

The _neck_ is often penetrated, but if the spine and the important
vessels and nerve trunks escape, little apparent damage may be done. If
infection occur and suppuration take place resulting abscesses should
be opened promptly, as they might migrate into the thorax or axilla.
Even in the neck bullets which are producing no disturbance need not be
disturbed; but if positive irritation or paralysis be caused by them
they should be removed. Wounds of the larynx or trachea, by involving
the parts in subsequent stricture, may call for tracheotomy.

_Gunshot wounds of the spinal column_ below the neck are often
complicated by perforations of the thorax or of the abdomen. So far as
the spine is concerned the principal question is regarding the injury
to the cord itself. In rare instances cerebrospinal fluid escapes
from the wound; hemorrhage, or even the possibility of air entering
the canal, is a more common possibility. I have seen perforation of
the spinal canal, in connection with penetration of the thorax and
lung, so that, after the operation of laminectomy, air escaped through
the bullet wound in the spine with each inspiration and expiration.
Infection in spinal injuries is always to be feared and caution should
be observed regarding the maintenance of asepsis. The indications for
laminectomy scarcely differ from those in other injuries to the cord.
(See chapter on the Spine.)

_Wounds of the thorax_ are more likely to be penetrating than formerly,
owing to the conical shape and greater velocity of even small-arm
bullets. Emphysema does not necessarily imply perforation of the lung,
as air may enter through the external wound with each respiratory
effort. When an imaginary line connecting the wounds of entrance and
exit would naturally pass through the lung, it may be assumed that this
viscus has been perforated. Signs indicating such lung injuries are
peculiar pain, disorder of the respiration, more or less cough, usually
with raising of blood; when the pleural cavity is more or less filled
with blood there will be signs of pressure on the lung from presence
of fluid. In other words a bullet wound of the lung will usually lead
to a more or less complete picture of traumatic hydropneumothorax.
Sometimes external hemorrhage is severe, even though it come from an
intercostal or internal mammary vessel; usually the blood from these
vessels escapes within the thorax. I have known an intercostal artery
to be divided by a small pistol bullet which scarcely penetrated the
thorax of a man, who died in consequence, when the insertion of a small
tampon would have checked the hemorrhage and saved his life. Lung
tissue rarely bleeds seriously. When hemorrhage is from the lung it
comes from a divided vessel of some size. A collection of blood in the
chest is subject to the danger of infection, and empyema is a frequent
but somewhat delayed consequence of gunshot wounds of the chest; while
abscesses in the lung or mediastinum occasionally result.

To the _primary occlusion_, which should be the _first attention given
to every bullet wound of the thorax_, there may be added complete
immobilization of the chest. Fluid already present, unless it be
clotted blood, may be withdrawn by aspiration. Traumatic, not to say
septic pneumonia, is a serious complication. Should any operation
be called for, like removal of fragments of rib or the checking of
hemorrhage, it is best to make a free opening and a liberal removal of
all particles or fragments, with ample provision for drainage. Hernia
of any of the viscera through such wounds occasionally occurs.

[Illustration: FIG. 57[12]

Result of frostbite without gunshot. After battle of Mukden. (Major
Lynch.)]

  [12] Figs. 57, 58 and 59, as well as the others preceding credited to
  Major Lynch, are due to the courtesy of Major Charles Lynch, now of
  the United States Army General Staff, who was attached to the Russian
  Army as our Military Attaché, and who took them himself.

[Illustration: FIG. 58

Result of frostbite after two days and nights of exposure. After battle
of Mukden. (Major Lynch.)]

The subject of _injuries to the heart_ will be dealt with in the
chapter devoted to the surgery of that organ. Not every perforation of
the heart substance is fatal, and there are enough successful cases on
record of radical intervention by resection of the thoracic wall, and
of exposure of the pericardium, even of the heart itself, to justify
this method of attack in any case which will permit of it. Not the
least of the dangers pertaining to heart injuries is the impediment
to heart action caused by a collection of blood in the pericardial
sac. Should anything further be called for it would be warrantable at
any time to explore this sac and withdraw fluid through the aspirating
needle, through a trocar, or even by incision and drainage.

In the _abdomen_ all conceivable forms of injury may be met with, from
contusions produced possibly by a spent cannon ball, to lacerations
from fragments of a bursting shell and multiple perforations produced
by one or more bullets. A first requisite in all such injuries is
immediate antiseptic occlusion. This will not prevent such prompt and
further study of the case as may indicate suitable treatment. When
shock is extreme, indicating the possible result of contusions or
laceration, or when perforation of the stomach, intestines, or bladder
is probable, laparotomy should be performed at once. According to De
Nancrède the order of probable frequency of these injuries of the
abdomen is small intestine, large intestine, liver, stomach, kidney,
spleen, and pancreas. Multiple lesions are also common. The immediate
dangers are those from shock and hemorrhage, to be supplemented later
by imminent danger of septic peritonitis.

[Illustration: FIG. 59

Scene in operating room in Second Field Hospital of Fifth Division of
Japanese Army, at Mukden Railway Station. (Major Lynch.)]

The modern small bullet causes few surface indications as to the amount
of damage done within, as in the thorax. A careful consideration of
the location of the wounds of entrance and exit will indicate the
probability of perforation, especially of the hollow viscera. The
appearance of blood, either in the mouth or from the rectum or urethra,
the recognition of a rapidly accumulating amount of fluid, the presence
of gas in the abdomen, are all significant indications of perforating
injury. Several years ago Senn advised the insufflation of hydrogen gas
into the colon, on the theory that its escape from the intestine into
the abdominal cavity and thence out of one of the abdominal wounds,
where it could be lighted as it passed through a small tube, would
afford a certain and unmistakable test as to perforation of the bowel,
and such is undoubtedly the case. Nevertheless, it is not one which
is always easy or even possible of application, and no time should be
wasted in waiting for a supply of hydrogen for this purpose.

The safest course and the most life-saving one is _exploration_ when
there is any doubt as to the nature of the injury. This means an
operator possessed of good judgment, a suitable environment, rigid
antiseptic precautions, and a small incision to begin with, with
the finger as the best of all probes. The escape of bloody fluid,
bloody urine, or fecal matter will immediately justify a much more
extended incision through which complete orientation may be obtained.
The first incision may be best made as an enlargement of the bullet
wound, but any extensive operation within the abdominal cavity can
be made through a sufficiently long median incision. Only in this
way can the source of hemorrhage be ascertained. Thus the intestines
may be systematically gone over inch by inch. When perforations are
found they may be either dealt with as they appear--each opening being
closed transversely--or the entire intestinal canal may be exposed.
Contused spots will eventually slough, and should be treated as if
they were perforations. Injuries, therefore, of short portions of the
intestines might justify the removal of several inches. Instead of
making multiple resections, it would be better to remove _en masse_ the
involved portion of the bowel, and then make lateral anastomosis or
an end-to-end suture. Perforations of the mesentery as well as tears
in the omentum should be carefully closed. Everything which is not
vitally necessary and which has been injured should be removed. The
posterior surface of the stomach, the lesser cavity of the omentum, the
region of the gall-bladder and pancreas, the kidneys and ureters, and
the bladder should be examined, in order that injury may be detected.
After operations of this kind the abdominal cavity may be flushed with
sterile salt solution; while the question of drainage should be decided
upon the individual merits and indications of each case, as it is safer
to drain the contaminated peritoneal cavity than to rely upon mere
cleansing and drying.

If the _spleen or kidney_ be injured, it is safer to make a primary
removal of them; if they are not removed, posterior drainage should be
made.

In uncertain cases of abdominal wounds the back as well as the abdomen
should be scrubbed in order that if posterior drainage be necessary it
can be made without delay.

The _after-treatment_ of such patients does not differ from that of
non-traumatic cases. Abstention from stomach feeding, the judicious use
of salines, dependence upon hypodermoclysis and rectal nourishment, and
the use of opiates are all matters of importance.

When the _bladder_ has been injured there is usually more or less
injury of some of the other pelvic organs. An empty bladder will
escape more often than one which is full; while the latter will nearly
always leak into the peritoneal cavity or along the bullet track, thus
infecting one or both. The appearance of blood in the urine is one
of the indications of bladder injury, and sometimes the bladder will
fill with blood clot, which will produce the phenomenon of retention.
Such a case may rapidly succumb to infection if relief be not promptly
afforded, and this may come through abdominal section or a combination
of it with exploration through the perineum. Particles of clothing and
bone and even the bullet itself have been removed from the cavity of
the bladder. It is advisable to open the bladder from below and insert
a self-retaining drainage tube, by which, especially when combined with
the method of drainage by siphonage, as described in the chapter on
Surgery of the Bladder, a satisfactory and continuous emptying of the
organ may be maintained.




CHAPTER XXIII.

PREVENTION AND CONTROL OF HEMORRHAGE; SUTURES; KNOTS.


The first requisite after the infliction of a wound is to arrest
and control the hemorrhage. In many operations upon the extremities
precautions are taken to avoid its occurrence, and the so-called
bloodless method of operating, which is effected by the use of an
elastic bandage of pure rubber, is frequently employed and generally
gives satisfactory results. The pure-gum bandage was first introduced
into surgery by Martin, of Massachusetts, and its combined use both as
an elastic bandage and tourniquet was so promoted by Esmarch that it is
generally known as Esmarch’s bandage, and Martin has failed to receive
the credit due him.

The _elastic bandage_ used for this purpose should be about three
inches in width and five or six yards in length, and made of pure
rubber. The operator begins by applying this to the tip of the
extremity which is to be made bloodless. It is wound around the limb
in spiral turns, with sufficient force to press out the blood from
the tissues and to empty the vessels into those of the trunk. It is
continued above the site of the operation, and then the limb is either
constricted with a _tourniquet_ of the old type or with one of the
rubber appliances used for this purpose. A few turns of the rubber
bandage may be passed more tightly about the limb at this point and
secured with forceps. The rest of the bandage is then unwrapped from
the limb, which will be found pale and bloodless. Operation may then
be practised without the loss of more than a few drops of blood. All
divided vessels should be secured before the constriction is removed
and the wound closed.

In septic, tuberculous, and malignant conditions no such pressure
should be made, as harmful elements might be forced into the
circulation. In such cases the elastic tourniquet is applied high up
and no attempt is made to force the blood out of the limb. The limb
should be elevated so that its veins may empty before the bandage is
applied, and a certain amount of blood will thus be saved.

Care should be taken in graduating the tightness of the constricting
band, as well as its narrowness, and in preventing undue pressure upon
nerve trunks. Cases are on record of temporary and even permanent
paralysis, due to too vigorous application of the tourniquet, and
except upon large and stout limbs it is not often necessary to apply
it as tightly as is often done. Moreover even a wide rubber bandage
when stretched taut becomes little better than a rubber cord or rubber
tube and sinks into the tissues. A sterile towel should be folded into
a strip and wound around the limb, and then a tourniquet should be
applied over it so that pressure may be more equably distributed and
danger of paralysis reduced.

Exigencies may require the application of the elastic tourniquet as
high as it can be possibly used, either upon the shoulder or the hip.
This necessity is usually observed in amputations at those joints,
and the special methods required will be more fully dealt with when
speaking of these procedures. (See Chapter LVII.)

The elastic bandage should have been unrolled and sterilized with the
rest of the surgical equipment required, and even when so protected it
would be well to cover the limb with wet sterile towels before applying
the bandage, which is usually done at the last in order to avoid
contamination. When this is not done the final scrubbing should not be
effected until the bandage has been placed, the tourniquet applied, and
the bandage again removed.

[Illustration: FIG. 60

Illustrating forced flexion for control of hemorrhage.]

_The first measure, then, in the treatment of a wound is to prevent
loss of blood._ This may be done in various ways, and the method
should depend upon the circumstances of the case. In emergency cases
it may be accomplished either by direct pressure, by constriction of
the limb above the injury, or in some instances by mere position. If
it be possible to make direct pressure through the medium of some
clean--preferably sterile--dressing or material, this of course
would be desirable. In all civilized armies soldiers are now equipped
with a package of sterile dressing by which an emergency pad for
this purpose can be promptly applied. Railroads and steamers are now
providing emergency outfits. In injury of the arm or leg advantage may
be taken of position, _i. e._, forced flexion, which is maintained by
any measure or material which can be made available for this purpose
(Fig. 60). _Digital compression_ over a main vessel may also serve a
good purpose. Mere elevation of the part, as, for example, the head,
when not otherwise contra-indicated, or a hand or foot, will do much
to check venous or arterial flow. Moreover, in these positions reflex
contraction of arteries occurs, even in those of the head when the arms
are elevated. For this reason in cases of serious nose-bleed it is
often advisable to keep the arms raised high above the head.

Of other means resorted to may be mentioned:


1. =Extremes of Heat and Cold.=--Water at a temperature of 130° to 160°
F. is a powerful hemostatic. It stimulates contraction of the muscular
coats of the vessels and produces coagulation of the albuminous
portions of the blood upon the surface to which it is applied, and
in this way plugs the capillaries and small arteries and so prevents
oozing. Heat with pressure will be serviceable in many instances.
Cold may be employed by means of ice or iced water and may be made
serviceable in cavities like the mouth, the vagina, or the rectum,
after patients have recovered from the anesthetic and at a time when
hot water could not be borne. Cold has more of a constringing effect
but less coagulating property.


2. =Pressure Directly Applied.=--This may be made with a tampon in
some cavity, or by a graduated absorbent dressing whose effect may be
regulated by pressure of a bandage or an elastic bandage. Care should
be always given that pressure be not too long nor too firmly made, and
it should be released as soon as there appears edema of the part below
or any evidence of insufficient circulation.


3. =Styptics and Chemical Agents.=--There are many substances which
contract vessels and cause more or less coagulation of blood, and
at one time there were many of these in general use, but they have
been supplemented by other products, _i. e._, cocaine, antipyrine,
and adrenalin. The effect of cocaine is temporary, but sometimes is
sufficient in the urethra or the nasal cavity. Antipyrine, in 5 to 10
per cent. solution, alone or with cocaine, has a similar effect, but
is more lasting. Some years ago the writer stated that by mixing 10
per cent. solutions of antipyrine and tannin there was precipitated a
gum-like material of extraordinary tenacity. This will check oozing
from any part to which it may be applied, but it may adhere so tightly
as to make it difficult to later remove the tampon. Of the hemostatic
drugs, adrenalin has the most marvellous properties. It can be procured
in solutions of 1 to 1000. A solution of this strength, somewhat
diluted, may be spread or applied upon an oozing surface with almost
instantaneous effect.

_The use of gelatin in checking hemorrhage_ has given some satisfaction
upon the Continent, but has not found much favor in this country. It
consists of a solution of 2 parts of pure gelatin to 100 parts of
normal salt solution, which should be thoroughly sterilized. It is
injected subcutaneously to increase the coagulability of the blood, and
has also been injected directly into an aneurysmal sac or its immediate
vicinity to induce coagulation. It is likely that if the surgeon have
a patient with the hemorrhagic diathesis the combined use of gelatin
in this way and of calcium chloride internally would give satisfactory
results.

A styptic has recently been introduced by Freund under the name
“_stypticin_.” It is a product of the oxidation of narcotin, one of the
opium alkaloids, and is a yellowish powder of bitter taste. Chemically
it is cotarnin hydrochloride. It has been used especially in the
treatment of uterine hemorrhage, with a certain degree of success,
regardless of the cause of the hemorrhage. It may also be given in
cases of too profuse menstruation. The average dose is 2 to 3 Gr. (0.15
to 0.20) at intervals of two or three hours. When a speedy result is
desired twice the above amount in 10 per cent. solution may be given
subcutaneously.


4. =Destructive Methods= may include the use of the sharp spoon,
chemical caustics, or the actual cautery. The curette is usually
employed for removal of surfaces which have attained a spongy or easily
bleeding condition, as the interior of the uterus, bleeding ulcers
in other cavities, etc. When fungoid tissue is scraped to a base of
healthy tissue there is usually a cessation of further hemorrhage.
Occasionally there are cases of fungating cancer which bleed upon the
slightest touch. The most radical way in which to deal with these for
temporary purposes is to destroy the spongy tissue which bleeds so
frequently. The gross part may be done with the sharp spoon and the
cautery may be made to finish the work. Bleeding piles, when it is not
permissible to treat them more radically, should be touched with the
actual cautery, with stretching of the sphincter. The cautery knife
should not be made too hot, as it may act similar to a sharp blade
instead of merely searing by its heat.


5. =Mechanical Means.=--When vessels of considerable size or masses
of tissue containing them can be made accessible, the best means of
control of hemorrhage are those which can be applied directly to the
vessels. When this is not possible they should be tied _en masse_. A
method formerly in use was acupressure. To effect this a needle was
passed through the overlying skin beneath the vessel and out again, and
around this a suture was tied to make pressure. Since the introduction
of absorbable materials this method has been supplanted by the use of
catgut sutures, which may be tied, cut short, and left to absorb.

Under the term “forcipressure” is included the method of seizing
vessels before, or as they bleed, in small forceps, which are variously
shaped and constructed, and grouped under the name of _hemostats_.
Small vessels seized between the blades of such an instrument will have
their walls so crushed that blood clot is so quickly entangled that the
forceps can be removed in a few moments with little or no danger of
subsequent bleeding. Larger vessels should be ligated.

_Torsion_ is a substitute for ligature, especially with the smaller
vessels, and denotes a twisting of the vessel end after its seizure,
breaking up its inner coat, and effectually sealing its lumen. Some
surgeons rely on torsion for the large vessels.

_Angiotribe_ is the name applied to strong crushing forceps, by which
a pressure of several hundred pounds can be made through a lever
mechanism. In this a mass of tissue, as the broad ligament, can be
secured and such tremendous pressure brought to bear that its vessels
are crushed and destroyed beyond possibility of bleeding. Downes has
improved upon this mechanism by adapting to it an electrocautery
arrangement, by which not only pressure but also heat is brought to
bear. His instrument is called an _electrothermic clamp_. To all of
these instruments there are at least theoretical objections, in that
they are more or less clumsy or unwieldy and require special equipment.
They devitalize a considerable amount of tissue, all of which has
subsequently to be removed either by a process of sloughing or by
active phagocytosis; but they serve perhaps a useful purpose in the
crushing treatment of hemorrhoidal tumors. They have been used only by
a few, and have not found wide acceptance.


6. =Ligatures.=--These are also mechanical means of controlling
hemorrhage, but deserve to be grouped by themselves. Ligation of
vessels may be preliminary or may be performed as needed during an
operation.

By a _preliminary ligature_ is meant taking such precaution as tying
the carotid before operations on the face, the brain, or the femoral
artery before amputation at the hip. There is also the method of
temporary ligation of vessels by the application of a ligature which
should not be drawn too tightly, but simply serve the purpose of gentle
constriction for the half-hour or so during which it may be needed,
after which the vessel is promptly released. If this ligature has not
been too tightly applied the vessel walls will not have been injured
and circulation is restored. Crile has effected the same purpose with
the carotids by a small clamp whose pressure may be regulated by a
thumb-screw.

Ligation of large trunks is made for the purpose of influencing
nutrition by diminishing blood supply, as when the femoral is tied
for elephantiasis of the leg, or the carotid is tied or excised, as
suggested by Dawbarn, to cut off the blood supply from cancer of the
face or neck.

Ligatures are usually made of absorbable material, such as catgut,
chromicized or not, as may be desired, or of silk, which disappears
after a time, but which is not regarded as absorbable. For special
purposes other material has been used at times, such as strips of ox
aorta. The surgeon has his choice of these, whether he intends to
ligate the end of an artery or tie a vessel in its continuity. For
the latter purpose the ligature is threaded into an artery needle, or
a specially devised curved forceps known as the “Cleveland” needle.
When tying the exposed end of a bleeding vessel it is desirable to tie
near the cut end, so as not to leave tissue which should be absorbed,
and for the same reason to not include unnecessary tissue. One of the
forms of knot similar to the “reef” knot, which will not slip, should
be used. Silk has the advantage over catgut in that a knot tied with it
will rarely become loose, whereas catgut knots, unless carefully tied,
will occasionally slip. The ligature knots should be left as short as
is consistent with protection against slipping.


=Fate of Ligatures.=--Silk or celluloid thread are the most
unabsorbable of ligature materials ordinarily used. Even these usually
disappear after the lapse of time. Absorbable ligatures of catgut
disappear after a few days or weeks, according to the method of their
preparation. Absorption is practically a matter of phagocytosis, the
end of the vessel or tissue beyond the ligature disappearing with the
latter by the process of tissue digestion.

When vessels of large size are ligated the blood supply is taken up by
the collateral circulation. On the possibility or practicability of the
latter will depend the success of such operations as ligation of large
trunks for the cure of aneurysm. Should the collateral supply prove
insufficient, gangrene, beginning at the tip of an extremity, is an
assured fact.

The effects of the ligature on the vessel wall will depend upon the
security with which it is tied. The damage done to the inner and middle
coats by a ligature tied for permanent purposes is usually sufficient
to rupture them, after which they roll up inside the outer coat, while
the blood contained in that part of the vessel coagulates, the clot
extending to the first vessels above and below. This quickly organizes,
becomes infiltrated with cells, and brings about the complete
obliteration of that part of the vessel and its transformation into a
fibrous cord. This can only occur, however, when asepsis has prevailed.
Should the ligature prove septic the patient is exposed to two dangers:
that of secondary hemorrhage by ulceration and breaking down of the
clot instead of organization, and the ordinary dangers of septic
infection.

There are circumstances under which it may be well to modify the
ordinary methods of ligation and not to tie knots too tightly--_i.
e._, when the vessels are greatly weakened by extensive disease, or so
stiffened by calcareous degeneration as to cause them to snap under
rough handling. It has been suggested to use pieces of ox aorta to
prevent these accidents.

The dangers of _secondary hemorrhage_ pertain mostly to septic
conditions. In an absolutely aseptic wound, properly cared for,
secondary hemorrhage is almost impossible, but as soon as germ activity
begins lymph barriers are broken down, tissues softened, and weakened
vascular walls may give way.

Secondary hemorrhage may call for ligation of a main trunk not
previously attacked, but in a majority of cases will demand reopening
of the wound and further search for bleeding points. Should the
patient’s condition be materially weakened the effects of position and
of pressure may be tried in suitable cases. But the pressure which may
be effective to check the hemorrhage may be sufficient to completely
shut off circulation from parts beyond, and such pressure should,
therefore, be judiciously practised and its effects carefully watched.
The _signs of secondary hemorrhage_ will vary with the location of its
source. Occurring on or near the surface it will usually stain the
dressing; occurring deeply, as in the pelvic or abdominal cavities, it
will produce prompt symptoms of shock, _i. e._, lowered blood pressure,
whose degree will indicate the extent of the blood loss. In these
cases, unless the patient’s condition contra-indicate the measure, the
wound should be opened under anesthesia, and the source of the bleeding
sought out and mastered. The surgeon should never overlook the fact
that after the gradual restoration of the force of the heart’s action,
as the patient recovers from anesthesia and becomes uncontrollably
restless, vessels may bleed which upon the operating table scarcely
emitted a drop of blood. Experiences of this kind teach the value of
hemostasis during operation, and even of absolute rest induced by an
opiate, immediately after.

There are certain conditions in which the surgeon is led by experience
to anticipate liability to unusual hemorrhage; such as cases of
hemophilia, or anything that savors of it or of scurvy. In patients
who claim to be “bleeders,” the surgeon should be extremely chary and
careful during his operative work. There are, furthermore, certain
toxemias, especially that of cholemia, during which the blood is slow
in coagulation. When the time for preparation is afforded no cholemic
patient should be operated without a few days’ previous preparation by
four or five daily doses of calcium chloride, 20 to 30 grains given in
plenty of water. This is known to greatly increase blood coagulability,
and thereby to measurably protect the patient against the danger of an
oozing of blood difficult to control.

The other measures needful in the treatment of secondary hemorrhage are
those described in Chapter XVIII.


TREATMENT OF WOUNDS.

The general consideration of wounds in the previous chapters
necessarily included many suggestions concerning their treatment. The
first essential in the treatment of open wounds is exact hemostasis;
the next is the removal of dirt and foreign material of all kinds,
_i. e._, visible and invisible. Accidental wounds are practically
never received upon surgically clean surfaces, and it may be always
assumed that the possibility of infection is present. It becomes then a
question to what extent the surgeon should go in removing or avoiding
danger. Obviously all visible foreign material should be carefully
removed and all dirt should be scrupulously washed away. Emergency
treatment of a bleeding injury in a well-regulated hospital is one
thing, and the exigency of a railroad accident or casualty away from
civilization is quite another. The canons of antisepsis and asepsis
have been elsewhere sufficiently well laid down to indicate what should
be done at the time when it can be done.

The protective vitality of the human tissues permits them to
bear frightful injuries or resist infection in a surprising way.
But occasional escapes from severe accidents by no means justify
carelessness when caution can be taken, and cannot be held as excusing
the surgeon for any neglect in antisepsis.

A _bruise_ or _contusion_ accompanied by a slight abrasion may seem a
trifling injury, and yet by virtue of the injury the resisting powers
of the tissues may be rendered insufficient to protect them from
infection through a break of the surface. No relatively small lesions
of this kind can be safely neglected, but should be cleaned and covered
with an antiseptic compress, either wet with some suitable solution
or smeared with a protective ointment, or used dry with a suitable
antiseptic powder, as, for example, bismuth subiodide. Injuries
followed by considerable swelling should be treated according to the
time which has elapsed since their reception. If, for instance, a
bruise or sprain be seen early and before much swelling has occurred,
ice-cold applications can be made in the hope that, by limiting the
flow of blood, the outpour of fluids may be prevented. This effort
should be seconded by position, and perhaps by gentle pressure.
Conversely when a case is seen late, after the tissues have become
waterlogged with fluids, heat should be applied in order that by
stimulating the circulation reabsorption may more speedily take place.
In this case, also, suitable pressure may be of service.

When there is actual _hematoma_, and the exuded fluid fails to
disappear, an incision properly made and in the right place may
permit the clot to be turned out, and then speedy recovery secured by
coaptation with sutures and pressure.

_Poultices_ are nauseous applications to make to the human body. By
their indiscriminate use much harm has been done and suppuration
encouraged or brought about, which but for them would not have
occurred. There are occasions when a hot flaxseed poultice may be
of use, but they are very few and far between. With regard to such
remedies as arnica, witch-hazel, etc., the best that can be said of
them is that they may be of some use by virtue of the alcohol which
they contain; they serve the purpose, then, of a diluted alcohol and
nothing else.

There is virtue in the use of a _cold wet pack_, or compress,
especially in the treatment of chronic affections of the joints, and
their value can be perceptibly enhanced by using solutions of sodium,
or preferably ammonium chloride, and the addition of a little alcohol.
Absorbent material wet in such a solution, wrapped around the part,
covered with oiled silk or some impervious material, while the part is
kept at rest, will render valuable service in conditions of this kind.

In regard to the relative worth of heat and cold for relief of pain,
the alleviating effect of heat is more promptly manifested, but that
of cold is more permanent, and especially is this true of chronic
affections of the joints and bones.

In the _treatment of open wounds_, bleeding having been first
controlled, all the surrounding parts, as well as the wound itself,
should be sterilized. In a scalp wound the scalp should be shaved as
well as scrubbed. All particles of visible dirt should be carefully
picked out, and every particle of tissue whose vitality is so
compromised that it apparently cannot live should be excised. The wound
may then be irrigated or washed out with hydrogen peroxide, and not
until all this is done should the operator consider how he may best
close it, as well as whether he needs to provide for drainage. A ragged
line of tearing will leave a jagged and more unsightly scar, especially
on the face; therefore the margins of such a lacerated wound should be
trimmed before coapting them.

The method of closure will depend on the degree of tension necessary
for the purpose. Parts that come together easily may require but slight
suturing, and with fine catgut which will loosen of itself within two
or three days; the intent in such cases always being to assist the
sutures by proper support of the external dressings.

Buried sutures will serve a useful purpose in many instances, and
upon the face or exposed parts of the body a subcutaneous suture of
fine silk or horse-hair may be so applied as to be easily removed by
a single pull and leave but trifling disfigurement. Female patients
will be doubly grateful if the surgeon can leave but a minimum of
unsightly scar. Fasciæ will sometimes retract widely. They should be
brought together by distinct separate catgut sutures. Before closure of
a wound it is important to determine that no such structures as nerves
or tendons have been divided, or, if such injuries have occurred, to
reunite their ends by fine silk or catgut sutures. The writer prefers
silk for most of these purposes, although in a nerve a fine formalin
catgut suture would perhaps be the most ideal.

There are occasions when it seems impossible with the means at hand to
tie or secure in any way a deep bleeding vessel which has already been
seized with a hemostat. In such case the forceps may be left _in situ_
for thirty-six to forty-eight hours. This may be done, for instance,
in the groin, in the axilla, in the depths of the neck, and about the
cranial sinuses. Life may be occasionally saved by this procedure which
would be lost from hemorrhage without it. At other times a firm tampon
of gauze may be forced into the depths of a wound for the same purpose,
and maintained there by position, or by the pressure of secondary
sutures, which serve the same purpose and require removal in two or
three days. These measures refer rather to wounds of veins than of
arteries.

If one can be absolutely sure of his asepsis, he may close even an
extensive wound with little or no provision for _drainage_; but unless
he is certain regarding it he should provide at least for escape
of fluid by omitting a suture occasionally, or by drainage with a
tube or a cigarette drain. In compound fractures not only must such
provision be made, but the treatment of the wound may also include the
introduction of wire sutures through bone ends or the use of other
mechanical expedients.

The further and equally important treatment of wounds consists largely
in maintaining physiological rest of the injured part, as well as
the general welfare of the patient. _Pain_ which becomes unendurable
causes the patient to lose self-control and to disturb not only the
dressings but apposition of wound surfaces. Pain, therefore, should
be controlled by the mildest expedient that may suffice to master it.
Elimination must be maintained, because the circumstances attending
the injury may act to disturb it. A patient who shows no irregularity
of pulse, temperature, elimination, or general comfort may be assumed
to be doing as well as could be expected, and the dressings need not
perhaps be changed for several days. On the other hand, with rise of
temperature or pulse, increase of restlessness, swelling of the parts,
or discomfort in the vicinity of the wound, the dressings should be
promptly changed. It may be necessary to make such change at the end
of forty-eight hours in order to permit the removal of the drain. The
second dressing may then often remain a week, but any dressing which
becomes saturated, even with blood, may dry and adhere to the skin, and
should be removed.

It would be best to inspect the wound in all cases when the temperature
and pulse are rising or when there is any disturbance in the wound. The
accumulation of blood in an aseptic wound may cause much discomfort,
and by its presence interfere with primary union. Should, therefore,
a wound be found pouting or its edges reddened and swollen it may be
safely assumed that there is something wrong, and as many sutures
should be removed as may be necessary to reveal its condition and
permit of its treatment.

_Wounds which are foul_ or septic when they come under surgical
observation should be treated differently. Here the first attempt
should be at antisepsis. In some cases continuous immersion in warm
water will give the best results. I have never found anything so
prompt, however, in cleaning up a sloughing area as brewers’ yeast.
When this can be obtained it should be used in sufficient abundance to
get the diseased surface thoroughly wet with it. In sloughing cases
moist dressings are usually preferable, and the best are the two above
mentioned. This is true of those cases where part of the wound is
granulating satisfactorily, while part is acting badly. Dressings in
all of these cases require to be frequently changed, that they may be
kept effective.

I have elsewhere called attention to the value of granulated sugar as
an emergency antiseptic material of great value.


SUTURES AND KNOTS.


=Sutures.=--There are many varieties of sutures which have found
favor. Until the surgeon becomes expert by long practice he should
confine himself to few sutures and knots. _Primary_ sutures include
_continuous_, _interrupted_, _plate_ or _modified plate_, _quill_
or _modified quill_, _chain_, and _transfixion_ sutures, and also
certain forms of suture used in intestinal surgery. The above forms are
illustrated in Figs. 61 to 66. Several of them may be used in making
what are known as buried sutures, _i. e._, those which are tied deeply,
whose ends are cut off below the surface and left either permanently or
for later absorption.

The purpose of a suture is to bring the parts into accurate apposition
and so maintain them. It is a mistake to employ a superficial suture
alone, which may leave a “dead space” beneath it. If but one suture
is used, as in closing an abdominal wound, it should pass through the
tissue layers of the abdomen and bring each layer into contact with the
corresponding layer on the other side. Unless this can be done a series
of sutures should be used uniting the tissues layer by layer. If these
be made of formalin or chromic gut they will remain _in situ_ for a
length of time sufficient to serve their purpose. Some prefer silk for
this purpose, but it may work out later; if sterile and freshly boiled
just before using it will rarely cause this trouble. In closing a thick
and fat abdominal wall four or five tiers of buried sutures may be used
and their effect may be reinforced by the addition of a modified plate
or quill suture, as shown in Figs. 63 and 64.

Fine wire is preferred by some operators, and horse-hair by others.
Success pertains rather to the perfection of the method than to the
material used. The primary feature of all wound sutures should be
_prevention of tension_ and protection against it. Further support in
the same direction can be made by the use of adhesive plaster after
fastening the dressing upon the wound, thus taking off strain.

Certain expedients have been resorted to in superficial wounds, some
of which include the affixion of a strip of plaster on either side of
the wound and then the application of the suture material through the
plaster rather than through the skin. Plasters with small hooks have
also been applied, and then a shoelace suture applied over the hooks,
thus lacing the wound margins together. Such measures are convenient
for certain cases, although they make the maintenance of strict asepsis
difficult or impossible. Fine-wire clips have also been introduced,
by which skin margins may be held together for three or four days,
or until they have had time to unite with some firmness, after which
they may be removed. These little implements can be sterilized and
repeatedly used.

[Illustration: FIG. 61

Continuous suture.]

[Illustration: FIG. 62

Interrupted suture.]

[Illustration: FIG. 63

Modified plate suture, using gauze instead.]

[Illustration: FIG. 64

Modified quill suture, using gauze.] ] [Illustration: FIG. 65

Billroth’s chain-stitch.]

[Illustration: FIG. 66

Transfixion suture.]

[Illustration: FIG. 67

Reef knot.]

[Illustration: FIG. 68

Granny knot.]

[Illustration: FIG. 69

FIG. 70

Clove hitch.]

[Illustration: FIG. 71

Staffordshire knot.]

When an absorbable suture will serve the purpose it is desirable to
use it, since the necessity of subsequent removal is thereby avoided.
Inasmuch as every point through which a suture is passed will show
its own minute scar, it is desirable for cosmetic purposes to use a
subcutaneous suture, which may be made of chromic gut, silk, or fine
wire. If of catgut it may be left to disappear spontaneously; but a
silk or wire suture should be left with ends protruding from the wound
so that after a few days it may be withdrawn by steady traction in the
proper direction.

Secondary sutures are those which are placed at the time of the
operation, but either not drawn so as to unite the wound edges, or are
tied with a bow-knot, so that they may be untied and utilized later.
They are useful when either hemorrhage or suppuration is anticipated,
and when it is compulsory to pack a cavity with gauze.

_Every suture which has failed of its purpose or ceased to be effective
should be removed._ Ordinarily they are left in place from four to ten
days. They should be removed by dividing upon one side of the knot,
which should be seized with forceps and pulled upward and to the other
side. The suture should be cut at a point where it is moist, so that
only its flexible portion may be drawn through the parts which it
has held. Moreover the buried portion is more likely to be sterile.
Secondary sutures are usually made of silkworm-gut, celluloid thread,
or wire. So soon as they are found unserviceable they also should be
removed.


=Knots.=--The purpose of a knot is not achieved if it slips, and the
“surgeon’s knot” is best for the purpose, since in the first formation
one end is carried twice around the other before being tied in the
opposite direction. It requires more force in making it taut, but it is
safer than the ordinary reef knot (Fig. 67).

Figs. 69 and 70 illustrate the clove-hitch, which becomes firmer
the tighter it is pulled. It is rarely used in ordinary sutures or
ligatures, but may be made exceedingly valuable. The Staffordshire knot
(Fig. 71) serves especially for securing pedicles, which are first
transfixed with a double thread, the loop thus formed being slipped
over the stump and secured between the two loose ends of the ligature,
one end being placed over and the other under it; each is pulled
tightly and secured by an ordinary knot. When properly applied it is
effective. When knots are improperly applied none of them should be
trusted.

When wire sutures are used it is sufficient to twist the ends, unless
very fine wire is used, when it may be tied.




CHAPTER XXIV.

ASEPSIS AND ANTISEPSIS; TREATMENT OF WOUNDS.


The medical student of the present generation has no conception of
the contrast between the results of today and those of a generation
ago, or before the introduction of antiseptic technique and its later
perfection, asepsis. Under the term “_antiseptic_” should be included
those measures intended to combat sepsis, or surgical infection, from
without. The term _asepsis_ is of later date, and was introduced when
it was found that the prevention of infection was better than measures
calculated to overcome it, or atone for its presence. A perusal of
former surgical horrors will afford but an insufficient comparison as
to the incalculable benefits for which we are indebted to a small group
of men, of whom Lister is the most important; although the names of
Pasteur and of Ogston should ever be held memorable in this connection.
The two great nineteenth century achievements in surgery were
anesthesia and antisepsis, both of Anglo-Saxon origin, one American,
the other British.

It was the recognition of the parasitic, _i. e._, the germ nature of
surgical infections, which led to Lister’s first attempts to exclude
and combat the infecting agents. And while the original technique
which he introduced has been changed in nearly every particular,
the correctness of the views upon which it was based has been ever
broadened and strengthened. We have learned that simple measures may
be as effective as those more complicated, and the principal changes
which have been made in three decades have tended toward simplicity
and prevention. Thus heat has been made to take the place formerly
occupied by carbolic acid. And we have learned that parts made clean
need little antiseptic protection. We have learned that healthy tissues
are endowed with large powers of self-protection, and also that this
self-protection is interfered with by causes over which the surgeon
has sometimes but little control. _A wound in a body loaded with toxic
products is by no means protected against infectious agents by mere
external agencies._ The appearance of pus in a wound is a reflection
upon the surgeon. The ideal aseptic technique will include many days of
local and constitutional protection, as has been stated in the sections
on Auto-intoxication and on the Preparation of the Patient.

The methods of either antiseptic or aseptic technique include as a
fundamental basis the necessity for perfect sterilization of everything
which may come in contact with the wound, so far as the surgeon can
control it. The atmosphere contains in suspension bacteria, but their
contact is no longer dreaded, because of reliance upon the germicidal
powers of the fluids and tissues of the body. It is known, however,
that in accumulation of fluids there is danger as well to the tissues,
either from rude handling, application of large pressure forceps, the
insertion of too many stitches, or whatever else may lacerate or impair
the circulation.

There are parts of the body where no precautions can afford complete
freedom from germ activity, as in the mouth, the vagina, the rectum.
Here the surgeon must be cleanly in his work, assuring himself that
he introduces nothing new from without. Furthermore, after operation
upon these parts he must ensure his precautions by the use of
mouth-washes, douches, etc. On the other hand, ample opportunity should
be afforded for sterilization of the field of operation, of the hands
of the operator and his assistants, the instruments, ligatures, and
dressings--everything which may come in contact with the raw surface.

_Heat_, moist or dry, is the simplest of all sterilizing methods. It
is used in dry and in moist form. The most resistant spores are those
of anthrax, which is supposed to be a laboratory germ, one not seen in
practice. Most of the imported catgut is made from the intestines of
sheep, and sheep die frequently (on the Continent) of anthrax; it will
thus be seen that the danger of an anthrax infection is not so remote
as might first appear, and that no precautions are sufficient which
do not include a degree of heat and length of exposure sufficient
to kill these germs. In the operating-room, as in the laboratory,
has been introduced the method of “fractional,” _i. e._, _repeated
sterilization_. Most of the materials thus exposed may be left in
superheated steam under pressure from thirty to sixty minutes. They
are then exposed once or twice more to the same heat at intervals of
twenty-four hours. In order to make heat thoroughly useful its effects
should permeate everything which it is expected to so sterilize; hence
the addition of steam _under pressure_, especially when dressings,
towels, etc., are folded. It is well to have a form of sterilizer that
permits steam to be turned off and drying to be accomplished slowly by
the aid of dry heat.

Next to steam thus utilized is _boiling water_, in which nearly
everything can be sterilized. Silk sutures and silkworm-gut may also
be sterilized in this way; animal suture does not permit of it unless
previously hardened. The effectiveness of boiling water is increased by
adding to it 1 per cent. of sodium bicarbonate, by which its boiling
point is raised.

Dry heat is employed in an oven, or its equivalent, preferably in some
apparatus by which temperature can not only be measured but maintained.
In such a mechanism it is well to have the temperature raised to 300°
F. for at least half an hour, and then let its contents cool slowly.

Another method of sterilization is by using _volatile_ or easily
volatilized _chemicals_, such as formalin in its fluid form, or its
equivalent called paraform, which comes in crystals or may be had in
tablets ready for use. Formalin is a powerful bactericidal agent, and
if used in such form as to be sure of its penetration, good results may
be expected. Some materials and instruments which are injured by steam
or dry heat may be kept in an atmosphere of paraform, or sterilized
by exposure to formalin vapor, being then subsequently protected
against exposure in a sealed package. Catheters which have been boiled
or cleansed can be thus exposed, as Hutchings has shown, and can be
regarded as safe for use. They can, moreover, be resterilized in the
same way. Naphthalene has similar properties, but is not quite so
strong. The writer is accustomed to use one or the other of these in
jars or receptacles containing dry dressings, catheters, and rubber
gloves.

If aseptic methods are practised there will be but little use for the
employment of any antiseptic, either in solution or in any other form.

Boiled water and sterile salt solution should be available for all
purposes. It is customary, however, to have a solution of mercuric
chloride on hand, which is colored in order that it may not be mistaken
for any other, in which to rinse the hands, especially after they have
been in alkaline solution.

The first thing to be sterilized should be that part of the body upon
which operation is to be made. In some cases, as about the feet,
the mouth, etc., this preparation should be begun two or three days
beforehand; in other cases twelve to twenty-four hours will suffice.
Preparation should be begun with soap, nail-brush, and razor, the parts
being thoroughly cleansed and shaved. It is then customary with most
operators to keep a moist and antiseptic dressing applied upon surfaces
thus cleansed, which should be protected from drying by a covering of
oiled silk or rubber tissue. Green soap is usually employed, which may
have added to it a small percentage of carbolic acid or lysol. The
mercurial preparations are too irritating to the skin. Carbolic acid
has the reputation of being absorbed rapidly. On tender skins and in
certain parts of the body it is impossible to make such applications,
especially of soap poultices. Under these circumstances repeated
washings and some protection should be practised. Feet upon which
operations are to be made should be soaked repeatedly and scrubbed.
Twenty-four hours previously to operating on the head the scalp should
be shaved--preferably forty-eight hours--and prepared as above. For
operations in the mouth the tooth-brush and antiseptic mouth-washes
should be frequently used. For those in the vagina, douches, etc.,
should be frequently administered.

The preparation of the field of operation includes a final scrubbing,
with a washing of alcohol or alcohol and ether. The hands and external
clothing of the surgeon and his assistants should be sterilized, also
the towels, suture materials, instruments, and dressings.

Lawson Tait was the first to teach the great value of absolute and mere
cleanliness. This applies in large degree to the hands of the chief
operator and of the assistants. With a large amount of scrubbing and
cleansing of the hands it is not possible to put them into a condition
of ideal sterilization. This is perhaps more true of the hands of
some than those of others. A realization of this fact has led to the
introduction of _gloves_, either thin rubber or cheap cotton. The
former may be used repeatedly. The latter are sterilized by repeated
boiling and may then be used again. Rubber gloves may be sterilized
by steam or boiling water, and may be cleansed with soap and water or
one of the stronger antiseptic solutions. The introduction of rubber
gloves has brought great improvement in results. The gloves, however,
constitute an impediment to some of the finer work and the easy
recognition of tissue. Not the least important of the advantages of
rubber gloves is the protection they afford to the surgeon’s hands and
to other patients. Many accidental infections may be saved the operator
if his hands can be kept out of pus, while the use of gloves permits
the operator to pass from a pus case to a clean one without exciting
fear. A snugly fitting glove is best drawn upon the dry hand by the aid
of sterilized talcum. But the hand which it encloses should have been
previously thoroughly sterilized so that it will not be a source of
danger should the glove be pricked or torn. The operator can keep his
hands in more favorable condition by using gloves dry in this way than
by macerating his hands inside of wet ones.

_The question of hand sterilization_ is an important one, whether the
gloves are to be worn by some or all of the operating staff. There
are occasions when it is important to make the hands absolutely clean
because no gloves can be procured. Even the hands encased in gloves
should be thoroughly prepared, as there is no knowing when the glove
may tear and the surgeon’s bare hand come into contact with the
patient’s tissues. Running water is preferable to a basin filled with
it, for while it runs it carries away such material as may be detached
by soap or nail-brush. If it be not possible thus to wash the hands,
then repeated basins of sterilized water should be used, and all the
crockery or metal ware used in the process should be sterilized, so
that the hands will not be contaminated by handling unsterilized
material. Nail cleaners are essential agents, to be vigorously used,
and nail-brushes should be sterilized after each using, and there
should be a separate brush for each operator. The common soaps and even
the officinal green soap are not sterile. The former should be relied
on only for the first cleaning, and the latter should be sterilized
before use. A dirty hand should not be thrust into a receptacle
containing freshly sterilized green soap. The outside coating of dirt
should first be removed by an ordinary soap. Vegetable fiber has been
recommended by many, but it is not as good as ordinary corn-meal, which
should be sterilized before using. It is not as gritty nor as keen as
sand, and yet it is sufficiently rough to serve admirably the purposes
of a curry-comb. A first scrubbing with common soap and a nail-brush,
followed by green soap with corn-meal, and this by a thorough use of
the nail cleaner and a clean nail-brush, will ordinarily serve to put
the hands in a reliable condition. It is the practice of some to add
antiseptics to the soap, _e. g._, lysol and thymol. A number of years
ago I introduced ordinary _mustard flour_ for this purpose, basing
its use upon the fact that the essential oil of mustard is one of the
most potent of the vegetable antiseptics, in addition to its power as
a deodorizer. (Parenthetically it may be said that when unpleasant
odor attaches to the unprotected hands after making a postmortem
examination, or opening an offensive collection of pus, the use of
mustard will quickly remove the taint.) Even mustard is not absolutely
reliable, nor is anything else which can be tolerated by the human
skin. A method much in vogue a few years ago was to wash the hands in a
solution of potassium permanganate, and then to decolorize the skin in
another strong solution of oxalic solution. This method was at one time
regarded as an effective one, but it is severe upon the skin. Another
method in use at present combines commercial chloride of lime with
saleratus; here free chlorine is supposed to be the active agent.

The bacteriological side of this subject has been investigated by
numerous observers, particularly Dr. E. R. McGuire, attached to the
Buffalo Surgical Clinic, who reached the following conclusions:
Absolute sterility of the hands is unattainable, but as toward this
result nothing takes the place of long and vigorous mechanical
scrubbing under aseptic precautions; the use of antiseptics on the skin
is of questionable value and often distinctly harmful; the operator
whose hands perspire freely should wear gloves in every case; the use
of rubber gloves is not ideal, but gives the nearest approach to it.

No material should be used which is so harsh that it will injure or
destroy the epithelial cells either upon the operator’s hands or upon
the patient’s skin.

Solutions of gutta-percha in its different solvents, or of collodion
in acetone, have been suggested as forming a covering for the hands
by quickly drying upon the skin. The merit of these preparations is
questionable, and the length of time required to dissolve the coating
makes them impracticable. They have found little favor among surgeons.

Next to the sterilization of the parts to be operated, and the
hands, may be considered _treatment of septic tissues or fluids_ and
_protection against further infection_. Clean and uninfected tissues
need no other precautions than those already described, _plus_ extra
care in hemostasis, in order that there be no clot left in which germs
may find a nidus, and the careful closure of the wound in such a way
that no cavities or “_dead spaces_” may be left in which blood may
later collect. Surgeons generally agree that the less clean tissues are
handled and the less contact they undergo with foreign materials the
more readily they heal. The ideal fluids with which to cleanse parts
or to wash away blood clot are sterile salt solution and boiled water.
Antiseptic solutions should not be used upon healthy tissue; but when
abscess cavities have been opened and when pus or other infectious
material have come in contact with fresh raw surfaces, every effort
should be made to overcome its effects. It is customary in abdominal
operations to “wall off” the site of a pus focus so that contamination
of adjoining surfaces may be avoided, by placing gauze packing around
it. Other expedients, _e. g._, the use of a rubber dam in any of its
modifications, which will aid in this purpose, should be adopted.
Upon brain surfaces, as upon the ruptured perineum, and in vaginal,
rectal, and numerous other operations, a continuous fine stream of salt
solution may be directed with great benefit.

An _abscess_ of any kind, no matter where located, should be
_thoroughly cleansed_, its cavity disinfected, and easy access made
to the outer wound. The interior of such cavities should be scraped
with a sharp spoon. After curetting, a thorough washing or swabbing,
often with the use of hydrogen dioxide, will often prove serviceable.
Even a treatment of this kind does not afford as complete disinfection
as may be secured by free application of pure carbolic acid or of a
strong solution of zinc chloride (50 per cent.). The effect of this is
not only to more completely sterilize, but to so sear the cauterized
surfaces as to make them incapable of absorption. Excess of the
caustic should be wiped away, or antidoted, in the case of carbolic
acid by further swabbing with alcohol, or in the case of zinc chloride
by merely washing out. Such a surface should heal naturally after
sloughing, yet it is rarely safe to completely close such a cavity. A
light packing of clean gauze, or, as the writer is fond of using it, of
gauze sopped in balsam of Peru, will permit such a cavity to quickly
close by the granulation process without further disturbance. Bone
cavities, especially, are well treated with zinc chloride, it being
difficult to so thoroughly disinfect such a focus that it may be safely
closed without drainage; or they may be filled with bone chips or
paraffin.

Visible tissue which is sure to slough should be removed with scissors
or the sharp spoon, in order to save valuable time. Sometimes the
actual cautery may be used to great advantage, as in chancroidal
buboes, where every particle of raw surface will be infected by the pus
which flows over it, and where it is advisable to cauterize not merely
the suppurative focus, but everything which may come in contact with
its pus.


=Instruments.=--Instruments are now all made of metal, usually
nickel-plated, which will stand at least a certain amount of exposure
to heat. It is not sufficient, however, to sterilize instruments
alone, but basins, irrigator nozzles, and everything else which may be
wanted during the course of an operation should be equally prepared
for it. Inasmuch as hard rubber does not well stand even boiling
water, instruments should be made, so far as possible, of metal or
of glass. Boiling water, or “live” steam, are universally employed
for this purpose; while to the water is often added 1 per cent. of
ordinary washing soda, which enhances its serviceability. Fifteen to
twenty minutes’ actual boiling, or its equivalent, will be sufficient
for ordinary purposes. All instruments, such as knives and scissors,
deteriorate after repeated use in this way and need to be frequently
sharpened. Catheters also may be sterilized by boiling and should be
constantly kept exposed to some volatile antiseptic, such as formalin
(see above). Sterile material should be used upon the inhalers, and the
metal parts of these, as well as mouth-gags, hypodermic syringes, and
the like, should all be boiled.


=Dressings, etc.=--Not only the dressings which are to be employed
after an operation, but the gauze, the cotton, or the sea-sponges
which may be used during the same should have been twice sterilized
either by dry heat or steam, in order to ensure security. No absorbent
material should be packed tightly if it is to be subjected to steam, as
it is not easily penetrated, even under pressure. Moreover, not only
these materials but the sheets, gowns, aprons, towels, splints, and
everything which may come into near approach or actual contact with the
wound should be prepared in the same way. After sterilization all these
materials should be enclosed in germ-proof, sterile wrappers of some
kind or in sterile jars or boxes.

As a postoperative precaution, all materials which can be destroyed
after use in a septic case should be _burned_. If this be not
practicable, they should be soaked for twenty-four hours in a strong
solution of corrosive sublimate, say 1 to 500. At the conclusion of
operation there should be no opportunity left for dissemination of
infection.


=Sponges.=--In place of sponges, gauze or absorbent cotton wrapped
in gauze are now generally in use, prepared as above. There are some
purposes for which sea-sponges are very convenient if they can be made
reliable. Those which are received fresh from the dealer should be
freed from sand by beating in a mortar, placed in a solution of 1 to
500 of potassium permanganate, and then transferred to a solution of
sodium sulphite containing 5 per cent. by volume of pure hydrochloric
acid; in this they remain until they are bleached out, which will take
but a few minutes. They are then thoroughly washed in sterile water and
stored in 5 per cent. carbolic solution.


=Suture Materials, etc.=--Wire, silkworm-gut, horse-hair, and silk or
linen thread may be sterilized, if not rolled too tightly, by twice
boiling for a half-hour, and then being allowed to dry, or preserved
in 5 per cent. carbolic solution or in sterile alcohol. Disappointment
often comes from rolling these materials so tightly upon spools that
sterilization of the deeper layers is not complete. This is true of
catgut as well as of the other animal sutures.


=Catgut.=--_Catgut_, so called, is usually made from the intestine of
the sheep, and must be freed from anthrax germs or spores. It should
be rolled loosely on spools or rods, each layer separated from that
beneath by a piece of gauze. The writer prefers to free it from animal
fat by a preliminary soaking in ether or benzene. After this it may
be sterilized by boiling in alcohol, preferably absolute, which must
be in a container not tightly closed. This is placed in water, raised
gradually to boiling, and should boil for two hours. This process
should be repeated at least once after the expiration of twenty-four
hours. This is the simplest of all procedures and generally proves
reliable. Other methods are those of exposure, for instance, to cumol,
a volatile paraffin oil, in which it is boiled under pressure in a
special apparatus, the temperature being raised considerably above
the boiling point of water (300° F.). When the receptacle is opened
the cumol is drawn off or evaporates and the catgut is left dry and
sterile. It should be either kept dry in a sterile jar or in alcohol.
Some prefer to add to the latter a small amount of oil of juniper,
which has a little hardening effect upon the animal material.

Catgut should be tested repeatedly to be assured of its sterility.
Special methods of preparing catgut are as follows:


=Formalin Gut= is prepared by placing the gut, wound as mentioned, in a
3 per cent. formalin solution for three hours. If the sterility of that
which is used be not assured, then this preparation should be boiled in
water for fifteen minutes. Catgut of large size should be immersed in
a solution stronger than the above. It will probably be sufficient to
give this a final boiling at the time of operation. This is almost as
lasting as chromicized gut.


=Chromicized Gut.=--Gut to be thus prepared should be wound in single
layers on spools and immersed in a solution of potassium bichromate
1.5 to 2.5, carbolic acid and glycerin each 10, and water 1000 parts.
It is allowed to remain in this solution for twenty-four hours, then
dried and boiled in water, or in alcohol under pressure, in which it
is subsequently stored. According to the length of exposure and the
strength of the solution, this gut will resist absorption from ten to
thirty days.


=Iodine Gut= is growing in favor with some surgeons. It is prepared by
immersing catgut in a 10 per cent. solution of iodine, in which it is
kept for a week. After removal it is allowed to dry and is stored dry,
but should be kept protected from exposure.


=Silkworm-gut= may be boiled in a 2 per cent. lysol solution for one
hour, which makes it pliable. Sometimes it is convenient to have it
stained black in order that the sutures may be better distinguished
when removed. In this case it is allowed to stand in a 1 per cent.
silver nitrate solution for from twelve to twenty-four hours. This
gives it an almost black stain, but tends to make it more brittle. It
may be kept in alcohol, or dry in a sterile receptacle.


=Silk.=--Silk should be spooled loosely, boiled in a similar solution
for one-half hour, and again in plain water just before using. It may
be stored dry or in alcohol. It may be also stained black.


=Celluloid Thread.=--This should be washed and scrubbed in green soap
and hot water, after which it is spooled, and then boiled for thirty
minutes. It may be stored dry or in alcohol. This is a linen thread
covered with a film of celluloid.


=Kangaroo and Reindeer Tendons= are prepared essentially as is catgut,
but if boiled in alcohol they must be kept covered with the fluid, as
they tend to disintegrate.


=Drainage Tubes= of rubber should be boiled in soda solution for
fifteen minutes, and may then be stored either in 1 per cent. formalin
solution, or dry in a suitable tube.


=Oiled Silk and Rubber Tissues= are first prepared by washing in 1 to
500 sublimate solution, then dried, and exposed in an air-tight jar to
the vapor of formalin or paraform.

The above are the methods usually in vogue in the writer’s clinic, and
may be relied upon. These materials should be frequently tested by
dropping fragments into culture tubes and watching the result, but only
after taking the precaution to precipitate or neutralize the antiseptic
previously used in their preparation.


=Antiseptic Solutions, Applications, etc.=--In well-regulated clinics
sterile salt solution is always at hand. As has been stated the old
six per mille solution may be improved by adding 1 part of potassium
chloride and 2 parts calcium chloride. For emergency purposes tablets
are now prepared which will permit the rapid preparation of these,
of any desired strength. To this a little corrosive sublimate may be
added without producing decomposition. When sublimate is used alone,
or in other combinations, a little vegetable or mineral acid, such as
tartaric or hydrochloric, should be added, as most of the water used
contains lime.

When a maximum of bactericidal effect is desired with a minimum of
irritation, the _silver salts_, either the lactate or the citrate,
will probably afford the best results. The former may be used as
strong as 1 to 300, the latter 1 to 500. The writer has frequently
used these solutions for washing out the peritoneal cavity, in cases
of tuberculous peritonitis, where they serve their purpose admirably.
For washing out tuberculous joints and many other abscess cavities,
solutions of silver nitrate of 1 to 1000 to 1 to 2000 are most
serviceable; or, for the same purposes, boiled water, to which has been
added sufficient tincture of iodine to give it a mahogany color. In
caring for such cases it is good practice to alternate the solutions,
using them on alternate days.

_Antiseptic powders or applications in dry form_ are useful for many
purposes. At one time iodoform was very popular; it was supposed to act
by virtue of the iodine set free in the presence of decomposing organic
material. It is now seldom used, partly because of its tell-tale odor,
and partly because of the disappointment which its use often brings. It
is, moreover, an active toxic agent of itself, and has many times given
rise to symptoms of intoxication, such as mental depression, delirium,
nausea, and anorexia. Under all these circumstances free iodine can be
detected in the urine.

There are numerous substitutes for iodoform, many of which are
superior to it in antiseptic properties, while most of them are free
from odor and toxic qualities. Two substances, however, are used
extensively--_naphthalene_ and _bismuth subiodide_ or red iodide. The
former has a marked odor and is more or less volatile, which makes it
particularly valuable. The latter is odorless, non-toxic, and of much
greater value as an antiseptic than most of the others, because it will
give off free iodine under favorable circumstances. A good plan is to
use it in the preparation of gauze and dressings, as well as for a
dusting powder upon the skin.

The absolute value of these local applications is questionable, because
a wound will sometimes heal under the protection of a piece of foil or
gutta-percha tissue as well as when dressed in any other way. This is
true only of wounds in part surgically clean.


=Drainage.=--Drainage has been resorted to, more or less
intermittently, since earliest historical times. It is provided for
the _removal of deleterious fluids or of superfluous exudates or
transudates_. _It is a recognition sometimes of a necessity, at other
times a confession of fear_ which may or may not be justified. It is
bad practice to cover a focus of previous gangrene or suppuration
in such a way that the infected cavity is closed to the escape of
accumulating fluid. This may be prevented by the use of a suitable
drain. At times a clean operation may be made, and yet in such loose
tissue, or to such an extent, that it is preferable to provide for the
escape of blood rather than let it occur and force apart surfaces which
should be in close contact. A drainage tube may serve as a vent through
which blood may escape that has oozed after closure of the wound.
After pelvic operations provision should be made for the withdrawal of
accumulating fluid which might serve as a culture medium for germs.
Drainage is therefore necessary in many instances.

It will suffice sometimes to suture loosely a part or the whole of
a wound, so that should tension occur from retention there may be
spontaneous escape. This may be termed _indirect drainage_, and
sometimes has to be made still more complete by leaving out some
sutures, or by placing _secondary sutures_, which are only utilized
some days later, when previously infected surfaces have become healthy
and are granulating, so that they can be brought together.

By _direct drainage_ secretions and fluids are guided toward the
dressings, which should be absorbent or so arranged as to provide
for their accommodation; thus in drainage of the gall-bladder or
of the urinary bladder the tube may be connected with a suitable
receptacle by siphonage. _Capillary drains may be_ made of a few
strands of silkworm-gut, which is non-absorbable, or of catgut, which
is absorbable, and to which, perhaps, no further attention need be
paid. This will answer for conducting away small amounts of fluid
which exude. Gauze, or its equivalent in the shape of some form of
wicking, affords an excellent material for removing fluid by osmosis.
The thinner the fluid the more perfectly it serves this purpose. The
gauze must be changed frequently, as these lesions may become filled
with coagulated material, in which case it would act merely as a plug.
The so-called _cigarette drain_ consists of folds of gauze, or a small
roll of it, surrounded by sterilized oiled silk or gutta-percha tissue,
in which are cut numerous holes. The same purpose may be achieved, but
often not so well, by a piece of rubber tubing split down one side. The
gauze drains by osmosis, and the rubber prevents any adhesion to the
wound margins and any pain in the removal of the drain; while a certain
amount of fluid may escape around and outside the smoother surface.

When the fluids to be removed are more dense--_e. g._, pus--_tubular
drains_ should be provided. These vary in size from that of a
lead-pencil to that of the finger. A tube which is too small becomes
easily plugged. They are perforated with numerous openings for the
ready entrance of fluid save in those cases, like the gall-bladder or
the pelvis, where it is desirable to drain only the depths of a cavity.
These tubes are usually made of rubber, the purer forms of gum being
preferable. For some purposes, especially in the pelvis, tubes of glass
or aluminum are used; these are non-collapsible. They may be emptied
by a capillary drain, or by the frequent use of a small syringe with a
long nozzle, by which they are pumped out at regular intervals. Metal
and glass tubes can be resterilized and used again. All other drainage
material should be burned as soon as removed. There are occasions
when it is well to use a _dressed drain_--_i. e._, a tube surrounded
by absorbent gauze, and this again by rubber tissue or oiled silk. In
many instances it is well to prevent the loss of a drainage tube by
passing through its outer end a safety pin, or by stitching it to the
margin of the skin wound. Tubes have been lost, especially within the
thoracic cavity after operating for empyema, more often than is perhaps
generally known, and for a lack of precaution in this respect.

Tubes of _decalcified chicken bone_ have been used and are occasionally
serviceable. They are made by cleaning the cooked bones of the
fowl, soaking them in 20 per cent. hydrochloric acid solution until
decalcified, trimming the ends, cleaning the interior, and are then
sterilized by boiling in a saturated solution of ammonium sulphate.
They are then washed in sterile water and preserved in alcohol. They
correspond to catgut, and will ordinarily last in the tissues for about
eight days. They may be chromicized, as is catgut, in which case they
endure considerably longer.




CHAPTER XXV.

PREPARATION OF PATIENTS FOR OPERATION AND THEIR AFTER-TREATMENT.


At the risk of some repetition it is proposed to epitomize here a
few directions on a subject of great importance, to which, as well
in theory as in practice, too little attention is often paid. For
present purposes patients may be divided into two classes: those who
have sustained accidents or sudden surgical diseases, where no time is
afforded for preparation; and those who, having chronic conditions,
are subjected to surgical measures which are, however, sometimes made
abrupt by sudden decision. In the former case the surgeon is compelled
to work hastily; for the latter, time for preparation should be
always afforded. Experience teaches that a few days, sometimes even
a few weeks, may be well spent in preparing a patient for a surgical
operation.

In emergency cases, aside from the usual scrubbing and shaving, there
may be several matters to which it is well to give attention. The
stomach should be washed out just before the administration of the
anesthetic, or soon afterward. If there be time the rectum should be
emptied, and the bladder always; too much care cannot be given to these
performances. The degree of shock should be estimated and appropriate
treatment given, according to principles stated in the chapter on Shock.

Foresight will often dictate the _preparation of some part of the body
not directly involved_ in the field of injury; for example, in any
gunshot or stab wound of the abdomen or in a case of acute pancreatitis
the back should be scrubbed and cleansed and the patient laid upon
sterilized material, so that should posterior drainage be required it
may be promptly made without waste of time required for preparation.
In head injuries, if the scalp or cortex of the skull be involved,
the entire head should be shaved. In preparation of patients for
operation upon the mouth, tonsils, or stomach an antiseptic mouth-wash
should be used in order to avoid, so far as possible, contamination
from these germ-laden regions. It Is especially in cases undertaken
for the chronic pathological conditions that time can be afforded for
careful preparation. It may be assumed that every patient suffering
from a chronic surgical malady has been so disabled, in at least some
function, that elimination has been interfered with. The emunctories of
the body comprise essentially the skin, the lungs, the intestines, and
the kidneys. Every one of these should be made to perform its work more
fully.

The skin should be stimulated by _hot-air baths_, for which purpose
patients may be sent daily to the Turkish baths, while others should
take their sweats in cabinets or in bed. If it be possible after the
skin has been made to perspire profusely the patient should be put into
a hot bath and the skin thoroughly scrubbed.

The _lungs_ may be stimulated partly by improving the heart’s action,
partly by certain exercises, and by getting the patient out into the
open. The intestines should be made to perform their work, preferably
by the mildest measures that may prove effective. Mercurials are
agents of great value, as they not only stimulate secretions but are
antiseptic in their effects. Sodium phosphate is useful when something
stronger is not required.

Many patients who are found in this class will have _impaired
digestion_, for which a regulated diet should be supplied; and such
cases may call for _lavage_, as well as for a careful examination of
stomach contents, in order that appropriate aids to digestion may
be given. Most patients suffer from intestinal torpor, especially
of the large intestine, and the daily administration of a high-up
_colon wash_, with the patient in the knee-chest position, will give
gratifying results.

It has been suggested that in all operations upon the upper alimentary
canal it would be of great advantage to feed the patient during the
previous forty-eight hours upon sterilized food.

_A careful study of the urine_ should be made, both quantitative
and qualitative. The gross measurement of the amount excreted in
twenty-four hours is of importance. It is necessary to know what amount
of solids is being daily excreted, as well as the amount of fluid.
_Renal insufficiency is one of the difficulties_ with which the surgeon
has often to deal, and caution should be used when operating upon a
patient suffering from this condition. Extra work is thereby imposed
upon other emunctories. A depraved blood circulation through the brain
will often impair its function and lead to delirium in mild or serious
form. The heart’s action will be impaired and septic infection is made
more possible, in spite of every precaution included in antiseptic
technique. In the chapter on Infection it was stated that certain cases
of surgical sepsis commence as infections from within, due to failure
in unloading the body of its content of disease germs.

_Hyperacidity_ should be also corrected. In order that this may
be properly done, the urine should be tested by a more accurate
method than by litmus paper. The restlessness and consequent wound
disturbances which may ensue after operation may be due to _failure in
the elimination of uric acid_ and the oxalates; alkaline diuretics,
therefore, are an important feature in the preparation of many surgical
patients.

_The blood and circulation_ should not be neglected in these cases.
These patients are frequently anemic. A high degree of anemia is
recognized by methods described in the chapter on the Blood. Much may
be done, even in a short time, to improve the quantity and the quality
of the blood, by attention to nutrition and elimination. By these same
measures the heart’s action will be also greatly strengthened, but much
can be accomplished in this direction by the use of digitalis, cactus,
or other of the heart stimulants, and by the administration, preferably
subcutaneously, of strychnine. This is usually given in too small
doses. Two hypodermic injections of ¹⁄₃₀ Gr. (0.002) a day will have a
pronounced effect. While the heart is thus fortified as against shock
before the ordeal, adrenalin will prove the most effective agent during
it and after it is passed.

_Intestinal fermentation_ or decomposition is a prominent feature of
many of these cases. If it be possible to select a drug which has
antiseptic properties that may be effective in the intestine and in
the kidneys, it will come near to being the ideal in this respect. The
attendant has here to choose from many remedies, and his choice will
depend largely on his personal experience. It is better to use a few
remedies and use them well than to be indiscriminate.

Salol, benzosol, betanaphthol, sodium sulphocarbolate, and the salts
of mercury and arsenic will furnish sufficient compounds from which to
select. When the urine is alkaline, as it often is in certain kidney
and bladder diseases, urotropin may be advantageously combined with one
of the others.

In the way of general preparation of those patients who have to undergo
operations upon the _mouth_, _the nasopharynx_, _the esophagus_,
_trachea or larynx_, _and upper alimentary canal_, they should be sent
to the dentist in order that their teeth may be put in good condition
and accumulations of tartar removed, and then use an antiseptic
mouth-wash, or, when necessary, a nasal spray, in order that there
may be avoidance of infection from the bacteria which abound in these
parts. Patients often have diseased and carious teeth, and, in hospital
patients especially, the mouth is often in a dirty condition. So long
as any wound surface is so situated as to be in danger of contamination
from these sources, this should be minimized as far as possible.


=Prevention of Peritonitis.=--Experiments have been made by Mikulicz
with regard to the value of _nuclein_ in producing an _artificial and
protective leukocytosis_ before abdominal operations, hoping thereby to
accomplish more or less in the way of prevention of peritonitis. The
procedure is based upon the well-known property of nucleinic acid, or
nuclein, to produce a prompt but transitory increase in the number of
leukocytes. To take advantage of this, 3 to 5 Cc. of nuclein solution
is administered beneath the skin, say twelve hours and again six hours
previous to the operation. Should any septic agent be introduced or
liberated during its performance, the leukocytes will be present
in additional numbers to act as phagocytes and exert their active
protective powers.


AFTER-TREATMENT.

The care of patients _after_ operation is a factor in a surgeon’s
success and calls for discrimination and judgment. The fact that the
odor of chloroform or ether persists about the patient and in his
breath for hours after their administration shows to what extent they
have been dissolved and are circulating in the blood. If elimination
have already been attended to, and so far improved as to permit
the emunctories of the body to do work up to their capacity, these
anesthetics may be promptly eliminated. The longer they circulate in
the blood the greater the disturbance to other functions and the more
difficult it is to get normal function equalized.

The things especially to be guarded against, so far as one may prevent
them, are _nausea_, _vomiting_, _extreme restlessness_, _pain_,
_inactivity of the bowels_, _insufficiency of the kidneys_, and the
toxic action of any antiseptics or drugs which may have been used, _e.
g._, iodoform.

_Nausea_ and _vomiting_ after operations are due not so much to mere
reflex activity as to the elimination of the anesthetic by the stomach
and its irritant action. No matter how produced, such vomiting is of
itself most depressing, mentally and physiologically, and is injurious
in a large proportion of cases, and efforts should be made to prevent
it. So long as it was regarded simply as a reflex act drugs were
theoretically sufficient for its treatment, but with the appreciation
of its actual causation it will be seen that the irritating material
should be removed. This may be done with the minimum of discomfort
and the maximum of advantage by means of the stomach tube. Lavage,
therefore, constitutes the most rational and effective treatment in
cases of postoperative vomiting.

That the anesthetic reaches the stomach by way of the circulation and
is excreted by the gastric mucosa has been proved by the studies of
Türck. He showed that the same is also true of morphine. He showed,
moreover, that the stronger anesthetics disturb the metabolism of
the cells and that toxic products are thereby produced which, being
reabsorbed, cause an auto-intoxication reducing vital resistance of
the blood serum and the tissues. Thus during anesthesia there occurs
an atony of the stomach walls with the escape of the anesthetic into
the stomach, which, acting as an irritant, leads to an increased amount
of toxin production. The discoloration of the gastric mucosa and the
capillary hemorrhage which take place, as shown _postmortem_ in cases
where persistent vomiting is a feature, illustrate the disturbing
effect of the stronger anesthetics upon the stomach itself. This
furnishes, then, the reason for _washing out the stomach immediately
after stopping the anesthetic_ and before the patient leaves the
operating table. It cannot be said that by this measure postoperative
vomiting will be abolished, but its frequency will be materially
lessened.

Lavage may also be practised to great advantage not merely immediately
after the operation, but during the ensuing twenty-four hours, or
later should vomiting recur or come on late. On the other hand, where
time has not been afforded in which to suitably prepare a patient
for operation, it is advantageous to wash out the stomach before
administering the anesthetic as well as after. This is recommended as
a general measure, and without special reference to those cases where
operation is directed to the stomach itself or to the intestinal tract,
where it has become an established part of the preparation to carefully
cleanse these viscera.

Several points in the performance of lavage will be of great service
to patient and operator. It should be performed quickly in order to
reduce the length of the discomfort, and the water used should be warm,
at least 110° F. If the throat be previously sprayed with weak cocaine
solution (2 per cent.), or if a cocaine lozenge be dissolved in the
mouth, the tube can be introduced with less gagging and difficulty. The
lubricant should be flavored with wintergreen or some other aromatic.

Where vomiting continues in spite of lavage it is advantageous to give
a full dose of chloral with a little starch-water in the rectum; 2
or 3 Gm. of chloral, with as much sodium bromide, to which, in case
of severe pain, a little opiate may be added, may be profitably used
in cases where the patient is restless and where sleep is fitful
or perhaps impossible. This will be more beneficial than drugs
administered by the mouth. It is seldom rejected, and is very soothing.

_Extreme restlessness_ is undesirable from every point of view. In
some cases when it comes on early it is an evidence of insufficient
oxygenation and may be combated by the administration of oxygen gas. It
frequently accompanies shock and constitutes one of its most disturbing
features. It may be combated by a subcutaneous dose of morphine or
heroine, or chloral in doses of 2 Gm., with as much sodium bromide,
thrown into the rectum with salt solution. The effect may not be as
prompt, but it is often much better. Restlessness is not always a
symptom of pain, but is occasionally an uncontrollable reflex nervous
phenomenon.

_After operations physiological rest of the operated part is necessary_
for the process of prompt repair. After abdominal operations,
especially when restlessness and vomiting are combined, much harm may
be done if the patient cannot keep the parts quiet.

_Pain_ will often accompany restlessness, and frequently accentuate
it, especially when patients have not yet fully returned to
consciousness. It may be relieved by warm or cold applications. In
some cases an ice-bag may be used as soon as the patient is placed in
bed--for example, after breaking up an ankylosis. In mild cases the
use of chloral in the rectum, as above, with an opiate added, may be
sufficient. When pain is severe hypodermics of _morphine_ or _heroine_
should be given. Secretion should not be disturbed by such drugs as
these, yet as between them or permitting patients to suffer intensely,
my opinion is that opium should be given judiciously, providing it
prove sufficient. In extreme cases morphine seems to be the only
medicament upon which complete reliance can be placed. When the opiates
seem to produce nausea the difficulties are heightened. It may be
decided in some cases to push the opiate to the point of narcotism,
preferring to keep the patient in this semistupefied condition for two
or three days and until the series of early dangers have been passed.
Opiates should be given with great discretion lest the opium habit be
encouraged if not formed.

Lately there has come into use a remedy which has little or no
unpleasant after-effects, and upon which a good deal of reliance can be
placed, namely, _aspirin_, which may be given in 1 Gm. doses, repeated
as necessary. If it be combined with phenacetin, in doses of half that
amount, the combination will be more effective than either alone. This
will often prove a serviceable substitute for opiates in any form.

After operation upon the lower bowel, or in any part of the pelvis,
patients may complain of pain, sometimes severe, referred to the
_rectum_. Relief may be obtained by throwing into the rectum, through
a flexible tube, one-half to one pint of warm linseed oil. This will
often take the place of an anodyne or a suppository.

The next question is one of _catharsis_. If the alimentary canal have
been properly emptied, as it should have been before the operation, the
bowels may be allowed to rest for the ensuing forty-eight hours. At
the expiration of that time the lower bowel should be emptied. Whether
this be done with laxatives administered by the mouth or by enema will
depend on the character of the case and the reliability of the stomach.
When vomiting is distressing little can be accomplished from above.
In most cases the first effort is to be made by the administration of
a thorough colon wash, or by the use of an enema, which may perhaps
best consist of ox-gall, glycerin, and a saturated solution of Epsom
salt. If this be thrown up high, and retained a while, it will in all
probability be effective. Should the operation have been one upon the
rectum extra care will be needed for the patient’s comfort, and just
preceding the stool a small amount olive oil should be administered
through a tube. Many patients will complain of gaseous distention or
other discomfort, due apparently to fermentation, and partly perhaps
to the air which they have swallowed during the act of vomiting, or
because of nausea. No matter how produced it will afford relief to get
rid of this gas, and while this may be partly accomplished by an enema,
it will be more thoroughly effected by a mercurial, given by the mouth,
to be followed by a saline laxative. In order that flatus may escape
without effort, a rectal tube may be inserted, which later may be
utilized for the administration of an enema. Save in rare instances it
is a mistake to allow accumulation of fecal matter, as the stercoremia
thus favored may easily lead into a more profound form of poisoning by
its interference with elimination and vital resistance.

Attention should be also given to the _bladder and to the urine_.
_Renal insufficiency_ is one of the great dangers pertaining to the
use of anesthetics. This may be combated by 2 Gr. doses of sparteine
sulphate every three hours (McGuire).

Many patients are unable to void urine after operations, particularly
after those upon the female genitalia, and _the use of a catheter_
is often necessary. This should be used with antiseptic precautions,
both as to the patient, the instrument, and the operator’s hands.
Much of this difficulty can be avoided by injecting 20 Cc. of a 2
per cent. sterilized boroglycerin solution through a catheter in the
evening after the operation. Its action is usually prompt, and in five
to ten minutes the patient spontaneously empties the bladder without
unpleasant after-effects.

After abdominal and pelvic operations the patient should not be allowed
to urinate, but should be systematically catheterized. The bladder
should never be allowed to become distended. The amount and character
of urine passed should be carefully noted. In serious cases the amount
of solids eliminated should be estimated, in order that it may be
kept up to the necessary standard. In fact, efficient and sufficient
elimination is more necessary after the prolonged administration of an
anesthetic than after almost any other event. When sufficient fluid to
keep up the standard cannot be administered by the stomach, it should
be introduced into the rectum or given beneath the skin. Two or three
enemas of salt solution should be administered each day, and in urgent
cases the normal solution should be thrown beneath the skin, and this
should be repeated as often and as long as may be necessary. When the
patient begins to show evidence of what is vaguely described as uremia,
_i. e._, _the toxemia of renal insufficiency_, not only should warm
water be used in these ways, but hot-air bed baths should be given
twice a day if necessary, in order that some of the work of the kidneys
may be assumed by the skin. Hot-air baths stimulate the kidneys as
well, and these measures will prove more effective than most of the
diuretics, although digitalis and pilocarpine by the skin may be of
assistance.

Patients frequently complain of excessive _dryness in the mouth_. This
may be relieved by occasionally dropping beneath the tongue one-half
of an ordinary hypodermic tablet of ¹⁄₁₀ Gr. pilocarpine; also by
mouth-washes which contain a little glycerin, and by keeping the lips
moistened with glycerin. _Excessive sweating_ can sometimes be relieved
by giving a hot-air bed bath or a hot mustard foot bath, as the extra
action of the skin thus induced checks the spontaneous drain.

_Delirium and acute mania_ occasionally supervene after operations. It
should first be made clear that these are not due to any antiseptic
or drug. Iodoform is less frequently used than formerly. Children and
aged people become delirious with less provocation than do those in
middle life. Such delirium is generally an expression of a toxemia,
and, in addition to such other measures as may be necessary, calls for
control and restraint and more active elimination, as in so-called
uremia. In proportion to the degree of mania must be the restraint
prescribed. A restraining sheet or a strait-jacket may be sometimes
needed. When these conditions arise in surgical patients more harm will
come from the violation of the principle of physiological rest than
from the drugs which may be needed to secure it. The milder measures
should be first used, abstaining as far as possible from opiates,
which are probably the least desirable of all, but which may be
occasionally demanded. Chloral, the bromides, cannabis indica, alone or
in combination, may be made to render more valuable service. Hyoscine,
in doses of ¹⁄₁₀₀ to ¹⁄₅₀ Gr. beneath the skin, will often control when
other remedies fail; it may prove invaluable. When delirium tremens
complicates a case it may be treated as suggested in the chapter on
Various Intoxications.




Part V.

SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE SYSTEMS.




CHAPTER XXVI.

CYSTS AND TUMORS.


GENERAL CONSIDERATIONS.

A tumor _is a new formation, not of inflammatory origin, characterized
by more or less histological conformity to the tissue in which it has
originated, and having no physiological function_.

By the above definition it is intended to separate the new-growths
from a distinctive class of neoplasms which are of inflammatory (_i.
e._, of infectious) origin, to which the generic term of _infectious
granulomas_ has been given. (See Part II.)

Exceedingly vague notions have prevailed concerning the _nature_ and
_origin_ of tumors, and, while the clinical observations of writers in
the past will never lose their value, the ideas which have prevailed
concerning their pathology constitute interesting reading in a
historical sense, but are now of small value. Accurate notions scarcely
prevailed until Virchow demonstrated that tumor cells nowise differ
from cell types which are met either in embryonic or in adult tissues.
Tumors, like all other parts of the body, are built up of cells, and
the points concerning which we need most light regard the influences
which determine cell overproduction in these characteristic forms.
Concerning the views that have prevailed, this is scarcely the place
in which to offer an epitome. I shall therefore take up but few of
the explanations which have been offered to account for tumor growth,
and will emphasize that, according to our present light, there is no
explanation sufficient to cover all cases, but that it is now one cause
and now another which may determine this peculiar form of cell activity.


=Irritation and Trauma.=--The effort is often made to explain the
presence of tumors upon the hypothesis or the known fact of some
previous injury. Frequently tumors appear in sites where there have
been previous traumatisms, but this sequence of events by no means
proves a definite relation of cause and effect. On the other hand,
there are forms of irritation which are often followed by tumor
formations. Probably no woman escapes without one or more bumps or
bruises upon the breast, yet they do not produce tumors in more than
a trifling proportion of cases. _Per contra_, upon the lower lip of
inveterate clay-pipe smokers and the scrotum of chimney-sweepers there
develop certain forms of malignant ulcer (epithelioma) which so often
and so significantly follow upon the irritation thus produced that it
is impossible to avoid conviction that one is the cause of the other.
Should events prove the parasitic nature of any of these growths they
will also prove that the irritation causes surface lesions through
which infection easily occurs. In regard to the relative frequency
with which cancer in some form follows trauma we should not forget the
well-known fact that traumatism usually diminishes tissue resistance.
If cancer be an expression of infection, as many (including the writer)
believe, the possible relation between trauma and malignant disease may
be better appreciated.


=Inflammation.=--This refers to inflammation in the sense in which it
has been used in the past, implying a variable condition, sometimes
including and sometimes excluding infection, the term covering a
confused mixture of irritation, hyperemia, and infection. In so far as
it concerns inflammation as considered in the present work it should
not be here included, since inflammation (_i. e._, infection) produces
neoplasms of a class considered in Part II and is distinctly ruled out
from present consideration (_i. e._, the infectious granulomas).

If inflammation in the former sense be more than hyperemia it may be
regarded as predisposing to cell activity, but not necessarily to tumor
formation as distinguished from hypertrophy of a given part or tissue.
If it refer to irritation, this has been acknowledged as a factor
in the etiology of tumors, but as an uncertain one. Cancer of the
gall-bladder or liver, which occasionally results from the irritation
of a gallstone, or the cancer of the breast that follows eczema of the
nipple, may be regarded in this light as additional illustrations if
it is preferred to interpret them in this way. If by inflammation be
meant the infectious granulomas, they have already been considered. As
the term “inflammation” can scarcely mean anything except hyperemia,
irritation, or infection, we seem to have completely ruled it out from
consideration as by itself an active cause leading to tumor formation.


=The Embryonal Hypothesis of Cohnheim.=--This in its ingenuity and in
its applicability is a fascinating explanation, which is undoubtedly
sufficient for at least a certain number of instances. According
to Cohnheim, only one causal factor for tumors exists--_i. e._,
_anomalous embryonic arrangement_. He regards them as _entirely of
embryonal origin_, no matter how late in life they may develop and
appear. Briefly summarizing his views, they are to the effect that
in the early stages of embryonal development there are produced more
cells than are necessary for the construction of a certain part, so
that a number of them remain superfluous. While these may remain very
small, they possess, on account of their embryonal nature, a potent
proliferating power. This superfluous cell material may be distributed
uniformly, in which case it will develop whole system arrangements,
like supernumerary fingers, etc., or it may remain by itself in one
place, and will then develop a tumor. In the latter case the tumor may
appear early or not until late in life, according to the time at which
the cell collection receives the necessary stimulus, or because of
its suppression by resistance of surrounding structures. It may be an
irritation or an injury, such as above alluded to, which shall give it
this stimulus; as, for example, it is reasonable to think that certain
nevi and other congenital conditions which develop later into cancers
do so in accordance with this view. Surgeons generally find little
fault with Cohnheim’s hypothesis, except that as yet they decline to
see in it an explanation for all cases. Nevertheless for dermoid and
teratomatous, and for all heteroblastic tumors, it seems to afford the
only tenable explanation. Thus chondromas of the parotid and of the
testicle are most easily explained in this way, and that cartilaginous
islands occur in the shafts of adult bones is well known.


=Heredity.=--In regard to heredity being a factor in the etiology
of neoplasms there is reason to believe that a favorable tissue
disposition may be inherited, but there is nothing to show that it
permits the actual transmission of the disease.


=Parasitic Theory.=--The _parasitic theory of tumor formation_ has
only within a few years taken definite form and shape, as a result
of evolution from vague suggestions and scattered observations. It
implies that tumors, and they are mainly of the malignant type, are
due to irritation produced by extrinsic agencies, _parasites of some
kind_, which, introduced from without, act as do bacteria in the now
well-known infectious granulomas. While this theory, perhaps, does not
afford an absolutely satisfactory explanation of all the phenomena of
malignancy, it nevertheless comes nearer to it than does any other
hypothesis now before the profession, the arguments in favor of it
being scientific and positive, and those against consisting mainly of
mere negations. Summed up these arguments may be stated as follows:


1. =Comparative Pathology.=--The argument from _comparative pathology_
begins with the lower forms of life. Tumors in trees and plants are
well known to vegetable pathologists and botanists as of frequent
occurrence. They vary in size from the most trifling galls to those
large woody masses known as xylomas, which are essentially tree
cancers, since they tend to the destruction of the tree. These are
known to be invariably due to extrinsic agencies, such as insects,
fungi, etc. As water freezing in the bark of a tree may crack it open
and thus leave opportunity for subsequent infection, so may injuries
upon the body surface make trifling lesions which predispose to
subsequent infection and cancer in man and animals. Exclude parasites
from such traumatic lesions on plants and there will be no xylomas.

[Illustration: PLATE XIV

Adenocarcinoma with Young Parasites. (Parasites blue. Plimmer’s method.)

This plate is introduced to illustrate the _presence_ of parasites,
whose minute and actual character is not yet positively determined, but
whose existence is undeniable.

From Gaylord’s paper in the Third Annual Report of the New York State
Pathological Laboratory of the University of Buffalo.]

[Illustration: PLATE XV

Rapidly Growing Carcinoma of Breast.

The parasites herein demonstrated are still subjects of careful and
minute study. It would therefore seem premature to make detailed
statements concerning their exact nature.

From Gaylord’s paper in the Third Annual Report of the New York State
Pathological Laboratory of the University of Buffalo.]

[Illustration: PLATE XVI

FIG. 1. Parasites, at one time called Russell’s Bodies, at Periphery of
Epithelioma of Tonsil. (Oil immersion.)

FIG. 2. Same in Lymph Node before Epithelial Invasion. (From N. Y.
State Path. Lab. Rep.)

FIG. 3. Papillary Adenocarcinoma of Ovary, showing Intracellular
Ameboid Forms of Parasites. (From N. Y. State Path. Lab. Rep.)]


2. =The Analogy Afforded by the Infectious Granulomas.=--These are
universally conceded to be of parasitic origin, while their clinical
course and behavior in every respect make many of them almost as
malignant as the true cancers become.


3. =Metastasis.=--This is in every other disease considered to be one
of the most significant expressions of infection, yet until recently
few of those who have willingly accorded to metastasis its now common
interpretation in tuberculosis have been willing to give it the
same dignity as a factor in the spread of cancer and an important
explanation of its nature. Why should every other disease characterized
by metastasis be everywhere viewed as parasitic, and cancer, in which
occur some of its most positive expressions, be denied? _Metastasis has
the force and significance of an inoculation experiment performed under
favorable circumstances._


4. =Evidence of Local Infectivity.=--The involvement of a part which
has lain in contact with a cancerous lesion, as about the mouth or the
vulva, and in many other ways and places of which medical literature
is now full, and the instances of cancer following the knife wound,
especially following the track of the trocar used for tapping a case
of cancerous ascites, stamp the disease as having an infectivity which
cannot be explained on any inherent property of its own.


5. =Microscopic Appearances.=--While it is true that but few observers
have been able to agree upon a definite cancer parasite, it is also
true that many of the best observers have seen, described, and figured
bodies that do not belong in the cells of a cancerous growth except
they are there in the roll of active agents, and the appearances which
have been described by Pfeiffer, Plimmer, Gaylord, Calkins, and others
are not to be explained away as mere artefacts, but must be given a
place in our estimation which they would attain of themselves, as
exciting suspicion, were there no other facts corroborating the views
that they are in some way actively connected with the production of the
disease. (See Plates XIV, XV, XVI.)


6. =Inoculation Experiments.=--No feasible plan has been devised for
practising inoculation experiments upon human beings. It is known,
however, that the disease may be transmitted in some cases among
animals of the same species, and the transfer has been made in a few
instances from man to the lower animals. In the Gratwick Laboratory
(Buffalo) the disease has been thus transmitted through hundreds of
mice, and has thus afforded the best means of studying it in its varied
phases, albeit in small animals, ever yet enjoyed. But cancer does
occur in animals and has proved to be capable of inoculation, and,
therefore, has responded to one of the severest tests of the value of
the theory. Moreover the facts cited above (under 4) are essentially
successful auto-inoculation.


7. =Clinical Observations.=--Add to the features already mentioned
above those impressions which come from accurate observation and
correlation of the phenomena attending many cases of cancer, and a
plausibility is thus lent to the parasitic theory which it can never
gain from study in the dead-house or through the microscope. The
resemblance between it and other known infections, the local and
general alterations of tissues and fluids, the chemical changes by
which the cachexia of the disease is brought about--these with other
features all conspire to give the keen observer of cases of cancer an
impression of parasitism or infectiousness which nothing can efface.
Add to these its endemic, sometimes almost epidemic occurrence, its
apparent transmission by contact, and the fact that it is but little
influenced either by nutrition or drugs, and the argument is still
strengthened. As against these arguments little has been advanced save
denials or negations.

In thus upholding the parasitic theory, the writer would not wish to be
understood as claiming either that the parasite has yet been discovered
or its nature positively made out, nor that it is a question of one
organism alone; rather, on the contrary, he feels that it is probably
a question of several agents, probably of protozoan character, perhaps
too small to be recognized with the lenses of today, perhaps belonging
to some as yet unstudied class of organisms, making themselves known,
however, as do the hypothetical parasites of syphilis and scarlatina,
by their effects. To accept the parasitic view is to reconcile many
discrepancies of earlier times and to give an entity to the disease
by which, and until something better be found, we may be more safely
guided in its management.

The parasitic theory lends plausibility to the statement which the
writer wishes to emphasize, that cancer, like many of the other
infectious diseases, is at first a local condition, that it is not
transmitted by inheritance, and that there is a time in the history
of every cancer when, _if_ it could be recognized sufficiently early,
and _if_ it were also accessible and thoroughly removed, _it could be
cured_.


=Nomenclature.=--The nomenclature of tumors has been much confused, and
if some new terms are introduced it is perhaps better than to cling
to some which have prevailed in the past. Various systems have been
followed of naming them according to their supposed nature or their
evident tendency, or according to some purely arbitrary classification;
thus there is the distinction into _homologous_ and _heterologous_
or _heteroplastic_, according as they are similar to or variant
from that tissue in which they seem to originate; or they have been
referred to as _benign_ and _malignant_ according to the disposition
which they evince; and these terms are in sufficiently frequent use
to demand acceptance. The distinction between benign and malignant is
convenient and in some respects accurate, implying little in regard to
histological structure, but much in regard to their effect upon the
individual.

So far as _method of classification_ goes, the _anatomical_ (_i. e._,
the _histological_) has proved far the most satisfactory, and is that
which is now generally adopted. It is the basis for the classification
followed in the ensuing pages. But even here it is impossible to
maintain abrupt or always accurate distinctions, because tumors are
frequently of mixed type, and it is required, if desired to express
their composition by their names, to sometimes combine words in an
awkward fashion.

By common consent that tissue which predominates furnishes the
concluding portion of the compound term, while by prefixing other terms
we endeavor to imply the composite character of the neoplasm.

Thus we have _osteochondroma_, _fibromyoma_, _myofibroma_, etc.,
and it is necessary often to reduplicate terms in order to be
accurate in description. While this complicates phraseology, it
nevertheless furnishes to the reader a reliable clue as to the
general character of such a growth; and if one reads, for instance,
of a _myxochondrosarcoma_, he promptly infers therefrom that thereby
is meant a tumor essentially a sarcoma, in which both myxomatous
degeneration and cartilaginous formation have taken place.

In the same way the prefix _cysto_ is frequently used to imply a
combination of originally solid tumor which had undergone cystic
changes in whole or in part.

The old term _cele_ is frequently used as a suffix, implying neoplastic
changes in an organ, or at least the formation there of a tumor. Thus
we have _bronchocele_, _hydrocele_, and _cystocele_. Again, certain
terms are used in a different sense from that originally intended. Thus
the term _sarcoma_ has a definite significance, whereas originally it
had little meaning and was applied inadequately and indiscriminately.
Old terms also, like _fungus hematodes_, are now used rather in a
descriptive sense, because for any such tumor we can find, on accurate
examination, a proper term taken from descriptive pathology. Therefore
the student of today should read the works of the older writers,
especially concerning neoplasms, with a certain amount of intelligence,
as well as of apology for the inaccuracy and misnomers of the past.


TREATMENT OF TUMORS.

The results of treatment of tumors leave much still to be desired,
particularly when dealing with those of malignant nature. So far as
purely internal treatment is concerned, we have not yet discovered
drugs which with any certainty influence cell growth to the extent of
making them reliable or effective. In the past, and even at present,
numerous remedies have been advocated as having more or less power in
this direction. Of them all it is probable that arsenic in some form
is more efficacious than any other. This is true in the case of the
disease elsewhere spoken of as _malignant lymphoma_, or _Hodgkin’s
disease_, which partakes much of the character of some of the other
neoplasms. But to say that arsenic alone or any other known remedy can
be relied upon at all times is making a bold assertion.


=Operable Tumors.=--The _treatment of operable tumors_ is _essentially
surgical_ (_i. e._, _operative_), although to a large extent results
are based upon the essential character of individual cases. But it
can be stated that to be successful in the removal of any tumor its
complete extirpation is imperative. Even the most benign growths will
return if only partially removed. This is true even of innocent cysts,
which will be often reformed if a portion of the cyst wall be allowed
to remain. Complete extirpation is ordinarily a simple measure when
tumors are _encapsulated_, as are often many of the innocent tumors.
On the other hand, the performance of some of these operations is
made difficult and hazardous by the location of the tumor, as in many
large uterine fibroids, tumors of the thyroid, etc. But when dealing
with malignant tumors the secret of success is to extirpate them,
sacrificing everything which may appear to be involved unless, like a
large bloodvessel or important organ, it be essential to the life of
the part or of the individual. These statements are made when speaking
of tumors in a general way. More specific directions will be given
when dealing with particular forms or in the chapters on Special and
Regional Surgery.


CLASSIFICATION OF TUMORS.

Following custom in large degree, yet being guided by undeniable facts
concerning histological structure, tumors will be classified and
considered as follows:

  1. Cysts.

  2. Dermoids.

  3. Teratomas.

  4. Tumors of connective-tissue type.

  5. Tumors of nerve elements.

  6. Tumors derived from epithelium.


1. =Cysts.=

A cyst may be defined as a _tumor containing one or more cavities
filled with fluid or semifluid contents_. This specifies nothing with
regard to the location nor the character of the cyst wall nor the
nature of the fluid contents. Following Sutton, I divide cysts into
four groups:

  _Retention cysts._

  _Tubulo cysts._

  _Hydroceles, or distention cysts._

  _Gland cysts._


=Retention Cysts.=--These imply a previously existing cavity whose
outlet is obstructed and whose contents consequently accumulate, often
to such a degree that the original character of both containing wall
and contained fluid is entirely altered. When this occurs in glands
or gland ducts there is usually complete atrophy of gland tissue,
providing sufficient time have elapsed. Such cysts are due either
to permanent or temporary arrest of flow. In _hydronephrosis_, for
example, there is obstruction of the renal outlet and dilatation of
its pelvis, with partial or complete atrophy of the kidney structure,
until a cyst of enormous size may be present. When a similar condition
obtains in the uterus, as by obstruction of the cervix, perhaps due to
injury done during labor, we have a condition known as _hydrometra_,
seen occasionally in women, often in the lower animals, and
particularly in those having a bicornate uterus, causing a condition
often mistaken for an enormously dilated Fallopian tube. Similarly,
when the common bile-duct is obstructed, which may be due to impacted
gallstones, to inflammatory lesions or tumors, there may be such
backing up of bile in the gall-bladder as to produce the condition
known as _hydrocholecyst_.

Under any of these circumstances pyogenic bacteria may produce
infection which will be more or less promptly followed by suppuration;
and then, instead of _hydronephrosis, ydrometra_, _hydrosalpinx_,
_etc._, we have _pyonephrosis_, _pyometra_, and _pyosalpinx_.


=Tubulo Cysts.=--These are _cystic dilatations of certain functionless
ducts and obsolete canals_ which no longer serve a useful purpose. They
comprise:


1. =Cysts of the Vitello-intestinal Duct.=--Cysts originating from this
functionless duct occupy the umbilical region, sometimes projecting
externally, sometimes internally. They are usually lined with mucous
membrane furnished with villi and columnar epithelium. Such a cyst
may be confounded with an umbilical hernia. These cysts occasionally
open at the umbilicus and discharge irritating material, sometimes
fecal matter. Cystic dilatation of the portion of the duct originally
connected with the ileum is also sometimes seen.


2. =Allantoic Cysts.=--These are connected with the urachus, which
should ordinarily be found as a fibrous cord, but which occasionally
persists in a pervious condition, in whole or in part. At birth it is
often traversed by a narrow canal lined with epithelium continuous with
that of the bladder. The urachus lies outside the peritoneum, and may
be dilated at any point between its two extremities. When the entire
urachus is pervious urine is discharged from the navel.


3. =Cysts Connected with Remains of the Wolffian Body.=--The Wolffian
body, or the mesonephros, is intimately related with the development
of the kidney, the ovary, and the testis. In the two latter locations
glandular elements may be met, persisting in adult life.

In the male the _tubules_ persist as _excretory ducts from the testis_,
but in the _female_ they persist, in a vestigial condition, as the
_parovarium_ and _Gärtner’s ducts_. The ovary proper consists of the
_oöphoron_ and the _paroöphoron_, the former being the egg-bearing
portion, the latter receiving the tubules from the adjoining structure
known as the parovarium. The _paroöphoron_ gives rise to cysts which
burrow deeply between the layers of the broad ligament, make their way
alongside the uterus, and raise the peritoneum. It is a peculiarity of
these cysts that their inner walls often become _papillomatous_, and
may even develop such a crop of warty outgrowths that these make their
way through the cyst wall and protrude into the abdominal cavity, where
they sometimes become detached and are dropped as loose bodies into
the peritoneal sac. The condition is also often accompanied by warty
growths upon the peritoneal surfaces. These need give rise to no alarm,
because they usually disappear spontaneously with removal of the tumor.
_Paroöphoritic cysts_ are to be distinguished from _parovarian cysts_,
which develop from the parovarium, this latter consisting of a number
of tubules situated between the layers of the mesosalpinx, composed of
an outer series known as _Kobelt’s_, an inner set, about a dozen in
number, known as the _vertical_ tubules, with a straight tube, running
at right angles to these through the broad ligament to the vagina,
known as _Gärtner’s_ duct, which is homologous with the vas deferens
in the male. Cystic dilatation of Kobelt’s tubes is often seen, these
cysts being very small and having no clinical importance. Cysts arising
from the vertical tubules are usually transparent until they attain
considerable size, when their walls thicken. Their contained fluid
is not harmful, and after rupture of such cysts internally the fluid
is absorbed. Such cysts may rupture and refill several times. _As
between the paroöphorous_ and _parovarian cysts_ the latter are easily
enucleated, carry the ovary upon one side, and have the Fallopian tube
stretched over them without communication.

The internal sections of _Gärtner’s duct_ are more often involved in
animals than in women, but excellent illustrations of cystic dilatation
of its various portions have been observed, usually in the walls of the
vagina.

Corresponding to the above-mentioned conditions in the female there
are in the male, as the result of changes in the Wolffian body,
two conditions--_encysted hydrocele of the testicle_, and _general
cystic degeneration_ of the same. Like the ovary, the testicle is a
complex organ with remnants of the mesonephros persisting among its
ducts, while only a few of the Wolffian tubules remain. True encysted
hydroceles arise sometimes in the efferent tubes of the testis and
sometimes in Kobelt’s tubes (the same structures which in the female
give rise to parovarian cysts), the two conditions, therefore, being
analogous and homologous. These cysts, though closely associated with
the testis, lie outside its tunica vaginalis. Their contained fluid is
usually clear or of a milky whiteness, due to fat globules. Sometimes
it contains spermatozoa. Another variety is cystic dilatation of one
or more of _Kobelt’s tubules_, which is often described as involving
the _hydatid of Morgagni_.

_General cystic disease of the testis_, known also as adenomatous
degeneration, was formerly referred to as hydatid disease of the same
organ. The multiple cysts appear to originate in the remnant of the
mesonephros still persisting, known as the _paradidymis_. The cavities
are lined with epithelium, and _papillomatous intracystic_ formation
is not uncommon. These tumors have been called by a number of improper
names, such as “cystic sarcoma,” etc.


=Hydroceles.=--The term hydrocele has covered numerous conditions. At
present, when no other locality is designated, hydrocele of the tunica
vaginalis is understood. (The term implies a _collection of watery
fluid in a previously existing serous cavity_.) This is the most common
form.

Possibility of its formation depends upon the prolongation of the
peritoneal cavity which takes place in advance of or along with
the descending testicle, and which in many of the lower animals
remains connected with the general cavity throughout life. In men
only is it expected to close, even before birth. When the portion
which extends along the spermatic cord is not completely obliterated
there is _encysted hydrocele of the cord_, or _funicular hydrocele_,
which is not common. The common form of hydrocele is constituted by
serous effusion into the tunica vaginalis, and occurs usually without
recognizable exciting cause. It will be treated more fully in its
appropriate place.

The corresponding process of peritoneum in the female is known as the
_canal of Nuck_; and, when persistent, this also becomes distended
with fluid and forms a cyst known as _hydrocele of the canal of Nuck_,
occupying the inguinal canal.

In many of the lower animals the ovaries are contained within a serous
sac derived from the peritoneum, which is so connected with the opening
of the Fallopian tubes that when the ova escape from the ovary they
enter these tubes and pass to the uterus without entering the general
peritoneal cavity. This ovarian sac is subject to serous distention,
and constitutes a condition called by Sutton an _ovarian hydrocele_.
An homologous condition occurs sometimes in the human female, by
pathological adhesion, and such cysts may attain large size. They
project from, and are intimately connected with, the posterior layer of
the broad ligament.


=Hydroceles of the Neck.=--Hydroceles of the neck, so called, are
cystic collections of congenital origin found in the cervical region,
due to dilatation of ducts or clefts which should have disappeared at
or before birth. The forms of cyst to which the name “hydrocele of the
neck” are usually limited are recognizable at or soon after birth, and
constitute fluctuating tumors, often extending beneath the clavicle
into the axilla or down upon the thorax. They may occupy the entire
lateral region of the neck, and may be unilateral or bilateral--may be
single or multilocular, and may even intercommunicate.

They originate always beneath the deep fascia. Some of these cysts are
undoubtedly due to dilatation of lymph spaces. This is particularly
true of the multilocular forms. There is noted in many of them a
tendency toward spontaneous recovery, but many again require operative
measures for their eradication. Occasionally their walls are extremely
vascular, even to the degree meriting the term _nevoid_.

Some of these cysts are considered by Sutton to be essentially examples
of the laryngeal saccules which are met with as diverticula from the
laryngeal mucous membrane, which undermine the deep cervical fasciæ of
certain monkeys. These air chambers, which are normal in the monkey,
communicate with the larynx through the thyrohyoid membrane, and
occasionally run down beneath the upper border of the thorax. Many of
the cysts having this resemblance are closely related to the hyoid bone
and to the larynx, and there is much to substantiate the view thus
quoted.


=Glandular Cysts.=--_Ranula_ is an altogether too comprehensive term
which has long been used in surgery, alluding to cysts in the floor
of the mouth, and not indicating minutely their character nor their
exact location. At present this term should either be restricted
in signification or be eliminated. If used, it should be confined
to retention cysts due to obstruction of the _submaxillary_ or
_sublingual_ ducts. Such obstruction is often caused by salivary
calculi impacted in the duct orifices. In other instances it is due
to cohesion of the margins of the outlet. A similar condition in the
parotid duct is known, but is less common. Aside from this, certain
other cysts originate from minute beginnings in and about the floor of
the mouth, being due to dilatation of the mucous glands, particularly
one near the tip of the tongue, sometimes known as _Nuhn’s gland_.
Dermoid cysts in this locality are not uncommon. Formerly cysts of the
floor of the mouth were described as _ranula_.

_Pancreatic cysts_ correspond in large degree to salivary cysts,
the pancreatic duct becoming dilated by retention when its orifice
is obscured; and, indeed, the condition has been referred to as
_pancreatic ranula_. Sometimes the canal is dilated in distinct
portions, so that the condition resembles a string of cysts; at other
times it is the terminal portion which is most enlarged. Such cysts
attain large size and contain mainly mucoid material. Examples have
been reported showing that they have attained a capacity of two gallons.

In the mesentery there sometimes develop cysts which are known as
_chyle cysts_, whose sacs appear to be formed of separate mesenteric
layers, their cavity being occupied by fluid identical with chyle. Such
tumors also sometimes attain great size.

In the eyelids one occasionally meets with cystic dilatations of the
lacrymal ducts. These are known as _dacryopic cysts_ or _dacryops_.
Fistulas result when they are opened through the skin, and if meddled
with at all they should be radically extirpated.[13]

  [13] In the treatment of cysts, as of many abscesses (_e. g._,
  those of the gland of Bartholin), it will be of advantage to empty
  the cavity through a small trocar or needle and then to fill it
  with melted paraffin, as suggested by Pozzi. When it has thus been
  distended it can be dissected out with much more deliberation and
  more easily than would be otherwise possible.


=Pseudocysts.=--In his elaborate work on tumors Sutton has made
a distinct classification of pseudocysts, which lack some of the
characteristics of genuine cysts, yet, nevertheless, are entitled to
consideration in this place. Among these are included _intestinal
diverticula_ and _vesical diverticula_, in either of which instances
hernial protrusions of the mucous membrane through the outer coating
of the bowel or of the bladder occur, thus forming pouches. These are
common in the bowel, rare in the bladder; especially in the former
locality they are often multiple. This condition is often referred to
as _sacculation_, and sacculation of the bladder may even be confounded
with true urachus cyst. They are of little consequence so long as
foreign materials, such as feces, urinary calculi, etc., do not lodge
in them. But they occasionally cause serious trouble. Diverticula have
been mistaken for appendices, while diverticula from the bladder have
been encountered in hernia operations.

_Pharyngeal diverticula_ give rise to rare but most interesting tumors.
It is well known that the branchial clefts, which in early fetal life
connect with the pharynx, are sometimes not completely closed, and that
a portion of one may persist abnormally, giving rise to a condition
known as the _pouch of Rathke_. There may also occur sacculation of the
pharyngeal wall where it joins the esophagus, or hernial protrusions,
especially in Rosenmüller’s fossa.

Cystic dilatation of Rathke’s pouch occurs near the upper part of the
pharynx, and may attain the size of a marble. Hernial pouches are
seldom mistaken for cysts, and are of importance mainly because of
the fact that food or other foreign material gathers and lodges in
them. Most of the other cystic abnormalities of the pharynx pertain
to dermoids, and will be considered shortly. In a general way, these
pharyngeal tumors have been grouped as _pharyngoceles_.

Similarly in the _esophagus and trachea hernial protrusions_ occur, and
lesions closely resembling retention cysts may be seen.

_Synovial cysts_ (_i. e._, those containing synovial fluid) may arise
(1) by protrusion of synovial sheaths, (2) by distention of bursæ
in the vicinity of joints, or (3) by hernial protrusions of joint
membranes. They are often met with in connection with the larger
joints, more particularly about the knee. In this way tumors as large
as goose-eggs may be formed, while their location may be so shifted
that they present themselves in perplexing ways. To that form produced
by hernial protrusion of the lining of a tendon sheath has been given
the name _ganglion_.

The simple ganglion is frequently seen on the back of the wrist, and,
while it is always connected with the tendon sheath, it undoubtedly
often connects with the synovial membrane of the carpal joints. The
compound ganglion, so called, is a much more serious and extensive
affair, being one which has prolongations in two or more directions,
and containing peculiar bodies, known as _melon-seed bodies_, which
appear to be fibrinous concretions worn round and smooth by attrition.
These are present sometimes in enormous numbers. (See Tuberculosis of
Synovial Structures, Chapter IX.)

_Bursæ_ are normal in many well-known situations in the body, but may
undergo cystic dilatation and become annoying tumors. In many other
places, under the influence of friction or mechanical irritation, there
develop bursæ which are known as adventitious. These are sometimes
subtendinous, and may communicate alike with joint sheaths and tendon
sheaths. These are true cysts of new formation not developed from a
pre-existing cavity.

They are largely the effect of peculiar occupation, as in housemaids
and carpet-layers there are formed frequently _prepatellar bursæ_,
while miners get them upon the elbow, porters upon the shoulder,
plasterers upon the forearm, etc. In the same way, by the pressure of
ill-fitting boots, an adventitious bursa is developed over the expanded
head of the first metacarpal bone, thus forming a condition known as
_bunion_.


=Neural Cysts.=--This term has been applied by Sutton to pseudocystic
dilatation of certain cavities found in the brain and central nervous
system. _Hydrocephalus_ is in one sense a pseudocyst of this variety.
Corresponding to it in fetal life is _hydramnios_. Hydrocele or
cystic dilatation of the fourth ventricle is well known. _Cranial
meningoceles_, which are hernial protrusions of brain membranes,
are also pseudocysts, to be included in this category. They will be
considered in Chapter XXXVI. _Cephalhematoma_ may be also included in
the same way. _Spina bifida_, a condition which will be described in
Chapter XXXVIII, is, nevertheless, practically a cyst of congenital
origin involving the spinal meninges. One form of spina bifida is
constituted by cystic dilatation of the central canal of the spinal
cord, and produces _syringomyelocele_. These conditions will be treated
more fully in their appropriate places.

Sutton has rendered a great service by showing that the brain and
spinal cord are evolved from a segment of the primary intestines, and
that the _intestinal canal and the neural canal communicate in fetal
life_ at their _lower terminations_; while it has been shown by several
that in the earlier forms of mammalian life they were also connected by
their _anterior terminations_. It is in this way that certain complex
tumors of the sacral and coccygeal region are to be explained. So also
is the collection of lymphoid tissue in the vault of the pharynx, known
as _Luschka’s tonsil_, and in the coccygeal region, known as _Luschka’s
gland_, it being a curious and instructive fact that lymphoid tissue
of this character is always met with in the neighborhood of obsolete
canals.


=Hydatid Cysts.=--These cysts are the indirect product of the eggs
of the Tænia echinococcus, a form of tape-worm which infests the
alimentary canal of dogs. The eggs reach in some direct or indirect way
the food or water taken into the human stomach and are there hatched;
the young animals migrate through vessel walls and are deposited in
some tissue or organ where the cyst later develops. These cysts have a
thick, elastic wall, with a lining containing cells, involuntary muscle
fibers, and a water-vascular system. After such a cyst has attained
the size of an inch or more, small vesicles, or “brood capsules,”
begin to develop, which present at one point a retractable head,
with scolices so arranged in crown form as to produce sucking disks.
According to the date at which the cyst is opened appearances will
differ. Sometimes a large cavity will be filled with multiple “daughter
cysts,” and sometimes these will have disappeared, so that the cyst
fluid contains nothing distinctive. After having ceased to develop,
hydatids frequently undergo atrophy and even become calcified; the
characteristic hooklets are the last of the distinctive features to
disappear.

These growths may be rapid, even to the point of producing necrosis
and rupture, or may be very slow and persist almost unchanged for
years. The disease is uncommon among the native-born population of
the United States, and most of its examples are seen in emigrants.
It is exceedingly prevalent in Iceland and in New Zealand. It occurs
most often in the liver, but is frequently met with in these countries
in the lungs, the brain and spinal canal, and the bones, but may be
encountered in any part of the body. When located near the intestinal
tract or the air tract the cysts are more liable to penetration by
ordinary germs of sepsis, and then may suppurate. It is not infrequent
to have conversion of an hydatid cyst into an abscess. Before or after
such change it may undergo rupture, spontaneous or traumatic, and this,
according to the nature and amount of its contents, and the location of
the opening, will promptly produce more or less grave symptoms. While
spontaneous recovery has, in rare instances, followed rupture, it has
perhaps more often led to fatal result. At all events, it will produce
serious and perhaps distressing symptoms.

The only radical treatment for hydatid cysts is extirpation. When this
is not possible the cyst may be opened and the margins of the opening
attached to those of the skin wound. After being evacuated it should
be packed and drained, and then may be expected to slowly contract,
perhaps even to the point of obliteration. The contents of such a cyst
should not be allowed to escape into any of the body cavities, since
their sterility can not be always relied upon.


=Cystic Degeneration.=--_Hematocele_ is an expression meaning a tumor
composed originally of effused blood which has undergone chemical
and other changes, which consist of lamination and thickening of
its exterior portion and fluidification of the interior, until in
course of time such an internal blood clot may be converted into a
distinct and plainly walled cyst. This condition may be seen in two
locations--namely, in the _pelvis_ and _between the cranium and the
brain_, or in the brain. The hemoglobin gradually disappears, and the
contents of these cysts are translucent or even watery in appearance.
Hematoceles may form where there has been internal hemorrhage in
certain locations which has failed to absorb, and where no pyogenic
infection has occurred.

Pseudocystic changes occur in other tumors and in other parts of
the body as the result of _mucoid_ and _colloid liquefactions_.
In the midst even of apparently dense and entirely defined tumor
masses changes of this kind occur, and lead to formation of cavities
containing fluid of variable consistence, causing the tumor when
divided to present the appearance of the geodes or quartz rocks,
containing cavities lined with quartz crystals. The occurrence of such
cystic changes is indicated, in naming such a tumor, by prefixing the
term _cysto-_, as cystosarcoma, cystofibroma, etc.


2. =Dermoids.=

Dermoids are _cysts or tumors containing tissues and appendages which
are developed from the epiblast_, and which occur when skin and mucous
membrane are not normally found. The simplest form of dermoid is a cyst
whose interior is lined with modified skin, containing sebaceous glands
and hair follicles, from which often numerous long hairs are produced.
Even sweat glands may be present. Its cavity is occupied by mixed
material, pultaceous in character, made up of sebum, cholesterine,
and growing hairs which are often rolled into balls. The sebum is the
product of the glands contained in the cyst wall.

A complex form of so-called dermoid cyst is met with in which there are
unstriped muscle fiber, teeth, mammary glands, etc. These belong rather
to the class of teratomas, as they contain more or less tissue not of
epiblastic origin.

A _dermoid tumor_ is one lacking cystic characteristics, made up of
tissue largely developed from the epiblast, with more or less tissue of
mesoblastic origin. Such a tumor may contain much connective tissue,
fat, fetal hyaline cartilage, and nerve tissue, while from its exterior
long hair may grow, and teeth project from its surface or be embedded
within its substance. Such tumors are generally found in the pharynx
and about the rectum.

The explanation of dermoids and teratomas may be gleaned from
embryology, and rests upon the arrangement of the different
blastodermic layers of the developing ovum, and upon the facts already
alluded to in explaining Cohnheim’s hypothesis of the origin of tumors.
Strictly speaking, a _dermoid_ should contain only that which may be
developed from the _epiblastic_ layer. It is well known that teeth
and hair, as well as sebaceous material, are epiblastic products.
Consequently such material may be found within a dermoid and needs
no further explanation than an epiblastic inclusion, according to
Cohnheim’s views. But so soon as such a tumor contains bone, muscle,
etc. (_i. e._, tissues of mesoblastic origin), we should drop the term
_dermoid_ and consider it a _teratoma_. Such is the distinction between
these two terms. According to Wilm’s researches, any tumor of this sort
which contains epithelial products as teeth or hair is sure to contain
also mesoblastic elements, and thus to belong to the latter. The term
_epidermoids_ has been applied to the former.

The most prominent characteristics of dermoid cysts are: (1) _Skin_,
which may be thick or thin, lined with papillæ, containing more or less
pigment, its deeper layers possessing a quantity of fat. (2) _Hair_,
which next to skin is the most constant structure found in dermoids;
this may be present in trifling amount or in long coils or balls. It
is of interest that in dermoids found in animals covered with wool we
find the same character of hairy structure, while in birds dermoids
contain feathers rather than hairs. (3) _Sebaceous glands_ and their
peculiar secretion are invariably found. These may be of large size,
and sebaceous retention cysts may be seen in the walls of dermoids.
Sometimes _horny_ matter or tissue is found in these, indicating the
same relation between horn and sebaceous structures, as we see upon
the external skin in other instances. So, too, material resembling
the texture of finger-nails is occasionally found projecting into the
cavity.

The fluid or semifluid contents of these cysts consist usually of
sebaceous material, cholesterin, epithelial debris, etc. Sometimes it
is thick, sometimes thin--and occasionally consists almost entirely of
mucus.

It is not uncommon to find structures in _ovarian_ dermoids closely
analogous to, or actually resembling, _mammary glands_. These may be
mere nipple-like processes of skin, or completely developed _mammæ_,
well formed, but without ducts or gland tissue, may occupy such a
cyst. These really are _pseudomammæ_, because they have no ducts.
Nevertheless, glandular tissue is not always absent. This resemblance
proceeds even farther, in that in some of these ovarian mammæ changes
occur analogous to those which take place in normal breasts.

The epiblast seems to have the power of developing mammary glands or
supernumerary mammæ in many locations--in fact, upon any part of the
body surface. About the thorax they are common; upon the abdomen they
are rarely observed; and they have been found even upon the labia.

_Sweat glands_ are infrequent in dermoids. _Teeth_ are quite common.
These may vary in number from two or three up to several hundred--may
be embedded in definite sockets or simply sprout from the cyst wall.
Occasionally bone material, lodging such teeth and crudely resembling a
jaw, will be found.

Dermoids containing _mucous membrane_ are found, especially in
connection with the ovary and with the postanal gut (_i. e._, the
original communication between the spinal and alimentary canals).

It is curious that under these circumstances mucous membrane is
sometimes furnished with hair, as it normally is in the stomach
or other cavities of some of the lower animals. Mucous glands and
retention cysts of these glands are also found in ovarian dermoids.
This will be more readily understood if the mutability of skin and
mucous membrane be not forgotten. The transition from one to the other
is not difficult, and we find all intermediate stages between the two
extremes--if not in man, at least in animals. This will account for the
fact that skin-covered dermoid tumors are found in certain parts of the
alimentary canal, and particularly in the pharynx. These tumors grow
also from the mucous membrane of the bowel, of the rectum, or even of
the small intestine.

Sutton has made a division of dermoids into three classes:

  1. _Sequestration_;

  2. _Tubulodermoids_;

  3. _Ovarian_.


1. =Sequestration Dermoids.=--Sequestration dermoids occur chiefly in
situations where during embryonic life coalescence takes place between
two surfaces possessing an epiblastic covering, although sometimes this
coalescence practically occurs late in life and by implantation.

Dermoids of the trunk occur particularly where opposite halves of the
body wall coalesce--that is, in the midline of the trunk and head.
Dermoid cysts are rarely found in connection with _spina bifida_, and
certain tumors spoken of as spina bifida undoubtedly are dermoids.
Anteriorly dermoids occur frequently in the scrotum, and occasionally
in the testicle. At the umbilicus they are rarely found--usually as
pedunculated tumors projecting externally. In the midline of the thorax
and neck they are most common opposite the manubrium, dropping down
behind it to invade the anterior mediastinum. Near the hyoid bone they
occur relatively frequently; about the head they are met with most
commonly at the angles of the orbits--more so at the outer than at the
inner angle. Dermoid cysts are known to oculists as growing upon the
iris or springing from the conjunctiva. About the ear they are not
infrequent; in the roof of the mouth, especially if this be incomplete,
we frequently find cysts of epiblastic origin.

Sequestration dermoid cysts are also undoubtedly found in connection
with the _dura mater_, in the scalp, most commonly at the anterior
fontanelle, at the root of the nose, and at the external occipital
protuberance, where they may be confounded with sebaceous cysts or with
meningoceles. In order that a dermoid of the dura may communicate with
the skin there must of course be osseous defect.

Sequestration dermoids upon the limbs have been mostly reported as
sebaceous cysts. They are rare, and usually associated with antecedent
injury, by which epiblastic structures are driven in and implanted
in such a way that as they develop they give rise to these peculiar
tumors. These are what Sutton calls _implantation dermoids_. They are
found upon the fingers and elsewhere.


2. =Tubulodermoids.=--These are largely connected with obsolete canals
and ducts. It is a great service which Sutton has rendered in proving,
apparently beyond the possibility of doubt, that the central canal of
the nervous system is really of intestinal origin, and may be regarded
as a disused segment of the primary alimentary canal. He has also shown
how it behaves occasionally as do other functionless ducts, and that
cysts and dermoids in connection with it are to be thus explained.
He and others have also shown the anterior as well as the posterior
communication of these canals, and the pituitary body are to be
regarded in this light as the same formation of lymphoid tissue around
an obsolete canal which we see in Luschka’s tonsil close by, and in
Luschka’s gland at the other extreme of the canal.

[Illustration: FIG. 72

Solid dermoid escaping from pelvis. (Original.)]

[Illustration: FIG. 73

Congenital dermoid cyst of pelvis. (Ahlfeld.)]

The primary alimentary canal was a continuous tube lined with a
continuous layer of columnar epithelium. That portion connected with
the yolk sac develops into the intestine, the balance into the central
nervous canal. Portions of this canal are in postnatal life absolutely
obsolete; others persist in a rudimentary condition. Dermoid cysts and
dermoid tumors develop in connection with each of these. In some there
is a large central cavity; others are almost absolutely solid. Thus
we find dermoids in the coccygeal region, which have been variously
regarded as sarcomas, adenomas, etc., which are really of origin as
stated above and should be considered simply as dermoid tumors. Most
of these project outwardly; some of them arise and develop within the
pelvis. Dermoid cysts and tumors are also met with in connection with
the rectum--sometimes between the rectum and the bladder, and between
the rectum and the spine. Dermoid tumors are also found in connection
with the pituitary body. These sometimes develop within the cranium,
or, again, protrude perhaps into the orbit, perhaps into the pharynx.

_Thyroid dermoids_ are tumors of great interest. They develop sometimes
about the craniopharyngeal canal, which may be detected as a small
canal in the macerated sphenoid bone of a fetus, and which before birth
is filled with fibrous tissue. It connects with a recess in the middle
line and at the base of the skull, presenting in the pharynx, which is
often referred to as the _bursa pharyngea_. It is around this recess
that the lymphoid tissue known as the “pharyngeal tonsil” develops.
It may be thus expected that the roof of the pharynx should be the
occasional site of dermoids. It is from the pharynx or the floor of
the mouth that in vertebrates the thyroid body arises. In higher forms
it becomes dissociated from the pharynx and shifts its position. The
thyroid body is developed around the thyroid duct, which first appears
as the thyrohyoid duct, which later becomes divided, that portion in
relation with the tongue becoming the thyrolingual duct, the remaining
portion persisting as the thyroid duct. These are present about once
in every ten subjects, according to Sutton, the canal when persistent
being lined with epithelium. When the extremities of these ducts
become occluded retention cysts may form. In the same way dermoids of
the tongue are formed, similar to those occurring on the scalp. These
are frequently mistaken for sebaceous cysts. They may be unilateral,
central, or even bilateral. The _lingual_ duct is also of interest,
because it would appear that certain cases of epithelioma of the tongue
arise along this duct, and perforating malignant ulcer of the tongue is
thus produced. Dermoid tumors of the lingual or thyroid ducts resemble
in structure the thyroid body. The thyroid duct may also be detected
in many adults running from the isthmus of the thyroid body to the
posterior aspect of the hyoid bone, and surrounded by muscle tissue.
Sometimes the space usually occupied by this duct is represented by
a series of detached bodies known as _accessory thyroids_. These are
not infrequently the seat of cysts, sometimes of considerable size.
(The accessory thyroids often enlarge when the main thyroid has been
extirpated for disease.) Thus cysts in close relation to the hyoid bone
are common. Some of them grow slowly, while others grow rapidly and
contain much fluid. Many of them are unilateral, and are often mistaken
for enlargements of one lobe of the thyroid. Cysts growing from
accessory thyroids are often filled with papillomatous masses, and are
occasionally the seat of malignant degeneration.

In the _omphalomesenteric_ duct or its remains, especially in relation
with the umbilicus, we often meet with small cysts or tumors in infants
and young children. When the duct is persistent it presents normal
intestinal structure, and, like the appendix, possesses much adenoid or
lymphoid tissue.

Another and very important form of _tubulodermoids_ develops in
connection with the _branchial clefts_ of the neck. Congenital fistulas
of the neck have been long known, but only comparatively recently
understood. Of the branchial clefts it is well known that the first
alone should persist, as the Eustachian tube. Occasionally, however,
they fail to become obliterated, and then we have congenital tumors
or cysts, which may, perhaps, not develop to appreciable size until
somewhat late in life; or there may be fistulous passages opening
either into the pharynx or externally, forming canals varying in
length from half an inch to two inches, secreting a little fluid
because lined with epithelium. When these become inflamed an abscess
results. When they open externally the opening is often marked by a
little tag of skin containing a fragment of yellow cartilage. These
are often referred to as _cervical auricles_. They open along the line
of the sternomastoid muscle. The internal openings of these fistulas
frequently form diverticula from the pharynx or esophagus. Thus it will
be seen that dermoid cysts about the neck are principally relics of
openings or ducts, which are normal in embryonic life, but which should
have been obliterated at or long before birth. Congenital fistulas,
however, may be met with in the middle line of the neck, which are not
to be confounded with branchial fistulas, but rather with the ducts
previously described.


3. =Ovarian Dermoids and Teratomas.=--These may be unilocular or
multilocular cysts, usually the latter. They are lined with epithelium,
and contain mostly mucoid fluid, the inner coat being practically
identical with mucous membrane. Occasionally, however, the skin is
furnished with hair, sebaceous glands, teeth, and even nipples. The
multilocular cysts are practically an aggregation of those just
described. They are surrounded by dense capsules, often attain great
dimensions, and are made up of primary cysts resembling large cavities
in a honeycomb-like mass, which itself is occupied by secondary
cysts, and belong rather to the class of mucous retention cysts,
these being occupied by still smaller ones, which are histologically
indistinguishable from distended ovarian follicles. In these large
tumors we find in some cases hair, in others teeth, and in others
sebaceous glands, etc., the dermoid constituents being scattered
throughout. As Wilms has shown, in almost every tumor of this character
a projection may be found whose summit is covered with epiblastic
elements, which when cut in serial transverse sections will show in
its deeper portion other epithelial collections representing a feeble
attempt to develop a nervous system, or lung tissue, while mesoblastic
elements, like connective tissue, cartilage, and bone, appear scattered
throughout, as though a very crude effort had been made to reproduce an
atypical embryo.


3. =Teratomas.=

So far the endeavor has been to limit the term _dermoid_ to tumors
which are essentially of _epiblastic_ formation, their location
being explained on the inclusion theory of Cohnheim. There is also
a still more complicated type of tumor, composed of tissues of both
_epiblastic and mesoblastic_ origin, perhaps even _hypoblastic_.
Their consideration belongs to that department of pathology known as
_teratology_, which is supposed to deal especially with monsters.
Strictly speaking a _teratoma_ refers to an irregular tumor or mass
containing tissues and fragments of viscera of a suppressed fetus which
is attached to an otherwise normal individual. Nevertheless the term is
often applied to growths which are the result of luxuriant mesoblastic
development in which neither form nor member of a suppressed fetus is
present.

The presence of supernumerary members is largely connected with what
is called _dichotomy_, alluding thereby to cleavage either at the
anterior or posterior end of the developing embryo. _When the whole
embryonic axis divides twins may be produced_, but should cleavage be
partial we may have a monster with two heads if it be anterior, or
one with three or more limbs if it be posterior. Children born with
these deformities are usually called _monsters_, and the study of such
cases belongs entirely to teratology. But in certain tumors small
portions of a suppressed fetus may develop, as, for instance, from the
posterior portion of the sacrum, or within the abdomen or thorax, or
upon the neck or face, which on dissection may contain a few vertebrae
or processes resembling fingers associated perhaps with a structure
resembling intestine or liver. This should be called a teratoma. Such
tumors possess for the pathologist the greatest value. In surgery,
however, they are rare, and there are scarcely two cases alike. The
question of operation will often arise, as it does with supernumerary
limbs, and each case should be studied upon its own merits. Sometimes
they are amenable to extirpation.


=Embryonal Adenosarcoma.=--Embryonal adenosarcoma is a term given to
certain teratomatous tumors peculiar to renal and adrenal structure,
which present peculiar characteristics in the mixture of elements which
enter into their composition. At various times these tumors have been
called adenoma, sarcoma, rhabdomyoma, congenital cystic kidney, etc.
They have been also likened to the thyroid. They comprise a group of
neoplasms, always congenital in origin, which usually appear early in
life, but occasionally occur in advanced adult life. One of the most
marked specimens of this kind the writer removed from a man over fifty
years of age. Most of the specimens, however, described in literature
pertain to the young. On minute examination they often present a
strange, mixed picture of voluntary muscle elements intermingled with
epithelium arranged to imitate acinous glands, with cystic dilatations
of the true kidney tissue. They often attain enormous size, and
undergo such proliferation of mesoblastic elements as to resemble
sarcoma. Their occurrence is to be explained only on the principles
of Cohnheim’s hypothesis. When the original Wolffian body is being
differentiated from the elements about it a confusion of the same
with the excretory tubular beginnings, which are to empty into the
Wolffian duct, occurs. Thus we have the commencement of a mixed mass
which presents itself as a more or less rapidly growing tumor, in
which even cartilage or other mesoblastic structures may be met with.
It is scarcely possible that any two specimens should yield exactly
the same microscopic picture, much depending on whether one element
or the other prevail. In a few of them there may occur also a mixture
of adrenal elements. Sometimes the renal structure itself is more or
less distinct, and rides, as it were, upon the surface of the tumor;
at other times it is entirely mixed up with it. While the condition
is usually limited to one side it may be a double affection, so that
the second kidney becomes useless and the patient succumbs. The only
treatment is extirpation.

Teratomatous tumors are sometimes found hanging in the pharynx,
attached by a small pedicle, where they may be confounded with dermoids
unless carefully examined after removal. Many instances of this type
of tumor are found in animals. Here no false sentiment will prevent
complete examination and preservation of the specimen. They are also
encountered in the sacral and coccygeal regions.


4. =Tumors of Connective-tissue Type.=


=Lipoma.=--Lipomas, or tumors composed of fat, are the most common of
the neoplasms. Their normal type is the _ordinary adipose tissue_ of
the body, and may be divided into the _encapsulated_ and the _diffuse_,
the former of which are surrounded by fibrous tissue. The diffuse
lipomas are those which have no capsule, and where the pathological
collection of fat merges into that normally present--in other words,
they are not circumscribed.


=Subcutaneous Lipomas.=--Subcutaneous lipomas are perhaps the most
common of all, and are usually irregularly lobulated and encapsulated,
adherent rather to the skin than to the deeper tissues. Usually but
one is found in an individual, though instances of multiple lipomas
are not rare. They develop sometimes to enormous size, cases being on
record where the tumor has even weighed one hundred pounds. They may
be met with at any point on the surface of the body. The lobules often
burrow between the muscles, and those found in the palm of the hand
penetrate even beneath the palmar fasciæ. They are sometimes markedly
pedunculated, and often hang by a small stem. The diffuse subcutaneous
lipoma is most common about the neck, in the groin, and in the axilla.


=Subserous Lipomas.=--Subserous lipomas are mostly retroperitoneal,
and large tumors of this character, mistaken for ovarian, have been
successfully removed by operation. They also occur in the hernial
canals and spaces. They develop beneath the peritoneum covering
the intestines, and in this location give rise occasionally to
_intussusception_. Here in their pathological development they have the
general form and significance of _appendices epiploicæ_.


=Subsynovial Lipomas.=--Subsynovial lipomas occur about various joints
and tendon sheaths; within the knee they assume a distinctive type
which has been called _lipoma arborescens_, where they take on a
dendritic appearance and arrangement. _Submucous_ lipomas are rare.
_Intermuscular_ fatty tumors are occasionally met with, an interesting
variety being that which develops between the masseter and buccinator
muscles. _Intramuscular_ forms rarely occur, as well as a variety known
as _parosteal_, which arises in connection with the periosteum. Fatty
tumors also occur within the spinal dura, as well as outside of it
within the spinal canal, and more or less lipomatous alterations are
common in connection with spina bifida.

Lipomas are ordinarily easy of recognition, save when deeply located.
The subcutaneous forms are intimately related with the overlying skin,
and have a dough-like consistence which is usually pathognomonic.
Tumors, suspected to be fatty, in the middle line of the back or
cranium are always to be viewed with suspicion, as they are often
connected with congenital meningeal protrusions.

An encapsulated lipoma when thoroughly removed will not return.

Mixed forms of fibrous and fatty neoplasm are occasionally seen, and
are referred to as _lipoma fibromatosum_ or _fibroma lipomatosum_,
according as one or the other tissue predominates. These growths are
innocent in their character, but call for thorough extirpation. They
frequently give rise to considerable discomfort or pain, and are called
_lipoma dolorosa_.


=Fibroma.=--Fibromas are tumors composed of fibrous tissue, which, when
of pure type, are found to be not so common as was formerly supposed,
the majority of tumors hitherto roughly grouped as fibromas containing
either muscle tissue or sarcomatous elements, which takes them out of
the category of pure fibroma. A typical fibroma is ordinarily dense,
and is composed of wavy bundles of fibrous tissue whose cells are long
and slender and closely packed together, the mass being permeated by
distinct bloodvessels.

Fibroma occurs most commonly in the _ovary_, the _uterus_, the
_intestine_, the _gum_ (epulis), in _nerve sheaths_, and in the
_skin_ in the form of so-called _painful subcutaneous tubercles_ and
_molluscum fibrosum_. There is also a fibrous tumor of the skin, known
as _keloid_, sustaining to fibroma the same relation that exists
between exostosis and osteoma.

_Painful subcutaneous tubercle_ is a sample of pure fibroma in the
shape of a small, flattened, pea-like tumor which never attains great
size. It is situated loosely in the subcutaneous structure and may form
a visible prominence. Insignificant as it would thus appear, it becomes
the seat of exasperating pain, particularly when touched or handled,
which may radiate to considerable distances. The etiology of these
growths is unknown.

In the ovary, the uterus, the intestine, and the larynx true fibrous
tumors are pathological curiosities rather than common lesions.

[Illustration: FIG. 74

Keloid of external ear: _a_, dense tissue of skin; _b_, fibrous
connective tissue; _c_, epidermis. (Klebs.)]


=Epulis.=--Epulis means any tumor growing upon the gum. The term was
formerly applied in an indistinct and too comprehensive way, although
it is still retained in literature. But pure fibromas do spring from
the fibroösseous structure of the gum and alveolar process. They are
covered with the gingival mucous membrane and seem to spring from the
periodontal membrane. They seldom attain large size, and then only by
neglect. By the pressure of such tumors teeth may be separated and
distortion of the mouth produced. They should be promptly extirpated.


=Keloid.=--Keloid is a fibrous neoplasm arising mainly in cicatricial
tissue, which is essentially fibroid in structure. It is a neoplasm
which often follows the general outline of the scar in which it
grows, consists in elevation of the surface, ordinarily quite smooth,
sometimes of a delicate pink from the dilated vessels which it
contains. Keloid is the _bête noir_ of surgeons, as it frequently
complicates and disfigures scars which have at first been satisfactory,
and since it indicates a condition which it is discouraging to deal
with, because when it is removed there is usually recurrence of growth
within a few months after cicatrization. It often occurs in stitch-hole
scars and upon the site of extensive burns, and may be observed after
puncture of the ears for ear-rings, and has also been observed in scars
left by smallpox, acne, etc. It is more prevalent in the colored race
than in the white. In negroes multiple keloid tumors are often seen,
occasionally in large numbers. Their explanation is unknown, and it
may be that some trifling injury has preceded each individual tumor
(Fig. 74).

The _treatment_ of _keloid_ will be considered in the chapter on the
Surgical Diseases of the Skin.


=Desmoids.=--This term has been applied to tumors of a certain clinical
type which arise from the fibrous structures, usually of the abdominal
wall, and produce neoplasms like the fibromas of other parts of the
body. The use of the term should be restricted to those tumors which
proceed primarily only from muscles, tendons, and aponeuroses, or
perhaps from ligamentous and periosteal tissues. These tumors are
usually single, attain sometimes considerable size, grow slowly, rarely
involve other structures, and not infrequently develop to such an
extent as to encroach upon either pelvis or the abdomen, or both. They
have been known to attain to the weight even of ten pounds or more.
They are usually more or less encapsulated, and are firm and dense
in structure. Under the microscope they have the general appearance
of cellular fibroma. Sarcomatous elements may be met, while they
occasionally undergo cystic degeneration. Their occurrence may be
explained, at least in some instances, on the embryological theory of
Cohnheim.

[Illustration: FIG. 75

Multiple enchondromas.]

The _treatment_ of desmoids consists in their complete extirpation.
They should not be allowed to attain large size because their removal
may entail a serious weakening of the abdominal wall. There should be
such plastic rearrangement of abdominal protecting membranes as to
reduce the resulting weakening to a minimum.


=Psammoma.=--Psammoma is a term applied to a form of hard fibroma met
with in the dura mater, in which there has occurred a petrefaction of
some of the cells--_i. e._, a deposition of calcareous salts, which
gives it a gritty or sandy appearance.


=Chondroma.=--The true chondroma is a tumor _composed of hyaline
cartilage_. It occurs in the long bones, usually in relation with
epiphyseal cartilages, and is often noted during the earlier years
of life. While it is usually a solitary tumor, multiple chondromas
are often seen, especially upon the hands. These tumors are often
encapsulated and form deep hollows, in which they rest. Unless
pressing upon nerve trunks they are painless and slow of growth. They
are exceedingly dense and hard, and ordinarily immovable. _Mucoid
softening_ (_i. e._, _cystic degeneration_) is common, and the
softened areas may give rise to fluctuation. There may be coincident
_calcification_ or _ossification_ in any of these growths. It is
noted as a curious circumstance by Sutton that their tissue resembles
histologically the bluish, translucent, epiphyseal cartilage seen in
progressive rickets.

To the small local hypertrophies of cartilage which are seen especially
about joints, about the laryngeal cartilages, and the triangular
cartilage of the nose, are given the term _ecchondroses_. They are
most common in the knee in connection with rheumatoid arthritis, and
occur as prominences along the margins of the joint cartilage. They
may project to such an extent as to be detached by accident, after
which they become movable and floating bodies in the joints. Many
of the floating cartilages or bodies found in joints are detached
ecchondroses, which may be smoothed off by attrition, and may be found
singly or multiple, even several hundred existing in one joint.

_Chondromatous changes_ as occurring in _sarcomatous tumors_ have been
alluded to. It seems to be easy for connective tissue to form hyaline
cartilage, and mixed tumors may thus be seen in connection either with
sarcoma, fibroma, or other forms.


=Treatment.=--The treatment of chondroma is solely operative. Unless
the integrity of a member or a limb be compromised, such a tumor can
usually be shelled out from its location, but requires that the matrix
be completely extirpated; all of which may call for the use of powerful
bone instruments. At other times _amputation_ is the only measure which
may relieve from deformity, pain, and disability. The _ecchondroses_
occurring within joints necessitate incision and evacuation, with
the most rigid aseptic precautions, with or without drainage. When
practised according to modern technique this is almost invariably
successful. In former times many lives were lost because of septic
infection.


=Osteoma.=--Under the head of nomenclature I have already endeavored to
distinguish as between _exostosis_, or irregular bone outgrowth, and
_osteoma_, as a distinct tumor which is composed of bone tissue, with
the subvariety _odontoma_, or tumors of dental origin and structure.
Osteoma is regarded by some as ossifying chondroma, for it is nearly
always found near epiphyseal lines, and is always covered by hyaline
cartilage when thus found. Nevertheless it is not invariably such.
We speak of _compact_ or _ivory_ osteoma and of a _cancellous_ form.
The former is identical with the compact tissue of the shafts of long
bones, and may occur anywhere, but is most common about the cranium,
at the frontal sinus, the external meatus, and the mastoid process.
Osteomas growing into the frontal sinus of oxen form large, lobulated,
bony masses, sometimes weighing several pounds, and as dense as ivory.
Some of these tumors growing into the cranial cavity have been regarded
as ossified brains. Osteomas in connection with the external auditory
meatus may partially obscure this channel and cause deafness. They
constitute _ivory-like growths_, which sometimes defy the finest steel
instruments with which the surgeon can supply himself.

[Illustration: FIG. 76

Double osteoma of the skull. (Musée Dupuytren.)]

Cancellous osteomas grow in the cranium as well as in the long bones,
and, like the compact forms, only occasion pain by pressure upon nerve
trunks.


=Exostoses.=--Exostoses are classed by Sutton as--

1. Those formed by _ossification of tendons_ and their attachments.
There should be excluded from this group such natural or evolutionary
processes as the supracondyloid process, the third trochanter of the
femur, etc. Over or around such exostoses bursæ will form to mitigate
as much as possible the effect of friction. Such an outgrowth is known
as an _exostosis bursa_; it is most frequently seen on the inside of
the femur immediately above the knee.

2. _Subungual exostoses_, occurring usually beneath the nail of the big
toe.

3. Exostoses due to _calcification of inflammatory exudations_,
including the rare condition known as _myositis ossificans_.

[Illustration: PLATE XVII

FIG. 1

Round-cell Sarcoma. (Low power.)

FIG. 2

Spindle-cell Sarcoma. (Low power.)]

When a true osteoma is once thoroughly removed there is no tendency to
recurrence. Thorough removal, however, calls sometimes for serious and
often mutilating operations, which may become dangerous when the growth
involves the curve of a rib or a large portion of the skull. At other
times amputation is rendered necessary. Special forms require special
treatment.


=Sarcoma.=--Formerly this name implied a fleshy tumor, and was made to
cover many different conditions. Now _sarcoma means a tumor composed
of immature mesoblastic or embryonic tissue in which cells predominate
over intercellular material_. Sarcomas are sometimes encapsulated;
they merge into and infiltrate the surrounding tissue and disseminate
widely, and have usually these propensities and characteristics to
such a degree as to constitute malignancy. For the laity sarcomas and
carcinomas are together included in the comprehensive term of _cancer_;
for the surgeon they constitute but one form of cancer. Sarcomas
are classified, according to the shape of their cells and their
disposition, into--

  A. _Round-cell_;

  B. _Spindle-cell_;

  C. _Myeloid_.

To these are added other varieties mentioned below.

[Illustration: FIG. 77

Osteoma of frontal sinus. (Neisser.)]

[Illustration: FIG. 78

Recurring sarcoma of parotid. (Original.)]


A. =Round-cell Sarcoma.=--This is simple in construction, and consists
of round cells containing very little intercellular substance. The
nuclei of the tumor cells stain easily, the cells themselves varying in
size in different cases. Bloodvessels lead up to the tumor, but in the
interior appear rather as channels. These tumors have no lymphatics:
they grow rapidly, infiltrate easily, recur quickly, and give rise to
numerous metastatic or secondary deposits. They may affect any part of
the human body. The size of the cells is supposed to be in some measure
an index of their malignancy--the smaller the cell the more malignant
the tumor. They appear at all periods of life. They are perhaps the
most commonly seen of malignant tumors in animals. (See Plate XVII.)


=Lymphosarcoma.=--This tumor is composed of cells similar to the
previous form, but enclosed in a delicate meshwork resembling that of
lymph nodes, hence the term _lymphosarcoma_. Lymphosarcomas are not
to be confounded with enlargements nor with the specific granulomas
involving these lymphatic structures.


B. =Spindle-cell Sarcoma.=--In this form the cells have a spindle shape
and run in all directions, so that sections will show them in various
shapes and sizes. In some cases the cells are small and slender, in
others large. The size of the cell is a measure of the malignancy of
the tumor. (See Plate XVII.)

The largest of these spindle cells are frequently striated transversely
like voluntary muscle fiber, and tumors composed of this form have
been considered as tumors of striped muscle tissue, and are generally
called _rhabdomyoma_. There is no tumor of striped muscle fiber,
and the rhabdomyomas of writers generally should be considered as
spindle-cell sarcoma, or may be dignified by the name _myosarcoma_.
(See Rhabdomyoma, under Myoma.)


=Alveolar Sarcoma.=--This is a rare form, in which the cells, contrary
to the general rule of sarcomas, assume an alveolar arrangement
strongly imitating that of epithelial cells in carcinoma. Almost
invariably, however, on close examination it will be possible to
distinguish a delicate reticulum between individual cells, which is
never met with in cancer.


C. =Myeloid, or Giant-cell Sarcoma.=--In this form the tissue resembles
histologically the red marrow of young and growing bone, containing
large numbers of multinuclear cells embedded in a matrix of spindle or
round cells. These tumors usually occur in the long bones, and when
freshly cut look like a piece of liver. They constitute most of the
_epulides_ or cases of _epulis_--_i. e._, spongy tumors springing from
the gums. (See Plate XVIII., Fig. 2.)

[Illustration: FIG. 79

Sarcoma of femur following fracture--_i. e._, developing in callus.
(Original.)]

Giant or multinuclear cells should be present in considerable numbers
to entitle a tumor to classification in this group. When round cells,
spindle cells, or giant cells mingle in nearly equal proportion the
tumor should be called a _mixed-cell sarcoma_.


D. =Osteosarcoma.=--Osteosarcoma is something more than sarcoma of
bone, which latter may spring from the fibrous or medullary elements.
It is sarcoma of the specific bone-forming connective tissue, including
the osteoblasts and osteoclasts; in other words, of the stroma of the
bone. Under these circumstances real bone develops throughout the
tumor, and it is essentially a bony neoplasm. In like manner there may
be true _osteofibroma_. These tumors are to be distinguished, even
clinically, from the medullary sarcomas, which develop within the bone
and expand it, even to enormous proportions, the bony covering then
being a mere shell.


E. =Chondrosarcoma.=--Chondrosarcoma resembles osteosarcoma in that it
is sarcoma of the stroma of cartilage, or of the specific tissue which
produces cartilage. In it true cartilage (white fibrous) also is found
throughout the tumor. Chondrofibroma is also possible. (See Plate XIX.)


F. =Endothelioma.=--Endothelioma has been called various names, and
its true character has been only lately determined. It is composed
particularly of the endothelial cells which line the lymph spaces, and
which have no peculiar secretion. It is met with most often in the skin
(especially of the face), in the parotid region, in the genital glands,
the bones, the lymph nodes, and dura.

[Illustration: PLATE XVIII

FIG. 1

Angiosarcoma. (Low power.)

FIG. 2

Giant-cell Sarcoma. (High power.)]

[Illustration: PLATE XIX

FIG. 1

Chondrosarcoma. (Low power.)

FIG. 2

Osteosarcoma. (Low power.)]

[Illustration: PLATE XX

Melanosarcoma of Skin. (Dry high power.)]

The microscopic picture of these tumors varies greatly, the endothelial
cells often shaping and grouping themselves so as to imitate
epithelioma. In doubtful cases the primary location or origin of the
growth should be ascertained.

Endotheliomas are mainly of rapid growth, and often show a high degree
of malignancy. If thoroughly extirpated before metastasis has occurred,
prognosis is fair; but metastases happen early because of the direct
connection of the tumor with the lymph current.

[Illustration: FIG. 80

Endothelioma of the soft palate: _a_, dilated lymph space; _b_,
endothelial cells with beginning cystic formation; _c_, completely
formed cyst. (Volkmann.)]


G. =Angiosarcoma.=--Angiosarcoma is a sarcoma arising from the
adventitia of the bloodvessels. It is characterized by its
extraordinary vascularity, the ease with which hemorrhages into the
structure of the tumor take place, and the frequency of pigmentation.
_Peritheliomas_ constitute a subvariety, met with especially in the
kidneys, the bones, and the skin, and originate in the perithelial
cells between the capillaries and the perivascular lymph spaces. They
are more vascular than the angiosarcomas. The latter are common in the
liver. In many cases the cells of these tumors simulate the columnar
epithelium of adenocarcinoma. (See Plate XVIII, Fig. 1.)


H. =Cylindroma.=--This is a term applied to tumors of the
angiosarcomatous type in which hyaline changes have occurred, so that
along the vessels appear cylindrical masses of altered cells. Similar
appearances are noted in certain endotheliomas and are due to the same
hyaline degeneration.


I. =Melanosarcoma= (_better known as Melanoma_).--This refers to the
deposition of pigment, rather than to type or shape of cell, the
distinguishing feature of these growths being the presence both in the
cells and in the intercellular substance of a variable quantity of
blackish pigment. Of all the forms the melanotic growths are considered
the most malignant. They invariably recur after removal, lead to
secondary deposits at long distances, and present the most intractable
and incurable forms of cancer. Deposition of pigment in carcinomas is
most rare, if ever met with, and the growths of melanotic type should
be relegated entirely to the class under consideration. The tumors most
often develop from pigmented nevi of the skin, though primary melanoma
of the deeper parts of the body is known. These will be treated more
fully in the chapter on the Skin. (See Plate XX.)

This name has been variously applied by different writers to different
growths. In order to avoid confusion it would be well, in using it, to
be definite.


=General Characteristics of Sarcomas and Endotheliomas.=--The vascular
supply of sarcomas varies within wide limits. In nearly all instances
it is of capillary character, the blood circulating rather through
vessels without well-marked walls. While large vessels may be found
about and in the periphery of these tumors, distinct vascular structure
is usually absent from the more internal portions, which will explain
the frequency of hemorrhage, its persistency after operation, and the
ease with which large extravasations occur. True hematocele may thus
take place within sarcomatous tumors, with the usual later cystic
alterations, and thus in one way we have the condition known as
_cystosarcoma_.

In attacking these growths the vascular and bloody area may be met just
about their margins, the bloodvessels expanding as they arrive at the
tumor, and sometimes bleeding extensively. Under most circumstances,
however, this hemorrhage can be controlled by packing or by operating
at a greater distance from the circumference of the growth.

_Metastasis in sarcoma is common_, dissemination occurring mainly
along the veins, as these growths connect with the venous channels and
permit of easy detachment of fragments, which are then carried along as
emboli. These emboli pass naturally to the right side of the heart, and
thence to the lungs, where it is most common to find secondary growths,
except in areas emptying into the portal veins, in which case the liver
will be the most common site. Sarcomas are destitute of lymphatics, and
dissemination does not occur through these channels.

Infiltration is also a common phenomenon with these growths. This is
generally seen in muscular tissue, particularly with growths proceeding
from the periosteum and projecting into it.

Sarcomas, like other tumors, tend to grow along the lines of least
resistance. Hence processes of these tumors will insinuate themselves
into fissures and interspaces, and penetrate perhaps even into the
cavities, from which it is hazardous or impossible to remove them.
Thus, sarcomas springing from the head of a rib have been known
to extend through an intervertebral foramen and give rise to an
intraspinal tumor, causing fatal pressure.

_Secondary changes_ are usually seen in sarcomas, the most frequent
being hemorrhage. _Myxomatous degeneration_ is also frequent, and gives
rise to _cystic_ conditions. _Calcification_ is common, particularly
in the slowly growing tumors which arise from bone. Upon the other
hand, _necrosis_ (_i. e._, ulceration) is common in growths which
project upon the surface or into any of the open cavities of the body.
Ulceration here is growth at a rate faster than nutrition will justify,
and gangrene is to be regarded as a failure to supply sufficient blood.
It may also mean infection, of which it is a usual expression.

Tumors of this character, which luxuriate upon reaching the surface,
and bleed easily upon the slightest touch, were formerly known
as _fungus hematodes_. The name may be preserved for the sake of
convenience, but should be held to mean, in almost every instance, a
rapidly growing round-cell sarcoma.

Sarcoma is common in the lower animals, particularly so in horses--most
common in those of gray color. It is met with also in cows and various
other domestic and undomesticated animals.


=Myxoma.=--The myxomas are composed of _mucous tissue_, whose
best-known normal representative is the Whartonian jelly of the
umbilical cord. True myxoma should be distinguished from _myxomatous
degeneration_, which occurs frequently in cartilage, fibrous tissue,
and sarcoma, and which brings about a similar condition of affairs,
though of essentially different origin. Myxomas appear under the
following forms:


1. =Polypi.=--These include many of those which grow in the nose.
The pure form of nasal myoma proceeds from the mucous membrane of
the nasal passages or sometimes from the accessory sinuses. But most
of the so-called nasal polypi are due to edematous hypertrophies
of the submucosa. The polypi usually hang as gelatinous tumors of
grayish-yellow tint, being present sometimes singly, sometimes in
clusters or in large numbers. Their principal effect is to produce
nasal obstruction, with, perhaps, subsequent serious disorder, due
to decomposition or to extension into the pharynx or other cavities.
Similar growths also occur from the mucous membrane of the tympanum,
and constitute the common variety of aural polypi.


2. =Cutaneous Myxoma.=--Cutaneous myoma is not common. It presents
usually as a sessile tumor, although about the perineum and labia the
tumors may become pedunculated. It is often difficult to distinguish
between a myoma of the skin and a sarcoma of the same which has
undergone myxomatous degeneration, and which then should be called
sarcoma myxomatodes. The latter tend to recur after removal; hence the
importance of exact diagnosis.


3. =Neuromyxoma.= Neuromyxoma is a similar condition involving the
nerve trunks, and is dealt with under Neuroma.

Myxomas require complete removal, and, in the nose especially,
cauterization or destruction of the surface from which they spring.
When this is thoroughly done they do not recur; otherwise, they are
likely to require subsequent operation.


=Myoma.=--The true myoma is a tumor composed of _unstriped_ or
_involuntary_ muscle fiber. Until recently it has been customary to
divide the myomas into the _leiomyomas_ in contradistinction to the
_rhabdomyomas_, the latter being supposed to be tumors of voluntary
muscle fiber. _Myomas_ are met with only where _involuntary muscle
fiber_ is found--namely, in the uterus and adnexa, the vagina, the
esophagus, alimentary canal, the prostate, the bladder, and the skin.
They form _encapsulated_ tumors composed of fusiform muscle cells with
a rod-like nucleus, the size of the cells varying greatly in different
specimens. The bundles of muscle fibers are much contorted, and it is
often difficult in a single section to decide to just what class of
cells they belong.

These tumors are most common in and about the uterus, and are referred
to as _intramural_ when developing in the true uterine tissue, and
_submucous_ and _subserous_ when situated just beneath one or the other
of the adjoining membranes. They differ in their rate of growth, are
firm in composition, and are moderately vascular, sometimes containing
areas of softening and becoming even cystic. In rare instances they
become enormously vascular, and are then known as _cavernous myomas_.
Aside from mucoid or colloid changes they occasionally undergo fatty
metamorphosis or calcareous infiltration. The latter is possible to
such an extent as to lead to a condition of _uterine calculi_.

Uterine myoma is liable to septic infection, which frequently follows
exploration of the uterus or the changes incident to pregnancy
or parturition. It then becomes a case for immediate operation.
Uterine myomas do not occur before puberty, rarely before the age
of thirty-five, and are most common between the thirty-fifth and
forty-fifth years of life. They produce disaster not alone by their
size, but by hemorrhage, by pressure on adjoining viscera (rectum,
kidneys, etc.), and occasionally by torsion of a long pedicle.

Myomas are found in the _esophagus_, in the walls of the _stomach_,
where they are frequently confounded with malignant tumors, in the
_prostate_ and wall of the _bladder_, and in connection with the
_skin_. As soon as they give rise to inconvenience or to dangerous
symptoms they are to be dealt with surgically, as no other treatment
has proved of lasting benefit.

The _rhabdomyomas_ deserve but brief description. The striated muscle
fibers of which these tumors are composed have been often confused with
spindle-shaped sarcoma cells. They are met with almost exclusively in
the mixed tumors of the kidney under Teratomas.

Myoma or myofibroma is exceedingly likely to undergo sudden conversion
into a form of growth entitling it to be called _malignant myoma_.


=Angioma.=--Angiomas are tumors composed of bloodvessels, and group
themselves under three headings, in accordance with the structure of
the vascular system:


1. =Capillary Angioma, or Nevus.=--Capillary angioma, or nevus, is
the most common form of all, and is frequently seen in the skin and
subcutaneous tissue. When the condition is spread over a relatively
large area it gives rise to a discoloration known as _port-wine mark_,
and called _telangiectasis_ by the pathologists. The condition is often
congenital or begins soon after birth. The color of the affected area
determines whether the vessels belong to the venous or to the arterial
system. These tumors may be found in all parts of the body, on the
surface, on the submucous surfaces of the tongue, the inside of the
mouth, the conjunctiva, and the vulva. The tendency is toward gradual
increase in size; rarely, spontaneous contraction and obliteration
occur.


2. =Cavernous Tumors.=--These are similar in structure to the corpus
cavernosum, and are called _erectile tumors_. They are common in
connection with the skin, and are exaggerated forms of the variety
first described, the vessels becoming not merely dilated but cavernous
in arrangement. They occur occasionally in the tongue, in the voluntary
muscles, and in the liver, and are noted very rarely in the mammæ, in
the larynx, and subperitoneally.

A similar condition is met with in the so-called cavernous tumors
which involve various organs, especially the thyroid and the liver. In
these instances a part or the whole of the organ may be involved, and
presents great increase in size and evidences of vascularity.

In cavernous growths of the thyroid are vessels, veins especially, the
size of the thumb, while with the ear not touching the body of the
patient a distinct venous murmur may be heard.


3. =Arterial or Plexiform Angiomas.=--Arterial or plexiform angiomas,
when of any particular size, are called _cirsoid aneurysm_ or _aneurysm
by anastomosis_. This form consists of arteries abnormal both in
number, length, and diameter, tortuous in arrangement, occurring often
in the scalp, but rarely in the perineum or genitalia, and seldom in
other parts of the body. (See Aneurysm, Chapter XXIX.) These tumors are
liable to rupture from external injury, and necessitate ligation of the
main arterial trunks, with perhaps extirpation of the tumor mass.

Recognition of angiomas is not difficult unless they are deeply
concealed. The effect of intermitting pressure, the emptying and
refilling, and the distinction between arterial and venous growths by
the result of alternating pressure and relaxation, either above or
below the growth, with discoloration of the skin, and, in the larger
growths, audible murmur, leave little doubt of the character of the
growth.

When such growths are small they may be dealt with by electrolysis, the
needles from both poles being introduced, or that from the negative,
the positive being applied upon some neighboring portion of the body.
The effect of the electric current is to determine coagulation of the
blood in the tissues acted upon, and this is followed by organization
of thrombus, conversion of vascular into cicatricial tissue, shrinkage,
and possible eventual disappearance of the mass. Radical excision
under an anesthetic should be made, dissecting out the mass, securing
bleeding vessels, and reuniting the parts by sutures, with the
expectation of securing primary union. This is the quickest and in
many cases the least disfiguring method. Old methods of ligation of
surrounding vessels or the subcutaneous ligature are now practically
discarded. The injection methods as formerly practised, especially
the use of iron salts in solution, are severely condemned, as death
is liable to occur. With electrolysis and excision the surgeon has
nearly all the measures which he will need to practise for the medical
treatment of angiomas.

[Illustration: FIG. 81

Lymphangioma of lip; macrocheilia. (Neisser.)]


=Lymphangioma.=--Lymphangiomas are tumors composed of lymph vessels and
bear resemblance to the tumors above considered. They may be divided
into three varieties:


1. =The Lymphatic Nevus.=--The lymphatic nevus is composed mostly of
lymphatics nearly normal in size, and occasionally colored red by the
presence of bloodvessels. When pricked, pure lymph or blood-stained
lymph, will flow. They are usually small, and are noticed during
childhood. They may occur anywhere upon the surface of the body or in
the mouth, generally in connection with the tongue, where they may
appear as large papillæ involving a portion or all of the dorsum. When
the lymphatic structures of the tongue are thus enlarged and involved
the condition is known as _macroglossia_, and consists of enlargement
of the organ, sometimes to a degree not permitting its retention in the
mouth, but leading to its constant protrusion (Fig. 81).


2. =Cavernous Lymphangioma.=--Cavernous lymphangioma corresponds to
cavernous angioma, and is a condition in which the lymph vessels become
positively cavernous and sacculated.


3. =Lymph Cysts.=--Lymph cysts are the still more aggravated form
which lymphatic dilatation may attain, and are usually encapsulated,
complicated with more or less tense tissue, and produce a condition of
the parts, especially about the scrotum and labia, to which the term
_elephantiasis_ is often applied (Fig. 83).

The question of _congenital occlusion or dilatation of lymph channels_
is one which has been made the subject of large separate monographs
(especially by Busey). Numerous tumors, essentially of lymph-vascular
origin, are found upon the lips, in the neck, and elsewhere, which
grow slowly, are more or less elastic and spongy upon pressure, are
frequently covered with skin, from which hair grows most luxuriantly,
and in which pigment or papillomatous structures are dispersed. These
tumors are called _cavernous tumors_, are of slow growth, and undergo
spontaneous involution, but usually require surgical relief. They are
often confounded with branchiogenic and other congenital cysts of the
neck.


=Treatment.=--The treatment for the smaller lymphatic tumors is simple,
but here electricity is less to be relied upon and excision is more
urgently demanded. Electrolysis will cause coagulation of blood, but
not of lymph--at least not to nearly the same extent; consequently its
usefulness is restricted to blood-vascular tumors. Excision, then,
is the best remedy. When this is impracticable much can be done by
galvanopuncture or ignipuncture, the cicatricial contraction following
multiple punctures leading to reduction in size of the affected part.
The enlargement of the tongue spoken of above as macroglossia may
be treated by ignipuncture or by electrolysis, if necessary under
an anesthetic, the effect of the electric current here being not to
produce coagulation, but apparently absorption of fibrous tissue and
changes which come slowly rather than by obliterative processes.

[Illustration: FIG. 82

Congenital lymphangioma. (Original.)]

[Illustration: FIG. 83

Lymphangioma of lower extremity. (Original.)]


5. =Tumors of Nerve Elements.=


=Glioma.=--Glioma is a malignant tumor developing directly from
actual nerve structure or that of the original nerve elements, and is
clinically allied to the sarcomas. It arises from the neuroglia, and
hence is confined to the central and peripheral nervous system, mainly
the former. It is most common in the brain, the cord, and in connection
with the optic nerve and fundus of the eye. It is often extremely
vascular, the vessels being sacculated, and is usually met with in
solitary form. When near the surface of the cortex such a tumor may
appear like a great convolution (Virchow). In the basal portions of the
brain it may attain considerable size. In the cord it is rare, usually
limited to the cervical region. In the orbit and eye it may produce
marked exophthalmos. It is more frequent in the young than in the aged.

Glioma is an exceedingly malignant form of tumor, and operation
is rarely performed sufficiently early to more than prolong life.
Dissemination by continuity is the rule rather than metastasis. It
kills usually by its pressure effect on the nerve centres.


=Neuroma.=--True neuromas spring from the structures of nerve trunks,
which trunks may also be the site of other tumors, mainly fibromas and
sarcomas, with which neuromas may be easily confounded. The most common
nerve tumor is the _neurofibroma_, which grows from the structure of a
nerve sheath, its long axis usually coinciding with that of the nerve
trunk. Tumors of this class vary greatly in size, are often multiple,
and in other instances affect nearly all the nerves in the body. They
are extremely liable to _myxomatous degeneration_, which will account
for many of the instances reported as _myxoneuroma_, etc. They attack
cranial and spinal nerves alike, and no nerve or nerve root in the body
is exempt. The sensory nerves appear more liable to attack than the
motor. The nerve least often attacked is the optic. They are not rare
upon the roots of the spinal nerves, in which location they may attain
to such size as to press upon the cord and induce paraplegia. Multiple
neuromas are often associated with molluscum fibrosum (_q. v._). There
is an instance on record in which 1600 of these tumors were found after
careful dissection of the neuroskeleton, and another in which at least
2000 were found, 60 of them involving the pneumogastric trunks and
their branches.

[Illustration: FIG. 84

Plexiform neuroma, dissected free from all adherent tissues. (Lexer.)]

[Illustration: FIG. 85

Plexiform neuroma of chest wall in a young child. Illustrating its
gross external resemblance to lymphangioma. (Lexer.)]


=Plexiform Neuroma.=--Plexiform neuroma is relatively rare. This is a
type of nerve tumor in which all the branches of a given nerve which
are distributed to a particular area become enlarged and elongated,
the overlying skin being stretched and thin. Such a tumor seems like
a loose bag containing a number of vermiform bodies, resembling the
sensation given when palpating a varicocele. On section each of the
affected nerves reveals a quantity of myxomatous tissue replacing the
nerve sheath. They are in large measure congenital. The skin overlying
a plexiform neuroma will frequently be found to be pigmented, variously
altered in thickness, and covered with fine hair. These growths have
been frequently _mistaken for lymphangioma_ (Figs. 84 and 85).


=Malignant Neuroma.=--Malignant neuroma (so called) will generally
be found to be a true sarcoma of nerve structures, usually of the
spindle-cell variety. _Traumatic neuroma_ is often seen in amputation
stumps, where the terminations of the divided nerves become bulbous,
attaining the size of cherry stones, the tumors being composed of a
mixture of connective tissues and nerve fiber, from which in time
the true nerve structure usually recedes or vanishes. They form
when suppuration has been profuse or healing long delayed, and when
sufficient care has not been exercised to prevent entangling of the
nerve ends in the scar of the wound. They give rise to much pain, and
often necessitate re-amputation. The bulbous enlargement is the result
of prolonged irritation in a nerve, and has been noted around various
foreign bodies.

True neuroma is innocent in tendency, though often painful. It is the
sarcoma of nerve tissue which produces signs of malignancy. A true
neuroma which causes unendurable pain should, when accessible, be
removed. It is sometimes possible to separate the tumor mass from the
balance of the nerve trunk, and thus to remove it without excision
of the nerve. At other times it is impossible to avoid division and
ensuing paralysis. Divided nerve ends should be brought together by
catgut suture, by which means it may be possible to avoid permanent
loss of function. Nerve grafting is also resorted to for repairing such
defects. Removal of painful neuromas due to injuries to the head has
more than once been the means of curing traumatic epilepsy.


6. =Tumors Derived from Epithelium.=

These tumors consist of specific epithelial elements supported and more
or less bound together by a vascular connective-tissue stroma. The only
apparent exception to this statement is tumor of dental tissue. The
teeth are positively modified and petrified or calcified epithelial
products.


=Odontoma.=--The odontomas are tumors composed of one or more of the
dental tissues, arising either from tooth changes or teeth in process
of development. They may be divided, according to Sutton, as follows:


1. =Epithelial Odontomas.=--These are provided with a capsule,
and present usually as a series of cysts separated by thin septa,
containing mucoid fluid, while the growing portions have a reddish tint
not unlike sarcoma. They are most frequent about the twentieth year of
life, but may occur at any age. They probably arise from persistent
remains of the epithelium of the original enamel organs.


2. =Follicular Odontomas.=--These are often called “dentigerous cysts.”
They arise in connection with permanent teeth, and especially with
the molars, sometimes attaining great size and producing conspicuous
deformity. The tumor consists of a wall representing the expanded
tooth follicle, and a cavity containing viscid fluid, with some part
of an imperfectly developed tooth, occasionally loose and more or
less displaced in location. The cyst wall always contains calcareous
material. These tumors rarely suppurate. They occur also in animals.


3. =Fibrous Odontomas.=--These consist of condensed connective tissue
in a developing tooth, presenting as a tumor with a firm outer wall
and a loose inner texture, blending at the root of the tooth with the
dental papilla and indistinguishable from it. The developing tooth thus
becomes enclosed within the capsule before it protrudes from the gum.
These tumors are most common in ruminants, being often multiple.


4. =Cementoma.=--A tumor of fibrous character whose capsule has
ossified or calcified, the developing tooth thus becoming embedded in a
mass of dental cementum. These tumors occur most frequently in horses.


5. =Compound Follicular Odontomas.=--These are tumors containing a
number of masses of cementum resembling small teeth, or even amounting
to well-formed but ill-shaped teeth composed of all three dental
elements. In such a tumor teeth may be found in great numbers. They
occur in the human subject as well as in animals.


6. =Radicular Odontomas.=--These are tumors which arise after the crown
of the tooth has been completed and while its roots are yet in process
of formation. The crown, being unalterable enamel, does not enter into
the composition of these growths, which then consists of dentine and
cementum in varying proportions. They are rare in man, but frequent in
other animals, and often multiple.


7. =Composite Odontomas.=--These are hard tumors, bearing little or no
resemblance in shape to normal teeth, occurring in the jaws, consisting
of a conglomeration of enamel, dentine, and cementum, presenting
abnormal growth of all the elements of the tooth germ. So far this
tumor has only been found in man.

Little is said about the _odontomas_ in general surgical literature.
These tumors, as they grow, are often regarded as due to necrosed bone
or to unerupted teeth, while fibrous odontomas have been often regarded
as myeloid sarcomas. No tumor of the jaw, especially in young people,
should lead to excision of the jaw until it has been demonstrated that
the tumor is not one of the above forms. When diagnosticated as true
odontoma its complete removal is all that is necessary.


=Papilloma, or Fibro-epithelioma.=--The type of papilloma is this
common wart, consisting of a central stem of fibrous tissue and
bloodvessels covered by epithelial projections and proliferations.
Papillomas are usually _sessile_ and _villous_.


1. =Warts.=[14]--These are sessile papillomas, most common on the
_skin_, often seen on mucous surfaces, and occurring sometimes singly,
often in crops. They are exceedingly common about the _perineum_,
where skin and mucous membrane meet, and are regarded as due to the
irritation of specific discharges. The papillomas occurring about the
genitalia are known as _condylomas_. The growths in these instances
are frequently so luxuriant and proliferative that they assume fungoid
shape, and are called _mulberry growths_. Warts grow slowly or rapidly
according to circumstances. Warty growths may attain enormous size and
become vascular. Late in life they are frequently the starting points
of epithelial ingrowths, and then become true epitheliomas--_i. e._,
cancer. Warty growths sometimes line the buccal cavity and complicate
cases of _macroglossa_. They occur also in the _larynx_, and when
situated near the glottis may cause dyspnea and fatal obstruction to
respiration. It is claimed by some that cutaneous warts will disappear
with continued small internal dosage of Fowler’s solution. (See Plate
XXI.)

  [14] Warts are by many pathologists considered as mere evidences
  of hypertrophy from persistent irritation. They are here retained
  among the tumors lest too much violence be done to formerly received
  notions.

[Illustration: FIG. 86

Papilloma of the bladder.]


2. =Villous Papillomas.=--These are met with most commonly in the
_bladder_, occasionally in the pelvis of the _kidney_. They are
identical with chorionic villi, and occur most often singly. It
frequently happens that long, fine tufts are detached and carried away
with the escaping urine. Another form of villous growth arises from the
choroid plexuses of the lateral ventricles in the brain. These may grow
and attain a size sufficient to produce disturbance (Fig. 86).


3. =Intracystic Villous Growths.=--These are seen, for example, in
mammary cysts. These, of course, are lined with epithelium, which acts
here as it does in other localities, and proliferates more or less
rapidly under unknown circumstances. In dealing with paroöphoritic
cysts the presence of these growths has also been alluded to.


4. =Ovarian Papilloma.=--There is a form of ovarian papilloma which
partakes of the nature of a malignant tumor, in that separated
particles seem to attach themselves to peritoneal surfaces, where
they grow luxuriantly. Either this is an expression of parasitism or
infectivity, or else of the implantation of tumors, which, to the
writer’s mind, constitutes a strong argument for the parasitism of
cancer. After abdominal section, with removal of the original focus,
these growths often disappear. This affords a parallel to the instances
of cure of tuberculous peritonitis after the same procedure.

[Illustration: PLATE XXI

Photographic Reproduction of Papilloma. Low power. (Gaylord.)]


5. =Cutaneous Horns.=--These are also epithelial outgrowths, and are
met with in four varieties (Sutton):

(_a_) _Sebaceous horns_, quite common, arising by protrusion of
contents of a sebaceous cyst through a rupture in its wall or through
its duct, with consequent desiccation by exposure to the air, while
fresh material is consequently added at the basis so long as sebaceous
secretion continues. These growths soften when soaked in weak liquor
potassæ.

(_b_) _Warty horns_, structurally identical with the above, but growing
from warts instead of from sebaceous cysts. Both these forms are often
found about the head. Cutaneous horns are also met with in ovarian
dermoids. They are common in the lower animals and may attain large
size.

(_c_) _Horns growing from cicatrices_, especially of bones, are rare,
but a cornified condition of the cicatrix itself, with formation of
scales resembling those from horns, is not uncommon.

(_d_) _Nail horns_ are simply overgrown nails, occurring on the digits
and toes of bedridden patients who never walk (Fig. 87).

[Illustration: FIG. 87

Nail horns. (Original.)]


=Treatment.=--All these forms of epithelial outgrowth call for radical
removal, which implies complete extirpation of the membrane or tissue
from which the growth occurs, after which, if effected, there is no
recurrence. If some be left there is tendency to recedive.


=Mucous Polyp.=--Similar papillary and often pedunculated epithelial
tumors frequently hang or project from the mucous membrane--_e. g._,
the rectum. The pedicle really projects from the submucosa. Between the
layers of the overgrown mucosa are found altered glands. So long as the
growth of these polyps is toward the exposed surface they are innocent
and wellnigh harmless, unless they attain fair size; but so soon as
they grow inward and the boundary of the submucosa is transgressed they
assume malignant aspects at once. Such transformation is by no means
rare, and constitutes a strong argument for their prompt removal.


=Goitre; Struma.=--Pathologically the various enlargements of the
thyroid known as goitre or struma constitute essential neoplasms. (See
chapter on Regional Surgery of the Neck.) In this condition either the
epithelial or the connective tissue may be primarily at fault.


1. =Struma Parenchymatosa Nodosa.=--This includes also the _colloid_
and the _cystic_ varieties, and refers to an enormous overproduction
of the epithelial elements (parenchyma) in distended alveoli, where
they often undergo colloid softening. So marked are these changes in
numerous instances that multiple cysts (minute or large) result. The
collective volume of such altered tissue may be very large.


2. =Struma Fibrosa.=--This presents itself in the way of dense
enlargement of the thyroid, the stroma being the tissue now involved,
even to the extent of causing much of the alveolar structure to
disappear or become obliterated. In this condition calcification is
common, and calcareous concretions or patches are often found.

Even benign tumors of the thyroid show occasionally a tendency to
metastases. Cases are on record of benign goitre causing general
metastases, and even of metastasis without noticeable thyroid
enlargement. These occur most often in the bones, less frequently in
the lungs and other organs. They are more common when the goitre has
undergone colloid changes. The reasons for these changes are unknown.

In either form hemorrhages are common, with their resulting blood
cysts or their solid residue, in which case pigment is usually found.
Both forms are often accompanied by enlargement of the vessels, and
sometimes these become enormously dilated and constitute an almost
insuperable obstacle to successful removal. (See Thyroidectomy.)


=Ovarian Cystoma.=--The cystomas of the ovarian region assume two
types: (1) Glandular cystoma, and (2) papillary cystoma.


1. =Glandular Cystoma.=--The _glandular_ type produces the multilocular
forms, with numerous small and large cavities, filled with fluid which
varies in color and appearance within wide limits, having usually
the consistency of mucus or thin pus, and containing a small number
of cylindrical epithelial cells. The cyst wall may contain tubular
glandlike structures reaching into the surrounding connective tissue.


2. =Papillary Cystoma.=--The _papillary_ type presents projections
into cavities of papillomatous outgrowths from their walls, which
are covered by cylindrical epithelium, which latter also lines the
cavities. It is most common in the parovarium.

It is rare to find a pure type of either variety; both forms are
usually blended. Malignant transformation, of the latter type
especially, occurs easily and insidiously, and explains many
disappointments in result.


=Adenoma and Fibro-adenoma.=--Adenoma is a tumor whose type is the
_normal secreting gland_, from which it differs in being an abnormal
outgrowth or product, but particularly in that it has _no power of
producing the secretion peculiar to the gland tissue_ or type from
which it grows. The adenomas occur for the most part as circumscribed
tumors in the _mammæ_, _parotid_, _thyroid_, _liver_, and in the
_mucous membranes_ of the bowels and the uterus. They may be single
or multiple; in the intestine they are usually multiple. In certain
locations (_e. g._, the mammæ) they attain enormous dimensions, and
in the ovary tumors of this character may be met with weighing forty
or fifty pounds. The true adenoma shows no tendency to infection of
neighboring lymphatics, and gives rise to no secondary deposit, and
when it causes death it is usually because of size or pressure upon
important organs. It displays a marked tendency to cystic alteration,
while the relative proportion of epithelium and connective tissue or
stroma varies within wide limits. In some cases, in which the former is
small in amount, the preponderance of the latter has caused the use of
the term _adenosarcoma_, which is really a misleading name.

The _distinction_ between _adenoma_ and true _carcinoma_ is in some
respects but slight, and this fact will account for the conversion
which many innocent gland tumors seem to undergo from one into the
other. As soon as the epithelial cells lose their regularity of
disposition and collect in groups, or make their way outside of
the acini into the tissues, then the change from the benign to the
malignant tumor has begun, and the entire clinical aspect of the case
has altered. This change may be the result of external irritation, of
such tissue changes as pregnancy and lactation, or of the undefined
changes which advancing years seem to produce. (See Plate XXII, Fig. 2.)

Adenoma occurs in the _breast_ as _cystic adenoma_ or _fibro-adenoma_.
The former often attains large size, is encapsulated, the acini are
much dilated, while from the walls of the epithelium-lined cavities
frequently project papillomatous processes, forming what are called
_intracystic_ growths. Cystic adenomas grow slowly, produce atrophy of
mammary tissue by pressure, occur after puberty until the menopause,
and rarely give rise to pain until they become large. As they grow
they distort the breast until it may become pendulous. When the growth
of connective tissue, peculiar to the tumor in that it is rich in
nuclei, forms well-marked partitions between alveoli, the growth is
called _pericanalicular adenofibroma_, which may assume a tubular or
an acinose type. When the alveoli and ducts are themselves invaded
by ingrowth of this tissue, then we have the _intracanalicular
adenofibroma_, which constitutes a growth sometimes bordering on the
malignant. When the arrangement of epithelial cells in the acini and
ducts becomes irregular and atypical, then malignant transformation has
begun.

[Illustration: PLATE XXII

FIG. 1

Fibromyoma of Uterus. (Low power.)

FIG. 2

Fibro-adenoma of Breast. (Low power.)]

[Illustration: PLATE XXIII

FIG. 1

Epithelial Pearl Formation in Squamous Epithelioma. (Middle power.)

FIG. 2

Malignant Adenoma of Rectum. (Middle power.)]

_Fibro-adenoma_ occurs also in the breast as a small tumor,
encapsulated, usually superficially placed, movable in its site,
often multiple; most common between the twentieth and thirtieth years
of life; often painful, especially during menstruation; tender upon
pressure. Both forms may occur in _young men_. A form of fibro-adenoma
in which fibrous tissue is greatly in excess, which never attains great
size, is common in the breasts of unmarried women. It gives rise to
much pain and distress, but is clinically not malignant. (See Plate
XXII, Fig. 2.)

Adenoma occurs frequently in sebaceous glands as:


1. =Sebaceous Cysts.=--Sebaceous cysts are generally known as _wens_.
These tumors commonly begin as retention cysts, the ducts of the
sebaceous glands becoming occluded. But in many cases there is no
occlusion of the ducts, and their secretion may be easily expressed.
They occur wherever sebaceous glands abound, but especially upon the
scalp. They are usually multiple, vary greatly in size, are easily
movable over the bone, and are intimately related to the skin, while
the duct orifice is frequently recognized by a black spot, after
removing which sebum can be expressed. These cyst-adenomas are
encapsulated, and can be easily shelled out of their matrices, save
when inflamed, in which case they are often astonishingly adherent.
Their contents consist of pultaceous debris resembling old epithelial
scales, fat, cholesterin, etc. The contents of these cysts are very
prone to decompose, and they become as offensive as anything with
which the surgeon has to deal. Putrefaction may be independent of
inflammation or coincident with it. When irritated these gland cysts
become inflamed and may suppurate, suppuration being tantamount to cure
by spontaneous processes. They may also ulcerate, without suppurating,
and form foul-smelling ulcers, or give rise to cutaneous horns.

[Illustration: FIG. 88

Multiple atheromatous cysts (wens). (Lexer.)]


2. =Sebaceous Adenomas.=--These arise from the sebaceous glands, which
are lobulated, like those about the nose and ear. Adenomas from this
source are extremely liable to ulceration, may undergo calcification,
and are often mistaken for epithelioma because of the fungous
ulcerations to which they give rise.


3. =Adenocarcinoma.=--Sutton has also described an adenocarcinoma
of the peculiar sebaceous glands named after Tyson. These are found
particularly at the base of the prepuce, this form of tumor being
rare. Adenomas arising from the _mucous glands_, which are usually
transformed into cysts, are also known, as well as other gland tumors
springing from the glands of Bartholin, Cowper, etc. (See Plate XXIII,
Fig. 2, and Plate XXIV.)

_Pituitary adenomas_ are either analogous to struma or belong to the
mixed tumors of dermoid or teratomatous type.

_Prostatic adenoma_ is in large degree fibromyoma of that body,
with more or less hypertrophy of its glandular structures. Minute
cystic alterations may occur also, as well as growth resembling
intracanalicular fibro-adenoma.

Adenoma is occasionally observed in the _salivary glands_, where it
is usually encapsulated, and may undergo cystic changes. It has been
observed in the liver and pancreas. In the former its pseudo-ducts
often contain inspissated material of bile-green tint.

The lesions of the _kidney_ referred to as cystadenoma are now grouped
among the teratomas, and are described under that heading. They present
interesting examples of mixed tumors.

In the _testis_, as in the _ovary_, epithelial tumors frequently
present themselves, but they partake less often of the type of pure
adenoma, and incline rather to that already described under Ovarian
Cystoma. Even in the paradidymis tumors of this same character are
found, with cystic or even papillary alterations.

In the _mucous membrane_ of the _stomach_ and _bowels_ adenoma usually
presents as an ovoid tumor, attaining such size as to give rise to
mechanical obstruction either by pressure or by traction. Adenoma of
the pyloric region is a repetition in structure of the pyloric glands.
In the _rectum_ it presents usually as a polypoid outgrowth, often seen
in young children. Such tumors are generally small, and when solitary
they often hang by a distinct stalk.

Similar polypoid tumors present in the cervical canal of the _uterus_,
where are also found sessile and racemose tumors, all of which are
structural repetitions of the glands met with in the cervix uteri.
Adenoma of the uterine cavity is seldom seen; it is also rare in the
_Fallopian tube_, but occasionally presents as a dendritic outgrowth
from the mucous membrane distending the tube.


=Epithelioma.=--Epithelioma is common, especially where there is
transition from one kind of epithelium to another, and, of all other
localities, particularly where skin and mucous membrane meet--_e. g._,
the lips, the vulva, and the anus. Epithelioma differs from papilloma
in that the former is no longer limited by basement membrane, but
passes beyond it into the underlying connective tissue and presents
_down_--rather than _up_--growth. Characteristic of epithelioma are
the so-called _cell nests_ or _pearly bodies_, where there seems to be
a tendency to globular arrangement of cells with such condensation or
alteration that they lose their ability to take stains, and appear as a
more or less lustrous mass, showing off by contrast among the standard
surrounding tissue. On this account they are often called _pearly
bodies_. Recognition of these is tantamount to diagnosis of epithelium.
(See Plate XXIII.)

This form of neoplasm is essentially the same, no matter what its
clinical varieties. These comprise a _wart-like_ growth or nodule,
which quickly becomes an ulcer with elevated edges, ulceration being
due to necrosis of cells farthest from the periphery; or, again,
the disease may start as an _ulcerated fissure_, ulceration and
infiltration keeping pace, in which case there is a sharply defined
ulcer with undermined edges. A third variety, often seen upon the lips,
comprises a _projecting mass_, with more or less horny surface. In
nearly all of these, however, the characteristic cell nests with their
onion-like arrangements of cells will be found.

Epithelioma, especially when exposed to the air or to surface
irritation, quickly _ulcerates_ and tends to involve all the
surrounding tissues, while occasionally the distinctive cells
proliferate so rapidly as to give the ulcer more or less of a bursal
or a _cauliflower-like_ arrangement. From such a surface there is a
constant discharge of foul-smelling detritus or of sloughs. Even bone
cannot resist its progressive invasion and slowly disintegrates before
the advancing mass. Cartilage is resistant, and usually preserves
its integrity. In other words, the tendency of epithelioma is toward
constant encroachment and infiltration, and toward a fatal termination
from hemorrhage by ulceration, from septic infection, exhaustion, or
other accidents. The wart-like forms run the slowest course of all, but
even here the malignant tendency is most evident.


=Lymph-node Infection.=--A striking characteristic of epitheliomas
is the _invasion of the adjoining lymph nodes_, which attain a size
disproportionate and bearing no necessary relation to that of the
primary growth. This constitutes one of the most serious complications
of the condition. This lymphatic invasion partakes of the malignant
character of the disease, and from every focus of this character
infiltration and destruction proceed. Infected nodes also show an early
tendency to central degeneration and to spurious cyst formation. When
the overlying skin becomes involved we have extensive sloughing and the
conversion into large malignant ulcers. Dissemination to a distance
(_i. e._, _metastasis_) is rare in epithelioma--much more so than in
carcinoma. (See Plate XXV, Fig. 2.)

About the mouth epithelioma is not common before the thirty-fifth
year, though I have seen it on the lip of a twenty-year-old woman. It
is vastly more common in men than in women, and more frequent on the
lower than the upper _lip_. In the _tongue_ it seldom occurs before
the fortieth year. It seems to be more common both on the lip and
tongue in men with bad teeth and in confirmed smokers, thus giving
rise to the view often held that it is purely a matter of irritation.
It may, however, be due to contact infection should it be regarded as
of parasitic origin. In one-fifth of the cases of epithelioma of the
tongue there are preceding lesions, usually described as _leukoplakia_
or _ichthyosis_ of the tongue--conditions characterized by epithelial
reduplication and the formation of dense plaques or scales. These
lesions are usually regarded as precancerous conditions. (See Plate
XXVI.)

[Illustration: PLATE XXIV

FIG. 1

Primary Papillary Adenocarcinoma of the Kidney. (One-half original
size.) (Gaylord.)

FIG. 2

_Papillary growth into tubule_

Section of the Primary Growth. (Gaylord.)]

[Illustration: PLATE XXV

FIG. 1

Carcinoma developing in a Thrombus in the Portal Vein. (Middle power.)
(Gaylord.)

FIG. 2

Metastasis of Squamous Epithelioma in a Lymph Node. Pearl Formation.
(Middle Power.)]

[Illustration: PLATE XXVI

FIG. 1

Epithelioma of Tongue. Enlarged three diameters.

FIG. 2

Paget’s Disease of the Nipple. Enlarged two diameters.

Photographs from hardened unstained specimens.]

The disease often starts near the stump of a _carious tooth_, in which
case infiltration and erosion begin promptly and progress rapidly.
Epithelioma of the _tongue_ has been known to follow along the
obliterated track of the thyrolingual duct, and in this way to bring
about a perforating ulcer.

Epithelioma of the _esophagus_ is a common cause of stricture of this
passage-way. It leads to ulceration, and usually to perforation into
the trachea or some other cavity or passage (_i. e._, a bloodvessel).
In the _larynx_ the disease is well known, and gives rise to intense
and finally fatal symptoms, but has been dealt with successfully by
radical operations for extirpation of the entire organ. (See Chapter
XLI.)

[Illustration: FIG. 89

Epithelioma of forehead and eyelid. (Neisser.)]

[Illustration: FIG. 90

Epithelioma of lip. (Neisser.)]

Occurring upon the _scrotum_, epithelioma has been called
_chimney-sweeper’s cancer_, or _soot-warts_, and has been ascribed
to the irritation of foreign material. Ulceration and infection of
the inguinal nodes usually proceed rapidly and disastrously. It is
believed also that tar and paraffin may produce similar irritation, and
_paraffin cancer_ has been described by various writers. It usually
occurs upon the scrotum.

The skin lesions which precede the formation of paraffin cancer
resemble those seen in chimney-sweeper’s cancer. The skin becomes
dry, thickened, parchment-like, while the openings of the sebaceous
glands become obstructed by the tar or other material, producing
acne-like lesions. Warty outgrowths then occur, and these become the
seat of malignant ulceration. In chimney-sweeper’s cancer the scrotum
is usually first affected in a chronic dermatitis, to which warty
outgrowths succeed, these enlarging and growing downward as ulceration
takes place.

About the external genitalia epithelioma is not uncommon, particularly
in and about the _prepuce_. Such a degree of phimosis as leads to
retention of smegma is certainly a predisposing cause, not only in man
but in the lower animals. Epithelioma of the _vulva_ has been described
under the name _esthiomène_, and requires to be recognized and dealt
with promptly if the surgeon should attempt a radical cure. In the
_vagina_ and about the _cervix uteri_ it is common, a large proportion
of cases of cancer of the uterus being essentially epitheliomas of the
cervix.

In and about _scars_ and upon _granulating ulcers_ epithelioma is quite
common. One danger to which a chronic ulcer is always exposed is that
of epitheliomatous transformation. These growths also attack _lupus
scars_, or even any tissues actively involved in the lupoid process.
This is particularly true between the fortieth and sixtieth years of
life.

Among the viscera the _gall-bladder_ is probably more often involved
in distinct epitheliomatous changes than any other. It presents as a
uniform thickening, and causes augmentation in size, so that a distinct
tumor projects from beneath the liver. In this location dessemination
is rare.

Epithelioma is to be regarded as having an essential malignant
tendency. Its treatment demands early removal of diseased parts and
complete extirpation of involved lymph nodes. It is only the small and
incipient growths which should be attacked by such destructive agencies
as cancer pastes or the electrolytic current.


=Rodent Ulcers.=--Under the name of _rodent ulcers_, _lupus exedens_,
_noli-me-tangere_, etc., writers, mostly English, have described a
variety of epithelioma, met especially upon the face, to which a
separate classification has usually been assigned. Until recently
it has been generally regarded as a local ulceration, distinct from
cancer. In some text-books it is described as _lupus exedens_. It
is preceded usually by a nodular condition of the skin, vascular,
breaking down into a regular ulceration, but little elevated, the base
of the ulcer deeply excavated, with a striking disproportion between
ulceration and new-growth. In this particular variety infiltration
seems to be continuously in advance of the rodent process, the former
being excessive, the latter but slight. This variety of epithelioma
rarely produces lymphatic involvement; the discharge is slight, the
pain complained of inconsiderable. Occasionally it entirely alters its
aspect, and may present features of the conventional epitheliomatous
type.

[Illustration: FIG. 91

FIG. 92

Rodent ulcer. (Original.)]

The development of cancer in lupus areas is now of sufficiently
frequent occurrence to demand attention. Whether the epithelium which
gives rise to it is to be accounted for by Cohnheim’s hypothesis, as
having been cut off in the course of healing and become a cell rest to
subsequently undergo malignant degeneration, is not yet settled. It has
been suggested that curettage might cause fragments of epidermis to be
loosened and then entangled in the cicatrix, and thus be responsible
for subsequent malignant changes. When lupus thus degenerates it
assumes usually the papillomatous form, which rarely involves lymph
nodes, while the change which follows _x_-ray treatment often succeeds
a hyperkeratosis and rapidly involves gland structure.

_Rodent ulcer_ allies itself with the type of tubular epithelioma
springing from the outer sheath of the hair follicle, sending out
cylindrical processes which freely blend with one another. It is to
be regarded as an equally malignant type of ulceration with other
cancerous ulcers, and demands the same thorough and radical measures
for its relief as do other forms of epithelioma. It is perhaps the most
favorable one with which to deal, because of the usual freedom from
involvement of deep lymphatics. No distinctive measures are necessary
for its relief--only those which are thorough.


=Carcinoma.=--Carcinoma is a tumor _springing from preëxisting gland
tissue_, which it more or less closely resembles in type, save that
the _structural similarity is incomplete_, the epithelial cells now
collecting in irregular clusters, or filling the acini and obstructing
the ducts, or bursting beyond the basement membrane and invading the
surrounding tissues. They frequently so fill the ducts as to appear
in columnar arrangement when seen under the microscope, and this
has given rise to the use of a term so vague as to have no place in
pathology--_i. e._, _cylindroma_. Carcinomas may arise from any of the
secreting glands, but more commonly from some than from others. They
have _no capsules_. They _infiltrate_ the surrounding tissues, _usually
involve the lymphatics early_, are liable to _spread to the superficial
tissues_ and to _ulcerate_, and to _undergo various degenerative
changes_. Nearly all cancerous tumors abound in lymphatics, which will
explain the rapidity with which the lymph nodes become infected, as
well as the tendency to dissemination, which is characteristic of these
growths. Dissemination leads to so-called secondary or _metastatic_
growths, which may make their appearance in any organ or tissue, even
in the bones, where they give rise to changes of texture that make
spontaneous fracture easy. It is characteristic of carcinoma that the
metastatic tumors which it may produce will reproduce almost perfectly
the type of the primary tumor whence the embolic fragments which have
produced them spring. The amount of dissemination varies exceedingly:
it may even become so marked and widespread as to produce a condition
analogous to that met with in miliary tuberculosis--_miliary
carcinosis_. A similar condition, much more rare, is seen in
dissemination of sarcoma, and is known as _miliary sarcomatosis_. A
constantly spreading cancerous infiltration of the superficial tissues,
which is noted most often after mammary cancer, is described under the
form of _cancer en cuirasse_, or _jacket_ or _corset cancer_. Instances
will be seen in which this infiltration of the surrounding structures
has extended nearly or even completely around the thorax. It gives
rise to a brawny induration which is unyielding, and is studded here
and there by nodules that tend to ulcerate, to fungate, and to bleed
easily. It is perhaps the most hopeless form of cancerous disease.

The older writers have constituted two or three clinically distinct
forms of carcinoma, based mainly upon the relative hardness or
softness of the tumor and the invaded tissues. The term _scirrhus_
is thus applied to a tumor in which connective tissue preponderates
and epithelial cells are relatively deficient. On the other hand, the
term _encephaloid_ has been applied to a tumor in which the connective
tissue seems barely sufficient to hold the mass together, while the
epithelial cells are in vast preponderance. These are all tumors of
the round epithelial-cell type, and these distinctions are of clinical
interest, yet have no great pathological import, save that in a general
way the greater the proportion of epithelial elements the sooner will
life be terminated by destructive processes. In other words, _the more
the tumor may partake of the encephaloid type the worse the prognosis_
or the shorter the probable duration of life. Again, these tumors
pursue a varying clinical course. In those tumors, particularly of
the scirrhus type, where the connective tissue largely preponderates,
there is often an eventual reduction in the size of the part involved,
and such reduction of vascularity and of nutritive activity that
the rate of growth is thereby perceptibly checked. The so-called
atrophying cancers of the breast are the best examples of this type of
cancerous disease. Here the volume of the gland is diminished rather
than augmented, and the disease may last for a number of years. It is
questionable whether it is well to operate.

The so-called _colloid forms_ of cancer are simply the expression
of pathological changes occurring in growths of more distinct type.
Thus colloid softening may occur in any tumor in which cancer cells
predominate, and the so-called colloid cancers of the peritoneum, the
ovary, etc., are either examples of such alterations or are possibly
endotheliomas arising in these locations. The term _villous cancer_,
with other terms like it, should be expunged from all scientific
literature, unless these terms are used in purely adjective and
clinical sense, for they imply nothing accurate as to histological
structure, and are often misleading and inaccurate.

Carcinoma is most common in the following regions:

In the _breast_ it appears particularly in two forms:

  1. _Acinous Cancer_; and

  2. _Duct Cancer_.


1. =Acinous Carcinoma.=--Acinous carcinoma is usually of the scirrhus
type. It may arise at any portion of the breast, and if anywhere near
the nipple it will cause _retraction_ of that prominence, which is
always pathognomonic; elsewhere it leads to puckering and adhesion of
the overlying skin. These tumors infiltrate widely, especially along
the connective-tissue stroma and the fibrous tissue which intersperses
the fat of the breast. They are usually firm and sometimes exceedingly
dense. A form of scirrhus known as _atrophying scirrhus_ consists
largely of strands of fibrous tissue, injected here and there with
epithelial cells. It is the slowest in growing of all the forms of
cancer, and by its contraction tends to reduce rather than augment the
size of the mamma.

Acinous cancer is rare before the age of thirty, most common between
forty and fifty. It occurs in women in all conditions of life, married
and single, but is rarely noted in the male breast. The most dangerous
form is that which appears _during lactation_. Ordinarily its progress
is slow. As it augments in volume it infiltrates the surrounding
tissues, becomes adherent to the pectoral fascia, infiltrates the
muscle fibers, and finally attaches itself to the periosteum of the
ribs. The infiltrated tissues tend to shrink rather than to increase
in volume. _Lymphatic injection_ occurs early in this form, and is a
pathognomonic sign. It occurs mostly in the axillary lymphatic nodes,
but may often be detected in the neck above the clavicle. When the
skin is involved there is a tendency toward ulceration and fungoid
condition. This is preceded by the purplish appearance of the tense
skin. (See Plate XXVII.)

[Illustration: FIG. 93

“Pig-skin” appearance of cancerous breast.]

_Pain is an uncertain_ and _variable_ feature. It is important to
emphasize this fact, as many of these conditions have been lightly
regarded because of freedom from pain. Pain is not a constant
phenomenon in cancer. On the other hand, it is sometimes intense,
either localized or radiating and referred to distant points. Pain
is particularly noticed in cases which assume the form of cancer _en
cuirasse_. Secondary deposits in viscera frequently occur, particularly
in the abdominal organs and the lungs; but any organ may be the seat of
secondary infection, and this is found occasionally in the bone-marrow,
not alone of the sternum or ribs, but of distant bones, and is called
_marrow injection_. As the result of cancerous affection of serous
membranes effusions of fluid frequently take place, as in the pleura,
peritoneum, and pericardium, and this fluid is often blood-stained.

In consequence of pressure upon the venous trunks in the axilla there
is often a swelling of the arm upon the affected side, dropsical in
character, known as _lymphatic edema_. The arm grows heavy, the patient
loses control of it, and the skin may become so distended by effusion
as to cause the limb to resemble a cast. This is due not alone to
pressure upon the veins but to involvement of the lymphatics, and upon
careful examination positive dilatation of the lymphatic vessels may be
noted. Pain is a usual accompaniment of this form of edema.


2. =Duct Carcinoma.=--This appears especially about the time of the
menopause, when glandular structure has disappeared and only ducts
remain. It is common, without reference to cancer in these instances,
to find cystic dilatation of numerous ducts, which vary in size from
a mustard seed to that of a cherry. These are referred to by Sutton
and others as _involution cysts_. They are filled with mucoid material
and have a bluish tint. They occur usually upon the under surface
of the gland. Such cystic breasts are common, and when appearing in
diffused form may be easily mistaken for cancer. Pain is not frequent.
_This condition is certainly a precancerous stage_, since the dilated
ducts are often the starting points of cancer, and occasionally of
papillomatous or villous outgrowths from their walls.

_Duct cancer_ implies the form which arises in these dilated ducts,
most commonly in the terminal branches, appearing ordinarily as
a single tumor, but sometimes as a mass of separate nodules.
_Intracystic_ and _intracanalicular_ growths of this character are
often found. When assuming the truly cancerous phases they may be
spoken of as _duct cancers_, otherwise as _duct papillomas_. They have
generally been referred to as _intracanalicular fibromas_. Duct cancers
are less tense than the preceding variety, and when situated near the
surface often discolor the skin. It is from these cases that there is
seen a more or less abundant discharge of fluid resembling _bloody
milk_. These tumors grow slowly, lymphatic involvement is late, and in
general they present the least malignant forms of breast cancer.

[Illustration: PLATE XXVII

FIG. 1

Scirrhus Carcinoma of Breast. (Middle power.)

FIG. 2

Soft Infiltration Carcinoma of Breast, showing Stroma. (Mallory’s
connective-tissue stain.)]

_Carcinoma of sebaceous glands_ is by all means most common in those
specialized glands named after Tyson, occurring about the prepuce. They
give rise to the usual forms of cancer in this locality.

Carcinoma in the _prostate_ is not common, and is usually confined to
old men. Infiltration proceeds around the base of the bladder at the
same time and binds the pelvic viscera together. The pelvic lymphatics
become early infected and dissemination is frequent. (See Prostatic
Hypertrophy.)

[Illustration: FIG. 94

Recurring carcinoma of male breast. (Original.)]

Carcinoma in the _salivary glands_ is not common; it is more frequent
in the parotid region, occurring at middle life, growing rapidly,
infiltrating surrounding parts, and tending to ulceration.

Carcinoma of the _liver_ varies in its arrangement and appearance.
Sometimes it appears in the form of nodules; at other times, as a
more diffuse malignant infiltration by cells relatively abundant in
number, so that the clinical aspects of the case conform rather to the
encephaloid or medullary type.

Carcinoma of the _kidney_ was formerly described as encephaloid,
meaning thereby simply a malignant tumor of soft structure. It is
probable that a large proportion of these tumors were sarcomas.
Nevertheless, true carcinoma of the kidney is possible.

Carcinoma of the _ovary_ may originate as such, or be the result
of a transformation from an ovarian cystoma (see above). No better
illustration can be offered of the infectivity of cancer cells (be the
secret of this infectivity what it may) than the rapid dissemination of
cancer throughout the peritoneal cavity, which sometimes follows the
removal of an apparently non-malignant tumor which is undergoing this
change.

On the other hand, in the _testicle_ such tumors are common--more
so than sarcomas. It is likely that many of them arise from the
paradidymis.

Carcinoma of the _stomach_ is a frequent disease. It involves the
tubular glands, especially in the pyloric region, and conforms to them
in type. After involving the mucosa it spreads to the entire coats of
the stomach and infiltrates adjacent structures, while the mesenteric
lymphatics are usually early and notably involved. Were it possible to
recognize this involvement early in the course of the disease diagnosis
of pyloric cancer and operative interference would be much more common
and hopeful. Secondary involvement is generally in the adjoining
viscera, but may be seen at a distance. Miliary carcinosis has been
noted after pyloric cancer. This form usually occurs between the
fortieth and sixtieth years of life, the duration of the disease not
being long.

In the _intestine_, and particularly in the _rectum_, carcinoma
proceeds also from the mucous glands, and tends constantly to extend at
its periphery and involve the entire lumen of the bowel. It seems to be
inseparable from a tendency to contraction of the gut and consequent
annular stricture. Ulceration, favored by surface irritation and
infection, occurs almost always early. Above the rectum it usually
occurs in the neighborhood of the sigmoid flexure. Cripps has observed
that when cancer of the rectum spreads downward and involves the
_anus_, it loses its typical glandular character and assumes the type
of epithelioma, or squamous-cell cancer. In these cases the pelvic and
mesenteric lymphatics are infiltrated and metastatic affections are
common.

Carcinoma may appear in any portion of the _uterus_, but is more
common in the lower than in the upper half. It assumes the type of the
cervical glands, spreads rapidly, infiltrates widely, ulcerates early,
and disseminates frequently. By extension of ulceration the formation
of urinary and of fecal fistulæ is common. Pyosalpinx and hydrosalpinx
are also favored, while the spread of the disease is, in fact, more
common when it involves the cervix than when it involves the uterine
fundus.


=Malignant Chorion Epithelioma.=--This has also been called _deciduoma
malignum_, a malignant growth of chorionic epithelium. Inasmuch as
this tumor also includes a syncytial layer it has been known as
_syncytioma_. Such tumors usually contain elements derived from both
layers of the chorion. They follow pregnancy, generally within a few
months, and are often preceded or accompanied by a _hydatidiform mole_.
This growth constitutes a malignant neoplasm. It pertains to ulcerating
uterine growths characterized by early extensive metastasis, which
prove fatal. It has been shown that similar growths occur not only in
the uterus but also in the testicle, and thus the scope of the term has
been much enlarged. In its biology it resembles the sarcoma; in its
histology, the carcinoma. It is more malignant than any other known
growth. (See Plate XXVIII.)

Occurring within the uterus its most important clinical feature is a
tendency to frequent and alarming hemorrhage. When occurring about the
testicle this trouble rapidly becomes fungoid, bleeding easily and
excessively, the lungs being among the first organs to show metastasis,
which takes place through the blood as well as the lymphatic vessels,
for the cells of these growths seem to penetrate the capillaries. By
the time a diagnosis is made a case is likely to be too far advanced
to admit of radical treatment. If scrapings could be examined early,
shreds of syncytioma would be found, and it might be possible that a
complete hysterectomy would be of use.

Metastatic nodules consist mostly of round, dark masses presenting a
more or less pronounced fibrous structure. These are generally found
in the lungs and cerebrum, where the vessels are large and the tissues
soft. There is usually a sharp contrast between such a tumor and the
surrounding tissues. The time which elapses between delivery and the
appearance of the growth is from three to ten weeks. The tumor rapidly
spreads to the upper portion of the vagina. The trouble probably begins
some time before delivery.

The latest tendency among pathologists is to refer a growth of this
kind to the teratomas. In women this tumor is particularly a teratoid
growth, some cells of the fecundated ovum giving rise to neoplasms,
while the ovum itself thus derived may misdevelop into a hydatidiform
mole. The tumor may be properly regarded as consisting in effect of
fetal cells; it is built up of these cells, without bloodvessels and
connective tissue, and so belongs to a class by itself. Occurring in
women it is almost always a consequence of pregnancy; occurring in
the testicle or in the ovary it should be regarded as proceeding from
ectodermal cells. For their treatment the earliest and most radical
measures only will suffice.


=Suprarenal Epithelioma; Hypernephroma.=--Grawitz has distinctly
established the right of these tumors to separate consideration, for he
first determined their origin and identity. Hypernephroma is a tumor,
found mainly in the kidney, composed of adrenal rests, or bits of
accessory suprarenal tissue imprisoned within the renal capsule. Their
minute structure is often that of the adrenals, with a tendency toward
the type of perithelioma. They have hitherto been considered examples
of sarcoma of the kidney, but are to be abruptly distinguished from it
in most instances. Tumors of this character have also been found within
the capsule of the liver and along the spermatic artery. In the kidney
the tumor portion is usually distinct from the renal tissue; it is
often enclosed within a sort of capsule, and rarely connects with the
pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely
escapes by the ureter. Hypernephroma is delicate in structure, and its
vessels give way readily. After this has happened a true hematoma may
result. (See Plate XXVIII.)

Similar neoplasms form in the adrenals themselves. These tumors vary in
degree of malignancy, some of them scarcely deserving the designation
malignant. They may be met at any age, but are more common in adult
life. Before removal they are not to be differentiated from other
tumors of the kidney. Their cells manifest this peculiarity in that
they contain a notable percentage of glycogen. It should also be added
that even in true sarcoma of the kidney proliferating adrenal elements
may be found.

[Illustration: PLATE XXVIII

FIG. 1

Hypernephroma Renalis. (Medium magnification.)

FIG. 2

Chorion Epithelioma.]


GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.

The following tables are here inserted, trusting that they may aid
the young practitioner in distinguishing in a general way between
benign and malignant tumors, and even in making a diagnosis between
sarcoma and carcinoma. I have also inserted a table differentiating
the clinical appearances of epithelioma and of lupus. In these tables
comprehensiveness has not been aimed at, rather simplicity, while
it is not denied that cases are met with in which diagnosis may be
exceedingly difficult, and in which the common signs herein mentioned
may be found either absent or misleading:

TABLE I.--DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT GROWTHS.

          _Benign Growths._                  _Malignant Growths._

  Common at all ages.               Rare in early life.
  Usually slow in growth.           Usually rapid in growth.
  No evidences of infiltration or   Infiltration in all cases,
  dissemination.                    dissemination in many.
  Are often encapsulated, nearly    Never encapsulated, seldom
  always circumscribed.             circumscribed.
  Rarely adherent unless inflamed.  Always adherent.
  Rarely ulcerate.                  Often ulcerate--nearly always when
                                    surface is involved.
  Overlying tissue not retracted.   Overlying tissue nearly always
                                    retracted.
  No lymphatic involvement when not Lymphatic involvement an almost
  inflamed.                         constant feature.
  No leukocytosis.                  Leukocytosis often marked.
  Elimination of urea unaffected.   Deficient elimination of urea (?).

TABLE II.--DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA.

           _Sarcoma._                         _Carcinoma._

  Occurs at any age.                Rare before thirtieth year of
                                    life.
  Disseminates by the bloodvessels  Disseminations by the lymphatics.
  (veins).
  Arises from mesoblastic           Arises from glandular (epithelial)
  structures.                       tissues.
  Distant metastases are more       Less so.
  common.
  Contains blood channels rather    Contains vessels of normal type.
  than complete bloodvessels.
  Less prone to ulceration.         More so.
  Involvement of adjacent           Almost invariably adjacent
  lymphatics not common.            lymphatics are involved.
  Secondary changes and             Degenerations not common; other
  degenerations are more common.    secondary changes rare.
  (Sugar present in the blood?)     (Peptone present in the blood?)

Differential diagnosis between epithelioma and ulcerating gumma will be
found in Chapter X.

TABLE III.--DIAGNOSIS BETWEEN EPITHELIOMA AND TUBERCULOSIS (LUPUS).

          _Epithelioma._                  _Tuberculosis (Lupus)._

  Preceded usually by continued     Irritation plays no figure. Preceded
  irritation or warty growths.      usually by nodules.
  Diathesis plays no known part.    Diathesis evident. Coincident
                                    evidences of tuberculous disease
                                    elsewhere.
  Rarely multiple.                  Often multiple.
  Area of thickening ahead of       Extension of ulceration not preceded
  ulceration.                       by thickening.
  Ulceration advancing from a       Various foci, which may coalesce.
  central focus.
  Border usually raised and         Border abrupt, eaten, irregular,
  everted, regular in outline.      thickened, firm, often inverted,
                                    irregular in outline.
  Often assumes fungoid type.       Never fungoid.
  Base may be deeply excavated.     Base nearly level with surface.
  Usually painful.                  Seldom painful.
  Bleeds easily.                    Seldom bleeds.
  Never tends to cicatrize.         As marginal ulceration proceeds
                                    there is often cicatrization at
                                    centre.
  Most rare in the young.           Common in the young.
  Discharge is very offensive.      Discharge rarely offensive.
  Lymphatic involvement nearly      Rarely.
  always.


GENERAL CONSIDERATIONS CONCERNING CANCER.

Cancer is one of the most fatal of diseases, yet has no _symptomatology
of its own_. It produces no _symptoms_ which may not be produced by
other affections, and this lack of pathognomonic features constitutes
one of the great difficulties in diagnosis. It may disturb every
function of the part involved. Experimenters have sought in vain for
a distinctive feature by which the disease can be recognized; neither
in the blood nor in the various organic tissues have such changes been
found that can be explained only on the hypothesis of cancer. The
pain which it is supposed to cause is often lacking, and is extremely
variable and uncertain. The cachexia of its terminal stages is not
characteristic, no matter how pronounced, and may be explained by a
variety of conditions, all of which may accompany the disease. The
search for the suspected parasites cannot be made with such certainty
as to lead to any definite conclusions. It is known by a complex of
clinical conditions or by microscopic sections of tissues already
removed.

When the disease is superficial it is easily recognized, but when
deep-seated, recognition comes later.[15]

  [15] Since the discovery of Spirochæta pallida in syphilis, Mulzer
  and Loewenthal have found spiral organisms on the surface of
  ulcerating tumors. Borrel also found spirochætæ in conjunction with
  helminthia in two enclosed mouse tumors, and also in a large tumor
  sent from Ehrlich’s laboratory. None of these authors attributed
  any significance to the presence of these organisms, but recently,
  through the publication of Gaylord, in the _Journal of Infectious
  Diseases_, who has found a characteristic small spiral organism in
  nine out of ten primary mouse tumors, and in all of the transplanted
  mouse tumors of three distinct strains in the New York State Cancer
  Laboratory, the subject has attracted new interest.

  [Illustration: FIG. 95

  Rat with primary cystosarcoma of thyroid; cage infection in
  previously healthy animal kept in cage formerly occupied by rat with
  same condition. (Gaylord and Clowes, Jour. Amer. Med. Assoc., January
  5, 1907.)]

  [Illustration: FIG. 96

  Rat with tumor produced by transplantation from that represented in
  Fig. 95. (Gaylord and Clowes, loc. cit.)]

  Gaylord’s organism is best demonstrated by the Levaditi silver
  method, but can be seen by experienced observers in the living
  fresh state. It measures from 2.5 to 7.8 microns in length, and
  the individuals have from four to thirteen closely packed abrupt
  turns. The organism measures 0.6 micron in diameter. Thus far it has
  been impossible to stain it with any of the aniline stains, which
  characteristic appears to distinguish it from the organism described
  by Borrel and Loewenthal. Calkins has also found this organism in a
  spontaneous mouse tumor in New York. The distribution of the organism
  in the growing periphery of the tumors, when considered in the light
  of Fischer’s work with Scarlet-R, would make it appear not impossible
  that the organism bears an etiological relation to the tumors in
  which it occurs.

  In the light of the well-authenticated cases of cage infection and
  the evidence of immunity now definitely determined, the way should be
  prepared for the discovery of the organism or organisms of cancer. At
  present this organism would appear strongly in evidence as its cause.

The microscopic picture may explain considerable in regard to the
future as well as the past. For instance, in a case of sarcoma the
presence of small, round cells, and especially of pigment, bespeaks a
degree of malignancy which probably nothing yet known can baffle. A
chemical examination of the tumor after removal may make the surgeon
alert regarding the future of the case, according to the amount of
glycogen contained within the mass, since the glycogen content is in
direct proportion to its malignancy. For a while some reliance was
placed upon the percentage of urea elimination, but this is influenced
by so many factors as to have proved unreliable.

The _relations which cancer bears to other diseases_ are of
considerable interest. Those between cancer and trauma have been
discussed; tuberculosis perhaps is the condition which, next to pure
local irritation, predisposes to cancerous invasion. The transformation
of tuberculous into cancerous lesions can be best appreciated where it
can be most readily inspected, _i. e._, on the skin, and it is well
known that lupus lesions frequently undergo this change. This is also
true of large ulcers, which may undergo a direct transformation into
epithelioma, or pass through the intermediate stage of tuberculous
infection. Cancer in tuberculous lymph nodes is also a matter of
interest. Again, cancers and tuberculous lesions may exist side by side
in the same organ, as in the lung or the brain. Distinct sarcomatous
nodules have been found in infiltrated lungs and alongside of
tuberculous cavities, while cancer of the face will not infrequently be
found associated with tuberculosis of the cervical lymphatics. Lubarsch
has claimed that 4 to 5 per cent. of tuberculous patients suffer also
from cancer, and that about 20 per cent. of cancer patients suffer from
tuberculosis.

The _method of death_ in cancerous patients is as free from distinctive
characteristics as the course of the disease. It is usually associated
with two prominent features, malnutrition and some terminal infection.
At the last there is usually some toxemia, which renders the closing
hours free from actual pain, while if the toxemia be profound patients
may linger unconscious for several days.


GENERAL REMARKS ON THE TREATMENT OF CANCER.

Accepting the views expressed when discussing the nature of the
cancerous process, the following may be assumed to be true: _Cancer
begins as a local disease._ There is therefore a period in its
history when _if_ it be recognized in time, _if_ it be or can be made
accessible, and _if_ it be thoroughly removed, it can be frequently
cured. The “ifs” in the foregoing statement afford such insuperable
obstacles in so many cases that the difficulties in the way of
treatment are very great. It has been said that, “The resources of
surgery are rarely successful when practised upon the dying.” It
happens too often that these cases are not submitted to the surgeon
until long after the favorable period above indicated is past. This is
explained by the difficulties of diagnosis, by the inaccessibility of
many primary cancers, and by the unwillingness of patients to submit
to the knife. Nevertheless the best time to treat a cancer is when its
existence is first suspected, and the best way is the most radical, _i.
e._, by thorough extirpation.

While such extirpation should include a wide area of apparently
healthy tissue and of the entire organ which seems to be involved,
for instance, in the case of the liver, this last may be impossible;
and yet by removal of a considerable area of healthy liver around a
cancerous gall-bladder the writer has seen complete and apparent final
recovery follow. The principal direction is to be thorough.

That cancer so often returns after operative attack is largely due to
the fact that the general practitioner, under whose observation most of
these cases first come, is slow to recognize the malady, and timid to
advise radical methods.

It has been recognized that in cancer the internal administration
of arsenic has been beneficial. In order to obtain the best results
from its use, it must be pushed to the physiological limit and in
preparations of the most active and reliable kind.[16]

  [16] The preparations of arsenic which have proved most satisfactory
  are the imported cacodylate of sodium, which comes in capsules ready
  sterilized for use, and the following solution, which is original and
  needs to be made up in accordance with the formula herewith furnished:

  (1) Dissolve 7 grains mercuric biniodide with 10 grains potassium
  iodide in a little water. (2) Dissolve 48 grains arsenic bromide in a
  little water with the aid of gentle heat. (3) Dissolve 24 grains gold
  chloride in a small amount of water. (4) Mix the mercuric and the
  arsenic solutions and then add the gold solution, which will cause
  a whitish precipitate, becoming brownish in color. (5) Heat this
  mixture and decant the clear portions, setting it aside. (6) Add 2
  drachms nitromuriatic acid to the above precipitate and heat gently
  until a clear red solution results. (7) Add to this the decanted
  portion of 5, which will cause a reddish precipitate. Heat the whole
  mixture up to the boiling point and until all residue is dissolved.
  (8) Add sufficient distilled water to make 15 fluidounces. The
  product should be bright, clear, and wine colored.

  Of this solution 10 drops are supposed to represent ¹⁄₁₀₀ grain
  mercuric chloride, ¹⁄₃₀ grain gold chloride, ¹⁄₁₅ grain arsenic
  bromide. The commencing dose is 10 minims, which may be increased to
  25 or more, taken in abundance of water.


=Treatment by Toxins of Erysipelas.=--A number of years ago Fehleisen,
calling attention to the fact that cancers had seemed to improve or
possibly even disappear after an attack of erysipelas, suggested
deliberate infection of the surface of such a growth from a case of
erysipelas. In this procedure he met with some success, but there were
numerous objections to it, one being the impossibility of controlling
the spread of the infection thus produced. Coley, of New York, then
undertook a much more systematic study of the relation between the two
diseases, and devised a method of injecting the toxins produced by the
streptococci of erysipelas and of reinforcing them, if necessary, by
those of the bacillus prodigiosus. The intent of this treatment is to
produce reasonable reaction in the hope of mitigating the rapidity of
the growth, checking its progress, or even causing its disappearance.
It has been on trial now for several years, and while in a few cases of
sarcoma, especially in the hands of its originator, the treatment has
apparently been of service, it has proved disappointing in the majority
of instances.


=Liquid Air.=--The application of liquid air to superficial malignant
growths has proved successful in a number of instances, but inasmuch
as this is practicable in only one or two of the largest cities of the
country, it is not a measure which need be discussed here at length.
The liquid seems to act as an almost painless escharotic, and its use
produces sloughing, or a drying up under a scab, which after a day or
two will loosen and be easily detached.


=Radium.=--This remarkable element has aroused within the past few
years an amount of scientific interest and experimentation with which
there is little else to compare. The enormous expense of a preparation
of any great activity, and the rather bewildering contradictory
statements which have been made by those who use the weaker
preparations, have caused it to occupy a doubtful position in any
list of reliable therapeutic agencies. It is undeniable that certain
rodent ulcers, tuberculous lesions of the skin, and a few carcinomatous
lesions have been much improved or apparently cured by its use. It
is ordinarily used in glass or aluminum tubes or capsules, which are
applied upon the surface of the growth to be treated. It has also been
used sprinkled upon a plaster whose surface has been prepared with
Canada balsam, and thus directly applied. Again, it has been enclosed
in a capsule to which a strong silk thread has been fastened so that
the former may be swallowed, retained in the stomach for a few hours,
and then withdrawn. These last means of using it are of questionable
value. Of still less value are the suggestions to dissolve it in water
or to administer water in which a receptacle containing radium has been
allowed to stand. There is much of interest and perhaps something of
value in _radiotherapy_, but nothing as yet of positive value in the
hands of the profession generally.


=Ultraviolet Light=, or, as it is often named after its promoter,
Finsen light, has proved of value in many cases of lupus, and in some
cases of superficial epithelioma. Its effects, however, can scarcely
be made to penetrate into the deeper tissues, and in its use it is
even necessary to make pressure upon the part treated with quartz
compressors, because ordinary glass shuts out a great proportion of
these rays from whatever source may produce them, and because it is
necessary to create a temporary anemia of the lesions, as the fluids
of the body have the same effect as does glass. For these reasons the
method, which is of but limited value, can be made serviceable in but a
small proportion of cases.


=X-ray Therapy.=--The Röntgen or cathode rays have played a large
part during the last few years in the therapy of cancer. Such varying
statements have been made concerning their value as to keep them
still on trial and nothing very positive can be said regarding their
efficacy. It may be said, however, that the nearer the malignant growth
is to the surface of the body the more promptly can their effects be
produced. The superficial growths, especially of the epitheliomatous
variety, often yield readily to their use; the deeper the lesion the
more vague the effect, both in character and permanence. It has been
the writer’s experience that they furnish the best method of relieving
pain, in a large number of these growths, short of the anodyne
effects produced by powerful drugs, which are in every other respect
undesirable. He holds that no one can predicate with certainty what may
be their effect in any given instance, but that they are worthy a trial
in every inoperable, painful, or otherwise hopeless case. Occasionally
improvement follows their use, while in the next, apparently a similar
case, one may be doomed to great disappointment. There are as yet no
indications by which the cases which are most amenable can be easily
recognized. Even in cases of extensive and disseminated abdominal
cancer marvellous improvement may follow, but never a cure. It is
indeed questionable whether deep cancer can ever be really cured by
these means. As against their undoubted and unchallenged value in some
instances, certain disadvantages are met in the difficulty of selecting
a proper vacuum tube, the frequency and duration of exposure, the
distance, etc. _Dermatitis_, sometimes mild, sometimes severe, has too
often followed the injudicious use especially of a “high” tube, and
more painful, irritable, or intractable ulcers are seldom seen than
some following so-called “_x_-ray burns” of the skin. Moreover this is
not the worst of these cases, for efforts intended for the best have
been in repeated instances turned into a travesty by the development
on surfaces thus burned of epithelioma, necessitating later mutilating
operation. A well-known American surgeon suffered amputation of one
hand and nearly all of the other as a penalty for inattention to the
destructive effects of too prolonged exposure of his hands. It has,
therefore, impressed itself upon the writer that the x-rays should not
be indiscriminately employed. Nevertheless in skilled hands and used
with great discretion they can be made a powerful instrument for good
in many cases, especially for the relief of pain. They should never be
regarded as a substitute for operation if operation be feasible, but
they may often be employed to advantage after operating, in serious
cases, where there is reason to fear recurrence.

The efficiency of the _x_-rays is apparently enhanced by the
_simultaneous administration of thyroid extract_; although the
explanation for this improvement is not known, it is, however, of
enough importance to be borne in mind. The extract should be given in
5-grain doses three or four times a day. All the remarks above made
may pertain as well to the employment of cathode rays in non-malignant
affections, _i. e._, tuberculous lesions, neuralgia, etc.


=Miscellaneous Measures.=--A large number of suggestions concerning
the treatment of cancer have emanated from various sources and from
men of widely different views. Beaston, of Glasgow, being impressed
by the physiological relationships and sympathies between the ovaries
and the mammary glands, has suggested the benefit of the _removal of
the ovaries in hopeless cases of mammary cancer_, holding that the
nutrition of the mamma being thus influenced there would be more or
less subsidence of pathological activity. He has reported instances in
which, apparently, this measure had the desired effect; nevertheless it
has not found general favor.

Based upon views concerning the hyperacidity of the blood and tissues
in the cancerous condition, it is believed that there is a pronounced
indication for the internal use of alkalies; and the hypodermic
injection of 5 minims of a 1 per cent. solution of a chemically pure
soap has been recommended by Webb, on the theory that it promotes the
separation of cholesterin from the living cell. He would increase the
dose until 60 minims are given at one time, every other day. A 20 per
cent. solution of Chian turpentine, dissolved in sterile oil, has
also been recommended to be used in the same way. These are recent
suggestions of unknown value.

In the general management of cancer patients, two things should be
kept in mind: (1) That they are entitled to _relief from suffering_
in the least harmful way in which it may be offered, and (2) there
comes a time in the history of many of these cases when all other
considerations may be set aside in favor of comfort and tranquillity.
Opium and other “drugs that enslave” have their disadvantages, but
these cannot outweigh the benefit which they may confer in the last
stages of cancer. _The terminal pains of malignant disease should he
assuaged at any necessary cost of other considerations._

But while all this is going on elimination must not be neglected.
Opiates are peculiarly liable to diminish secretions and peristaltic
activity. The skin, the kidneys, and the bowels should be kept active
by measures which serve this purpose, and if it be desirable to prolong
life, nutrition should be regulated and frequently administered, but it
is absolutely _necessary to maintain elimination_.

The latest suggestion, viz., to treat cancer by injections of
pancreatic ferments (trypsin and amylopsin), seems to the writer to be
based upon erroneous notions concerning the nature and causation of the
disease, and to hold out only specious hope of self-justification.




CHAPTER XXVII.

THE SKIN.


It is proposed here to treat only of those diseases of the skin which
may complicate surgical cases or call for surgical treatment.

_Dermatitis_ may be produced by chemicals, caustics, and various
irritants; the former, for instance, by the use of strong antiseptics
upon sensitive skins, and the latter as when fecal matter or urine is
poured over unprotected skin or allowed to remain in contact with it.
Ammoniacal urine will prove irritating, as will also that of diabetes.
When carbolic acid was in general use it gave rise to great trouble
upon the hands of many surgeons, while iodine, iodoform, and other such
remedies, as well as the stronger mercurial preparations, will cause
local symptoms similar to those produced by poison ivy.

This may be prevented, when the condition has occurred, by applying
soothing lotions or mild astringents, with anodynes, in dry dusting
powder or in ointment form. Cocaine in small amounts, or preferably
orthoform with menthol, may be employed in either of these ways. When
an acid discharge is expected the skin should be protected with an
ointment or with collodion or rubber cement; the latter by drying will
leave a thin film upon the surface. Thus around a fecal fistula the
skin will be irritated and more or less macerated, and should always be
thus protected when possible.

Between sixty and seventy drugs are known to produce distinct forms
of dermatitis, such as copaiba, cubebs, the various preparations
of iodine, bromine, and arsenic, some of the aniline preparations,
quinine, etc.; while the various antitoxic serums, especially that
of diphtheria, will sometimes produce a skin disturbance. In these
cases it is only necessary to recognize the source of the trouble and
remove the cause by stopping the drug. Should dermatitis produce such
restlessness as to interfere with the physiological rest necessary for
a wound or fracture an opiate should be administered.


DERMATITIS CALORICA.

_Dermatitis calorica_ means the varying degrees of irritation which may
be set up by extremes of heat and cold, continuous or alternate, as in
so-called _chilblains_. These are often seen upon the feet, but occur
upon the hands and even the face, _i. e._, in places most exposed and
least supplied with blood. The lesion occurs in patches, often with
livid discoloration, and causes sensations varying from discomfort to
acute pain, almost always aggravated by warmth; while the skin appears
inflamed, though to the touch it usually seems cool.


=Treatment.=--Chilblains occur most frequently in the anemic and
those with uric-acid diathesis, but may be met at any time. The
constitutional treatment should not be overlooked. Much pertains to
good care of the feet, especially after exposure. After wetting or
chilling they should be dried and then rubbed with boric-acid talcum
powder, containing 1 or 2 per cent. of menthol; this may be dusted
upon the feet, before going outdoors, upon return, and when there is
discomfort.

It will often give relief to immerse the feet in warm water containing
sufficient tincture of iodine to give it a mahogany color; or the feet
may be simply dipped in this and then allowed to dry without using a
towel. The use of hydrogen dioxide diluted two or three times has been
highly commended. If this proportion of dioxide be added to four or
five parts of hot saturated solution of sodium bicarbonate the efficacy
of the measure will be much enhanced. In extreme cases frequent use
of the following formula will probably give more relief than anything
else: Carbolic acid 1 part, ichthyol and tincture calendula each 4
parts, and glycerin 16 parts. With this the skin may be kept constantly
moistened.

The expressions of dermatitis produced by heat may vary from an
efflorescent rash to complete destruction, and will be treated of under
the following head:


BURNS AND SCALDS.

The term “burn” is applied to lesions produced by flame or dry heat,
while moist heat (_i. e._, boiling materials or steam) causes injuries
known as “scalds.” Between the two there is but little essential
difference, except that with the latter there is usually loosening of
the hair of the part, and sometimes much loosening of the epidermis
as well, so that it is easily detached in more or less large patches.
Whether heat is relatively feeble but prolonged, or higher in degree
and of shorter duration, the results of dry heat are about the same.
Some differences will exist according to whether the part is exposed to
actual flame or to hot or melted material, sufficiently hot perhaps to
cause complete charring or carbonization of a part.

[Illustration: FIG. 97

Burn by electric current from “live wire” carrying 1200 volts.
(Original.)]

Similar injuries are produced by concentrated caustics, acids, or
alkalies, while such materials as phosphorus or sulphur produce
deep burns. The burn produced by lightning is rarely deep, although
it may be extensive (Fig. 97). Persons coming in contact with live
wires sustain burns which partake much of the nature of the electric
discharge, and are sometimes of a character to deserve the term
“_brush-burn_.” Formerly burns were divided by Dupuytren into six or
seven degrees, but this classification is too cumbersome and artificial
to be acceptable. Morton’s classification is now everywhere accepted,
by which they are divided into three degrees: (1) Dermatitis without
vesication. (2) Vesication even to the formation of bullæ. (3)
Destruction of the skin, with or without that of the deeper parts,
which may include actual carbonization of a limb.

Burns may vary within the widest imaginable limits. To an extensive
burn of the surface may be added the features produced by inhalation of
smoke, steam, or flame; accordingly the eyes and the mucous membrane of
the nose and mouth suffer, the parts becoming chemotic and disfigured,
so as to make the individual unrecognizable. Burns constitute one
of the most painful and distressing injuries known to the surgeon,
particularly when the area is large and the case is complicated by
injuries which necessitate more or less prolonged rest in bed. When the
body is burned completely around it is difficult to ensure rest without
the use of anodynes.

_Shock_ is a marked feature of every serious case of burn or scald,
and albumin quickly appears in the urine in these cases. _Ulceration
of the duodenum_ may follow extensive injuries of this kind, and is
occasionally the cause of death. It is to be attributed to a toxic
action produced by absorption of putrid material connected with the
surface sloughing process. A temporary diabetes is sometimes noted.
Laryngitis, bronchitis, and pneumonia may occur from inhalation of
steam or smoke, while the inhalation of flame may bring about a rapid
_edema of the glottis_, which may necessitate tracheotomy as an early
and emergency measure. It is generally stated that a burn of the second
degree, which even involves half of the surface of the body, may prove
fatal; while this is not invariably the case, it is too frequently
true, and may afford aid in prognosis.

Burns of the second degree are always followed by exudation with
formation of blebs, usually within a few hours. In the more serious
cases the exudate may be bloody. Burns of the third degree are
necessarily followed by more or less gangrene, and this fact affords
the reason for the radical treatment recommended.


=Treatment.=--By the time the surgeon is called to treat a burn the
first indications are usually relief of pain, and perhaps stimulation
for shock. The circumstances attending such injury generally leave the
patient in an excited mental condition, and for several obvious reasons
it would be well to use sufficient anodyne to tranquillize and give
comfort. An excellent application in emergency cases is a saturated
solution of sodium bicarbonate, or it may be dusted over the affected
surface.

The unpleasant visceral complications that follow burns are due to
absorption of decomposing fluids or tissues, so retained or so in
contact with readily absorbing surfaces as to produce a more or less
violent degree of toxemia. In this way are to be explained delirium,
convulsions, or coma, as well as the ulcerative and toxic intestinal
symptoms which constitute the distressing complications.[17] For this
reason the radical method of prevention is the best; hence whenever
there is any prospect of sloughing, or when even the epidermis is
so burned as to make it appear that it will soon separate, the best
method of treatment is to anesthetize the patient and then with a stiff
brush and antiseptic soap scrub the part and remove everything that
is at all loose, if necessary even using a wire brush, scissors, or a
razor. Beneath every sloughing area toxic absorption will go on, and
it will be far better to have fresh raw and bleeding surfaces than
those which cover sources of danger; the resultant scar will not be
any greater, while the subsequent course of the case will be favorably
influenced. Exquisitely tender surfaces thus have their sensibility
blunted, and the comfort of the patient is greatly enhanced by thorough
cleansing and sterilization; moreover, dressings will not need to
be so frequently changed. A soothing, antiseptic ointment should be
applied; there are few better than the ordinary ointment of zinc oxide,
to which may be added bismuth subnitrate and orthoform.[18] Treatment
of this kind would probably not need to be repeated, and the duration
of the trouble would be reduced to one-quarter or one-third of the
time which would otherwise be required. When actual carbonization
has occurred amputation is generally necessary. Diluted solutions of
ichthyol have proved satisfactory, and the dressings should be covered
with some impermeable material, so as to exclude the air. Another
advantage is that the amount of subsequent discharge is limited, and
thus there is less need for frequent change of dressings. In extreme
cases there is no method which gives so much comfort and certainty
as _continuous immersion in warm water_; to this may be added common
salt or some other antiseptic, but the water alone is sufficient, if
changed frequently. In burns covering a great part of the body this
treatment is the most serviceable. It should be employed until the
sloughs have separated and surfaces are granulating and ready for skin
grafting. This implies, of course, immersion of the entire body in a
bath-tub, the body lying on a sheet fastened to the sides of the tub.
The advantage of brewers’ yeast dressing, when sloughs are present, has
been previously emphasized in the chapter on Ulcers and Ulceration.

  [17] _The Poisons Produced in Superficial Burns._--The intoxication
  which often proves fatal in from a few hours to a few days after
  an extensive burn of the surface, with its attendant delirium,
  albuminuria, hematuria, vomiting of blood, diarrhea, etc., is very
  similar to the acute intoxications produced by bacterial products.
  The sympathetic nervous system is seriously involved in both. These
  toxins are evidently the result of hemolysis, and it has been shown
  that they are slow poisons, especially for nerve tissue, apparently
  eliminated by the intestines and kidneys, which thus suffer during
  the process of elimination. This is a more rational explanation
  than the theories of thrombosis or of alterations in the red
  corpuscles, which would not account for duodenal ulcers, necroses in
  the Malpighian bodies of the spleen, etc. These poisons are formed
  in the burnt area and not externally; hence, if this burnt area be
  removed immediate death may be prevented, whereas if it be permitted
  to remain for a few hours it may be too late. The poisons seem to be
  produced in the skin, as the burning of the muscle is not followed
  by any such degree of intoxication. They seem to be neither ptomain
  nor pyridin derivatives, but rather resemble the poison of snake
  venom. Pfeiffer believes them to be derived from the splitting up of
  proteids altered in composition by the heat of the burn.

  [18] Cargile membrane makes an excellent covering for burns whose
  surfaces have been cleaned of sloughs and which are granulating. It
  adapts itself perfectly to all irregularity of contour, may be snugly
  applied and not changed until necessity requires it.

The disfigurement caused by a superficial burn will fade after a few
months. In cases where the skin has sloughed there is a tendency to
cicatricial contraction as soon as granulations begin to form, and
the tendency then is to the formation of _disfiguring scars_. About
the limbs the flexor muscles will always overcome the extensors, and
bridle-like deformities will be formed at flexures of the joints.
These are to be prevented so far as possible by two measures--proper
splinting and early skin grafting. About the face splints cannot be
used, but one of the grafting methods should be used.

[Illustration: FIG. 98

Epithelioma following ulcer due to burn. (Lexer.)]

A tendency in the scars of old burns is to formation of _keloid_ (see
below) and _epithelioma_. The writer has seen epitheliomatous ulcers
covering at least an area of a square foot, which had formed upon the
sites of burns received years previously. In one case of this kind
it was necessary to remove the entire upper extremity; even then the
disease recurred and finally destroyed the patient (Fig. 98).

Burns produced by _caustic acids or alkalies_ call for appropriate
chemical antidotes at first and later essentially the same treatment
as that already mentioned. In cases of severe burn there is danger of
neglecting the ordinary rules of general treatment, which consist in
maintaining elimination and nutrition.


FROSTBITE.

Effects similar to those produced by heat are caused also by cold,
varying from a superficial dermatitis with its surface irritation, its
possible vesication, and, later, desquamation, to complete freezing of
an extremity or a part (_e. g._, the nose, or the ear), which may be
followed by _gangrene_. Portions which are not frozen beyond the point
of restoration of vitality undergo a marked reaction and become swollen
and discolored, save in rare instances where they shrivel. Gangrene is
not so immediate a process as in a severe burn, as it takes a number of
hours, sometimes days, for the establishment of the so-called _line of
demarcation_, by which the dead tissue is separated from the living.
On one side of this line putrefaction goes on rapidly, as in moist
gangrene from any cause; on the other side there is active circulatory
disturbance, with phagocytosis, by which the line becomes more marked;
no portion of tissue on the distal side of this dead line can be saved.
The location of the lesion and the exigencies of the case will indicate
where amputation should be made. (See chapter on Gangrene.)


=Treatment.=--A rapid restoration of warmth to the part is most
undesirable. The thawing-out process in a case of severe freezing
should be begun in cold or ice-cold water. Crude petroleum at a
temperature of 60° F. has been recommended as a substitute for cold
water, and immersion may be continuous for several hours. A rubbing
with alcohol and water may be substituted for the cold water, and then
a gradual restoration to the ordinary temperature of the air. Unless
this treatment be skilfully managed there may be such a rapid reaction
as to be painful and even injurious. By the time there is any active
exudation, or putrefaction has begun, an absorbent dry dressing and
suitable antiseptics may be used.


DERMATITIS OF RADIO-ACTIVE ORIGIN.

The common expression of this form of skin affection is called a burn.
This is something more than its name implies, for it is understood
that the active factors are the ultraviolet rays, or the rays beyond
the color region of the spectrum; that it is not due to the heat rays
is shown by the intense burning that is frequently seen in the Arctic
regions. In the skin of the young and tender, _sunburn_ is sometimes
followed by vesication and desquamation; ordinarily it simply produces
the latter. Any soothing ointment or solution is usually sufficient for
the _treatment of sunburn_, which should, however, include avoidance of
the exciting cause.

[Illustration: FIG. 99

“_X_-ray burn,” result of nine exposures in nine days. Extensive
necrosis and sloughing, with an intractable ulcer. (From collection of
Dr. G. W. Wende.)]

Much more intense actinic effects are produced by the _x_-rays, leading
sometimes to complete destruction of the skin. These phenomena are
usually called _x-ray dermatitis_. They vary from local discomfort,
with itching, loss of hair on hairy surfaces, and partial anesthesia,
with later a glossy appearance, to edema of the cellular tissue, by
which anatomical outlines are effaced. The natural color of the skin,
owing to pigmentation, appears dark. If the exciting cause be stopped
before or as soon as this stage is reached complete recovery is
possible, save that hair does not always grow from the surface which
has lost it. The _x_-ray treatment should be pushed up to this stage.
Careful management is now necessary, especially should any surface
irritation like chafing occur. That _x_-ray burn, so called, may result
from _x_-ray exposure made some time previously seems to be established
by a case reported to me by Dr. L. L. McArthur, of Chicago, where he
had to do skin grafting upon a lesion of this kind which did not appear
until fifteen months after the last exposure.

The stage of danger is characterized by extreme itching with multiform
eruptions in successive crops, desquamation, formation of minute
vesicles, and ulcers; or the process may be more acute and the skin
begin to slough. Small lesions will become confluent, and large
excavations may be formed. The sloughing process is usually slow, and
by it are produced ulcers characterized by extreme pain and discomfort
and a lack of tendency to heal.

These ulcers are exquisitely sensitive and applications intended for
relief are of themselves most distressing. Everything about such an
ulcer seems sluggish, while small areas which have apparently healed
break down again; healthy scabs are not formed and granulations are
extremely indolent.


=Treatment.=--In the treatment of these lesions, so long as they are
mild, the surgeon should confine himself to soothing applications and
rest; at the same time discontinuance of _x_-ray exposures and even
avoidance of light seem to be essential. Any operator threatened with
such trouble should wear thick rubber gloves during all his work. The
local treatment of this lesion is not essentially different from that
described in the chapter on Ulcers and Ulceration, but the surfaces
are often so erethistic as to demand either anodyne applications,
containing such remedies as orthoform, anesthesin, or even cocaine, or
else they need radical treatment with a sharp spoon.

Sloughing surfaces should be treated with brewers’ yeast until
the surface has become healthy. Picric acid in solution has been
recommended, a saturated solution being diluted seven or eight times
before using.

The writer has rarely seen any more distressing or obstinate lesions
than presented in some of these cases. In speaking of epithelioma it
has been stated that some of these ulcers are prone to thus degenerate.
It seems an extreme contradiction in physics that the agent used so
frequently in the treatment of superficial cancers should, when used to
excess, produce lesions which themselves become cancerous. It has been
the writer’s privilege to witness amputation of all of one hand and a
large part of the other, in the case of a well-known colleague, who
carried the x-ray treatment to excess, and until he suffered to this
extent. Careful and discriminating judgment is therefore necessary in
the management of vacuum tubes.

Since _radium_ has come into use it has been found to exercise a
deleterious effect upon the skin. The radium emanations are known to
influence living cells and tissues, and their inhibiting effect upon
the growth of larvae has been well established. The prohibitive price
of radium preparations will make these lesions rare. After exposure
there appears an erythema followed by an active dermatitis, which so
closely resembles lesions above described, in their early stages, that
one description will suffice for both. Moreover, the treatment of a
radium burn differs in no essential respects from that of an _x_-ray
burn.


ACUTE INFECTIONS OF THE SKIN.


=Furuncle or Boil.=--A furuncle is a phlegmon having its origin in
a hair follicle and involving a small area of skin and subcutaneous
tissue. The infection is produced by one of the ordinary pyogenic
organisms, which have easy access to the base of the follicles.
Sometimes these organisms are of unusual virulence, but ordinarily
there is a local condition which favors the infection, while it may
be encouraged by a general diathetic condition, such as diabetes. The
lesion is usually single, but may be multiple. Boils appear sometimes
in groups or in crops, and when the condition has become chronic it is
called _furunculosis_, which may be local or general. A boil commences
as a tender papule, which rapidly enlarges into a conical swelling,
sometimes of considerable size. Around it there is an area of dusky
discoloration, while the apex becomes quite dark. Pus, travelling in
the direction of least resistance, comes more or less readily to the
surface, the apex of the boil yielding and pus finally escaping, if not
evacuated by incision, usually with a small amount of necrotic tissue,
which may be sufficiently large to justify the term “core.” With the
escape of pus the throbbing pain is much relieved. A furuncle arising
in tissues where swelling is not easily treated, as in the nose, the
external meatus, and also in the axilla and the perineum, will produce
an abnormal amount of pain.


=Treatment.=--The domestic treatment of boils consists of poultices,
usually made of hot flaxseed. These are always nauseous applications,
and tend to favor the development of similar trouble in adjoining
follicles. An equally comforting application can be made with a piece
of spongiopiline, or a compress, saturated in an antiseptic solution,
and covered with rubber tissues, outside of which, if necessary, a
hot-water bottle may be applied. Inasmuch as it is tension which
produces pain, _early incision_, which can be made under a little
freezing spray, or with cocaine, will give the greatest relief. This
may be practised even before pus has appeared. After such incisions the
same moist applications may be applied. Incisions should be made as
soon as pus is shown to be present. The appearance of a whitish point
at the apex of the furuncle will always indicate the presence of pus
beneath.

_General furunculosis_ has almost always an underlying diathesis as
a cause, and this should be sought out and treated according to its
nature. In the absence of recognized constitutional conditions the
writer has never found anything equal to aromatic sulphuric acid, given
in 10 or 12-drop doses, with tincture of arnica in teaspoonful doses,
to be freely diluted with water.


=Carbuncle.=--This differs from a furuncle in the extent of the local
infection, involvement of subcutaneous tissue, and the amount of
necrosis which it produces. It is in most instances a more serious
affair, life often being destroyed by the extent of the resulting
necrosis and the amount of toxins produced. It begins as a local
process, but always with constitutional disturbance, and sometimes even
with a chill. The affected surface rapidly assumes a brawny hardness,
and the infiltration is often extensive; pain is severe and throbbing;
the surface becomes more dusky in appearance, numerous pustules appear,
development of all the features of a serious carbuncle usually taking
place in a few days. Later it begins to soften and the skin gives way
at several points, at each of which a small drop of pus is discharged,
while after removing this there may be seen white necrotic tissue
beneath. The sloughing process extends deeply, generally to the deep
fascia, and this itself occasionally succumbs. A person may have a
distinct carbuncular lesion where the area primarily involved is not
much larger than that of a five-cent piece; on the other hand, in
debilitated or dissipated subjects, a lesion of this kind may become
as large as a dinner plate, while the sloughing process may expose the
underlying bone. This is often the case on the back of the neck and
trunk. A carbuncle may occur in any part of the body, but is usually
seen on the back; when upon a limb it generally involves the extensor
surface. It is especially serious and dangerous when occurring upon
the face, as septic thrombosis may readily extend to a cranial sinus
and rapidly kill. It was formerly believed that carbuncles of the lip
always terminated fatally; while this is not necessarily true it will
indicate the seriousness of the condition (Figs. 100 and 101).

[Illustration: FIG. 100

Carbuncle of the neck. (Lexer.)]


=Treatment.=--There are few lesions where both constitutional and local
treatment need to be more judiciously combined. Many of these patients
are diabetic, and then it assumes malignant tendencies. Others are
syphilitics or alcoholics, whom dissipation has reduced to a condition
of serious malnutrition. The urine should always be examined for sugar
and albumin, and whatever indications it may afford carefully followed.
Septic intoxication and infection may so rapidly depress the already
weakened patient as to call for stimulants and tonics, and pain may be
so severe as to justify the use of anodynes.

The _local treatment_ should consist of soothing applications until
the extent of the plastic exudate has declared itself, after which it
should be more radical. It is better, therefore, to excise under an
anesthetic, the area which ordinarily would require days or weeks to
slough. The most satisfactory treatment is the radical. The knife, the
scissors, and the sharp spoon constitute the best means of combating
this disease. In other respects the treatment was discussed when
dealing with septic infection. Nothing will so hasten the sloughing
and cleaning up process as brewers’ yeast. The writer’s custom is to
make a thorough excision of the affected area and treat the part with
yeast for some days. About the lip and face the sharp spoon should
take the place of the knife, but even there, if the case be attacked
early, tissue can be saved and disfigurement reduced to a minimum. The
method used by some of injecting 5 per cent. carbolic solution is less
satisfactory, although the measure above recommended is a rather severe
operation and usually requires complete anesthesia.

[Illustration: FIG. 101

Anthrax carbuncle of forearm. (Lexer.)]


CHRONIC INFECTIONS OF THE SKIN.


=Tuberculosis.=--Most of the skin lesions formerly described as
scrofulous are now known to be expressions of tuberculosis. So, also,
are some of the papillomatous growths and the chronic ulcers, which do
not assume distinctive form.

_Lupus vulgaris_ is perhaps the most common of these cutaneous lesions,
especially in certain parts of the world. It is seen more often among
the young than the old. The lesions begin with a papule, which becomes
the well-known lupus, smaller nodules coalescing and forming eventually
a brownish-red patch, whose borders are somewhat elevated and scaly.
This lesion usually goes on to ulceration, particularly in those parts
of the body where it is kept moist or frequently irritated. It is in
these lesions that a healing or cicatrizing tendency is seen at one
point and progressive ulceration in another. Ulceration does not always
occur, but the papule just described sometimes undergoes spontaneous
absorption, the tissue atrophying, losing its peculiar skin functions,
and the scar being depressed and scaly.

Lupus vulgaris is to be distinguished from lupus exedens, referred
to under Epithelioma. It is often mistaken for the latter, and a
differential diagnostic table has already been given. (See p. 293.)

_Verruca necrogenica_, as it used to be called, is now known as
_verrucose tuberculosis_. It consists of cutaneous warts, surrounded by
an erythematous zone or patch, which tend to break down, and covered
with scabs, intermixed with pustules. The lesion rarely proceeds to
complete ulceration. It occurs especially upon the hands and exposed
parts of those who handle cadavers or carcasses. The lesion is usually
slow and sometimes disappears spontaneously.

On or about the mucocutaneous borders of individuals suffering from
tuberculosis there appear small ulcers, secreting a thin, puruloid
material. These are seen especially about the nose, the mouth, the
anus, and the vulva. These lesions should be regarded as local
infections from a constitutional source. They are often sensitive, show
little tendency to heal, and are sources of danger to others. They
should receive radical treatment.

Under the term _scrofuloderm_ are included a variety of subcutaneous
tuberculous nodules which spread and involve the skin. They begin
in the superficial lymph nodes. The overlying skin becomes bluish
and gives way, while an ulcer remains which discharges more or less
puruloid material. The edges of these ulcers are frequently undermined
for a considerable distance. These are ordinarily chronic lesions,
which sometimes undergo a spontaneous recovery, leaving disfiguring and
discolored scars, usually irregular and more or less striped or banded.

Some of the scrofuloderms are included under the erythema induratum of
Bazin, lesions which appear mostly on the calves of the legs of young
women, consisting of deep-seated nodules, which break down into deep
ulcers, having elevated and overhanging edges. Again, there is the
so-called lichen scrofulosorum, _i. e._, a papular eruption seen in
the young, especially those who show other evidences of tuberculosis.
It consists of rounded groups of papules, usually on the sides of the
trunk, at first bright in color, new papules appearing as the old ones
fade. In addition there is the pustular scrofuloderm, which crusts
over, heals, and leaves small cicatrices.

In all of these lesions the tubercle bacilli can be usually
demonstrated. There are other skin lesions in which no bacilli can be
demonstrated, which are supposed to be due to the toxins generated in
tuberculous foci elsewhere. Hallopeau suggests calling all tuberculous
skin lesions _tuberculides_ and to group them as follows: (_a_) Those
in which bacilli are present, bacillary tuberculides, and (_b_) those
arising from tuberculous toxins, toxic tuberculides.

[Illustration: FIG. 102

Lupus of skin (hypertrophicus et exulcerans). Finally healed by
excision and plastic operation. (Lexer.)]

[Illustration: FIG. 103

Lupus vulgaris. (Hardaway.)]

Among the latter he describes what he calls _folliculitis_, _i. e._,
small papules, firm, at first red, then elevated, becoming nodules,
appearing on the extremities, and gradually producing crater-form
ulcers covered with black crusts, leaving small pock-like scars. This
condition is chronic, lasting years. In these patients the skin is
furfurated, showing a sluggish circulation.


=Treatment.=--Inasmuch as tuberculous skin lesions tend to spread and
to recur, they need radical treatment--_i. e._ the sharp spoon, the
scissors, and caustic. Ordinarily it is best to scrape the affected
surface, to trim away all unhealthy edges, and then to apply a
strong caustic for a brief space of time, thereby sterilizing it and
searing the mouths of the absorbents which may have been opened by
the scraping. Treatment for two or three days with brewers’ yeast
will usually suffice to put the surface in a healthy condition, after
which it may be skin-grafted or treated by any of the ordinary plastic
methods.


=Rhinoscleroma.=--The bacillus of rhinoscleroma was described in the
chapter on Inflammation, under the heading Pyogenic Organisms. It is
a specific infection, primarily of the skin, which appears invariably
upon the nose. It begins either in the skin or mucous membrane, or
both, and having once thoroughly invaded the tissues grows in all
directions. It shows no tendency to heal, but gives to the tissues a
distinctive brawny induration. From the nose it extends to the palate,
pharynx, and antrum, making steady encroachment upon the parts which it
affects, distorting the features, obstructing respiration, and often
causing pain by pressure on the sensory nerves. Its first appearance is
characterized by nodules, frequently covered with dilated bloodvessels.
Unless it can be seen and recognized early it is a wellnigh hopeless
condition with which to contend. Extirpation of the affected tissue
is the only satisfactory method of dealing with it. It is a different
disease from rhinophyma described elsewhere. (See Figs. 7 and 8, p. 55.)


=Mycosis Fungoides.=--This form of skin infection, of somewhat
uncertain origin, is met in shape of fungoid nodules, and likely to
involve the upper part of the body; they tend to increase in number
and size, to infiltrate, often to ulcerate, sometimes to disappear by
spontaneous absorption, but in severe cases cause death, either by
malnutrition or sepsis. Tumors are thus formed which attain the size
of a child’s head. As soon as surface infection or ulceration begins
the breaking-down process is rapid; there is early involvement of the
lymph nodes, and the general health begins to suffer. The tendency in
almost every case is to fatal termination. Cases may run from a few
months to fifteen years, however, before this stage is reached. By some
authors the disease is considered as a peculiar form of sarcoma. It is,
however, generally regarded as a granuloma, whose specific organism has
not been ascertained.

[Illustration: FIG. 104

Ulcerating gumma of skin, cicatrizing in certain areas. (Lexer.)]


=Actinomycosis, Syphilis, Leprosy, and Glanders= should be included
among the chronic infections of the skin, and have been described.


=Radesyge.=--Radesyge is a granulomatous involvement of the skin,
peculiar to certain parts of Europe, particularly Norway, which has
been by some considered to be an expression of leprosy, by others to be
a disease by itself. It is generally held that the lesions which have
passed under this name are really expressions of cutaneous syphilis.


=Framboesia; Yaws.=--This is an endemic tropical disease, of which we
see our nearest specimens in the West Indies, and involves especially
the negro and Oriental races. It begins with an eruption, papules
maturing in fungoid form, being met with most often at mucocutaneous
borders, but appearing anywhere upon the surface. It is specific and
inoculable, having a period of incubation of about two weeks, and
becoming generalized in from fifteen to twenty weeks. The papules
increase in size, become covered with yellow crusts, which fall off and
expose a rough surface which discharges an offensive puruloid material.
After remaining in this condition for an indefinite time the lesions
spontaneously improve and may disappear, leaving only pigmented spots
to mark their previous sites. Beyond local cleanliness and antiseptic
applications the lesions require but little treatment. If anything
more is attempted it should be thorough and effected with the cautery
or the sharp spoon.


=Mycetoma.=--Mycetoma is more commonly known as _Madura foot_, or
sometimes _the fungus foot of India_. It prevails especially in
Southern India and about Madras, and is apparently confined to that
part of the globe. Nevertheless it has been reported from Algiers and
from South America. It is a specific infection of the foot, beginning
in the skin; it rarely occurs on the hands, the scrotum, etc. It leads
to the formation of an infectious granuloma, which gradually destroys
the texture and identity of the tissues, and finally demands amputation
or ablation of the part.

Russian bacteriologists have discovered parasites resembling the
protozoa which they have found in the granulations and ulcerations of
the Delhi boil. They were also occasionally seen in the leukocytes. By
these observers these parasites have been regarded as active agents and
have been given the name ovoplasma orientale.


=Oriental Boil.=-This also is a slow infection of the skin, met
with especially in Southern India, where it is known as the _Biskra
button_ and the _Aleppo_ or _Delhi boil_.[19] It appears mainly on the
unprotected parts of the body at first as a papule and then a nodule,
which enlarges, ulcerates, usually tends to heal spontaneously, and
leaves an ineffaceable scar. It is practically a granuloma of the skin,
is auto-inoculable, and is best treated by complete excision.

  [19] Delhi boil is now known to be another of the local infections of
  exposed surfaces, occurring especially about the lower extremities
  and the genitals, due to the invasion of one of the trypanosomas, its
  actual pathology having been only recently demonstrated.


=Guinea Worm, or Filaria Medinensis.=--This worm is about one line in
diameter and two or three feet long, and is found generally throughout
the tropics. The embryo is taken into the intestines with drinking
water and migrates to the skin, beneath which it develops. The male
worm has never been discovered. What is known of the evidence of its
presence pertains only to the female. When fully developed it can be
felt in a coil beneath the skin. It produces local inflammation, a
vesicle forms, and the head of the worm then protrudes. When it is
exposed it can be frequently extracted by gentle traction, removing as
much each day as protrudes. Christie has suggested to destroy the worm
by electrolysis, and others inject into the vesicle some antiseptic,
by which the worm is killed, it being afterward absorbed without
difficulty (Fig. 105).

[Illustration: FIG. 105

Guinea-worm bleb just cut off. (Bryant.)]


=Blastomycetic Dermatitis.=--This is a true protozoan infection of
the skin, first described by Wernicke in 1892, which has now become
quite generally recognized and described. The parasite is a very
small, spheroid protozoan, and is found in the skin elements, as well
as in the pus and debris discharged from the lesions. It has been
successfully cultivated and inoculated. It is classed among the yeast
fungi. It produces lesions very much like some of those met with
in syphilis, tuberculosis, and mycosis fungoides. Indeed it may be
necessary to use the microscope in order to complete the diagnosis,
which is best accomplished by teasing a small portion of tissue on the
slide in liquor potassæ (Hardaway).

The lesions begin usually as small papules, which may later coalesce
and become covered with a fine scab. Around these there develop
thickened borders, with fungus-like projections. Between the little
elevations pus may form, or an exudate occur in sufficient quantity
to dry into a large-sized crust. Here, as in lupus, cicatrization may
be going on at interior points while the lesion is encroaching around
the margin. The affection is slow, and the ulcer may attain a size of
several inches in diameter.

The treatment consists in radical measures, _i. e._, strong caustics,
curetting or complete extirpation with the knife, which may be followed
by more or less plastic work, as required.


=Coccidioidal Granuloma.=--Under this name is described a rare form of
granulomatous lesion of the skin, whose exciting cause is not one of
the ordinary bacteria, but a form of mold--one of the varieties of
_oidium_. The clinical manifestations of this lesion resemble those of
blastomycetic dermatitis, save that in the latter the primary focus
of infection is always found in the skin and remains there localized,
whereas coccidioidal granulomas may occur as well in the deeper tissues
or viscera as upon the skin; in fact, the skin lesions of the latter
may be described as _oidiomycosis_ in distinction from blastomycosis.
It produces miliary skin nodules which closely resemble tuberculous
lesions, and may even caseate or assume an acute type and break down
rapidly. The lesions are progressive, with a tendency to dissemination,
both by the lymph and the blood currents. The lymph nodes are usually
early affected and often suppurate.


=Cysticercus, or Tænia Solium=, may be found in the subcutaneous tissue
in the shape of small nodules, covered by unaffected skin. When young
these tumors are tense and elastic, but are subject to calcareous
changes. They occur frequently on the back.


=Echinococcus Cysts= are also found in the skin, where they may attain
a size which will make them fluctuate. The treatment for all such
lesions is complete eradication.


=Trophoneuroses. Perforating Ulcer of the Foot.=--This has already
been alluded to in the chapter on Ulcers and Ulceration. The lesion
apparently begins as a thickening or callosity, usually beneath the
head of the first metatarsal bone, at a point where much pressure is
made, owing to the natural position of the foot. Beneath the thickened
skin there develops an adventitious bursa, in which, or in the skin
itself, the first degeneration may take place. The result is a deep
ulcer, with overhanging borders, and a thin, often foul discharge. The
lesion is not painful, and patients are less likely to spare the foot.
It is usually associated with some central spinal disease, or with a
peripheral neuritis. It is more common in those patients who have had
disease leading to loss of sensation in the foot.

The treatment consists in excision of the ulcer down to healthy
tissues, with careful protection. Skin grafting is often found
successful.


=Ainhum.=--Ainhum is essentially a disease of the negro and of tropical
climates. It usually begins in the little toe or little finger, and
goes on to spontaneous amputation, the result of an anemia caused by
the formation of a sclerotic ring, which encircles the digit and shuts
off the blood supply. It is an annular scleroderma, or keloid, which
produces the disturbance.


CYSTS OF THE SKIN.

The most common cysts of the skin are the _sebaceous_, known also as
_steatomas_, which result from obstruction of the ducts of sebaceous
follicles, and accumulation therein of sebaceous secretion. They
are found where these glands abound, and may attain the size of a
hen’s egg or larger. They are frequently infected and suppurate,
or their contents may undergo slow change and lose their original
characteristics by the time they are evacuated. Peculiar changes occur
in rare instances, since they may calcify, or their bases serve even
for the development of cutaneous horns, while in the other direction
they not infrequently undergo malignant degeneration. In some of these
cysts a small opening can be found, through which, on pressure, fatty
or butter-like contents can be exposed. When their contents begin to
putrefy the odor becomes offensive.

Another variety of the skin cyst is the so-called _atheromatous_,
which is more allied to the cutaneous dermoid, and whose contents
are often nearly pure cholesterin. Sometimes they contain hair or
other epithelial products. They occur usually in the scalp. These
are essentially inclusion cysts and purely epiblastic products. When
infected their contents putrefy and smell badly. (See Fig. 88, p. 285.)


=Treatment.=--The treatment for any cysts of the skin consists in
extirpation of the sac. It is sufficient to split them thoroughly with
a sharp, curved bistoury, and then, on either side, to seize the edge
of the divided sac with forceps and enucleate it. All this can be done
under local anesthesia. The cavity should be thoroughly disinfected and
not too tightly closed.

Under the name Cock’s peculiar tumor some English writers have alluded
to the offensive ulcerated surface, with raised edges, which is left
after the contents of these cysts have undergone putrefaction and
escaped by breaking down of the surface. Such a lesion is on the
border-land between mere ulceration and malignancy.


HYPERTROPHIES AND BENIGN TUMORS OF THE SKIN.


=Corns.=--_Clavi_, or _corns_, vary in density. A soft corn differs
from a hard one only in that it is located where it is softened by
moisture of the parts. A hard corn is a reduplication or callosity,
conical in shape, representing great hypertrophy, with condensation of
surface epithelium. Beneath old lesions of this kind will frequently
be found small cysts, while nerve fibers become entangled, and these
little lesions are sometimes exceedingly sensitive. They frequently
become inflamed, the process proceeding to suppuration or ulceration.


=Bunions.=--When beneath such an indurated area of skin there forms an
adventitious bursa, or a natural one becomes involved, the lesion is
called a _bunion_. These are more frequent over the joints of the toes,
where they sometimes cause intense discomfort. The bursæ sometimes
connect with the joint cavity, and should one suppurate the other
necessarily becomes involved. An infection of either of these lesions
causes local and possibly fatal disturbance. I have seen death from
pyemia follow infection of a bursa beneath a soft corn (Fig. 106).

[Illustration: FIG. 106

Distorted foot, from pressure and bunion. (Erichsen.)]

These lesions are not met with among the savage races or those who go
barefooted. They are essentially products of the footwear affected
in modern society. Were shoes made to fit the natural foot and not
to constrain it in abnormal positions, corns and bunions would be
practically unknown.


=Treatment.=--Preventive treatment is the most important and pertains
to properly adapted footwear. Unfortunately the treatment of these
minor lesions is too frequently left to charlatans and so-called
chiropodists, who may give temporary relief in many instances, but
have no knowledge of either the nature of the difficulty or its proper
surgical treatment.

Soft corns will usually disappear if the parts can be kept clean and
dry. Hard corns are essentially callosities, which should be pared down
or trimmed off until the surface is almost ready to bleed. It may then
be painted with a collodion containing 20 per cent. of salicylic acid
and a little alcohol. If this mixture be applied to the surface of a
clean and dry corn it can often be peeled away with the corn after a
few days. When it is desirable to soften any callosity of this kind,
previous to paring or trimming it, it can be done by applying for a few
hours a mixture of equal parts of glycerin and liquor potassæ; this
will so soften a callosity as, when applied over night, to make it
endurable through the following day.

Bunions are so often associated with hypertrophy of the underlying bone
as to entitle them to consideration under deformities of the feet. The
most pronounced expressions are usually seen in connection with hallux
valgus (_q. v._), and their treatment comprises excision of the bunion
and its underlying bursal sac, along with exsection of the joint. By
this radical local measure complete relief is usually afforded.


=Cutaneous Horns.=--These have the consistence of an ordinary nail,
are epiblastic products, varying in size, length, color, and shape.
They have been alluded to in the chapter on Tumors. Sutton has divided
them into _sebaceous_, which occur most often upon the head and spring
from an old sebaceous cyst (see above); _warty_ horns, which much
resemble them; _cicatricial_ and _nail_ horns, which are instances of
exaggerated growth of the finger-nails.


=Treatment.=--A simple excision of the growth with its base is all that
is needed in these cases.


=Warts; Verrucæ.=--These constitute one variety of papillomas, the
overgrowth having its original site in the prickle-cell layer of the
rete. The most common form occurs upon young subjects on the exposed
parts, as the face, hands, and feet. These are usually multiple; they
frequently occur upon the surface, and retain dirt in such a manner
as to be nearly always recognizable on the surrounding skin. They
frequently disappear with as little known reason as that which caused
their appearance.

Dilated papillary growths, like a fringe, are sometimes seen about the
face and neck of elderly people. These have been known as _filiform
warts_, while Unna gave them the name _fibrokeratomas_.

A form described as the _seborrheic wart_ occurs upon the face and
elsewhere in elderly people. It is frequently pigmented, may itch
intolerably, and is perhaps the form which most often undergoes
malignant degeneration. To the acuminate form of wart, which is
usually soft, and most often met with as a venereal wart about the
genital region, has been given the name _condyloma_. These appear in
either sex, grow rapidly, are covered with a puruloid secretion, bleed
easily, and assume often such shape and resemblance as to give rise
to expressions “strawberry growth,” “raspberry growth,” etc. They are
always produced by irritation, usually in connection with one of the
venereal diseases, and are generally due to lack of cleanliness. They
may grow luxuriantly and over a considerable area, and, when appearing
on the surface of the vulva, conceal completely the parts underneath.
They also occur in connection with the mucous patches of tertiary or
hereditary syphilis, but have essentially the same structure, no matter
how produced.


=Treatment.=--In the treatment of ordinary warts nothing is better than
absolute cleanliness. A dry wart touched daily with formalin solution,
or covered with collodion containing 1 to 2 per cent. of corrosive
sublimate, will usually shrink and become detached in a few days.
Thorough excision of any true wart is sufficient to finally dispose of
it. If the wart be cut through it is likely to bleed profusely, since
its vessels are larger than those of the surrounding skin. Any growth
of this kind can also be destroyed by the actual cautery, or by one of
the strong caustic agents, which, however, should be used with great
care.

_Venereal warts_, _condylomas_, are best treated radically, either with
the actual cautery or with scissors and sharp spoon. Local anesthesia
is always advisable in order that this may be thoroughly done. In
instances of extensive growths of this kind a general anesthetic may be
profitably given.


=Molluscum Contagiosum.=--Molluscum contagiosum, sometimes known as
_epithelial molluscum_, is a name applied to small warty growths more
or less embedded in the skin, from which, by pressure, some epithelial
debris can be forced out. The lesions are rarely single and yet rarely
numerous. They may be met upon any part of the body, especially upon
exposed portions. They are doubtless results of skin infections by
various organisms. The best treatment is excision, although they may be
split and cauterized and thus made to shrivel, or the same effect may
be produced by electrolysis.

[Illustration: FIG. 107

Keloid occurring in a laparotomy scar. (Lexer.)]


=Keloid.=--This has already been mentioned under the heading Fibroma,
in the chapter on Cysts and Tumors. It deserves further mention here,
however, because of the disfigurement produced by keloid scars, and
because the spontaneous expressions of the disease may occasionally
demand surgical intervention. In cicatricial tissue it often follows
the scars left by burns or excision of tuberculous lesions. Since
subcutaneous sutures have been introduced there is less keloid than
there was years ago (Fig. 107).

[Illustration: PLATE XXIX

Keloid. (Hardaway.)]


=Treatment.=--The surface indication is always for excision or
eradication, but one cannot give the slightest guarantee against
recurrence in even worse form in the same scar. Electrolysis may have
a beneficial effect on some of the lesions, but will only occasionally
prove satisfactory. A number of years ago _thiosinamin_ was introduced,
and has perhaps given a larger measure of success than any other
remedy. It is used in 5 or 10 per cent. solution, which is injected
into and around the growth, and may lead to gradual absorption of the
hypertrophied tissue. The pain which the injection produces does not
last long and I have seen many excellent results follow its use.

The same injections may be resorted to in general keloidal disease,
which is seen most often in the colored race. In negroes it may follow
traumatism of the skin surface, and attain the size of a saucer or
plate. (See Plate XXIX.)


=Neurofibroma.=--Fibroma of the skin may happen at any time and is
likely to develop in the finer branches of the cutaneous nerves, where
it will constitute a small tumor, known as _painful subcutaneous
tubercle_. These little tumors attain the size of a pea and appear
between the skin and superficial fascia. Sometimes they are painful
and are always tender. Unless thoroughly removed they tend to recur.
Nevertheless complete removal is the only remedy.


=Fibroma Molluscum.=--A much larger, softer, and more complex tumor
is that known by Virchow as _fibroma molluscum_. These tumors may
attain large size, and may be single or multiple. Over four thousand
of these lesions have been counted on one subject. They develop from
the connective tissue of the cutaneous nerves, and involve later
the globular and follicular structures of the skin, softening and
undergoing such changes as to deserve the adjective molluscum. Changes
analogous to these lead to what has been described as _dermatolysis_,
_i. e._, hypertrophy of the skin, with loosening of the subcutaneous
tissue, by which it is thrown more or less into folds. Another clinical
expression of the same condition has been known as _pachydermatocele_,
in which pendulous masses of skin hang from various parts of the body,
especially the face and neck, and undergo pigmentation and other
changes.


=Treatment.=--These lesions can be excised, always with temporary
cosmetic improvement, but not always with a guarantee against
recurrence of the trouble.


=Scleroderma.=--This name is given to a leathery induration of the skin
occurring in circumscribed areas, which have been called “morphea,” or
in diffuse patches, which shade off into surrounding normal skin. The
first indication is a stiffening accompanied by some thickening and
hardness. Sometimes the affection is painful, and the brawny hardening
which it produces makes it irksome and uncomfortable. The skin thus
affected can not be picked up between the fingers, and is more or less
adherent to the tissues beneath. When the difficulty is pronounced the
sweat and sebaceous glands cease to functionate. If it occur about a
joint the movement of the latter may be interfered with, even to the
extent of producing ankylosis. Wherever it appears there is impediment
to motion and flexibility of the parts beneath. The tendency usually
is to spontaneous disappearance with atrophy. While subsiding at one
locality it may recur in another. Upon the hands it may effect such
great disturbance of function as to produce what has been described as
“sclerodactylia.” The skin over bony prominences, when irritated, may
break down; ordinarily it does not go on to ulceration.


=Pathology.=--The pathology of scleroderma is very obscure. Whether
it depend upon primary disturbances of circulation, both of blood and
lymph, or whether it is produced by cellular hypertrophies has not been
determined.

The characteristic induration of this disease is not imitated in other
affections except _scleroma neonatorum_, but it may, nevertheless, be
confused with the infiltration of tuberculosis, of syphilis, or of
malignant disease. While the disease persists, in most cases it is not
often fatal.


=Treatment.=--It is to be treated mainly by tension, the general and
constitutional conditions by massage, and inunction with soothing oils
or with the ichthyol-mercurial ointment. It has been successfully
treated, as is keloid, by the subcutaneous use of a 10 per cent.
alcoholic solution of thiosinamin. The ultraviolet rays and even the
x-rays, used judiciously and carefully, may also be of service.


=Rhinophyma.=--This form of tumor is to be differentiated from
rhinoscleroma, the latter being due to a peculiar specific bacillus,
while rhinophyma is a filth disease, due to hypertrophy of the
sebaceous structures of the nose from obstruction of the sebaceous
ducts. It is often seen among alcoholics, perhaps less frequently at
home than abroad. Pathologically it consists of enormous and irregular
hypertrophy of the sebaceous gland elements and connective tissue of
the skin of the nose. Each hypertrophied gland secretes in proportion
to its increase in size, and even the vessels of the part become
engorged. In consequence there results a lobulated, distorted, most
disagreeable appearance, which often becomes exceedingly offensive. The
tumors thus formed sometimes increase to a size sufficient to interfere
with breathing and with feeding. The resulting nasal enlargement is
usually trilobed. The first impetus to the overgrowth comes sometimes
from such cutaneous irritation as frostbite, or local irritation of
some kind.


=Treatment.=--The treatment of rhinophyma consists in the unrestricted
use of scissors and the sharp spoon, with the preservation of so much
of the integumentary structure as may serve to cover the reduced
dimension of the nose. These lesions will bleed freely at first, but
bleeding is usually easily checked. When a plastic covering of the
defect is impossible, the surface may be left to granulate, with a
certain feeling of security that the cicatricial contraction following
will reduce the enlargement to normal proportions.


=Xanthoma.=--This name is applied to a macular lesion, papillary or
tuberculous, marked by the appearance of yellowish spots, occurring
singly or in groups, often about the eyelids, but seen anywhere upon
the skin. When occurring in papules it is called _xanthoma planum_;
when in nodules, _xanthoma tuberosum_. There is a variety met with in
diabetes which is temporary and usually disappears spontaneously.


=Treatment.=--The _treatment_ for xanthomatous patches is either
electrolysis or complete excision, under local anesthesia.


=Keratosis.=--Keratosis is a term applied to thickening of the normal
epidermis, occurring in limited areas, the skin being transformed
into tense or almost horny tissue. The form which occurs in elderly
individuals is called keratosis senilis. It occurs upon the face, the
hands, and forearms, but may be seen on any part of the body. The
involved areas become discolored, sometimes by true pigmentation, more
often by a deposit of dirt. As long as epithelial reproduction occurs
away from the basement membrane the lesions are simple and innocent,
but in elderly people it requires but little irritation to provoke a
down-growth of epithelium, and then the development of epithelioma is
rapid.


=Treatment.=--These reduplicated epithelial elements can be kept soft
by an application of equal parts of glycerin and liquor potassæ.
After being softened they may be easily scraped down to a normal
level, but will later reform. If they begin to ulcerate they should be
excised. Should excision be declined the area may be treated with the
thermocautery or with one of the caustic pastes.


=Vascular Growths.=--These have already been mentioned in the chapter
on Tumors, under the head of Angioma. So far as the skin is concerned
they usually occur in the shape of nevi (called strawberry growths) or
the more disseminated form, sometimes involving considerable areas,
commonly known as “port-wine marks,” which are essentially cutaneous
telangiectases, are almost always of congenital origin, and frequently
appear in complete form even at birth. They may occur rapidly or
slowly. An isolated nevus should be treated by complete excision.
Large vascular areas, or port-wine marks, are best treated by repeated
electrolysis. If treated early they are sometimes eradicated by the
local use of sodium ethylate.

The so-called _nevus pigmentosus_, or pigmented mole, is generally
of congenital origin, and may or may not be accompanied by vascular
changes. It is not infrequently covered with hair, and sometimes forms
a patch of considerable size, often upon the face. These lesions
occasionally occur in such form as to entitle them to be styled nevus
verrucosus or nevus pilosus. Occurring upon the back or trunk they are
usually disregarded. When upon the face they should receive surgical
treatment.


=Treatment.=--Excision is, of course, the best method of treatment
unless a disfiguring scar be feared. This can usually be prevented by
proper plastic methods. When excision seems inadvisable electrolysis
is the next best method of attack. No matter how vascular may be the
lesion itself, the vessels a short distance from the margin of these
growths are rarely dilated, and hemorrhage is not a feature which need
deter one from radical treatment.


=Lymphangioma.=--This has also been described in the chapter on Tumors.
A circumscribed form is occasionally found in or beneath the skin.
It occurs early in life, constitutes a more or less sessile tumor,
which collapses on pressure, fills slowly, its surface being often
irregular, warty, or horny. Should the surface be injured lymph will
escape rather than blood. An extended form of it constitutes one kind
of elephantiasis. (See chapter on Lymphatics.) Any septic infection of
a growth of this character is likely to result seriously and at once.


=Treatment.=--The best treatment is excision under thorough aseptic
precautions; next to this is destruction with the cautery, which will
lead to resulting sloughing and cicatrization.


=Malignant Disease.=--All forms of cancer may appear, primarily,
in or upon the skin. From the ordinary surface epithelium springs
_epithelioma_; from the glandular elements possibly _round-cell
carcinoma_; and from the mesodermic elements any of the radical
varieties of sarcoma, while endothelioma is less common.


=Epithelioma.=--This is a frequent infection of the skin, which may
arise primarily as an original lesion, usually following surface
irritation, or secondarily, either as the extension of similar disease
from other parts or of degeneration of previously innocent epithelial
tumors. Epithelial outgrowth, so long as it be an _outgrowth_, and do
not transgress the limits of the basement membrane, is essentially
innocent in character; but so soon as growth in the downward direction
begins we have the beginning of a skin cancer, which may proceed to
fatal extent if not promptly recognized and properly treated. These
growths vary very much in rapidity and malignancy. Occurring upon
surfaces which are kept constantly moist and warm they develop more
rapidly, as upon the tongue, within the vulva, rectum, etc. The slowest
form of growth of this kind is the so-called rodent ulcer. Epithelioma
which begins in or upon the skin or mucous membrane tends to spread to
and involve everything in its neighborhood; even bone and cartilage
succumb to its ravages, and, becoming involved, lose all their
characteristics and melt away in the surrounding ulcer. This produces
in the course of time hideous and serious developments. No tissue is
exempt from its ravages, and yet life may be prolonged for many years,
even when the face is almost entirely eaten away. Epithelioma and
rodent ulcer have been described in the chapter on Tumors.

[Illustration: FIG. 108

Epithelioma.]

More deeply seated carcinomas of the skin infiltrate in both directions
alike, and grow downward, sometimes in cylinder form, thus giving
rise to a clinical type called _cylindroma_. Lenticular carcinoma is
also described as differing from the ordinary epithelioma, in that
it exhibits a true alveolar structure. This form is rare, and is
distinguished from the common form by the absence of the so-called
“pearly bodies,” which characterize common epithelioma. The lenticular
form is most often seen in recurring cancer of the breast, or in the
vicinity of scars showing where deep-seated cancer had existed.


=Diagnosis.=--Epithelioma in its various forms should be distinguished
from skin lesions due to syphilis and tuberculosis. A diagnostic table
has been given (see p. 293) by which diagnosis as between it and lupus
may ordinarily be made. The lesions of syphilis are usually multiple
and accompanied by other manifestations which stamp their character.
There is, moreover, usually a history which will be suggestive if
not actually helpful. In cases of actual doubt, as upon the tongue
and elsewhere, the therapeutic test may be applied. If resorted to,
it should be vigorously made. When mercurial inunction is thoroughly
practised, and the internal administration of the iodides effects no
improvement within three weeks, the hypothesis of syphilis may be
abandoned.

All cancerous lesions tend to advance and to destroy in spite of all
local measures. There never appears about them any indication of a
tendency toward cicatrization, and, while the edges of malignant
ulcers may be thickened and everted, the more central portions are
always excavated. They cause, moreover, involvement of the adjoining
lymphatics, although this may be said as well of syphilitic and
tuberculous lesions.


=Treatment.=--Concerning the treatment of epithelioma and other
malignant skin diseases there is little to be said which has not
already been summarized in the general considerations concerning
the treatment of cancer. Radical excision of the original lesion, in
its early stages, will usually lead to final recovery. If there be
involvement of the lymphatics the indication is made thereby more
positive for cleaning out all infected areas, while, at the same time,
the prognosis is rendered less favorable. There comes a time in the
history of all these cases when excision can be recommended only as a
palliative measure, _i. e._, when it may be regarded as useless. In the
more hopeless cases benefit will but rarely be obtained from the use of
_x_-rays, ultraviolet light, or radium.


=Paget’s Disease.=--Paget’s disease includes lesions now regarded as
a _precancerous stage_, which appear upon the breasts and around the
nipples of women during the middle decades of life. Something similar
is seen in other parts of the body and in both sexes, but it is most
common around the nipple on one side. For a long time it appears as
an ordinary eczema, which, however, does not tend to heal but to
spread, while the skin beneath becomes more or less infiltrated. A
gradual retrocession of the nipple is usually seen. Certain discomfort
accompanies the lesion, which may go on indefinitely until it becomes
unmistakably cancerous. This is a precursor not so much of round-cell
cancer (scirrhus) as of epithelioma. _Eczema of the nipple is to
be regarded with suspicion_, especially when occurring after the
menopause. Until diagnosis is fairly established it is best treated
with soothing applications. So soon as the cancerous stage has been
determined the breast should be removed. (See Plate XXVI.)

Other forms of malignant or border-land tumors which occur upon the
skin are _chimney-sweeper’s cancer_, _paraffin cancer_, and that met
with in _aniline workers_. Chimney-sweeper’s cancer was the name
applied to epithelioma of the scrotum occurring among a class of
laborers whose occupation is now almost entirely extinct. It began
usually as papilloma and merged into epithelioma. Among workers in
paraffin and coal-tar factories there is an analogous lesion, the
result of surface irritation, the skin becoming dry, thickened, covered
with acne-like pustules, and then with papillomas which ulcerate and
frequently change over into true epitheliomas.


=Sarcoma.=--Only the outer layers of the skin are truly epiblastic. In
the depths of the integument mesoblastic elements enter largely, and
from these various forms of sarcoma may develop. These have already
been treated in the chapter on Tumors. They may be single or multiple,
and a general _disseminated sarcomatosis_ is occasionally observed.
It corresponds to miliary tuberculosis, but presents many distinctive
lesions in the skin, by which it may be easily recognized. A form of
multiple pigmented sarcoma involving the hands is represented in Fig.
109. These growths are almost always tender on pressure and more or
less painful. They coalesce and finally form fatal lesions.


=Melanoma.=--This term was introduced by Virchow, who made it cover
all pigmented growths. By common consent it is today limited to tumors
of the skin and uveal tract which contain pigment; metastases may
occur in any or all of them. They occur as malignant degenerations of
nevi, moles, and other small growths. Pathologists are still disputing
as to whether they should be considered sarcomas or endotheliomas.
The coloring matter which they contain is amorphous, finely granular
material, lying between the cells in moles, but occurring free in
the tissues and blood and even in the urine. It is soluble in strong
alkalies, from which it can be recovered as melanic acid, containing
a small proportion of sulphur. Of its origin nothing is positively
known. It seems to be generally accepted that the deposit of pigment is
not of itself a causative agent of the growth of the tumor, but that
the growth of cells and their pigmentation are coincident processes.
Johnston has offered much evidence lately to the effect that growths
from nevi are really of endothelial origin. Hutchinson has described
_melanotic whitlow_. (See below, the Nails.)

Melanoma is a pigmented ulcerating neoplasm, which possesses at first
only a local malignancy like that of rodent ulcer; the more it assumes
the endotheliomatous type of growth the more it tends to disseminate
and to prove fatal.

The melanoma arising from a mole or nevus, thus known as
melano-endothelioma, begins to increase in size and becomes more
full, as well as to assume a darker tint. For a variable time it is a
single, rather firm, gradually growing, flat tumor, rarely ulcerating,
but sometimes exuding a thin dark fluid. Suddenly there appears rapid
local spread as well as dissemination. The latter may be first noted
in the adjoining lymph nodes. Thus numerous secondary tumors may be
felt in and beneath the skin, at first colorless, becoming more or
less rapidly pigmented. Metastasis may take place to every organ in
the body, but usually the liver and lungs--less often the brain--are
involved. In one case known to the writer the heart was a mass of
nodules of this same secondary character.

Another expression of the same serious condition is seen in a lesion
called by the French malignant lentigo, which also begins with
pigmented spots, on the feet of old men, sometimes upon the face. These
lesions cause thickening of the skin and early ulceration.

Rodent ulcer, which is one form of epithelioma, occasionally assumes
the melanotic type, and is called melano-epithelioma.

[Illustration: FIG. 109

Fibrosarcoma of hands. (Hardaway.)]

The most marked collection of pigment in the human body, within small
space, is along the uveal tract within the eye, and orbital melanomas
are not infrequent. Beginning within the sclerotic they rapidly
perforate this dense membrane and spread to adjoining tissues, while
dissemination and metastasis occur early and rapidly.


=Treatment.=--For melanoma there is but one successful treatment,
and this is successful only when practised early, _i. e._, complete
excision or destruction. Every mole, nevus, or other skin lesion which
shows the slightest tendency to changes noted above should be promptly
excised, along with a wide area of its surrounding tissue. It _may_ be
thus possible to make a radical cure. Neither _x_-rays nor any other
less radical method of treatment will have the slightest effect. The
treatment of any case left to itself until mistake in diagnosis is
impossible will probably be of little avail.


SKIN APPENDAGES; HAIR AND NAILS.

The only lesions of the hair and hair follicles that concern the
surgeon are those which have been described under the head of Syphilis
of the Skin, or some of the congenital growths, such as plexiform
neuroma, lymphangioma, etc., whose surfaces are frequently pigmented
and hairy, and may call for excision, along with the underlying tumor.


=The Nails.=--Onychia implies any disturbance of the nail border and
matrix. Simple onychia occurs frequently in the fingers of marasmic
children. It is evidenced by softening and swelling of the skin around
the nail, by more or less pain, disturbance of circulation beneath the
nail, which becomes finally loosened, sometimes leaving a foul ulcer.
This ulceration may extend and involve nearly the whole finger. It may
occur in one or in several fingers. Lesions of this kind are regarded
as local infections, occurring usually in vitiated constitutions.
It is a common expression or complication of syphilis; when of such
origin it yields readily to treatment; at other times it is often slow
and tedious. Except in specific cases, where mercurials locally and
internally will usually be sufficient, the treatment should be radical
and should consist of thorough exposure of the ulcerating and fungous
surfaces, thorough curetting, and the use of suitable caustics and
antiseptic dressings.


=Onychia Maligna.=--Onychia maligna implies, according to some writers,
a more distinctive type of phlegmonous lesion, while the term has also
been applied to malignant ulcers, sometimes pigmented (see Melanoma
above) and sometimes of more ordinary type. In either type of lesion
granulation tissue may be exuberant and fungating, and it is possible
that at times there will be doubt in diagnosis. The finger-tips,
with their peculiar tactile sensibility, should never be sacrificed
unnecessarily, yet any malignant lesion calls for amputation of the
finger.


=Ingrowing Toenail.=--This is due almost invariably to ill-fitting
footwear, the toes being crowded into too narrow shoes, with too high
heels. The real lesion is not so much an excessive growth of the nail
as overgrowth and overriding of the skin margin around the matrix.
It is painful and annoying, sometimes even disabling. The maceration
of a perspiring foot in a warm and tight shoe serves to aggravate
the difficulty. Palliative treatment is afforded by chiropodists and
quacks, who pack cotton beneath the edge of the nail and keep patients
under treatment for indefinite periods, never remedying the footwear
and never curing the case. In simple cases it is usually sufficient
to excise a portion of reasonably healthy skin on either side of the
terminal phalanx, in order that by cicatricial contraction the skin may
be drawn away from the nail border. Serious and long-standing cases are
best treated by avulsion of the nail, which may be usually performed
under local anesthesia or by the aid of nitrous oxide gas. The blade of
a knife or scissors is driven under the centre of the nail sufficiently
to ensure its passing completely beneath the hidden matrix. The nail
is then split in the middle, each half seized at its split border by
strong forceps, and by a rapid movement torn loose from its bed. The
border of the skin should be scraped, after which a simple dressing
suffices, providing the operation has been performed with proper
antiseptic precautions.


TATTOO MARKS.

Many an individual is tattooed in youth who would gladly be relieved of
the discoloration later in life. Tattoo marks are difficult to erase.
The following is a method attributed to Ohmann-Dumesnil: “Wash the skin
with soap and water, then with eight or ten fine cambric needles, tied
together and dipped in glycerole of papoid, tattoo the stained skin,
driving the needles into the tissues so as to deposit the digestive
in the corium, where the carbon is located. Repeat as necessary. The
pigment is liberated by the digestant.”




CHAPTER XXVIII.

SURGICAL DISEASES OF THE FASCIÆ; APONEUROSES; TENDONS AND TENDON
SHEATHS; MUSCLES AND BURSÆ.


Fasciæ and aponeuroses are such non-vascular and indifferent tissues
that they have practically no primary diseases, except such fibrous
and malignant tumors as have their origin in them; nevertheless they
suffer in a variety of morbid processes. They lose vitality and break
down under the influence of both acute and chronic septic infections.
By virtue of their resistant structure, when they slough they break
down slowly and the process ends usually with the help of scissors and
forceps. Many an old suppurating lesion, especially of the hand and
foot, is kept active by the fact that dense, fibrous tissue remains
concealed, which ought to have separated. Under these circumstances
free incisions should be made and all necrotic tissue trimmed away.

Pus which has formed beneath these fibrous investments will give
pain largely in proportion to the intensity of the process and the
unyielding character of the fasciæ; hence the urgency of early incision
in case of deep phlegmon. Moreover, the direction of least resistance
may cause pus when confined to travel where its presence is most
undesirable, as from the neck beneath the deeper muscle planes down
into the thorax. When pus escapes from beneath firm tissue it is
usually by a small opening, after which it may spread out again beneath
the skin before finally escaping. This condition has been called
“_collar-button abscess_.” Care should be exercised in opening the
superficial collection not to miss the small opening. The fascia must
be split sufficiently to permit of thorough cleaning out of whatever
collection there may be beneath it.

In the presence of cicatricial contraction of the skin, in
shortening of muscles by chronic spasm, as in wryneck, or in certain
deformities--for instance of the foot--numerous signs of a shortening
or contraction of fasciæ and aponeuroses are seen. In many instances of
club-foot it thus becomes necessary not merely to divide tendons but to
make extensive incisions through the plantar aponeurosis or elsewhere,
in order to release sufficiently the parts whose extension is desired.
Underneath the joint contractures which have been produced by burns and
their resulting scars similar conditions will be found, which in old
and extensive cases constitute bridles of dense tissue that make it
almost impossible to release the parts.


DUPUYTREN’S CONTRACTION.

Dupuytren’s contraction presents the most serious and insidious
appearance of slow but almost irresistible contraction of fibrous
elements which the human body presents. It is produced by contraction
of the palmar fascia, with its numerous minute prolongations, rather
than by flexor tendons. It is seen in the hands of men who from the
nature of their occupations are subject to much irritation of the
palmar surface. It begins nearly always in the fourth or fifth fingers,
but may spread to and involve all the digits and even the thumb.
The view held by Adams and others that it is a chronic hyperplastic
inflammation, with scar-tissue contraction of the palmar fascia and
of the adjoining connective and fatty tissue, which does not involve
them evenly, but only at certain points, is correct, at least when
small nodules may be felt in the palm which are the precursors of the
disease. Either hand may be affected, but generally both are involved.
It is found in from 1 to 2 per cent. of those who depend upon their
hands for their support. Deformity may proceed to pressure dislocation
and finally to ankylosis. Its causation then is very obscure; it is
rarely the result of definite injury, but follows continued irritation
of the surface. It seems to have a local origin, and yet it is
frequently associated with the gouty diathesis to such an extent that
the prolonged use of alkalies will relieve some cases. The first
significant sign of the condition is the formation of small nodules in
the palm of the hand, as stated, and this usually precedes the finger
contraction by a year or two.

[Illustration: FIG. 110

Dupuytren’s contraction. (Adams.)]

[Illustration: FIG. 111

Dupuytren’s contraction of palmar fascia, showing contracted fingers.
(Burrell.)]


=Treatment.=--There is considerable difficulty in treating these cases
satisfactorily. Cooper advised subcutaneous division of the tense bands
and forcible stretching of the fingers; this rarely proves sufficient.
Adams advocated multiple sections made with a small tenotome, which
is more effective. The best method is that of Kocher, which consists
in excision of the fascial bands by longitudinal incisions along the
cords, and the dissection of the skin from the underlying fascia. The
cord is carefully dissected, with its prolongations and then completely
removed, while the margins of the skin wounds are closed with sutures.
The more thoroughly the dissection is performed the more satisfactory
the result. The fingers should be straightened and kept from
contraction by the use of a mechanical device. In desperate cases the
entire skin of the palm has been removed, with the diseased fascia, and
a plastic operation made with skin taken from the thigh or the chest,
the flap being sutured in place but not detached completely for ten to
twelve days.

Two somewhat allied conditions involving the hand and the foot are the
so-called _lock_ or _trigger-finger_ and _hammer-toe_.


LOCK OR TRIGGER-FINGER.

Lock or trigger-finger implies a peculiar obstruction to free movement
of the finger, which requires extra effort and then is overcome
quickly, as if a knot had been slipped through a small opening. It is
supposed to be due to a thickening of the tendon at some point, as by a
small fibroma, which becomes entangled along the course of the sheath,
through which it is moved with difficulty. It is probably due to a
local irritation, as in the case of Dupuytren’s contraction. Injury to
the tendon sheath may also produce a similar condition.


=Treatment.=--Should it fail to respond to rest and massage the sheath
should be opened and the cause of the difficulty sought out and
removed.


HAMMER-TOE.

Hammer-toe produces deformity with more or less ankylosis. An angle
is formed between the first and second phalanges, and the tip of the
toe is made to bear more than its proportion of weight. This deformity
is in large degree due to the use of shoes which are too short. In
consequence there will develop over the protruding joint a corn or
bunion.


=Treatment.=--Should the trouble come on in childhood the toes should
be fastened to a straight splint and shoes for a time abandoned,
while later they should be properly adapted to the needs of the case.
In troublesome cases complete excision of the involved joint gives
satisfactory results.


SURGICAL DISEASES OF THE TENDONS AND TENDON SHEATHS.


TENDOSYNOVITIS.

Acute inflammation of a tendon sheath is known as _tendovaginitis_ or
_tendosynovitis_. It always implies an infection, and occurs about the
hands and feet. It is a frequent complication of felons. Many felons
begin in such a manner that it is difficult to decide which part of
the fibrous structures of the finger is first involved. Infection
having once occurred within a tendon sheath will travel rapidly until
it meets with a natural barrier. The frequency of these lesions makes
it important to recall here the anatomy of the tendon sheaths of the
hand. There is a common palmar tendon cavity, which connects with the
thumb and little finger and the space above the annular ligament, but
communication with the first, second, and third fingers is ordinarily
destroyed. This accounts for the apparent vagaries of cases where
infection beginning in the thumb spreads to the little finger before
the others are involved. It will also show the location where incisions
should be made.

[Illustration: FIG. 112

Cicatricial contraction and deformity resulting from consequences of
neglected phlegmon and osteomyelitis of hand. (Lexer.)]


=Suppurative Tendosynovitis.=--Suppurative tendosynovitis needs prompt
intervention, as adhesions may result from retention of exudate, or
lest necrosis of tendon occur from perversion of its nutritive supply.
Ordinarily it is the result of a local infection, perhaps through a
small, trifling surface irritation, but it results occasionally as a
metastatic expression of gonorrhea, or distinct septic infection. A
gonorrheal tendosynovitis is, however, less likely to suppurate, but
more likely to assume the plastic form and interfere with function by
producing adhesions between a tendon and its sheath. The combination
of virulent bacteria and susceptible tissues will produce local
destruction in almost as short a time as in the appendix. The pain is
intense, because of the inelasticity of the structures.


[Illustration: FIG. 113

Suppurative tendosynovitis (felon), with sloughing tendons and necrotic
bone. Unfortunately poulticed for two weeks. (Lexer.)]

=Treatment.=--Every appearance of this kind calls for early incision,
by which not only the skin but the tendon sheath as well should be
freely incised. An incision at either end of the involved sheath,
with flushing and drainage, may save a tendon and preserve function.
Incision should not be delayed, as destruction may have occurred and
deformity be the result. When the common palmar sheath is involved a
long incision from the base of the index finger, around the base of
the thumb and up the wrist to a point considerably above the annular
ligament, will afford considerable relief. It will, moreover, shorten
the time of ultimate restoration of function.


=Chronic Tendosynovitis.=--Chronic tendosynovitis may be the result of
rheumatism, in which case it assumes the plastic form, or of gonorrhea;
the same being true of a tuberculous invasion, which may vary much
in intensity. In the subacute forms the deposition of tubercles may
lead to a plastic outpour which, being detached by constant motion of
the parts, is broken into masses whose minute portions become rounded
off by friction and condensed by time, and appear as the so-called
“_melon-seed_ or _rice-grain_ bodies.” Some of the same material may
be found adherent to the walls of such a cavity. In slower forms there
is less tendency to plastic outpour, but much more to the formation
of granulation tissue, such as is seen in tuberculous lesions in all
parts of the body. When, therefore, a case of this general character
presents we have the signs of local tuberculosis, or of dropsy of the
tendon sheaths, with the fluctuation somewhat modified by the presence
in the fluid of rice-grain or melon-seed bodies. Should, in such a
case, an acute infection be added we will have the chronic symptoms
merged suddenly into acute. A tendovaginitis of this type appears as a
ridge or swelling along the course of one or more tendons. It will be
elastic and fluctuate in proportion to the distention of the sheath.
When the palmar bursa is involved there is usually, in the palm of the
hand, a bag of fluid which may be forced above the wrist by pressure,
while frequently the little bodies above described are recognizable by
the sensations (crepitus) which they produce. The plastic type rarely
proceeds to suppuration or ulceration unless secondarily infected. The
granulation type proceeds to ulceration and destruction.


=Treatment.=--Treatment of the rheumatic and gonorrheal forms is at
first rest, with later passive and forced motion, in order to break up
adhesions and prevent their re-formation. If one wait too long he meets
with great difficulty in these efforts and the cases become exceedingly
tedious. Forcible motion should be practised under nitrous oxide
anesthesia and should be repeated every two or three days. Meanwhile
massage should be employed. If pain or reaction be extreme ice-cold
applications should be applied. Extreme swelling may be combated by the
use of a rubber glove. If this be worn, ichthyol-mercurial ointment
should be used beneath it, in order to promote absorption.

Treatment of the tuberculous cases is often disappointing.
Non-operative measures afford but temporary benefit, while operation to
be effective should be thorough. It should consist of free incision,
with exposure in whole or in part of the affected channel or cavity,
thorough cleaning out of its contents, removal of all edematous or
tuberculous tissue or granulations, and the use of an antiseptic as
strong as it can be employed.

The new _opsonic_ serum treatment, now being placed on trial as this
work goes to press, promises much in the treatment of all these septic
affections, though detailed statements would be premature.


TENDOPLASTY.

It was a step in advance in surgical technique when Stromeyer and
Dieffenbach, in 1842, introduced the method of subcutaneous division of
tendons and aponeuroses, and showed how easily contracted tendons could
be lengthened by tenotomy. From their time until somewhat recently
tenotomy has held its place in the treatment of various deformities,
and until Anger, Gluck, Hoffa, and others have taught the surgical
profession what can be done by various plastic and suture methods
in overcoming defects and atoning for loss of function in paralyzed
muscles. To the surgery of tendons and muscle terminations have been
added the further resources of tendon suture, _i. e._, _tenorrhaphy_,
and _tendoplasty_, by which latter something more than the mere suture
is meant, _i. e._, the plastic rearrangement and grafting of tendons
one upon another.[20]

  [20] The method of transplanting one tendon upon another is to be
  credited to Nicoladoni, who perfected it in 1882. Later it fell into
  disuse, but was revived in this country, especially by Goldthwait, of
  Boston, in 1896.

[Illustration: FIG. 114

FIG. 115

FIG. 116

FIG. 117

FIG. 118

FIG. 119

FIG. 120

FIG. 121

Illustrating various methods of dealing with tendons in tendoplasty.
(After Vulpius.)]

_Tendon suture_ is practised as an emergency measure when one or more
tendons has been accidentally divided, this being considered now
as much a part of the surgeon’s duty as to close any other part of
the wound. No additional resource or expedient is needed, it being
necessary only to observe the principles of asepsis, which should be
maintained in every case. A tendon raggedly divided should be cleanly
cut and its edges brought together with formalin-gut or freshly boiled
silk. A series of divided tendons should be treated after the same
fashion, matching the ends as closely and completely as possible. After
uniting the tendon ends, if the case be clean, the tendon sheath should
be closed and the parts put at rest, in such a position that no tension
is made upon the injured sinew until it is seen to have united.

[Illustration: FIG. 122

FIG. 123

Shortening a tendon.]

It was a great service, in which perhaps Gluck figured most
conspicuously, to show that when tendon ends could not be neatly
coapted an animal material could be interposed in such a way as to
serve as a trellis along which cells could group, or around which
they might organize, and thus gradually and finally become a part of
the complete tendinous cord. Silk and catgut have best served this
purpose, and new tendons have gradually formed around these artificial
substitutes, to the length of 10 Cm. In every fresh case where there
has been such loss of original structure as to justify a measure of
this kind, or in certain old cases where tendons have long since
sloughed away, it may be possible to resort to these expedients.

It has been possible to _transplant fresh tendons_ from the smaller
animals and to see them serve the same purpose in a satisfactory manner.

Among these methods of tendoplasty is _tendon grafting_, by which a
part or all of the tendon of an active muscle is inserted into the
terminal portion of a paralyzed muscle and thus made to assume to a
greater or less extent the purpose and function of the latter; in other
words it assists in ingeniously diverting the activity and direction
of a given muscle to a purpose different from its original intent. By
this diversion a more equal or equable distribution of muscle force is
afforded the parts into which the affected muscles are inserted. For
its successful performance only those muscles which are still active
can be utilized. Among the simplest of cases where this expedient can
be used are those produced by traumatic and peripheral paralyses, or
traumatic loss of a given tendon or a set of tendons. It is rarely to
be practised as an emergency measure, but as an expedient to be availed
of later. It finds its greatest usefulness in cases of long standing.
It is equally applicable where muscles and tendons have been divided by
injury, or paralyzed by injury to their nerve supply, as well as where
deformities are produced by chronic neurotic disturbance, by scars, by
excessive callus, etc. It proves equally serviceable in paralyses of
spinal origin, particularly those due to anterior poliomyelitis.

Tendon grafting will serve both as a substitute in cases of lost
function and as a provision against future deformity. In cases of the
ordinary paralyses of children, tendoplasty should be deferred for
several months after the occurrence of the paralysis. In the case
of growing children it is desirable not to wait too long, as other
objectionable features may present themselves. In the congenital
and hereditary paralyses and in conditions like athetosis or the
dystrophies of syringomyelia, meningocele, etc., also in such
conditions as habitual dislocations of the patella, much can be
accomplished by a carefully planned tendoplasty. It will be easily seen
then how wide a field of usefulness lies before one who familiarizes
himself with the recent technique of tendon surgery.

[Illustration: FIG. 124

FIG. 125

Two methods of tendon implantation and fixation. (After Vulpius.)]

[Illustration: FIG. 126

FIG. 127

FIG. 128

Transplantation of a portion of the anterior tibial tendon, into the
bone or into the opposed group of muscles. (After Vulpius.)]

So far as technical considerations are concerned these operations
should be performed only with the minutest attention to asepsis. When
this has been secured a permanent dressing may be applied, the limb
being left in the position most desired, and maintained there for
several weeks. For this plaster of Paris makes the best support. The
use of the rubber bandage will permit the operation to be bloodlessly
made, by which it is greatly facilitated. If careful suturing be
practised, there will be but little tendency to subsequent oozing or
interference with repair. Fine discrimination is always needed in the
matter of adjusting the length of tendon ends and the point of their
fixation. A useless tendon which has been long stretched over a curved
joint will have become elongated, and the tendon to be applied to it
should be affixed farther down than would be otherwise necessary. The
disposition of the upper portion of the useless tendon and muscle may
also call for serious attention. It is rarely necessary to extirpate
them. They are already atrophied, and to remove them would be to still
further reduce the dimensions of the part. The excluded portions can
thus be simply discarded. When there has been deformity with more or
less pseudo-ankylosis the malposition should be forcibly redressed and
the tendon grafting deferred until a subsequent time; the latter, to be
successful, should be performed alone.

Incisions are usually made along and over the course of the tendons to
be exposed, but not so close that the cutaneous scar can interfere with
the tendon sheath. The lower end of a paralyzed muscle will appear very
differently from that of one which is healthy; in the former instance
the tissue will have lost its muscular character, and will be yellowish
white and fatty. A fascia which has been stretched out of shape may be
sutured in folds and will serve of itself to give support and shape to
the part which is renewed.

The methods of uniting tendons are so numerous that they can be better
estimated by a glance at the accompanying diagrams after Vulpius than
by description (Figs. 124 to 128). It is not necessary to utilize all
of the tendon of a healthy muscle, as it can be split and a portion
diverted to its new function. It is not to be expected that tendons
thus arranged will perfectly serve their purpose the first time they
are used. There must elapse a period of education of the nerves and
muscles whose relations are thus altered, and improvement in the use of
the parts thus operated will accrue for months and even years. It is
desirable that tendon surfaces thus applied to each other be made broad
and extensive in order that their adhesion may be more firm.

[Illustration: FIG. 129

Showing methods of lengthening tendons. (Burrell.)]

A modification of tendon grafting consists in implanting the tendon
end into the periosteum instead of into some other tendon. There are
various ways of making this implantation, either by simple suture or
by boring into the bone or canalizing under a periosteal bridge. Fig.
129 illustrates how the tendon of the tibialis anticus can be utilized
in both ways. It will thus be seen that a tendon can be given either
tendinous, periosteal, or osteal implantation. Tendons thus utilized
rarely undergo necrosis or degeneration. So long as the possibility
of infection be excluded almost anything can be done with these
structures, in spite of their apparent lack of vascularity and vitality.

There are times when it is necessary to _lengthen a tendon_ as well
as to shorten it. Fig. 129 illustrates methods by which both of these
measures can be performed. Analogous methods have been practised with
muscles themselves, although here the circumstances are different and
nothing similar can be accomplished. Portions of the pectoralis major
have been grafted into the biceps for paralysis of the latter.

_Liberating the ring finger in musicians_, by dividing the accessory
tendons of the extensor communis digitorum, is an expedient suggested
some years ago by Brinton. It is made by an incision less than a
quarter of an inch long, through the skin and fascia, just below the
carpal articulation of the metacarpal bone of the ring finger, and
above the radial accessory slip, parallel with and on the radial
aspect of the extensor tendon of that finger. The point of a narrow
blunt-pointed bistoury is then inserted flatwise beneath the accessory
slip down to a point just in front of the knuckles of the ring and
middle fingers, where the blunt point should be felt beneath the skin.
The bistoury is now turned upward, the middle finger strongly flexed,
and the ring finger extended so as to make the slip tense when it is
divided. The accessory slip on the other side of the extensor tendon
is similarly divided through a distinct incision. Snug compression is
made with a bandage over the wounds, with the thumb free, and after two
days the patient is permitted to use the fingers in piano-playing in
order to prevent reunion of cut surfaces.


MYOTOMY AND TENOTOMY.

Myotomy is a measure seldom practised. It is performed either
subcutaneously or by open incision. _Tenotomy_ is indicated whenever
contracted tendons need simply to be divided, either in chronic
orthopedic cases or after injuries or operations when it is desired
to put muscles temporarily at rest. The tendo Achillis has thus been
divided to prevent the consequences of muscle spasm when dealing with
certain fractures, especially compound fractures of the leg. There are
obvious advantages obtaining in subcutaneous tenotomy when properly
performed; the freedom from hemorrhage, the minuteness of the opening,
the rapidity of healing, are all in its favor. It is performed with
a small-bladed knife, known as the tenotome, with either sharp or
blunt point, the cutting portion being from 1 to 2 Cm. in length.
The sharp-pointed tenotome suffices for its own insertion, the blunt
one being used after an opening has been made with a sharp one. The
puncture is made obliquely through the skin, which should be drawn
a little aside from the site of the deeper opening in order that it
may be hermetically closed as it slips back into place. Whether the
cutting blade should be turned outward or inward will depend largely
on the preference of the operator and the location of the tendon. In
some locations, as about the hamstring tendons, the puncture should be
made with the sharp instrument and the deeper tenotomy with the blunt
one. If the tendons alone have been divided there will be trifling
hemorrhage and the puncture can be occluded without entrance of air.
Similarly an _aponeurotomy_ may be performed. Not only may the tendons
be divided by the open method, but everything else which resists. This
is practised more in contracted knee-joint and in club-foot, when
operated on by Phelps’ method, than anywhere else. Special indications
for the operation will be given in other parts of this work.


GANGLION.

This term is applied to a cyst of new-formation, which occurs in
connection with the sheath of a tendon, having a lining membrane
continuous with the sheath and containing thick, gelatinous, mucoid
fluid. It is termed “_weeping sinew_.” It is often seen on the back
of the wrist in connection with the extensor tendons, but may occur
in various parts of the body. It probably begins as a hernia of the
synovial membrane through a weak spot in the tendon sheath, which tends
to increase in size, weakening surrounding structures by pressure,
and interfering more or less with the function of the tendon whose
sheath is involved. These cysts sometimes connect with joint cavities,
especially those occurring behind the knee-joint; as a rule, however,
they do not. At first they constitute merely a disfigurement; later
they produce natural impairment of function. In the majority of cases
the sac becomes finally shut off from the tube with which it originally
connected.

When these lesions are new they may be successfully dealt with by
forcible rupture, such as can be made by firm pressure. When old, or
when rupture has failed, they should be treated by incision, practised
the same as a tenotomy, by moving the skin to one side, pricking the
sac, turning the blade of the tenotome so as to permit the fluid to
be emptied by pressure, and then, by manipulating the point, irritate
and do some damage to the sac lining. Such provocation as this will be
followed by a hemorrhage, and the resulting clot may obliterate the sac
by organization and cicatricial contraction. This failing, excision is
the only expedient which promises success. The slightest operation upon
a ganglion should be done under aseptic precautions.


FELON, OR WHITLOW.

Felon, or whitlow, was discussed in the previous chapter, especially
the form which has its origin around the root of the nail. It often
originates in tendon sheaths and even in bone or close to it. It is so
often accompanied by a suppurative _thecitis_, _i. e._, tendosynovitis
of destructive form, especially when not primarily incised, that the
necessity for early treatment needs to be emphasized. It gives rise
to excessive pain, with throbbing, and to swelling of livid hue and
intense degree. The parts involved are too essentially fibrous and
resisting to yield, hence the intensity of the pain. Deep incision at
the earliest moment, for the purpose of relieving tension, is the only
proper treatment. To temporize with hot poultices, etc., is to invite
necrosis and sepsis. This incision may be made with local anesthesia.
Even though little pus be obtained the relief of tension will afford
the greatest comfort (Figs. 130, 131 and 132).

[Illustration: FIG. 130

Felon of thumb. (Burrell.)]

[Illustration: FIG. 131

Neglected suppurating thecitis resulting in palmar abscess. (Burrell.)]

[Illustration: FIG. 132

Same, dorsal aspect. (Burrell.)]

A more striking example of similar trouble is that which gives
rise to _palmar abscess_, the suppurative process extending up the
wrist beneath the annular ligament, and down into the little finger
and thumb. This is not infrequently the result of infection of
callosities in the palm of the hand. Infection may travel rapidly,
and when confined beneath resisting structures will prove exceedingly
destructive; the muscles of the forearm may melt down and great
permanent damage be done.

Here, as when the finger alone is involved, early, free, and deep
incision will prove the salvation of the part. These incisions should
be made as indicated in Figs. 133 and 134, _i. e._, parallel with the
nerves, tendons, and vessels, all of which should be spared, as well
as the palmar arch. Should the latter be divided, the vessel ends may
be ligated or the wound packed. If cavities be left by the destructive
process they should be opened and the part treated by continuous
immersion in warm water, or the openings may be packed with gauze
saturated in brewers’ yeast. A few days of this treatment will clean up
all sloughs.

[Illustration: FIG. 133

Diagram of palmar incisions.]

[Illustration: FIG. 134

Diagram of dorsal incisions. (Burrell.)]


SURGICAL DISEASES OF THE MUSCLES.


CONTUSIONS OF THE MUSCLES.

Muscles react like other tissues under the influence of contusions.
Hemorrhages not too copious are gradually absorbed, and muscle tissue
repairs itself, as indicated in the chapter on Wounds and their Repair.
Much outpour of blood into a muscle will temporarily seriously impair
its function, while pigmentation or ecchymosis may result after a few
hours or days, according to the depth of the injury. There is the same
liability to suppuration after infection of muscles as elsewhere. A
large hematoma can scarcely form within a muscle, save in consequence
of a rupture of a considerable portion of its substance. _Strains_ and
_sprains_ of lesser degree of violence provoke impairment of function
proportionate to their severity. In nearly every instance there is a
certain amount of rupture of muscle fiber and outpour of blood.


RUPTURE OF THE MUSCLES.

Complete rupture across a muscle is unusual. It may occur in the belly
of the muscle or near one of its terminations. A tendon may be torn out
of a muscle or may itself snap. These accidents are almost invariably
accompanied by symptoms that indicate both the nature and location of
the injury. A severe strain followed by intense pain, with a sensation
of yielding, leaves little doubt as to what has happened. Unless the
muscle lie deeply its parting may be appreciated by palpation, though
the depression or interval may be obliterated by the outpour of blood.
The large tendons of the arm and shoulder have been ruptured by a
violent effort, the abdominal muscles by contusions and by such efforts
as wrestling, the sternomastoid by excessive traction during forceps
delivery, and the tendons of the legs and ankles by jumps during such
games as lawn tennis, etc.; while the frequency with which the muscles
of the perineum and even the sphincter ani are torn during parturition
is well known. It is also well known that muscles are weakened by the
exanthemas and the infectious diseases.


=Treatment.=--An injury of this kind and of moderate degree seen early
may be treated by physiological rest and position. (See chapter on
Treatment of Wounds.) When, however, there is marked impairment of
function, such as will follow the yielding of one or more tendons or
muscle insertions, then suturing offers the greatest promise of a cure.
When the quadriceps tendon is torn away from the patella or the tendo
Achillis from the heel, prompt suture under aseptic precautions will
save a long period spent in partial recovery of function.

Occasionally one or more tendons will be completely _avulsed_, as when
a finger is torn out of the hand and brings with it one or more of the
tendons belonging to it. In accidents of this kind six to twelve inches
of tendon and muscles may be lost. In such a case nothing can be done
except to care for the wound resulting from the injury.


DISLOCATION OF TENDONS AND MUSCLES.

Tendons and muscles are occasionally dislocated, that is, forced from
their normal positions. Accidents of this kind usually occur with the
long tendon of the biceps, which is torn from its bicipital groove;
the peronei and the posterior tibial in the leg, the extensor muscles
of the thigh, and those of the back of the wrist. The lower angle of
the scapula is normally held down by a small portion of the latissimus
dorsi; should this be displaced the scapula rises somewhat in wing
form. These injuries lead to more or less loss of function, and, when
they become disabling, may justify operation, which would include
incision, exposure of the tendon in its abnormal position, and its
restoration to its proper place where it should be held by sutures.
Such operation should be followed by enforced physiological rest of the
part.


HERNIA OF MUSCLES.

Hernia of muscle is the name applied to the escape of muscle through
a ruptured fascial or aponeurotic covering. Such a protrusion will be
recognized only during the contraction of the muscle and will disappear
at other times. When the diagnosis is made the edges of the rent in the
fascia should be united by sutures and the part put at rest.


WOUNDS OF MUSCLES.

Wounds of muscles in no way differ from other wounds which have
been considered in the chapter on Wounds and their Treatment. If
circumstances permit there is every indication for the suture of a
divided muscle in order that its function may be less impaired after
the wound is healed. These sutures, when inserted, should be made to
separately include the divided fascia or aponeurosis with which the
injured muscle is in relation.


MYALGIA.

There are numerous painful affections of muscles known as _myalgia_.
It is questionable whether a rheumatism of muscle fiber ever occurs.
That which patients describe as muscular rheumatism is not that which
it is termed. Sometimes it is the result of previous exudate between
muscle fibers, sometimes the result of hemorrhage of interstitial type.
Muscles thus affected are more or less tender and give pain when used.
It will usually be found that there is some marked toxic condition,
such as uric acid, syphilis, or lead poisoning, behind it.


=Treatment.=--Many of the muscle pains of which patients complain after
operation, which are also toxic, are relieved by the administration of
aspirin in 0.5 Gm. doses. The injection of a small amount of atropine
into the body of the muscle will often give relief. Those remedies
which hasten elimination, including hot baths and massage, are often of
great value.


MYOSITIS.

This may be _non-inflammatory_ and be due to prolonged use of a member,
as in writers’ cramp; or _toxic_, as in lead palsy; or _traumatic_,
caused by minute lacerations and hemorrhage. The more acute forms may
be due to extension from neighboring foci or to direct infection. A
form of infection involving both muscles and tendon sheaths, and lately
recognized, is the postgonorrheal. It has been shown that _gonorrhea_
may produce an active disturbance in synovial sheaths and in muscle
structures and a _gonococcus myositis_, as well as a _gonococcus
tendovaginitis_, are now well recognized. These do not always proceed
to suppuration, but may provoke loss of function for some time.

The suppurative form of myositis is seen more often after typhoid and
gonorrhea than after the other internal infections, but may occur after
any of them. In these cases abscess results in the belly of the muscle
involved, while the pus evacuated will show the appropriate organism.
It is met with less often in endocarditis and erysipelas.

Any or all the active and destructive infections may occur primarily in
muscle structure. They are usually the result of an extension, although
they maybe even in this way very disastrous. The amount of muscle
destruction that may be seen in a limb after an infected and neglected
compound fracture is astonishing.


=Myositis Calcificans.=--Calcification and ossification of muscles
are alike due to deposition of calcium salts, but under different
circumstances. _Myositis calcificans_ may be the result of tuberculous
disease following caseation, as it does in lymph nodes and in other
parts of the body, or occurring as a general deposit throughout the
muscles, essentially an infiltration, as is seen in the muscles of the
legs. _Myositis ossificans_ implies a formation of true bone in muscle
substance. A peculiar form arising in the adductor longus results from
the pressure of the limb against the saddle; this has been known as
_rider’s_ or _cavalryman’s bone_. Something similar in the deltoid
has been called _drill bone_, because usually seen in soldiers who
carry their weapons upon the shoulders; while a form which occurs in
the brachialis anticus has been referred to as _fencer’s bone_, and
one in the calf muscles as _dancer’s bone_. It occurs in two types,
one of which is characterized by ossification in succession of the
various muscles, this occurring first in the trapezii, latissimi, and
rhomboidei. In explanation of these lesions, it has been suggested
that all of these connective mesoblastic tissues may manifest certain
atavistic tendencies and thus revert to bone. The question is certainly
not one of periosteal origin. Binnie has shown, in a remarkable case
reported by himself, that ossification is both of the fibrous and
cartilaginous type. Only in the localized forms can the periosteum be
suspected. In these it may be that there has been detachment of some
of its tissue or escape of some of its cells into the muscle area.
The ossifying lesions of surrounding muscles will sometimes interfere
with the motions of joints after they have been injured. Any localized
calcareous or ossific deposit which can be recognized may be removed.


=Myositis Syphilitica.=--This occurs in gummatous form, no muscles
being exempt; those of the tongue are most frequently involved. It is
seen also in the sternomastoid. Not infrequently these gummas have
been mistaken for malignant tumors. Sometimes they degenerate and
sometimes suppurate. A lesion of this kind will usually be multiple,
but it may have enough infiltration around it to be difficult of
recognition. Lesions of this kind are also seen in hereditary cases. A
more distinctively interstitial affection of muscles leads sometimes to
their contracture, as seen about the arms, beginning with malaise and
incoördination, and extending to disabling lesions. These will yield to
properly directed antisyphilitic treatment.


=Myositis Tuberculosa.=--This affection is usually the result of
extension from adjoining foci. As in the case of syphilis it may
assume the infiltrating or the gummatous type. It is more frequently
encountered than the muscular expressions of syphilis; it does not
yield nearly as readily to treatment, and calls for excision of the
affected area and for cauterization or other protection as against
re-infection.


PARALYTIC AFFECTIONS OF MUSCLES.

More or less permanent paralysis is sometimes the result of contusion
or direct injury of a nerve trunk. Thus the paralysis of the deltoid
which follows injury to the circumflex nerve in connection with
dislocations of the shoulder is a frequent accident. It does not
require continued pressure upon the nerve to produce this. It may
follow a dislocation reduced within a few moments. Again, paralysis
of the arm muscles is occasionally the result of pressure made by
crutches. It has been known to occur from similar pressure while the
patient was upon the operating table with his arm hanging over the
table’s edge. This is an accident which should be carefully avoided.
Moreover, it follows sometimes from mere violent muscle effort. The
condition, while simple in its etiology, is difficult and sometimes
impossible to cure.


=Treatment.=--The treatment should consist mainly of massage and
electricity, with the elimination of all possibility of toxemia. The
resources of tendoplasty (see above) should also be considered, as well
as those of neuroplasty.


ATROPHIES AND CONTRACTURES OF MUSCLES.

Muscular paralysis is always followed by atrophy, which will lead
to marked diminution in size of the part; when the atrophy concerns
a single muscle or muscle group it will frequently be followed by
deformity due to action of the opposing muscles. Tonic spasm of muscles
unopposed may lead to contractures, often with ankylosis. The degree of
deformity which is produced may eventually require amputation of a limb.

Other forms of contractures are produced either as the result of
central or spinal scleroses or as expressions of irritative spasm
provoked by a neighboring bone or joint trouble. The two types may
cause similar deformities, which vary widely in their etiology. The
former are seen in certain cases of brain and spinal-cord diseases, the
latter especially in connection with tuberculous arthritis. Inasmuch as
the flexors are stronger than the extensors these deformities consist
largely of hyperflexion. Ultimately the shape and growth of bones and
the nutrition, appearance, and function of the part are influenced.

Muscle atrophy which is the result of confinement in one position, as
after the treatment of fractures, is of minor importance and tends to
disappear spontaneously as soon as function is resumed.


=Treatment.=--In most of these instances patience may be easily
overtaxed while waiting the tardy results of massage and such
correction as apparatus may afford. Very frequently the additional help
of an anesthetic, with forced movements, often with tenotomies and
sometimes with tendon grafting, will be required. When contractures
can be foreseen, as they may be in connection with many lesions which
produce them, such as burns and others not specifically mentioned, they
should be guarded against by splints, apparatus, or whatever may best
serve the purpose.


PARASITIC AFFECTIONS OF THE MUSCLES.

The parasitic affections of muscles are rare. Trichinosis rarely
produces tumors which come under the surgeon’s hands. Still there may
result from it a form of myositis with formation of cysts which may
so far interfere with muscle function as to demand removal. _Hydatid
cysts_ and _cysticercus_ are extremely rare, especially in this country.


DISEASES OF THE BURSÆ.

There are two types of bursæ in the body: first, the _subcutaneous_,
or _mucous_, which are loose sacs containing a clear mucoid fluid.
They develop regularly when bony prominences are exposed to friction
and develop adventitiously wherever undue irritation is produced. Thus
beneath every _bunion_ there will be found a good-sized and thickened
bursa.

_Synovial bursæ_, the second type, are met with in close proximity to
joints, and between tendons which play upon each other. They frequently
communicate with the joint which they overlie, and infection may easily
spread from one to the other. They are liable to traumatism, either
extrinsic or intrinsic, the former from chafing or more direct injury,
the latter by excessive muscle exertion. When infected they suppurate,
forming abscesses of conventional type. As the result of contusions
they are frequently filled with blood, in which case there is a _bursal
hematoma_. _Acute bursitis_ usually merges into localized abscess.

[Illustration: PLATE XXX

Foreign Body (Broken Needle) in Foot. Buffalo Clinic. (Skiagram by Dr.
Plummer.) Illustrating the Value of this Method of Exactly Locating a
Foreign Body and involving the Tissues Considered in Chapter XXVIII.]

[Illustration: FIG. 135

Hygroma of a prepatellar bursa (“housemaid’s knee”). (Lexer.)]

_Chronic bursitis_ constitutes a circumscribed collection of fluid,
often with thickening of the bursal sac, and frequent deposition
of products of exudation. Here, too, pus may form as the result of
infection, while calcification sometimes takes place in old cases. A
chronic bursitis is likely to be either of syphilitic or tuberculous
origin. It is usually seen beneath old bunions, and in the prepatellar
bursa, which is equally exposed to irritation, and which also gives
rise to _housemaid’s knee_. This lesion used to be considered as always
of syphilitic character, but this is far from correct.

_Hygroma_, or _hydrops_, is a term frequently applied to these
localized collections of fluid. The former is more likely to be of
tuberculous origin, and the retained fluid may contain rice-grain
bodies. A chronic bursitis, originally of traumatic origin, may become
infected and present a tuberculous lesion, or it may be influenced
if not caused by a syphilitic diathesis, especially about the knee,
where these conditions generally occur. Other bursæ which produce
disturbances that eventually take the patient to a surgeon are met with
in the following locations: _beneath the ligamentum patellæ_, which
will give a prominence on each side of the ligament, particularly when
the knee is flexed; _over the tubercle of the tibia_; _beneath the
quadriceps extensor tendon_, which will cause a swelling two or three
inches above the upper border of the patella; _between the tendon
of the semimembranosus and inner head of the gastrocnemius_, which
will present in the popliteal space as a somewhat globular swelling;
_beneath the deltoid_; _beneath the gluteus muscles_, where the tendons
pass over the great trochanter; _between the tendo Achillis and the
calcis_; _over the outer malleolus_, occurring in tailors by virtue
of the position in which they work. Large bursæ often develop on the
_outer sides of club-feet_, on the ends of amputation stumps, and
wherever there is prolonged irritation of mild degree.[21]

  [21] A bunion is in many instances due to flat-foot, causing the
  great toe to turn out. This condition should be remedied by the usual
  arch, or raising the inner border of the shoes. Four out of the five
  tendons attached to the great toe tend also to draw it outward. If
  the tripod of the foot can be restored without operation this should
  be done.

The treatment of acute bursitis is that of threatening phlegmon in
any other part of the body. As soon as the presence of pus can be
determined, or even before, a free incision should be made. Such an
incision should not be entirely closed after evacuation of the sac, but
should be permitted to heal by granulation.

Chronic bursitis, whether with or without formation of granuloma, is
best treated by _excision_, when the sac has become thickened and a new
formation has practically occurred. Housemaid’s knee, for instance,
like bunion, is more satisfactorily treated by a clean excision of
all diseased tissue than by any other less radical method. Every
tuberculous lesion of this kind should be rigorously extirpated, and
every syphilitic lesion should be treated by constitutional as well as
by local measures, the former being, save in exceptional instances, the
more important of the two.[22]

  [22] _The Radical Cure of Bunions._--The term bunion is generally
  used to indicate a painful swelling over the inner aspect of the
  ball of the great toe; it is never seen on the feet of those who go
  barefooted, but is the result of badly fitting shoes, almost all
  of which crowd the great toe outward, thus making its base more
  prominent and exposing it to irritation and pressure. The inner
  border of the foot is nearly a straight line, but shoes are rarely
  made to conform to this. The result of the consequent partial
  dislocation of the toe, and of the pressure made at its base, is
  chronic periostitis, and the development of a bursa. It becomes
  greatly thickened and forms a small tumor, usually sensitive and
  painful. The dislocation often proceeds to such a degree that the
  great toe lies across the others, either over them or under them, in
  such a position as to receive and deserve the name _hallux valgus_,
  which is generally given it when this is pronounced. There is nothing
  to do but to exsect the head of the first metatarsal bone, and at the
  same time excise the bursa and some of the overlying and thickened
  skin.




CHAPTER XXIX.

SURGICAL DISEASES OF THE HEART AND VASCULAR SYSTEM.


A generation ago a chapter on the surgery of the heart would have been
regarded as a surgical fantasy. Today the subject is not only a live
one, but experience is constantly accumulating as to the value of
surgical intervention in diseases of the heart and pericardium.


MALPOSITIONS OF THE HEART.

The heart may be displaced by congenital or acquired causes.
Malpositions of the former type may vary from _dextrocardia_, where
the heart is placed upon the right side, and may be accompanied by a
general or partial transposition of the viscera, to those cases where
there are defects in the diaphragm or the chest wall, through which the
heart protrudes. Dextrocardia has an interest for the surgeon, as, for
example, in the following case under the writer’s observation: Disease
on the left side which simulated appendicitis, in which the diagnosis
was confirmed by finding the heart upon the right side, and later by
operation. It was a case of complete transposition.

The acquired malpositions may be due to intrinsic or extrinsic
causes. They are pressure effects, usually found in connection with
intrathoracic aneurysms and other tumors or collections of fluid,
or may be due to change in the shape of the spine in pronounced
curvatures. Occasionally the heart is hindered in its action by
pressure from beneath the diaphragm. These cardiac displacements are
surgically interesting when the cause can be removed by operative
measures.


WOUNDS OF THE HEART.

Wounds of the heart are mainly of the punctured or gunshot type. It
was formerly considered that injuries of the heart were essentially
fatal. This has been disproved by human and comparative observations.
As far back as 1855, Carnochan reported a case of gunshot wound of
the heart where the bullet was found in the heart substance after the
patient had lived eleven days. The museums contain many illustrations
of penetrating wounds of the heart or of foreign bodies in it, some
of which had remained embedded for many years. Nevertheless the fact
remains that the majority of wounds of the heart are fatal, either by
arrest of its activity, by shock, by the outpour of blood between it
and the pericardium or outside the latter, or later by processes which
consume at least a few days, either infective or degenerative. Other
things being equal the larger the wound the more dangerous, while an
injury to the heart muscle which has not opened one of its cavities
is less dangerous than one which perforates them. A punctured wound
made by a small stiletto or knife-blade, or even by a needle used for
homicidal purposes, may leave but small trace and not prove fatal, save
through injury to one of the cardiac vessels, especially a coronary
artery.[23]

  [23] Illustrating the surgery of foreign bodies in the heart,
  Jordan has reported the case of a young woman who stated that she
  had received a blow on the front of the chest the previous day, and
  showed on examination a small projecting point in the lower part of
  the third left intercostal space about half an inch from the sternum,
  which was tender to the touch and seemed to move or pulsate with
  the heart. It gave to the finger the sensation of a hard substance
  beneath the skin without any external marking. Upon making an
  incision and dissecting partly through the muscle the broken end of a
  black steel pin came into view. After removal with forceps it proved
  to be a shawl pin, one and one half inches long, with its glass
  head broken off. The patient remembered having had such a pin in
  her bosom at the time of the accident. On the following day she had
  pericarditis. She apparently recovered, but had a relapse, and died
  on the twenty-fourth day, the autopsy showing pericarditis.

In practically all of these injuries there will be evidence of some
external violence. It is of advantage to ascertain the nature of the
accident and the character of the missile or instrument. If the depth
of penetration of a knife-blade, for instance, can be ascertained
more accurate conclusions can be drawn. The special indications of
cardiac injury pertain to disturbance of its own function, that is,
embarrassment and uncertainty of action, bellows sounds, enlarged area
of dulness owing to distention of the pericardium with blood, dyspnea,
and distress, and sometimes pain and syncope. These symptoms and signs
do not appear instantaneously, but increase in severity.


=Treatment.=--In such an emergency everything possible should be done
to relieve the embarrassment of the heart’s action--the head should
be kept low, the body absolutely quiet, and nervous excitement should
be allayed at once with a full dose of morphine. Heart stimulants
should not be given. Ice applied over the chest will help quiet
cardiac activity. If the patient be not failing too rapidly operation
is advisable, and should be done in a well-equipped hospital, with
trained assistants. The purpose of the operation is to expose the
injured portion of the heart substance and close it with suture; at
least to remove the fluid or partially coagulated blood within the
pericardium.[24] As it is not always possible to expose the heart
without opening the pleural cavity, there should be at hand not only
the means for a tracheotomy, but an apparatus by which artificial
inflation of at least one lung can be effected. _Pneumatic cabinets_
have been devised for this purpose, especially by Sauerbruch, where a
difference of pressure can be maintained between the outside and the
inside of the cabinet, so that the chest may be widely opened and the
lung not collapsed; but such a cabinet is available in few places in
the United States. The improved Fell apparatus, by which a mask is kept
over the face and pressure maintained with the foot through a bellows,
has been found useful. Even in the absence of such apparatus the
surgeon should not abstain from the effort, though it may appear less
promising.

  [24] _Suture of Heart Wounds._--Stewart has tabulated 60 cases of
  suture of the heart reported up to May, 1904, with a remarkably
  high recovery rate of 38 per cent. (Amer. Jour. Med. Sci., October,
  1904). Of the 60 cases 55 were stab wounds and 5 were gunshot wounds,
  2 of the latter recovering. In 4 of the cases the coronary artery
  was injured, and only 1 of these recovered. The injury occurred
  through a puncture while suturing the heart, and an extra suture was
  necessary in order to control it. Of the 60 cases the left ventricle
  was wounded thirty times, with 30 recoveries. The right ventricle
  was wounded 21 times, with 7 recoveries. The operation has only been
  practised for about ten years. The results reported certainly justify
  its performance in all cases of this kind.

In the operative procedure one may feel inclined to utilize the already
existing wound, either as a part of his incision or for exploratory
purposes, or he may decide to disregard it. The operation consists
in raising an osteoplastic flap on the chest wall, by which the
pericardium and then the heart are exposed. The incision through the
skin is extended to the bone and only enough of the soft structures
separated from the ribs and cartilages to expose them sufficiently
for division. Ordinarily it would be preferable to divide the third,
fourth, and fifth costal cartilages at their rib terminations, and then
to turn up the flap with its base at the sternum, though the procedure
can be reversed to almost as good advantage. The cartilages and the
ribs may be divided with the costotome and the rest of the structures
with stout scissors. The flap, having been gently elevated at the edge,
is separated from the underlying cellular tissue and pericardium until
its sternal margin has been reached. When detached it may be sprung
upward, and thus a complete window is made in the chest wall. When more
room is desired bone and cartilage may be cut away with a rongeur.

[Illustration: FIG. 136

Result after thoracotomy for heart wound. (E. J. Meyer.)]

The pericardium being thus exposed may be found much distended or
altered by the imbibition of blood. It should be opened to an extent
sufficient to permit evacuation of its bloody contents and sufficient
exposure of the heart to permit not merely inspection but suture of
any wound in the heart substance. This is exceedingly difficult on
account of motions of the heart, and the insertion of sutures will be
as difficult as trying to hit a flying target. Nevertheless it may be
done in many cases. Unless imperative, a coronary artery should not be
included in the heart suture. Hemorrhage from the heart being checked
the pericardium is then to be united, preferably with hardened catgut
sutures, with or without drainage. In most instances the former is the
better plan, and the drain may be of the cigarette type, that is, gauze
wrapped in oiled silk.

Should it be found that the pericardium alone is injured and not the
heart the case may be regarded in a more favorable light.

There are sufficient cases on record where procedures analogous to
the above have been practised to justify the attempt in every case.
Hardened animal sutures may be used in the heart substance, and the
interrupted method will probably prove the better. A suture which will
hold firmly for three or four days will suffice, as has been proved on
animals.


RUPTURE OF THE HEART.

Rupture of the heart can scarcely be considered a surgical condition,
though it has frequently been one of medicolegal interest. It may,
however, afford a sudden and unexpected termination to surgical cases.
The cardiac muscle may be so softened by the poisons of diphtheria
and other acute infections as to be greatly weakened, even though an
intubation or tracheotomy has apparently afforded security.


TUMORS OF THE HEART.

Primary malignant tumors of the heart are very rare. Secondary and
metastatic manifestation are much more frequent. True primary sarcoma
has been repeatedly observed, and, with the exception of endothelioma,
is practically the only primary cancer that could appear in this
location. Carcinoma is found only as a secondary deposit, with which,
however, the heart may become so involved as to permit of terminal
rupture.


THE PERICARDIUM.

This closed sac is interesting to the surgeon in cases where it becomes
filled with air; with blood, as the result of injury (see above); with
fluid, as in acute pericarditis, or with pus, as a later stage of the
latter, with its consequent _pyopericardium_. With the introduction of
the aspirating needle it is possible to draw off collections of serum
or pus, and _paracentesis of the pericardium_ is now a conventional
minor operation. It is managed in the same way and with the same
instruments as when the pleural cavity is involved. It is ordinarily
safe, and affords much relief.

The surgeon may go even farther than this and practise _cardicentesis_,
as the writer did once by accident while hospital interne. After
introducing the needle and withdrawing three or four ounces of pus he
discovered that he had given great relief, which, however, was only
temporary. The autopsy two days later revealed that he had passed the
needle point through the pericardial sac into the heart wall and had
tapped the abscess therein. This was in 1877, and was probably the
first time that the heart wall was ever thus entered.

Now the operator goes still farther than this and practises intentional
cardicentesis in cases of engorgement of the right side of the heart
connected with lung disease which is threatening death from dyspnea
with an overstrained heart. In such cases the needle may be introduced
just above the fourth rib, from one-half to one inch to the right of
the sternum, or entrance can be effected just above the fifth rib in an
upward direction. From 100 to 250 Cc. of blood may be withdrawn.

For ordinary tapping of the pericardium the needle is inserted two
inches to the left of the median line and in the fourth or fifth left
interspaces, pushing it carefully until resistance is no longer felt
and fluid flows through the tube. For either of these purposes the
patient should be recumbent, unless the distress in this position is
too great, in order that the heart may fall away from the chest wall.
Aspiration can be repeated in case it gives relief. Little or no harm
seems to ensue from the wound which a needle-point will make upon the
heart substance. As the sac is progressively emptied the needle-point
should be gradually withdrawn. When aspiration, exploratory or
therapeutic, reveals the presence of pus, the well-known rule will
apply, _i. e._, that pus left to itself will do more harm than will
the surgeon’s knife. For pyopericardium there is but one successful
treatment when aspiration fails, and that is open incision and
drainage. This is not so severe a measure as exposure of the heart, as
it may not even require the removal of one costal cartilage, although
it would probably be better to take out at least one, since the shape
of the pericardial cavity will change to such an extent after it is
emptied as to raise the opening to a higher level than is given it at
first. Open incision, then, with drainage, in these cases is no longer
an experiment but a life-saving procedure. It will prove successful
in at least half of the cases, which otherwise would certainly perish
without it.


PNEUMOPERICARDIUM.

Pneumopericardium implies the presence of air in the pericardial
sac, a condition of which there are now about 40 cases on record.
The air nearly always enters through an ulcerative perforation from
adjoining parts or through a wound, yet in 5 of these cases no opening
could be found. In these it was probably due to the presence of a
gas-forming bacillus, such as may also cause pneumothorax under certain
circumstances. The perforation was in the esophageal wall in 7 cases,
in 4 cases it was the result of softening of a lymph node, while in
other instances it has followed abscess of the left lobe of the liver,
pleuropneumonia and gastric ulcer perforating through the diaphragm.
Of the 8 cases of penetrating wound from without, I included the small
puncture made by paracentesis, while in 7 cases there had been fracture
of the ribs or the sternum, with wound or laceration of the lung or the
pericardium.

The most characteristic sign is a splashing, gurgling sound,
synchronous with the heart beats, such as the French have called the
“water-wheel bruit.” These sounds are louder than in hydropneumothorax,
and are heard distinctly over the heart. The area of precordial dulness
will change with position.

In unmistakable cases operation is indicated, the trap-door exposure
being the best, the inner end of the fifth and sixth ribs being
elevated. Irrigation and drainage will be necessary. It is encouraging
to know that 11 of the 40 cases above mentioned have recovered.


CARDIOLYSIS.

Cardiolysis refers to the operative release of the heart from adhesions
which have formed between it and the pericardium or the chest wall.
When with every contraction the heart itself is subjected to the strain
of an adhesion the work proves excessive and it will finally succumb.
It has been suggested by Delorme, Peterson, and Simon to either
temporarily resect the chest wall, open the pericardium and break down
or divide the adhesions, or else to resect those bony portions of the
chest wall, _i. e._, the sternum, cartilages, or ribs, which are so
inflexible as not to yield, not removing the bands but making them
harmless.[25]

  [25] Those interested in the modern surgery of the heart and lungs
  should consult Rickett’s recent work on this subject.


THE ARTERIES.

There are few parts of the body which adhere more closely to the
normal standard than do the larger arteries. Even here malformations
and congenital defects are met with. In calculating the chances of a
given procedure the surgeon should consider the condition of the venous
and lymphatic systems before deciding to operate on a portion of the
arterial system. This is particularly true when ligating the femoral
artery for elephantiasis of the leg.

Thrombosis and embolism have already been considered in the chapter
on the Blood. Nevertheless it may be well to remind the student at
this point that thrombus means a blood clot, while thrombosis refers
to the process of its formation; that embolus means something which
has passed into the blood current of an artery and plugged it, the
obstruction usually being a fragment of clot or tissue, though it may
be a droplet of fat or a bubble of air. Emboli, like thrombi, may
be sterile, and in this respect innocent, or it may be composed of
material loaded with septic, tuberculous, or cancerous germs.

[Illustration: FIG. 137

Anastomosing circulation in sartorius and pectineus of dog, three
months after ligature of femoral. (After Porta.)]

[Illustration: FIG. 138

Collateral venous circulation, from a woman aged forty-seven, under
the care of W. W. Gull, in whom the inferior vena cava was completely
obstructed from cancer. (Guy’s Hosp. Mus., Drawing 44⁴⁰.)]

[Illustration: FIG. 139

Direct anastomosing vessels of right carotid of goat, five months after
ligature. (After Porta.)]

The readiness with which vessels, both arteries and veins, lend
themselves to the exigencies of extra work has long been recognized,
and the natural provision for collateral circulation is one of which
surgeons have for centuries availed themselves. On the contrary,
vessels which are no longer needed or whose function is lost will
undergo atrophy almost to obliteration; thus after amputation of the
thigh the corresponding iliac vessels become much reduced in size
(Figs. 137, 138 and 139).


ARTERITIS; ENDARTERITIS.

That arterial walls are resistant is shown by the fact that they are
usually the last tissues to yield to gangrene. Whether a primary acute
arteritis often occurs is a question of less interest in this place
than the fact that even arterial walls will succumb to infection and
that secondary hemorrhages from ulcerative processes are by no means
rare. The pathological processes which occur in the various structures
of the heart are repeated in the arterial walls; thus there may be
a _periarteritis_ corresponding to pericarditis, a _mesarteritis_
which in many ways resembles myocarditis, and an _endarteritis_ which
corresponds more or less closely to endocarditis, and all of these in
their acute or chronic forms. The acute forms which concern the surgeon
are due usually to the presence of infected emboli, which have the
same effect upon the arterial walls that infected thrombi have upon
the venous walls, _i. e._, they lead to occlusion, infiltration, and
suppuration.

Of the more chronic types those produced by syphilis are the most
common. Here it is usually the outer and inner coats which suffer
most. Tuberculous infection of an artery is of frequent occurrence
and pertains only to those vessels which are in intimate relation
with previous tuberculous lesions, while the syphilitic forms are
diffuse and generalized and as likely to involve one part of the body
as another. It is well known that arteritis in various degrees of
intensity may be met with in most of the infectious diseases. Whether
they are due to the living germs or to toxins generated during the
process concerns us at this point but little. It is of importance,
however, to realize that vessels so compromised may thus receive
their first impetus to degeneration and subsequently form aneurysm.
The degenerative types of greatest interest to the surgeon are _fatty
degeneration_, which occurs in the interior rather than the exterior,
and _calcification_, which is rather an involvement of peripheral
vessels and which occurs mainly in the middle and the outer coats. The
latter may be limited or may involve an entire vessel. When the radial
arteries are involved the condition may be appreciated at the wrist.
Calcification frequently follows other degenerations, especially fatty,
of the intima, and then may be seen in the interior of an artery. A
true ossification has been described, but is exceedingly rare.


ARTERIOSCLEROSIS.

Arteriosclerosis is a term generally applied to a combination of
these degenerations, with thickening and diminution of caliber. The
changes combined are comprehended in the term _atheroma_, which is
seen as a localized lesion in nodules or plaques in the aorta and
larger vessels and in diffuse form in the smaller. Atheroma, as a
complex degeneration, constitutes an interesting study, as it leads to
well-marked changes in the vessel walls, which are softened at points
by fatty changes, the little mass of debris resulting being called an
_atheromatous abscess_ (an unfortunate name), which may empty into the
vessel, leaving a small cavity and opening known as the _atheromatous
ulcer_. Around this occur usually the calcific changes above described.
The disturbance and the roughening thus produced lead to the formation
of fibrinous thrombi, which attach themselves firmly at these points.
When to such a weakening of the vessel wall as is thus produced are
added the elements of compensatory cardiac hypertrophy, and the
sudden changes of blood pressure produced by certain occupations and
alcoholic and other excesses, it will be seen how atheromatous patches
constitute points of least resistance, where blood pressure may cause a
vessel wall at least to bulge and thus to afford the beginnings of an
aneurysm; while, by combination of various processes, final rupture may
result.

The conditions are not so very different in the more diffuse forms,
especially in patients who have not only a tendency to vascular disease
but to increase it by the added toxemias of gout and syphilis, of
various excesses and bad habits, in which not only do arterial coats
suffer, but the heart muscle and lining as well. The relations then
of systematic toxemias to arterial disease and finally to surgical
conditions are not so circuitous as may at first appear.


ANEURYSM.

_An aneurysm is a tumor communicating with an artery and containing
circulating or coagulated blood, or both._ It may be formed entirely
from the wall of the vessel, or some portion of it may be formed by
surrounding tissue. Several varieties of aneurysm are indicated by
descriptive adjectives. They are divided, first, into _true_ and
_false_, the former being composed of all the vascular coats and being
small and infrequent; the false aneurysms imply those in which the
entire arterial wall does not participate. Aneurysms inside the body
cavities are called internal, and those involving the limbs external.
The terms _spontaneous_ and _traumatic_ apply here as elsewhere.
_Fusiform_ aneurysm implies a spindle-like dilatation of the vessel in
somewhat regular form. The _sacculated_ aneurysm is essentially a pouch
protruding from one side of the vessel with which it communicates. When
the sac ruptures the aneurysm becomes _diffuse_. If the outer coat
gives way and the inner protrudes there is a _hernial_ aneurysm. The
_dissecting_ aneurysm is one formed by separation between the arterial
coats, so that blood coagulates or flows between them. Such an aneurysm
tends to assume a sacculate form and to rupture. A _varicose_ aneurysm
is a sac through which an artery and adjoining vein communicate. A
_cirsoid_ aneurysm corresponds to a varix on the venous side of the
circulation, and implies dilatation of an artery and its branches. (See
Figs. 140 to 145.)

[Illustration: FIG. 140

True aneurysm; the sac formed by all the coats. (Holmes.)]

[Illustration: FIG. 141

False aneurysm; the sac formed by the outer coat only. (Holmes.)]

[Illustration: FIG. 142

Traumatic aneurysm; the sac formed by the tissues around the vessel.
(Holmes.)]

[Illustration: FIG. 143

Dissecting aneurysm. (Holmes.)]

[Illustration: FIG. 144

Hernial aneurysm; the sac formed by the inner coat only. (Holmes.)]

[Illustration: FIG. 145

Sacculated aneurysm of ascending aorta. Death by pressure. (Erichsen.)]

The formation of an aneurysm implies _previous disease_ of the
bloodvessel _or traumatism_, by either of which its coats must have
been weakened or divided. The previous disease which leads to this
change is either of syphilitic or other toxic origin, and usually of
the type of the endarteritis already alluded to, or its continuation
into atheroma. A so-called atheromatous ulcer may lead to giving way of
the intima and the passage of blood between the coats of the vessel.
It is in this way that most dissecting aneurysms are formed. On the
other hand, violent strain may stretch the vessels already weakened by
increasing blood pressure, or those conditions which induce abnormally
high blood pressure may produce it by slow processes. Lastly a vessel
may be partly divided, as by a bullet or stab wound, or its adjoining
supports may have been weakened by disease or by accident to such an
extent that it constitutes a weakening of the arterial wall. The result
of this will be expansion in the direction of least resistance and the
formation of a _sacculated_ aneurysm.

As a morbid condition spontaneous aneurysm seems to be less frequent
now than in the past. Certain features pertain to all cases, the
most essential being a pulsating tumor, giving physical signs of its
presence by pressure, which causes pain, sometimes paralysis, and
nearly always absorption of surrounding tissues as the tumor expands.
_Pulsation_ is characteristic and pathognomonic of aneurysm, but an
aneurysmal sac may have become so filled with clots as to minimize the
prominence of this symptom. The same is true of the _aneurysmal bruit_
or murmur which is heard on auscultation. This sound and pulsation,
especially of the _expansile_ type, when present will rarely deceive.
They may, however, be simulated by a solid tumor which overlies a large
vessel and transmits its pulsation or even some of its murmur. Even in
this case the significant expansile character of the pulsation will be
lacking.

The _progress_ of an aneurysm may be checked by spontaneous or
surgical processes, but no vessel involved in this way can return
to its previous condition. As the vessel expands the tendency is to
fortification of its weakened walls by coagulation of the blood around
the periphery of the sac. This process may be a continuous one or may
occur at intervals in such a way as to produce laminated coats of
blood clot, complete or incomplete, which in certain specimens can be
peeled off, one after another, much as an onion can be peeled, the
innermost portion representing the most recent coagulum. In this way
an aneurysm is strengthened and thickened, and rupture postponed for
an indefinite period. On the other hand, as the aneurysmal tumor grows
slowly but steadily it tends to make way for itself at the expense of
every other tissue in the body. The hardest bone will disappear before
the constant advance of such a growth, and this permits aneurysms which
have had their origin in the thorax to develop into large extrathoracic
tumors whose walls, lacking resistance, become thinner and finally give
way, death from hemorrhage being the result. In fact, _rupture is the
natural tendency_ of such lesion, the question being whether it may be
averted by spontaneous or non-operative methods, or whether it should
be subjected to operation (Fig. 146).

[Illustration: FIG. 146

Thoracic (aortic) aneurysm. Death from external rupture.]

Aneurysms may be minute and multiple, or single and large. The former
are seen in the brain in connection with syphilis, and in the mesentery
(Fig. 147). No artery in the body is necessarily exempt, though
obviously the larger arterial trunks are the more frequent sufferers.

Spontaneous cure by natural methods is brought about in one of the
following ways: (_a_) By consolidation of laminated clots. (_b_) A
portion of the clot may become detached and plug the vessel on the
distal side, effecting the same occlusion there that is produced with
a ligature; in some cases the vessel may be occluded above the sac by
a clot from the heart. (_c_) That which occurs naturally may be caused
by accident as the result of some trifling injury. (_d_) The clot
contained within the sac may have become infected, so that suppuration
with necrosis of the sac contents is produced. In connection with this
there is sufficient acute arteritis to occlude the vessel, and the
resulting abscess within the sac may be opened and its contents cleared
out. This method is extremely rare and can only terminate happily when
the surgeon intervenes promptly.

In an aneurysm in which spontaneous cure has occurred there may be
progressive condensation of its contents, obliteration and partial
reduction in size, and a slow process of absorption.

The importance of collateral circulation, in recovery from aneurysm,
cannot be overestimated, as only by taking advantage of it is it
possible to furnish blood for the needs of the part affected. There is
no vessel with which the surgeon can interfere where natural provisions
in this direction appear insufficient (Fig. 148).

Certain conditions predispose to aneurysm of the idiopathic type,
such as age, with its accompaniment of arteriosclerosis; _syphilis_,
with its well-known tendency to chronic endarteritis; _occupation_
and _sex_, in that it is most frequent in those who are liable to
violent exertion and dissipation, because of the well-known tendency
to arterial structural changes after excesses of all kinds. Again,
aneurysm may be the secondary result of embolism when an embolus leads
to a local arteritis with disorganization.

[Illustration: FIG. 147

Multiple aneurysms of the mesenteric arteries. (Eppinger.)]

[Illustration: FIG. 148

Change in the trunk after ligature; with anastomosing vessel.
(Erichsen.)]


=Classification.=--For surgical purposes there is no better
classification than the one used by Eve:

  1. _Sacculated aneurysm._
      (_a_) Hernial;
      (_b_) Diffuse, being a form of false aneurysm.

  2. _Fusiform, cylindrical, or tubular aneurysm._

  3. _Dissecting aneurysm, which may become_
      (_a_) Sacculated;
      (_b_) Diffuse and false; or
      (_c_) Circumscribed.

  4. _Traumatic aneurysm._
      (_a_) Circumscribed;
      (_b_) Diffuse;
      (_c_) Arteriovenous.

  5. _Arterial varix, cirsoid or racemose aneurysm._

  6. _Angioma or aneurysm by anastomosis._


1. =Sacculated Aneurysms.=--The sacculated are the most common. They
assume various shapes and dimensions, and may be seen anywhere in the
body. The opening between the sac and the main vessel may vary in
size. These sacs are usually strengthened by plastic exudate in and
around them, and condensation of surrounding tissue. In thickness they
vary from 1 Cm. to the thinnest which will sustain blood pressure.
In old scars may be found a stratiform or layer-like arrangement,
especially where the blood stream is less active. Should spontaneous
cure take place the sac may be obliterated, while later calcific or
other changes in the old scar may occur. When the outer portion of
such a sac has disappeared and the inner coat is pushed out so as to
assume, apparently, a secondary aneurysmal arrangement, the condition
is referred to as a _hernial_ aneurysm. When the ordinary sacculation
gives way as the result of necrosis, of pressure from within, or loss
of support from without, the opening first made is usually small and
the extravasation outside the true sac will depend upon the nature and
resistance of the surrounding tissues. In this way a _diffuse_ aneurysm
is formed, which is one of the varieties of false aneurysm.


2. =Fusiform Aneurysms.=--Fusiform aneurysms are more or less tubular
and spindle-like dilatations of arterial trunks, in whose walls may
occur the changes common to all these lesions, the dilatation rarely
being sufficiently large to permit of laminated coagula unless a
sacculation occurs later at some particular portion (Fig. 149).

[Illustration: FIG. 149

Fusiform aneurysm of popliteal artery, due to arterial disease (man
aged 59), requiring amputation of thigh on account of gangrene.
(Lexer.)]


3. =Dissecting Aneurysms.=--The dissecting aneurysms are nearly always
expressions of previous atheromatous changes, by which blood is forced
between the arterial coats, separating them and causing them to bulge
at one or more points into sacculations or distortions. In a _false
aneurysm_ there is no true arterial coat; the sac is made up of
surrounding tissue.

[Illustration: FIG. 150

Traumatic aneurysm of axillary artery. (Park.)]


4. =Traumatic Aneurysms.=--Traumatic aneurysms are generally
sacculated by the time they come under the surgeon’s observation.
They are circumscribed and diffuse. According to their age and other
circumstances they may contain old and dense laminated clots as well
as those which are fresh and stratified. Much will depend upon whether
the artery has been extensively injured or only slightly punctured,
and also upon the location and distensibility of the surrounding
tissue. Such a case seen in a fresh state will show infiltration
of blood and ecchymosis (Fig. 150). _Arteriovenous_ aneurysms are
now seldom seen. When venesection was more frequently performed the
artery and one of the veins at the bend of the elbow were often thrown
into communication, as the result of the indifferent performance of
this operation and the use of the old-fashioned lancet. When the
communication is direct such a condition is known as an aneurysmal
varix; when indirect and through the sac it is called a _varicose
aneurysm_ (Figs. 151, 152 and 153.)

[Illustration: FIG. 151

Aneurysmal varix. (Bryant.)]

[Illustration: FIG. 152

Arteriovenous aneurysm at bend of elbow: _a_, brachial artery; _b_,
radial artery; _c_, basilic vein; _d_, median basilic vein; _e_,
aneurysmal sac; _f_, dilated vein. (Lenoir.)]

[Illustration: FIG. 153

Varicose aneurysm removed from its connections. (Erichsen.)]

[Illustration: FIG. 154

Cirsoid aneurysm. (Bruns.)]


5. =Cirsoid or Racemose Aneurysms.=--Cirsoid or racemose aneurysms
constitute vascular tumors of irregular shape and outline, according to
the extent of the arterial system involved.


[Illustration: FIG. 155

Cirsoid aneurysm of femoral artery and telangiectasis, with lengthening
of affected limb from hypernutrition. (Parker.)]

6. =Angioma or Aneurysm by Anastomosis.=--The difference between
_angiomas_ and cirsoid aneurysms is more artificial than natural. When
a single vessel is involved with all its branches it constitutes an
elongated tumor and partakes of the nature of a varix. When the growth
is a collection of small arteries the condition is then known as an
angioma. Between these there may be all varieties of vascular changes.
Fig. 154 illustrates a case of this kind in the scalp, while Fig. 155,
contributed by Parker, illustrates a congenital involvement of the
vessels of an entire limb, with overgrowth of the same from increase of
blood supply.


=Diagnosis.=--All aneurysm so constituted as to be easily palpated
can scarcely be mistaken for a tumor of any other kind. It can be
recognized by its circumscribed nature; its pulsation, which is always
of the expansile type; its bruit, which is synchronous with systole.
It can be emptied by pressure, fills somewhat slowly if pressure is
made above it, but more rapidly if pressure is made below it, being in
this respect the counterpart of a venous angioma. Its size and rapidity
of pulsation are influenced by position, and its location is usually
that of one of the large arterial trunks. The murmur, heard through
the stethoscope, is sometimes more than a mere bruit, and may be of a
tumultuous, almost roaring character, the sounds being modified by the
smoothness or roughness of the interior blood channel as well as by the
thickness of the parts outside. Naturally the sounds can be altered by
pressure. The overlying integument is at first unchanged, but if an
aneurysm is working its way toward the surface and threatening rupture
the skin will be stretched and discolored and may finally ulcerate.
Blood pressure as measured by the sphygmomanometer is not altered in a
limb which is affected by aneurysm.

Signs and symptoms which are not local are also produced in most
cases, their variety being great and depending upon the location of
the primary disturbing cause; for example, there is generally edema
with venous congestion of parts situated distally, these features being
so extreme in some cases as not only to threaten but even to occasion
gangrene. By pressure upon nerves both pain and paralysis are produced
and important functions impaired.

The tendency in all aneurysms is to increase in size and cause atrophy
or disappearance of the tissues upon which they exercise their present
influence.

[Illustration: FIG. 156

Varices of saphenous and branches (phlebectasis). (Lexer.) Compare with
Fig. 153.]


=Regional Indications. Innominate Aneurysms.=--Innominate aneurysms
usually appear behind the right sternoclavicular joint. As they
increase in size they cause pain and edema of the right arm and the
right side of the face, cough, dyspnea, and dysphagia. As the swelling
increases it rises above the rib and sternum, pushing forward the
sternomastoid and the clavicle. After being displaced the bones and
cartilages in front begin to disappear by erosion, and the growth makes
its way to the surface, where pulsation can be easily seen as well
as felt and heard. In proportion to their increase other significant
pressure symptoms, with venous turgescence, will occur. Innominate
aneurysms can sometimes be differentiated from aortic by the sign,
described by Porter, of _tracheal tugging_. This is elicited by
causing the patient to sit up and bend the head forward, after which
the cricoid is grasped and drawn forcibly upward, thus stretching the
trachea. If with each cardiac impulse a well-marked tugging sensation
be felt it may be attributed to the pulsation of an aortic aneurysm.


=Subclavian Aneurysms.=--Subclavian aneurysms of the first part of the
vessel present similar features, only that the bruit is propagated down
the axillary artery rather than up the carotid, and is not influenced
by carotid pressure, while the pressure symptoms are limited mostly to
the arm. In _axillary_ aneurysm the radial pulse is more delayed.


=Carotid Aneurysms.=--Carotid aneurysms are not always easy of early
diagnosis, as at the root of the neck solid tumors often transmit a
deceiving pulsation and convey an exaggerated vascular sound. They
may also give rise to the same pressure symptoms as do subclavian
aneurysms. Non-vascular tumors do not have an expansile pulsation, nor
is the arterial sound conveyed upward along the carotid as in true
aneurysm. In aneurysms of the _external carotid_ there may be paralysis
of the tongue as well as difficulties in speech and deglutition.
Aneurysms of the _internal carotid_ tend to extend inward rather than
outward. _Intracranial aneurysms_ are difficult of diagnosis, but
they usually give the symptoms of brain tumor, with possibly a bruit
that may be heard and described by the patient himself, especially in
certain positions of the head.

Wardrop used to formulate the diagnostic features of certain aneurysms
at the base of the neck, as follows: Innominate aneurysms generally
monopolize the episternal notch or rather its right side, taking up
this whole space, even though not rising high. They first present to
the inner side of the right sternomastoid, while carotid aneurysms
appear in the interval between the sternal and clavicular heads, and
subclavian aneurysm to the outer side of this muscle.

In the _abdomen_ the _aorta_ is most frequently involved, and sometimes
its larger branches. An aneurysm of the renal or mesenteric arteries
can easily be mistaken for an aortic aneurysm. The aorta proper
terminates at the level of the umbilicus. A pulsating tumor below this
level should belong to one of the _iliacs_. Recognition will depend
largely upon the thinness of the abdominal wall and the absence of fat.
In many cases expansile pulsation can be detected even here, while the
pain is radiated along the well-known branches of the sympathetic, and
the location to which it is referred may be of aid in deciding the
part of the aorta most involved. Aortic pulsation is communicated by
growths overlying it, and the surgeon is liable to be deceived by a
certain abnormality of the natural pulsation through this trunk, as it
is often exaggerated and appears pathological when it is not. _Abnormal
pulsation of the abdominal aorta was first described_ by Cooper, and
has served as a topic for surgical essays ever since. Schede’s test may
be applied here to advantage: if firm pressure be made simultaneously
upon both femoral trunks the extra blood pressure thus caused inside
the tumor will give rise to pain, whereas in the absence of aneurysm it
produces no such effect.

_Iliac_ and _femoral_ aneurysms may be made difficult of recognition
by obesity, but the bruit can almost always be heard, and this, with
such extra aid as the rectal or vaginal examination may afford, coupled
with pressure symptoms confined to one limb, will usually facilitate
diagnosis. Fig. 157 illustrates what features a tumor of this kind may
present when located in the upper part of the thigh.

[Illustration: FIG. 157

Sacculated aneurysm of femoral artery. (Parmenter.)]


=Treatment.=--The general purpose of the treatment of aneurysms is
to favor _coagulation_ and to effect a cure in this way. In the
pre-antiseptic era it is not strange that men resorted to the method
of starvation, by which the coagulability of the blood was much
increased, or to the rest treatment, with the use of cardiac sedatives,
by which the heart’s activity and power were greatly reduced. Nor was
it strange that non-operative, yet mechanical, methods were used, in
order to minimize the danger attending operative procedures. With
the confidence, however, which Lister and his followers have given,
it is generally conceded that with an aneurysm which can be made
accessible by an operation radical methods are more satisfactory. To
the surgeon belong all aneurysms except, perhaps, those of the aorta
and the innominate, and even these have not been exempt from surgical
methods. The following operative measures are worthy of discussion in
these cases: (1) _Ligature._ (2) _Open operation._ (3) _Extirpation._
(4) _Opening and suture._ (5) _Introduction of wire, with or without
electrolysis._

1. Ligation includes the application of a ligature in one of the
following situations: (_a_) Proximal ligation (Anel’s) at a convenient
point shortly above the sac; (_b_) proximal ligation (Hunter’s) at a
distance from the sac; (_c_) distal ligation, either of the main trunk
just below the sac (Brasdor’s) or of the highest main branch given off
below the sac (Wardrop’s). Thus proximal ligation could be practised
in case of aneurysm, either of the external or internal carotid, by
tying the main trunk, or in the case of popliteal aneurysm (Hunter’s
suggestion), by tying the femoral in Hunter’s so-called canal.
Brasdor’s distal ligation may be illustrated by ligature, in Hunter’s
canal, of the femoral for aneurysm in the groin, while Wardrop’s
modification would consist in tying one of the tibials for popliteal
aneurysm, or one of the lesser carotids for aneurysm of the common
trunk. Should _ligation_ be determined upon, circumstances will dictate
where the ligature should be applied, and the surgeon will decide
the character of the suture material. The methods of attack upon the
large vascular trunks will be considered later. Inasmuch as it takes
time to establish collateral circulation, attention should be given to
physiological rest, as well as to all other general measures calculated
to make any operation successful.

[Illustration: FIG. 158

Anel’s operation.

Hunter’s operation.

Distal operation.

(Erichsen.)]

[Illustration: FIG. 159

Brachiocephalic aneurysm; ligature of the subclavian only.

Brachiocephalic aneurysm; ligature of the carotid only.

Brachiocephalic aneurysm; ligature of the subclavian and carotid.

Different schemes for application of the ligature according to the
necessities of the case. (Erichsen.)]

2. _Open division_ was first suggested in the fourth century by
Antyllus. It soon fell into disuse and was taken up during the middle
of the past century by Syme, to whom the operation has been frequently
credited, although it was really the revival of an antique method;
but Syme gave it so much of his anatomical exactness and brilliancy
of operative skill that he almost made it his own. The method was
essentially one by long and free incision, through which the interior
of the sac was fully exposed, its contained clots turned out, its
vascular openings plugged, while a ligature was applied above and
below in order to prevent further arterial communication. Performed
before the days of anesthesia or of antisepsis it was an exceedingly
bold procedure, yet in Syme’s hands it gave brilliant results.

3. The _open division_ has been replaced by the more perfect procedure
of _extirpation of the sac_, based upon the general principle that an
aneurysm is a _tumor_ and should be extirpated, the parts being sutured
and expected to heal promptly. It constitutes in many cases the ideal
method of treatment. There could be but one improvement on it, namely,
that suggested by Matas, of _arteriorrhaphy_, as one of the radical
methods which is often applicable to aneurysms of the extremities, or
to those where rupture has occurred or is imminent. The part should be
made bloodless, as in this way perfect control can be secured; should
this be impracticable, the vessel should be ligated above the aneurysm
before proceeding to its excision. This done, and the vessels secured
above and below, the wound may be closed as after any other operation,
and in this way radical cure achieved within a few days.

Fig. 160 illustrates a recent case of this kind in the author’s hands,
where an aneurysm of the common carotid, of about the size of a lemon,
was treated in this way, the patient leaving the hospital in eight
days, and having no unpleasant complications.

[Illustration: FIG. 160

Aneurysm of the common carotid successfully treated by complete
extirpation. (Park.)]

4. _Open division with arteriorrhaphy_ has been proposed by Matas and
Murphy and in their hands has been successful. Its greatest usefulness
is found in traumatic aneurysms of long standing where the arterial
opening is usually small and the vessel wall healthy, so that after
excision of the sac a sufficient amount of aneurysmal wall or stump
may be retained in order to afford a firm surface for union. The
circulation being controlled the sac is exposed, opened, and dissected
down to a location near the arterial opening. Here the arterial walls
are trimmed and freshened, turned in or rolled in, and a row of sutures
applied, one line apart, through the outer and middle coats. Matas
suggests that after the suture is complete the size of the vessel
should be less than its normal, in order that pressure may be reduced
at this point and more perfect union follow. The method may also be
resorted to in certain fusiform aneurysms, where the arterial wall is
still sufficiently healthy to sustain sutures. Here an elliptical piece
can be excised, or it may be possible to infold the coats of the sac
and apply sutures through a series of folds, on the same principle that
they are applied in cases of dilatation of the stomach. Arterial suture
as practised in these cases is similar to the Lembert suture used in
intestinal surgery. It is necessary to support the tissues around the
sutured artery by other buried sutures in such a manner as to fortify
them against yielding of the arterial coats.

For these radical methods, either by excision or this combined with
suture, the arteriovenous aneurysms afford an inviting class of cases.
The parts having been made bloodless and the vessels separated, sutures
may be applied, if there be sufficient room for them without too much
occlusion of the vessels, which would afford but little advantage over
ligatures.

In spite of what has been said about the rarity of these lesions, which
is true in civil life, it has been shown, during recent wars, that
bullets of small caliber having high velocity have produced instances
of this character.

5. For cases so situated as to make any of the above methods
inexpedient there is still the more or less promising method of
treatment by the _introduction of wire, coupled perhaps with the use of
the electric current, and the injection of gelatin solutions_. While
ligation of the abdominal aorta has been practised with temporary
success it has not yet proved so encouraging as to justify its
performance, save in exceptional cases, but into any intrathoracic or
intra-abdominal aneurysm, which appears to be otherwise inoperable, a
number of feet of fine steel wire may be introduced, in the attempt
to coil it up irregularly within the sac and thus to afford a sort of
skeleton framework, upon which coagula will more readily form and by
which they may be retained. In some cases the end of this wire has been
attached to the negative pole of a galvanic battery, the other pole
being affixed to an external electrode, and a weak galvanic current
has been passed for a period of say from five to thirty minutes, the
time varying in accordance with the strength of the current. By this
procedure coagulation is much encouraged. In cases of intra-abdominal
aneurysm the abdomen may be opened and the sac more or less completely
exposed, after which this insertion may be more minutely performed.

Occasionally surgeons have exposed an aortic aneurysm and endeavored
to externalize or exclude it by producing adhesions around it, while
some portion of the sac is exposed to the outer world. After adhesions
have formed such methods of treatment can be repeated as may be
desired. They may also be combined with the subcutaneous use of 2 per
cent. sterile gelatin solution, or this may be thrown into the sac in
small amounts. It is true, however, that cases of this character are
desperate, and while life has been in perhaps half of the operated
cases more or less prolonged, but few instances of final recovery have
been recorded.

The after-treatment consists of physiological rest of the part
operated upon, and rest and abstention from violent exertions of any
kind. During this time elimination should not be neglected, emotional
excitement should be avoided, and, in the presence of syphilitic
disease or a well-founded suspicion of it, conventional antispecifics
should be administered in sufficient amounts. When the aneurysm is of
traumatic origin and there is no general vascular or cardiac disease,
there will be a quick restoration of the integrity of parts as well as
of their usefulness. Massage and an elastic bandage will be useful, in
order to atone for the results of a disturbed circulation.


SUTURE OF BLOODVESSELS.

This is almost a new topic in surgery, especially suture of the
arteries. Surgeons have learned that the walls of the arteries and of
the veins, when not too much diseased, will tolerate sutures and unite
easily. The larger the vessel the easier it is to apply a suture, as
its walls are thicker and the method easier. The greater, too, will be
the need of suture when the vessel is an important one. Small vessels
are relatively so unimportant as not to demand so formal a procedure.
The vessels to which the method is most applicable are the common
carotid, the subclavian, axillary, brachial and femoral, with their
accompanying veins, including the common jugular. It is applicable when
it is an injury to the vessel which has necessitated an operation, or
when, during its performance, some trunk has been torn out or torn
open, as in separating adhesions. It is serviceable, also, when both
artery and vein have been involved, as in the groin, where the danger
of gangrene of the limb would be enhanced if both the outflow and the
inflow of the blood were shut off.

[Illustration: FIG. 161

End-to-end suture of a divided artery, permitting a certain degree of
invagination. (After Murphy.)]

_Lateral suture of injured bloodvessels_ may be regarded as a standard
procedure, as it is nearly always possible to temporarily control the
circulation on both sides of the field of operation, either by elastic
constriction or temporary ligation or clamping. For this purpose fine
silk makes the best suture material. It should be threaded into round
needles and the sutures should include only the two outer coats.
After completing the suture the distal provisional closure of the
vessel should be first removed. As the blood backs up in the artery
it will test the efficacy of the sutures. Should there be no leakage
the proximal clamp may be removed, and then if the condition appear
satisfactory the arterial sheath should be carefully closed, and over
this the other tissues, with buried sutures.

_End-to-end suture_ of bloodvessels is a recent measure, for which we
are indebted to Murphy. It is applicable to vessels which have been
divided circularly and completely or almost completely. In the event
of the adoption of this method the ends should be divided squarely and
then reunited by sutures threaded upon the needles, passing through all
the coats, about 1 Mm. from the margin of division, as well as about
the same distance apart. If the upper end can be drawn into the lower
one, and gently held there by a series of U-shaped stitches, it may be
considered the best method.[26] (See Fig. 161.)

  [26] There are now before the profession three methods of repairing
  arteries--by _invagination_, by _suture of the two outer coats_, by
  the _through-and-through method_--each of which has its advantages
  and disadvantages. The presence of sutures in the interior of the
  vessel does not seem to produce coagulation, even though the intima
  of the vessel is injured by the passage of the same. Nevertheless
  sutures must be kept out of the blood stream. Liability to secondary
  hemorrhage is reduced if a double line of sutures can be used.


LIGATION OF ARTERIES.

Arteries are exposed and ligated in their continuity for the purpose
of controlling hemorrhage, either for temporary or permanent purposes.
The results of permanent ligature have been described in the chapter
on Wounds. The application of a ligature should be so made as to
thoroughly break up the intima without serious injury to the other
coats of the vessel. Coagulation and organization of the thrombus soon
produce a permanent occlusion and obliteration. It is a mistake to
endeavor to tie the ligature too tightly. Hardened catgut or freshly
boiled silk make the best ligature material. It is seldom a difficult
matter to find the desired artery upon the normal individual or upon
a cadaver. In some cases in practise the tissues through which search
must be made will be found infiltrated with blood or otherwise altered,
and the discovery of and attack upon the vessel may be thus made very
trying. The vessel when exposed in its continuity will be recognized
by the sense of touch rather than that of sight, and almost the entire
maneuver may be made, by touch alone, by one whose tactile sensibility
has been well trained and without any clear view of the vessel. The
arteries which are thus exposed have their own sheaths, especially
the larger ones, which should be opened with care, not alone to avoid
injury to the vessel itself, but in order that the amount of separation
may be as slight as possible, as the sheath is necessary for support
and for nutrition. Having exposed the vessel and divided the sheath
the ligature is introduced with a blunt, curved needle attached to a
handle, and known as an _aneurysm_ or _artery needle_. It is made to
carry the ligature, or it is so insinuated and brought out from behind
the vessel that the ligature may be threaded into its eye. Caution
should be exercised that nothing but the artery itself is included;
this is especially necessary in the neck, where the relations between
the large vessels and the nerves are very intimate. As a general rule
the needle should not be threaded until after it has been passed. The
knot should be tied in the depths of the wound, and the vessel should
not be disturbed by efforts to secure the knot. If the operation have
been done as it should it will not be necessary to drain such a wound,
but it may be closed by buried and superficial sutures. When one of the
limbs has been involved in this operation it should be kept absolutely
at rest, in a somewhat elevated position, and warm applications made,
in order that the warmth previously maintained by the free circulation
of arterial blood may not be allowed to drop too low.


=Innominate Artery.=--The innominate had been tied between thirty-five
and forty times, up to 1905. A number of patients have survived
the operation, and died within a few weeks of cardiac and arterial
disease. Some have progressed a number of weeks, with rapid recovery
from the operation and temporary improvement sufficient to justify
this operation in apparently favorable cases. This vessel and the
carotid also should be tied, in order that the resulting clot may be
more perfect and that there should be no return pressure made upon the
aneurysmal sac. The incision is made along the anterior border of the
sternomastoid down to the clavicle and then along the inner third of
this bone, thus forming a flap whose free edges are 10 Cm. in length.
The sternal and clavicular heads of the sternomastoid are divided,
while the sternohyoid and sternomastoid are separated from the sternum,
care being taken especially of the anterior jugular vein, which may be
double ligated, if necessary, and, in the deeper dissection, of the
pneumogastric and the recurrent laryngeal nerves, which wind around
the innominate, and the phrenic, which is in close relation with it.
In view of the great engorgement which the aneurysm may produce in
the veins of the neck it would be a great help in this operation to
follow Crile’s suggestion for removal of goitres, placing the patient
in the semi-upright position and having him wear the pneumatic suit,
in order that, by suitable pressure from without, the blood pressure
may be kept at the proper degree, while, at the same time, the veins
of the neck are emptied by gravity. The carotid, having been found, is
traced downward and will lead to the innominate and the sac. When the
ligature is ready to be drawn tight the table should be lowered and the
pneumatic pressure in the suit reduced.

Obviously the deeper the surgeon dissects the more difficulties he will
encounter. The innominate artery is crossed by the left innominate
vein, which may be in the way, while all the other vessels may be so
much disturbed as to alter their relations and make their recognition
difficult. The gradual progress of the aneurysm may have caused the
tissues to become matted to each other and thus lose their identity.
The innominate having been found is traced downward behind the sternum
and a suitable base is sought for the ligature. This search may be
aided by changing the position of the patient’s head, and with the
assistance of artificial light. In the depths of the wound the veins,
the vagus, and the pleura can only be avoided by care in keeping the
point of the artery needle in contact with the artery. If necessary
gentle traction on the carotid trunk may aid by lifting the sac and
making its isolation more easy.

As suggested by Bardenheuer the upper end of the sternum may be
removed with sufficient of the inner end of the clavicle to facilitate
approach. This has been done in this country by Burrell. The aneurysm
needle is passed from without inward and from below upward, in order to
avoid injury to the pleura. An artery needle made with a flexible tip,
which may be bent to suit the exigencies of the case, will make the
most difficult part of the work more easy. The ligature should not be
tied too tightly, and for this purpose silk is the preferable material.
Strips of ox aorta and other animal materials have been used, but if
the knot is not too tight no harm will be done to the artery wall.[27]

  [27] Sheen (Annals of Surgery, July, 1905) reports a successful case,
  his method being as follows: Median incision from the cricoid to one
  inch below the sternal notch, exposure of the carotid and innominate,
  then a silk ligature carried around the innominate distally and tied
  with Balance’s stay-knot; pulsation ceased, to later reappear. A
  second similar operation also failed. A third operation was performed
  through a five-inch transverse incision above the clavicle, the
  artery being twice ligated proximally. Sheen advises that ligature
  should always be of silk, that the incision should be central, with
  horizontal and vertical division of the manubrium; that the carotid
  should also be tied; that two ligatures be placed; that drainage
  is inadvisable, and that next to sepsis as a cause of death stand
  cerebral lesions. Statistics are thirty-six cases of ligature, with a
  mortality of 78 per cent.

As stated above, the common carotid should also be tied at the
conclusion of the other ligation. These cases should be drained
with a few strands of catgut. Absolute rest is an essential of the
after-treatment.


=The Common Carotid.=--The common carotid may be tied above or
below the omohyoid. The carotid divides at the level of the thyroid
prominence, and it is more easily exposed above the omohyoid than
below. It may be reached by an incision, 10 Cm. in length, along the
anterior border of the sternomastoid, whose centre should be at the
level of the intended ligature. The sternomastoid, after exposure, is
drawn outward and the other muscles inward; bleeding veins are secured;
the artery recognized by its pulsation; its sheath opened, preferably
on the inner side, and the needle passed from within outward, the
operator taking pains to avoid the descendens noni. The internal
jugular is more likely to be in the way and to need retraction on the
left side than on the right. In this operation when the omohyoid is
exposed it is retracted upward.

Through this exposure _temporary occlusion_, either by provisional
ligation or the employment of Crile’s clamps, may be practised.

Ligature above the omohyoid is performed in the same way, the veins
being divided and secured. The omohyoid is now drawn downward and the
other muscles separated as above. The so-called carotid tubercle is the
anterior projection of the transverse process of the sixth vertebra,
and the ligature is usually applied at the point where the vessel
can be felt pulsating upon this prominence. The same care should be
exercised in avoiding the descendens noni. Nélaton is reported to have
said that it would take a man four minutes to bleed to death after
opening the carotid artery, but it should take only two minutes to tie
it.


=The External Carotid.=--The incision now is placed higher, from the
angle of the jaw to the level of the cricoid cartilage, still along
the anterior border of the sternomastoid, which is to be retracted
outward. The posterior belly of the digastric will now appear, with the
hypoglossal nerve below it, both being carefully avoided. The great
cornu of the hyoid being sought and found, the artery is found opposite
its tip, and ligated between the superior thyroid and the lingual
branches, or perhaps below the latter. The superior laryngeal nerve
which passes behind the vessel is to be scrupulously excluded.

_Excision of the external carotid_ has been recommended, especially
by Dawbarn, for the purpose of cutting off the blood supply from
certain inoperable cancers of the tongue, face, and jaws. He regards
mere ligature as insufficient and insists that, since anastomosis
is perfected too soon after the other procedures, it is necessary
to completely excise a portion of the vessel. He does this first on
the side most affected, and then, say a few weeks later, attacks the
other side. He advises to ligate the external carotid just beyond its
origin, to divide it, to seize the upper end in forceps, and then,
controlling the vessel, to isolate it up to a point where it disappears
in the substance of the carotid, tying each branch as it is exposed. He
would again tie it just below the origin of the internal maxillary and
temporal branches.


=The Internal Carotid.=--The internal carotid is very rarely attacked
in this way. It lies at first to the outside and back of the external
carotid, and here it may be sufficiently exposed to admit of ligation.
The incision does not differ essentially from that for the external
carotid. After the vessels are exposed the external branch should be
drawn inward, the digastric upward, or divided, if necessary, and the
needle passed from without inward, avoiding the jugular and the vagus
(Fig. 162).

[Illustration: FIG. 162

Aneurysm of the right internal carotid. (Peacock.)]


=The Lingual Artery.=--The lingual artery may be conveniently tied
before some of the radical operations on the tongue, and it is also
tied in cases of cancer in order to shut off nutrition. Incision is
made 2 Cm. above the hyoid, parallel with it, from the middle line
nearly to the angle of the jaw. Through this the submaxillary gland
will be exposed and should be retracted upward and out of the way.
The fascia is then divided, and the posterior border of the mylohyoid
identified. The digastric tendon is then drawn upward from the
hyoglossus, upon which it rests. The hypoglossal nerve is now seen,
the artery lying behind it. It is, therefore, necessary to divide the
hyoglossus by a short incision in order to reach the vessel. The most
important precaution is to avoid injury to the nerve (Figs. 163 and
164).

[Illustration: FIG. 163

FIG. 164

Surgical anatomy of the neck; ligation of the carotid, lingual, and
facial arteries. (Bernard and Huette.)]


=Other Arteries of the Face and Head.=--The _facial_ may be tied
through an incision nearly identical with that for the external
carotid, or at the margin of the lower jaw 1 to 2 Cm. in front of the
angle. The _temporal_ may be attacked through a vertical incision
over its course between the tragus and the condyle. Branches of the
facial nerve cross the artery at right angles to it; these should be
avoided. The _occipital_ may be tied close to its origin, through the
same incision as that for the external carotid, or behind the mastoid,
through an incision commencing at its tip, carried backward and
upward. It will be necessary here to divide the posterior fibers of the
sternomastoid, of the splenius, and perhaps of the trachelomastoid. The
vessel is then recognized by its pulsation between the mastoid and the
transverse portion of the atlas.


=The Vertebral Artery.=--The vertebral artery is tied through an
incision commencing at the clavicle, extending along the outer border
of the sternomastoid, some of whose clavicular fibers must be divided.
This muscle and the anterior jugular veins being drawn to the inner
side, the transverse processes of the sixth and seventh vertebræ should
be found in the space between the scalenus anticus and the longus
colli. The artery should be found below the seventh cervical vertebra
as it enters the foramen intended for it. The vein lies in front of it,
the pleura close to it, and on the left side the thoracic duct is not
far away.


=The Inferior Thyroid Artery.=--The inferior thyroid artery may be
tied through an incision along the inner border of the sternomastoid,
which is retracted outward, the carotid being found and also retracted
outward. The artery lies a little below the level of the sixth
vertebra, whose transverse process may be easily found. It passes
inward and to the rear of the carotid, close to whose main trunk the
ligature should be applied, in order to avoid the recurrent laryngeal.

[Illustration: FIG. 165

FIG. 166

Surgical anatomy and ligation of the axillary and subclavian arteries.
(Bernard and Huette.)]


=The Subclavian Artery.=--This is best tied by making an incision 2
Cm. above the clavicle, beginning nearly at its sternal joint, and
extending outward to the anterior border of the trapezius. In exposing
it the cervical branches of the superficial nerves should also be
divided. The external jugular lies here, near the posterior border of
the sternomastoid, and winds around it to empty into the internal.
Unless it can be avoided it should be carefully double ligated. The
omohyoid should appear at the inner angle of the wound and may be
drawn out of the way in either direction. The suprascapular artery
and perhaps one or two other vessels may cross the wound and require
retraction. It is usually necessary to remove considerable adipose
tissue in which these vessels lie. The brachial plexus, of course, will
be encountered. The scalenus anticus, which should be followed down to
its tubercle of attachment on the first rib is of special importance.
To its inner side is the internal jugular, with a somewhat bulbous
enlargement. In front is the subclavian vein and behind the muscle is
the artery. The phrenic nerve passes down upon the anterior surface
of the scalenus anticus, and the thoracic duct ascends close to it,
opening into the angle between the subclavian and internal jugular
veins. While it is not impossible nor even impracticable to apply a
ligature to the subclavian on the inner side of the scalenus anticus it
is rarely necessary, and the ligation is almost invariably performed to
its outer side, in the free part of its trunk. There must be sufficient
space in which to work with safety, and, when necessary, adjoining
muscles, _i. e._, sternomastoid and trapezius, may be divided to
any necessary extent. The patient should always be placed in such a
position that the shoulder is pulled well down, with the arm passed
behind the back, while the neck is stretched by extending the head
to the opposite side. The artery needle should be passed from above
downward and from behind forward, the vein being carefully held out
of its way. The patient should wear the Crile pneumatic suit, in the
semi-elevated position, in order that the veins in the neck may be less
engorged (Figs. 165 and 166).


=The Axillary Artery.=--The axillary artery is practically tied in its
third portion, beyond the lesser pectoral. The incision is made through
the middle of the axilla, over the course of the vessel, the deep
fascia exposed and divided, the coracobrachialis and musculocutaneous
nerve retracted outward, and the artery recognized with the finger-tip.
It should be so cleared, especially from the median nerve, as to be
easily raised upon the blunt hook. The accompanying veins should not be
enclosed in the ligature (Figs. 167 and 168).

[Illustration: FIG. 167

FIG. 168

Surgical anatomy of the axilla and ligation of the axillary artery.
(Bernard and Huette.)]


=The Brachial Artery.=--The brachial artery is easily found in the
middle of the arm, near the inner edge of the biceps, whose inner
border is identified. The median and other nerves should not be brought
into view. The parts will be relaxed by flexing the forearm. The venæ
comites should be carefully excluded from the ligature (Figs. 169 and
170).

[Illustration: FIG. 169

FIG. 170

Surgical anatomy and ligation of the brachial artery. (Bernard and
Huette.)]


=The Radial Artery.=--The radial artery is the direct extension of
the brachial and passes underneath a nearly straight line to the
neighborhood of the scaphoid bone. High up in the forearm it may be
exposed between the supinator longus and pronator teres, being found
beneath the former. In the middle portion of the forearm it may be
exposed along the ulnar border of the supinator longus, and lying upon
the pronator radii teres. At the wrist it may be exposed with perfect
ease, where it is usually outlined when feeling the pulse (Figs. 171
and 172).


=The Ulnar Artery.=--The ulnar artery is the larger of the two main
trunks, and is rarely tied in the upper part of the arm, lying too
deep for easy exposure. Should it be divided by a wound of this region
the opening may be enlarged sufficiently for its detection and double
ligation (Figs. 171 and 172).

Of the large vessels of the trunk the _abdominal aorta_ has been tied,
although it is questionable whether this would ever be a justifiable
operation, as all recorded cases have succumbed from one cause or
another.


=The Common Iliac Artery.=--The common iliac artery is best tied by an
incision commenced parallel with Poupart’s ligament and curved upward
and outward. The abdominal muscles and fascia having been divided, with
the least possible injury to their fibers, the peritoneum is detached
from the iliac fascia, the patient being turned upon the side in such
a way that gravity may assist in the exposure of the vessel behind
the peritoneum. A needle of medium length, and strong, with oblique
lateral curve, should be passed from within outward, the vein lying
behind the artery on the right side, near to its inner side, and behind
on the left side. In the fossa thus formed, and lying upon the psoas,
will be found not only the common trunk but the external cutaneous
nerve, running downward and outward, and also the iliac branch of the
iliolumbar artery.

The operator may decide, for some reason, to open the abdomen directly,
and to go through from front to rear, drawing aside the intestinal
loops, with the patient in the Trendelenburg position, exposing the
main trunk by a small incision through the posterior peritoneum and
applying the ligature there. By this same _transperitoneal_ method
the _internal iliac_ may be attacked. Its course inward and downward,
rather than outward, makes it more easy of attack in this way. The
ureter, which lies in front of the artery, should be raised, along
with the peritoneum, in order that it may be avoided. This vessel has
thus been tied for hypertrophy of the prostate, for inoperable cancer
of the uterus, during excision of the rectum, and even for the cure of
vascular tumors or aneurysms affecting its terminal arteries.

[Illustration: FIG. 171

FIG. 172

Surgical anatomy and ligation of the radial and ulnar vessels. (Bernard
and Huette.)]


=The External Iliac Artery.=--The external iliac artery is exposed
without great difficulty by a 10 Cm. incision about Poupart’s ligament,
beginning near the pubic spine, extending outward and slightly
upward. It will probably be necessary to double ligate and divide
the superficial epigastric artery, after which the outer border of
the conjoined tendon is to be recognized at the lower and inner end
of the incision. The lower fibers of the internal oblique are then
to be divided, the transversalis exposed and transversely divided,
after which the deep epigastric artery will probably come into view.
The pulsations of the external iliac will now identify it. The
subperitoneal tissue should be carefully detached and the peritoneum
gradually separated from the vessels and properly retracted. Beneath
it the areolar tissue which helps form the sheath of the vessel must
be avoided, after which the artery needle may be passed from within
outward. In closing the wound the deep layers should be brought
together, each by itself, in order to avoid the possibility of ventral
hernia. Through this same incision both the _deep epigastric_ and the
_deep circumflex arteries_ may be exposed (Figs. 173, 174 and 175).

[Illustration: FIG. 173

FIG. 174

FIG. 175

Surgical anatomy and ligation of the femoral, external iliac, and
epigastric arteries. (Bernard and Huette.)]

[Illustration: FIG. 176

FIG. 177

Surgical anatomy and ligation of the femoral artery. (Bernard and
Huette.)]


=The Femoral Artery.=--The femoral artery is usually tied either at
the base of Scarpa’s triangle, just below Poupart’s ligament, or in
Hunter’s canal. In the first location its pulsation can be easily felt
before dividing the skin, and will serve as the best guide. It requires
an incision made downward over the course of the vessel, from the
middle of Poupart’s ligament. In approaching it here a number of lymph
nodes may be encountered, some of which may be considerably enlarged.
They should be disturbed as little as possible, unless involved in
cancerous or serious septic disease. The anterior crural nerve lies to
the outer side of the vessel and the vein to its inner side. Between
these it may easily be found and tied (Figs. 176 and 177).

In Hunter’s canal the femoral artery may be found nearly beneath the
long saphenous vein, and near the outer edge of the sartorius. If the
leg be abducted, and the adductor magnus thus stretched, the position
of the canal, between the latter and the vastus internus, is easily
recognized. The canal itself is partly formed by fascia which should be
divided, while the artery will be found within.

[Illustration: FIG. 178

FIG. 179

Surgical anatomy and ligation of the posterior tibial artery. (Bernard
and Huette).]

The lower part of the femoral artery, or practically the _popliteal_
artery, may be found, if necessary, by an incision in the middle of
the popliteal space, the operator gradually working down by blunt
dissection to the location of the vessel, which is easily recognized by
its pulsation.


=The Posterior Tibial Artery.=--The posterior tibial artery nearly
underlies a line from the centre of the popliteal space to a point
between the inner malleolus and the heel. To expose it easily the limb,
somewhat flexed, should lie upon its outer side, the patient lying
nearly on his face, and incision made in the calf of the leg, beginning
at the head of the fibula, after which one may expose the junction of
the two heads of the gastrocnemius. Through this the tendon of the
plantaris is to be sought, after which it may be necessary to divide a
portion of the soleus. Here the vessel should be sought by the sense of
touch, the operator seeking for its pulsation. Lower down, and in the
lower part of the leg, it may be found by incision along the imaginary
line which it underlies, lying on the flexor longus digitorum, with its
accompanying nerve on its outer side. Still lower, at the ankle, it may
be easily found, just behind the malleolus. (See Figs. 178 and 179.)

[Illustration: FIG. 180

FIG. 181

Surgical anatomy and ligation of the anterior tibial and peroneal
arteries. (Bernard and Huette.)]


=The Anterior Tibial Artery.=--The anterior tibial artery underlies a
line drawn from a point between the head of the fibula and the outer
tuberosity of the tibia, to the front and centre of the ankle-joint.
At almost any point along this line it can be exposed between the
tibialis anticus and the common extensor of the toes, the latter being
held downward and outward and the former upward. Here in the depths
it may be recognized upon the interosseous membrane. In the lower
part of the leg the extensor pollicis lies to its outer side. Here
the accompanying veins should be avoided. Quite low in the leg and in
front of the ankle the vessel will be found between the tendons of the
tibialis anticus and extensor pollicis (Figs. 180 and 181).


THE VEINS.


The veins are of interest to the surgeon particularly because of the
role they play in the pathology of sepsis, especially of pyemia, and
because of their various dilatations and even new formations which
admit of none but surgical remedy; that is, varices, under their
various names--for example, hemorrhoids, varicocele, and nevi.

The veins have an endothelial lining, between which and circulating, or
more especially stagnant, blood there exist peculiar susceptibilities
and relations which cannot be well described. The pathologist
appreciates what disturbances of the endothelium will provoke
coagulation of the blood in contact with it, but is not yet in a
position to explain the relationship. Veins, moreover, are provided
with valves to a more perfect degree than are the lymphatics, but the
valves often become inadequate for their purpose, and then we have such
conditions as varicosities; the fact that they are usually seen about
the rectum and the lower extremities illustrating the _disadvantages
accruing from the upright position_ into which, by the process of
evolution, man has erected himself from the quadrupedal. Even the
myriads of years that have elapsed since this change took place have
not sufficed to afford sufficient protection against the added weight
of the column of blood inseparable from it.

Of pathological changes which interest the surgeon there may be
_atrophy_ as the result of pressure from without or prolonged
distention from within, even to such an extent as to permit of rupture
and serious or fatal hemorrhage. _Fatty degeneration_ occurs in the
serious intoxications and infections. _Calcification_ occurs only in
limited areas and is secondary to other changes or to thrombophlebitis.
True osseous patches have been found in the walls of veins, but are
great rarities. Calcification occurs in the portal and also in the
femoral veins and their branches. In other directions vein walls
become _hypertrophied_, all coats partaking in the change, enlargement
or distention being especially likely to occur where there is most
tendency to stagnation. The changes which lead to the varicose
condition include not only absolute thickening, but increase in every
dimension, the venous tubes becoming _elongated_ as well as distended
and thickened, to such an extent that they take a spiral or curved
course, sometimes almost doubling on themselves.


PHLEBITIS.

In all forms of phlebitis, whether acute or chronic, the three
venous coats are practically involved in the same manner. With
enlarged knowledge of the lymphatics it is difficult to separate
an acute phlebitis from a lymphangitis of the venous wall. Only in
this way can descending phlebitis be accounted for, the infection
travelling apparently against the blood stream. This accounts for the
discoloration along the subcutaneous veins when they become involved,
the same red lines appearing in the skin as when the lymphatics are
involved. The relations between the intima and the blood have been
mentioned above. In cases of acute phlebitis in which the intima is
involved there is coagulation of the contained blood, the clot and the
vein wall undergoing changes which simulate a _thrombophlebitis_.


=Acute Phlebitis.=--Acute phlebitis is of infectious origin. It may
be seen in connection with injury, erysipelas, childbirth, and the
superficial and deep infections, as from a hypodermic injection, a
pin-prick, etc. It is also seen in typhoid, pneumonia, diphtheria, and
gonorrhea. In most of these instances it is difficult to trace the path
of infection. I have seen death from pyemia following gonorrhea, where
the earliest recognizable disturbance occurred in the peri-urethral and
prostatic veins. I believe it to have been my report on these cases,
in 1885, which first called attention to the fact that gonorrhea might
terminate fatally by the pyemic process.

When the venous system has become involved in a septic process of
this kind neither its fate nor that of the patient can be regarded
as secure. Occlusion, with serious circulatory disturbance, may
permanently impair function, while there may be speedy death from
pyemia. This is nowhere more true than in those portions of the venous
system having rigid walls without valves, to which is given the name
“sinuses” (cranial), in which exactly similar processes may occur,
which by virtue of their location will always give rise to the gravest
anxiety. To phlebitis occurring in these channels there has been given
the somewhat distinctive name _sinus phlebitis_. It nowise differs from
the same condition elsewhere, save that it is of almost invariably
extravascular origin. It takes but a small venous branch, lying in the
midst of an infected area, to commence the process that may extend from
the basal sinus to the vena cava.

In most of the surgical infections acute phlebitis has an extravascular
origin, the lymphatics of the outer wall communicating the infection to
the inner coats, and so distributing it that coagulation occurs, after
which the path of infection from the containing veins to the contained
clot is direct. The thrombi thus formed may completely or only
partially occlude the vessel. As a continuation of the lesion we have
infiltration and separation of the coats of the vein from each other,
and finally their necrosis. Thus in the terms of the pathologist an
acute phlebitis may lead to a phlebitis desicans, and this to phlebitis
gangrænosa. In every case where the patient survives such conditions as
these the veins lose their identity and become obliterated by the very
violence of the process in which they have participated.

A somewhat different type of acute or subacute phlebitis is produced
by intravascular irritants, namely, toxins or bacteria circulating in
the blood, or to some chemical or thermic agency which may produce
thrombosis, such as extremes of heat and cold. These, too, may lead
to partial or complete occlusion, and the latter may be followed by
calcification or the formation of _phleboliths_. The destructive
character of the entire process will, therefore, depend upon the nature
and virulence of the exciting cause. As between fatal septic infection,
local gangrene of a part as the result of involvement of the majority
of its veins, or comparatively slight and temporary disturbance, such
as edema, there may be degrees of activity, with results varying
between fatality and evanescent discomfort.


=Chronic Phlebitis.=--This is of the proliferative type and is followed
by more or less organization. _Phlebitis obliterans_ is sometimes seen
in connection with syphilis and other chronic intoxications, and with
various operations upon the veins.


=Symptoms.=--Phlebitis may occur without known cause or may follow
as an expected result from deep or surface lesions. The deeper the
involved veins the more obscure the case. Involvement of superficial
veins, especially in acute cases, is easily made known by the
dark-bluish or dusky red cord which occupies the place of the
previously healthy vein. As its contained clot becomes firmer the
clot becomes harder. This is accompanied by more or less fever, with
extreme tenderness, often pain. If a single vein only be involved the
disturbance will be quite local; if thrombosis be general there will
be edema of the parts to which the vein is distributed. Involvement of
certain veins implies the establishment of a collateral circulation
through others. If there be no others available then danger from
venous insufficiency threatens, and it may not be possible to avert
gangrene. “_Milk leg_,” or so-called _phlegmasia alba dolens_ (“painful
white swelling”), is an expression of portal, pelvic, and femoral
thrombophlebitis. In many instances in which it does not kill it may
cripple the individual for life. Phlebitis of the deep veins can be
inferred rather than detected. Phlebitis of the _hemorrhoidal veins_
frequently follows inflammation and suppuration of piles, while that
of the pelvic veins, especially the perivesical, frequently follows
gonorrhea and prostatitis. _Mesenteric phlebitis_ and _pylephlebitis_
frequently follow the ulcerative infections of the intestines, while
in the _newborn a phlebitis of the umbilical vein_ plays an important
part in the mortality of infants. The _cranial sinuses_ are likely
to be affected in connection with middle-ear disease, while in acute
osteomyelitis there are distinctive pictures of the lesion in the veins
of the bone and the marrow. No matter where the lesions may centre
they are of the most serious character. The role of the veins in the
production of metastatic foci has been described in the chapter on
Pyemia. The danger attending the liquefaction of a thrombus and the
escape of its fluid debris into the general circulation stamps an
acutely infected clot with a dangerous character. This fact justifies
such measures as are now pursued in connection with the cranial
sinuses and mastoid disease, where there is not only a sinus exposed by
removal of a portion of the temporal bone but the jugular opened low in
the neck and the entire intervening channel freed from its putrefying
contents by the probe and the irrigating stream. In other words, a
recognition of the pathology of thrombosis and sepsis may lead to the
performance of difficult operations.


=Treatment.=--It is difficult to separate the treatment of phlebitis
from that of lymphangitis, which generally accompanies it. The first
essential is physiological rest for the part involved, such as
confinement in bed, and the least possible disturbance of the inflamed
area, which should be placed in the most restful position and handled
as little as possible. Local soothing and evaporating lotions may be
used, or, as seems to the writer preferable in most cases, applications
of a 10 per cent. ichthyol-mercurial ointment, or of the Credé silver
ointment, neither of which should be rubbed in, but spread upon the
skin and covered with an impermeable material. These will, after a few
days, prove irritating, and a substitution of something milder may be
required; but in the acute stage they will render greater service than
anything else. _A phlebitis which has been provoked and is perpetuated
by the presence of septic material cannot be successfully treated so
long as its provoking cause remain._ Puerperal sepsis which results in
pelvic phlebitis calls for thorough curetting of the uterus, while an
abscess in the jaw or about the mouth, resulting from diseased teeth,
necessitates the extirpation of the latter, providing the jaws can be
separated sufficiently to permit of it. What may be needed in cases of
thrombophlebitis of the cranial sinuses has just been mentioned.

In any part of the body a vein which is filled with a breaking-down
clot can be promptly and judiciously treated by exposure and removal
of the involved part, or by free and open incision, with suitable
after-treatment.

A chronic phlebitis that produces such lesions as varices will be dealt
with under its proper head.


INJURIES OF VEINS.


=Rupture of Veins.=--Rupture of small veins is the inevitable
consequence of every injury sufficiently serious to be in any sense
disabling, its visible expression taking the form at least of
ecchymosis, sometimes of distinct hematoma. Again, after long-continued
pressure by which return of venous blood is prevented, certain
degenerations take place in the vein walls which lead to their yielding
on apparently trivial provocation; thus veins situated distally to
large aneurysms sometimes give way, while the frequency with which they
rupture in large varices of the limbs and in hemorrhoids is everywhere
recognized. In the days when venesection was so frequently practised,
usually at the bend of the elbow, a traumatic communication between
the artery and the vein was frequently produced, with consequent
anastomosis. When this was direct, the vessels being in contact with
each other, it was an _aneurysmal varix_. When there was more or
less of an intervening sac, through which the blood flowed from one
to the other, it was spoken of as a _varicose aneurysm_. Save in
rare cases produced by puncture or gunshot wounds such lesions are
curiosities. Should operation be required the sac, if there be one,
may be extirpated, or the vein may be ligated above and below the
communication. (See above.)


=Air Embolism.=--Air embolism may follow injury to the large venous
trunks, especially about the head and neck. This term implies the
entrance, by aspiration, of air into the veins, its bubbles being
carried along to the right side of the heart, where they are supposed
to more or less interfere with its action. Sometimes at the instant
of the accident a sucking or gasping sound may be heard. Formerly the
condition was considered alarming, but now it is almost a bugbear. It
is probable that minor degrees of the accident often occur without
perceptible alteration in heart action. Serious disturbance, however,
is possible, especially if the longitudinal sinus or the common jugular
be extensively opened, and the patient’s head is above the level of
the body at the time. Such an accident might call for artificial
respiration, and it has been suggested to aspirate the right side of
the heart. When its danger can be foreseen precautions should be taken
by pressure on the proximal side of the injury. Air embolism is said
also to have followed parturition, and even exposure of veins in the
stomach by the ulcerative process. (See p. 38.)


=Treatment.=--Most injured veins can be tied _in situ_ and their
function left to the collateral circulation. Fear is sometimes felt
about the axillary and the femoral veins, and serious discussions
have arisen as to whether amputation might be called for should these
large channels be so injured as to be made useless. Experience has
shown that either of them may be ligated, with nothing worse than
temporary edema of the limb beyond. Should there then occur, by
accident or during an operation, an opening of these venous trunks
one may apply the ligature, if necessary. Before resorting to this,
however, one may consider the advisability of the application of a
fine _suture_ to the margins of the wound in the vein, which has
become a standard procedure, or, if the opening be small, and it can
be seized with a hemostat, it may be left _in situ_ for two or three
days, closing the wound around it, and so supporting and protecting the
part with dressings that it shall not be disturbed. A small forceps
or its equivalent may thus be left upon a cranial sinus, a jugular,
subclavian, axillary, femoral, or other vein without jeopardizing the
result.


VARICES AND PHLEBECTASES.

The term _phlebectasia_ implies an extensive affection of a portion of
the venous system, characterized by more or less uniform enlargement
of all its veins. A similar involvement of isolated veins is usually
spoken of as _varix_. These conditions may be congenital or acquired.
Fig. 182 illustrates a congenital varicose condition occurring in a
lad aged sixteen years. Such a lesion may be explained by congenital
defect in some of the deeper veins, thus compelling the venous blood
to return through the more superficial channels. These congenital
lesions are more common in the lower extremities, but may be seen in
all parts of the body. Varices, also, by virtue of their exciting and
contributing causes, are most common in the lower extremities and
in the lower venous terminals, as in the scrotum, the rectum, etc.
Acquired varices usually imply previous lesion in the vein walls,
sometimes inflammatory, sometimes toxic. The walls of the veins thus
become at first atrophied, this condition being often followed by
irritative hyperplasia, by which finally the veins become thickened and
strengthened, and sometimes calcified. The enlargements are irregular
and sacculations frequently form. In such sacculi thrombi may occur and
be followed by calcification, the resulting concretions being known
as _phleboliths_. These can often be recognized through the skin in
old and chronic cases. Sometimes adjoining sacculi become confluent
and there forms what is called an _anastomotic varix_. By such
communications cavernous conditions are produced which, when placed
subcutaneously, lead to peculiar and distinctive tumor formations.

[Illustration: FIG. 182

Congenital varices. (Park.)]

As already stated, the tendency to varices is indirectly the result
of man’s assumption of the upright position, by which greater stress
is placed upon the valves and the lower veins than they are prepared
to bear. Naturally these conditions occur often in those who are
constantly engaged in hard work upon the feet. Varices, then, are
lesions, not so much of the leisurely and sedentary as of the active
and working classes. Anything which predisposes to venous stasis may be
regarded as a contributing cause--thus their relations with weakened
hearts and obstructed lungs are indirect, but positive. Many women
suffer in this way as the consequence of their first pregnancy, with
its pressure upon the pelvic veins; while tight garters, corsets, and
belts also predispose to overloading of the lower veins. Slight but
almost permanent causes of this kind, through the influence of gravity,
thus produce varices in the course of time.

To varices in certain locations have been given special names. To such
a dilatation of the spermatic and pampiniform plexus has been given
the name _varicocele_. When the hemorrhoidal veins are involved the
condition is known as _hemorrhoids_ or _piles_. The former is often
credited with being due to the anatomical arrangement of the left
spermatic vein, through which blood is not as directly poured into
the vena cava as on the right side, while the relation of chronic
constipation, with its obstruction to the circulation in the rectal
walls, will account for many cases of hemorrhoids, and the disturbance
implied by the term cirrhosis of the liver will furnish an explanation
for many others. A similar condition in the esophageal veins has
given rise to the term _esophageal hemorrhoids_. Most indicative and
extraordinary expressions of closing of deep circulation may be seen in
some instances of intrathoracic and intra-abdominal diseases, _i. e._,
cases in which the superficial veins of the chest and thorax become
remarkably enlarged. Such expressions as these are to be regarded as
natural efforts to obviate a difficulty, and no attempt should be made
to eradicate such varices.


=Symptoms.=--In cases requiring surgical intervention, varicose veins
present the following features, which are particularly indicative; they
not only enlarge in diameter but elongate, and consequently have to
assume a tortuous arrangement to accommodate their increased length;
they cause a constant sense of fulness and discomfort, which often
amounts to actual pain, especially after laborious effort. This pain is
due to the distention of the venous trunks, to pressure upon cutaneous
nerves, and often to disturbances of nutrition. In fact, nutrition
is so often disturbed as to be accompanied by _skin lesions_, which
begin as eczema and terminate in extensive ulcerations. So frequent is
this association, and so distinctive its type, that such ulcers are
frequently referred to as varicose. If the term be used to imply the
association it perhaps may stand; if intended to typify a peculiar type
of ulcer it is objectionable, as the ulcer itself is simply such as may
happen on any surface whose nutrition is more or less perverted.

The most common causes of varicosities in the lower extremities are
previous lesions, such as phlebitis following typhoid, injuries of the
limbs or trunk, the pressure of tumors, fecal accumulations, garters
or belts, laborious work in the upright position, and the possible
complications of all cases from variation in the original anatomical
arrangement of veins and their valves; pregnancy also should be added
to this list.

The condition is rare in early life. Liability to it increases with
age. Varices rarely occur in the upper limbs in connection with certain
occupations or athletic sports, _e. g._, baseball and tennis.

The measure of the distention of veins can often be taken by the
sensation of fulness and muscle cramp. In few surgical lesions do
appearances give as much aid in diagnosis. This is particularly true of
superficial varices. Varicosities of the deeper veins maybe suspected
when patients complain of discomfort, pain, cramp, and swelling of the
feet after hard work.

Varices would rarely lead to ulceration were it not for the superficial
infections incurred in many obvious ways--sometimes by the finger-nails
of the individual, who is constantly tempted to scratch or rub the area
in which he feels such incessant discomfort.


=Treatment.=--Suitable treatment of varices of the internal veins,
varicocele, hemorrhoids, etc., will be indicated in its proper place.
In this chapter only _varices of the extremities_ will be considered.
When a tendency to the varicose condition is noted early, and a cause
can be discovered, removal of the cause may be all that is needed. When
the condition is well established, and yet not sufficiently prominent
to justify radical treatment, it should consist largely in support
by bandages or elastic stockings, applied discriminatingly, with
sufficient pressure to prevent undue distention and not sufficient to
cause edema. It frequently affords much relief and prevents aggravation
of the condition; on the other hand, once the veins become accustomed
to this support they yield more readily upon its withdrawal, and the
treatment by gentle constriction once begun, which is sufficient for
many cases, can rarely be discontinued, even after a lapse of time.

A maximum of rest and elevation of the limb are requisite in the
non-operative treatment of varicose veins. The compression exercised
by elastic stockings is of only temporary benefit, and is simply
such an assistance as is a crutch to a cripple. The less the patient
remains upon the foot and the less he takes hot baths or indulges in
other relaxing measures the better. Cold shower or tub baths are far
preferable, with massage of the deeper muscles, the large veins being
avoided. Such a patient should never walk slowly, but always rapidly,
and rest as soon as fatigued. All diathetic conditions should receive
attention.

When it is not possible to early and speedily remove the existing cause
there is but one cure for varices, and that is by _radical surgical
treatment_. A generation ago this was effected by the injection
into the veins of perhaps one of the iron salts, in order to produce
artificial and instantaneous thrombosis, by which later occlusion of
the vein could be induced. The coagulating effects were decided, and
so also were the effects of the germs introduced at the same time, in
the absence of ordinary antiseptic precautions. Thus it resulted that
the mortality, even after this trifling procedure, was tremendous and
led to its abandonment. When it had been demonstrated, through Lister’s
achievements, that the surgeon could be clean about such work, it was
learned also that veins could be more radically treated than had been
previously realized. With the advent of the antiseptic era came more
effective and extensive operations upon veins. Now we know that with
strict asepsis they can be handled with absolute impunity, and open
methods of treatment have replaced the subcutaneous. No hesitation is
at present felt in exposing the veins at one point, or numerous points,
and applying ligatures; these, however, have been found to be less
effective than a long incision made over a vein, with its complete
_extirpation_. Thus the long internal saphenous should nearly always
be excised, though it take an incision twenty inches in length, in
order to take off the weight of its column of blood. It is ordinarily a
simple matter to clamp and tie each branch as it is divided, and, after
removal of the principal trunk, to bring together the entire incision
with subcutaneous or continuous sutures. In the same way numerous
incisions may be made in the leg. It is possible, however, to meet with
so many enlarged veins that the surgeon may feel that he cannot thus
eradicate each one. In such cases it is my custom to extirpate the
principal trunk or trunks involved above, and then to combine this with
_Schede’s suggestion to completely or partly circumcise the leg_, below
the knee, down to the deep fascia, cutting across every vein and tying
on each side those which bleed to any extent. After all these veins are
ligated the incision is usually brought together again, as above. By
this means all communication between the subcutaneous veins above and
below the line of incision is cut off. Wound healing is accompanied
by a temporary edema of the foot and leg, especially when these are
held down, and by more or less numbness of the skin due to division of
the cutaneous nerves; but circulation and nerve supply both rearrange
themselves in time, and the result is usually satisfactory.[28]

  [28] _Extirpation of the Internal Saphenous._--Keller has quite
  recently suggested a new method of extirpating these varicose veins
  without extensive scarring. He exposes the vein at two points
  a considerable distance apart, and ties above and below after
  separating it from its surroundings. The vein is then cut below
  the proximal end, the upper end of the section to be removed split
  and a strong ligature tied to it, care being taken to include no
  more tissue in the ligature than will pass through the lumen of
  the vessel. Then from the lower end a wire loop or probe is passed
  upward, a ligature is threaded into its eye and the probe is then
  withdrawn, carrying the ligature, after which traction is made upon
  the latter, the edges of the vein being inverted into its own lumen,
  it being thus extirpated by being turned inside out and withdrawn
  from its sheath. With the internal saphenous, when a slight puckering
  is seen about midway between the incisions, indicating that the
  anterior branch of the vessel has been reached, a third incision
  is made, the branch is ligated and divided, and then the traction
  renewed until the vein is entirely pulled through the lower opening.
  Several cases thus treated have been very successful.

Should ulcer, _i. e._, the so-called _varicose ulcer_, be present, it
may also be attacked radically, and at the same time completely, by
_excising_ the affected area, _with its indurated border_, down to the
level of the deep fascia, and covering the surface thus denuded with
Thiersch skin grafts from some other portion of the body. Should such
an ulcer require treatment after this fashion it is best to attend
to excision of the infected area first, in order to clear away all
material which might harbor germs. The usual procedure, then, should
be excision of the ulcer, extirpation of the veins, to be concluded
by skin grafting. A limb thus radically treated should be included in
a comfortable dressing, and then be affixed to some splint or other
device by which absolute rest and repose may be maintained.

In milder cases, where no single large dilated vein seems to call for
extirpation, it may suffice to practise Schede’s operation alone.
Experience has taught this fact, that in dealing with extensive varices
the surgeon is more likely to err on the side of leniency than on that
of thoroughness.


VENOUS ANGIOMAS.

These have already been mentioned in the chapter on Tumors as
constituting one variety of the angiomas. Many of them are of
congenital origin. In many instances they produce erectile tumors.
They frequently occur in the liver, in the thyroid, and other internal
organs, as well as on the body surface.

A venous tumor, composed of good-sized veins, distended perhaps far
beyond their normal capacity, constitutes a _compound varix_, of which
the best expression is a hemorrhoid or a varicocele. Another form is
composed almost entirely of capillary veins, which are increased not
only in size but also in number. These constitute the growths called
“_mothers’ marks_,” “_strawberry growths_,” etc. Technically they are
_venous nevi_, which vary in size from trifling lesions to large tumors
of varying shapes. These growths are always most conspicuous about
the hands and face, because these are the visible parts of the body.
They may, however, occur at any point, but mainly about the face and
the orbit. A diffuse form, whose area may be almost unlimited, but
usually circumscribed, is that called “port-wine mark,” which occurs
more frequently about the face. It has been attributed to mental
impressions during pregnancy, but there seems little to justify this
view. The affected surface is sometimes pigmented and generally more
hairy. Surface markings of this kind may accompany that form of neuroma
described as plexiform neuroma. Fig. 183, from Holloway, illustrates
another form of congenital growth of this kind. These growths rarely
occur in the nasopharynx, where they not only obstruct but are sources
of actual danger from hemorrhage.

[Illustration: FIG. 183

Congenital venous nevus. (Holloway).]


=Treatment.=--The most satisfactory treatment of a limited growth of
this kind is _excision_, especially if this can be made at an early
age. The resulting scar will be smaller, the healing more prompt, and
the result in every way better. When excision seems impracticable
_electrolysis_ should be employed, one or both poles of a galvanic
battery of six to ten cells being connected with needles, which are
inserted directly into the growth, and whose position is constantly
changed, so that the coagulating effect of the electric current may be
equably distributed throughout the growth. Occasionally the growth may
be so shaped as to permit of _ligature_, and it is best employed either
with or without the use of a needle, after which it may be excised or
will slough off. This is essentially one method of treating external
hemorrhoids. Methods by injection of coagulants are all open to serious
objection, are hazardous, and should be abandoned. A port-wine mark may
be sometimes treated by a tattooing process, which should, however, be
practised with strict antiseptic precautions. Electrolysis may also be
practised over a small area at a time. The more destructive method, by
use of the cautery, is likely to leave scars almost as conspicuous as
the original condition. Occasionally a lesion of this kind will be so
shaped and placed as to justify excision with an autoplastic operation.




CHAPTER XXX.

INJURIES AND DISEASES OF THE LYMPH VESSELS AND NODES.


An appreciation of the pathology of the lymphatic system requires
a brief allusion here to the latest investigations and conclusions
regarding the purpose of the lymph as a fluid and the channels by
which it is distributed. Under the term lymph, Hall has included four
different types: (1) Tissue lymph, which fills the intercellular spaces
throughout the body; (2) circulating lymph, which passes through
the lymphatic capillaries into the circulatory system by way of the
thoracic duct; (3) chyle, or the peculiar circulating lymph of the
intestinal tract, which carries into the general circulation its load
of nutritive material; (4) serous lymph, _i. e._, the contents of the
serous cavities. Closely related to the latter are the aqueous humor,
the cerebrospinal and the synovial fluids. All these fluids, except
chyle, contain at least 95 per cent. of water and nearly 4 per cent. of
proteids.

The lymph is the only fluid which comes into contact with all the
living cells of the body; it pervades every part of its substance
to such an extent that it has been said that the higher animals are
essentially aquatic because they practically live in a watery medium.
Blood normally comes into contact only with the endothelial cells
of the vessels and with those cells in the splenic pulp and perhaps
other localities which have to do with its elaboration, and these are
but a minute proportion of the total cells of the body. All the rest
receive their nutrition and even their oxygen through the lymph, which
receives them from the blood. Moreover, nearly all the waste materials
of the body are emptied into the lymphatic system, and thus directly
or indirectly find their way into the blood to be further extruded.
Thus, with the exception of the endothelium, the lymph is the medium of
exchange between blood and tissue. In this the lymph and the lymphatics
play a role which even for the surgeon must be of the greatest
importance.

The amount of lymph which empties into the vena cava from the thoracic
duct represents only that which comes from the viscera, bearing its
special load of nutritive material. When we consider the communication
between the blood-vascular and the lymph-vascular systems, the
promptitude with which material injected into the tissues (_e. g._,
salt solution) is taken up by the lymphatics and its effects made known
through the bloodvessels, we will better appreciate how deleterious
material also can be quickly distributed through the system. The lymph
then must be regarded as a fluid derived from the blood by combined
filtration and osmosis, which makes its way back into the blood again
with equal ease.

Lymph vessels which are sufficiently large to be recognized have thin
walls and are provided with valves like the veins, the lymph stream
being propelled by a _vis a tergo_ from the heart. Any injury which
permits blood to escape will also injure numerous minute lymph vessels;
in fact, in such little maneuvers as vaccination the attempt is made to
draw lymph alone and not blood. If a large lymph trunk be divided there
may be an outpour of lymph, and if this happen to be the _thoracic
duct_ the external escape of its lymph stream may seriously interfere
with nutrition. Injuries which divide it within the thorax are usually
fatal, but it may be divided in the neck by a puncture or stab wound,
or during a deep operation. Escape of lymph into the abdominal cavity
under similar circumstances gives rise to _chylous ascites_, and when
into the thorax to _chylous hydrothorax_. In the former case repeated
tapping may tide over the emergency and lead to eventual recovery; in
the latter, aspiration or even open incision may be necessary. When
the thoracic duct has been injured in the neck it may be possible to
close the opening with sutures or to suture tissues over it. In a few
instances final recovery has followed the formation of a _chylous
fistula_. Injury to this duct is to be recognized by the flow of milky
(_i. e._, chylous) fluid from the wound or from the duct itself. When
poured into the abdomen or the thorax the retained fluid has the same
milky appearance. It has been suggested to withhold all food in order
to favor the spontaneous closure of such an opening, supporting the
patient meanwhile by rectal nourishment and by the introduction of milk
into the veins. The right lymphatic duct is less liable to injury, and
such lesions on the right side would be of less importance.

[Illustration: PLATE XXXI

Diagram of the Nodes and Vessels of the Head and Neck, showing the
Regions that are Drained into Each Group of Nodes. Deep structures in
red, superficial in black. (Gerrish.)]

[Illustration: PLATE XXXII

Diagram of the Nodes of the Right Upper Limb and their Superficial
Tributaries, showing the Areas Drained by Each Group. Deep structures
in red, superficial in black.

Diagram of the Superficial Inguinal and the Popliteal Nodes of the
Right Side and their Superficial Tributaries, showing Areas Drained by
Each Subgroup. Deep structures in red, superficial in black. Frequent
variations in dotted lines. (Gerrish.)]

[Illustration: PLATE XXXIII.

Diagram of the nodes of the trunk and their tributary vessels. (F. H.
G.)]


THE ARRANGEMENT OF THE LYMPH VESSELS AND NODES.

Inasmuch as most of the surgical infections, including cancer, are
disseminated by means of the lymph vessels it is necessary that the
surgeon should know the relation of vessels and nodes to the other
parts of the body. The surgical anatomy of the lymphatics can be
appreciated by reference to Gerrish’s admirable diagrams. (See Plates
XXXI, XXXII, and XXXIII.) They will indicate at a glance what it would
take pages to describe. The reader should also make frequent reference
to these diagrams in connection with studies of septic infection,
tuberculosis, and especially of cancer.


OCCLUSION OF LYMPH VESSELS.

Occlusion of lymph vessel; may be either _congenital_ or _acquired_.
The congenital type is of extreme interest pathologically, but perhaps
of less interest to the surgeon, since it rarely permits of a surgical
remedy. The reader interested in this subject should consult the
writings of Busey, who has contributed memorable monographs on the
general subject of occlusion of the lymphatics. The acquired forms have
to do with various conditions, such as thickening of vascular walls,
the pressure of exudates or of tumors, or even of callus, and with
the specific infections, of which syphilis and cancer are perhaps the
most illustrative. The result which is brought about by these various
causes is not so much the dilatation of the vessels as the saturation
or water-logging of the tissues on the distal side of the obstructive
lesion. The former is indicated by the formation of vesicles or bullæ
which will frequently ooze or weep continuously. Should the pressure
be localized and circumstances favor it, a truly cystic collection of
fluid may result. The more common type is the so-called _lymphedema_,
which, when chronic, is always accompanied by hyperplasia of the
affected tissues, their overgrowth resulting from a superabundance of
nutrition, the connective tissue apparently appropriating the larger
amount of this material for itself. Therefore with the dimensions
of a member enormously increased it will be found that almost every
other tissue except the connective has been starved out. Lymphedema
differs from that produced by venous obstruction by its obstinacy
and the density of the infiltration; in fact, it has been sometimes
spoken of as solid edema. If it continues for some time there are
permanent changes which do not admit of later dispersion, and permanent
enlargement is the result. The most unmistakable expressions of this
kind occur in the legs and the external genitals of both sexes (Fig.
184).

[Illustration: FIG. 184

Lymphedema.]

When compression, position, massage, and such measures fail the only
other resort is amputation.


LYMPHANGIECTASIS AND ELEPHANTIASIS.

These terms refer to dilatation of the lymphatics, with a minimum
of actual obstruction, often as a sequence of some previous lesion
which has disappeared. In some of its expressions the condition is a
manifestation of a widespread general disease or a parasitic infection.
This is particularly true in those forms due to the presence of filariæ
in the blood, in which it is not a question of the obstruction of one
of a series of vessels, but plugging of a number of them by the adult
worms, which reside especially in the larger lymph and chyle passages,
sometimes even causing the appearance of chyle in the urine.

_Elephantiasis_ is an expressive term given to any enormous enlargement
of a part of the body, due to a combination of causes, of which
lymphatic dilatation and obstruction together constitute the most
important feature. The so-called congenital forms may have to do
with congenital deviations from the normal standard, but should be
differentiated from instances of gigantism, which have already been
alluded to in Chapter I, into whose etiology different factors probably
enter.

[Illustration: FIG. 185

Elephantiasis of leg, scrotum, and penis.]

[Illustration: FIG. 186

Elephantiasis of hand, acquired.]

Of the acquired forms of elephantiasis, those seen in the tropics are
nearly all expressions of filariasis. Sporadic instances are met with
in colder climates, and a condition resembling it is occasionally
observed for which no existing cause can be detected. Such a case
is illustrated in Fig. 186, which occurred in a convict in the
penitentiary in Buffalo, who had never been outside the limits of the
county, and in whom no parasites could be detected. Figs. 185, 187, and
188 illustrate typical instances of elephantiasis, Fig. 188 being taken
from a Klamath Indian woman in the Northwest Territory, the condition
being similar to that met with in the tropics.

The worms belong to the nematoids, the adult being 0.03 or thereabouts
in length, thinner than the diameter of a red corpuscle, rarely
remaining long in the quiescent state. They can thus pass into the
capillaries, which they may plug. The mosquito is discovered to be
the medium of transportation, either directly or indirectly, through
exposed drinking water, where the insect deposits her infected eggs.
The adult worms outside the body may attain a length of 1 Cm. From
the intestinal canal they pass into the lymph current and are carried
until their progress is checked, where they establish a permanent home
and breed and act as local irritants. The embryos which they produce
are innocent; it is the adult and parent organisms that produce the
damage. Lymph flow being thus obstructed the area previously drained by
a given vessel will undergo various changes in the direction already
described. In proportion, then, to the number of adult worms, and in
accordance with their location, will be involvement of an entire member
or of a more limited area, _e. g._, lymph scrotum (Fig. 187) or chylous
hydrocele.

[Illustration: FIG. 187

Elephantiasis of scrotum.]

[Illustration: FIG. 188

Elephantiasis of vulva (Klamath Indian woman).

(Contributed by Dr. H. L. Raymond, U. S. A.)]

As yet there is no cure for filariasis; hence there is no relief for
elephantiasis produced by it, except, when localized, to remove the
part. In the tropical forms it is the lower part of the body which
is usually involved. It begins in a limb, usually in the toes. It
produces discomfort rather than actual pain, at least until such time
as distention of the parts becomes unbearable. Along with lymphatic
engorgement there is a peculiar liability to erysipelas, which becomes
an exceedingly serious malady in tissues so saturated with lymph,
and with such possibility for the propagation of germs. A milder
degree of cutaneous and subcutaneous infection than is implied by
the term erysipelas, as used in this work, may be called erysipeloid
or cellulitis; it is quite common and frequently recurs. With each
attack of this kind the condition is aggravated and the limits of the
lesion extend. After a time the member becomes enlarged to a degree
which disables, while the skin itself undergoes changes that alter
its appearance; not only is it thickened, but there develop upon it
papillomatous projections, with infiltration of the corium, that give
it an unnatural appearance and feeling. Epithelial proliferation is
also rapid, and is accompanied by a sort of caseous discharge which may
decompose and add extremely offensive features to these cases.

The management of these cases becomes very difficult. Total disability
finally succeeds inability, and patients in the last stages are often
bedridden. The repeated attacks of erysipeloid should be treated with
antiseptic applications and elevation of the part, but without too much
compression, as germs may be forced into the circulation.

In elephantiasis of the lower extremities it has been suggested to tie
the femoral arteries, hoping thereby to deprive the limb of at least a
portion of its fluid supply. This may be of some avail early, but when
it is done late it is likely to be followed by gangrene of the limb,
from whose consequences not even amputation can save the patient.

In the tropics, especially where the external genitals are sometimes
involved, extensive operations have been of great service, and among
the surgeons of India reports of operations of this kind are frequent.

[Illustration: FIG. 189

Elephantiasis (“Barbadoes leg”). (E. J. Meyer.)]

Elephantiasis is most common in men; occurring in women it is not
limited to the external genitals, for the writer has seen illustrations
of the disease in the legs alone. In the Western Hemisphere it is met
frequently in the Barbadoes, and is called _Barbadoes leg_ (Fig. 189).
The principal dangers from operations on these cases pertain to the
risks of hemorrhage, shock, and infection. Nothing short of amputation
of limbs or ablation of the genitals is of real benefit. In all these
operations the veins as well as the arteries should be ligated, and the
ligatures used _en masse_, introduced with a needle. There is usually
copious oozing, and drainage should be provided.


CHYLOCELE.

This term is applied to a condition also referred to as _chylous
hydrocele_. It implies a collection of milky fluid in the cavity of
the tunica vaginalis. Occurring in a patient known to be suffering
from filariasis it may be diagnosticated before exploration. In some
instances where the sac of fluid is less translucent than usual, if
the candle test fail when applied, chylocele may be suspected. Careful
examination of the sac may show widely opened lymph vessels or lymph
spaces. It is to be distinguished from spermatocele, whose contents
also are milky fluid, but rarely collecting to the same amount.
Chylocele may be treated by tapping, or by open division or extirpation
of the sac, exactly as recommended elsewhere for the treatment of
hydrocele. (See Fig. 187.)

Chylocele is to be distinguished from _lymph scrotum_, which is
a form of localized lymphangitis of mild degree rather than a
circumscribed collection of chylous fluid. It presents febrile, not to
say inflammatory features, and in the chronic form the skin will be
frequently seen to ooze fluid closely resembling lymph, which condition
is called lymphorrhagia. The scrotum rarely becomes as large as in
extreme cases of dropsy, and yet may assume an uncomfortable size. This
condition, like that previously mentioned, is usually associated with
filariæ. It may appear, however, spontaneously, and after persisting
for a long time disappear, with as little apparent reason as that which
produced it. When the condition becomes unbearable ablation may be
practised. (See Fig. 187.)


CHYLURIA.

The presence of chyle in the urine gives it an appearance as if
emulsified oil had been mixed with it. It occurs with or without known
reason. Sometimes it co-exists with lesions like lymph scrotum, etc.;
at other times it seems to neither produce nor be accompanied by
other disturbances. Ordinarily the urine or the blood when examined
_at night_--_i. e._, the sleeping hours-will reveal the pathogenic
organisms, _i. e._, filariæ. It is a condition but little influenced
by treatment, which should be symptomatic in the absence of special
indications.


MACROMELIA.

The more typical congenital forms of occlusion of lymph vessels produce
such changes as we see, for instance, in macrochilia, where the lips
and cheeks are affected; macroglossia, where the tongue is too large
to be retained inside the mouth; and sometimes macrodactylia and
macropodia, where the fingers and hands or toes and feet are involved
(Figs. 190 and 191). It is difficult to separate some of these cases
from gigantism, as already stated. The more distinctive lymphatic
lesions are frequently accompanied by pigmentary, cutaneous, or
papillomatous conditions, which stamp them as something more than mere
expressions of disproportionate growth. The patient of Dr. Gerrish,
whose condition is illustrated in Fig. 190, presented lesions which
might be assigned to either of these groups. It will usually require a
careful study to make a proper assignment of such cases as macromelia.

[Illustration: FIG. 190

Macromelia. (Gerrish.)]

[Illustration: FIG. 191

Macroglossia. (Neisser.)]


MACROCHEILIA.

While this condition is usually regarded as an expression of
lymphangiectasis, it has been shown that it may be due to multiple
adenopathy of the mucous glands in the lips. The lips are well supplied
with such glands, which lie beneath mucous membrane in a mixture of
more or less connective and vascular tissue. When the lips undergo
marked hypertrophy in adult life, it is very likely that the affection
may be explained by the hypertrophy of these collective glands, and
this is particularly true when anything like nodular arrangement can be
detected. A recognition of this cause will indicate the proper remedy,
_i. e._, excision of the affected tissue. The writer has on more than
one occasion made an elliptical incision both from the lower and upper
lip and accomplished its purpose, with great improvement of appearance.


LYMPHANGIOMA.

Lymphangioma has been described in the chapter on Tumors. It seems
necessary to allude to but one expression of this kind in this place,
_i. e._, the so-called _lymphangioma circumscriptum_. This presents as
a cutaneous area dotted with vesicles, sometimes regularly, sometimes
irregularly distributed, usually in annular form, seen most commonly
on the upper limbs and in the region of the shoulders. The vesicles
occasionally become sufficiently large to be called bullæ, while the
contained bloodvessels are dilated and discolor the area involved,
which may also be more or less pigmented. Here, as in elephantiasis,
there is great liability to surface infection of low grade, which
may perhaps be called erysipeloid. The tissues gradually become
thickened and covered with scabs or warty collections of epithelium.
It is met with early in life, rather than late, and is supposed to
be of congenital origin. It may be distinguished from herpes by the
pronounced vascular changes and by the discharge of lymph.


=Treatment.=--Treatment has been too often unsatisfactory and the
trouble often re-appears after apparent recovery. If the area involved
be not too large complete excision will probably prove the most
satisfactory method of attack.


LYMPHANGITIS.

This term applies rather to gross and visible lesions of the larger
lymphatics than to the involvement of the ultimate lymph-filled
ramifications. When the smaller lymph capillaries and interspaces are
involved the lesion takes the type of an erysipelas or cellulitis,
but as the collected products return through the lymph channels from
such an involved area they will disturb and infect the lymph vessels
themselves, and this leads to what is called a lymphangitis. Formerly
the term spontaneous or idiopathic was given to some of these cases.
Assuming, as is done throughout this work, that there is no true
inflammation that is not of microbic origin, we may expunge the term
“idiopathic” and say that lymphangitis is also an expression of
infection, and that the inflamed vessel represents a channel through
which products of inflammation are being conveyed. Histologically the
walls of these vessels become infiltrated with a coagulating exudate,
which may completely occlude the vessel. The bloodvessels immediately
adjoining the lymphatics also become involved, and, being engorged,
give rise to the peculiar red lines or streaks which are frequently
seen when cutaneous lymphatics are thus involved, this appearance
being due to a _perilymphangitis_. The infected lymph passing through
this channel is filtered out in the first lymph nodes with which it
communicates, which themselves become thus infected; hence the rapidity
with which these enlarge and break down, so that by their own sacrifice
they may perhaps protect the rest of the body from serious infection.
Under these circumstances suppuration and necrosis of these lymph nodes
is to be regarded as a vicarious destruction on their own part.

Lymphangitis proceeds from the periphery toward the centre, and is
followed by a certain amount of pain, with great soreness and sense
of stiffness in the parts; the skin overlying the infected vessels
becomes reddened in streaks, which indicate their course, or becomes
more or less infiltrated and involved throughout in a form of
infectious dermatitis. According to the virulence of the germ, and the
susceptibility of the individual and his tissues, there will or will
not occur suppuration. This may perhaps be averted by prompt treatment.
Should deep tenderness and pain take the place of or be added to their
more superficial expressions it may be inferred that the superficial
lymphatics have now infected the deeper ones, and that there is greater
danger of phlebitis and a generalized septic infection.

Constitutionally, at least, the expressions are those of septic
intoxication, often of true septicemia or septic infection. Local
appearances, increasing temperature, or accession of chills may
indicate the presence of pus.

In proportion to the distance of the diseased part from the body
centres the prognosis becomes more favorable. When an entire limb is
involved the matter is very serious; when in the face or abdomen, still
more so, the fear being of septic phlebitis and a fatal termination by
a more or less typical pyemic process.


=Treatment.=--All exciting causes, including sloughing tissues, foreign
bodies, pus, etc., should be thoroughly removed. Pus, when present,
should be evacuated, and when its presence is suspected suitable
exploration should be made. Tension should always be relieved by
incision. In cases where breaking down has already begun, continuous
immersion in hot water is beneficial. Nothing, however, will take the
place of removal of pus or necrotic tissue, and this should be first
attended to or proved to be unnecessary. In an open and sloughing
wound nothing is as satisfactory as brewers’ yeast; next to this is
hot water. Over an unbroken area which is simply edematous and pits
on pressure, may be applied the ichthyol-mercurial ointment (10 per
cent. ichthyol, 40 per cent. mercurial ointment) or the Credé silver
ointment. This should not be rubbed in, but smeared freely over the
surface, and then covered with oiled silk, twice daily, in acute cases.
The surgeon should satisfy himself as to the presence or absence
of pus; even when only suspected it is advisable to make incision
early, as tissue and possibly life may thus be saved. Constitutional
treatment should not be neglected. It will consist in improving
elimination, maintaining nutrition, and overcoming the acute toxemia
due to absorption, the toxins being best antidoted by alcohol in some
palatable form, strychnine and quinine being serviceable, but not so
valuable. (See chapter on Septic Infections.)


=Chronic Lymphangitis.=--Chronic lymphangitis is seen in connection
with the slower infections, tuberculosis--syphilis, filariasis, etc.
Here the lymph vessels are not involved so much as the lymph nodes.
Chronic lymphangitis does not occur without a toxic or infectious
process behind it.


LYMPH NODES.

For the surgeon’s purpose, at least, he may assume that lymph nodes
are never enlarged except in the presence of toxemic or infectious
processes. The role which they play as filters of the fluid returning
through the lymph vessels subjects them to daily possibilities of
contamination. They may be acutely infected and actually break down by
a phlegmonous process, or their lesions may be very slow, chronic, and
intractable. The lymph nodes, like the leukocytes, are among our best
friends; they serve as guardians at the various portals of the system,
excluding, sometimes at the risk of their own existence, various
deleterious elements.

The term “lymph gland” should be expunged from medical terminology,
the node having, so far as known, no secretion nor any title to be
considered a gland. This would mean abandonment also of the expression
“lymphadenitis,” and so the writer would prefer to use the expressions
lymphitis, lymphangitis, etc., which at least do not imply a wrong
conception of the process. The morbid activity which the lymph nodes
present will be an expression of the general virulence of the whole
process which has produced it. To a tender enlargement, in acute
cases, there will succeed rapid swelling, with pain and soreness
commensurate with the density of the surrounding tissues and the degree
of tension thus produced. The result is essentially an abscess, or
multiple abscess, which necessitates prompt treatment by free incision,
evacuation, and drainage, as does any other abscess. It is as often
necessary to use a curette as a knife, and when so-called specific
features are present, as in chancroidal bubo, a strong antiseptic
should also be used. Under these conditions the collection of lymph
nodes in the axilla or in the groin may become involved in multiple
abscess, and it is then good practice to make a complete cleaning
out of these regions. The ultimate effect of such extirpation is
beneficial, and the patient does not seem to suffer from the loss of
the involved lymph nodes; indeed, it is probable that new ones form to
replace those which are destroyed.

The _chronic affections of the lymphatics_ which come under the
surgeon’s care are expressions of tuberculosis, syphilis, gonorrhea,
cancer, or of some of the other less frequent surgical diseases. In
every one of these instances the disease has assumed constitutional
proportions, and the lymph-node involvement will be general. The
ultimate fate of these affected nodes will differ with the different
diseases; in _tuberculosis_ they sometimes suppurate by secondary
infection, and they frequently caseate, or remain enlarged for
indefinite periods, often throughout life. Around them will be found
an area of infiltration which produces firm adhesions and frequently
makes their extirpation very difficult. The lymph vessels which connect
the various nodes will also be involved in a similar process, which
adds to the difficulty of operation. In many cases these involved
nodes can be felt where they cannot be attacked--for example, in tabes
mesenterica. If, under suitable climatic and constitutional conditions,
it be possible to favorably affect other tuberculous conditions, these
expressions of the disease may also subside or at least cease to
trouble.[29]

  [29] At date of going to press I do not feel justified in lauding too
  highly the work done by numerous workers with the _opsonins_. Justice
  to what has been done with and claimed for them demands, however,
  their extensive trial, and suspension of any judgment not as yet
  favorable.

_Syphilis of the lymph nodes_ has already been considered, as well
as the frequency, nay, the certainty, with which the lymphatics
become involved in this disease. So true is this that any general
lymphatic involvement which cannot be accounted for in some other
manner is usually attributable to syphilis. The condition of the
lymphatics may be considered a fair index as to the success and
effect of antisyphilitic treatment, for if, under such treatment,
these enlargements subside completely it may be regarded as eminently
successful. On the other hand, it is not felt by many that it is
safe to discontinue treatment in the presence of these enlargements.
Syphilitic enlargements may, moreover, undergo secondary infection,
either acute or chronic, _i. e._, may suppurate or become tuberculous.
In _gonorrheal bubo_ the pus which the lymph-node abscesses contain
will often be found almost a pure culture of the gonococcus, thus
illustrating the specificity of this kind of infection.

The extent to which the lymphatics are involved in cases of cancer
will often be the guide for the surgeon in advising removal or the
reverse. The principal advance in the modern operative surgery of
cancer has come through a better working knowledge of the area of
lymph distribution of given regions. All cancerous lymph nodes which
can be reached should be extirpated. If others can be discovered which
are beyond reach it raises a doubt whether the operation should be
performed. At all events, in these cases it should be represented as a
temporary rather than an absolutely curative resort, not only because
this is true, but because the surgeon may need to protect himself
against charges which may be made later by disappointed patients.

The advisability of removing diseased lymph nodes is often a matter
for serious discussion. There is little to justify their removal when
the exciting cause cannot also be taken with them. It is a mistake to
operate on nodes in the neck and leave diseased teeth through which
the infection may be spread. So, too, it is a mistake to operate on
nodes which may prove to be syphilitic. In many instances, then, it is
best to apply the therapeutic test. In cancerous disease it can rarely
be advisable to remove lymph nodes alone except for purely temporary
purposes, as to check hemorrhage, remove breaking-down material, or
something of the kind. In the neck, groin, or axilla the operation is
not to be lightly undertaken, for it is made extremely difficult by
adhesion of the surrounding structures. The surgeon should be prepared
then for careful dissection, which should be made with a not too sharp
knife, and he should be ready to sew up a rent in the jugular vein or
tie it, as it and its large branches are frequently so displaced and
obscured as to be injured, even by the most careful operator.


HODGKIN’S DISEASE.

This is one of many names applied to a condition whose most conspicuous
characteristics are a progressive anemia, with enlargement of lymph
nodes, as well as usually of the spleen, with secondary or metastatic
growths in the viscera, bone-marrow, and elsewhere. That its
etiology hitherto has been considered obscure and that its clinical
characteristics vary in different cases may be shown by a partial list
of the names by which it has been previously known: _lymphadenoma_,
_malignant lymphoma_, _infective lymphoma_, _progressive glandular
hypertrophy_, _lymphosarcoma_, and _pseudoleukocythemia_. To the
writer’s mind, if the disease is to be known by any other name rather
than that of the one who first described it, it might be called
malignant lymphomatosis, as its tendency is downward, in which sense it
is malignant in an almost hopeless degree.

The changes which occur in the blood are at first in the direction of
simple anemia, followed by marked reduction in the number of red cells,
with poverty of hemoglobin and increase in the number of leukocytes.
In the anemia of extreme cases the red cells may be reduced 1,000,000
per Cm., while the leukocytes, especially the polynuclear forms, may be
numbered by the hundreds of thousands. In one case recently under my
observation the leukocytes amounted to about 300,000 when treatment was
begun. (See chapter on the Blood.) It is a disease of early rather than
of later life, and occurs more often in males than in females. The most
pronounced objective changes occur in the lymph nodes, which enlarge
steadily, the swellings thus formed being hard or soft according to
the rapidity of the disease. The swellings thus formed will appear
conspicuously in the neck and will be noted also in the axilla and the
groin. Careful examination will show that every lymph node in the body
which is accessible is involved in the course of the disease. Sometimes
the tumors become so large as to cause serious pressure, and when in
the neck perhaps to require tracheotomy to prevent suffocation. Fig.
192 illustrates a case under the writer’s observation, in which he had
to resort to this emergency measure. The microscopic picture of this
enlargement is that of hyperplasia of the tissues composing the lymph
nodes, while the lymphoid cells are multiplied in number.[30]

  [30] Pathologists have long suspected that Hodgkin’s disease and
  sarcoma have, at least, certain features in common if they are
  not more or less actually associated in character. Yamasaki has
  recently reported several cases of typical Hodgkin’s disease without
  any suspicion of tuberculosis, in which there were unmistakable
  sarcomatous formations in various parts of the body, especially in
  the viscera, and he believes, as do others, that the affection which
  begins as Hodgkin’s disease may later assume the characteristics of a
  general sarcomatosis.

[Illustration: FIG. 192

Hodgkin’s disease.]

Less conspicuous but equally distinctive changes occur in the spleen in
four-fifths of the cases, it becoming enormously enlarged and occupying
the left half of the abdominal cavity, being universally enlarged and
preserving its original outlines. This splenic enlargement sometimes
is simply an hypertrophy, but in many instances the spleen itself will
be occupied by tumors, _i. e._, lymphomas, which are scattered through
it and cause part of its enormous dimensions. Late in the disease the
liver also becomes enlarged and lymphomas are also scattered throughout
its substance. The same lymphomatous or adenoid tissue may be met with
in many other parts of the body, the bone-marrow, the alimentary canal,
the ductless glands, kidney, lung, etc.

Hodgkin’s disease is doubtless closely related to other varieties of
leukemia and to Banti’s disease, or splenic anemia, all of which should
be regarded as expressions of an infection by organisms not yet clearly
described, although their better recognition and identification are
clearly foreshadowed in work now under way. Death comes as the result
of the exhaustion and poisoning of a terminal infection, save when it
is produced earlier by absolute starvation or suffocation. To run its
entire course an average case consumes from eighteen months to two and
a half years.


=Diagnosis.=--So far as diagnosis is concerned the microscope will
serve a certain purpose even early in the disease, enabling one
to recognize an increasing anemia and leukocytosis, but not until
perceptible enlargement of lymph nodes and of the spleen is found
can the diagnosis be made absolutely certain. One has to distinguish
mainly between those forms of leukemia in which lymphomatous changes
are not conspicuous, cachexia of cancer and syphilis, and the condition
of lymphosarcoma, as it has been called by some, in which there is the
involvement of the lymph nodes without the characteristic blood changes
met with in Hodgkin’s disease. In splenomegaly we may have enormous
enlargement of the spleen without the marked involvement of the lymph
nodes. From lymphatic tuberculosis it is to be distinguished by absence
of fever, the tendency to universal involvement of the lymphoid tissues
in all parts of the body, and the absence of suppuration and caseation
which occur so distinctively in tuberculous disease.


=Treatment.=--Few drugs are of much or any avail in this disease. Of
them all nothing compares with arsenic, which should be given for a
long period and pushed to the physiological limit. The formula which
was given in the chapter on Cancer will serve in the treatment of
Hodgkin’s disease (p. 296, note). Next to this, and especially in
patients with enlargement of the spleen, the _x_-rays are the most
effective. In one case much of this character, in which I began active
treatment by both methods, I saw in forty-eight hours a diminution of
100,000 leukocytes. This did not persist, however, for the proportion
was later somewhat increased, but the immediate effect as well as the
benefit were very pronounced. All the affected regions may be exposed
to the x-rays, which should be used with great care.


TUMORS OF THE LYMPHATICS.

The term _lymphoma_ has been indiscriminately ascribed to various
enlargements of the lymph nodes and lymphoid tissue throughout the
body, so much so as to have really lost its significance. If by the
term is meant simply a tumor of a lymph node it will usually fall
under the proper classification as being a granuloma, a syphiloma, a
carcinoma, etc. If by the term is meant a general involvement of lymph
tissue throughout the body, such as is seen in status lymphaticus, then
it would be best to use some other term. Finally it may be questioned
whether there is any distinctly marked lymphoma, _i. e._, a tumor of
true lymphatic structure, which is not of infectious origin. The term
_lymphosarcoma_ is still in use and probably will not be expunged until
our notions of pathology are clearer. The expression _lymphadenoma_
should be discarded. Multiple malignant lymphoma, as stated above, is
but another name for the condition ordinarily described as Hodgkin’s
disease. That sarcoma and endothelioma may arise in the lymph nodes is
universally conceded, although as primary neoplasms in these localities
they are rare. Not much can be said, then, that is distinctive about
lymphoma.

In a general way, it may be said of any tumors of the lymph nodes that
if isolated or not too multiple they should be extirpated.




CHAPTER XXXI.

SURGICAL DISEASES OF THE JOINTS AND JOINT STRUCTURES.


The joints, by virtue of their function and anatomical relations, are
liable to a variety of injuries and affections, most of which are
essentially surgical. The joints most subject to traumatism belong to
the extremities. On the other hand, the deeper joints (_e. g._, of
the spine) are quite prone to toxic and infectious diseases and less
liable to serious injury. The surgeon cannot disregard the structure of
the joint when considering the pathology of its surgical affections.
More or less completely protected externally, though sometimes with
but a thin coating of integument and fibrous textures, it is composed
largely of resistant, white, fibrous tissue, seen in its ligaments,
of spongy bone in the expanded bone ends, covered with cartilage of
incrustation, the articular termination of the bone shaft not being
firmly affixed until a certain age has been reached, while the interior
is lined with a serous membrane whose lymphatic connections are most
abundant, portions of which are often loaded with fat. In certain
joints--particularly the knee-there enter separate considerations in
the shape of interarticular cartilages which are not so firmly attached
but that they may be sometimes displaced.

Lymphatic connection between the exterior and the interior is often
free, and after trifling abrasions or infections of the overlying
skin the joint beneath may suffer seriously or even fatally. Many of
the surgical diseases of the joints begin within the joint membranes
proper, _i. e._, the synovia. Numerous other expressions, particularly
of tuberculosis, have their origin in the bony structure contiguous to
the joint cavity.

In any destructive affection of the joint in childhood the
corresponding epiphyses are often involved. This is also true of
fractures extending into joints or occurring near them in the young.
Below will be found a table of the time when the epiphyses are usually
consolidated with the main portion of the bone. In general, they unite
earlier in the upper limb than in the lower, or, as Sappey puts it, the
upper limb first arrives at maturity. The following table represents
simply the average, there being considerable variance on either side of
it in different individuals:

  UPPER EXTREMITIES.

  Clavicle                          23d  year.
  Humerus, upper                    20th year.
  Humerus, lower                    17th year.
  Radius, upper                     16th year.
  Radius, lower                     20th year.
  Ulna, upper                       16th year.
  Ulna, lower                       19th year.
  Phalanges                 18th to 20th year.

  LOWER EXTREMITIES.

  Femur, head and great trochanter  19th year.
  Femur, lower epiphysis            21st year.
  Tibia, upper                      21st year.
  Tibia, lower                      18th year.
  Fibula, upper                     21st year.
  Fibula, lower                     20th year.
  Phalanges                         18th year.

These dates should be remembered, as an ununited epiphysis may be
involved in a necrotic or suppurative process and thus break down
and require removal. Moreover, these facts will also be of value in
considering fractures, for up to these dates epiphyseal separations
will often be met.


INJURIES TO JOINTS


=Sprains.=--A sprain is either the result of a momentary dislocation
of a joint, the parts returning immediately to their proper position,
or else is produced when a joint has been strained beyond its
probable physiological limit without any true displacement. It
may be the consequence of direct or indirect violence, or even of
incessant muscular action. It always implies a certain degree of
tissue injury, which may vary from minute lacerations of ligaments,
fasciæ, aponeuroses and periosteum, up to a degree where ligaments are
violently sundered or torn out of their bony attachments.

A sprain is generally followed by hyperemia, with its attendant
phenomena, as described in a previous chapter, and as long as
possibility of infection can be excluded the resulting outpour which
produces the extreme joint swelling will more or less quickly disappear.

In fact, as insisted throughout this work, the differences between
hyperemia and its consequences, and true inflammation with its results,
can nowhere be more perfectly demonstrated than in such a case as this.
Even with great damage and effusion there can be complete repair, so
long as infection is excluded. Once the germ element enter, the whole
aspect is altered and a serious feature is then introduced.


=Symptoms.=--The symptoms of sprain are loss of function, swelling,
pain, and later ecchymosis. The first is usually immediate, the
swelling takes place rapidly, and ecchymosis occurs after two or three
days, unless the joint be near the surface. The degree of tenderness
will afford a measure of the amount of damage done. The swelling may
be produced either by serous outpour or by hemorrhage, or by both.
Ecchymosis is usually due to minute lacerations, and may spread to
a considerable distance. Where there has been much outpour of blood
into a joint it sometimes produces a reactional hydrarthrosis, which
appears only after a week or more. Such hemorrhage is serious, and is
frequently the cause of more or less pseudo-ankylosis by organization
of clot.

Sprain may then be of all degrees of severity. From the mildest of
these one may expect perfect functional recovery in short time, while
in the more severe cases chronic thickening, with hydrarthrosis, tender
areas, and muscle atrophies, often persist for a long time or even
permanently.


=Treatment.=--The ordinary treatment of a sprain consists, first, in
physiological rest. If the swelling be already pronounced when seen
by the surgeon he will endeavor to promote absorption by elevation,
gentle compression, perhaps with an elastic bandage, and by cold wet
compresses. If seen _early_ and before much swelling has occurred it
will often give great relief, especially in certain joints (_e. g._,
the ankle), to partially immobilize the part by _strapping_ it with a
series of adhesive strips, 2 Cm. in width, cut sufficiently long to
encircle the foot, ankle, and lower part of the leg. The strapping
should be begun at the base of the toes, and each strap as thus applied
should be made to slightly overlie the preceding one. It is possible by
neatly compressing the involved region in this way to almost prevent
swelling, and to give such support that function is but slightly
impaired, and pain reduced to a minimum. The objection to plaster of
Paris or the more fixed dressings is that they are usually allowed to
remain too long. Far better in most of these cases is either a splint
or a dressing which permits of daily examination. With the subsidence
of acute symptoms, massage and passive movement should be practised.
There are cases in which swelling will be so extreme that aspiration or
even incision may be advisable for the purpose of emptying the joint.

The surgeon sees many a case of this kind after it has become chronic
and after domestic or simple applications have failed. Most of these
cases require massage, practised skilfully, and with intelligence, by
which absorption is much promoted. The same result, as well as relief
of soreness or pain, follows the constant use of cold wet compresses,
perhaps combined with the use of ice-bags. If the material used for
these compresses be dipped in solution of sodium or ammonium chloride,
say 5 per cent., the effect is much enhanced, while laudanum can also
be used upon them. Tenderness and localized pain in old cases may be
treated by a succession of blisters, but can be better treated by the
application of the _flying cautery_, _i. e._, by the light touch of a
glowing cautery point swept rapidly over the surface involved. This is
one of the most powerful agents for the relief of pain. Occasionally
the cautery point may be applied more deeply, _i. e._, _ignipuncture_.
If localized collections of fluid form they may be incised.

The statements and advice given in regard to sprain will apply equally
well to the ordinary contusions of joints.


PENETRATING WOUNDS OF THE JOINTS.

These are inflicted as are wounds elsewhere, and, while always serious,
have an importance proportionate to the infection which may have
occurred with the injury or afterward. In practise it may be assumed
that the skin, like the clothing outside, is always dirty and infected,
and that every penetrating wound should be regarded as an infected
wound. Not every wound in the vicinity of a joint is penetrating,
and it is advisable to ascertain whether a joint cavity be actually
open, as much of the method of treatment will depend upon this fact.
The majority of these injuries are of the punctured or small incised
variety. The actual joint opening is usually smaller than that in the
skin. It may be so small as to escape observation. Outflow of blood
is not pathognomonic, but escape of synovial fluid always indicates
that some serous cavity, possibly a bursa or tendon sheath, has been
opened. Immediate accumulation of fluid within a joint after probable
wounding of the synovial membrane is quite suggestive, as it is likely
to imply that the joint is filling with blood. After any injury which
may loosen them the epiphyses should be carefully examined, in order
to determine if they have been loosened, while it should be estimated,
so far as possible, whether the epiphyseal junction has been disturbed
or is probably infected. The student should remember that punctured
wounds of joints are not necessarily made from without inward. A
spicule or fragment of bone may, by protruding, produce exactly the
same condition, only in this case there may be a compound fracture to
complicate it. Infection does not invariably follow these injuries.
Their gravity is in large degree measured by the presence or absence of
a suppurative synovitis. This does not necessarily instantly follow the
injury, but develops within the ensuing two or three days. Therefore
the fate of such a joint is not necessarily determined by inspection
within the first few hours. Esmarch’s dictum regarding gunshot wounds
may here be paraphrased. _The fate of every punctured joint depends
upon the man who first takes care of it._ If the proper thing be done
promptly a good result may usually be obtained.

The first indication in every such case is _sterilization of the
parts_, including the area of the wound. If by a small elliptical
incision the wounded skin can be excised, it may perhaps very much
improve the prospect. A small punctured wound may be watched for a day
or two, especially if it be believed that the first attention were
prompt and antiseptic. Should no unpleasant features appear little need
be done except to apply ice externally and maintain rest. On the first
appearance of sepsis or of increasing trouble in the joint it should be
promptly incised, irrigated, and drained.

In the larger openings of joints it should be assumed from the outset
that infection has occurred. In such a case the wound margins should
be trimmed, the joint cavity thoroughly irrigated, and explored for
foreign bodies, by enlarging the existing opening. After thorough
irrigation a drain should be inserted for at least a few hours. For
this purpose a catgut strand or a drainage tube may be employed.

As soon as the _presence of pus_ (acute pyarthrosis) is made clear the
case takes on a larger aspect, in that drainage not alone at one point
is indicated, but probably at two or three. Nothing is so disastrous
to an involved joint as pus retained within its hidden recesses.
Almost every other consideration is sacrificed to its discovery and to
affording a means for its escape. Counteropenings in numbers sufficient
for the purpose are, therefore, indicated, and it will often be best to
draw through the affected joint a drainage tube, of a size sufficient
to prevent its occlusion by thick pus or debris. Daily and continuous
irrigation may be practised to great advantage, or, as is possible with
the ankle, the wrist, or elbow, continuous immersion may be substituted
as a still better measure. Wherever infection and destruction to this
degree have taken place it may be presumed that the future of the joint
is seriously compromised. There will, therefore, be room for display of
judgment as to when to begin passive and when active motion; moreover,
a guarded prognosis concerning restoration of function should be given.

_Gunshot fractures of joints_ constitute almost a category by
themselves. Under the old _regime_, and in the pre-antiseptic era,
gunshot wounds of joints condemned one to amputation and loss of
at least the part below. The mortality attending injuries of this
kind, with the resulting amputations, during our Civil War, and all
others previous to it, was extreme. The Continental surgeons first
appreciated the value of antiseptic occlusion, and taught the rest of
the world that this wholesale sacrifice of limb, and often of life,
was unnecessary and could be avoided. Reyher’s first papers on this
subject revolutionized previous views and practises, and established on
a firm basis the general principle of _primary antiseptic occlusion_ of
those injured joints. The accumulated experience of military surgeons
since his time, as well as of civil surgeons all over the world, has
demonstrated that if a gunshot wound of a joint be afforded prompt
antiseptic occlusion and _rest_ the chances are in favor of restoration
of function, with a minimum of disturbance and a maximum of result.
It was because of these results that soldiers were provided with the
“first aid to the injured” packets, so that a punctured wound might be
protected immediately after its reception. Even the complete tunnelling
of a joint, which the Mauser bullets so often accomplish, does not seem
to be so serious an injury today as was the puncture of a needle or
an awl in the pre-antiseptic era. Therefore the best thing to do with
a gunshot wound is to practise _antiseptic occlusion_. If it become
troublesome it should be treated in accordance with the advice given
above.

This relegates the matter of _amputation_ or of _primary excision_ of
an injured joint to those cases of extensive and mutilating injury
where not only the soft structures are widely opened and infected, but
the joint ends of the bones also are seriously involved. When it comes
to the treatment of _compound dislocations_ it is difficult to lay
down principles which shall be universally applicable. As a general
rule primary excision will usually be indicated, and prove not only
life-saving but limb-saving. In compound dislocations of the astragalus
its removal will be nearly always indicated. Only in cases of extensive
damage will amputation be necessary.

Inasmuch as it is _infection_, leading to suppurative synovitis or
arthritis, which gives to all serious cases their greatest dangers, it
will be sufficient at this point to remind the reader to this effect
and to describe the condition itself a little later.


SYNOVITIS AND ARTHRITIS.

The various surgical affections of a joint may be of primary or
secondary origin, and of rapid or chronic type. The acute are usually
expressions of serious infection, while the chronic are frequently
of toxemic origin, including under this heading manifestations of a
particular diathesis or defective metabolism. Others are so exceedingly
slow in their course and are so intimately connected with other
indications of disease of the central nervous system as to be called
_neuropathic_. (See below.)

Nearly all the acute affections begin in the synovial sac proper.
From this they may spread and involve the adjoining parts. The acute
toxic lesions also arise within the synovial cavity, such as those
which follow gonorrhea, typhoid, scarlatina, pneumonia, influenza,
etc. Tuberculosis may primarily affect either the synovia, in which
case we have a condition corresponding to tuberculous peritonitis, or
it may take its origin in the expanded bone ends or in the epiphyseal
cartilages. Syphilitic affections of the joints are rarely acute. They
lead rather to chronic disintegrations or hypertrophy. No matter how
the lesion may have arisen it will nearly always extend to and involve
other parts; thus in acute suppurations the articular cartilages are
soon attacked, while in the more chronic forms, which have their
origin in the bone, the joint cavity is slowly encroached upon and its
integrity impaired or destroyed.

So long as the type of joint disease be not destructive a complete
or nearly complete restoration of function can be expected, provided
suitable treatment be given early. If, however, a case occur only after
fibrinous outpour has organized into adhesions, muscles have withered
from disuse, and the entire joint become distorted or disarranged,
then it may be too late to cure, and it is a question then of how much
improvement can be effected. Even after acute suppuration, if the
case be properly managed from the outset, very useful joints can be
regained.


=Dry Synovitis.=--In synovitis, as in pleurisy, there may be a minimum
of serous outpour, such exudate as escapes into the joint being
exceedingly rich in fibrin and coagulating easily. This material is
variously disposed of, and may form adhesions which will limit motion,
or masses of condensed fibrin which may be broken up into shreds or
rounded off into seed-like or _rice-grain_ bodies. When tenderness
subsides sufficiently to permit it these may sometimes be felt within
the joint. At other times they lead later to an hydrarthrosis, which
may prove more or less disabling and require subsequent operation.
Another form of _synovitis sicca_ is met with in acute and perhaps
chronic rheumatism, where masses of fibrin become loosened and can be
felt as foreign bodies, or fringes, beneath the joint covering.


=Acute Synovitis.=--The ordinary acute synovitis is characterized by
more or less effusion, and corresponds to pleurisy with effusion. It
is the result usually of external injury, or it is combined with what
has already been described as sprain. The fluid outpour is watery, is
rarely blood-stained, save in cases of lacerations, usually distends
the joint capsule, often to a painful degree, but represents nothing
more than the consequences of hyperemia. If this fluid collection
can be protected from contamination by germs it will disappear under
suitable treatment, with a return to almost normal original conditions.
Let it once become contaminated, however, and the type of disease is
quickly changed, for there will then be an acute inflammation with its
attendant phenomena and consequences.


=Treatment.=--Cases of simple character are of short duration, _i.
e._, one to two weeks. If seen early they should be treated by gentle
compression and the application of ice-cold, wet compresses. Heat
applied at this time may give temporary comfort, but will encourage
effusion. Even if a joint thus affected be not seen until the swelling
is extreme, wet compresses will still afford the simplest and the
most comforting method of treatment, although they need not now be
kept cold; in fact, gentle heat may now promote absorption. If the
compresses be moistened in salt solution, to which a little alcohol
has been added, the stimulating effect will probably be still greater.
Such a joint needs to be placed at rest, save perhaps in the case of an
ankle-joint or wrist-joint, which may be snugly strapped after injury.
In some of these latter cases the patient can resume use of the joint
almost at once.


=Purulent Synovitis.=--This rarely begins as a purulent condition, but
may be the result of the non-inflammatory and non-purulent form. In
such a case the character of the fluid outpour soon merges into the
seropurulent, and later become almost nothing but pus. If the interior
of a joint could be inspected, under these conditions, the intensity
and extent of the vascularity and cellular changes going on within the
synovial membrane and beneath it would present a different picture from
that of the non-purulent form. The appearance of a joint interior,
under these circumstances, is similar to that of a well-marked purulent
conjunctivitis. Articular surfaces are quickly eroded or perforated,
while cartilages thus once affected are often loosened from their
attachments through necrosis and remain as foreign bodies in the fluid
collection. Even strong ligamentous tissues will melt down and become
so weakened as to permit a looseness of motion foreign to the natural
joint. In fact, as between purulent synovitis and acute suppurative
arthritis it is but a matter of extent of destruction, not of character
of lesion. In this way _pathological dislocations_ are produced,
sometimes even within a few days, being the combined result of
destruction of ligaments and the pull of muscles which are thrown into
reflex spasm by the presence of intra-articular disease. Not only do we
see caries of the exposed bone ends, but epiphyseal separations are not
uncommon in the young, while every structure around and outside of the
joint participates, even to the extent of abscess formation. Abscesses
may form without the joint and work into it, or the purulent collection
within may escape at points of least resistance and burrow, forming
perhaps numerous foci at some distance from the joint first affected.
If such a case is to be saved it will require numerous openings and
counteropenings, with free drainage, while even then there can be no
expectation of restoring joint function. There is, then, in these cases
at least a sacrifice of joint, sometimes of limb, and in neglected
cases of life itself.


=Symptoms.=--Of the large joints only the shoulder and hip, especially
the latter, are placed so deeply as not to permit of easy examination
and diagnosis. Pain, swelling, and loss of function, with or without
history of injury, will predominate in well-marked cases, while very
early in most, and promptly in all, there will occur reflex spasm of
those muscles which have to do with motion of the affected parts, by
which they become more or less fixed and beyond voluntary control of
the patient. This condition has been described by Sayre as “_muscles on
guard_.” It is a significant feature, and has as much to do with active
joint disease as has abdominal rigidity with surgical intra-abdominal
conditions. Swelling will be proportionate to the acuteness of the
case. Tenderness is nearly always extreme, especially along the
articular line. The joint capsule is frequently distended to its
extreme and the normal contour of the part completely obliterated.

The most common position in which limbs are held is midway between
extremes; thus when the knee is involved the leg will become flexed
upon the thigh, at about 75 degrees. If the shoulder be at fault
the arm is maintained close to the body. In disease of the elbow
the forearm is carried midway between the right angle and complete
extension. This is partly due to the fact that the flexors are always
stronger than the extensors, as it represents a compromise between the
antagonism of the opposing groups of muscles.

_Pus_, when present, is commonly also manifested by the usual signs
of its existence. There will be pitting on pressure or edema of the
overlying parts, while an acutely inflamed joint may be at any time
so swollen as to impede return circulation and lead to edema of the
parts beyond. To the local signs of phlegmon, then, we simply have to
add in greater detail those mentioned above. Along with these there
will be constitutional septic disturbances, usually proportionate to
the gravity of the local condition. The opportunities for absorption
afforded by a large synovial surface are great, and the lymphatics are
sure to carry toxins in abundance. The signs, then, of septicemia,
sometimes even of pyemia, are often pronounced. In the presence of
a joint full of pus the prognosis may be regarded as exceedingly
grave. Pain and tenderness seem to bear but little relation to the
swelling. Usually pain is an expression of distention, yet some of the
non-inflammatory forms of apparently milder type are extremely painful.
Pain is influenced by the position of the joint, and the patient
instinctively seeks that position in which suffering is minimized. In a
joint disorganized by the presence of pus there is less sensitiveness,
except on rough handling, unless the trouble have extended far
beyond the joint limits, and cellulitis be present, with suppuration
threatening. In metastatic joint abscess tenderness rather than pain is
the common rule.

In the presence of an acute inflammation in the joint end of a
long bone the other joint structures will participate to an extent
proportionate to its acuteness. With an acute osteomyelitis--_e. g._,
near the articular surface--the synovial membrane will participate,
just as does the pleura in many cases of pneumonia, and we may look
for fluid in the joint in one case as we do for fluid in the chest
cavity in the other. Moreover, pictures of acute or chronic tuberculous
affections of the synovia correspond very closely to those of the
pleura. Tuberculous disease is liable to spread in every direction
in both diseases. The reverse of this, however, is not true in all
diseases of the chest, and there are many synovial as well as pleural
affections which are confined to their respective sacs.

[Illustration: FIG. 193

Pneumococcus infection of ankle; rapid destruction of all joint
structures. Child aged nine months. (Lexer.)]

The same statement, almost, can be made concerning the bursæ and tendon
sheaths in proximity to infected joints. Particularly is this true when
any of these connect with joint cavities.

The _metastatic forms of pyarthrosis_, as a collection of pus within
the joint capsule is called, are more insidious, though sometimes
equally destructive. They are by no means confined to one joint, and
in pyemia especially many of the joints will become involved. (See
Pyemia.) These secondary affections seem to be purulent from the
outset. In gonorrhea the effused fluids will often be found nearly pure
cultures of the gonococcus; after typhoid they contain typhoid bacilli,
etc. Such expressions are less frequent after pneumonia, influenza,
and the acute exanthemas, but may be seen even after smallpox. It is
often in these severely destructive joint lesions that spontaneous
dislocation occurs (Fig. 193).


=Treatment.=--In the presence of a single joint lesion indications
for treatment are quite clear. When we have multiple and pyemic or
gonorrheal pyarthrosis it is often exceedingly difficult to determine
what is for the best interest of the patient. In general it may be said
that pyemia progressed to this extent will almost certainly be fatal,
and we may rest content with aspirating the affected joints, or perhaps
in leaving them alone; because we may feel that they constitute but
a small proportion of the metastatic foci which eventually determine
death. On the other hand, in other infections with pyarthrosis it would
be better to aspirate or to open and drain, because these cases are
slow and chronic, and the exudate is sometimes so rich in fibrin as to
lead to quite firm spurious ankylosis.

Thus _gonorrheal synovitis_ is usually monarticular, although several
joints may be involved. It is readily recognized in the presence of the
active disease, but there are times when recognition is made difficult
by the latency of urethral symptoms or the concealment of their
existence. The knee is usually the joint most often involved; next
the joints about the foot, and sometimes the tendon sheaths and bursæ
adjoining them.

_Syphilitic arthritis_ is a chronic and mildly but steadily progressive
affection. It rarely assumes purulent form without some secondary
infection. It is frequently combined with gumma along the epiphyseal
border. In _hereditary syphilis_ numerous joints may be involved in
changes of the rachitic type.

_Gout_ or some of its allied rheumatoid manifestations may lead to
a dry form of synovitis, with deposit of urates or of lymph, and
the formation of _tophi_ in the neighborhood, or it may assume the
form of a chronic and intractable hydrarthrosis. The acute forms are
accompanied by great pain, with redness and swelling, peri-articular
and intra-articular. The tendency of these cases is to chronicity and
recurrence.


=General Treatment.=--Upon the nature of the condition will depend
the treatment of joint diseases. The questions of when to operate
and when to abstain, when to enforce rest and when to begin passive
and when active motion, call for discriminating judgment. An acute
or even mild traumatic synovitis should, first of all, be protected
from becoming purulent. Should injury be accompanied by a bruise, the
greatest care should be given to antisepsis, and the part sterilized
and dressed with every precaution. Should there be no external injury
we may rely ordinarily upon cold, wet compresses, with suitable elastic
compression and physiological rest. Should two or three days of this
treatment fail to bring about nearly complete resorption the aspirator
may be employed to withdraw the fluid. If this should be found to be
bloody or too thick to run through the needle, it will be advisable to
make small incisions on either side, under the strictest precautions,
and to practise thorough irrigation, by which the joint cavity will
be completely cleared of foreign material. As soon, however, as the
presence of pus is indicated, or even suspected, the whole character of
the treatment should change. The surgeon should now endeavor to be as
radical as possible. The more purulent the collection the more are free
incision, irrigation, and drainage indicated and the more complicated
the condition the more he should make counteropenings here and there,
wherever joint pockets may be emptied.

When muscle spasm not only seriously disturbs the patient but
threatens to draw the limb into an undesirable position it should be
overcome, either by employment of traction with weight and pulley,
or by forcible reposition and fixation in suitable splints, such as
plaster of Paris. Some of the most extensive operations that are called
for are necessitated by neglect to observe these precautions early.
Often nothing will afford so much relief as the use of traction, with
sufficient weight, tiring out contracted muscles, and thus not actually
separating joint surfaces, but overcoming that muscle spasm which
brings them tightly together and thus gives pain.

In the more chronic form of cases absorption may be promoted by
elastic compression, by massage, by wet compresses, and sometimes by
blistering. Ordinarily, and especially in those cases characterized by
pain, more can be accomplished with the actual cautery drawn lightly
and rapidly over the surface of the joint than by blistering. This
application is referred to as the _flying cautery_, and it is one of
the most effective agents known for the relief of deep-seated pain,
as well as of cutaneous hyperesthesia. Its use causes little if any
unpleasant sensation, and should be repeated at daily intervals until
the primary object is attained.

Should aspiration of a distended joint be practised at any time, one
should atone for the loss of intra-articular pressure thereby produced
by external compression, preferably with an elastic medium.

In the writer’s opinion it is not advisable to use a small aspirating
trocar in those cases which are likely to call for irrigation. The
aspirating needle should be confined to the non-purulent collections
of fluid, although some surgeons advise and practise throwing into a
mildly infected joint, through such a needle, some reasonably strong
antiseptic fluid or emulsion, hoping thus to gain its bactericidal
effect without external incision.

The active manifestations of disease being mastered, one addresses
himself naturally to the greatest possible prevention of deformity
and restoration of function. Indeed, these should be kept in view
from the outset, although we have, for a time, to disregard them in
favor of more imperative indications. If ankylosis appear inevitable
the joint should be kept in that position in which, when stiff, it
will be most useful. This position will be, at the elbow, at a right
angle; at the hip or knee, nearly complete extension. When, on the
other hand, restoration of function is hoped for it will be obtained
through a combination of massage, active and passive movements,
with the use perhaps of some sorbefacient ointment, such as the
compound ichthyol-mercurial, or by the nearly constant use of cold,
wet compresses, combined with the other measures. The greatest care
should be exercised in determining the time when absolute rest given
to an inflamed joint should be changed to the gentle or more forcible
movements required for restoring use to previously inflamed joint
surfaces.


=Chronic Synovitis and Arthritis.=--A chronic serous effusion into
a joint is given the term _hydrarthrosis_. This condition is never
primary; it is always the residue of some previous acute lesion, or
else it is the result of neuropathic or rheumatoid changes going on in
and about the joint, accompanied by relaxation of membranes permitting
passive distention with fluid. The contained fluid is ordinarily
pure serum. It may contain a little blood or numerous particles or
shreds of fibrin, while in rare instances there will be found in
it drops of oil or even fat crystals. The degree of distention of
a joint capsule is the measure of the gravity of the case, as this
membrane, like any other, will yield to gradual distention, although
it at the same time undergoes thickening as a protective measure.
Thus the synovia may, under certain circumstances, become as thick
as the pleura. The result is a tough, leathery condition of this
membrane, which makes it exceedingly difficult to manage. The joint
thus involved will appear more prominent than it should, because of
the atrophy of the surrounding structures. Accurate comparisons can
only be made by measuring corresponding joints. Neighboring bursæ and
tendon sheaths often participate in the distention. These collections
are ordinarily painless, or nearly so, but interfere, to varying
extent, with the function of the joint. Anatomical outlines disappear
or are concealed by the bag of fluid. It is rare that there are any
constitutional symptoms except perhaps those of the disease which
causes the disturbance. The amount of fluid which may be contained in a
long-distended knee-joint, for instance, is relatively very large. The
prognosis in these cases will depend much upon the underlying cause, as
well as upon the age, vitality, and docility of the patient.


=Treatment.=--Removal of the fluid is always the indication. After
reasonable effort has shown that this is not possible by the employment
of massage, the actual cautery and elastic compression, combined with
functional rest, it should be withdrawn by the aspirating needle or
trocar. The more experience, however, we have with affections of this
class the more we will realize that the interior of the synovial
membrane is frequently studded with deposits, fringes, etc., which are
not affected by mere aspiration, and the more cogent argument will
be gained for sufficiently free incision to permit inspection of the
interior of the joint, removal of tags of tissue, thorough washing
out and sponging, by which a change in circulation and nutrition
is certainly affected; and this may be combined with excision of a
liberal portion of the thickened membrane, by which the dimensions
of the joint may be materially reduced when the opening is sutured.
For long-standing cases of well-marked hydrarthrosis, especially in
the knee, the writer would urge this method of treatment. Drainage,
if called for at all, can be made with strands of silkworm, or some
temporary material which will quickly disappear or be promptly removed.
This is particularly applicable for the milder forms of tuberculous
synovitis, in which the joint is thus treated on the same principle
that is applied in washing out a tuberculous peritoneal cavity.

[Illustration: FIG. 194

Arthritis deformans, knee. (Ransohoff.)]


ARTHRITIS DEFORMANS AND OSTEO-ARTHRITIS.

Under this general name have been grouped a number of conditions,
including the so-called _rheumatoid arthritis_, and referring to a
variety of chronic progressive lesions of joints which involve the
articular cartilages and synovial membranes, later the bones, and
which produce more or less loss of function and deformity. Although
often spoken of as “rheumatoid,” the condition has nothing to do with
rheumatism as such, whatever that may be. It moreover presents no
analogies to the forms of acute synovitis already described. These
lesions are more common in women than in men, occurring oftener in
those who have been sterile, and during or after the menopause.
So far as their etiology and pathology are concerned, it is true,
though it seem trite to say it, that they are the result of disturbed
nutrition, which itself may be referred back to perverted trophic
influences. Exposure, bad hygienic surroundings, improper food,
mental perturbation, and depression are more or less potent factors
in most of the cases. In some instances occurring in advanced age
they seem to be due to changes ordinarily regarded as senile. When
joint lesions are multiple and symmetrical, and accompanied by other
nutritive changes, we may refer the cause back to the central nervous
system. When monarticular they are more likely to be the residue of
some previous infection or injury, such as gonorrhea, influenza, or an
acute exanthem. If in connection with the joint manifestations we find
the spleen and lymphatics enlarged, then the case may be regarded as
doubtless infectious in nature.

The pathological changes within these joints include almost every
imaginable alteration. Bones soften and atrophy at one point, or at
another become enlarged and thickened, and throw out osteophytic
projections by which the whole shape of the joint is materially
changed. Cartilages atrophy here and thicken there, and disappear, at
times, to an extent by which bone is exposed, the exposed surfaces
frequently becoming polished or _eburnated_. The position of the joint
and its general contour may be materially altered by these changes, and
marked deformity or notable enlargement result. _Subluxations_ are not
infrequent, while the ligamentous structures are sufficiently strong to
perform their function, and the joint yields or “_wabbles_.” Meanwhile
the synovial membrane undergoes corresponding changes, and becomes
distended with fluid so that hydrarthrosis is a frequent accompaniment.

On the other hand, there is another type of analogous changes where
the tendency is atrophic throughout and little if any extra fluid
accumulates. Such a joint may become smaller rather than larger,
especially if, as in some cases, some part of the bone practically
disappears.

At all events muscle atrophy, sometimes with pseudo-ankylosis,
sometimes with actual ankylosis, will characterize most of these cases,
and muscles naturally disappear as they functionate less and less.

_Pain_ is an irregular feature, some of the lesions being quite
painful, others almost free from it. The lesions are essentially
progressive in their character, unless the whole body condition and
environment can be changed for the better. Consequently individuals
become more and more crippled. Muscle spasm is rarely present, but when
such changes occur in the intervertebral joints the individual becomes
gradually bent over or deformed, partly because the muscles no longer
have strength to maintain the erect posture, and partly from actual
changes in the bones and joints. Most of the instances, however, are
characterized by tenderness, while a general _myalgia_ or malaise is
a frequent complaint. There are sometimes exacerbations, during which
both severe neuralgic pains and mild fever are quite pronounced. Not
infrequently on handling the affected joint pseudocrepitus or actual
crepitus will be obtained. Sometimes the joint surfaces are roughened,
and then this sensation is most pronounced. When the synovial membrane
is proliferated, in _pannus_ form, over the cartilages, its enlarged
fringes will give a soft crepitus which is quite distinctive. Fragments
of these fringes, as well as of cartilage, may become detached, and
loose objects of this kind in the joint may be recognized by the sense
of touch.

[Illustration: FIG. 195

General osteo-arthritis, with multiple synostoses (“ossified man”).]

While this is going on within the joint, adjoining tendon sheaths
and bursæ become more or less involved, and even the periosteum will
undergo considerable thickening.

The monarticular type is more frequent in men than in women, and occurs
more often in a large joint or in the spine, in which latter case it
is hardly to be considered monarticular. The changes that may occur
in the _spine_ are distinctive, varying from trifling stiffness and
limitation of motion to pronounced deformity, by which, for instance,
not only the kyphosis of acute spondylitis may be imitated, but the
body flexed to an angle with the axis of the pelvis and fixed there,
so that the individual is bent to nearly a right angle. Some of the
other deformities of this condition are more or less characteristic.
In the _hands_ the fingers are bent toward the ulnar side, and often
strongly flexed, perhaps even overlapped, thus giving the hand a
peculiar claw-like appearance. The _feet_ are extended completely,
the joints rigid, the toes turned outward, and also overlapping. By
such changes in the hip and knee the legs and thighs may be flexed and
the hips perhaps so ankylosed as to prevent separation of the knees.
While these changes are, as stated, most common in the later years of
life, _children are not exempt_, girls being more frequently affected
than boys, the condition coming on at first with more or less acute
symptoms. These children will often be found to have enlarged spleens
and lymph nodes, to show malnutrition, while some of them will display
certain symptoms of exophthalmic goitre. In other words, they are in
that condition included under the term status lymphaticus, to which
subject the reader is referred. (See p. 163.)

It would appear, then, that we can expunge the term chronic articular
rheumatism, since by it is not meant the ultimate result of an acute
rheumatic affection, but rather one of the vague conditions described
above.

Fig. 195, taken from a skeleton in the author’s possession, illustrates
an extreme condition of this kind, characterized by multiple
synostoses, nearly all of the principal joints being involved.

As between the terms _osteo-arthritis_ and _arthritis deformans_ it
is not practicable to make such accurate distinctions as shall be
acceptable to all. In a general way the more the bone participates
the more we may use the former designation, whereas when other joint
structures are chiefly involved we may resort to the latter.

In general, then, all these conditions are evidenced by joint
deformity, especially by irregularities, by more or less effusion, by
considerable tenderness, by creaking of the joints when used, by pain
which is a variable feature and may be referred to nerve disturbances,
occasionally by muscle spasm, but always, in cases of long standing,
by muscle atrophy. A view of the interior of joints thus affected will
give a complex picture of atrophy here and hypertrophy there of each or
all of the component structures of the joint, sometimes with a gradual
overgrowth of articular bone surfaces, sometimes with more or less
complete disappearance of the same, _e. g._, in the acetabulum.


=Treatment.=--So far as treatment of these conditions is concerned,
it should be recalled, first of all, that the disease itself is
exceedingly chronic in its tendency, and due to conditions which
have probably been of long standing. Constitutional treatment is as
essential as local, and must consist in restoring the environment
and the nutrition of the patient to normal standards. Elimination is
deficient in such cases, and should be stimulated by hot-air baths,
massage, and such exercise as may be possible, as well as by the use of
diuretics and laxatives to the degree indicated. The local treatment
may consist also of massage, elastic compression, aspiration in rare
instances, the use of wet packs, and, in many cases, the use of hot,
dry air. Various forms of apparatus are now upon the market by which
almost any of the joints may be subjected to the influence of dry, hot
air at a temperature of 280° F. When properly used, great relief and
improvement may be expected. Their use, however, calls for the best of
judgment and a combination of the measures already mentioned.[31]

  [31] The following types of arthritis bear little, if any, relation
  to true rheumatic disease, though often spoken of as rheumatoid:

  The _chronic villous_ form, most common in the knee, purely local,
  without effusion, and giving dry crepitus or creaking. The joint
  fringes are numerous, and sometimes vascular. If the crepitus be
  marked and the fringes too extensive the latter may be relieved
  by operation. Otherwise this form is to be treated by early local
  stimulation, with some support, at least with a bandage.

  The _atrophic_ form, of unknown etiology, causing progressive and
  finally crippling swelling, with later atrophy. There is little if
  any fluid present. Here the changes occur in both bone and cartilage,
  with a tendency to abnormal calcification. In this form rest and
  hypernutrition, especially with normal proteids, are called for, and
  every possible stimulus to elimination through all the emunctories.

  The _hypertrophic arthritis_, by which cartilages are first thickened
  and then ossified, interfering with motion and with contour. This
  form causes great limitation of motion and sometimes pressure on
  nerves, with referred pains. It seems to have some relation to
  cold, exposure, and injury. Detachment of pieces of cartilage is
  not uncommon, so that there are loose bodies in the joint cavity.
  Treatment here consists of fixation, with improvement of nutrition
  and elimination. This form may subside under proper treatment.

  The _chronic, gouty arthritis_, with deposits of sodium urate in
  and around the joint tissues, with perhaps some bone absorption
  beneath them, which are not connected with the bone. In the digits
  entire phalanges may disappear by absorption. The treatment here is
  essentially constitutional and directed toward the gouty diathesis.


NEUROPATHIC JOINT DISEASE.

This received its first full and classical description from Charcot
in 1868. The term refers to joint lesions which follow and are
apparently connected with certain injuries and diseases of the spinal
cord, or the peripheral nervous system. The non-traumatic forms are
mostly associated with locomotor ataxia and syringomyelia. Some of
them have an abrupt onset, while others come on very insidiously.
Pain is usually notable by its absence, and the involved joints show
few, if any, evidences of hyperemia or inflammation. They become
unnaturally mobile and relaxed and usually much, sometimes enormously,
distended with fluid. The morbid changes within the joints comprise
imaginary combinations of atrophy and hypertrophy, with proliferative
formations in bone cartilages. Osteophytes and exostoses are met with,
and ossification may occur in the neighboring tendons and ligaments.
Surprising alterations take place in certain joints; thus, as shown
in Fig. 197, the head of the humerus may disappear and corresponding
changes may occur in other joints. While it is the knee which suffers
most frequently, no joints, not even those of the spine or jaw, are
exempt.

[Illustration: FIG. 196

Charcot’s disease of elbow.]

[Illustration: FIG. 197

Atrophic disappearance of bone after chronic joint disease.]

[Illustration: FIG. 198

Tabetic arthropathy. (Case of E. A. Smith.)]

[Illustration: FIG. 199

Neuropathic arthritis (tabetic joints). (Lexer.)]

Locomotor ataxia is a common disease, but syringomyelia has been
regarded as exceedingly rare. Nevertheless, Schlesinger has collected
130 cases of it, in one-fourth of which bone and joint symptoms were
present. That the nervous system is primarily at fault is made clear,
among other things, by the rapidity of involvement occasionally seen,
where, for instance, an entire limb becomes edematous, with every
indication of severe disturbance. In tabes the lower extremities
suffer more often than the others; the reverse is true in cases of
syringomyelia. While floating bodies in the joints and ossification
of the muscles and soft parts are common in arthritis deformans, they
seldom occur in the neuropathic lesions. Suppuration and necrosis are
rare in any of these forms, occurring more frequently in the finger
than elsewhere, and are probably due to infection of those areas
where sensibility is lost and trifling injuries less guarded against.
The neuropathic lesions are more commonly symmetrical, and are often
accompanied by a cretinic general appearance (Figs. 196, 197, 198, 199,
200 and 201).

[Illustration: FIG. 200

Skiagram of joints shown in Fig. 199. (Lexer.)]

[Illustration: FIG. 201

Arthropathy of syringomyelia. Left elbow, illustrating disintegration,
etc., without ulceration or suppuration. (Quenu.)]

The joint complications of syringomyelia are frequently characterized
by skin lesions which tend to suppurate, by sudden edema, occasionally
followed by phlegmon and even necrosis, also by other disturbances of
innervation.

Surgical treatment of these lesions is less discouraging than would
at first appear, as even in these patients serious wounds heal
readily, while in healthy tissues primary union may occur. The wisdom,
therefore, of incision, resection, or even amputation may be decided
on their merits, and there can be no objection to open drainage when
it would otherwise be indicated. Even in cases of spontaneous fracture
proper treatment usually gives good results, although the amount of
callus may seem disproportionate.

In any of the joints distorted by deforming osteoarthritis or
neuropathic lesions, the question of partial or complete resection or
exsection may be discussed upon its merits, since these operations,
when duly indicated, have often given satisfactory results, even in
elderly people.


=Diagnosis.=--Differential diagnosis will be made more easy by the
exclusion of syphilis and of the acute or ordinary infectious forms
of disease. The relative freedom from pain, the relaxation of the
joint structures, the large amount of fluid present, and the age of
the patient will aid in excluding all but the neuropathic elements
associated with spinal disease.


=Treatment.=--Treatment is rarely curative; usually it can be
palliative at best. Measures above mentioned, when they seem indicated,
coupled with mechanical support, by which the parts may be maintained
as nearly as possible in their proper position, will give the best
result. If the disease be monarticular, exsection will frequently
give a satisfactory result. Multiple lesions rarely permit of serious
operations.


HYSTERIA AND HYSTERICAL JOINTS.

A different form of distinctly neuropathic joint affection is the
so-called _hysterical joint_. This is characterized by the absence of
every objective and the presence of nearly every subjective symptom.
It occurs most often in young women and girls, follows perhaps some
trifling injury, and involves most commonly the joints of the lower
limbs. These cases are characterized by a disproportion between the
character of the complaint and the actual condition. Imitation of
organic trouble is a predominant feature of all hysterical complaints,
and is nowhere seen to better advantage than in these cases. The pain,
the tenderness, the loss of ability and even the muscle spasm and
muscle atrophy of genuine lesions will be simulated. So true is this
that diagnosis largely rests on the exaggeration of symptoms which
have no apparent existence. _Hyperesthesia_ is sometimes extreme, but
pertains usually to the waking hours. Rarely is there actual swelling
or thickening, or any objective evidence whatever of disease, save
perhaps muscle atrophy due to disuse. It is possible to have the
hysterical element as a complication of actual joint disease, but the
truly hysterical joints usually are easily recognizable.


=Treatment.=--The treatment of such a joint should be psychical as well
as physical. Sometimes appeals to reason, at other times to fear or
necessity, will be the wiser course. Restoration of self-confidence is
an important feature, and these are the cases where any form of faith
cure will produce its most brilliant results. Many of these cases are
bedridden, and need to have elimination stimulated in every possible
way. They also need sunlight, fresh air, massage, and renewed use of
the parts. Hyperesthesia is best treated by continuous application of
ice-cold compresses, intermitted perhaps daily for the purpose of using
the “flying cautery,” as already described.


GONORRHEAL OR POSTGONORRHEAL ARTHRITIS.

This condition may occur during the active stage of gonorrhea or
after its apparent subsidence. It was probably the discovery of the
pathogenic gonococcus by Neisser, in 1879, which gave to this lesion an
identity of its own, and induced the profession to _abandon the name
gonorrheal rheumatism_, by which it had been known. It has nothing to
do with rheumatism, and should not be linked with it in name any more
than in idea. In well-marked cases the gonococcus will nearly always be
found, usually in pure culture, in the joint fluid.

It appears in different degrees of severity, from a mere hydrops,
which is mild, accompanied by slight tissue changes, to a phlegmonous
condition, with widespread destruction of joint structures and serious
constitutional disturbances. As between these extremes there may be
a pyarthrosis or empyema, which is usually the result of a mixed
infection.

As a complication of urethritis it occurs in 4 or 5 per cent. of cases,
the percentage being larger in children than in adults, the knee being
affected in about one-third of these cases. It is not necessarily
monarticular, however, and sometimes several joints will be involved.
Along with the joint condition there will frequently occur cardiac
lesions (endocarditis) and eye complications. In fact, some of these
cases terminate fatally through the mechanism of a seriously involved
heart, _i. e._, septic endocarditis or myocarditis. When it occurs in
the ankle or in the tarsal joints the ligaments and surrounding bursæ
are often involved. This involvement, unless recognized and properly
treated, may lead to serious deformity, _e. g._, flat-foot of the most
painful kind. Many of these lesions at the heel are accompanied by true
exostoses, which are often painful and more or less disabling (“painful
heel”). Thus, Jaeger has recently reported a group of ten such cases.
These may require excision. In general this form of arthritis is
characterized by severe pain, often worse at night, and a peculiar
distortion of the swollen joint, because it is usually complicated
by a distention of the adjoining tendon sheaths and bursæ, which is
rare in other forms of arthritis. It has been aptly stated that if in
these cases the same zeal were displayed in seeking for gonococci that
has often been shown in looking for uric acid it would be less often
neglected. So far as treatment is concerned, I desire in this place
only to call attention to the absolute inutility of all the so-called
antirheumatic remedies and diet. However, if the urine be hyperacid it
should be corrected by ordinary means. At first absolute rest, with the
local use of the ichthyol-mercurial or Credé ointment, should be given.
Such antiseptics as one has most confidence in may also be administered
internally for their general beneficial effect. An overdistended joint
should be tapped and irrigated. As soon as the presence of pus can be
determined, either with or without exploration, the joint should be
opened, thoroughly irrigated, and drained. If this were always done in
time the more severe phlegmonous and destructive cases would rarely
occur.


TUBERCULOUS ARTHRITIS.

Tuberculous disease of the joints is one of the most frequent of
surgical lesions. It has produced characteristic appearances which have
been known under the name of “scrofula of joints,” until a clearer
recognition of the pathology of the condition led to the abandonment of
the term scrofula. _Tumor albus_, or _white swelling_, was another term
commonly applied to these lesions, because of the anemic appearance of
the surface of the swollen joint.

_Tuberculous arthritis_ assumes different phases in proportion to the
involvement of the different component structures of the joint. Some
cases begin purely as a tuberculous synovitis, and may for a long time
be limited to the synovial structures. Others begin within the spongy
texture of the expanded joint ends of the long bones, the disease
spreading from such foci and involving everything in the path which its
products take in the effort to secure spontaneous evacuation, products
of softening and infection travelling in the _direction of least
resistance_.

It has been the writer’s custom to always follow Savory, in his
suggestion to students to let their mental pictures of consumption
of the lungs and pleuræ serve for illustration in similar disease of
joints. Thus the cancellous bone structure much resembles the lung
tissue in its spongy character. In both a capsule surrounds the mass
of tubercle, and in each, by breaking down of its contents, a cavity
is formed. Moreover, the pleura bears practically the same resemblance
and relation to the lung and the chest wall that the synovialis does
to the bone end and the joint cavity; as we may have pleuritis with
phthisis, so we may have synovitis with tuberculous ostitis; and as
adhesions tend to form in the pleural cavity, so also do they in the
synovial cavity. Furthermore, in each case obliteration of deeper veins
causes the more prominent appearance of the subcutaneous veins, and as
tuberculous pleurisy often terminates in empyema, so does tuberculous
hydrarthrosis often terminate in pyarthrosis, perhaps with fungous
ulceration. In almost every feature, then, the progress and effect of
tuberculosis in the lung and bone end may be likened to each other.

In some clinics bone and joint tuberculosis constitute nearly one-third
of the total of cases treated. Joints of the lower limb are the ones
most frequently involved in children, while in the adult those of the
upper extremity are generally attacked. It is not often that more than
one joint is involved at one time. The relation of traumatism to this
disease has been frequently discussed, and is variously regarded.
The disease is more common in those who are predisposed to it by
environment or by heredity, in the latter case hereditary evidences
usually being well marked. In such predisposed individuals, especially
in the early years of life, severe injuries are usually promptly
repaired, while the milder traumatisms, which are often frequent and to
which too little attention is paid, seem often to so far lower tissue
resistance as to favor an infection to which the individual is already
favorably predisposed. The true position to take, then, would appear to
be this, that _traumatisms rarely lead directly to joint tuberculosis,
but only indirectly by affecting tissue susceptibility_.

Thus lesions which begin in the epiphyses lead to what is known as
_osteopathic_ joint disease, while those which have their origin in
the synovia give rise to the _arthropathic_ forms. The former are more
common in children and the latter in adults (Fig. 202).


=Pathology.=--In regard to the pathology of these conditions it does
not vary from that mentioned in the earlier portion of this work in
connection with the general subject of Surgical Tuberculosis. The
deposit of tubercle in the tissue whose resistance has been weakened
is followed by the formation of granulation tissue, which, so long as
the germs survive, tends to increase and to make room for itself at the
expense of surrounding tissue. At the same time there occurs a tissue
struggle by which the attempt is made to throw around an active focus a
protecting barrier, which in soft tissues consists of condensed fibrous
and connective tissue, and, in bone, of a sclerotic capsule, as though
the intent were to imprison the disturbing cause, and, by completely
enclosing it, effect protection. When this attempt at encapsulation is
successful spontaneous recovery follows. It will be made successful,
to some extent at least, by treatment whose most important local
feature is physiological rest. On the other hand, when the attempt is
unsuccessful and the barrier is transgressed by granulation tissue, the
lesion will advance in the direction of least resistance, while its
progress will be made known, especially as it approaches the surface,
by very significant signs: adhesion of the overlying structures and
finally of the skin, with purplish discoloration of the latter. Finally
softening occurs with escape of granulation tissue, which, so soon as
it is freed from pressure, will grow more luxuriantly and with more
color, constituting the _fungous granulation tissue_, to which German
pathologists so often allude, or so-called “proud flesh.” When this
appears upon the surface it is soon infected with pyogenic organisms,
breaks down, and an abscess cavity results, connecting with the
original focus and its extensions. This may be so placed as to lie
outside the joint capsule, which, in some respects, is fortunate for
the patient. The joint function may then be compromised to only a minor
degree.

[Illustration: FIG. 202

Central sequestrum. (Ransohoff.)]

Often the direction of least resistance is toward the joint cavity,
this fungous tissue loosening and perforating cartilage or periosteum
before it enters the joint. Having penetrated it again it grows
extensively until the cavity is distended, its rapidity of growth
diminishing with the degree of pressure produced by its surroundings.
This pressure will also make it less vascular, and when such a joint
is opened it at first appears pale and anemic. In proportion as the
joint distends it loses in motility, while should recovery occur
spontaneously or as the result of treatment this tissue will to some
extent disappear, to be replaced by adhesions by which pseudo-ankylosis
is produced. The extent of the intra-articular involvement will cause
obstruction to the deeper return circulation, and thus is brought about
the prominence with which the subcutaneous veins appear. The degree of
hydrarthrosis is apparently not limited except by the distensibility of
the joint. In the articular or arthropathic forms there is always more
or less synovial outpour.

[Illustration: FIG. 203

Tuberculous panarthritis. (Ransohoff.)]

To the condition already described may be added the destruction
produced by suppuration, infection occurring either through the
circulation, as is quite possible, or through some trifling surface
abrasion. In more chronic cases _caseation_ may occur, especially in
bone foci. Finally, as the result of a combination of morbid processes,
there is produced more or less complete disorganization, all of
which is summed up in the term _tuberculous panarthritis_. To that
condition in which the articular surfaces are more or less studded with
fungous patches the term _pannus of the joint_ is often applied. To
reiterate, then, as between a chronic hydrarthrosis and a destructive
panarthritis, perhaps even with necrosis of epiphyses, it is but a
difference of degree and of combination of infectious processes (Figs.
203, 204, 205 and 206).

Among the other consequences of panarthritis may be the formation of
_sequestra_ in or near the epiphyses, and such destruction as shall
lead to _pathological dislocation_, the latter being well illustrated
in Figs. 204 and 207. This dislocation is always the result of the
pull of muscles thrown into that condition of reflex spasm which is a
characteristic feature of this disease. It appears conspicuously at the
knee, usually as a backward subluxation (Fig. 207), and at the hip as
an upward dislocation, sometimes with more or less apparent migration
of the acetabulum. Another consequence of tuberculous hydrarthrosis,
which frequently persists even long after the subsidence of the acute
stage of the disease, is the occurrence within the joint cavity of
_rice-grain_ or _melon-seed bodies_, for whose presence it is not easy
to account. The generally received explanation is that they are the
result of fibrinous outpour, whose fluid portions have been absorbed,
while the remaining nearly pure fibrin is broken up into particles
and rounded off by attrition during the movements of the joint. They
may accumulate in astonishing amount, thus stamping the disease as
having a chronic rather than an acute character. After a time they
provoke a fresh outpour of fluid, as a result of the irritation which
they produce. This fluid is at first usually clear serum, but becomes
turbid or seropyoid, and, if infected, becomes pure pus, in which the
rice-grain bodies are dissolved or disintegrated.

[Illustration: FIG. 204

Bony ankylosis of knee. (Ransohoff.)]

[Illustration: FIG. 205

Section of bony ankylosis of hip. (Original.)]

[Illustration: FIG. 206

Tuberculous panarthritis, illustrating various types of degeneration
and destruction. (Lexer.)]

_Recovery is possible_ in many cases when the lesions have not advanced
too far. It is rarely ideal, and usually leaves some evidence of its
existence in limitation of motion, thickening, or other recognizable
symptom. Constitutional as well as local measures have much to do
with bringing about this result. It is for this reason that it is so
essential to take tuberculous-joint patients out of the environment
in which ordinarily they live and get them outdoors, exposed to
sunlight and benefited by the best of nutrition. _Rest, oxygen, and
hypernutrition_ are the three best general measures for combating these
conditions. When recovery does occur it is by the death of all active
germs, the absorption to varying extent of disease products, including
granulation tissue, and the organization into fibrous and cicatricial
tissue of the unabsorbed residue. No tissue which has been actually
disorganized is completely restored. The best that can be hoped for is
substitution of fibrous or cicatricial tissue. Function may be more
or less completely regained. This will depend largely upon how early
treatment is instituted. In general it may be said that there is always
hope for tuberculous joints _if suitable treatment be instituted early
and if the environment can be made satisfactory_. Unfortunately this
is not often possible, and the best that can be hoped for is subsidence
of disease at the expense of more or less ankylosis, perhaps deformity,
while, at the worst, there may be loss of joint if not of life. It
might be misinterpreted should it be said that there is one kind of
treatment for the wealthy and another for the poor, yet so much does
depend upon what the patient or the parents can afford in the way of
change of surroundings that the whole plan of treatment often depends
upon the patient’s circumstances. Radical measures may therefore be
deemed best in those who cannot afford long delay and temporization,
while at other times expensive apparatus and change of residence may
bring about the desired result.

_The general appearance of a tuberculous joint_ is one of manifest
enlargement which is made more conspicuous by wasting of the limb above
and below. Nevertheless by actual measurement it will usually be found
to have a greater circumference than its fellow of the opposite side.
Its covering skin is pale and often glistening, with prominent veins,
while in proportion to the distention by fluid there will be more or
less distinct fluctuation. When the joint is evidently distended and
does not fluctuate the inference is that it is filled with granulation
tissue. There will also be marked thickening of all the articular
coverings, the synovial membrane itself being often as thick as sole
leather. At points where perforation may threaten there may be dimpling
and retraction of the skin, with fixation and discoloration.


=Symptoms.=--_Tuberculous joint disease is characterized especially by
loss of function, muscle spasm, muscle atrophy, pain and tenderness_
of rather significant character, and the other joint features already
mentioned. _Loss of function_ may be partial or complete. It depends
on the amount of tenderness and the deformity already produced by
muscle spasm. Motility is more or less restricted even under an
anesthetic. This is induced by actual limitation of motion by products
of exudation, by muscle spasm and wasting, and by the involuntary
shrinking of the patient when tender joint surfaces are pressed against
each other.

[Illustration: FIG. 207

Backward displacement of tibia due to the muscle spasm of a tuberculous
knee-joint, with final bony ankylosis. (Lexer.)]

_Muscle spasm_ is one of the most significant features of these cases
as well as almost the earliest. It is of the greatest diagnostic value,
and, if genuine, should never be neglected. It subsides under the use
of an anesthetic, hence it is not advisable to employ anesthetics for
diagnostic purposes. It produces at first fixation, without particular
deformity, but may lead later to this or to pronounced subluxation.
It is most helpful in the early stages when it does not particularly
interfere with a medium range of motion, and seems to lock the joint
before the extreme of motility is reached. Muscle spasm is pronounced
even after muscle atrophy is well advanced, and serves more and more
to fix joints until they are held by adhesions formed within. _Muscle
atrophy_ is also significant and begins about the time when diagnosis
becomes fairly possible, _i. e._, in the early stage of the disease.
With the advance of disease it becomes more pronounced and a joint
which is fixed by intra-articular lesions will stand out prominently
because of the notable wasting of the muscles by which ordinarily it
would be moved. It is this which gives the elbow and knee especially
their spindle shape. (See Plate XXXIV.)

_Pain_ is also a characteristic feature, especially that which is
produced by motion and allayed by rest and that which is accompanied
by involuntary muscle spasm, and occurs during sleep, _i. e._, the
so-called _osteocopic or starting pains of tuberculous panarthritis_.
These occur most distinctively in children, but may be complained of at
any period of life. Children thus affected will cry out sharply during
their sleep and appear for a few seconds very much distressed, and yet
do not awaken sufficiently to recall or describe their sensations.
The explanation of this phenomenon is a sudden reflex spasm of the
muscles by which tender joint surfaces have been suddenly pressed
tightly together and pain thereby provoked. Something of this kind may
occur in syphilitic bone disease, but, taken in connection with the
other signs and symptoms above mentioned, such pains are practically
pathognomonic.

The various measures to which orthopedists and surgeons resort for
employment of traction, by splints or weights, are directed against
overcoming muscle spasm by tiring out the muscles. It must not be
thought that by any reasonable degree of traction joint surfaces are
actually separated widely from each other. All that it is expected to
accomplish is by a steady pull to exhaust the muscles, and prevent them
from thus exercising deleterious pressure by pulling joint surfaces
together.

The pain complained of is by no means necessarily limited to the joint
involved; in fact, some of the most significant pains are those which
are described as _referred_. These furnish illustrations of the fact,
well known to physiologists, that _irritation in the course of a nerve
is referred to its distribution_; thus in hip-joint disease most of
the pain will be centred in the knee, and when the knee is involved
the ankle will be the part to which the patient will refer much of his
discomfort.

There also comes an overuse of the unaffected joints of a limb by which
the diseased joint may be spared as far as possible. The flexors, as
a group, being always stronger than the extensors, the former will
overcome the latter in time, and these joint _contractures are a later
expression of chronic muscle spasm_. This is true even when atrophy is
well advanced.

Tuberculous joint disease usually has at first no particular
constitutional complications. These come on later in proportion as the
general health suffers from the confinement entailed by the disease.
General health will suffer quicker when the lower limb is involved
than when it is the upper. By the time joint lesions are well advanced
careful observation will usually reveal a rise of evening temperature
and progressive anemia. The symptoms included under the term _hectic_
are those belonging to the destructive stage and are due to a
combination of causes in which auto-intoxication figures largely.


=Diagnosis.=--Tuberculous joint disease is usually easy of recognition,
except perhaps in the earliest stages. (See the general subject of
Orthopedic Surgery.) Differential diagnosis between this condition and
syphilis, or between it and hysteria, has occasionally to be made,
and may at first cause some difficulty. An hysterical hip or knee may
so strongly simulate tuberculous disease as to lead one at first into
serious doubt. Again, as between the tuberculous and non-tuberculous
forms of hydrarthrosis, there may often be doubt, even after aspiration
and examination of the fluid. In fact, that which began as one may
terminate as the other. Fortunately in these last cases local treatment
is about the same for each, and, while the question of diagnosis
may never be absolutely satisfactorily decided, the patient may
nevertheless recover in either event.


=Treatment.=--The treatment of tuberculous arthritis should be both
local and general, one being about as important as the other. The
general treatment for this as for every other tuberculous disease may
be summed up as follows: The remedies for tuberculous disease are
_oxygen_ and _hypernutrition_. The best place for the patient is the
place where these means can be procured. As explained above, this
will, to a considerable extent, depend upon the circumstances of the
patient or the family. When it can be afforded a high altitude is
almost as good for joint tuberculosis as for that of the lungs. The
nearest approach that can be made to it will be the most desirable.
Hypernutrition will in some cases consist almost in forced feeding.
Here as elsewhere in tuberculous disease it is of at least theoretical
as well as of practical advantage to saturate the system with some
bactericidal remedy, if such there be, and for obvious reasons.
Creosote or its congeners, in more or less palatable form, seem at
present to best serve this purpose. In addition to this arsenic, iron,
and the iodides, the latter especially if there be any suspicion of
syphilitic complication, can be used to advantage. In proportion as
patients become confined to the house their elimination is usually
restricted. All measures then by which elimination may be improved will
be indicated.

The use of _tuberculin_, or some of its modifications, has been
occasionally followed by excellent results. It is an agent to be
employed with great discretion, but is well worth a trial in those
cases where its effects may be carefully watched.

_Locally_ the most important measure is the enforcement of
_physiological rest_ of the affected parts. This may imply confinement
to bed, especially when the spine, the pelvis, and the hip are
affected, but should be reinforced by mechanical contrivances, by which
traction or “_extension_” may be carried out. The purpose of traction,
as mentioned above, is to overcome muscle spasm and thus ensure rest.
It is effected by many of the orthopedic apparatuses. (See chapter
XXXIII.[32]) It may be enforced by fixed dressings of plaster, etc.

  [32] The fundamental idea expressed in all of the methods for
  enforcing rest by traction is of American origin, and constitutes
  one of the advances in surgery for which the world is indebted
  to America. For a long time it was referred to in Germany as the
  American method, and yet now the Germans claim so much for it that
  one of their surgeons has written a book of 600 pages devoted to the
  employment of traction for various surgical purposes, in which but
  very little credit is given to the men who originated it.

[Illustration: PLATE XXXIV

Normal Knee-joint. (Child, seven years old.)

Tuberculosis of Knee, with Partial Dislocation.

(Child, seven years old.)]

With a better appreciation of the pathology of the condition numerous
methods were devised by which the germs should be attacked _in loco_.
Thus various antiseptics have been injected in varying strengths,
either into joint cavities or around them. Lannelongue devised a
“sclerotic method,” by which zinc chloride solutions were injected
into the peri-articular tissues, to so condense and harden them as to
imprison and destroy their contained germs. The method, however, is
an extremely painful one and has not found general favor. For a long
time iodoform was employed for the same purpose, in emulsions of 10
per cent. and 20 per cent. strength, in sterilized glycerin or olive
oil. It affords a curious paradox that the iodoform itself must be
sterilized before being thus used. This emulsion has been injected
into the peri-articular tissues or into joint cavities, which, when
containing appreciable amounts of fluid, should be first emptied and
washed out; all of which can be done through the same small trocar used
for introduction of the iodoform. The verdict of surgeons today is
rather against the employment of iodoform, since they have learned to
not rely upon it because of disappointment so often following its use.

Bier, in 1891, advised the so-called _congestion treatment_ of
tuberculous joints, basing it upon the fact that tuberculosis does not
develop in lungs which are the seat of venous stasis from valvular
heart disease. He proposed to produce an artificial stasis, in the
joint structures and about them, by which living germs should be
destroyed and their disease products encapsulated, claiming that as
the result of the hyperemia thus produced the alexins are thus brought
into more complete contact with the bacilli. The method is applicable
to the limbs below the shoulder and hip. It consists in the application
of an Esmarch bandage above the affected joint, applied with sufficient
firmness to obstruct the returning blood, but not to interfere with
the arterial supply. If there be room the limb is also bandaged below
the joint with an ordinary cotton roller. This congestion is kept up
at daily intervals for increasing periods, beginning with perhaps half
an hour and continuing until it is in operation at least half of the
time. Meantime other methods of treatment are not interdicted. In the
earlier stages of tuberculous joint disease this method has given very
encouraging and pleasing results. (See Fig. 208.)

_Tuberculous hydrops_ may be treated by aspiration and elastic
compression. Should fluid distend the joint it should be opened and
thoroughly cleaned, then closed and perhaps drained.

The treatment of _pyarthrosis_ and of _peri-articular cold abscess_
has long been a mooted subject. The orthopedic surgeons still adhere
to mildly or absolutely non-operative measures, whereas the general
surgeon prefers to adopt more radical methods. Each case should be
judged on its own merits, and these should include a careful estimation
of the general condition of the patient. Should evidences of septic
intoxication be present or the ordinary general signs of the presence
of pus, then these collections should be opened and cleaned out. If
hectic can be excluded, then other considerations will indicate what
is best. At all events there will be seen many cases where a delay
in operation will be advisable, in order to permit of improvement of
the general condition by measures above described. To merely open
up a tuberculous focus and leave at least two fresh raw surfaces
exposed to contamination is rather to invite the spread of the
disease than to correctly meet the indication. Every old focus will
be lined or surrounded with a more or less dense membrane formerly
called _pyogenic_, but now more correct knowledge shows it to be
_pyophylactic_. (See p. 113.) To leave this _in situ_ is to leave
germ-laden walls, while to dissect it thoroughly is to make a larger,
fresh raw surface and to open up innumerable absorbent vessels. Thus,
whether it be removed in whole or in part, or allowed to remain, some
sufficiently strong caustic material should be promptly employed, by
which both destruction of living residual germs and closure of the
mouths of the absorbents shall be effected. This has been set forth
more fully when dealing with cold abscesses in general, but is of so
much importance that it may be reiterated here. Whether the actual
cautery, pure carbolic acid, strong zinc chloride solution, or some
other agent be used should depend upon circumstances, but every portion
of the surface which it is proposed to leave more or less exposed to
the possibility of infection should be thus protected. In proportion
to the intensity of the caustic action there will be separation of
more or less cauterized and sloughing material, for whose escape
provision should be made; but it will be separated by the granulation
process, aided by an active phagocytosis, and when removed will leave
a granulating surface which is but slightly absorbent. These facts
pertain to small incisions for drainage as well as to extensive
arthrectomies.

_The operative treatment_, then, of tuberculous arthritis varies
from tapping, with or without drainage, to complete arthrectomy or
amputation. When the joints of the foot or ankle are extensively
diseased, and the patient, as usually happens, is in poor condition, it
may appear that amputation will afford the most complete relief, and
that a stump with an artificial member will be of much more use to the
individual than a mutilated, tender, and disabled foot.

[Illustration: FIG. 208

Calcified mass in old “cold abscess” about hip-joint. (Buffalo Clinic.
Skiagram by Dr. Plummer.)]

To incision with or without drainage is given the name _arthrotomy_.
When the joint is widely opened and portions removed with the sharp
spoon or otherwise, it is known as _arthrectomy_. When bone is
removed irregularly the measure is called _atypical resection_. When
entire bone ends are removed the operation becomes an _exsection_ or
_resection_. The ordinary arthrectomy is not sufficient when foci are
present in the epiphyses. Here at least atypical resection is called
for. Arthrectomy may properly include a wide exposure of articular
surfaces and the removal of the thickened and diseased synovia, with
its fringes, or with the cartilages, by which cancellous structure is
more or less widely exposed. When arthrectomy is undertaken it should
be thoroughly made and by a large incision, since the more completely
the joint cavity can be inspected and attacked the better are the
interests of the patient subserved. All fresh or cold abscess cavities
which connect with the joint or lie in contact with it should also be
attacked at the same time, and those which do not communicate with it
should be separately drained. While drainage by tube or other means
will usually suffice, there are cases where the disease is so extensive
that it will pay to pack the cavity with balsam gauze for a few days,
placing secondary sutures by which the incision can be closed after its
removal. In the shoulder and hip, for instance, such a method will give
satisfactory results.

The advantage of avoidance of resection is the non-interference with
the epiphyses and their junctions, thus permitting the growth of the
bone to continue. _Therefore complete and typical excisions should be
practised as seldom as possible, especially in growing children._ They
may be practised to advantage even in advanced age, and the writer
has seen satisfactory results after complete excision of tuberculous
joints in senile cases. When operating upon a tuberculous tarsal joint
the surgeon is likely to find one or more of the tarsal bones so much
involved in the tuberculous disease that he is compelled to scrape it
out and thus leave a cavity almost the size of the bone itself. Should
he have to do this to a series of the bones it would be better to make
a formal resection of the tarsus or possibly an amputation. The cavity
should be left open with a sufficiently large incision so that it may
be easily packed. A cavity of this kind left unpacked will fill up
with clot, which will disintegrate and the result will be much less
satisfactory. In the former case there is an open cavity which fills
with granulations, but this can be kept accessible under observation
and with more effect and comfort. This is equally true of those
cavities where both arthrectomy and bone curettage have been practised.


MOVABLE BODIES IN THE JOINTS.

Several different terms have been applied to loose and movable bodies,
even in the various joints, depending on their size, arrangement,
and appearance. Thus we have the _rice-grain_ or _melon-seed bodies
(corpora oryzoidea)_, which have already been described and are
now supposed to indicate a form of tuberculous synovitis which has
undergone a partial if not complete subsidence. Again we have larger
masses occurring singly or in very small number, especially in the
knee, to which the Germans have given the significant name of _joint
mice_. Also in the knee, owing to its peculiar construction, another
form of movable body is met with, _i. e._, a displaced and more or
less _motile semilunar cartilage_. This condition was first described
by Hey, and especially studied by Allingham, who made it a prominent
feature of what he described as “internal derangement of the knee.”
Lastly, in those joints in which _synovial fringes_ occur, the knee
especially, it is held that portions may become detached by having
been infiltrated and cast off or broken loose, and thus form a fourth
variety of floating body. The joints most often affected are the
knee and the elbow. In many instances there is a history of injury,
especially when the mass is of considerable size. The theory of an
“osteochondritis dissecans” has also been invoked to account for the
resemblance between some of these bodies and the articular cartilages.
Some pathologists have held that they may result from the organization
of clots, which are subsequently rounded off and shaped by attrition
(Fig. 209). These bodies then may consist of condensed fibrinous
material, of cartilage, of true bone, or of hyperplastic and fatty
synovial tassels. To these may be added rare instances of mucoid
connective tissue.

[Illustration: FIG. 209

Floating bodies--“joint mice”--from knee-joint. (Lexer.)]


=Symptoms.=--_Rice-grain bodies_ may be suspected in cases of chronic
tuberculosis and often in arthritis deformans, while in many instances
they may be felt gliding beneath or between the joint structures. A
perfectly loose _floating body_ will produce symptoms which are quite
distinctive. They consist of sudden and intense pain, with such muscle
spasm as to fix the joint and prevent its use, thus “locking it.”
Occurring at the knee the individual is instantly disabled, but usually
learns by some peculiar manipulation, with or without assistance, to
“unlock” the joint, and after a few moments to resume its use. Such a
complaint as this should always suggest the condition. Patients who
have had it for a long time learn how to avoid it as well as how to
relieve it, and will often discover and be able to indicate to the
surgeon the existence of a movable body, and even to describe its usual
resting place.

Partial or complete _dislocation of a semilunar cartilage_ in the knee
is usually the result of traumatism, a distinct history of which can
generally be obtained. It may not have been discovered at the time,
owing to swelling or tenderness, but will produce its peculiar symptoms
later, _i. e._, after use of the joint is resumed. Here, again, so
long as it remain in proper position, it interferes but little; with
a misstep or sudden movement, however, the patient is seized with
sudden and painful disability. Here the movable cartilage may be felt
projecting near its proper location. In such cases as these it is
movable only to a certain extent and makes no free excursion about the
joint. When not detected it may be suspected from the description which
the patient gives of his seizures.


=Diagnosis.=--So far as diagnosis is concerned, when a movable body
can be felt all doubt is set at rest. When it cannot be discovered
its existence may be inferred with an accuracy proportionate to the
patient’s description of his difficulties.


=Treatment.=--The treatment of rice-grain bodies is essentially that
of the chronic hydrarthrosis and probably tuberculous condition which
have led to their formation. It will consist usually in arthrotomy,
with thorough irrigation; often in some form of arthrectomy. With the
larger floating bodies, the “joint mice,” the most radical measures
are the best. In most of these instances there will be some degree at
least of hydrarthrosis. The joint cavity being distended and relaxed,
the indication for arthrotomy is the more urgent, since it will permit
also of irrigation or of dry sponging, with the same benefit with which
analogous intraperitoneal conditions are treated by the same measures.
The joint may be opened by a sufficiently ample incision, through which
the foreign body or bodies may be removed. The operator should not be
satisfied with mere removal of one, but should make a thorough search
for others which may have escaped previous detection.

Perhaps no operative measure in surgery better illustrates the
advantages of asepsis. This operation, which now can be done with
impunity, was in the pre-antiseptic era one which had a discouraging
fatality, death resulting from septic infection in about 40 per cent.
of cases.


FOREIGN BODIES IN THE KNEE-JOINT.

“Joint mice” are of sufficient frequency and significance to justify
brief separate consideration. According to Connell these may be grouped
as follows:

  Those composed of foreign material, fatty tissue, fibrous tissue,
  etc.;

  Those composed of bone, cartilage, or of a mixture of the two.

Among the many explanations offered are the following:

  Dry arthritis, with overgrowth of the margins of the cartilages;

  Bony growths, separation from their attachments;

  Infarct of the articular cartilage, with final separation;

  Plate of bone formed outside of the joint and then invaginated;

  Calcification or chondrification of enlarged synovial fringes;

  Irritation and growth of embryonal cartilage or bone cells in the
  synovial fringes;

  Concretions whose nuclei are clots, torn fringes, or some foreign
  body;

  Some portion of the articular cartilages broken off by injury, or
  damage and subsequent separation.

Injury figures largely in the opinion of most of the authorities, it
being well established that an injured portion of articular surface may
become subsequently detached by a fatty necrosis, spoken of by König
as osteochondritis dissecans, or by Paget as “quiet necrosis.” Others
imagine that these floating bodies are rarely of traumatic origin.

Symptoms are usually marked and significant. There is sudden sharp and
shooting pain, sometimes so severe as to cause faintness. Along with
this there is “locking” _i. e._, fixation of the joint, usually in the
flexed position, probably due to the entanglement of the floating body
between the articular surfaces or between the bone and the capsule.

[Illustration: FIG. 210

Ankylosis of hip with contracture of knee, following post-scarlatinal
arthritis.]

It is the smaller rather than the larger bodies which give the most
acute symptoms. This “locking” may last for only a few moments or for a
number of hours and may or may not be followed by acute effusion. When
with the above symptoms the presence in the joint of a movable mass can
be made out diagnosis is complete. Some patients discover the movable
body in their own joints before they go to the surgeon.

When the diagnosis is established the removal of the offending material
is imperative. In the pre-antiseptic era this was an extremely
hazardous operation. It is now one involving only theoretical risks.
These bodies are sometimes extremely movable and slip about within the
joint in a manner to almost defy removal even after the joint cavity
is open. If such a body can be felt and fixed by digital pressure, or
by the method of “stockading” suggested by Andrews some years ago, _i.
e._, fixation by forcing sterilized pins into the tissues around it
so that it cannot escape, it is then an easy matter to cut down upon
it and remove it. Otherwise incision may require to be sufficiently
ample to permit insertion of a finger and the general exploration of
the joint before it is encountered. These bodies sometimes exist in
small numbers, and it may be possible to remove several through a
single opening. If the joint be opened and explored it should be done
thoroughly in order that nothing may escape. After removal the capsule
is closed with buried sutures, the balance of the wound closed as
usual, and the limb then dressed upon a splint with absolute fixation
for several days, in order to ensure physiological rest (Fig. 209).


ANKYLOSIS.

The term _ankylosis_ implies _angular deformity_, but is used to
designate partial or complete fixation of joints, such fixation being
usually accompanied by more or less deformity or displacement. It is
a name for a condition and not for a disease, but is always produced
by the latter or by injury. The term itself implies nothing as to the
nature, extent, or appearance of the exciting cause. The actual cause
may have been disease of the joint, of the tissues around it, or may
have been the result of injury rather than of infectious or other
active disease.

For convenience we speak of _fibrous_, _false_, or _pseudo-ankylosis_,
and of that which is _bony_ or _actual_. A more accurate use of terms
would lead us to refer to the former as contracture rather than true
ankylosis.

_Contractures_ are the result of acute, usually septic intra-articular
and peri-articular processes, where muscle spasm is a pronounced factor
and where the intensity of the process has more or less weakened the
joint structures. The profession is hardly in the mood to accept
acute rheumatism as an infectious process. If true or not the acute
rheumatic affections are frequently followed by fibrous ankylosis with
contractures. Disfigurements of this kind are often produced as the
result of the surface lesions of severe burns or ulcerations, followed
by cicatricial contraction and the formation of dense bands and scar
tissue. This is a condition which can always be foreseen and which
should be guarded against with very great care. (See Treatment of
Burns.) Contractures also occur as the result of certain diseases of
the spinal cord, either as the result of active contraction of one set
of muscles, or of paralysis, by which the opposing muscles are deprived
of resistance and thus draw the limb out of shape.

_True ankylosis_ is sometimes fibrous, sometimes osseous, and
occasionally both combined. The older the case the more probable is
actual osseous union of joint surfaces. Bony ankylosis implies a
sharply destructive type of arthritis, which may have been originally
of pyogenic, gonorrheal, or tuberculous character, or else indicates
a series of very slow ossific and calcific changes, such as are
connected with the osteo-arthritis already described. Many of these
cases are to be referred to lesions of the cord, and many of them are
of polyarticular character. Fig. 195, illustrating one of the cases of
so-called “ossified men” under the writer’s observation, will portray
a series of lesions of this kind, most of the vertebral as well as the
other joints being involved in an absolute osseous union.

[Illustration: FIG. 211

Bony ankylosis of hip. (Ransohoff.)]

[Illustration: FIG. 212

Bony ankylosis of knee. (Ransohoff.)]

[Illustration: FIG. 213

Bony ankylosis of hip with deformity. (Ransohoff.)]

When a joint is stiff bony ankylosis may be inferred. So long as
there is any motion possible it is essentially of the fibrous type.
The condition is one easy of recognition, and is seen in all degrees
of completeness. In many instances joint fixation is accompanied by
adhesions of tendons and tendon sheaths, while as time passes all the
structures around a joint thus fixed become less movable and more
stiffened. Even the patella may become firmly attached to the bony
surface upon which it normally rests, and thus interfere with motion
of the knee almost as much as though the femur and the tibia were
alone involved. Occasionally one of the acute exanthems is followed
by contractures of a joint, with or without actual joint lesions,
by which when neglected distressing deformities are produced; such,
for instance, as partial flexion and fixation of the knees, or such
stiffening of the hips as to prevent the thighs from being separated.
While in such cases stiffening cannot always be prevented, deformity at
least can be if suitable measures instituted sufficiently early.

Figs. 211 and 212, from Ransohoff, illustrate osseous union in the hip
and the knee, while Fig. 213 illustrates the deformity which may be
produced by contractures and ankylosis at the hip.

The following tabular presentation of the types of ankylosis will
perhaps convey the greatest amount of information in small space:

                 {               {Capsular
                 {Peri-articular {              { Tendinous
  Ankylosis,     {               {Extracapsular { Tendovaginal
  true and false {               {              { Muscular
                 {          {Synovial
                 {Articular {Cartilaginous
                 {          {Osseous

Murphy has prepared the following table of the types of arthritis which
lead to some of these varieties, and which may be classed as follows:

            {(_a_) Primary hematogenous fibrous arthritis
            {(_b_) Dry fibrous arthritis. Non-traumatic
            {                                  {With fracture
            {(_c_) Traumatic fibrous arthritis {into joint
            {                                  {Without fracture
            {                                  {(contusion)
            {                  {             {Cryptogenetic
            {                  {             {           {Typhoid
            {                  {Hematogenous {Metastatic {Scarlatina
  Arthritis {                  {             {           {Pyemia
            {                  {             {           {Gonorrhea
            {(_d_) Suppurative {             {Traumatic
            {                  {          {         {Tuberculous
            {                  {          {Osteitis {Osteomyelitic
            {                  {Extension {         {(infective)
            {                  {          {Peri-arthritis (phlegmon)
            {                  {          {Panarthritis
            {(_e_) Ossifying arthritis (primary)
            {(_f_) Static adhesive


=Treatment.=--The best method of treatment should be determined by
the original character of the exciting cause, the duration of the
condition, the amount of deformity present, and the degree of joint
fixation. That which will be possible if done early will be useless
if not resorted to until the case is old and chronic. In every acute
or subacute condition which may threaten ankylosis every possible
precaution should be taken to prevent it. If ankylosis be inevitable
it should occur with the limb in the most suitable position. At the
elbow, for example, this will be the right-angle position; at the knee,
one with the leg almost completely extended. In the lower extremity
traction with weight and pulley will serve a useful purpose in many
instances, either to overcome a threatening condition or to improve
one actually existant. Mechanical measures (_i. e._, use of various
splints or forms of orthopedic apparatus) will sometimes be of great
use. These may be arranged for the purpose of providing absolute rest,
with fixation in a desirable position rather than in one which is
undesirable, or they may be made with such devices as shall permit of
frequent change of position.

The mildest operative measure which can be practised in these cases
is manipulation, either gentle and frequent, combined with massage,
or more violent and painful, such as requires anesthesia for its
performance. The question of when to resort to these manipulations
is one calling for the soundest judgment, as on one side the surgeon
faces the possibility of setting up a renewed and more or less acute
disturbance, and on the other of seeing a joint gradually stiffen,
perhaps in a bad position. There is also a third difficulty, _i.
e._, the necessity for continuing motion in order to prevent the
re-formation of adhesions, and this in spite of the fact that it may
be intensely painful to the patient. Fortunately, however, the use of
nitrous oxide anesthesia usually permits this to be done as often as
may be necessary with a minimum of discomfort.

Firm, fibrous ankylosis will be attacked with great hesitation by the
experienced surgeon. Even though he may succeed in restoring the limb
to a better position, he may feel quite positive that the patient
cannot undergo the pain of the subsequent frequent handling. With
bony ankyloses he may feel that nothing short of radical measures
will suffice. Here it is rarely a question of restoring motility but
rather of overcoming deformity. At the knee a wedge-shaped portion
of the joint may be removed, its angle corresponding to the angle of
deformity, and thus a crooked leg may be restored to the straight
position; in fact, with a raised heel under such a limb it may be
made almost as useful as ever. At the hip one may do a subcutaneous
osteotomy, dividing the femoral neck either with chisel or with a
small and protected saw, and then bringing the limb down into the
normal position of extension, allowing the bone to repair itself, and
effecting improvement only in position, or, by constantly moving it,
securing a false joint; or a more formal exsection may be made and
by removing the head of the femur and clearing out the acetabulum a
degree of motion may be established at this point. At the wrist, elbow,
and shoulder-joint resections will usually give good results if the
operation be performed before the muscles have almost disappeared by
atrophic processes.

Danger attaches to the performance of the so-called bloodless
operations, in that there is a possibility of laceration of nerve
trunks or of large vessels which may have become fixed in the condensed
tissues and be torn with them. There is more danger of this perhaps
at the knee than in other joints, and ruptures of the popliteal
vessels and nerves have been repeatedly reported. The first attempt in
breaking up such a joint should be to increase the degree of flexion.
If by efforts in this direction the tissues can be first released,
then there is less danger of their yielding when extension is made.
Another danger which threatens in all resistant cases, and especially
in elderly people, is fracture of bones. The writer has seen the upper
end of the tibia as well as the neck of the humerus yield under these
circumstances. In the latter event one should endeavor to prevent bony
union, and thus to gain a false joint in place of the original.

In regard to the nature of the operative attacks upon the above types,
the following is copied from Murphy:[33]

  A. Extracapsular   {1. Tendon elongation (tendoplasty).
     disease         {2. Tendovaginitis (exsection of sheath).
                     {3. Cicatrices (removal).

  B. Intracapsular   {1. Adhesive synovitis (exsection of capsule).
                     {2. Replacement by aponeurosis or muscle.

                     {1. Disconnect bones.
                     {2. Remove neighboring bony processes or
                     {   prominences.
  C. Osseous         {3. Liberate soft parts.
                     {4. Prevent subsequent bony contact.
                     {5. Interpose tissue to form hygroma or fibrous
                     {   surface.

                     {1. Mandibular.
  D. Joints suitable {2. Hip.
     for operation.  {3. Shoulder.
                     {4. Elbow.
                     {5. Knee.

                     {1. Flap formation (skin flap with fascia, or
                     {   muscular).
                     {2. Exposure of ankylosed area.
                     {3. Osseous separation.
  E. Technique       {4. Transplantation and fixation of interposition
                     {   flap.
                     {5. Replacement of bone.
                     {6. Fixation of parts.
                     {7. Drainage.

                     {1. Passive motion
  F. Subsequent      {2. Active motion.
     treatment       {3. Forced traction.

  [33] Journal American Medical Association, May 20, 1905, p. 1573.

To the various expedients which may be adopted for making stiffened
joints more useful may be given, in a general way, the term
_arthroplasty_. A variety of mechanical contrivances have been resorted
to in the past, operators hoping to be able to secure, for instance, a
movable knee instead of one which is stiff. Artificial joints, made of
celluloid, ivory, etc., have been used for experimental purposes, but
while occasionally they have given good results in animals, they have
rarely been satisfactory in man. For the prevention of re-adhesion,
plates of celluloid, thin metal, gutta-percha, rubber, etc., have been
used. These are either wrapped around a bone end or are used for lining
a bone cavity, and rapidly accumulating experience is showing that this
may be done with great benefit.

Thoroughness of operative work is one of the important contributing
agents to the securement of wide range of motion, especially in
complete removal of synovial membrane, capsule, and ligaments. Soft
parts should be liberated thoroughly. Of the materials which can be
interposed between bone ends in order to prevent reunion, muscular
aponeurosis, with a certain amount of fatty tissue, makes the best
material for interposition. When aponeurosis cannot be secured, then
muscle should be tried, with some fat, as the former flattens out and
undergoes structural changes, with conversion into fibrous tissue.

It should be represented to the patient as a legitimate scientific
experiment, and in such a way that no matter what may happen no blame
can be attached to the operator. In general it may always be stated
that the older the lesion the less satisfactory will be any measure of
treatment except possibly resection and arthroplasty.


ARTHRODESIS.

This term applies to the intentional production of ankylosis in a joint
previously healthy or nearly so, with the intention of stiffening a
useless limb and thus enhancing its usefulness. The measure applies
mainly to those cases of infantile paralysis, with loss of control
of the knee or ankle, or both, when by stiffening the limb it can
be made to serve the purpose of a crutch. It is the last resort in
this direction when there is no possibility for tendon grafting. Long
confinement of a limb in a fixed dressing will lead to considerable
stiffening of the joint, yet a joint so immobilized lacks that firmness
of support called for in cases above mentioned. Therefore when it
is desired to perform arthrodesis the joint is usually opened and
more or less of its articular surface removed, the intent being to
produce the effect in the shortest time and in the best way. It can be
better attained by a removal of articular surfaces with the saw and
the apposition of fresh bone surfaces to each other, their retention
being ensured either by sutures (tendon or wire) or accurate fixation
in plaster of Paris. Under these circumstances drainage should not be
necessary, and limbs can be completely enclosed in a fixed dressing.


MAJOR OPERATIONS ON JOINTS.

Aside from arthrotomy and partial or complete arthrectomy, as above
mentioned, the latter, including removal of synovia or cartilage, and
perhaps curetting of bone foci, the formal _resections_ or _excisions
of joints_ remain to be considered. The latter is the preferable term,
as it is meant to include removal of the component parts that enter
into the construction of joints, while the term resection implies
rather the removal merely of portions of bone.

_Joint excisions_ are practised especially for the following purposes:
(_a_) To atone for the result of old unreduced dislocations; (_b_)
in certain compound dislocations, with or without fracture; (_c_) in
certain comminuted fractures where there is no prospect of recovery
with useful joints; (_d_) in the destructive forms of acute arthritis
where the entire joint is disorganized and the bone ends carious;
(_e_) in tuberculous arthritis or panarthritis, with or without
suppurative complications; (_f_) in occasional instances of disabling
osteo-arthritis; (_g_) for relief of ankylosis, either for improvement
of position (knee) or restoration of motion; (_h_) occasionally after
gunshot injuries. _Excisions required by the exigencies of traumatisms
should be promptly done._ If the case be complicated with septic
infection the prognosis is much less favorable. For convenience of
description excisions may be classified as _primary_, _intermediary_,
and _secondary_. According to the joint involved, as at the knee, the
purpose underlying the operation is to effect an absolutely rigid bony
ankylosis.

The development and perfection of the general method of joint excisions
is a matter of but little more than a century. Previous to that time
amputation was almost the only resort when destruction had occurred.
The most prominent surgeons in the early development of the measure
were Park, of Liverpool, and Moreau, of France. During the latter part
of the past century Ollier, of Lyons, greatly improved the technique
by demonstrating the importance of the periosteum and by introducing
the so-called _subperiosteal methods_. This is of great value in
_uninfected_ cases. It is a mistake, however, to endeavor to save
periosteum which has become involved in the tuberculous process; in
fact, in the presence of tuberculous disease we cannot be too radical
in the removal of all affected tissue.

In the so-called subperiosteal method the operator endeavors, so far as
possible, to preserve the periosteum of the parts exposed to attack,
and, if possible, the capsular ligament as well. Thus at the elbow the
capsule, _if not diseased_ or obliterated, should be preserved, the
osseous tissue being shelled out from within, so far as possible. The
less, then, the connections between the capsule and the periosteum
are disturbed the better. The French apply to this method the term
“subcapsular periosteal.” When the bone covering can be preserved new
bone is easily formed to replace that which has been lost, especially
during adolescence, while the preservation of the capsule, with its
ligamentous connections, affords a better joint cavity than will the
substitute which results from natural processes. Furthermore the
surrounding tendons are less disturbed and the condition remains more
like the original. Nevertheless one does not exsect healthy joints,
and the method is not always easy nor even possible of performance.
It will suffice to say that it should be adhered to only as far as
circumstances may justify or permit.

Surgeons, however, have not been satisfied with the older methods, and
have endeavored to still further enhance motility in operated joints.
(See above--Arthroplasty.) To this end the interposition of muscle,
fascia, or of foreign membrane has been suggested. Thus, after removal
of the head of the femur a strip of fascia lata may be interposed
between the raw-bone surface and the cavity of the acetabulum, being
fastened there by catgut sutures. In the shoulder a similar procedure
has been carried out, utilizing a strip of deltoid muscle. At the
elbow a piece of the pronator radii teres may be detached and fixed by
sutures to the brachialis anticus. In every case the method should be
adapted to the demands made, the intent being to cover divided bone
ends with tissue which will prevent osseous union, as it is known
to do in many cases of fracture where such interposition produces
non-union. In so far as one attempts here to imitate conditions which
are considered undesirable in certain other traumatisms, Murphy has
done more than any other American surgeon, both in the experimental and
clinical study of this subject. (See above.)

For the joints below the hip and shoulder the _bloodless method_ will
facilitate operative work. In case of a septic joint, however, it would
not be advisable to apply the elastic bandage below and then over and
around the joint, as by the pressure thus made some septic material
may be forced into the absorbents. In clean cases the rubber bandage
is a great advantage to the operator. It has this objection, however,
in that hemorrhage which does not occur during the operation has to be
checked after its conclusion, and I have often thought it advisable to
avoid the use of the bandage and to secure vessels as they are divided,
in order that when bleeding has once ceased there be no fear of its
recurrence later.

The question of _drainage_ is one of importance. In a general way one
may feel that in an absolutely clean case drainage is not required,
save possibly a small opening for escape of blood. If practised at all
it should be thoroughly done. Drainage tubes are often too small and
do not permit the escape of either clotted blood or debris of injured
tissue.

The _after-treatment of excisions_ demands, first of all,
_physiological rest_ of the part involved, especially if, as at the
knee, sutures or other expedients for maintaining apposition have
been inserted. When motion is sought there will soon come a time when
passive motion can be begun. This will vary with the size of the joint
and the magnitude of the procedure. Actual rest should be maintained
until firm wound healing has been secured. Passive motion is then
begun, to be practised daily, the sensation of the patient being the
guide as to the range of the movement and extent of manipulation. Thus,
after exsection of an elbow with prompt union of the wound passive
motion should be begun in about two weeks, but it should not be begun
for a month if the joint has been thoroughly disorganized and the
cavity is still discharging. Motion should be begun as early as is
considered feasible in order to guard against a false joint.

_The remote consequences of joint excisions_ are usually very
satisfactory. The best results are obtained in the young, _i.
e._, those whose tissues are still undergoing natural changes and
whose bones are growing. In the course of time, by condensation of
surrounding tissues, a new joint capsule is formed, its interior
smoothed off, apparently covered with endothelium and filled with a
sufficient amount of fluid, similar to that of normal joints, to serve
the purpose; in this way a new joint becomes gradually substituted
for the old, which serves the original purpose, in a surprising and
gratifying way. Even in those of advanced years a satisfactory result
is often obtained. It is often necessary to afford some support, by
which too great a range of motion may be avoided; thus at the elbow the
result at first is what may be called a “flail-joint,” which permits
much undesirable lateral movement. This can be avoided by having light
leather corsets fitted to the forearm and arm, connected by two lateral
hinged braces. This being constantly worn, and no motion permitted
which is not an imitation of the normal, the parts in time adapt
themselves to the purpose, so that all apparatus can after a while be
removed.

Excisions, like amputations, may be practised and the general methods
learned on the cadaver, but their actual performance in the presence
of extensive disease will be found to be a different procedure from
that learned upon the dead body. For reasonably representative cases
typical operations can be devised, with explicit directions. It is
not advisable to try to do such work through too short incisions. A
long incision heals as kindly as one shorter and affords more room for
operative work. The incision should be so planned and executed as to
afford the maximum of exposure with the minimum of damage to important
structures. The region of the great vessels is avoided in all the
classical operations, while nerve trunks, if exposed, are retracted and
kept out of harm’s way. After the knife has once laid open the joint
it is used but little except for the division of resisting structures,
_e. g._, ligaments. The greater part of the work is then done with
elevators, or periostomes with reasonably sharp edges and sufficiently
broad surface, so that the periosteum can be divided with the latter
and separated with the former to the necessary extent. Obviously
epiphyseal junctions should be spared whenever possible, especially in
the young. To remove an entire epiphysis is to materially impair the
later growth of the limb. In some of the most serious cases it will be
found already loosened and lying as a sequestrum in the joint cavity.
In this case it may be easily lifted out of place. Tendons should never
be divided unless absolutely necessary. Incisions in their neighborhood
should be so planned as to be parallel with their direction and permit
their displacement without division. The sharp spoon should be employed
for curetting the interior of a joint capsule or cleaning out a bone
focus (erasion). A capsule involved in tuberculous disease should
be completely extirpated. Diseased bone ends should be sufficiently
exposed to permit of the use of an ordinary saw or a chain or wire
saw.[34] Considerable force will often be necessary in making bone ends
accessible for this purpose. The chisel is rarely used except in cases
of bony ankylosis, where it is not possible to force bone ends through
the opening in order to attack them with the saw. As remarked above,
clean cases may be closed without drainage. Visible vessels should be
secured, and, while a certain amount of oozing may be expected, if
the part be enclosed in suitable compressive dressings and elevated,
it need not cause alarm. The gentle application of an elastic bandage
for three or four hours may afford additional security. It should
not, however, be allowed long to remain. The terminal portion of the
limb will always afford an indication as to the condition of the
circulation. Should it become cyanotic or cold the dressing should be
renewed and the wound examined promptly.

  [34] Wyeth’s “exsector” is an admirable substitute, especially at the
  shoulder and hip.


=Special Incisions.= =The Shoulder.=--A longitudinal incision suffices
for most cases (Fig. 214). This may be made posteriorly between the
fibers of the deltoid or anteriorly and externally over the bicipital
groove. It is better to separate the deltoid fibers than to divide
them, although they may be divided. Should the straight incision
afford insufficient room another incision at right angles will afford
ample access. The capsule, having been exposed, is opened, the wound
widely separated with retractors, the arm rotated through a wide
arc, while with a stout knife the capsular ligament and the various
muscular attachments around the neck of the bone are divided. The
greater and lesser tuberosities, with their muscles undivided, should
be retained, when circumstances permit. The head of the bone, being
freed, is dislocated and forced out through the wound, where it may be
seized with large forceps and removed with a saw. The higher the bone
is divided the better. Every other consideration, however, should be
sacrificed to removal of all foci of disease. The capsule may then be
extirpated and the glenoid cavity thoroughly cleaned out with a sharp
spoon. Should the case be one of serious infection it is advisable to
make a posterior opening, even through the deltoid, for purposes of
thorough drainage. The greater part of the first incision is to be
closed with sutures, the arm dressed in a comfortable position, with
the elbow at a right angle, and the patient allowed to be up and around
as soon as he feels in the mood for it.

[Illustration: FIG. 214

Excision of the shoulder: _A_, regular incision; _B_, supplementary.
(Ollier.)]


=The Elbow.=--Here a variety of methods have been advised, and the
extent of the operation must depend, to some degree at least, on the
nature and extent of the condition which necessitates it. Partial
excisions have been recommended, though in the writer’s experience
incomplete operations often give less satisfaction than those which
are complete. However, when it is a question of removing callus or
displaced bone fragments, which, after fracture into the joint, impair
its function, then partial resections may be serviceable.

[Illustration: FIG. 215

Excision of the elbow-joint: _A_, von Langenbeck; _B_, Ollier.]

[Illustration: FIG. 216

Excision of the elbow-joint: _A_, Nélaton; _B_, _C_, Hueter.]

[Illustration: FIG. 217

Osteoplastic method: _A_, by external incision; _B_, von
Mosetig-Moorhof.]

The essential incision is a long posterior one, which may be somewhat
modified (Figs. 215, 216 and 217). It is essential here to avoid the
ulnar nerve, which passes between the internal epicondyle and the
olecranon, and the vessels and nerves in front of the joint. If it be
made an inviolable rule to always _keep close to the bone_ both of
these dangers may be avoided. Ligamentous and muscular structures,
among the latter the anconeus, should be spared as much as possible.
After separating the joint surfaces thoroughly, by forced flexion,
it is usually easier to force out the lower end of the humerus and
first remove it, after which the upper ends of the radius and ulna are
exposed and removed. When there is bony ankylosis it is preferable to
divide the bones of the forearm first. The tendon of the triceps is
not only detached from the olecranon, but divided by the first long
incision. After concluding the incision, the capsule, if it remains,
is to be closed with chromic catgut sutures and the end of the triceps
tendon or some of its periosteal attachment united to the periosteum of
the upper end of the ulna.

The arm is now fixed in the right-angle position and held comfortably
to the body by a suitable sling.


=The Wrist.=--It is rare that in disease of the wrist-joint this is
found to be limited to a single bone of the carpus. Should an _x_-ray
examination indicate such limitation then the focus can be exposed and
cleaned by an incision upon the dorsum of the wrist, where it may seem
best adapted for the purpose. Suppurative and tuberculous affections of
the wrist usually necessitate removal of the carpal bones, including,
possibly, the lower extremities of the ulna and radius. When the
wrist-joint is involved it may be sufficient to remove the latter with
the first row of the carpus.

Fig. 218 illustrates the incisions to be recommended for wrist
resection, of which the Langenbeck line is to be preferred.
Occasionally two lateral incisions, with through drainage, will better
serve the purpose. It may be necessary to divide the short radial
extensor, but this may be united again with suture. In most instances
it is possible to retract the tendons to either side and thus clear the
carpal region. By hyperextension the extensor tendons are relaxed and
more room is thus made. The incision marked “_A_” combined with that
marked “_B_” in Fig. 218, affords the best exposure when disease is
extensive. The incision along the inner border of the wrist is made 5
Cm. above the styloid process of the ulna, and between the latter and
the ulnar flexor down to the middle of the last metacarpal bone. Here
the tendon of the latter muscle should be divided at its insertion
and lifted out of its groove in the ulna. The collection of extensor
tendons is then separated from the back of the wrist and lifted up,
it being usually necessary to divide the unciform process of the
unciform bone with forceps. The knife should be kept from the palmar
surfaces of the metacarpal bones in order to avoid injury to the deep
arch. After dividing the anterior radiocarpal ligament the carpus is
extirpated through the ulnar incision. The ends of the ulna and radius
are now easily accessible for removal with forceps or a metacarpal saw.
The same is also true of the proximal ends of the metacarpals. After
spreading the hand and forearm upon a flat splint drainage can be made
to the desired extent and the wound closed.

[Illustration: FIG. 218

Excision of the wrist: _A_, Lister’s radial incision; _B_, Lister’s
ulnar incision; _C_, Ollier; _D_, von Langenbeck.]

[Illustration: FIG. 219

Excision of the hip: _A_, Sayre; _B_, Ollier.]

So far as the _hand and fingers_ are concerned little resecting need be
done, the surgeon usually confining himself to the removal of sequestra
or curetting of carious bone. In cases of compound comminuted fracture
bone fragments may be removed; only in cases of lost or destroyed
phalanges will amputation be necessary.


=The Hip.=--In its structure the hip-joint is one of the simplest
in the body. Although it lies deeply it is easily made accessible.
Fig. 219 illustrates the incisions by which the joint is attacked
for the purpose of exsection. If necessary either extremity of the
incision can be extended or enlarged by a cross-cut. When the joint
is disintegrated by disease, especially when partially dislocated,
the parts will lend themselves to an easy and simple operation. When,
however, the operation is done for ankylosis or for disease, by which
great thickening and fixation have been produced, the measure may
become difficult. For ordinary purposes the simplest method is to drive
a sharp-pointed, strong-bladed knife directly down upon the neck of the
bone from a point midway between the great trochanter and the crest of
the ilium; then keeping the knife-blade in contact with the bone the
incision is carried downward over the trochanter and along the shaft
to a length making it sufficient for easy exposure of the bone and of
the joint. Nothing is gained in these cases by trying to work through
a short incision. A long one heals as readily and makes the operation
more simple. It is as easy to make the entire incision in one cut
as to divide the muscles layer by layer. The capsule of the neck of
the femur being exposed by a wide retraction of wound margins, it is
necessary next to divide muscular attachments to the great trochanter
by raising the periosteum to which they are attached and saving both.
To expose these insertions the femur should be rotated inward and
outward, while the capsule is at the same time divided. The ligamentum
teres, which offers a theoretical obstacle, usually disappears in the
presence of any active disease and is scarcely ever encountered; it can
be divided with curved scissors. Now by more or less powerful effort,
including flexion and adduction to the extreme limit, with more or
less rotation, the head of the bone is forced out from its socket and
through the wound. Whether the bone should be decapitated with chain
saw, metacarpal saw, or by the exsector of Wyeth will depend partly
upon the freedom with which it can be exposed and on the equipment of
the operator. It may be advisable to divide the neck with a chisel.
The trochanter major should be preserved whenever its removal is not
made imperative by the progress of the disease. The head and neck of
the bone having been removed, the acetabulum is now more or less easily
exposed, especially with retractors, and it should be cleaned with a
sharp spoon. The capsule also should be removed, at least when the
operation is done for tuberculous or other infectious condition. It is
advisable to irrigate, then to wipe dry all the original joint surfaces
and raw bone, and finally to cauterize either with pure carbolic or
with zinc chloride, which should be washed away with the irrigating
stream, the intent being to close the mouths of all the absorbents and
prevent absorption from fresh exposure. Sinuses if present should be
thoroughly excised, scraped, and treated in the same way. A drainage
tube is usually preferable to the use of gauze.

The above is the method usually relied upon for hip exsection. Other
methods have been devised, especially by _anterior incision_; of
these the best probably is that of Barker. The cut is made along the
outer border of the anterior surface of the sartorius and rectus,
and through it the femoral neck is reached. By wide retraction the
anterior surface of the joint can be completely exposed and opened,
and through this opening the neck of the femur can be divided with a
chain saw or chisel, before removal of the head from the acetabulum.
The disadvantage of anterior incision is that pertaining to drainage.
Nevertheless this can be obviated with capillary drains. Its advantages
are that splinting and protection can be more perfectly effected, with
less necessity for frequent interference. In other words it makes the
subsequent care of the patient easier. Many English surgeons are in
favor of it. Ollier devised a so-called osteoplastic excision, made
through a curved incision with a downward convexity, the top of the
great trochanter being exposed and divided with a chisel sufficiently
to permit of its being turned up with the flap, and then being reunited
to the main part of the bone after the removal of the neck and head.
This method has its advantages in a limited number of cases, but it has
not become popular in this country. It would seem to be an advantage
to preserve the trochanter, although some surgeons remove it. So long,
however, as disease is confined to the head and neck of the bone it is
unnecessary to remove this projection.

The _after-care_ of a hip excision is not an easy matter. Most surgeons
prefer to maintain the limb in position by the aid of traction, with
sufficient weight to overcome all muscle spasm. If the case be such
that dressings need only be made at long intervals, then it matters
little, but in a septic case in which there is considerable discharge
the problem is sometimes a serious one. Various beds or suspension
splints have been devised, consisting essentially of frames with
cross-strips of stout material, upon which the patient lies. After
raising the frame one or two of these strips are released and the
parts exposed. This arrangement also permits of the easy management
of a bed-pan. In young children a wire splint with a fenestrum, or a
plaster-of-Paris spica or breeches with large opening cut opposite
the wound, will often be serviceable. The tendency is rather toward
adduction, and this should be overcome. Something will depend upon
whether the surgeon is working for ankylosis or for a movable joint.
In the former case a rigid dressing should be employed as soon as the
condition of the wound permits. In the latter passive movement should
be begun as soon as the wound is healed.

While the operation is usually performed quickly, and is not regarded
as serious, it nevertheless has a considerable mortality, especially
in the young and the aged, because of the conditions which necessitate
it. After a complete exsection, even by the most ideal method and in
the most ideal case, the limb remains somewhat shortened. This may
be compensated by raising the heel of the shoe worn on the affected
side. In severe cases it may be necessary to supply even two or three
inches of artificial support for this purpose. Unless this is done
compensatory spinal curvature will ensue.

[Illustration: FIG. 220

Excision of the knee-joint: _A_, semilunar incision; _B_, Ollier’s
incision.]


=The Knee.=--The knee is generally more accessible for operation than
the elbow, as the important structures which should not be disturbed
lie grouped upon its posterior aspect. Protection for one of these is
protection for all, and the freedom with which the joint may be opened
makes it especially easy to do either complete or partial operation.
Here the surgeon should endeavor to preserve the epiphyses, especially
in children, as they have much to do with the growth and length of
the limb. So long as incision is confined to the anterior aspect of
the joint it can be made in almost any manner. The usual method is
that represented by line _A_ in Fig. 220, by which a horseshoe flap is
raised and the joint interior exposed. Occasionally the direction of
the flap is reversed, and it is turned downward rather than upward.
In the former case the ligamentum patellæ is divided; in the latter,
the tendo patellæ. Whichever way the flap is turned it is made to
include the patella, although this bone can be removed at any time. The
lateral ligaments being divided, as well as the crucial, and the limb
completely flexed, exposure of the joint surfaces is made. It is now
possible to do an arthrectomy, a partial exsection or a complete one,
according as the disease is more or less extensive. In the complete
operation the articular surfaces of the femur and of the tibia are
usually removed with an amputating saw. If this be introduced from the
front and made to work its way backward the popliteal vessels should
be amply protected against possible injury. Here it should be borne
in mind that the leg is not constructed in a straight line, but that
there is a lateral angle at the knee, as the femurs diverge as they
pass upward, and this angle should be imitated in directing the saw and
removing the bone end. Again, a slight bend anteriorly will make the
limb more useful than one which is absolutely straight. The intent thus
should be to give the knee at a slight angle anteriorly and interiorly,
and the saw should be manipulated with great care. In a complete
operation the patella is also removed. In tuberculous and other septic
disease the capsule should be completely extirpated. This offers no
difficulty, save at the posterior surface, where it may approach
closely to the region of the great vessels.

Various modifications have been practised in these operations. Some
open the joint by straight cross-incision with division of the patella,
the latter being reunited with tendon or wire sutures. Others have
practised a more complicated H-shaped incision, the transverse portion
being carried either through the patella or just below it. The line
marked _B_ in Fig. 220 was suggested by Ollier. It is questionable
whether any of these methods offer any advantages over the one first
described.

After exsection it is desirable to maintain the bone ends in an
accurate position if speedy reunion be desired, and for this purpose
various methods are in vogue. The bones may be drilled and fastened
together with tendon or wire sutures, or ivory nails may be driven
in, one on each side, directing them obliquely, so that displacement
cannot easily occur, or metal nails may be used for the same purpose.
Another plan is to insert two long metal drills, one on either side,
which perforate the skin two or three inches above the wound, and are
passed downward and toward the other side so as to fix the surfaces, as
it were, by a cross-forked arrangement. After two or three weeks these
drills may be withdrawn. Fixation of this kind is advantageous, for
when complete excision has been practised the surrounding tissues are
lax and the parts are not easily held in position by external dressings
alone. In a clean case, with careful hemostasis, very little drainage
will be required. What is needed can be provided by an absorbable drain
passed through the lower portion of the wound on either side. In a
septic case it would be well to provide for ample drainage on each side.

The limb may be dressed upon a fenestrated wire or gauze splint, which
is easier when frequent change of dressing can be foreseen, or it may
be immobilized in a plaster-of-Paris splint.


=The Ankle.=--The ankle is usually reached by an incision on either
side, three or four inches in length, extending from above each
malleolus downward and forward on to the tarsus. The knife-blade
should be forced to the bone, so as to divide the periosteum, which
is subsequently separated and lifted by an elevator, in order that
the operation may be made subperiosteally. The fibula is usually
first divided, with a chain saw or a chisel, an inch above its tip.
The divided fragment is wrenched from its place with forceps, and
severed from the ligaments by knife or scissors, being careful not
to injure the external lateral ligament. The inner incision is made
in practically the same way, the periosteum separated, the internal
lateral ligament divided, and the end of the tibia forced through the
incision by everting the foot. Its joint end may be removed with a saw,
dividing on the same level and plane with the lower end of the fibula.
Through the gap thus made the astragalus may be either removed or its
upper surface divided with a metacarpal saw. The fresh bone surfaces
left in this way will unite and ankylosis will result, unless fibrous
or muscular tissue be interposed to favor the formation of a false
joint.

As in other operations methods may be varied to meet the exigencies of
certain cases. Longitudinal incisions may be placed farther forward
than indicated above, as is shown in Fig. 221, which illustrated
König’s method. Here the bone surfaces are divided with broad chisels.
A transverse incision of the front and upper part of the ankle may be
made, through which the tendons are exposed, lifted in a group out of
harm’s way, and curetting and bone sawing performed. Kocher makes a
semilunar incision from the outer border of the tendo Achillis to the
outer border of the extensor tendons, its line passing beneath the
external malleolus. By this method the joint is opened and the peroneal
tendons divided, their ends being reunited after the completion of the
balance of the work. This method is usually applicable in children.

Ample drainage is required in these cases, for the operation is seldom
performed in the absence of septic complications. The foot should be
kept in proper and right-angled position by metallic splints, or by
plaster of Paris, the latter preferable, fenestra being cut in order to
make access to the wound.


=Excisions of the Tarsus and Osteoplastic Excision of the
Heel.=--Removal of the tarsal bones is confined usually to cases of
tuberculous disease, and may be performed by a variety of methods.
Thus the tissues of the sole of the foot may be divided transversely
by an incision carried from the tubercle of the scaphoid beneath the
sole and across to a point one inch behind the base of the metatarsal.
Through this, access can be made to the inferior surface of the tarsus.
Conversely the upper portion may be exposed by a similar transverse
incision across the dorsum of the foot, by lateral incisions, or by a
combination of both. It is seldom necessary to divide the tendons, it
being nearly always possible to gather them into a group and lift them
out, while the bones are attacked with a sharp spoon or a chisel.

Occasionally the calcis becomes involved in cancerous or tuberculous
disease and it would appear that removal of the heel proper would be
all that is required. To meet these indications Wladimirov, in 1871,
and Mikulicz, in 1880, independently devised a method by which the
ankle-joint may be opened and as much of the heel and adjoining tarsus
as necessary removed, the foot being later fixed in the extreme equinus
position. This is referred to as _osteoplastic excision or amputation
of the heel_. Fig. 222 illustrates the line of incision, which extends
from the tubercle of the scaphoid beneath the heel to a point on the
opposite side, then obliquely upward and backward to the base of each
malleolus, and then transversely and posteriorly, thus including within
its line the region of the heel. These incisions extend to the bone,
the ankle-joint is opened posteriorly, the lateral ligaments divided,
the lower extremities of the tibia and fibula removed with a saw,
the astragalus and calcis separated from their attachments, and the
posterior articular surfaces of the scaphoid and cuboid also removed.
The lines of division of bone are indicated by dotted lines in Fig.
222. Thus the lower ends of the leg bones are brought into contact
with the upper end of the divided tarsus by straightening the foot in
the extreme equinus position and maintaining this position with wire
sutures or bone or metal pins.

[Illustration: FIG. 221

König’s incision for excision of the ankle.]

[Illustration: FIG. 222

Osteoplastic excision of the foot. (Mikulicz.)]

The cases in which this method is of use are rare, but when indicated
it has usually given satisfactory results. It is a substitute for
amputation of the leg, and it is often an open question as to which
will give the most satisfactory result. It has probably not been
practised a hundred times.




CHAPTER XXXII.

SURGICAL DISEASES OF THE OSSEOUS SYSTEM.


At the outset of a study of surgical diseases of the osseous system
it is necessary to emphasize a fact which students and young
practitioners are liable to forget, namely, that bone, even the
densest, is _a tissue_, and that as such it is liable to infection,
suppuration, gangrene, etc., just as is any other tissue; that all
infectious processes are identical in general character, their gross
manifestations varying only by virtue of the peculiar characteristics
of the tissue in which the infection occurs. Bone is vascular, and even
that exceedingly hard variety, which is met with in the petrous portion
of the temporal, or the ivory exostosis, has sufficient connection with
the vascular system to permit of its proper nutrition. The firmest and
hardest bone will bleed when divided or injured, and any tissue which
will thus bleed can react injuriously to various irritants.

All bone-marrow begins as red marrow, with 1 or 2 per cent. of fat, and
ends by becoming yellow, with 60 or 70 per cent. of fat, and whether
this change shall take place suddenly or rapidly depends upon diverse
conditions. Many years ago it was claimed by Bourgery that bone is
simply a large cavernous arrangement where stagnation of the blood
current favors the deposition of fat. Fatty alteration progresses from
periphery to centre, and the bones of the hands and feet undergo fatty
alterations before those of the trunk and pelvis. In other words, the
truncal skeleton remains as “red bone” longer than the balance of the
osseous system, and he whose sternum has become a “yellow bone” should
have reached a ripe old age. In long bones distal extremities first
become fatty. Individual peculiarities seem to govern these changes.
Thus the neck of the femur will sometimes be fatty and friable at the
fortieth year, or reasonably firm and still red at the eightieth. This
fatty condition is not to be confounded with true osteoporosis or
rarefaction in bone, though it is often associated with it. When the
two conditions are combined we have _osteoporosis adiposa_. Into this
condition immobilized limbs pass more easily than those which are used.
Their weeks have been equal to years of ordinary inactivity. Red bone
seems to be too highly vascular to be a favorite site for tubercle, and
distinctly yellow bone too non-vascular. Consequently bone tuberculosis
is less often seen at the extremes of life. White bone, as those who
make anatomical preparations call it, is most favorable for tuberculous
infection on account of its minimum contents of blood and fat. These
bones come from phthisical subjects.


ACUTE OSTEOMYELITIS.

This condition was never accurately recognized until described by
Chassaignac, in 1853, and even he missed many of its distinctive
features, although he gave to it a most descriptive name, “typhus of
the limbs.”


=Pathology.=--The disease is a distinctly infectious process, limited
sometimes to the bone-marrow and internal portion of the bone,
sometimes apparently involving every particle of the osseous structure.
Its onset is sudden, its manifestations acute and serious, and its
ravages, when not promptly checked, most extensive. The following more
or less distinct varieties may be distinguished:

  The staphylococcus;

  The streptococcus;

  The pneumococcus;

  The tuberculous;

  Miscellaneous infections, including the colon bacillus, the typhoid
  bacillus, etc.

It is known that the virulence of cocci growing under pressure is
thereby much enhanced; hence the extreme rapidity of some of these
disease processes may be thereby better explained.

[Illustration: PLATE XXXV

Acute Osteomyelitis, showing Purulent Foci and Accompanying Disturbance
(Kocher.)]

[Illustration: FIG. 223

Typhoid infection of bone; focus in rib. (Lexer.)]

The mechanism of the infection and the lesions produced by the organism
are essentially similar, and may be described together. These consist
of rapid _thrombosis_, _coagulation necrosis_, and _suppuration_,
along with the local destruction incident thereto, and with unlimited
possibilities in the way of _auto-intoxication_ from the local lesions
and from the disturbance of the general economy and interference
with excretion. Every severe case is accompanied by more or less of
general septic intoxication, presumably from the ptomaine produced
by the bacteria, while in many instances, particularly those where
the bacteria at fault seem extremely virulent, the intoxication is
overwhelming and the course a rapidly fatal one. Death has been known
to follow within thirty-six hours after the first symptom of an acute
osteomyelitis. For the average case three more or less distinct
stages can usually be distinguished: first, a period of _purulent
infiltration_, with the formation of local foci in the bone-marrow and
speedy secondary involvement of the periosteum and synovial membrane;
second, a period of _sequestration or formation of a sequestratrum_
inside of an abscess cavity; third, the _stage of repair_.


=First Stage.=--During this period there occurs violent inflammatory
infiltration, localized areas becoming at first hyperemic, then
infiltrated with hemorrhagic exudate, whose rapidity of production will
indicate the intensity of the infection. Often at the same time are
found enlargement of the spleen and hemorrhagic exudations in distant
serous cavities, such as the pleura and pericardium. The locally
infected areas of bone-marrow break down into collections of pus, which
spread either toward the epiphyseal line or else along the Haversian
canals toward the periosteum, which becomes both infiltrated and
loosened. The loosening is particularly marked about the shafts rather
than the joint ends, while, as a rule, that end of the bone toward
which the nutrient artery is directed is the one whose epiphyses are
first loosened. Nevertheless about the knee it would seem as though the
lower end of the femur and upper end of the tibia are the particularly
predisposed localities.

In many instances obliteration of nutrient vessels and thrombosis are
early features. The area of separation of the periosteum is usually
an index of the extent of deep destruction. From the periosteum the
infection may extend toward the covering of the soft parts, in which
case there may be a parosteal abscess, or it may perforate toward
the joint cavity, leading quickly to pyarthrosis and destruction of
joint structures. It would appear in children, particularly, that the
epiphyseal cartilage often forms a barrier to the advancement of the
lesion in the direction of the joint, and thus it happens that we have
acute necrosis of the shaft of a long bone, with perforation through
the periosteum at both of its ends. In adults this takes place less
often, the joint ends being often primarily involved. Softening and
separation of cartilages are usually secondary to the other processes.
It is possible even to have the primary infection in the joint end
proper, and extension therefrom to the epiphyses permitting of
epiphyseal separation and extrusion of this fragment as a sequestrum.
This separation occurs in many instances rapidly and before the
attendant is aware of what has happened.


=Second Stage.=--The second stage includes, coincidently with
the occurrence of suppuration, the proliferation of considerable
granulation tissue, by which more or less protection is afforded; also,
when time is afforded, the rapid formation of new bone, whose effect
is to wall off the scene of conflict and death from the surrounding
tissue, by which event prognosis, so far as the patient’s life is
concerned, is improved. Intra-osseous abscesses may quickly coalesce,
and the result may be one long tubular abscess extending through the
shaft. At other times both bone-marrow and the cancellous tissue are
bathed in pus, while if the periosteum have been totally separated
the consequence will be a sequestrum whose dimensions correspond with
those of the shaft. When periosteum is not loosened the necrosis will
probably be central and more or less circumscribed. (See Plate XXXV.)


=Third Stage.=--The third stage is the period of efforts at spontaneous
repair. There is a natural effort toward elimination of the sequestrum
by the process of softening or liquefaction in the direction of least
resistance. This process may extend over months, when surgical relief
has been delayed, and may be accompanied by so much other disturbance
as to completely ruin a bone or limb for further use. In neglected
cases several sinuses may lead down toward the central sequestrum. On
the other hand, once this sequestrum of eliminated an extraordinary
amount of activity is usually displayed in the direction of repair
(Fig. 224).

[Illustration: FIG. 224

Acute necrosis of tibia, with formation of cloacæ for affording
opportunity for escape of sequestra. Illustrating also the extensive
openings which necrotomy may necessitate. (Lexer.)]


=Symptoms.=--In a general way the signs and symptoms of acute
infectious lesions in bone are strikingly similar, and are significant
when construed aright. Patients complain usually first of _exhaustion_,
followed by _pain_, which may become agonizing. This is often
accompanied by an introductory _chill_ with high fever, after which the
general character of the disease assumes the typhoid aspect. Evening
temperature may rise high and be followed by some morning remission.
The spleen is usually enlarged, the primæ viæ disturbed, and often we
have to do with a fetid diarrhea. In the young the sensorium is early
affected and children soon become delirious. The _pain_, at first
vague, quickly focuses in the particular bone or bones most involved,
and as it increases in intensity there is a significant _tenderness_.
Ordinarily there appear early reddening and swelling of the affected
parts. With all these evidences there is also a characteristic muscle
spasm, by which certain posture signs will be produced, varying with
the bone involved. Pain is always intensified by the slightest degree
of disturbance. In consequence the limbs (for it is the limbs which
are usually involved) are contracted, and every effort to overcome the
contractures is followed by aggravated pain. The more acute the pain
the more vivid the external evidences of inflammation and the edema of
the parts, especially below and about the lesion. Thus it may happen
that within forty-eight hours there may be swelling and edema of the
part involved, which should be regarded as pathognomonic.

A little later, superadded to the other signs of inflammation, there
is _fluctuation_ if parosteal abscesses have formed, or possibly the
evidences of _epiphyseal loosening_ or complete separation. When the
disease is primary in an epiphysis the corresponding joint will be
early involved, and the joint symptoms will assume the type of an acute
purulent synovitis, but with more pain. It is probable that under few
circumstances is complaint of pain more serious or aggravating than in
cases of acute osteomyelitis of the fulminating type.

So far only local symptoms have been described. To these there should
be added the list of those pertaining to _thrombosis_ and _metastatic
infection_, with their septic and disastrous consequences. The disease
is frequently so acute and rapid that even within the first day or
two not only are added extensive thrombosis in and along the bones,
with rapid purulent degeneration and thrombi, but soon that even
more serious general condition to which these lesions so easily give
rise--_i. e._, unmistakable _pyemia_.

The general symptoms are common to the disease, no matter what bone be
involved. Local symptoms will change in accordance with their location.
While not so common, the flat bones, like the pelvis, cranium, and
sternum, may be involved in active manifestations of this disease. The
same is true even of the vertebræ, but, as a rule, it is in the long
bones of the extremities that its ravages are most frequently seen.


=Prognosis.=--The prognosis depends upon the early recognition of the
disease and prompt surgical relief. There is perhaps no disease less
amenable to purely medicinal treatment, and if bones are to be saved
in their entirety early and free incision is called for. Consequently
when the case is seen late it almost invariably entails necrosis,
with more or less disturbance of function, or possibly such a serious
condition as to call for amputation. The fulminant cases when not early
recognized and promptly operated often prove fatal, and death has been
known to follow within thirty-six hours after the onset of the first
symptom, the fatal result being due to overwhelming septic infection,
with thrombosis, etc. Almost every case, however, if seen sufficiently
early can be saved.


=Complications.=--The complications are to be divided into the
constitutional and the local. The former refer rather to the spread of
septic infection and its more or less disastrous and remote ravages.
Metastatic infections may produce serious or fatal complications,
while, when less acute, important functions may suffer a serious
impairment. Among the local sequels are to be considered mainly the
results of destruction of bone tissue and neighboring joint structures.
When the disease occurs in young and rapidly growing children partial
or complete arrest of development in the bone involved is not
infrequent. This may lead to inequalities in length of the femora or
humeri. It may lead also to compensatory hypertrophy of bone, with
perhaps considerable distortion during subsequent growth.

An entirely distinct consequence of osteomyelitis is _bone abscess_, in
which the acuteness of symptoms has long since subsided, but in which a
distinct local focus remains.


=Etiology.=--The disease is an infection from the beginning, but the
source of the infection is not always easy to trace. Two distinct
causes seem to conspire to produce the majority of these bone
infections--_microörganisms_ of more than ordinary virulence, and a
_predisposing condition_ of the system, due sometimes to constitutional
weakness or inherited taint, or to the results of exposure and fatigue.
The causes of suppuration have been discussed in Chapter III. It is a
fact, however, that the majority of cases occur in children and after a
combination of exposure and fatigue--as, for instance, sitting upon the
ice after being exhausted by skating--all of which would be inoperative
to produce an infection were not the germs at hand ready to assail
every tissue whose resistance is thus temporarily lowered.

The infection may occur _from within_ or _from without_--from within
perhaps through the alimentary canal or the respiratory tract, probably
from the tonsils and the pharynx. Infection from without may occur
through an abrasion or scratch, a blister upon the foot made by an
ill-fitting shoe or by a skate-strap. These cases occur generally
in the young, more often in boys than in girls, probably because
in the former more opportunities for infection are permitted. Bone
infections, however, are possible even in the _newborn_, in which case
the infection may occur through the pharynx or through the umbilicus,
while the local resistance may have been lowered by the injury due to
mechanical delivery, turning, etc. In elderly people the disease is
almost unknown.


=Diagnosis.=--The disease for which this is most commonly mistaken is
acute rheumatism. There may have been some excuse for this in the past
because of the lack of general knowledge of bone infections; now there
is none. The majority of cases of necrosis following osteomyelitis
which have come under the writer’s observation were the result of
errors in diagnosis.

Rheumatism is _never followed by suppuration_ and seldom produces a
septic type of disease; its painful lesions are rarely so painful as
those due to osteomyelitis. Lesions of rheumatism are usually multiple;
those of bone infection are mostly single. The first complaint of
pain in the latter is generally along the shaft of a bone than at the
joint end, while this is not true of rheumatism. Moreover in acute
osteomyelitis the disease assumes from the outset a seriousness which
is seldom approximated by acute inflammatory rheumatism.


=Treatment.=--The treatment for acute osteomyelitis is essentially
surgical. Anodynes may be necessary for relief of pain, but no time
should be lost, when once the diagnosis is made, in making _incisions_
to expose the bone involved, and then opening to its interior to
relieve tension and to remove septic products. The incision over the
femur or tibia, for instance, may be ten or twelve inches in length.
The tissues will invariably be found edematous or infiltrated, with
evidence of the proximity of pus; the periosteum will be thickened
and infected, and between it and the bone, as well as outside of it,
there may be collections of pus. If seen late the characteristic
muscle appearances already described may be noted. The periosteum
should be incised to the bone throughout the length of the incision,
and then an ordinary bone drill may be used to perforate the bone for
exploratory purposes. From the punctures in the bone thus involved
will exude purulent fluid, often sanious, thus indicating the condition
within. A deep groove or channel should now be cut, opening into the
marrow cavity, in which numerous foci will be found, or in which all
distinctive structure of bone-marrow may be lost, the cavity being
filled with pus. The pus cavity should be scraped and disinfected
with hydrogen peroxide and cauterized with zinc chloride or its
equivalent, and then packed, the wound being left open. Even this may
not be sufficient, but if there be epiphyseal separation, or evidences
of joint infection, the neighboring joints should be explored under
aseptic precautions; if pus be found they should be opened, washed out,
and drained. Meanwhile if in the soft tissues exposed by the incision
the parosteal veins are found filled with septic thrombi, they should
be opened as far as exposed and their contents removed.

These operations are often severe, but nothing in the way of operative
treatment can be so severe nor so serious as the disease itself when
left unoperated; the rule is stringent that every infected tissue, and
especially every infected bone interior, should be exposed and cleaned
out. Only in this way can lives be saved. Moreover, it is necessary to
carry out this treatment in the fulminant cases _as early as possible_;
and errors in diagnosis by which it may be postponed until metastatic
infection or grave pulmonary and cardiac complications have set in are
unfortunate. So long as the local indications are as above described,
surgical treatment is desirable, whether the systemic complications
are pronounced or not. The immediate effect of the operation having
passed the relief thus afforded will often be so pronounced that within
twenty-four hours patients may be out of danger.

[Illustration: FIG. 225

Total necrosis of humerus, as seen by aid of the cathode rays. (Lexer.)]

The results of this operation are a wound which will discharge at first
freely, and which so soon as septic material is out of the way will
begin to _granulate_. Ordinarily no attempt should be made to close
such a wound, though much may be done to favor rapidity of granulation.
While some antiseptic dressing is always employed, it will be of
advantage occasionally to change the character of the same, and to
alternate between various antiseptics, the effect of any one drug being
apparently lost after it has been used for some time.

There are some cases where an entire diaphysis or bone shaft will
be found separated from one or both epiphyseal terminations, lying
in a subperiosteal abscess cavity, bathed in pus, and dead beyond
possibility of repair. This is _total necrosis of the shaft_ from an
acute infectious process, and is to be treated by complete removal of
all dead and dying tissue. In the case of the forearm or leg it may be
that the remaining bone, when only one is involved, as is usual, will
be sufficient to maintain the integrity of the limb until new bone
can be reproduced within the periosteal bed occupied by the old one.
More or less complete _regeneration of bone_ is possible, particularly
in the young, and in connection with compensatory hypertrophy of the
parallel bone will permit the restoration of the leg to partial or
complete usefulness. On the other hand, should this later prove a
complete failure, amputation and substitution of an artificial limb may
be required.

When the disease has involved the articular side of an epiphyseal
line, and when there is complete epiphyseal separation with consequent
_pyarthrosis_, the probable consequence will be necessity for a
complete or partial resection of the joint and the probability of
subsequent ankylosis. Patients may find later that a modern artificial
limb with its possibilities will be preferable to such a condition, and
may readily consent later to an amputation which they would at first
refuse.


=Acute Infectious Periostitis.=--This is an infection of the same
general character and type as the osteomyelitis just described, but
refers to those cases where the disease apparently is confined to the
periosteum and the outermost layer of the bone. In its possibilities
for harm it is scarcely less serious, although in its tendency to
spontaneous perforation and escape of pus it is less likely to prove
fatal.


=Causes.=--The causes and the general clinical manifestations are
practically identical. The disease is perhaps less grave in its acute
manifestations, the localization of pain more exact, with ordinarily
less tendency to joint complications. Local tenderness is exquisite,
and particularly in those bones which lie near the surface--_e. g._,
the tibia--and early recognition of fluctuating areas is easy. It may
be localized over a small area, or the entire periosteum of the shaft
may be involved; in which case, so soon as pus forms and the periosteum
is separated from the bone, there is probability of acute necrosis of
the shaft. Here, again, there may be a tendency to mistake at least the
first signs of the disease for acute rheumatism, from which it must
necessarily be early differentiated as above.


=Treatment.=--Here also there is the same necessity for immediate
intervention, if possible before pus be formed, in order that there may
be little or no periosteal separation and encouragement to necrosis.
Anesthesia is necessary, with prompt incision, the use of the sharp
spoon, and disinfecting agents: no attempt should be made to close
the wound, but drainage should be favored in every way. The intensity
of the pain is promptly relieved and the whole clinical picture
immediately changed by such a procedure.

The ordinary _bone felon_ upon a terminal phalanx is practically an
expression of this type of disease, and experience corroborates the
wisdom of deep and early incision, even in the case of so small a bone
entity as a phalanx.


=Acute Epiphysitis.=--This is a term applied rather indiscriminately
to a form of acute osteomyelitis involving primarily and especially
the epiphyseal lines, or to a condition of hyperemia and neurovascular
excitement at epiphyseal junctions stopping short of suppuration, but
giving rise to intense pain, muscle contraction, joint tenderness, etc.
It is often seen at the upper end of the tibia. Sympathetic disturbance
may extend even to serous effusion into a joint, although this is not
necessarily the case. The limbs are early drawn up, and every attempt
to extend them simply aggravates the distress. So long as there are no
evidences of suppuration, it is sufficient in these cases to apply a
sufficient degree of traction to overcome muscular contracture and to
straighten the limbs. This should be applied first under anesthesia,
and the patient kept under anodynes for a few hours thereafter. So
soon, however, as the muscles are tired out by the steady traction,
pain subsides, and the intensity of the condition may be thus relieved
within forty-eight hours or less. It would be well to continue
physiological rest and traction as long as there remains the slightest
tenderness. Should evidences of suppuration at any time supervene,
incision and evacuation of pus and exudate should be practised. Should
epiphysitis occur in one of two parallel bones, there may result such
failure of growth of that bone as shall cause marked deformity in the
attacked hand or foot. In some of these cases, should operation be
required on one bone, the other may be shortened at the time, or later,
by exsection of a portion of the shaft, or even of the epiphyseal
junction.

[Illustration: FIG. 226

Osteogenesis and osteosclerosis in slow infective processes. (Buffalo
Museum.)]


=Periostitis Albuminosa.=--This is a rare manifestation of bone
disease, only given an identity of its own since 1868, when Ollier
first distinguished it, since which time it has been the subject of
considerable controversy. The name refers to a condition less acute
than the infectious periostitis just described, almost always localized
in a single bone, necessitating incision and evacuation of a fluid
which is _gelatinous_ or _mucoid_ in appearance rather than purulent.
It is because of the peculiarity of the subperiosteal collection of
fluid that it received the name _periostitis albuminosa_, and it was
not generally regarded until recently as a variety of the infectious
form of periostitis. It is, however, now conceded as being a mitigated
form of infection, in which the products of exudation assume the serous
rather than the purulent type. In some instances it appears to be the
tubercle bacilli which are at fault. At all events, the organisms
which produce the disease are more or less virulent, else the clinical
form of the disease would be less serious than it really is. Cultures
made from these subperiosteal collections have in almost all recent
instances revealed the presence of some one of the numerous pyogenic
organisms. Quite recently Dor has described a polymorphic microbe,
in instances of this kind, which he has called the _Bacillus cereus
citreus_, with which he claims to have been able to reproduce the
disease in animals.


=Chronic and Latent Osteomyelitis.=--As in the lungs, however, chronic
lesions are met with, and as in the lungs, again, it is possible for
collections of microörganisms to become more or less encapsulated and
for a long time to lie _latent_ until some provoking cause excites
them again into activity. In this way are to be explained the numerous
instances of recurring abscesses within the bone necessitating repeated
operations, often at long intervals. (See Plate XXXVI.)


=Possible Consequences of Any and All of the Bone Infections.=--Bone
is a living tissue, calcified and stiffened by inorganic material
for the purpose of giving it strength; it may suffer remotely from
the consequences of local infections, the same as other tissue. Thus
it may have its nutrition impaired so as to produce _atrophy_ on
one hand, or increased so as to lead on the other to _hypertrophy_,
either regular or irregular in outline. Again in its texture it
may be altered to a wide extent between the sponginess or porosity
on one side (_osteoporosis_), or to the density attained by ivory
(_osteosclerosis_) on the other. Similar changes are also noted in
cases of bone tuberculosis, which is to be considered by itself.
The _densest_ bone has sufficient vitality to permit its nutrition
and life, and may assume dimensions much larger than that of the
original, and a hardness which will defy the best steel instruments
should it become necessary to operate upon it. The other extreme
of _osteoporosis_ includes a condition where the bone has barely
sufficient inorganic material to permit it to retain its shape and
ordinary proportions. Such bone is fragile in the extreme and scarcely
serviceable as a supporting tissue. The principal portion of its bulk
is constituted by marrow tissue, which makes it extremely vascular,
but far from strong. When spongy it is ordinarily unserviceable for
its proper function. Astonishing pictures of _osteosclerosis and
osteoporosis side by side_ are present in many instances of disease,
the latter being often evidence of more or less ossification of
new-formed granulation tissue. This is often a happy combination,
because the bone, which has been sadly weakened by disappearance of its
calcareous material by liquefaction and by absorption, is reinforced
along some of its lines by a pillar of osteosclerotic tissue, by means
of which it still functionates as a more or less useful support (Fig.
226).

The operating surgeon should familiarize himself with the density of
normal bone in various locations, as in many operations upon the deeper
bones he detects healthy bone rather by the sense of _touch_ and of
_hearing_, and the _resistance_ which it offers to his instruments,
than by sense of sight.


TUBERCULOSIS OF BONE.

In Chapter IX, on Tuberculosis in general, we entered into considerable
detail in regard to the nature of tuberculous lesions, which were
stated to be essentially the same whether occurring in hard or
soft tissue, the active agent being the now well-known _Bacillus
tuberculosis_, which, finding lodgement, for instance, in the osseous
tissue, acts as a specific irritant, and so provokes the production,
first, of a typical tubercle, and, later, of typical granulation
tissue, by whose ravages the distinctive signs of bone tuberculosis
are produced. This process, then, is in no respect different in bones
from similar lesions in other parts, though modified to a slight
extent pathologically, to a greater extent clinically, by the dense
environment. Nevertheless, trifling or most extensive destruction
of bone substance is produced by this tissue, while by continuity
or by metastasis there is more or less involvement of the adjoining
textures, either parosteal or articular. It is by granulation tissue
that so-called _caries_ is produced, and it is by the same tissue that
distinct portions of bone are sometimes completely segregated from
their vascular surroundings and shut off from nutrition, so that they
die and form what are known as _sequestra_. _Necrosis_ may then be the
result of tuberculous disease.

[Illustration: PLATE XXXVI

Tuberculous Disease of Hip-joint and Pelvis, involving the Muscles
(rare). (Lannelongue.)

_o_, rarefying ostitis (_i. e._, osteoporosis); _f_, fungus granulation
tissue.]

So long as the process is active, this granulation tissue tends to
enlarge its boundaries, and, like pus, to spread in the direction of
least resistance. When produced in the shaft of a long bone this may
lead to involvement of the entire shaft, or there may be liquefaction
and absorption of dense bone and the formation of a sinus from the
marrow cavity to the periosteum, beneath which the granulation tissue
will spread, and through which it will sooner or later perforate, to
resume its progress toward the surface, _always in the direction of
least resistance_. In this progress _tendon sheaths_ or _bursæ_ may be
involved, or dense aponeuroses may turn the granulation column aside,
causing it to perforate toward the surface at some remote point; while
it may spread out more or less beneath the skin before finally causing
its destruction. Sooner or later, if uninterrupted by treatment, this
escape will occur, and then we have the condition of a tuberculous
ulcer of the skin, from which leads down, by a devious path, a _sinus_
toward the original focus.

When this original focus has been juxta-epiphyseal there is involvement
of the epiphyseal cartilage and a pathological _diastasis_, which may
early lead to spontaneous or pathological _luxation_. Or, again, a
focus having once originated at an epiphyseal extremity, tends usually
to perforate quickly into a joint cavity, after which a considerable
length of time is usually expended in filling up this joint cavity with
exuberant granulation tissue. This is the material so often found in
tuberculous joints, and is well characterized by the name given to it
by the Germans, _fungous tissue_, they calling such joint affections
_fungous joint inflammations_. (See previous chapter.)

Seen thus in joints, after it has been long exposed to friction and to
more or less pressure, it may have lost some of its original luxuriant
features. It is best seen when it is freshest and has been exposed to
least disturbance. Under these circumstances it is vascular, dark red
in appearance, friable, and easily removed from the tissue upon which
it has grown. Ordinarily it is infectious, and by its inoculation into
animals is capable of reproducing the disease.


=Pathology.=--The pathology of tuberculosis of bone may then be
virtually summed up in saying that it consists of the ravages produced
by the presence of this granulation tissue, with the irritative
hyperplasia of surrounding tissues which its presence always excites,
even though they be not actively infected. This is the explanation
for the majority of cases of _caries_, of _tumor albus_, of _Pott’s
disease_, of _spina ventosa_, and of the condition which has been known
under many other names.


=Varieties.= =Acute Miliary Tuberculosis of Bone.=--This corresponds to
a similar invasion of the lungs. It might be fittingly described as an
_acute tuberculous form of osteomyelitis_. It may run its destructive
course within a short time and cause such involvement of structures
as to necessitate amputation of a limb, or it may appear in the
truncal skeleton as a primary disease, spreading rapidly therefrom and
involving the viscera or the cerebrospinal membranes, and causing an
early death, perhaps within a few weeks after its onset. This condition
has been more prevalent than is generally understood, and has not even
yet received the attention it deserves. It is less painful than the
pyogenic forms of osteomyelitis, and may assume less of the septic and
more of the typhoid or meningeal type of disease. The pain also may be
less severe, though reflex symptoms, especially muscle spasm, will be
an early and marked feature of these cases. When a limb is involved
the case may not be hopeless; but when involving the cranium, spine,
or trunk it is fatal, and little can be accomplished by treatment. The
operative treatment for parts which are accessible is given under Acute
Osteomyelitis.


=Chronic Tuberculous Osteomyelitis.=--This is the ordinary form of the
disease, and is exceedingly common. In some sections it constitutes
nearly one-third of the diseases necessitating surgical treatment in
clinics and hospitals. This is particularly so in the thickly settled
portions of the European continent. In Buffalo it constitutes from
15 to 20 per cent. of cases found in my wards and in my clinic. The
proportion some years has been larger.


=Symptoms.=--_The essential symptoms of bone tuberculosis_ are _muscle
atrophy_, _muscle spasm_ and _pain_, direct or referred, and upon
the existence of these, coupled with _local tenderness_ and _local
swelling_, _a diagnosis can almost always be made_. _Muscle atrophy_
is distinct, and is not alone that of disuse, but is a distinctive
evidence of the tuberculous process. It involves the parts above and
below the lesions.

_Muscle spasm_ is never lacking, but is most noticeable about the spine
and the joints of the extremities. In Pott’s disease, for instance,
the condition causes a stiffening of the back and an inflexibility of
the spine. About the joints it leads gradually to _fixation_, usually
in the condition of more or less flexion, the flexor muscles being
ordinarily stronger than the extensors in all parts of the body. Thus
we see the knee and the elbow drawn up, and most other joints in a
condition of flexion so far as it may be permitted.

It is characteristic also that _muscle spasm_ is frequently
exaggerated, usually in a reflex way, by which pain is always
augmented. These sudden but brief contractures occur more often during
sleep than during the waking hours, and give rise to the so-called
_starting pains_, usually nocturnal, which are noted in nearly every
case of this kind.

The _pain_ is in large measure the result of contracted muscles pulling
tender joint surfaces together, and is consequently augmented during
the muscle spasms just described to an extent causing the patient
to cry out even during sleep. There is also usually a more or less
deep-seated and constant pain or soreness, manifested in increasing
degree as the lesion advances. These pains are also often _referred_,
lesions in the upper ends of long bones usually giving rise to pain
which patients refer to the lower ends. In hip-joint disease pain is
often referred to the knee, and in Pott’s disease to the anterior part
of the trunk. Slight but slowly increasing disturbance of function
of a joint inaugurated by trifling muscle spasm, with complaint of
aching pain, is significant and needs careful examination, it being a
mistake to anesthetize patients for this purpose, as by the anesthetic
the pathognomonic muscle spasm is abolished and mistakes in diagnosis
favored.

[Illustration: FIG. 227

Tuberculous disease of the hip. (Buffalo Museum.)]

[Illustration: FIG. 228

Healed tuberculosis of the spine. (Buffalo Museum.)]

It will be seen that these features are also met with in
tuberculous-joint disease, the fact being the conditions are not only
allied but often associated.


=Treatment.=--The treatment of tuberculosis of bone is constitutional
and local. The former consists in the best possible hygiene and in
those measures which are everywhere recognized as helpful in similar
conditions. I believe in the internal use of _benzosol_, or its
equivalents, in doses sufficiently large to influence the tissues. In
addition the tonics and evacuants should be judiciously used. But it is
mainly with local treatment that we shall here have to deal.

The _local treatment_ may be divided into the _non-operative_ and the
_operative_. The former consists in enforcing the general principles
of physiological rest, which is done partly by _orthopedic apparatus_
proper and partly by the general principles of _traction_, and is
resorted to mainly in a class of cases treated of under Orthopedic
Surgery, the best methods for the purpose, apparatus, etc., being found
in the next chapter.

Aside from this a hopeful method has been that suggested by Bier,
consisting of making an _artificial chronic congestion_, it having been
long known that tubercles do not thrive when bathed in much blood. The
congestion is secured by wearing an elastic bandage above the point
involved, elastic constriction being made to a degree as great as
may be comfortably borne. The result is venous congestion, possibly
edema of the parts below, which to be made effective should be carried
nearly to the tolerable extreme. Constriction may be at first enforced
for only a short time, but can be later borne for longer periods,
until a time is reached when the patient can wear a bandage almost
continuously. Marked improvement in many cases follows this method.

_The operative treatment_ consists in _ignipuncture_, _curettage_, _or
formal extirpation_. _Ignipuncture_ is the insertion into the bone
focus of the glowing point of the thermocautery. It should be practised
under an anesthetic, and when the bone is superficial the cautery
should be plunged through the skin, making it burn its way into the
depth of the bone. This is not difficult when the cancellous tissue is
that at fault. If the bone be deep an incision may be made down to it,
after which the cautery is applied as above. The result in almost every
instance is relief from pain.

This effect seems to be brought about partly by relief of tension,
partly by destruction of diseased tissue, and by the acute congestion
which is the result of vigorous counterirritation. It need occasion
no fear nor difficulty, and is applicable to all accessible bones. It
must not be expected to cure every case, but is a measure which may be
confidently expected to relieve pain and to do good.

The _radical_ form of _treatment_ is necessary when it can be
determined that the carious process is advancing or that pus or
caseated deposits are present. This is made known in various ways;
but when reasonably sure of their presence it is best to begin the
operation as an _exploration_, going as far as the findings may
justify. This may include scraping out of a small focus, or it may
entail removal of a large portion of a bone or resection of a joint,
or even amputation, according to the severity of the deep lesion. It
is best to do whatever may be necessary, and to do it all at once. The
operator should not rest content with mere operative attack, but should
carefully _disinfect_ the entire tract, cutting away or removing with
the spoon the sinus wall and fungous tissue, which he should follow
wherever it may lead, disinfecting freely with hydrogen peroxide or
caustic pyrozone, and then using an active caustic, like zinc chloride
or the actual cautery, unless caustic pyrozone has already been used.
In this way material may be destroyed which has escaped the instruments
used, and absorbents are eared or closed and protection afforded. My
personal preference is for a packing made of bismuth subiodide gauze,
soaked in a mixture of balsam of Peru containing 10 per cent. of
_guaiacol_, which I find more advantageous than anything I have used.
There should be added to these measures, however, whatever may be
necessary in the way of after-treatment, both local and constitutional,
and the surgeon should be prepared to operate once or twice again
should latent foci subsequently manifest themselves or should there be
recrudescence of the active disease.


BONE ABSCESS.

Bone abscess is a term applied to _deep and circumscribed collections
of pus within the bone_, mainly within the shafts of long bones.
They are due either to the acute ravages of pyogenic cocci or to the
slower lesions produced by the tubercle bacillus. They are frequently
evidences of return of disease in its acute type after a long period
of latency. The manifestations are usually localized, in this respect
differing from those of acute osteomyelitis. The pain is deep-seated
and boring, while there is local tenderness, often with considerable
enlargement of the overlying bone. The lesion occurs more often in the
tibia than in all of the other bones together--at least under those
clinical conditions which entitle it to be called bone abscess. The
pain is frequently _nocturnal_ or osteoscopic, and patients may endure
it for weeks or months before seeking relief.

The surgeon may always expect to find a layer of condensed, sometimes
extremely hard bone around these local foci, and it is due to this that
they do not either perforate or diffuse and cause extensive trouble.


=Treatment.=--Treatment is always _operative_; it should consist in
anesthesia, exposure of the bone, effective exploration by means of
the bone drill, as the hypodermic needle would be used for exploration
in the soft parts, and then the free use of the bone chisel or other
instruments by which the area may be widely exposed. The density and
firmness of the bone under these conditions will sometimes almost
defy the best-tempered instruments. Care should be taken to make the
external opening nearly the size of the deep focus, in order that the
surface may not heal too readily and before the deeper part is filled.
The same directions with regard to cauterization and packing the cavity
obtain as given before.


SYPHILIS OF BONE.

[Illustration: FIG. 229

Syphilitic gummas of head and face. (After Jullien.)]

[Illustration: FIG. 230

Syphilitic ostitis and osteosclerosis.]

Syphilis of bone may assume the type of _gummatous involvement_ of
the _periosteum_ or of the _bone_ itself or of _syphilitic caries_
and _necrosis_. The former appears usually as a distinct tumor,
ordinarily tender and exceedingly painful, especially at night, it
being characteristic of almost all cases of bone syphilis that the
pain, however great during the day, is exaggerated at night. The true
syphilitic _gumma_, or syphiloma, of _bone_ is but little different
from gumma in other tissues, which may become secondarily infected
and then suppurate with the formation of sinuses, etc. Suppuration,
however, is rare. _Central gumma_, like central osteosarcoma, is
possible, and may lead to expansion of the surrounding bone. Syphilitic
_necrosis_, so far as the bone lesion is concerned, scarcely differs
from the other varieties. It is, however, almost always of the slow
form, and involves more often the _flat_ than the long bones. It is
especially seen in the cranium and the sternum. Syphilis of bone is
often mistaken for rheumatism or pseudorheumatism because of the
deep-seated and somewhat indolent pain. Syphilitic disease of bone
permits occasional spontaneous fracture, the bone affected with this
disease being always more friable than natural. There is also another
form of bone syphilis--namely, the _hereditary_. It leads either to
bone _enlargement_ or to _caries_ and necrosis, the latter usually upon
the cranium, where extensive ulceration and sequestrum formation may be
observed, even the dura being exposed by breaking down of the fungous
tissue.

[Illustration: FIG. 231

Caries of lower end of femur. (Buffalo Clinic.)]

Hereditary bone syphilis is also characterized by osteophytic
formation, by the substitution of gelatinous for spongy bone tissue
in the neighborhood of epiphyses, and by early and easy epiphyseal
separations. It is characterized also by irregularity of ossification
of cartilage and consequent deformity of bone ends, especially about
the phalanges and the metacarpal and metatarsal bones. In almost every
case where doubt would in other respects arise the other evidences of
congenital or acquired syphilis are so plain as scarcely to permit
uncertainty (Fig. 230).

The _possible combination of syphilis and tuberculosis_ in the same
subject may occur, the lesions partaking of one or the other character
according as the tuberculous or syphilitic taint may predominate.

There is urgent necessity in all cases of syphilis in bone, whether
operated on or not, for the _combination of suitable internal treatment
with surgical intervention_. Only by this combination can the efforts
of the surgeon be crowned with success. In failure to appreciate this
fact operation often seems to be almost futile.


CARIES.

Caries is a term applied to infiltration, and substitution in
healthy bone of granulation tissue, which has been in use for many
centuries, from a time long before the pathology of the condition was
understood. Caries never occurs except in the presence of a _specific
irritant_, which, in general, is tuberculous and sometimes syphilitic
in character. The pure type of caries is connected entirely with
the formation of granulation tissue, and the slow ravages connected
with its presence in and substitution for the original bone. As long
as _septic infection_ (pyogenic) is _avoided_ it assumes the _dry_
type, as it used to be known, called by the older writers _caries
sicca_. When the fungous tissue is invaded by putrefactive or pyogenic
organisms suppuration takes place, and then occur the _moist_ forms
of caries, the _caries humida_ of our forefathers, connected with the
presence of pus. When closed areas of bone, small or large, being
thus shut off from nourishment, die as the result of its presence the
complicated condition used to be known as _caries necrotica_. Occurring
under any circumstances, _caries is a result and not a cause_, and is
to be dealt with accordingly.

Peculiar alterations and markings in bone are the consequence of
carious changes, and bones are given a fantastic and peculiar
appearance in consequence. The surface is almost always irregular,
tunnels or canals are formed, and the bone is often honeycombed,
as it were, by the excavations just made. Along with the process
of osteoporosis and disappearance of bone at one point may be seen
osteosclerosis in an adjoining area, and the bone, which is apparently
much weakened by the destructive process, is strengthened in a
compensatory way by the artificial density of the tissue undestroyed.

The clinical evidences of caries are those of joint and bone
tuberculosis or syphilis, which have been already discussed, and its
operative treatment consists always in surgical attack with bone chisel
and sharp spoon, according to the rules already laid down. The bone
which is completely carious calls for _extirpation_--_i. e._, usually
amputation. In the carpus and tarsus _resection_ will often suffice,
and also when the disease is limited to joint ends. Occurring in the
pelvis, ribs, sternum, or cranium, more or less extensive _resections
of flat bones_ are necessary, in the latter place leading to exposure
of the dura (of which one need have no fear). The same rules with
regard to cleansing and packing the wound should be observed as in
operation on tuberculous bones.


NECROSIS OF BONES.

Necrosis corresponds to gangrene of soft parts, and the term, when used
by itself, is limited to death of bone tissue. Necrosis by itself is
a distinct disease, but indicates the termination of some preceding
disease process. It may be considered as:

  1. Traumatic;

  2. Pathological--_i. e._, the result of disease; or

  3. Toxic, due to the presence of specific poisons in the system.


1. =Traumatic Necrosis.=--Traumatic necrosis is due to the
discontinuance of the blood supply by accident or by separation of
the whole or a part of a bone in the same way. Thus in consequence of
_multiple fractures_ fragments occasionally die and require removal.
The same result has been ascribed to traumatic or non-_traumatic
embolism_ of the principal nutrient artery of a bone, but the
possibility of this condition is doubtful, bone being too well supplied
by its surrounding periosteum. Necrosis in connection with fracture is
rare except in compound fractures, and, when a detached fragment can be
seen, may be anticipated by removal of the same.


2. =The Pathological Form.=--The pathological form is due to the
preëxistence either of _tuberculosis_, _syphilis_, or an _acute
infection_, such as _osteomyelitis_. It may also be the result of
_acute infectious periostitis_, where the periosteum is completely
loosened from the shaft of a long bone. These conditions are connected
either with the slow ravages produced by granulation tissue, or with
the acute septic processes by which infected exudates shut off large
areas from sufficient blood supply, or by which in consequence of
septic thrombosis a similar condition results. In consequence there may
be met bone dying in small visible particles, or the entire shaft of a
long bone or several smaller ones may be involved in the destructive
processes.

The portion which dies is known as the _sequestrum_, which may assume
irregular and unusual shapes, varying entirely with the area involved.
The general character and size of a sequestrum will depend upon the
nature of the cause. In acute osteomyelitis it is either a bone shaft
or an epiphysis which thus suddenly dies. In the slower processes the
fragments may be of almost any imaginable size and form--irregular with
jagged ends, or long, extending completely through a bone, either from
end to end or from side to side.


3. =The Toxic Forms Of Necrosis.=--The toxic forms of necrosis
are due mainly to two substances used in the arts--_mercury_ and
_phosphorus_--whose use seems to be inseparable from the manufacture of
many modern industrial products.

_Mercurial necrosis_ may come either from the volatilization of the
metal in factories where mirrors are made or from refineries where
amalgam is distilled. It also occurs from the _internal use_ of the
drug. Its effects are seen more frequently in the alveolar portion of
the lower and upper jaw than elsewhere. It is through some unknown
peculiarity that the jaws are the bones commonly involved in both of
these forms.

_Phosphorus necrosis_, on the other hand, manifests itself almost
entirely in the lower jaw, and occurs usually among the young,
in factories where matches are made. It is due to the vapors of
phosphorus, which cause a form of nearly distinct maxillary necrosis--a
fact which has been so widely recognized as to lead to State
legislation preventing the employment of the young in such work.

Phosphorus necrosis _begins as a periostitis_ with the production of
osteophytes, and is completed as a nearly total necrosis of the entire
bone.


=Treatment of the Toxic Forms.=--The _preventive_ treatment should
consist of supervision of the teeth, the use of alkaline mouth-washes,
inhalation of terebinthinate vapors, which neutralize those of
phosphorus, and the ventilation of establishments devoted to
match-making. The curative treatment consists of buccal antisepsis,
opening of abscesses, and the removal of diseased bone, especially
of dead bone, upon the first provocation. The occurrence of fistulas
should always be regarded as pathognomonic of diseased bone. In
aggravated cases, such as are rarely if ever seen since legislation has
been brought to bear upon the subject, practically complete necrosis of
the lower jaw, either _en masse_ or in portions, was far from unknown,
and the possibility of regeneration of the bone was for a long time
discredited, until the late James R. Wood, of New York, exhibited a
specimen, both at home and abroad, which proved its possibility. Since
then we have learned that it is possible for bone thus to regenerate,
the cause of the disturbance having been removed.

[Illustration: PLATE XXXVII

Necrosis of Shaft of Femur with Sequestra. (Life size.)]

[Illustration: FIG. 232

Phosphorus necrosis of the lower jaw. (Musée Dupuytren.)]


=Sequestrum Formation.=--To the portion of bone which dies is given the
name _sequestrum_, while multiple sequestra are by no means uncommon.
The sequestrum is white and ivory-like in hardness when it consists of
original compact structure. It is rare to find a distinct sequestrum of
spongy tissue, as this yields so readily to the presence of granulation
tissue and of pyogenic infection. A sequestrum may include an entire
bone shaft, or epiphysis, or only a small fragment. A portion of
the bone having lost its vitality becomes a foreign body which the
surrounding tissues endeavor to extrude or to wall off and surround.
The extrusive effort is the one which is usually seen. This is done
by the continued presence of granulation tissue, which gradually
perforates the surrounding bone at places of least resistance, the
result being the slow formation of a sinus or several sinuses,
ultimately connecting with the surface, and in which in neglected cases
the dead fragment of bone can be seen or felt, or from which it can be
withdrawn almost without operation. While this weakening of bone is
going on in certain portions a corresponding strengthening process is
also being put into effect; and the result is a quantity of new bone,
which is often wrapped around the sequestrum and is simply the effort
to atone for its pathological weakness and to strengthen it. This new
osseous tissue which so often surrounds the sequestrum is called the
_involucrum_, and in many instances it is necessary to remove more or
less of the involucrum before the sequestrum can be lifted out of its
bed or removed. (See Plate XXXVII.)

The whole necrotic process is intelligible if read aright as an
endeavor on the part of Nature to get rid of dead and irritating
material. When this effort is properly interpreted the natural efforts
can be seconded by the interference of the surgeon at a time when
disturbance is limited to the minimum and before external sinuses have
had opportunity to form. On the other hand, ignorance and neglect may
lead to the extreme condition, and most fantastic arrangements of
sequestra and involucra are seen in all pathological museums, some of
which seem to partake almost of the perplexities of Chinese puzzles.
The explanation, however, is always as above afforded. (See Figs. 233,
234 and 235.)


=Treatment.=--The treatment should be surgical, and consist in removal
of the dead portions and restoration of the parts to a condition
favoring rapid regeneration. It should always be radical, but is
sometimes made difficult by the inaccessibility of the fragment or by
the density of the involucrum and the necessity for large external
openings in order to remove the sequestrum.

Large and powerful forceps and strong and well-tempered bone chisels
are usually necessary, while, after making the necessary opening for
removal of the sequestrum, the sharp spoon should be used thoroughly
to scrape away all the lining material of cavities in which fragments
have been lying or all fungous tissue which may fill sinus tracks. It
will be well after this to thoroughly cauterize the wall of the cavity,
after which it is to be packed.

[Illustration: FIG. 233

Central necrosis of the tibia, long central sequestrum.]

[Illustration: FIG. 234

Sequestrum inside of a core of new-bone tissue, arranged much like a
puzzle.]

[Illustration: FIG. 235

Necrosis of tibia, showing sequestra after removal. (All three
specimens from the Buffalo Museum.)]

The packing of old bone cavities is of importance, and operators should
appreciate the reason for so treating them. The packing is essentially
a foreign material which the tissues will naturally endeavor to
extrude as they did the sequestrum. The method of extrusion is by
filling up beneath and around it with granulation tissue, which later
may ossify. The packing is therefore a constant provocation to the
formation of this tissue, which is now desirable, and is used mainly
for this purpose. It is antiseptic material, and will serve to prevent
decomposition of the pyoid material which would otherwise fill such a
cavity as the result of waste--Nature’s effort at formative material
gone to waste. A number of years ago Gunn suggested the use of _wax_
for this purpose, wax being plastic and incapable of absorption. A
piece of white wax was heated in hot water, molded with the fingers
to fit the cavity, where it served the purpose of a packing, and was
reduced in size with each dressing, as was necessary to permit it still
to remain. It is not now used as much as it deserves to be. (See p.
431.)

In favorable cases it may be possible to so thoroughly cleanse the bone
cavity without the use of caustics as to justify the attempt, after
rigid asepsis, of allowing it to fill with blood, which will coagulate
and organize into connective tissue. When this effect is desired the
wound should be covered with green silk protective, over which the
other dressing may be snugly applied. This healing by the _aseptic
blood clot_ is the ideal method when possible.

The extent to which regeneration of bone is possible is often amazing,
especially in the young. Thus after removal of the entire shaft of a
tibia there may result, in time, not a complete restoration to former
integrity, but, in addition, the formation of so much new osseous
material as to restore a great degree of strength, and which shall,
with the compensatorily hypertrophied fibula, make the leg as useful
as ever. In the thigh, however, complete necrosis of the femur means
amputation, as it will also in the arm unless the necrotic portion is
but a small proportion of the length of the humerus. The treatment of
necrosis of the skull, or, in fact, of any bone in the body which is
accessible, is based practically on the principles already laid down.


BONE TRANSPLANTATION AND TRANSFERENCE.

In the effort to atone for extensive loss of bone many experiments have
been tried, first on animals and afterward on men, success with the
former having lent much prospect to the latter. It has been learned,
for instance, that portions of living bone can be removed from some of
the lower animals and transferred into a bed of more or less healthy
sterile human tissues, often with the result that a fragment thus
transplanted becomes vitalized and incorporated, and serves the purpose
for which it was intended; still these efforts do not in all instances
succeed. However, experience has led to the effort to utilize some
portion of the patient’s own osseous system. This becomes more easily
possible in the case of the forearm or leg where, especially in the
latter, a small or less important bone can be utilized to take the
place of the greater. Thus, when the entire shaft of the tibia has been
removed for necrosis resulting from acute osteomyelitis, the fibula has
been sawed across, opposite the site of the ends of the lacking tibial
shaft, and transplanted into the trough-shaped depression, thus making
it functionate for the lost tibia. Huntington has recently reported a
case in which not only was this done, but later the upper and lower
ends of the fibula attached to the tibia, with good bony union and
with an almost perfect functional result. This will illustrate what
elsewhere may be done in this direction.


FILLING OF BONE CAVITIES.

Our methods for removal of sequestra and cleaning out of infected
bone cavities are now simplified and made safe. The difficulty which
is still universal is to secure a rapid filling or closure of these
cavities. If we could be certain of cleaning out every particle of
infected tissue and the removal of every germ which might excite
putrefaction, then we might resort to Schede’s plan and allow even a
large cavity to fill with blood clot and await its organization, but
no complicated and infected cavity in such tissue as bone-marrow can
ever be so treated to a theoretical degree of perfection. Therefore
disappointment often follows this attempt. Senn endeavored to improve
upon the plan by the insertion of chips of decalcified bone, but this
method is open to the same objection. Dentists have the advantage
of surgeons because they deal with small cavities, and in tissues
which can usually be thoroughly sterilized. Other things being equal,
the methods to which they resort could, with advantage, be imitated
by surgeons. In 1903, Mosetig-Moorhof suggested a mass containing
iodoform 60 parts, spermaceti 40 parts, and oil of sesame 40 parts.
When this mixture is slowly heated to 100° C. and allowed to cool,
there remains a soft material which, when desired for use, is melted,
being constantly stirred to keep the iodoform properly suspended, while
it is poured into the cavity, where it immediately solidifies. It is
claimed that its physical properties permit of its gradual absorption
and replacement by granulation, and finally by new bone, as has been
shown by a series of skiagrams. A cavity in which this preparation is
used should be prepared as dentists prepare theirs. It is successful
in proportion to the absolute disinfection of the same. For this
purpose wide opening and ready access are necessary in order to dry and
cleanse. Should oozing be persistent strands of catgut may permit of
escape of the blood which enters the cavity. It would probably be best
to use the elastic bandage and bloodless method, and to protect for a
few moments the solidifying mass before allowing the blood to return to
the limb. The originator uses, in his own clinic, a hot-air blast. The
air is heated by an electric contrivance, and both dries and disinfects
the cavity. After the cavity is thus filled the tissues are closed
over it and a sterile dressing applied. It is serviceable in chronic
cases and after thorough work. In acute osteomyelitis it is scarcely to
be thought of because of the acute character of the infection.


OTHER PARASITIC AFFECTIONS OF BONES.

These are mainly of two varieties--_hydatid disease_ and
_actinomycosis_.

[Illustration: FIG. 236

Achondroplasic skeleton. (Porak.)]


=Hydatid Disease of Bone.=--Hydatid disease of bone consists in the
development of hydatid cysts, which may be either of primary or
secondary origin. Almost all the bones of the skeleton are liable to
cyst formation, except the short bones of the carpus, tarsus, and
digits. In the long bones they occur most frequently in the region of
the epiphyses. The particular vascularity of this region is the main
factor in their location at this point. The cysts may be unilocular
or multilocular, and around them may be a thin or a large area of
infiltration. In other words, their boundaries may be abrupt or not.
Their volume is exceedingly variable, unilocular cysts sometimes
attaining considerable size and distending the bone beyond its normal
proportions. (See Chapter XXVI for further reference to the pathology
of hydatid cysts.)


=Treatment.=--The treatment is purely operative. The contents of the
cysts should be evacuated and its walls radically destroyed by caustic,
spoon, etc. All sequestra should be removed; in the limbs _amputation_
is sometimes necessitated by the extent of the affection.


=Actinomycosis.=--The general character of this parasitic disease has
already been considered. (See Chapter VIII.)

The peculiar fungus may be found in the periosteum, in the compact
outer layers of the bone, or within its more spongy depths. When the
lesion is sufficiently large to be recognizable to the naked eye it
assumes, for all practical purposes, the appearance of caries, like
that due to tuberculous or leprous diseases, while in the pus or debris
discharged from the same or contained within the invaded bones the
characteristic yellow, cheesy, or calcareous particles will always
be recognized. In this disease there never seems to be the slightest
tendency to encapsulation nor to protect against further spreading
by any process of repair. The diseased area constantly enlarges its
dimensions, involving everything as it spreads, it being limited by no
membrane or tissue of the body. Occurring in the bones, it is usually a
secondary or metastatic infection, and may be found in any part of the
body.

The symptoms will be those of osteoperiostitis, first occurring
frequently in the jaws, as it nearly always does in cattle, and often
in man; this is accompanied by loosening of the teeth and involvement
of the submaxillary tissues. The course of the disease is slow, with
little or no tendency toward spontaneous recovery.


TROPHONEUROTIC DISEASES OF THE BONES.

Under this heading it is proposed to group a number of diseases whose
clinical manifestations are distinct or classic, but whose underlying
causes are more or less obscure.


=Achondroplasia.=--This is a lesion of intra-uterine life which
includes a softening of primary cartilaginous structures and curvature
or malformation of the bones which should be formed from them. It
belongs to that period of fetal life between the third and sixth
months. It is sometimes referred to as _intra-uterine rickets_. Under
this name it was first described by Müller, in 1860, and since then
under various names, most commonly as _fetal rickets_. It appears
that in this disease the fetal cartilage contains mucus abnormally
collected, quite generally, in minute cavities or cells just at its
borders. The chondroblasts and osteoblasts are not regularly dispersed,
and the development of the growing bone is thereby much interfered
with. The periosteum appears to have nothing to do with this condition.
In consequence the cartilage does not do its proper duty. The long
bones fail to attain their proper proportionate length, but become
thicker than normal, the periosteum being unaltered. On the other hand,
those bones into whose formation cartilage enters but slightly, such
as the clavicle and the ribs, retain their normal proportions--the
consequence is a peculiar malformation and disproportion of the whole
skeleton (Fig. 236).

These deformities are symmetrical, and pertain mostly to the bones at
the base of the skull and to the long bones of the limbs; therefore
the distinctive appearance may be recognized even at the birth of the
child. The head is disproportionately large, the spinal column short,
the lumbar curvature exaggerated, all of which is rather the reverse of
the ordinary rachitic manifestations. The disease is not common (Fig.
237).

[Illustration: FIG. 237

Achondroplasia. (Lugeol.)]


=Prognosis.=--The prognosis is unfavorable, because it seems impossible
to undo the faults of the intra-uterine condition. The disease,
however, is not incompatible with a long life.


=Rachitis.=--This also is a constitutional condition, and has been
described in Chapter XIII. So far as the manifestations in the bones
are concerned it is a constitutional dystrophy caused by improper
deposition of calcareous material in the softened and somewhat
perverted fetal cartilages. It is a condition, however, pertaining
rather to postnatal life, and while inconspicuous at birth becomes more
and more marked as the child develops. It is essentially a disease of
malnutrition, and consequently may be seen in all walks of life, as
well in the bottle-fed babies of the wealthy as in the best-nourished
children of the poor. The subject should be studied also in connection
with the facts set forth in the chapter on the Status Lymphaticus,
which bear on the relation of the ductless glands to tissue growth, and
especially to rickets. The lesions are widely distributed. The disease
is divided by some writers into three periods: (_a_) _Rarefaction of
bone tissue_; (_b_) _softening of same_; (_c_) _re-ossification_.

The first stage is the intra-uterine part; the second and third stages
are postnatal. To fetal rarefaction have been attributed intra-uterine
fractures, even by Hippocrates.

The general dyscrasia and visceral alterations of rachitis interest
us here less than deformities of the various bones. The head is
disproportionately large, the vertex flattened, the frontal and
parietal eminences pronounced; the anterior fontanelle closes very
late. To the atrophic alterations of the head have been given the name
_craniotabes_. The face is disproportionately small, the lower jaw
assuming a polygonal shape. The palatal vault is of the Gothic type,
dentition irregular and retarded. In the thorax the clavicular curves
are exaggerated, by which the bones are shortened and the shoulders
made narrow. The costochondral junctions are enlarged, the result
being the so-called _rachitic rosary_. The sternum projects and gives
the peculiar appearance known as _pigeon-breast_. The pelvis is often
deformed, and frequently distorted to such an extent as in after years
to make normal delivery impossible. The spinal column may either be
distorted early or is likely to undergo alterations of curvature,
due to the combined results of pressure and traction upon softened
vertebræ. The joint ends of the long bones are enlarged or clubbed,
this being true even of the phalanges. Joint movements are often
accompanied by crepitation. The axes of the long bones are distorted,
and more or less marked deviations and curvatures result, giving rise
to such deformities as knock-knee, bow-leg, etc. (See pp. 161 and 162.)


=Osteomalacia.=--As rickets is essentially a disease of early
childhood, osteomalacia is practically confined to adults. The name
implies a peculiar _softening of the bones_, by which their resistance
and rigidity are weakened and deformity permitted. The disease is
common to man and to animals in confinement, and is frequently noted
among wild animals dying in zoölogical gardens. It commonly occurs in
_pregnant women_, where it would appear as if the mineral elements
needed for the growing fetus were abstracted from the mother’s bones
rather than from the food ingested. It is brought about also by
_starvation_, possibly by _lactation_, especially among those who nurse
their children for unusual periods.

[Illustration: FIG. 238

Osteomalacia: celebrated case of Moraud, 1753. (Skeleton now in Musée
Dupuytren.)]

_Spontaneous fractures_, especially of the long bones, are frequent.
These may refuse to unite properly and false joints may result. The
urine will under these circumstances contain an excess of mineral
salts, carbonates, phosphates, and oxalates, and when these are
discovered in the urine of those suffering from fractures it should
always be a warning to administer calcium salts and mineral acids,
preferably phosphoric, internally, and to carefully watch the
excretions. The progress of the disease is slow, yet steady, and often
not easily checked, if at all affected, by mineral acids. Occurring in
pregnant women, it may be checked after delivery, especially if the
child be not allowed to nurse from the mother. In some instances it
occurs with each successive confinement in the same patient, and makes
distinct advance with each fresh attack.


=Prognosis.=--The prognosis is therefore unfavorable, least so in
puerperal cases.

An _infantile form_, as well as a _fetal form_, have been noted, but it
is doubtful whether these forms really come under the same category,
and whether they are not manifestations of rickets. A _senile form_
has also been described which affects most frequently the sternum and
thorax, which is characterized by excess of nervous excitability and
by bone pains, as well as by liability to multiple fracture upon the
slightest provocation. This form, however, differs but little from
the osteoporosis of advanced years, and scarcely deserves distinct
consideration. Certain writers have also mentioned a _symptomatic
form_--cancer, syphilis, scurvy, etc.--which, however, is unnecessary,
since the fractures occurring in cases of cancer or syphilis are due to
secondary lesions of the same character, while those occurring during
scurvy are simply an expression of starvation and weakening, even of
the bones. Cases of cancer, for instance, where bones have broken
without being previously weakened by secondary growths, are exceedingly
rare.

Under the name of _osteogenesis imperfecta_ has been described the
“fragilitas ossium” of certain writers. The condition has also
been known as congenital fetal rickets. These cases may usually be
recognized in infancy, in that the extremities are more or less bent
and deformed, and the bones very fragile. Sometimes intra-uterine
fractures occur, which may be recent or old, and united with more or
less callus and deformity. The spinal column will be soft and friable,
with marked divisions, and the ribs are often fractured. The clavicle
shows lesions of this kind more frequently than any other single
bone. Bones so affected will be found extremely fragile and delicate,
and sometimes so thin that they may be crushed between the fingers.
They are defective in every respect of structure. But these changes
pertain mostly to the shafts of the long bones, and do not concern
the cartilages. They are to be distinguished from chondrodystrophia
fetalis, in which the extremities are shortened, the skin thickened,
and the subcutaneous tissues extremely fatty or edematous.

The condition is to be distinguished from rickets, as there is no
enlargement of rib ends or epiphyses and no disturbances of the
alimentary or nervous systems. Osteomalacia usually occurs after
puberty. Hereditary syphilis, in very rare instances, is a factor, but
should give additional evidences in other parts of the body. At present
there is no satisfactory explanation as to the cause of the condition.

[Illustration: FIG. 239

Osteopsathyrosis. (Blanchard’s case.)]


=Treatment.=--The treatment for all these conditions should be removal
of the cause if discoverable and the administration of calcium salts
in accessible shape, as in cases of rickets, combined with thymus or
pituitary extract.


=Osteopsathyrosis, or Fragility of Bones.=--This is a condition
distinct from osteomalacia and is due to trophic nerve disturbance.
The condition seems to be hereditary, often extending through several
generations. It is characterized by fracture of long bones upon the
slightest provocation, and is common to all ages. While apparently
congenital in origin, it persists often throughout life, no impression
being made upon the condition by medication. It is not characterized by
distinctive histological changes, and all theories heretofore advanced
toward its cause are disappointing. It is seen, at least in this
country, most often in _paretics_ and _inmates of insane asylums_. The
ease with which the bones of such patients are broken has given rise
to repeated charges of violence or homicide. From one case in which
this charge was made I secured specimens of the ribs, which were so
fragile that they could be crumbled between the fingers. Such patients
might easily sustain serious fractures when undergoing necessary
restraint, even of the gentlest nature. Allegations of undue violence
are frequently made in these cases, which, especially in asylums, may
be most unjust and difficult to prove or disprove.

The _relationship of osteomalacia to exophthalmic goitre_ furnishes
another illustration of the peculiar and mysterious influences which
the thyroid exercises upon nutrition. The conditions have a similar
geographical distribution, as well as being coincidental in the same
individual. Honicke, who has recently studied the subject, believes the
bone condition to be an expression of thyroidal disorder, the more so
in that castration does not remedy the disease, thus proving that the
genital glands are not at fault.

The peculiar relationship between the bone and the thyroid in these
cases is probably one of disturbance of the elaboration of the
phosphorus compounds which are necessary for the proper development of
bone, these compounds being excreted rather than utilized.

Osteopsathyrosis of this congenital type is perhaps best illustrated
by a case reported by Blanchard,[35] of Chicago, in the case of a
woman twenty-seven years of age at the time of his report, who up to
that time had sustained over one hundred fractures. In her case it was
sufficient to merely gently slide from the sofa to the floor to break
some bone. Treatment in her case had been of no avail. (See Fig. 239.)

  [35] Trans. Amer. Orthopedic Assoc.


=Senile Fragility of Bones.=--This means weakening of the bones which
is incident to advanced age in either sex, due to and comprised under
the term _osteoporosis_. Added to this, in certain places is a positive
change in shape, also characterizing the senile condition--_e. g._, the
neck of the femur. Under these circumstances bones will break with a
minimum of violence and without invoking any theory of osteomalacia,
osteopsathyrosis, or the like. As bone disappears under these
circumstances fat usually takes its place, so that while the volume of
the bone may not be particularly diminished, its weight and density are
materially altered. (See introductory remarks to this chapter.)


=Atrophic Elongation.=--This is a term first applied by Ollier, and
refers to a distinct type of alteration in long bones by which their
actual volume is relatively diminished, although they _increase in
length_. It is produced largely by lack of pressure, and is seen in
many amputated stumps, in which it has much to do with the conicity of
the same. It is seen in certain cases of typhoid fever or in forced
confinement of the young in bed, where the bones appear to grow at
a much more rapid rate than normal. It may also be due to unequal
amounts, or defects, of nutritive supply, especially that furnished by
the periosteum, and in certain other cases seems to be a purely reflex
or trophoneurotic change which is always inexplicable. Frequently
accompanying it is muscular wasting, which is to be explained rather by
reflex action through the cord, produced perhaps through the mechanism
of the terminal filaments of the articular nerves.


=Ostitis Deformans.=--Ostitis deformans is often called _Paget’s
disease of the bones_, and is a condition found alike in long and
flat bones, the osseous tissue being condensed in texture and
increased in amount, or at other times the osseous tissue becoming
quite porous and the spongy tissue rarefied without alteration in
the marrow. It is due to the unknown causes which may be summed up
in the expression trophoneurotic, a _painful_ and a _painless_ form
having been described, the former the more frequent. It produces
deformities, disfigurements, and hypertrophies of the long bones. It
is distinguished from _arthritis deformans_, described in the previous
chapter, which is a distinct malady.

In the skull it is usually the face bones which are most involved,
although the disease often commences in the cranial bones. The skull
proper may be thickened even to 3 Cm. The thorax becomes globular or
cubic in form, the arms are relatively too long, and there is usually
dorsal kyphosis; the pelvis is thickened and distorted; the ribs are
augmented in size and the femora irregularly curved; the patellæ
enlarged; the tibiæ more massive and their curves exaggerated. The
disease is essentially _symmetrical_, commonly commencing in the
cranium and radius. Fractures are rare, because the bones become
stronger rather than weaker.

In many instances these changes are accompanied by severe pains,
which may be exaggerated by pressure. The malady is usually regarded
as rheumatism, but it may be said that even were accurate diagnosis
made early it would scarcely avail in treatment, since there is none
for it. It may require to be distinguished from hereditary syphilis,
in which the tibiæ have more of the saber shape; from _acromegaly_ or
_leontiasis_, which begin in the bones of the face and involve the
cranium only secondarily.


=Osteoarthropathie Hypertrophiante Pneumique.=--Under this title, which
has no exact equivalent in English, was described, in 1890, by Marie, a
peculiar affection, often wrongly spoken of in this country as Marie’s
disease. This is in large part a pulmonary affection accompanied by
enlargement of the extremities. There is reason to believe that there
are present microörganisms, giving rise to products that are absorbed
into the general circulation, the result of whose presence is an
irritative hypertrophy of certain parts, particularly the joints and
ends of the fingers, the elbow-, shoulder-, and knee-joints, and often
the wrist. There is also ordinarily dorsolumbar kyphosis, which in
acromegaly is usually cervicodorsal. The cranium remains intact; the
borders of the jaw are sometimes involved.


=Acromegaly.=--Acromegaly is so named from its tendency to increase
the volume of the bone extremities or apices. The first case of
this disease was published by Marie in 1885. It is characterized by
progressive increase in weight, by enlargement of all the extremities,
bones and soft tissues alike; but the most characteristic involvement
is that of the lower jaw, the upper jaw being little if at all
affected. The lower jaw assumes enormous size and projects so that
its teeth are far in front of those of the upper. The supra-orbital
ridges enlarge, as do also the sternal ends of the clavicles and
costal cartilages. As the disease progresses the ribs are widened and
the scapulæ enlarged, the vertebræ and the intervertebral cartilages
thickened and fused together, causing usually cervicodorsal kyphosis.
The long bones of the limbs suffer later, especially at the lowermost
joint ends--_i. e._, hands and feet. The viscera are rarely affected,
but there is a peculiar and characteristic enlargement, usually of
the thyroid and pituitary bodies. The lower cervical ganglion of the
sympathetic is also sclerosed; the mucous membrane of the nose is
usually hypertrophied; the uvula is enlarged and the larynx often
participates in the changes. Acromegaly is essentially symmetrical, and
for each change upon one side of the body is noticed a corresponding
alteration upon the other. Particular features are observed in
individual cases, but the above are practically common to all.

[Illustration: FIG. 240

Osteoarthropathy. (Marie.)]

[Illustration: FIG. 241

Acromegaly. (Original.)]

The underlying pathological condition is as yet undetermined, though
most indications point to late alterations along the original
_craniopharyngeal tract_ of the young embryo, whose remains are best
known in the pituitary body and the thyroid. On this account there is
reason for trying the treatment by extract of the pituitary body, or
even of the thyroid. The greatest complaint usually is of headache,
which is difficult of relief. The disease is steady, progressive,
unaffected by treatment, and the prognosis bad, though its course is
slow.


=Leontiasis.=--A diffuse bilateral, symmetrical hypertrophy of the
bones of the face and later of the cranium, described first by Virchow,
the real origin appearing to be in the superior maxillæ, the result
being a peculiar leonine appearance of the face, hence the name given
to the disease. There is no distinct tumor formation in the bone, but
rather the entire structure of the bones involved is affected. As it
advances function of the parts is interfered with, mastication becomes
impossible, headache and pain are constant. The special senses are
disturbed because of involvement of their nerves, and patients die
usually from inanition, because no longer able to chew and swallow
food. It is distinguished from Paget’s disease, because it shows no
tendency to involve the rest of the skeleton; from acromegaly, in which
the general shape of the jaw is preserved, though its dimensions are
magnified; from tumors of the jaw or face, because of its symmetrical
enlargement. Its pathogeny is as obscure as that of the other bone
affections mentioned in this list, and its treatment as unsatisfactory.

[Illustration: FIG. 242

Leontiasis: skull of a Chinese woman. (U. S. A. Museum, No. 10,620.)]


TUMORS OF BONE.

As between the various hypertrophic conditions of the bones above
noted should be distinguished the true neoplasms, which answer all the
requirements of the definition given in Chapter XXVI. There are few
of the true tumors which may not be met with in bone, including the
periosteum.

[Illustration: FIG. 243

Multiple enchondromas of fingers.]


=Fibromas.=--Fibromas may spring from the periosteum, especially
about the jaws and from the base of the skull, from which latter
place they may project into the nasopharynx and interfere with the
welfare of the patient. Some of these tumors are soft and succulent,
as well as extremely vascular, and I have seen death occur upon the
table in an endeavor to remove a growth of this kind, hemorrhage being
uncontrollable.

[Illustration: FIG. 244

Multiple ecchondroses and exostoses.

Skeleton in the museum at Lyons. (Poncet.)]

[Illustration: FIG. 245

Multiple ecchondroses and exostoses. (Lexer.)]

[Illustration: FIG. 246

Cancellous osteomas springing from the diploë. (Musée Dupuytren.)]

[Illustration: FIG. 247

Sarcoma of femur. (Buffalo Clinic.)]

[Illustration: FIG. 248

Fungating osteosarcoma of cranium. (Pemberton.)]


=Cartilaginous Tumors.=--Cartilaginous tumors, as stated in Chapter
XXVI, are not often found outside of the bony skeleton. They may spring
from cartilaginous extremities of growing bones, from epiphyseal
cartilages, or from the interior of long and short bones, where their
origin is probably due to inclusion of cartilaginous elements, as
comprehended in Cohnheim’s theory. In young children they are often
multiple and involve various parts of the body. Occurring in adults
they are less often multiple, but may attain considerable size. (See
Fig. 243.) They are found usually about the ribs, sternum, pelvis, and
femora. If the entire structure of a given bone be involved in a growth
of this kind, its eradication--that is, amputation--will probably be
necessary.

[Illustration: FIG. 249

Exostosis bursata. (Orlow.)]

When otherwise, complete removal with careful cauterization of the
base of the growth or surface from which it sprang will usually be
sufficient. These cartilaginous tumors tend on one hand to mucoid
softening and cystic formation, and on the other to calcification or
ossification, by which the original cartilaginous character of the
growth may be concealed.


=Osteomas.=--Osteomas are by some writers made to include _exostoses_
and _hyperostoses_. In accordance with the system followed in this
work only those growths are considered as tumors which are of
no physiological usefulness, and it is preferable to maintain a
distinction between osteomas and the exostoses or bone hypertrophies,
which pertain either to evolutionary relics or to constitutional
affections.

There is, however, a peculiar form of exostosis which becomes covered
by an adventitious bursa, whose walls become in time quite thick,
which is called _exostosis bursata_. In the cavity of this bursa may
frequently be found rice-grain or other fibrinous concretions. This
lesion is common in the neighborhood of joints, and the new bursa
frequently communicates with the joint cavity (Fig. 249).


=Myxomas.=--Myxomas are rare in bone, and are seen usually only as
degenerated forms of cartilaginous bony or malignant growths. They
lead to cystic degeneration. A primary growth of this kind has for its
origin the bone-marrow.


=Sarcoma.=--As already described, sarcoma of bone should not be
confused with osteosarcoma. (See Sarcoma.) The former refers to sarcoma
springing from the true osseous tissue or periosteum. When central
the bony walls are expanded and form a shell. Osteosarcoma refers to
a tumor springing from the original connective tissue which holds
the bony elements together, and contains osseous tissue scattered
through it. Sarcoma occurs usually in the long bones, although none
are exempt; mostly single, it nevertheless may be multiple. It occurs
frequently in the young, is seen even at birth, and in these instances
is supposed to take its origin usually from epiphyseal structures. No
period of life is, however, exempt. Tumors attain sometimes enormous
size. Marsh has recently described such a tumor weighing thirty-three
pounds. Microscopically these tumors may assume any of the varieties,
endothelioma, angiosarcoma, etc., those of the most rapid growth being
found rather of the _round-cell_ type, while those of slow growth are
usually _myeloid_ or contain giant cells.

Sarcomas frequently arise from the _periosteum_. Commencing in the
interior of a bone, they develop for the most part very slowly, and
expand the bone more or less symmetrically, in distinction to those
growths of external origin which are in evidence on one or another
aspect of the bone involved (Figs. 247 and 248).

Sarcoma not infrequently has its origin from the callus of a delayed
bone union, and I have had repeatedly to amputate for this sequel of
fracture. (See Fig. 252.)

As the disease advances there is increase of pain, usually with
increasing cachexia, while augmentation in size of such a tumor may
make a limb not only useless, but the source of greatest annoyance and
difficulty in management of the case.


=Treatment.=--There is but one treatment in cases which will permit
it--amputation of limbs, extirpation of tumors from certain bones, or
excision of entire bones. Thus for sarcoma of the scapula we extirpate
the entire bone; for sarcoma of the skull we make extensive resections
of the same, removing the underlying dura when involved; for sarcoma
of the lower or upper jaw we remove it in whole or in part. Sarcoma
of the spine is inoperable, that of the pelvis almost equally so. In
absolutely inoperable cases treatment by the toxins of erysipelas
may be tested. In all cases where pain is severe opiates should be
administered, which under these circumstances are anodyne, stimulant,
and almost nutritive. Patients in this condition should not be allowed
to suffer, and opium in assimilable form should always be administered
to any amount necessary.

[Illustration: FIG. 250

Sarcoma of periosteum of humerus. (Pemberton.)]

[Illustration: FIG. 251

Bone cyst of tibia. (Buffalo Clinic.)]


=Myeloma (Kahler’s Disease).=--Collins[36] reports the tenth recorded
case in this country. The disease was first described by Bence
Jones in connection with a peculiar proteid found in the urine. It
is characterized by changes in the bones, with pain in the chest,
back, and loins. In the urine albumose appears, which seems to be
pathognomonic when taken in connection with such symptoms as those
above. On section numerous small tumors are seen in the bones. The
disease has hitherto been regarded as an expression of osteomalacia.
All the bones of the skeleton may be involved without any tendency to
metastasis in other tissues. On minute examination the myelomatous
tumors met with seem to be found alike in the bone substance and the
marrow, and to be cell proliferations of myeloid tissue. The matter is
still left somewhat in doubt as to what should be meant by the term
_myeloma_, this being a feature to be cleared up later. It is seen
more often in males than in females, and in the later part of life.
Aside from constant malaise, with pain in the back and side, there
occur progressive weakness, with anemia, and such final softening and
fragility of bones as to lead to spontaneous fractures, or to the
projection of tumors, which may be especially noted about the ribs,
with deformity of the vertebræ. On close inspection the urine will be
found turbid and albumose is detected. The disease is usually regarded
as hopeless; there is no information regarding its successful treatment.

  [36] Medical Record, April 29, 1905.

[Illustration: FIG. 252

Sarcoma developing in callus. (Haberen.)]




CHAPTER XXXIII.

DEFORMITIES DUE TO CONGENITAL DEFECTS OR ACQUIRED DISEASES OF THE
LOCOMOTOR APPARATUS; ORTHOPEDICS.


In previous chapters have been considered the various morbid conditions
of bones, joints, muscles, and tissues which help to form the locomotor
apparatus of the body. It would seem then quite proper in this place
to insert the chapter usually relegated to the end of text-books on
surgery where it stands by itself, _i. e._, the chapter on Orthopedics.
As a subject orthopedics deals with the causation and the treatment of
deformity, whether inherited or caused by disease. The term is used in
a more or less elastic sense, and is made by some to cover a larger
field than others would accord it. The subject divides itself into two
parts:

1. The consideration of deformities produced by tuberculous or other
infectious disease, and

2. Non-carious, congenital, and acquired deformities.

Tuberculous lesions do not differ in pathology or other respects from
the tuberculous diseases of bones and joints described in earlier
chapters of this work. Inasmuch, however, as some of them form distinct
and clinical types of deformity they assume an importance which
justifies reasonable consideration by themselves. Of these we shall
consider spinal caries, sacro-iliac disease, hip disease, and tumor
albus.


SPINAL CARIES, SPONDYLITIS, KYPHOSIS, POTT’S DISEASE.

These various terms have reference to deformities of the spine of
similar type, but with considerable variations, produced by caries
(tuberculosis) of the vertebral column. Where osseous structures are
separated by cartilaginous or more or less complete joint cavities the
primary focus may form within the spongy structures of the vertebral
bodies or in the softer tissues of the intervertebral joints. In
other words, it is caries of the ordinary type which assumes special
significance only because of the accident of its location. The entire
vertebral column should be regarded as the main support of the body,
while to it is due the maintenance of the erect position which raises
man above the animal. When diseased and softened it yields to pressure,
the result being exaggeration or distortion of its natural curves. As
the instinctive tendency of the human being is to maintain the head
in the line of the centre of gravity above the pelvis, any marked
degree of curvature in one direction brings about, by natural causes,
a compensatory curve in its opposite direction. A well-marked case of
kyphosis, then, is characterized by more than one exaggerated curvature
or protuberance, one being due to disease, the other to compensation.

While there may be several foci of active tuberculous disease, even in
one vertebra, there may be found pronounced forms of angular curvature
as the result of destruction occurring in but one or two of them.
The carious process once begun may be checked at any point in its
course, or it may proceed to complete softening and destruction, with
formation of cold abscess. The tuberculous process once begun spares no
tissue, and thus bone and intervertebral cartilage melt and disappear
in the same manner. There may be a possible danger from spreading of
tuberculous disease to the spinal meninges or to the cord, or of its
being generalized. In the former case there is pachymeningitis and
myelitis with paralysis; in the latter case it causes more or less
rapid, acute general tuberculosis. Paralysis is more often induced,
however, by actual compression than by mere tuberculous involvement,
although the disease products which cause this pressure are likely to
come from a caseous pachymeningitis.

The disease is most common in childhood, about 80 per cent. of cases
occurring before puberty. Of the three regions of the spine the
thoracic is the one most often involved, next the lumbar, and lastly
the cervical. The most common site of all is in the lower dorsal
region. Deformity once established as the result of this disease cannot
be expected to spontaneously disappear.


=Causes.=--Slight injuries occurring in those of tuberculous diathesis,
by which there is produced a focus of least resistance, or secondary
infections following upon such conditions as scarlatina and typhoid,
constitute the most frequent recognizable causes. There can usually
be obtained a history of some injury in about half of the cases. The
disease once established may assume either an acute or chronic type.


=Symptoms.=--As indicated when discussing caries in joints the
principal signs and symptoms are pain, muscle spasm, muscle atrophy,
tenderness, deformity, and impairment of function. These are all
present in Pott’s disease, to which they give that distinct clinical
picture which Pott so graphically described about a century ago.


=Pain.=--Pain is rarely absent. It may be misleading, but is usually
referred to the terminal distribution of the intercostal nerves, and
thus may be complained of in the chest, the abdomen, or the legs. Many
a “stomach-ache” in children is of this character and origin, and a
complaint of frequent “growing pains” should be carefully investigated.
Even in sleep these pains are characteristic, and have been previously
described as “starting pains.” Children cry out with them in the night.
They tire easily and tend to seek rest instinctively. Pain is always
aggravated by excessive pressure upon the upper spine or by jars,
such as may be received in jumping. It is not necessarily constant.
Vertebral tenderness may sometimes be detected by pressing upon the
ribs. This will especially aggravate symptoms when respiration is of a
groaning character or when there is any expression of dyspnea. There
may be vomiting or dysuria. A sudden increase of these painful features
means a fresh focus of infection, impending abscess, or a danger of
paralysis.


=Muscle Spasm.=--It is by muscle spasm that we account for the
attitudes and postures of Pott’s disease. It is a constant feature,
but will vary in its expressions with the location of the disease. In
caries of the cervical spine the chin is raised, the head is balanced
somewhat backward, while the lower spine is straightened and given a
backward curve. In the stooping posture the head is supported by the
patient’s hands in the instinctive effort to protect it. In caries of
the mid-dorsal region there is elevation of the shoulder, with marked
tendency to support the weight of the upper part of the body by placing
the hands upon the knees or thighs. Lumbar caries often produces
perceptible backward curve in the lower portion of the spine.

In all cases there are stiffness and rigidity of the spine, and
patients resort to all sorts of instinctive expedients to avoid
motion in the affected area. When that part of the spine which is in
relation with the psoas muscle is involved there is more or less psoas
contraction, with characteristic flexor deformity at the hip, which is
usually bilateral. This will give a peculiarity to the gait and cause
it to be not only stiff in appearance, but it will be seen that the
patient walks more upon the toes and with slightly bent knees, which
are thus made to act as springs. An attitude assumed in stooping or in
the effort to lean over as if to pick up an object from the floor is
characteristic; the spine will not be curved forward and the patient
will not stoop as usual for the purpose, but the spine will be more or
less erect and stiff and lowered to the floor by flexing both knees and
hips until the squatting position is assumed. In rising the same effort
will be made to protect the spine from any motion between its component
parts. (See Figs. 253 and 254.)

During sleep this muscle stiffness becomes even more pronounced, so
that in the morning patients are “stiffer” than later in the day. The
existence of muscle spasm can often be detected by palpation of the
spinal lesion. Some lateral deviation or asymmetry of signs may often
be noted, according as the muscles of one side are more pronouncedly
influenced by the location of the disease focus, and it is the more
common in proportion to the greater severity of the case.

The confinement caused by the disease will naturally be followed by
more or less atrophy of the body muscles, but, in addition to that,
those immediately involved about the centre of the disease undergo an
atrophy due to it and often apparent on inspection.


=Tenderness.=--In numerous distinctive ways the patient constantly
evinces tenderness and makes invariable efforts to protect against
movement or even jar. Tenderness can also be evoked by pressure upon
the head or shoulders, which will cause severe pain, or by causing the
patient to jump down a step or to rise upon the toes and then come
down abruptly upon the heel. Pressure upon the spines of the affected
vertebræ or upon the ribs which connect with them will also cause
complaint of pain.


=Deformity.=--This is the most striking objective feature of
well-marked Pott’s disease. It is practically a backward projection
known as kyphosis, the vertebra first affected being usually the first
to yield, the others following or changing in shape as the disease
spreads or as the growth of the individual permits accommodation and
necessitates rearrangement. The more acute the disease the sharper the
projection. Old and mild cases cause an abrupt curvature rather than a
protuberance.

[Illustration: FIG. 253

FIG. 254

Typical postures of the spinal muscle spasm of spondylitis. (Bryant.)]

It is well to keep a record of the deformity in cases under treatment.
This may be graphically preserved by putting the patient flat upon the
abdomen upon a straight surface and bending a strip of lead so that it
shall fit the contour of the spinous processes. After it has been made
to fit it may be removed and a tracing of the curve made upon a sheet
of paper. Comparison of tracings thus made at intervals will afford a
graphic record of the progress of the disease or of the improvement
made. Kyphotic deformities lead to a shortening of the spine, so that
growth is stunted and patients become dwarfed in appearance. Secondary
curvatures are produced above and below the primary projection.
Gradually as the shape of the vertebral bodies and of the entire spinal
column changes the ribs are pressed more or less together, often being
made to overlap, the shape of the chest undergoes alterations, the
sternum sometimes being depressed and sometimes protruded, giving the
chest, in the latter case, the so-called “pigeon-breast” appearance.


=Loss of Function.=--There are but few disorders which produce more
pronounced and widespread accompaniments than spinal caries. As change
in the shape of the spine occurs and assumes a marked type we see
changes occurring through the body, not only in the direction of anemia
with general impairment of function, mental irritability, and cachexia,
but there occur trophic alterations as well. The shape of the face
changes, the expression assumed is one of anxiety, and the features
become less mobile.


=Complications and Sequels.=--Tuberculous meningitis, cerebral or
spinal, is the most dangerous and acute condition, while other
tuberculous complications may occur in various regions of the body.
In fatal cases meningitis, in consequence of acute or mixed septic
and terminal infection, furnishes the explanation for the great
majority. Paralysis is not infrequent as a sequel, assuming the type
of paraplegia and developing slowly. Motion is first impaired and a
considerable interval may elapse before sensation is affected. Motor
impairment varies from mere mild paresis to complete paralysis,
beginning as fatigue, loss of strength, and inability to stand.
Unless the disease be located in the lumbar region the reflexes are
exaggerated and muscle spasm is easily provoked or occurs without
perceptible cause. As above noted the muscles become atrophied, and
when the cord is seriously compromised are rigid in chronic spasm. The
rectum and the bladder suffer finally, especially in disease of the
lower segments. Occasionally in cases of high dorsal disease the arms
will suffer more or less motor impairment. Sensory paralysis begins
usually as paresthesia. In merely bedridden but not actually paralyzed
individuals the reflexes should be normal. Of the muscle contractures,
those of the psoas are the most common and distinctive. Paralysis
follows rather than precedes deformity, and is noted in perhaps 20 per
cent. of advanced cases. It should rarely occur if effectual treatment
has been begun.


=Abscess.=--Abscess is usually of the “cold” type. Its general
character has been previously described. It may be of the purely
tuberculous type, but is not infrequently the result of a secondary
pyogenic infection. It is a consequence of neglect, but cannot always
be prevented. Signs, both local and general, of the presence of pus
or of pyoid are noted here, as under other circumstances. There is
exaggeration of local tenderness, with development of tumor, which
fluctuates as it approaches the surface. General septic features,
proportional to the activity of the process and its location, accompany
the local indications. Sometimes it occurs insidiously and with but few
evidences.

Pus travels here in the direction of least resistance. The fascial
planes of the body are mostly so placed as to protect important body
cavities, consequently pus will travel usually around them and toward
the surface, burrowing long distances, for instance, from the lower
dorsal region to the groin along the psoas muscle. Cervical abscesses
usually spread anteriorly toward the pharynx (postpharyngeal) and
deeply into the thorax (mediastinal); they may open into the trachea
or esophagus or externally through an intercostal space; or they may
burrow laterally, opening behind the sternomastoid muscle. Dorsal
abscesses usually travel posteriorly, opening not far from the spine,
or they burrow downward and forward along the psoas so as to appear
beneath Poupart’s ligament. Lumbar abscesses escape through the psoas
sheath as psoas abscesses, so called, or between the fasciæ of the
spinal muscles and those of the abdomen to appear upon the side; they
may extend downward beneath the iliacus, escaping over the brim and
into the pelvis and then out through the sacrosciatic notch. Of all
these the psoas abscess, opening in the groin, is the most common. This
will in time destroy the muscle fibers of the psoas, but it leaves the
vessels and nerves intact, whose sheaths are much more resistant, and
which can be found passing through such a cavity like cords through a
chamber. This form of cold abscess, with its consequent bulging and
final escape in the groin, has been mistaken for hernia as well as for
abscess due to perinephritis and appendicitis. The most serious mistake
would be to take it for a femoral hernia. The customary routes of all
these collections of pyoid have been thus indicated. Nevertheless
abscesses may burrow and appear almost anywhere. They will give rise to
varying and to superadded symptoms, according to their location. For
example, retropharyngeal abscess may seriously threaten respiration
by pressure upon the upper air passages, while a collection of pus in
the mediastinum might cause serious respiratory difficulty of another
character.

_Cold abscesses_ of spinal origin may remain stationary, the fluid
portion of the pyoid material may even absorb, while the balance
undergoes more or less degeneration and conversion into inert material,
or they may slowly or rapidly increase in size. The best that can be
hoped in such cases is absorption, with encapsulation of the solid
residue. Even this may be a source of danger, as it is a focus of
lessened resistance, in or about which subsequent trouble may result.
Those abscesses which seem to remain stationary would best be let
alone, hoping for subsidence under good treatment. Those which open
spontaneously leave tuberculous fistulas behind them, which may
possibly close in time, but which lead often to subsequent acute
infection, and which are the _bête noir_ of surgeons, for it is often
impossible to heal them. The best that can be done in such instances
is to wash them out, keep them clean, and guard them from infection
from without. It is often possible to pass a tube along the sinus and
through this to irrigate with a solution of iodine, of formalin, or of
any other antiseptic which may be preferred. If anything be done with
them in the operative way it should be as radical as possible, seeking
the original lesion, thoroughly curetting its site and the whole
interior of the cavity, and making ample opening so as to provide for
effective drainage.

_Retropharyngeal abscesses_ usually necessitate evacuation because
of the obstruction which they cause within the pharynx. _Lumbar_ and
_psoas abscesses_ may be let alone. When this is not practicable,
then choice should be made between simple aspiration, aspiration with
washing or injection of some antiseptic fluid, and free opening with
radical treatment. In these cases we are to be guided by the peculiar
features and surroundings of each, and by our own facilities for such
work and for subsequent care of the case. An abscess which will soon
rupture should be opened and counterdrained; but in one where this is
not impending, and where home features are such that the patient can
receive no adequate or prolonged care, it would be wiser to abstain.
Under the best of circumstances in these cases it is always a difficult
problem to decide. Even aspiration leaves at least a needle track
to be subsequently infected, while the contents may be too thick to
flow through a small trocar. Aspiration with thorough washing out and
then with injection of emulsions of iodoform or of other irritating
antiseptics have found favor with only a part of the profession. If any
radical measure is to be adopted the greatest care should be given to
carry out the principles expressed in the general consideration of cold
abscesses. (See p. 114.)


=Diagnosis.=--Intelligent comprehension of signs and symptoms should
enable one to make a diagnosis in most cases. Nevertheless the surgeon
is occasionally in doubt and has to distinguish, for example, as
between Pott’s disease and sprain, lateral curvature, hysterical
spine, cancer, cord tumors, rheumatic arthritis, rickets, syphilis,
actinomycosis, hydatid disease, acute osteomyelitis, _i. e._,
non-tuberculous diseases, and certain abdominal affections followed by
suppuration, such, for example, as peri-appendicular abscess. Moreover,
spondylitis may be simulated in the course or as a complication of
typhoid, scarlatina, gonorrhea, and other acute infections. Psoas
abscess should be distinguished from perinephritic abscess as well
as from acute appendicitis, which often causes psoas contraction,
especially when the appendix is posteriorly placed and left in contact
with that muscle. We may also have to distinguish this condition from
sacro-iliac disease and from ordinary hip disease.


=Prognosis.=--In some degree prognosis depends on what is meant by a
cure. Absolute cure, with restoration to the original condition, is
exceedingly rare. Arrest of disease, with improvement of deformity, is
possible in cases seen early. Even considerable motion may be restored
under suitable treatment. In late cases hectic, amyloid degeneration,
and dissemination of the disease make the outlook very discouraging.
At best its relief is slow and in time it is always chronic, no matter
how rapid the onset, except in those instances where dissemination
occurs early and rapidly, in which case there is little or no hope. In
ordinary cases there is a certain tendency to spontaneous recovery, but
not without deformity and impairment of function, while obviously the
occurrence of abscess prolongs a case to a considerable degree.


=Treatment.=--Those general measures so necessary for the treatment of
any tuberculous lesion, namely, hypernutrition, fresh air, and general
constitutional measures, are needed here as in any other such disease.
Physiological rest, _i. e._, absolute rest in a bed without springs,
the patient lying flat on the back or on the face, and not on the side,
and lying quietly, constitutes the best part of local treatment. In
the case of children it is best to have a gaspipe frame, across which
cloth may be stretched, on which a fretful child can be secured by
straps across the shoulders, pelvis, and knees. This frame may be laid
upon the bed and lifted from it while a cross-piece is removed for
toilet purposes, or a suitable opening may be left if a single piece
of cloth be stretched across it. If the patient can be made to submit
to this repose, then a pad may be placed under the projection. After
a sufficient length of time, with the desired improvement, a plaster
shield may be molded to the back, with the patient lying upon his face;
and then, after removing and suitably trimming and lining this mold,
the patient can be returned in it to the previous position in bed, from
which he may gradually be raised. This is the best method to follow in
acute or severe cases, or when the disease is higher up in the spine.
It will also best serve the purpose when the case is complicated by
abscess. To it may be added, if necessary, traction upon the head (Fig.
255).

[Illustration: FIG. 255

Child in bed-frame, with head traction. (Lovett.)]

[Illustration: FIG. 256

Jury-mast for high dorsal and cervical caries. (Lovett.)]


=Treatment by Apparatus.=--The simplest of all apparatus is the plaster
jacket, or corset, which was brought into favor in this country
by Sayre, although not invented by him. It is usually applied in
suspension, _i. e._, with the patient in the erect position beneath
the frame, from which hangs a support by which firm traction can be
made, both upon the head and the arms or the shoulders. The intent of
such a jacket is to apply it with the patient so stretched out that
a certain degree of the projection will at least be eliminated and
the back made more nearly straight than it otherwise would be. In
cases where this is impossible it at least affords better expansion
of the thorax and supports the ribs in better relation to the spine,
affording more chest room. The plaster is not applied next to the skin,
but a thin undershirt or its equivalent of woven materials should be
applied, care being taken to see that it fits snugly and is not allowed
to fold in ridges. After the patient is completely suspended to a
degree where discomfort begins, then a small “stomach pad” is slipped
beneath the under-jacket, in front, in order that more room may be
given for enlargement of the abdomen after a full meal. Finally with
the first turns of the plaster a strip of tin or a couple of strips of
moistened pasteboard should be applied directly over the middle line
in front and incorporated in the successive turns of bandage, in order
that there may be material there which may be cut down in removing the
jacket. Small pads should be placed over the iliac crests and over the
protrusion if it be at all marked or tender. Now by the use of a series
of bandages of gauze, in which reliable plaster of Paris has been
incorporated, the entire trunk is enclosed within a corset, which will
quickly harden as the plaster becomes firm. It should extend well down
over the pelvis and nearly to the trochanters, since from this portion
it takes its fixed support. It should then be extended as high as can
be permitted under the arms and higher yet over the chest and back.
Enough material should be used along with the plaster-of-Paris cream,
as the former is applied, to ensure sufficient firmness and strength.
If the plaster be reliable it will not be necessary to keep the patient
suspended more than a few moments after the completion of the jacket.
The finishing touches may be given it after he has been taken from the
frame and placed again upon a soft surface.

Another method of application is to have the patient recumbent and
properly supported, and this is particularly necessary in acute cases,
where suspension is likely to cause faintness or unpleasant symptoms.
In this attitude the spine is really put in better position. The method
is not at all available in those few cases of lateral curvature which
demand jackets (Fig. 256).

Substitutes for these jackets are made of various materials, such as
leather, rawhide, aluminum, thin strips of veneering, celluloid, paper,
glue, etc. These have to be constructed over a mold which is taken
from a plaster jacket. When the disease extends above the level of the
fifth dorsal vertebra there should be incorporated within the jacket a
support for the head, known since Sayre’s time as a “jury-mast.” This
consists of a metal upright, with cross-pieces, which are incorporated
with the jacket and which is curved up behind and over the head and
made to carry the frame from which the leather straps and supports pass
beneath the occiput and the chin, and thus give to the head a certain
amount of fixation. The support is so arranged as to permit of sliding
and of sufficient expansion so that traction upon the head can be made
effective.

[Illustration: FIG. 257

Frame for application of plaster jackets in recumbent position.
(Lovett.)]

Fig. 255 shows the application of traction to the head, while Fig.
256 illustrates one form of apparatus by which the jury-mast is made
effective in producing traction on the head in the upright position.
Figs. 257 and 258 show a convenient frame and method for making
plaster-of-Paris corsets with the patient in the recumbent position.
Figs. 259 and 260 show another form of apparatus intended for the same
purpose.

[Illustration: FIG. 258

Application of a plaster jacket in the recumbent position. (Lovett.)]

The variety of apparatus which has been devised for the maintenance of
rigidity and correction of deformity, and, in suitable cases, traction
upon the head, is to be measured almost by the number of orthopedic
specialists, nearly every surgeon inclining to some device or at least
modification of his own. Judson probably has formulated the best
rule covering the entire matter when he says: “The apparatus may be
considered as having reached the limit of its efficiency if it makes
the greatest possible pressure upon the projection compatible with
the comfort and integrity of the skin. It is essential that the brace
is efficient; second, that it is one that can be constantly worn, if
necessary, or can be easily detached from the body if not to be worn
at night.” Certain ambulant cases can be treated by an effective brace
through the day, and rest at night upon a reasonably hard mattress,
with traction upon the head. Concerning the multitude of these special
aids to treatment it hardly seems worth while to go into any elaborate
description in this place, inasmuch as one who is incompetent to judge
as to what is best should not retain the management of such a case,
while one who is really competent will probably desire to make his
own selection, and the writer’s recommendation would count for but
little. Every case must be a law to itself, and every special brace
must be constructed especially for the individual for whom it is meant;
otherwise it loses all its serviceability.


=Forcible Reduction.=--The feasibility and propriety of forcibly
reducing the deformities due to spinal caries was first suggested by
Chipault, of Paris, who suggested wiring the spinous processes of
the affected vertebra, and then, by Calot, who, in 1896, described a
method of forcible reduction under an anesthetic. The first to actually
wire the spine under these circumstances was Hadra, of Texas, who had
actually done the operation four years before Chipault. The method
has probably less to commend it in actual practice than in theory,
and, attractive as it may be in respect to time and completeness
of reduction, it is often followed by serious accidents, such as
hemorrhage, rupture of abscess, fracture of the spine, etc. Bradford,
in 1899, collected 610 cases performed by 29 different operators, with
a record of 21 immediate deaths from local trauma and 15 cases in which
there were at least alarming immediate symptoms. Of 229 of these cases
complete correction was effected in 119, incomplete in 94, while no
gain whatever was made in 16. Of results reported later, 66 showed some
gain, there was no relapse in 17, while 49 showed more or less return
of deformity. The claim has been made that the more or less wide gaps
or bony defects which may result from forcible manipulation are filled
in by new bone, but there do not seem to be any observations to confirm
this statement. The amount of force which must be employed is a matter
for the finest discrimination. The method includes complete anesthesia,
traction upon the spine in each direction from the location of the
deformity, and direct pressure force applied to the protection itself,
as by a sling passed around the body and just beneath the projection,
which can be used as a fulcrum upon which the rest of the spine can be
applied as a double lever, with the application, at first, of gentle
force, and, finally, sufficient to either satisfy the operator that
he should go no farther or that the desired effect has been obtained.
Immediately after completion of the maneuver a snugly fitting plaster
jacket should be applied and the patient kept absolutely at rest in bed.

[Illustration: FIG. 259

Anteroposterior support: back view. (Lovett.)]

[Illustration: FIG. 260

Anteroposterior support with head-ring for high dorsal caries: side
view. (Lovett.)]

The method seems most applicable in the presence of paralysis, even of
long standing, and this feature has often been relieved.

_Psoas contraction_ is best treated by traction, with the patient in
bed, and with the maximum of weight and power applied which can be
tolerated by the individual. If this seem impracticable, then the
patient should be anesthetized and force applied until it is evident
that more harm than good results. Should this harm appear, then open
division of the tissues may be practised. Finally, as a last resort, in
intractable cases, a subtrochanteric osteotomy may be made.

_Pressure paralysis_ necessitates _operative relief_. This may be
practised late and should consist of a laminectomy and exposure of the
area compromised by bone pressure or that produced by pachymeningitis.
The operation is done in the same way as for fracture, and will be
described in the chapter on Surgery of the Spine.

Finally of all cases of Pott’s disease it may be said that each should
be studied by itself, and for each a suitable method or apparatus
devised, rather than to endeavor to apply indiscriminately unchangeable
methods or forms of apparatus. Every apparatus has its disadvantages as
well as its benefits. The more acute the case the more is absolute rest
in bed, with traction, demanded. This is particularly true of disease
in the upper spine. On the other hand, the more chronic and the lower
the disease the easier it is to handle, and with such simple expedients
as plaster corsets. When the sacral region is rigid, however,
recumbency is usually necessary, because of the difficulty in securing
adequate fixation within any apparatus that can be worn. The necessity
for general constitutional, dietetic, and climatic treatment should
never be forgotten, and the danger of possible acute dissemination kept
ever in mind. This is particularly imminent when too much freedom is
allowed. Time, patience, and discernment are the dominating factors
beyond the general principles already inculcated.


SACRO-ILIAC DISEASE.

Under this name is included a tuberculous condition of the bony tissues
on either side of the sacro-iliac synchondrosis, or of the cartilage
itself, similar to that which produces the special caries described
above. It is an uncommon expression of tuberculous disease occurring
often in the young, identical in pathology with other tuberculous
bone lesions, and giving rise to peculiar symptoms, mainly because of
its location. Early in the course of the disease these may consist of
mild discomfort in the lower abdomen, irritability of the bladder and
bowels, disinclination for exercise, while, as the disease becomes
more pronounced, there will be actual pain, intensified by standing,
relieved by lying down, often severe at night, usually referred
along the course of the sciatics. A most significant symptom is the
tenderness and complaint produced by firm pressure made upon both
sides of the pelvis, thus forcing tender surfaces against each other.
In the later stages of the disease abscess may develop and present
either externally in the lumbar region or internally, breaking into the
pelvis and appearing perhaps in the groin or close to the perineum. The
disease is usually unilateral, and will cause characteristic limping
and aggravated pain upon standing on the limb of the affected side.
Naturally this limb will be spared in every possible way. It is likely
to be mistaken for sciatica or lumbago, in neither of which diseases is
there any tenderness at the sacro-iliac joint such as can be evoked by
pressure from the sides of the pelvis. It also has to be distinguished
from hip disease by the fact that motions at the nip are not interfered
with, and from Pott’s disease of the lower spine, which usually causes
prominence of the spinal processes and local tenderness in a different
region.

The surfaces and tissues involved are extensive and the disease is
always serious. It is one of the most chronic of all such affections,
and too often tends to suppuration, with its slow but inevitable
consequences, or to dissemination. Thus of 38 cases with abscess
reported by Van Hook only 3 recovered.


=Treatment.=--Treatment should consist of absolute rest, with traction,
so long as the symptoms are active, and avoidance of all irritation
when patients rise from bed. Abscess due to sacro-iliac disease
should be radically attacked, especially if this can be done early.
Intrapelvic pus collections may require trephining of the pelvic walls
or resection of some portion of the ilium, by which complete evacuation
may be made and drainage be amply provided. When the joint itself is
thoroughly broken down the case will have a hopeless aspect.


CARIES OF THE HIP.

_Hip-joint disease_, or, as it is often called, _coxitis_ or _morbus
coxæ_, is worthy of special consideration on account of its frequency,
its importance, and the deformities which result from its existence.
The most frequent site of the disease, which is of the usual type of
tuberculous ostitis or osteomyelitis, is on the femoral side of the
joint, usually in or near the head of the bone. In a small proportion
of cases the first lesions appear upon the acetabular aspect of the
joint, while in some cases the primary tuberculous lesion is of the
type of a tuberculous synovitis. (See chapters on Bones and Joints.)
In addition to those changes already described in previous chapters
there occur certain distinctive alterations about the hip-joint which
are worthy of note. On the pelvic side the margins of the acetabulum
occasionally become softened, and naturally yielding in the direction
of pressure as the result of muscle pull upon the thigh toward the
pelvis, cause, first, an elongation of the originally merely circular
cavity, and, finally, considerable shifting of position, often referred
to as _migration of the acetabulum_. Thus the head of the bone may
be found in a socket thus formed on a level one inch higher than on
the well side. So also perforation of the acetabulum may occur, with
perhaps final escape of the head of the bone into the pelvic cavity.
On the other hand, similar changes produce decapitation or marked
alterations of shape in the head and neck of the femur.


=Symptoms.=--When the symptoms and signs of tuberculous disease in this
location are studied in accordance with what has already been stated in
general about caries of the joint ends of the long bones, we have among
the most significant features:


1. =Pain.=--This is referred most commonly to the knee because of
the relations of the obturator nerve to the hip-joint and to the
region of the knee. Pain may also be radiated in other directions,
but the complaints made of pain in the knee are classical. Pain is
not, however, a pathognomonic feature and may be almost wanting, but
the evidences of tenderness, if not of pain, are invariably seen in
the unconscious protection of the joint afforded by muscle spasm. It
is perhaps in hip-joint disease that night pains and cries are most
frequently heard.


2. =Muscle Spasm.=--Fixation of the affected joint is always noted.
It begins as a limitation of motion, naturally first noticed in the
extremes of rotation, flexion, and extension, and is perhaps the most
important early sign of the disease. It furnishes the explanation
for the subsequent postural features, as well as an index regarding
the gravity and extent of the morbid process. It may be seen even in
the lower spinal muscles, where it is detected by laying the patient
upon the face, lifting first one leg and then the other, noting the
freedom of hyperextension; in fact, this spinal muscular involvement
is sometimes so marked as to give rise to the suspicion of low Pott’s
disease, from which it is to be distinguished by the fact that the
spasm affects one side rather than both.


3. =Muscle Atrophy.=--This involves in time all the muscles concerned
about the hip. It begins early, but may not be very pronounced until
quite late. It can usually be determined by measurement if not apparent
upon inspection and palpation. There will also be noted more or less
obliteration of the gluteal crease or fold.

The three cardinal features--pain, spasm, and atrophy--having been
thus considered, we can better appreciate the characteristic gait
and postures peculiar to this disease. Limping is an early feature,
sometimes insidious at first, sometimes abrupt. Patients will avoid
coming down quickly upon the heel, while they walk with the knee
slightly flexed, in order to give more spring. Stiffness is most
apparent on rising from bed in the morning, while the limp is more
pronounced at night, and it is at this stage especially that night
cries are most frequent. To mere limping succeeds actual lameness with
more constant pain. Muscle spasm now leads to malpositions, no one of
which is necessarily first to appear, and any of which may occur with
others in various combinations, although flexion and adduction are
usually the first to be seen, the patient unconsciously assuming that
position which happens to give him most relief.

It is important to realize that a marked degree of adduction will cause
apparent shortening, and of abduction apparent lengthening, and it
is very important to demonstrate that these variations in length are
apparent and not actual. This is to be done by placing the patient upon
a hard surface with the pelvis at right angles to the spine and the
limbs in absolutely symmetrical position. If there be adduction it may
mean that the limbs should be crossed; while if there is abduction the
healthy limb should be abducted to the same degree as the one affected.
Careful measurement will show that the differences are apparent
rather than real. The same care is needed in regard to rotation, and
particularly in regard to psoas contraction which leads to flexion.
One of the most characteristic evidences of hip-joint disease is
flexion of the thigh, which, when the thigh is brought down to the
proper level, will cause an arching upward of the lumbosacral region.
By this time also will be found well-marked limitations of motion in
every direction. All of these features should be ascertained without an
anesthetic, as they depend upon muscle spasm, which anesthesia would
subdue. It is somewhat difficult with intractable young children to
make a thorough examination of this kind, but a second or third effort
will usually succeed when the first has failed.

Peri-articular symptoms affording corroboration are found in thickening
of the tissues about the joint, especially enlargement of the upper
end of the femur, or increase in thickness of the pelvis, which may
perhaps be felt from the outside or be detected by rectal examination.
There is usually involvement of the inguinal lymph nodes, and there is
frequently prominence of the superficial veins, due to infiltration of
the deeper tissues and obstruction to the return circulation. A good
skiagram will also render much aid.

As the disease progresses there will appear evidences of deep
suppuration, as abscess is frequent in the advanced stages. This may be
peri-articular or may connect with the joint. It may cause separation
of the epiphyses of the femoral neck and complete loosening of the
head of the femur, which will then become a foreign body in a joint
cavity probably filled with pus. Perforation of the acetabulum may also
occur. Much of this abscess formation goes on insidiously and without
marked increase of symptoms. There is no fixed date when pus may begin
to form. It may occur relatively early or late. It is possible for
small amounts of pus to absorb in whole or in part, or to leave a
residue more or less encapsulated, which will frequently lead later to
a secondary abscess, the latter tending to burrow along between the
fascial planes or muscle sheaths and appear at some distance from its
origin. Pelvic abscesses result from perforation of the acetabulum and
may break internally or externally. Nearly all of these collections are
of the cold type, and after a long time, if they have opened, may cease
to discharge characteristic pus or even pyoid, and simply give vent to
a watery seropus. Pus left to itself usually escapes anteriorly to the
tensor vaginæ femoris, but it may travel in any direction.

The _deformities_ and possibilities which may result from the advanced
stage of hip disease are striking. Persistent muscle spasm leads to
more and more flexure of the thigh, with abduction or adduction, as
the case may be, while later the leg is drawn up so that the knee may
almost touch the abdomen. As the bony portions of the joint change
their shape there occur actual shortening and final dislocation, while
all the adjoining parts show the effect of muscle atrophy and perverted
nutrition. In addition to this the region of the hip may be riddled
with abscesses or with sinuses, and the condition in every respect made
extremely distressing.

While the disease is generally confined to one side, it may occur
in both hip-joints, in which it, however, very rarely begins
simultaneously. Existence of double joint disease of this character
makes the case more than usually troublesome and complicates it
seriously in every respect. The writer has been compelled to make
double simultaneous resection of both hips.


=Diagnosis.=--This has usually to be made from congenital dislocation,
hysterical joint, infantile paralysis, non-tuberculous disease--such as
synovitis, bursitis, etc.--acute osteomyelitis of the upper end of the
femur, Pott’s disease in the lumbar region, and sacro-iliac disease, as
well as from perinephritic abscess and appendicitis.


=Prognosis.=--Hip-joint disease usually tends toward recovery, but
generally with more or less deformity. When the circumstances are not
favorable, ankylosis, with or without deformity, is inevitable, while
abscesses, with persistent fistulæ, are not uncommon, and one may in
extreme cases witness death from general tuberculous dissemination or
from the consequences of hectic, with amyloid degeneration, or from
acute septic infection.

One may naturally ask what may be considered as constituting recovery.
In cases of this kind an absolute cessation of all symptoms and
indications of the disease, with a minimum of deformity and of
limitation of motion, are the nearest approach to ideal recovery
that can be expected to secure. In favorable cases, seen early and
properly treated for a sufficient time, there may be achieved almost
a restitution _ad integram_, but such an ideal is seldom attained;
otherwise there is nearly always more or less limitation of motion,
with very frequent pseudo-ankylosis or actual ankylosis. Even this is
favorable and most anything may be considered so which falls short of
actual suppuration.


=Treatment.=--The essential in the early treatment of hip disease is
_traction_, so applied and regulated as to be effective. It should not
be thought that by such traction as can be tolerated joint surfaces
are actually pulled apart. What it really accomplishes is to tire out
muscles which are in a condition of clonic spasm, overcoming thereby
the deformity which they produce and thus permitting a reduction of
their activity and of the harm which they have done. To do even this
requires a considerable degree of traction, especially when muscle
spasm is very prominent. Therefore it is best in pronounced cases of
deformity to place patients in bed, and to apply traction by weight and
pulley to a degree which actually overcomes the defects which we are
combating. This will often require more weight than many men are in the
habit of using. It should now be a question, not of amount of weight,
but of effect, and of the easiest and best way of bringing this about.
Physicians are very likely to use too small an amount of weight, and
to neglect the use of counterextension and the benefit of more or less
lateral traction, as well as that in direct line of the limb. Moreover,
they often use inadequate means of applying traction, resorting to
it only in such manner that traction is made at the knee and not at
the hip. Even in young children it is often necessary to use twenty
pounds, with a suitable traction apparatus, and four or five pounds for
effective lateral traction.

_Traction should be maintained_ until deformity has been overcome or
the effort shown to be impracticable. After its complete benefit has
been obtained it should be followed by fixation, the ideal method
being that which accomplishes both fixation and traction at the same
time; as, for instance, by the so-called Thomas splint, which permits
the patient to be up and about with the use of crutches and a high
shoe beneath the well limb, in order that the diseased limb may not be
permitted to touch the floor, but rather to hang, and by its own weight
afford a certain degree of traction. The Thomas splint is the simplest
and cheapest for hospital work, while modifications in more elegant and
expensive form are illustrated in works on orthopedic surgery. In cases
which seem to demand it fixation can be effected by a plaster-of-Paris
spica put on while the patient is standing upon the well limb and upon
an elevation. The character of this work affords space neither for more
elaborate description nor illustration than the hints embraced in the
foregoing paragraphs.

The surgeon as such is perhaps the more concerned in the _treatment
of abscesses_ which frequently complicate these cases. Much that
has been already said about psoas abscess will apply here. It is a
question requiring considerable discrimination as to just how to
treat a small, cold abscess about a diseased hip. Much will depend
upon the environment of the patient, _i. e._, upon the attention and
expert care which he may receive. Such abscess should be treated
kindly, _i. e._, by nothing more severe than aspiration, until ready
for more radical treatment. By the latter term is meant readiness for
following it down to the joint cavity and exsecting the head of the
bone, if need be, following this with extirpation of the capsule,
etc. When there is actual pyarthrosis the condition of the patient
is sufficiently serious to warrant radical measures. Extra-articular
abscesses are apparently quite common, yet most of these, if carefully
traced, will be found to lead through the periosteum at some point
into the osseous structure beneath. Such abscesses are, moreover,
multilocular, and have ramifications in even unsuspected directions
which should be followed with the sharp spoon and the caustic, in
order that absorbents may be seared and that no infectious material
remain. Old and persistent fistulas should also be treated kindly
until one is ready to be radical. Some long-standing cases will heal
after absolute physiological rest of the joint, _i. e._, by fixation
in plaster-of-Paris splint, with openings opposite the fistulas for
dressing purposes. The general constitutional condition of patients
with these lesions is a predominating factor in their improvement--a
fact which should never be forgotten.

The deformity which has resulted from old, long-standing, and quiescent
hip disease affords opportunity for the best of surgical judgment. It
is possible to effect great improvement in position by subcutaneous
osteotomy after ankylosis, but this should not be attempted during the
active stages of the disease.

_The question of excision of the hip-joint is one of importance._
In few other instances do social surroundings or factors enter so
largely into the question of surgical judgment. The wealthy can afford
long-continued treatment, which to the poor is prohibited, and one may
be tempted in one case to exsect early when, under other conditions,
he would treat the case tentatively. Nevertheless certain indications
make the operation expedient in all cases, as, for instance, when the
destructive process is steadily progressing or so acute as to shorten
not only the limb but life itself. It is necessary also when there
is necrosis, and in most instances of suppuration extending into the
joint cavity. In those cases where skiagrams confirm other indications
to the effect that the disease is localized in the neck or head of
the femur, Huntington’s suggestion may be adopted, after exposing the
upper end of the femur, to drill or tunnel in the direction of the neck
until its diseased focus is reached and thoroughly clean it out. In
cases treated otherwise conservatively, yet accompanied by a great deal
of pain, especially those of the femoral side of the joint, one may
frequently get relief by exposing the upper end of the femur and making
ignipuncture in the same direction as above.

_In general it is impossible to lay down succinct rules for the
treatment of hip disease._ Cases differ so greatly in location, in
severity, as well as in environment and their personal surroundings,
that what is advisable in one case is not to be thought of in another.
Of the mechanical features of treatment one may say that that is the
best splint or apparatus which best meets the indication in each
particular case, and that none will be effective in which the element
of traction is neglected, nor that of physiological rest. No patient
should be released from treatment whose hip is still sensitive or in
whom there remains any muscle spasm. Rest and protection should be
maintained for months and even years after apparent recovery, while the
same attention should be given to diet and climatic surroundings as in
any other case of well-marked tuberculous disease.


TUBERCULOUS DISEASE OF THE KNEE-JOINT; TUMOR ALBUS.

This subject deserves special consideration, mainly because of
the peculiar deformity produced by the disease rather than any of
distinctive peculiarity in its nature. Years ago it received the
name of _tumor albus_, and is frequently called _white swelling_ by
the laity, because of the pallor of the surface and the increased
dimensions of the limb due to thickening, always of soft parts, and
usually of the bone itself. The disease may begin in either epiphysis,
in the patella, or in the synovial membrane, oftener in the bone in the
young and in the synovia in adult cases. Its most distinctive feature
is the deformity produced by excess of muscle spasm, the hamstring
muscles especially producing a backward subluxation which frequently
fixes the knee, not only at a right angle, but with very much disturbed
joint relations, so that the head of the tibia is in contact with the
posterior surface of the condyle rather than with their proper terminal
areas. The soft tissues outside of the bone are frequently very much
thickened and infiltrated, often edematous, while the joint cavity may
be more or less distended with seropus or with old pyoid material. The
exterior surface is so anemic from deficient blood supply as to make it
appear comparatively white, while the superficial veins are made much
more prominent by their engorgement owing to obstruction of the deep
circulation. The picture, then, of an advanced case of tumor albus is
quite typical.

Here the joint cavity is so large that there is early effusion of
fluid, in most cases, which is in this location easily recognizable;
hence the distinctive symptoms consist of pain, tenderness, swelling,
limp muscle spasm, with, finally, limitation of motion, deformity,
and atrophy. In addition to these features there may be added those
due to the formation and the escape of pus, _i. e._, one may have the
signs of acute or old suppuration, while the parts about the joint may
be riddled with old sinuses. The deformity of these cases is usually
characterized by a certain amount of external rotation of the leg,
while a species of knock-knee is not uncommon. Actual lengthening of
the limb due to overactivity at the epiphyseal junctions may also be
noted.


=Treatment.=--_The treatment of white swelling_ is based upon the
principles already laid down for the treatment of spinal and hip
caries, the underlying feature being traction to a degree sufficient to
overcome muscle spasm, unless it be too late to permit a subsidence of
active changes. When seen early a few weeks of confinement in bed, with
effective traction, followed by fixation with plaster-of-Paris bandage,
combined with the Thomas splint (see above) or with some other form of
more elaborate apparatus, by which rest and traction can be continually
maintained, will be needed. The presence of tuberculous disease about
the knee permits of the application of the elastic bandage above the
knee, by which the congestion treatment of Bier can be more or less
effectually carried out. It would, however, be a mistake to rely
entirely upon this to the neglect of traction and rest, nor should too
much be expected of it in severe cases. It is a method to be used early
rather than late.

_The final resort is excision_, which is practically adapted to cases
of moderate type in young adults, where the bones have attained their
full growth and where it will afford a prospect of cure in a minimum of
time. It is undesirable in children because it is so often necessary
to remove the epiphyses, and because of the arrest of development
that follows such removal and the consequent shortening of the limb.
Nevertheless even in children it may be demanded and may be considered
as a resort superior to amputation, the latter being reserved usually
for a life-saving measure or for desperate cases where destruction has
been practically complete and the limb is hopelessly useless.

Of the other large joints, all of which may be involved in tuberculous
processes similar to those just discussed, it may be said that they
come under the general rules of treatment already laid down.


NON-CARIOUS DEFORMITIES.

TORTICOLLIS; WRYNECK.

This term includes a peculiar postural deformity by which the head is
rotated and inclined abnormally to one side in a more or less fixed
position. As to the causes of the deformity two will be considered:

Congenital causes include:

1. Injury to the sternomastoid muscle at birth, which is perhaps the
commonest.

2. Abnormal intra-uterine position and pressure.

3. Arrest of muscular development.

4. Intra-uterine myositis, the muscles being sometimes found actually
altered in structure.

5. Defective development of the upper vertebrae or such distorted
growth as is often met along with other deformities, _e. g._, club-foot.

The acquired causes include:

1. Traumatisms, either direct, as by injury to the muscles, such as may
happen from gunshot wounds, etc., or follow operations by which the
spinal accessory has been injured, or by burns, and other lesions which
cause much cicatricial contraction.

2. Reflex activity in connection with disease of the lymph nodes, deep
cervical abscesses, parotid phlegmons or tumors, etc. Whitman states
that tuberculous disease of the cervical nodes caused the condition in
50 per cent. of over 100 cases analyzed by him.

3. Reflexes from the eyes, as Bradford and Lovett have described from
the orthopedist’s standpoint, and Gould from that of the oculist,
refractive errors causing the head to be held in unnatural positions in
order to improve vision.

4. Compensation in high degrees of rotary lateral curvature, the effort
being to keep the head facing to the front.

5. Myositis, usually rheumatic, but sometimes a sequel of the
infectious fevers, or even of gonorrhea.

6. Habitual deformity, the result of occupation or sheer bad habit.

7. Tonic or intermittent spasm leading to spastic contractures whose
causes are difficult to seek, but appear to inhere in the central
nervous system.

8. Paralyses of certain muscles, permitting lack of opposition and
consequent deformity.


=Pathology.=--According to circumstances significant pathological
changes may be found in the affected muscles. These are usually
the sternomastoid and the trapezius, although in long-standing or
complicated cases the deeper muscles of the neck may also participate.
A long contracted muscle may change almost into mere fibrous tissue.

The secondary effects of contraction of the sternomastoid and the
trapezius are really far-reaching and noteworthy. The jaw may be drawn
down and to one side, so that teeth do not appose each other as they
should, or perhaps even do not meet. Compensatory curvatures occur also
in the spine and there is well-marked change in gait and in most of
the body habits. In the young and rapidly growing cranial and facial
asymmetry also become pronounced. The later results and deformities
of torticollis are not to be mistaken for congenital elevation of the
scapula, sometimes known as “_Sprengel’s deformity_,” which consists
not merely in elevation, but in rotation of the shoulder-blade so that
its lower angle is too near the spine. There may be some limitation
of motion of the scapula and of the arm. Sprengel accounted for this
abnormality by maintenance of the intra-uterine position of the arm
behind the back. The acute forms of torticollis occur nearly always in
acute phlegmons of one side of the neck, and should subside with the
other and causative lesions. Nevertheless from such spasm may develop a
chronic form which may persist.

The position of the head varies with the muscles particularly involved
and the associated spasm. The sternomastoid muscle alone will draw the
mastoid down toward the sternum, with rotation of the face to the other
side. When the trapezius is involved the head is drawn backward and the
chin raised. The more the platysma, scaleni, splenii, and deep rotators
are involved the more complex becomes the condition, to such an extent
even that in serious cases it is almost impossible to decide which
muscles really are at fault. When the superficial muscles are involved
they can usually be distinctly felt to be firm and contracted, while
the sternomastoid will stand out like a cord. Pain is a rare complaint,
but a feeling of tenderness or soreness is not unusual.

The spasmodic or intermittent form is less common, but more difficult
to account for and even to treat. It seems to be due to choreiform
spasm of those muscles which produce it, and here the condition
is reflex, the causes lying deeply in the nervous system. In some
instances, however, they are of ocular origin and can be relieved by
correcting refractive errors. Intermittent spasm is usually absent
during sleep and quiescent in the recumbent position; it is usually
confined to one side.


=Diagnosis.=--In the matter of diagnosis it is necessary mainly to
eliminate only spinal caries, while as between involvement of the
anterior and posterior groups of muscles the determination is made by
palpation and inspection.


=Treatment.=--There are few morbid conditions whose cause it is more
necessary to discover. Could this be done operative treatment would
be less often demanded. Treatment should depend, therefore, on the
exciting cause and the possibility of its removal. The spasmodic or
intermittent form may spontaneously subside. Cases of essentially
ocular origin need the services of the oculist, and other acute cases
usually subside with the successful treatment or the subsidence of
their causes. On the other hand, chronic cases usually need either
mechanical or operative treatment.

The most common operation for relief of torticollis is simple _tenotomy
of the sternomastoid_, taking care to divide the sheath and everything
which resists, and, at the same time, to avoid the external jugular
vein as well as the deeper structures. Mere tenotomy of one or both
of its lower tendons is an exceedingly simple measure, but in serious
cases an open division will permit of more thorough work. Here an
incision made one inch above the clavicle and parallel to it will
permit division of everything which resists and also any recognition
of that which should be spared. In any event the position of the head
should be immediately rectified, and kept so either by plaster or
starch bandage, or by a traction apparatus applied to the head, the
body being in the recumbent position, while later some efficient and
well-fitting brace should be worn for some time. The posterior cases,
_i. e._, those where the posterior muscles are involved, afford greater
operative difficulty, muscles involved lying too deeply and being in
too close relation with important vessels and nerves to justify the
ordinary wide-open division. Nevertheless in extreme cases there need
be no hesitation in extirpating completely those muscles which are
primarily and mainly at fault. The writer has removed the sternomastoid
and the trapezius, with sections of the still deeper muscles, and has
seen nothing but benefit follow the procedure. It should be resorted
to when repeated anesthesia with forcible stretching and a suitable
brace fail to give relief. These forms of wryneck which are due to
contraction of muscles infiltrated from the presence of neighboring
phlegmons, etc., will usually subside with massage and semiforcible
stretching under an anesthetic. They need conservative rather than
operative treatment. Attack upon the spinal accessory and the deep
cervical nerves will be described in the chapter on Surgery of the
Nerves. It, however, will rarely be justified, since the primary causes
inhere not so much in those nerve trunks as in the nerve centres. Such
operations are usually of questionable benefit, and cases should be
carefully watched before being submitted to them.


ROTARY LATERAL SPINAL CURVATURE; SCOLIOSIS.

Under these terms are included certain deviations from normal
relationships of the vertebræ, both in their superposition in the
median line and in their rotation on each other, by which are produced
lateral curvatures, with more or less rotary displacement. Of these
deformities there is a rare congenital form which is due to fetal,
or rather intra-uterine, rickets, but practically all rotary lateral
curvatures are acquired. One-half of such cases begin before the
twelfth year of life. It may also come on during adult life, as the
result of bad postural habits, exclusive use of the right hand, etc.
Altogether it occurs in about 1 per cent. of females and in a smaller
percentage of males. Scoliosis being not a disease but rather a process
of irregular growth, cannot be said to have a symptomatology. It is
known rather by signs. Only in the advanced stage can it produce
symptoms. It is rarely seen in its incipiency by either the surgeon
or the physician. Not until parents have noticed distortions of the
spine are these children usually taken to their medical advisers.
Exception, however, should be made to this in respect to certain
gymnasia and athletic training schools, where trainers are quick to
notice irregularities of this kind. The abnormal curves thus produced
are at first flexible, but later become fixed. In rapidly growing girls
who take but little exercise there may be some muscle weakness, which
may cause fatigue or even actual soreness. Pain is rarely present. The
rate and extent of deformity are not subject to any rule. Spontaneous
cessation ensues in practically every case, _i. e._, a stage of
convalescence and arrest, at a time when the deformity may be but
slight, or perhaps hideous.

The nervous phenomena attending lateral curvature, like the discomforts
attaching to it, are mainly due to the increasing strains and stresses
that are imposed on certain structures as the deformity occurs and
increases. Of these, muscles and ligaments suffer most, especially
those uniting the thorax and spine. Pressure effects on nerves and
tissues may be produced by distorted ribs and vertebræ or by final
displacement of viscera. The conditions which lead up to spinal
curvature are attended often by neurasthenic and neurotic features,
both mental and physical. As deformity increases impairment of function
of thoracic as well as of the upper abdominal viscera will occur, and
such patients are usually thin and anemic, rather than fat.

_To mere lateral distortion is added, in every pronounced case, more
or less rotation of the entire trunk._ The curvature consists of one
primary curve, with one or two secondary curvatures, according to
the location of the first. If the primary curve be located in the
mid-dorsal region there will occur compensatory curvature above and
below in order that the head may still be kept in the line of the
centre of gravity above the pelvis. Such secondary alterations are of
much less import than the primary. The most common of the mid-dorsal
curvatures, which occurs in nearly four-fifths of the cases, has its
convexity to the right. While the right shoulder seems higher its
scapula will be more pronounced and carried backward, the back and the
chest below it will be more rounded, and in front the breast on the
opposite side more prominent. The whole trunk in marked cases becomes
so warped that the arm on one side will hang free while the other
touches the pelvis; thus the back loses its symmetry either in the
erect or stooping position. In the lumbar region there is compensatory
curvature to the opposite side, which makes one hip and flank more
prominent. By virtue of the rotation of such a warped spinal column
there result certain anterolateral curvatures that may later become
pronounced. While such changes are going on in the upper part of the
trunk there is sufficient rotation of the lumbar segment to lead to
tilting of the pelvis, with consequent limp, or a peculiarity of gait.

The degree of torsion of the spinal column is the best index of the
real severity of a given case, and to it are due the most disfiguring
features of the deformity. Torsion may even precede curvature, causing
a prominence of one shoulder or hip as the first visible evidence of
its existence.

Those forms of lateral curvature due to _rickets_ occur most often
in the dorsal region, and as frequently in boys as in girls. In most
of these cases the constitutional condition will be indicated by
other significant features. Another form much less frequent, yet well
known, is the result of inequality of the length in the limbs, so
that patients stand ordinarily with tilted pelves; hence, the limbs
should be carefully measured in every instance. A truly _paralytic
form of scoliosis_ is also known, which is of the infantile type and
due to some form of infantile palsy. Again, scoliosis is produced by
_shrinkage of tissues_ and contraction of old exudates occurring within
the thorax and following chronic disease, as when the ribs on one side
are drawn down after an old pleurisy or empyema. _Extrinsic causes_
of lateral curvature are met with among several occupations when one
side of the body is used more than the other, or when the individual
habitually stands in an unsymmetrical position. In addition to this,
the habitual right-hand habit, which seems instinctive, and which the
majority of people exhibit, leads to excessive use of the right side of
the body, with overdevelopment and consequent warping of the upper part
of the skeleton. The young should be taught the use of the left hand as
well as the right, _i. e._, to become ambidextrous.

The foreign surgeons have given the term _ischias scoliotica_ to a form
of lateral curvature involving rather the lower part of the spine and
occurring usually in adults or elderly people, which is accompanied
by more or less acute pain, usually assuming the type of sciatica.
Its etiology is obscure, as is implied by the synonym scoliosis
neuropathica. It is not a frequent malady, but usually chronic and
refractory. It is best dealt with by fixation or immobilization.


=Etiology.=--Predisposing causes of scoliosis may be both
constitutional and inherited. They include general debility,
rickets--with its accompanying osseous instability and liability to
abnormal curvature--the consequences of various diseases of childhood,
and anything which greatly lowers vitality. The actual causes include
congenital or acquired defects, such as differences in the lengths of
the limbs or other skeletal asymmetries; acquired abnormal position
of the head due to defective vision, with its natural sequences;
results of intrathoracic disease, such as empyema; faulty attitudes
and bad developmental habits, such as those assumed often in school
and elsewhere in sitting at a desk or standing in bad position, or at
work in various ways. To these should be added the right-hand habit
already mentioned. These may all be summed up as among the causes
of asymmetrical growth and deformity, occurring as the result of
ignorance or inattention, and allowed to go on indefinitely or until
it is too late to correct the malposition. Theories of paralysis of
individual muscles or certain muscle groups have been advanced, as
well as of contractures, but usually these are effects which have been
mistaken for causes. The bones have been blamed, but their changes are
secondary results of pressure, save perhaps in some cases of rickets.
The structures of the thorax have relatively considerable superimposed
weight to carry, and both lateral halves of the thorax should be
developed symmetrically in order to distribute this weight evenly.
Nothing so influences skeletal development as exercise; thus even to
assume and maintain the normal erect attitude requires a certain amount
of muscular effort, and if each side be not given an equal task one
will develop at the expense of the other, and thus lateral curvature is
sure to result.

It is important to impress this on parents, teachers, nurses,
dressmakers, and all who have a part in the care of the young, in order
that they may realize the importance of ensuring symmetrical growth
and of preventing the right-hand habit. It is to be expected that
after deformity has occurred there may result a series of perversions
of function in nerves, as well as in viscera; thus, respiration and
circulation may be interfered with, the liver may be compressed, while,
of course, autopsy will show all sorts of distortion of bone, among
other pathological changes.


=Prognosis.=--Too often the condition is regarded as so trivial that
it is likely to be outgrown, or else is quite disregarded, or, on the
other hand, occasionally it is regarded as one of gravely serious
import and maltreated or overtreated on this account. In the majority
of instances scoliosis is a self-limited condition, whose limit may be
reached at variable stages of deformity in different individuals. In
slight cases any serious illness may cause such muscular weakness as
to permit of serious increase of distortion. Therefore, the patient’s
general condition is to be taken into account just as much as the shape
of the back.


=Treatment.=--If one may be permitted a Hibernicism, the proper
treatment for scoliosis is _prevention_. This may be made to include
the earliest possible recognition of trifling deviations from the
normal. It should be made to include, in general, supervision of
school desks and the way in which children work at them, as well
as of children’s games and exercises, in which it should be made a
point that they be taught to make as much use of one hand as of the
other. It should include also supervision of children’s methods of
seating themselves at the piano or at the sewing table, as well as the
posture which they assume during sleep, while they should be taught
to stand and walk properly and to avoid a too early use of corsets.
_Active treatment should consist, first, of correction of bad postural
and other habits by methods as vigorous as are military drill and
discipline._ Patients tire easily after such exercise, and sufficient
rest should be taken, the patient lying symmetrically upon the back.
There is usually opportunity with young children for great ingenuity
in devising suitable exercises without making them too irksome. They
should be taught to play games at least as much with the left hand as
with the right. Gymnastic exercises, especially those with dumb-bells,
will be found effective, and it is advisable to have a heavier
dumb-bell in the left hand than in the right. The more severe cases
should be handled with great care in order not to overdo that which
should be done. Each case should be studied by itself, which means
that such cases should not be taught in classes. Roth calls that “the
key-note position” which is closest to the normal that the individual
can voluntarily and comfortably assume. From this as a basis the
surgeon should work up. Perhaps as much can be done without apparatus
as with it, particularly if will power is concentrated on the effort.
This is harder with the young, but pride may sometimes be appealed to
as a substitute for volition. As strength is gained more strenuous
gymnastics may be prescribed, including suspension from rings or the
simple horizontal bar, while much heavier dumb-bells may be used, as
taught by Teschner.

_Mechanical corrective treatment_ is directed mainly to stretching
shortened ligaments and contracted muscles. For this purpose many
forms of apparatus have been devised. Their principal benefit lies in
increasing backward flexibility at the point where curvature is most
pronounced. As a substitute for such apparatus, and in private houses,
padded stretchers or lounges may be supplied on which patients may lie
either quietly or during massage. Finally the matter of corrective
corsets and braces remains to be considered. External support takes
away from the muscles and ligaments their functions and work.
Nevertheless in some cases this is necessary. No appliance of this kind
that may be supplied should be continuously worn. It should be removed
for work and exercise, as well as for toilet purposes. Recumbency in
bed is much better than too vigorous bracing. Only in old, neglected,
or peculiar cases should it be considered necessary to resort to much
external aid.


CURVATURES FROM OTHER SOURCES.

The relaxation and debility of old age permit of such deformities
as rounded and stooped shoulders, certain degrees of kyphosis, and
sometimes even pronounced stooping and deformity, whose merely senile
causes are more or less combined with rheumatoid arthritis of the
vertebral and costovertebral joints. These features are accompanied
by more or less pain or difficulty in locomotion. Many instances of
ischias scoliotica, referred to in the preceding section, would find
a place among these clinical pictures. Postmortem there are found
exostoses, synostoses, or ankyloses sufficient to account for the
deformity. Rickets also causes skeletal deformities, in which nearly
all the bones may participate, the spine rarely totally escaping. In
such cases various typical and atypical deformities may be met.

Paralytics may show various curvatures, as do also subjects of
pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in
pregnancy and in congenital hip dislocation, where it is purely
compensatory in each instance and does not outlast its real cause. In
fact it may be encountered as a compensatory feature of any other kind
of spinal curvature.

A still more marked condition of chronic ostitic changes is seen in
_spondylitis deformans_, which differs little from arthritis deformans
of other joints, save that in these cases it usually spares the joints
of the extremities. It has been known as a rare sequel of gonorrhea,
even in the young. Osteophytic outgrowths occur frequently and fuse
together, causing ankyloses and sometimes great deformity, even to
the extent of making the spine assume a right angle with the extended
limbs. Considerable pain is frequently experienced during the course
of these very slow changes. The entire spine becomes more or less
rigid, consequently there is little or no angular prominence, while the
ribs become immobilized as well. For this condition there is little
or no treatment of any avail. Sometimes paralysis supervenes and the
condition is not infrequently fatal.

_Acute osteomyelitis_ of the vertebræ is occasionally noted. It occurs
nearly always in young and growing children, and is most common in
the lumbar spine. It is essentially the same here as occurring in the
long bones or their joint ends, and has been described in the previous
chapter. Its symptoms may be severe, and it is not infrequently
followed by abscess. When such abscesses point posteriorly they may be
recognized and incised. When, however, pus takes the anterior path it
will probably escape detection, at least until too late. The prognosis
is often unfavorable.


TYPHOID SPINE.

This name was proposed by Gibney for what seems to be an infectious
periostitis involving the vertebral column, of a character similar
to that which has been described in a previous chapter. It is
characterized by excessive pain, tenderness, and later stiffness. It
may occur during or after mild as well as severe cases of typhoid.


TRAUMATIC SPONDYLITIS.

Kümmel has shown that a traumatic and non-tuberculous ostitis of the
vertebræ occurs, with succeeding kyphosis resembling that of Pott’s
disease, but not so angular, usually without associated abscesses,
but with occasional paralyses. This may occur without necessary
reference to that curvature which may follow a healed or healing
spinal curvature. Inasmuch as the condition occurs only after the
lapse of considerable time after injury, it is questionable whether it
represents any distinct form of disease.


CANCER OF THE SPINE.

Malignant disease of the spine may assume a type either of sarcoma when
primary or carcinoma when secondary. The latter type is much the more
common, and is not so infrequent as an expression of metastasis from
cancer in various other parts of the body, even the more distant. It
is most common in the lower spinal region. Pain occurs early and is
usually severe. It is as often referred as localized. It may lead to
curvature of the spine with some of the grosser signs of spinal caries,
but the prominence, if any occurs, will be rounded rather than angular.
When paralyses occur they usually assume that type described by Charcot
as paraplegia dolorosa. (See Plate XXXVIII.)

When symptoms of a general type like those produced by spinal caries
occur in adults who are known to have had previous or present malignant
disease the inference will be that they are to be interpreted as local
expressions of the same character. Under these circumstances treatment
can only be palliative. There is no hope of cure.


SPONDYLOLISTHESIS.

The term spondylolisthesis implies a partial displacement forward of
the body of the last lower or next to the last lower lumbar vertebra,
usually the former, which slips forward on top of the sacrum with very
little perceptible displacement of arches. The condition may be slight
or well marked, and may or may not be followed by secondary changes.
There appears to be a real fragmentation or separation of the body
from the arch, which may be traumatic, congenital, pathological, or
the sole result of pressure from above; later exostoses or osteophytes
appear about the separation, thus forming a new fixation and preventing
further displacement.

The condition is more common in females and in the young, and most
cases give a traumatic history. In those which do, deformity may follow
accident or it may be long postponed, perhaps until pregnancy.


=Symptoms.=--The lesion is recognized by certain alterations of gait,
with a sharp lumbar lordosis and unduly prominent buttocks and iliac
crests, so that these patients much resemble those having congenital
hip dislocation, the pubes being higher and the sacrum lower than the
normal, this diminution of pelvic obliquity being practically always
pathognomonic. On vaginal or rectal examination undue prominence may
be felt above the sacrum. Some of these cases complain of much pain,
either local or referred, down the limb, the same being made worse by
exercise.

[Illustration: PLATE XXXVIII

Sarcoma of the Spine and Cord. (Goldthwait.)]


=Diagnosis.=--Diagnosis should be made as between this condition,
Pott’s disease, double congenital dislocation of the hip, and rickets.


=Treatment.=--The condition does not admit of extended treatment, save
that a certain proportion of cases are benefited by such fixation as
is afforded by a plaster jacket, which firmly encloses the pelvis and
supports the lower part of the trunk upon it.


KNOCK-KNEE AND BOW-LEG.

The plane of the terminal articular surface of the lower end of the
femur is not at right angles with the axis of its shaft; in other
words, the inner condyle is placed a little lower or beyond the
location of the outer. In this way sufficient angular arrangement of
the leg upon the thigh is permitted so that, with the upper ends of the
femora separated by the width of the pelvis, the knees and the ankles
may, under normal circumstances, be made to touch when the limbs are
fully extended. Thus a slight degree of angular deflection at the knee
is normal. When this is exaggerated to a degree not permitting the
ankles to touch when the knees are in contact the condition is known as
_genu valgum_, or _knock-knee_. When, on the other hand, the angle is
lessened or reversed so that the knees are more or less separated when
the ankles are in contact the condition is then known as _genu varum_,
or _bow-leg_. These two conditions constitute the typical and classical
types of knock-knee and bow-leg. Other conditions, however, which lead
to the same result occur through various and irregular curvatures or
irregularities of the femur or the tibia, or both, and there thus
may be produced atypical yet most pronounced instances of these same
deformities. These deformities may be apparent almost from birth, may
appear during early childhood, or not until adolescence. As a rule they
are not manifested until young children are learning to walk. Whenever
they appear before this time they are expressions of infantile rickets,
which should be recognized as such and corrected by mere manipulation
while the bones are still flexible, the correction being maintained,
and by suitably feeding and medicating the patient. (See the general
subject of Rickets.)

[Illustration: FIG. 261

Rachitic changes in limbs. (Lexer.)]

In fact rickets supplies the explanation for the great majority of
these deformities; incomplete ossification and calcification of the
bones accounting for the comparative ease with which they yield to
pressure or other deforming influences. Rickety children always
manifest a tendency to defective ossification at epiphyseal lines,
and it is here that the change usually takes place. Nevertheless
marked instances of curvature are seen in all the bones of the lower
extremity. As deformity in any given direction becomes more pronounced
the tendency to its exaggeration becomes greater. Finally these changes
involve not only the bones proper but the ligaments and the other joint
structures, which yield where pressure is abnormal and greatest, thus
completely changing their shape and internal relations. Along with
other changes in knock-knee there is a tendency to external rotation,
perhaps even to spiral curvature of the tibia; the patella lies outside
of its normal position, the tendons are more or less displaced, while,
at the same time, there may be inflection of the feet as an effort at
compensation (Fig. 261).

With the exception of spinal curvatures and torticollis there is
perhaps no more conspicuous deformity than that produced by these
abnormalities at the knee-joint. While at first gait is not seriously
affected, it is in time, especially in cases of double knock-knee. When
these knees are bent to a right angle the angular deformity disappears
and all that remains is the rotation of the tibia. Hence it follows
that all correction of these deformities, either slow or operative,
should be applied to the fully extended leg. In advanced cases there
is frequently a complication with flat-foot, which may or may not be
painful. The condition is rarely produced by paralytic affections, and
should be differentiated from mere atrophy of wasted and contracted
legs. A form of knock-knee is occasionally seen in the adult, which
is of traumatic origin and is due to improper care or neglect in the
treatment of the injury.


=Treatment.=--_The treatment of this condition is either mechanical or
operative._ Mechanical treatment varies between the gentlest expedients
and the use of more or less extensive and cumbersome apparatus.
When a young and growing child begins to show evidence of either of
these deformities it is usually sufficient to supply shoes which are
reasonably stiff, and raise one or other border of the sole and heel,
according as we wish to influence the growth of the limb, _i. e._, in
knock-knee the inner border of the foot is to be raised, in bow-leg
the outer. The consequence of even slight influence thus constantly
maintained when the child is upon its feet is usually sufficient to
rectify slight degrees of these deformities. When, however, the case is
pronounced more radical measures should be applied. Massage has been
recommended along with manipulation, but should be gently performed.
The different forms of apparatus in use afford various methods of
making pressure against that condyle which is too prominent. It is
possible to make them efficient, but only when they are both well
planned and well made in the first place and intelligently applied and
watched. The special forms of apparatus sold in the instrument stores
are of little value. Too often it happens that when efficient they
cannot be tolerated, and that when tolerated they are inefficient.
Much speedier and more satisfactory results are achieved by operative
methods, so that, in general, they may be regarded as the more
desirable.

_Operative treatment_ consists in some modification either of
osteoclasis or osteotomy.

_Osteoclasis_ has to do with the forcible stretching, bending, or
even breaking of those parts which show the greatest effects of the
deformity or are known to be its primary seat. In young children with
tender and still somewhat flexible bones this may be accomplished by
the hands alone, the patient being under an anesthetic. Manual power
failing a simple instrument known as the _osteoclast_, which affords a
means of applying powerful pressure by the agency of a screw at just
the desired point, is used. Pressure is then applied and carried to
the necessary degree, even with partial or complete fracture of the
bone at fault. In this way is inflicted a simple fracture which permits
of the immediate redressing of the limb, with such overcorrection of
the deformity as seems desirable. The limb thus treated is completely
encased in a suitable plaster-of-Paris splint, and should be held in
the desired position until the plaster is completely hardened and not
likely to yield. Osteoclasis, though it often appears an exceedingly
barbarous procedure, is one of the most beneficent when properly
managed, and is rarely followed by an undesirable result.

_Osteotomy_ is performed by the use of the chisel and mallet, the
former being introduced through a small incision made in the skin,
passed down to the bone with its cutting edge parallel to the bone
axis until the bone itself is reached, after which it is turned at
right angles to it and the mallet used until the chisel has been driven
partly or completely through the shaft of the bone or the portion which
it is intended to attack. The chisel should be partly withdrawn and
its position changed if it is necessary to continue its use. Thus by a
partial division of the bones of the young it is possible usually to
so weaken them that, without undue force, and by manual power, they
are fractured at the desired point. The operation should be done with
the most complete aseptic protection. The procedure recommended by
Macewen is now universally accepted. The incision is made at the inner
side of the thigh just above the tubercle for the adductor magnus,
and the osteotome (as the chisel especially made for this purpose
is called) is passed through it, down to the bone, turned at right
angles, and made to cut nearly through the shaft. Lest it become too
firmly wedged it may be moved a little laterally after each blow of
the hammer. The operation, if properly done, is practically bloodless;
the small opening made for the chisel is sealed at the moment of its
withdrawal, the deformity corrected with the least amount of handling
or disturbance, and the plaster-of-Paris bandage immediately applied,
with the leg in exactly the position which it is desired should be
maintained. Such a dressing may be left for three or four weeks before
being changed. One change is usually sufficient, and in from six to
seven weeks the patient is allowed to slowly regain use of the member.

A special set of osteotomes, after Macewen’s pattern, is furnished by
the instrument dealers for those who practise osteotomy. It consists
of a set of three straight chisels, consecutively numbered, the first
being a little thicker and the third the thinnest of the three, and
thus made with the intent to use the thickest first in order that in
the notch made by it the thinner instruments can be subsequently more
easily manipulated.


BOW-LEGS.

_Bow-legs_ are nearly always of rachitic origin, occurring with less
angular deformity, and as the result of the warping or bending of bones
which are not sufficiently rigid to sustain the weight they are made to
carry. Most cases of bow-legs have their origin within the very early
years of childhood. Other cases are seen in infancy and before children
have ever borne much weight upon their feet. The deformity must be
accounted for by muscle tonus, mere muscle activity serving to place
enough stress upon the bones to swerve them from their normal axes. The
bones probably bend outward because the muscles on the inner side are
the stronger. Children thus affected walk not so much with a limp as
with a waddle, with the feet rather apart, and some inversion of the
toes. Double and complicated curves occur in many of these cases, both
femurs and tibias participating, and having an anterior as well as a
lateral bowing. Such complications materially increase the difficulty
of any treatment.


=Treatment.=--The _treatment_ of bow-leg is generally considered
simpler than that of knock-knee. Occurring in _young_ and growing
children it can be overcome, if taken early, by the expedient already
mentioned, elevating the outer border of the sole of each shoe. The
more mechanical and the purely operative methods of treatment are
essentially the same as those just described for knock-knee, based
on similar but reversed principles. In the very young manual force
will often serve the purpose of a more formal osteoclasis, but the
osteoclast may be used whenever it seems indicated. In those cases
where the bowing is due to abrupt and almost angular deformity,
_osteotomy is indicated_. This is made on exactly the same principles
as mentioned above. In all instances spiral curvatures should be
overcome so far as possible during the process of forcible correction
and dressing in the plaster-of-Paris bandages ordinarily used. Here,
as previously, all treatment should be addressed to the limbs in their
fully extended position. If the rings of the ordinary osteoclast be
sufficiently padded and protection afforded in this way, the skin
rarely sloughs, and the damage, which is, at least, theoretically done
to the tissues, is quickly repaired. Failure in union after any of
these operations is exceedingly rare.


CLUB-FOOT; TALIPES.

In general the term talipes is applied to any malformations of the
foot by which it is more or less misshaped and its function impaired.
The commonest of these is that known and described below as talipes
equinovarus. Of these various deformities there are four principal
types, according as the foot is inverted, everted, hyperflexed, or
hyperextended. More particularly they are:

  1. Talipes equinovarus, the commonest type, the ordinary club-foot;

  2. Talipes valgus, or flat-foot;

  3. Talipes equinus;

  4. Talipes calcaneus.

These forms may be variously blended, as well as seen in varying
degrees from the slightest possible deviation to the most pronounced
form. Statistics show that about one child in every five hundred is
born with some form of club-foot.

Club-foot may be either of acquired or congenital origin. Acquired
club-foot is essentially always of paralytic nature, following usually
infantile paralysis or those injuries by which nerves have been divided
or caught in callus or in tumors. As the result of such loss of nerve
or muscle power, in certain muscle groups, malpositions of the feet are
caused which simulate those of congenital origin.


1. =Congenital Club-foot; Talipes Equinovarus.=--This consists
anatomically in an inward dislocation at the metatarsal joint of the
anterior part of the foot, in consequence of which the relations
of all of the other component parts of the foot are deranged; the
scaphoid is swerved on to the inner and lower side of the astragalus
to such an extent as to touch the internal malleolus; the cuneiforms
follow the scaphoid and the metatarsals follow the cuneiforms; the
cuboid is shifted to the inner side and does not articulate squarely
with the calcis. In infants these bones are cartilaginous, but as
the individuals grow and these miniature bones develop and ossify
they take similar and abnormal shapes and positions. The calcis is
drawn into a more vertical position than normal by drawing up the
heel, and is even somewhat rotated on its own vertical axis; thus its
anterior articulating surface is made to look obliquely inward. This
displacement of bones causes dislocation of tendons, the anterior
group being drawn mostly to the inner side. The patient walks more
and more on the outside of the foot, and as he does this adventitious
bursæ develop on the outer border, which become very thick and form in
time large callosities. In the most pronounced cases there occurs, in
connection with all this, curvature or spiral inward rotation of the
tibia, and even of the femur of the affected limb, while the contracted
muscles become overdeveloped and those which are disused underdeveloped
(Fig. 262).

[Illustration: FIG. 262

Talipes equinovarus.]

Among the causes of club-foot heredity seems to play a considerable
part, as it often happens that two or three club-footed children are
born of one mother. The deformity has been ascribed to abnormal or
exaggerated posture _in utero_, with compression. This theory is at
least attractive and has the force of argument from antiquity, for
Hippocrates thus believed. Unquestionably the normal intra-uterine
position of the fetus includes a certain degree of equinovarus. Yet if
this were the real cause the condition would occur apparently much more
frequently. It has been ascribed also to disparity in strength between
opposing groups of muscles, that group which causes the deformity being
naturally the stronger, it being at the same time unimportant whether
one group is relatively too strong or the other relatively too weak.
Most monstrosities or seriously defective infants have also club-foot,
from which some argue that the central nervous system has something
to do with it; yet it has been shown in over 1200 cases of club-foot
that only twice did such defect of the central nervous system as spina
bifida occur. The embryologists and comparative anatomists regard it as
an expression of arrested development, while evolutionists consider it
an atavistic reversion to an earlier anthropoid arrangement. None of
these theories really satisfactorily explains the deformity. Therefore
we should hold that either there are different and variable causes or
that we have not yet found the true one.


=Treatment of Congenital Club-foot.=--There being in these cases no
tendency to spontaneous improvement, mechanical or operative treatment,
or both, are required. If these be afforded early the prospects of
restoration, practically to the normal, are good, but treatment should
be begun early and conducted with great care and patience. It is not so
difficult to correct the deformity, but correctional supports should
be worn for a relatively long time, while the older the case the more
difficult become all the features, both mechanical and durational.
Parents are often eager at first, but later become inattentive or
careless. The main objects are to be attained by correction of position
by force or by division of contracted or shortened tissues, or
retention in position, with the addition of any other features which
may influence growth and development according to normal standards.
Of these we will speak first of rectification: (_a_) bloodless, as
by purely mechanical force, or by means of certain apparatus, and
(_b_) operative, as by subcutaneous tenotomy, aponeurotomy, etc., or
by open incision, through which are performed osteotomy, excision,
astragalectomy, tarsectomy, etc., as the operator may see fit.

In all of these the anterior part of the foot is to be forced outward
as well as raised, two distinct features, which should be combined but
not confused.

In the young infant gentle force applied many times a day, with the
persuasion of a strip of adhesive plaster, applied beneath the foot
and over its outer border, and spirally upward to the inside of the
leg, can be made effective in mild cases; but overstretching of the
tendo Achillis is a necessary part of this maneuver every time it is
practised. The more positive method consists of fixation of the foot
in overcorrected position within a plaster or starch bandage, the same
extending above the knee, which should be slightly flexed, the dressing
to be renewed every two or three weeks, and correction increased until
it has become overcorrection.

In well-marked and in resistive cases an anesthetic should be given,
while by the use of sufficient force, which may be relatively great,
but which should be gently applied, the resisting tissues are so
stretched, if necessary to the point of something yielding, that but
slight pressure is required to hold the foot in an overcorrected
position. When the knife is required the tendo Achillis should
always, and the plantar tendons and fasciæ usually, be subcutaneously
divided, under aseptic precautions. The foot is then enveloped in
suitable dressings and put up in overcorrected position for two or
three days, in a rigid dressing at first of starch, but after this
in plaster of Paris; this is the writer’s plan of procedure. The
insertion of the point of the tenotome sufficiently deep to divide all
resistive ligaments and tissues (_e. g._, the astragaloscaphoid or
the calcaneocuboid) nowise complicates this method, but makes it more
efficient.

Cases which are resistant are best submitted at once to _open
operation_ (that is, after vigorous stretching of the contracted
tissues), always under strict asepsis. After decades of milder
ineffectual methods it remained for A. M. Phelps, of New York, to show
the benefits of this method by which all contracted tissues on the
concave aspect of the foot are exposed and divided. Incision is made
here from the top of the inner malleolus to the inside of the first
tarsometatarsal joint. With a little care the artery can be avoided,
but I have never seen any harm come from its division. Everything
which proves resistant is divided, even the inner osseous ligaments.
Sometimes the incisions can be made in wedge-shape, or obliquely, so
that the wound does not remain so widely open. No attempt is made to
close this wound. The operation may be done bloodlessly, under the
Martin rubber bandage, but whether this be used or not any vessel
which can be recognized as such should be tied; otherwise the wound
is snugly packed with gauze (upon which I like to use Peru balsam).
An ample surgical dressing is applied over it. This is covered with
gutta-percha tissue, to prevent too free access of air to the blood
which will ooze into the dressing, and the whole is then covered with a
starch bandage, in overcorrected position; this is left, according to
circumstances, for from three days to a week--the longer the better.
Then everything is removed, fresh gauze placed in the wound, which will
be found already largely filled up; fresh dressings are applied, and
the foot put up in plaster of Paris, with or without a fenestrum or any
provision by which the region of the wound may be easily uncovered for
necessary renewal of dressing.

It is in the most pronounced types of cases only, with marked bone
deformity, or those in which previous operations have failed, that
the still more radical division or removal of some part of the tarsus
is necessary. As to this no universal rule can be applied save this:
take out sufficient to correct deformity. In some cases it will be
sufficient to excise the astragalus (_astragalectomy_). In other cases
it is better to remove a wedge-shaped piece of the tarsus, without
reference to the name of the bones attacked (_tarsectomy_). I have
never found it necessary to touch the external malleolus, though this
has been suggested, nor to do osteotomy of the calcis or of the leg
bones above the ankle, as a few have done.

[Illustration: FIG. 263

Park’s club foot brace.]

These operations are usually practised, _after a preliminary
stretching_, through a curved incision on the outer aspect of the foot,
through which, at the same time, the thickened bursæ may be removed, or
the callosities included in the incision. The chief convexity of the
incision should be over the os calcis at its anterior portion. As the
dissection is made the tendons are drawn aside and spared. If it be
necessary to divide one or more of them it should be re-united later.
According to the density of the structures a strong knife may be used,
and strong scissors, or an osteotome manipulated either by hand or with
the hammer. After sufficient V-shaped or wedge-shaped bone has been
removed the defect should be held together, if practicable, by buried
tendon sutures or wire; it is rarely necessary to use drainage. The
external wound may be loosely closed with buried sutures, a suitable
dressing applied, and the foot put up in a rigid splint; this should
permit of removal, or at least inspection of the wound after a few
days, for renewal of those dressings which are saturated with blood and
for application of new dressings. After this the foot and leg should be
put up in overcorrected position in plaster of Paris.

In aggravated cases of club-foot Wilson believes combined operation
to give better functional results than can be obtained by any other
method. The astragaloscaphoid joint is exposed by an incision over
the prominence of the scaphoid, and, being cleared, is opened with
chisel or bone forceps, while sufficient of the articular surfaces is
removed to destroy them as such and to take out a sufficiently large
wedge-shaped piece from either bone so that the desired arch of the
foot is restored, or even exaggerated. Then the tendon of the extensor
proprius hallucis is exposed and divided just above the great toe, the
upper end of the tendon being drawn out through the first incision.
To this end is attached a strong silk ligature. The scaphoid is then
perforated with a bone drill at some distance from its superficial
aspect and at such an angle, with the foot in correct position, that
the canal thus made shall be in line with the action of the tendon. The
drill is then withdrawn and the tendon passed through the opening by
means of its attached silk. One inch beyond the bony canal the tendon
is cut off and split in halves, each half being turned in opposite
direction and fastened to the periosteum of the scaphoid with fine
silk, while the foot is held in overcorrected position, so that the
tendon is sewed in its new place under moderate tension. The foot is
then dressed in this overcorrected position in plaster of Paris, the
splint extending nearly to the knee, and the wound area being exposed
by a fenestrum cut in the splint before it is hard.

The location of the incision over the dorsum or outer aspect of the
foot may be varied to suit the needs of the case and the method of the
attack. In a general way a flap of soft tissues is raised and tendons,
so far as possible, are held outward. This is usually practicable,
and it is rarely necessary to divide the latter. After operation of
any type and recovery from the same it will be necessary for a long
time to have the patient wear a corrective appliance. This should be
applied as early as possible, and should be worn continuously, _i. e._,
night and day; inasmuch as growth is continuous there should also be
continued correctional influences. Many types of apparatus have been
devised. That which the writer has found effective and has adopted for
a number of years is illustrated in Fig. 263. It may be made single
or double, as occasion requires. A part of the appliance is a spiral
spring and a provision for a constant outward pressure is made upon
the foot, by which inversion is more easily overcome, as well as any
inward spiral twist of the bones of the leg. No such apparatus can
be made effective unless connected suitably with a waist-band. This
is, therefore, included in the shoe shown in Fig. 263. Furthermore
the appliance should be so made as to permit adjustment commensurate
with the rapid growth of the patient, and in order that it need not be
too often renewed. Some degree of mechanical ability is required for
its application and management. The principles are, however, easily
mastered and most parents can soon learn to manage it.


2. =Talipes Valgus.=--This condition is known also as _talipes planus_,
or, more briefly, _pes planus_, the common names being _flat-foot_,
_splay-foot_, or _pronated foot_. A particularly painful variety has
been often spoken of as _pes planus dolorosus_.

This type of deformity is rarely of congenital origin. It is
characterized by abduction and pronation of the foot, on whose inner
border there often appear two prominences, one the head of the
astragalus the other the head of the scaphoid. The bones show much less
alteration in actual shape than in club-foot. The scaphoid is deflected
somewhat to the outer side and the astragalus turned a little outward
and downward. A prominent feature is that the arch of the foot is more
or less obliterated, while its inner border becomes convex instead of
remaining concave. This is due in large measure to relaxation of the
ligaments binding the foot to the calcis, especially that extending
from the astragalus (Fig. 264).


=Etiology.=--The common cause of the condition is lack of sufficient
strength of the parts to carry the weight of the superimposed body.
It is produced often by ill-fitting shoes, accompanied by excessive
strain or rapid growth and gain in weight. It is sometimes complicated
by a certain shortening of the gastrocnemius (Shaffer), which prevents
flexion to its complete degree and compels some degree of eversion
of the foot in completing a step. In some instances it is induced by
previous morbid conditions, such as rickets, paralysis, diseases of
the spinal cord, and postgonorrheal arthritis. Ill-fitting footwear is
the most common cause, as it compresses the front part of the foot and
prevents adaptation of the foot to the position it should assume when
the weight of the body is thrown upon it. The effect of this weight is
to necessitate a greater divergence of the toes than such shoes permit
and gradually causes the patient to walk on the inside of the foot.
_Flat-foot is seldom seen in those who habitually go barefooted._

The condition is best relieved by making a graphic record of each case.
This is done by making the barefooted patient step first on smoked
glass or on wet dusted paper, and then upon a piece of plain paper. If
such a print be compared with the print similarly obtained from the
normal foot it will be seen how different are the points of contact
and how differently distributed is the body weight. A non-graphic but
sufficient inspection may be afforded by having the patient stand
upon a stool whose top is made of glass and by using a mirror beneath
the feet. In any event it will be shown that the inner border of the
foot is at least nearly straight or even convex, whereas it should be
neither.

[Illustration: FIG. 264

Talipes valgus.]

There are tender points over the astragaloscaphoid joints, at the base
of the first and fifth metatarsals, in front of the internal malleolus,
as well as often beneath the heel. Patients who thus suffer find that
the feet perspire very easily. In walking the feet are everted, and
when tenderness is very great it is because too much weight is borne on
the inner borders of such everted feet. Inspection of the shoes will
also show wearing of the inner border and over the inner malleolus.

Spontaneous cure of such cases does not occur, except perhaps after
long confinement in bed from other causes, but patients occasionally
become tolerant after a time, though many of them grow steadily worse
and avoid using the feet more than is absolutely necessary.


=Treatment.=--Mild cases will be benefited, often practically cured, by
simply raising the inner border of the sole and heel of the shoe. This
causes more weight to be borne on the outer border than in the natural
attitude of the foot. It will be sufficient usually to make from ³⁄₈
inch to ⁵⁄₈ inch difference in the level between the inner and the
outer borders of the sole and heel. Shoes may be so constructed that
this difference is made invisible, or suitably bevelled narrow strips
of leather may be sewed beneath the sole along the inner side, or laid
in between its upper and lower layers.

While this suffices for the milder cases it is not sufficient for the
more severe cases, which require forcible correction, and often under
an anesthetic. The best way to accomplish this, after having patients
thoroughly relaxed with chloroform, is to make a thorough manipulation
of the foot, trying especially to so loosen its outer ligaments that it
may be more easily put in proper position and finally overcorrected.
The foot is then put up in plaster of Paris in this much overcorrected
position. Such splints are worn for five or six weeks, after which
suitable shoes should be provided, either with their inner borders
elevated or with metal flat-foot plates inserted, or both. These plates
are now in general use, and may be procured from instrument dealers and
in shoe stores. In particular cases it is advisable to make a mold of
the lower aspect of each foot, to have this cast in iron, and then over
the iron model to have a suitable metal plate hammered so that it shall
exactly fit the individual for whom it is intended.

Only in extreme cases, rebellious to other treatment, has it been shown
necessary to resort to such treatment as division, by osteotomy, of the
neck of the calcis or of the astragalus.

Most of these cases may be benefited subsequently by gymnastics and
massage, _i. e._, by stretching the contracted gastrocnemius, if
necessary, with some mechanical device, and improving the general
condition of the leg muscles by suitable massage.


=Metatarsalgia; Morton’s Disease.=--Under this name has been described
a peculiar painful affection of the third and fourth or the fourth and
fifth toes, which gives rise to constant sensitiveness and sometimes
attacks of acute pain, especially when the foot is shod, and which is
often only relieved by immediately removing the boot or shoe. These
affection’s are more common in the upper walks of society, especially
among women who are disposed to cramp their feet in shoes which are too
small for them. Aside from the location of the pain there will often be
found a tender spot at the point of greatest complaint. As these cases
become worse pain radiates farther and farther up the leg, and may even
assume the type of a sciatica.

[Illustration: FIG. 265

Talipes equinus.]

Careful inspection usually reveals either a mild degree of flat-foot,
or of distortion by which the anterior part of the foot is broadened
and held in a depressed position--or else the dorsal part of the foot
is depressed behind the anterior part; there is also usually limitation
of dorsal flexion of the foot and plantar flexion of the toes.

Morton, who first described the affection as having a peculiar type
of its own, thought it due to entanglement of the external plantar
nerve between the heads of the fourth and fifth metatarsal bones,
and recommended for its relief excision of the head of the fourth of
these. The etiology of the affection is not always apparent, but it is
sometimes due to what has been described as a non-deforming type of
club-foot, while in practically all other instances it is in some way
connected with the use of badly fitting footwear.


=Treatment.=--Without proper treatment it does not subside. A really
weak and pronated foot should be supported with a proper plate and
elevation of its inner border, while a short gastrocnemius should be
stretched. Only in extreme cases or when these milder measures have
failed need resort be had to Morton’s suggestion and excise the head of
the fourth metatarsal.


3. =Talipes Equinus.=--In this condition the _equinus_ position is
simulated, and the patient walks upon the anterior part of the foot
only, perhaps even upon the ends of the metatarsal bones. While the
congenital form is extremely uncommon the acquired form is that which
commonly occurs. Appearing thus in all possible degrees it may in
mild cases cause merely a slight limp, while the extreme cases cause
a pronounced deformity and alteration in gait. The actual condition
is one of shortening of the tendo Achillis through contraction of its
component muscles, with corresponding change in shape of the bones
of the foot. There is also more or less shortening of the plantar
aponeurosis, and depression of the astragalus, which is drawn down upon
the calcis (Fig. 265).


=Causes.=--Perhaps the most common cause is paralysis, either of
infantile or cerebral and spastic type, of the anterior muscles of the
leg, the condition being simulated sometimes in hysteria. The spasm
which follows disease of the ankle-joint may also produce it. It may be
the result of muscle contraction after fractures or even after certain
fevers, the foot dropping naturally into this position and remaining
there altogether too long. Hence may be seen the necessity for putting
the foot in the right-angle position whenever the lower limb is dressed
in plaster or other rigid dressings after fracture. Talipes equinus
may also be due to injury to and loss of power in the anterior muscles
of the leg, or it may be compensatory, as when one leg is longer than
the other. In any of these events the body weight is borne on the ball
of the foot, and some degree of arching of the foot, which may be
excessive, is sure to occur.


=Treatment.=--In the milder cases, when seen early, it may be
sufficient to thoroughly and repeatedly stretch the sural muscles,
but, in the more severe forms, tenotomy of the tendo Achillis, with
subcutaneous or perhaps open division of the plantar structures,
will be needed. In paralytic cases tendon grafting (_q. v._) will be
required, probably with one or more of the measures mentioned above.
In some instances nerve grafting might be profitably employed. After
recovery from operation, braces adapted to each particular case will in
all probability be required, at least for a time.


4. =Talipes Calcaneus.=--In this deformity the anterior part of the
foot is drawn upward by its anterior flexors and a little to the outer
side, while the sural muscles are relaxed; thus the patient walks upon
the heel. The condition is often more or less combined with talipes
valgus. It is rarely of congenital origin, but is generally due to
paralysis of the distal muscles following injury or poliomyelitis. It
is sometimes of hysterical origin, and it may occur as the result of
muscle spasm following bone or joint disease (Fig. 266).

[Illustration: FIG. 266

Talipes calcaneus.]

[Illustration: FIG. 267

Pes cavus, hollow clawfoot.]

Those forms due to infantile paralysis are to be treated mainly by
tendon grafting or some similar expedient, and this to be followed by a
suitable shoe containing a sole plate with an upright attachment and a
joint opposite the ankle. Other forms must be treated, each on its own
merits, but according to general principles already enunciated.


=Pes Cavus.=--Here the anterior part of the foot is drawn backward and
the plantar arch made much more prominent. It may even be converted
into a Gothic arch. Extremes of this type are seen in the feet of
Chinese women. One form is due to contraction of the peroneus longus,
owing to paralysis of the sural muscles, by which the long flexors
are permitted to work to extra advantage; and yet another form is
often of congenital origin, having its explanation in paralysis of the
interossei and other small intrinsic muscles of the foot (Fig. 267).

When an ordinary metal sole plate fails to give relief a subcutaneous
or open division of the contracted structures may be practised.


CONGENITAL MISPLACEMENT (DISLOCATION) OF THE HIP.

Perhaps a more proper name for this congenital deformity would be
“misplacement” rather than dislocation. It is seen much oftener in
females than in males. It may be either unilateral or bilateral. The
displacement is usually upward and backward upon the dorsum of the
ilium. In rarer instances it is anterior and sometimes the head of the
femur lies not far away from the anterior superior spine of the ilium.

Regarding its cause absolutely nothing is known. It represents
defective development rather than arrest, and is a condition of
intra-uterine life. The acetabulum is usually found incomplete, but
whether this is the cause of the misplacement or whether it fails to
develop because of the absence of the head of the femur from this
cavity it is not easy to decide. The influence of heredity in these
cases is undeniable, for it is known to have prevailed in certain
families. Thirty years ago but little was known in regard to the
affection, and nothing could be done to atone for it. Of late years it
has been the subject of special study by numerous investigators (Figs.
268 and 269).

[Illustration: FIG. 268

Double congenital displacement of the hip. Buffalo Clinic. (Skiagram by
Dr. Plummer.)]

[Illustration: FIG. 269

Skiagram of coxa vara; deformity most marked at the epiphyseal
junction. This illustrates the mechanical limitation of abduction
caused by the deformity, and the compensatory tilting of the pelvis.
(Whitman.)]

[Illustration: FIG. 270

Congenital misplacement, with consequent atrophy and shortening.
(Calot.)]

Pathological changes are noted in the capsule itself, as well as in the
bony components of the joint. Thus the capsule is usually elongated
and stretched out of shape, while its lower portion may be adherent to
the margin of the acetabulum or may be shut off into a small cavity
by itself, this cavity having but a small connection with the balance
of the capsule and affording irresistible obstacles to reduction. With
changed joint relations the muscular arrangements are also changed,
some being lengthened, others shortened, as would naturally follow
from the approximation or separation of their points of origin and
insertion. Conspicuous change is seen in the upper end of the femur,
which is often atrophied, while the neck is shorter than normal, its
angle lessened, and the head of the bone often altered in shape. A
secondary acetabulum is in time formed and is usually found upon the
side of the ilium. This is shallow and insufficient to ensure firm
support for the head of the femur, even were this well developed.
Aside from these changes the pelvis is usually poorly developed on the
affected side, its inclination increased, the sacrum forced forward and
downward, the pelvic outlet widened, while a considerable degree of
lumbar lordosis is present (Fig. 270).

The condition is rarely noted until a growing infant begins to learn
to walk. The condition is one which has _no symptoms, only signs_, and
these do not at first attract attention. Sometimes it will have been
noted that there is an abnormality about the hip, with too free play,
or a snapping sound about the joint. When the condition is unilateral
there is a marked limp which increases with the age of the child.
With each step the femoral head is pushed upward on the side of the
ilium, and, in consequence, the pelvis is tilted toward the outside,
as well as twisted downward and forward. The limb being thus actually
shortened, the limp or waddling gait is easily accounted for. Along
with it there is usually flattening of the tibia, while the trochanter
may be felt and often seen on a level considerably above that where it
properly belongs. Motility in the joint is abnormally free, and with a
child on its back, by alternately pulling and pushing, the abnormally
free play of the upper end of the femur may be easily demonstrated,
either with the limb in its extended or the flexed position.

When the misplacement is _bilateral_ the individual is more
symmetrically deformed. The lordosis is increased, the abdomen
protrudes, the thighs are separated more widely than is normal, leaving
perhaps a considerable space in the perineum; the gait is of a peculiar
waddling character, which makes locomotion apparently difficult,
although it is free from pain. In these cases abnormal mobility of the
hip may be demonstrated on each side.

As these patients grow through adolescence into maturity they sometimes
improve, but usually suffer more and more difficulty in locomotion,
while the abdominal protrusion and the lordosis become more and more
pronounced.

Three varieties of congenital misplacement are described as _backward_,
_upward_, and _forward_. It is in those instances where the head of
the bone rests well back or well forward upon the ilium that the gait
is most pronounced, but in all instances the great trochanter will be
found above Nélaton’s line.


=Diagnosis.=--The diagnosis offers few difficulties. The peculiar
waddling gait may be seen in extreme cases of bow-legs, but then the
hip-joints will be normal. Extreme lordosis may be seen in cases of
lumbar spinal caries, but here again the hip-joints will be normal,
while the spinal muscles will be rigid and the patient disinclined
to walk. Traumatic dislocations and the results of hip-joint disease
will be indicated by a history to correspond, as will also early acute
joint affections following the exanthems. The diagnosis is to be made
principally from _coxa vara_, considered below, and the various defects
following infantile palsy. In coxa vara there is no corresponding
abnormality of motion, while in the paralytic cases there will often be
failure in muscle power, which is not present in cases of congenital
misplacement. Finally in instances which offer difficulties the Röntgen
rays now afford a method of diagnosis.


=Treatment.=--For a long time after this condition was recognized its
treatment was unsatisfactory, and it was not until Hoffa, about fifteen
years ago, advanced his operative method of relief that surgeons felt
at all like advising operation in well-marked cases. Then came Paci and
Lorenz, first with improvements on the Hoffa operation, and then with a
method of so-called “bloodless” reposition, which has been under severe
test and testimony. Last of all come Bradford and Sherman with their
improved methods of operation, which seem to me the most promising of
all as well as the most scientific.

[Illustration: FIG. 271

A plaster bandage applied by Lorenz, illustrating the extreme thickness
of the pelvic portion and discoloration of the adductor region.
(Whitman.)]

Lorenz was doubtless correct when he stated that the principal
obstruction to reduction is the narrowed part of the capsule, just
at the upper part of the acetabulum, and that if this could be torn
here sufficiently to permit the passage of the head, reduction
could be accomplished by manipulation alone, and maintained if the
acetabulum were sufficiently deep. An almost insuperable difficulty
in most cases is, however, this narrowed capsule, and the number of
accidents, including not only fractures of the femur and the pelvis,
but various other injuries which have resulted from too great violence,
is altogether too large and too disturbing to justify the use of such
force as has often been used. Of more than one hundred children upon
whom Lorenz operated when making a tour through the United States,
but little over 10 per cent. have given anything like ideal results;
while the danger from fracture and laceration of muscles and nerves,
as well as of bloodvessels, is fully as great as that pertaining to
any open operation. It may therefore be maintained that the percentage
of success from the use of manual force without incision does not
justify the risks of the method. Sherman argues that if we may open a
knee-joint without hesitation to take out a small piece of cartilage,
we need not fear to open a hip-joint in order to clear away a small
obstacle. The patient is thereby saved from many dangers and exposed to
so few that it seems more humane and desirable in every respect.

Sherman’s method is to make traction upon the limb, drawing the
femoral head down to a point just below the anterior superior crest,
where it can easily be felt, and to here make an incision over it
in the direction of muscular fibers so that they are not divided.
After division of the capsule the head of the bone is exposed and
retractors substituted by long loops of suture, put in on either
side of the opening in the capsules. In many cases a tenotomy of the
adductor tendons close to the pubis will also be of advantage. The leg
is next released from traction and the head of the bone allowed to
glide upward, while the finger is slipped into the capsule and down
toward the acetabulum. Upon this finger as a guide a long, straight,
probe-pointed bistoury is passed, and with it the narrower portion
of the capsule is cut through, down to the bone, taking care to not
cut off the ileopsoas tendon. The incision must be large enough to
give free access to the acetabulum. Traction is then again made with
sufficient manipulation so that the femoral head may be forced into
its proper cavity. When the head is in the acetabulum the retracting
sutures are tied together so as to close the upper part of the capsule,
and other sutures are introduced, as needed, to close the wound,
leaving space for a cigarette drain. The limb is then put into a
position of abduction of from 50 to 90 degrees, rotated in or not, as
needed, and a comprehensive plaster-of-Paris spica applied. In this
both limbs or only one may be included. The drain should be removed in
two days and the dressing left otherwise undisturbed for three months.

Bradford has added somewhat to our methods by showing not only the
arrangement of the capsule, but the fact that the acetabulum is often
filled with dense fibrous tissue which sometimes obliterates it, and
that this tissue can be curetted out, but that if it could be utilized
to aid in retaining the reduced head of the femur it would be a great
benefit. He operates as follows: The hip is subjected to preliminary
forcible stretching of all soft parts which can be stretched by manual
or mechanical force. A posterior incision is then made, which, without
dividing muscles, permits free opening into the capsule and affords a
channel to the deepest portion of the acetabulum. The posterior wall
of the capsule is then split, after which all constricting and other
obstacles at any point are carefully divided. These may be detected
by the finger, and can also be seen by a small electric light passed
down inside of a sterilized glass test tube. The capsular wound is then
retracted by deep retaining silk sutures, placed at the lower rim of
the acetabulum, thus affording a pathway for the reduction of the head.
After this has been accomplished as described above, the sutures are
tied closely around the femoral neck, and these retain it in position.
The other portions of the split capsule are then sewed around the head
and neck, to the trochanter and fascia, in such a way as to retain the
bone where it has been placed.[37]

  [37] American Journal of Orthopedic Surgery, October, 1905.

The earlier the operation is done the better. It is necessary to always
maintain the limb in a position of well-marked abduction, and for a
long time, nor can patients be released from this at the expiration of
the first dressing period, usually twelve to fifteen weeks, although
the abduction can usually be reduced with each dressing until at last
the limbs are permitted to come together after the expiration of nine
to eighteen months. Even after the lapse of this length of time it
may be necessary to provide some form of apparatus by which too much
rotation in either direction may be prevented, or by which pressure
may still be made over the trochanter, in order that it may be kept
constantly pushed into the acetabulum (Figs. 271 and 272).

[Illustration: FIG. 272

Unilateral congenital dislocation, showing the fixation bandage. A
shoe with a cork sole about two inches in height should be worn on
the operated side, while the attitude of exaggerated abduction is
maintained. (Whitman.)]

[Illustration: FIG. 273

Coxa valga, with defective development of the right femur. (Albert.)]


COXA VARA AND VALGA.

This term is applied to an _abnormality in the shape of the neck of the
femur_, consisting of a downward curvature or bending of the femoral
neck, which is thus displaced until it stands almost at a right angle
with the shaft instead of at the normal obtuse angle. At the same time
there is often posterior curvature, or sometimes an anterior curve,
of the neck, which causes a corresponding rotation of the axis of the
whole limb. The pelvic side of the hip-joint is unaffected, the change
occurring usually solely in the upper end of the femur, the joint
not being involved. It may appear in congenital form and then may be
attributed either to intra-uterine pressure or to antenatal rickets or
osteomalacia. The acquired form is usually due to a non-inflammatory
softening, or to structural changes which permit of yielding, as above
described. Doubtless different cases have different causes, and they
are not to be included in one brief sentence. The condition corresponds
to those abnormalities at the knee which produce knock-knee and
bow-leg. Were the bone as easily examined at the upper end of the femur
as at the knee the condition would be more easily recognized. Therefore
the term has reference not so much to the results of active disease as
to deformities of congenital or acquired character. Fully three-fourths
of the cases are met with in male subjects, and the majority of
these occur only on one side. Thus of 190 quoted by Whitman, 85 were
unilateral, while only 26 occurred in females.

The more nearly the angle of fixation of the neck of the femur
approaches a right angle the further above Nélaton’s line will the
trochanter appear, and the more conspicuous this change the greater the
difficulty in abduction. Moreover, to shortening may be added internal
or external rotation, with consequent tilting of the pelvis and
compensatory alteration of the spinal curves.

The disease is by no means often of traumatic origin, although
traumatisms may produce an arthritis deformans, even in juvenile cases,
and that this may simulate a non-symptomatic coxa valga is now well
established (Fig. 273).


=Symptoms.=--Coxa vara produces certain symptoms, among them pain in
the joint, radiating down the front and inside of the thigh. If the
deformity be very marked, joint function is impaired. Tenderness is
rarely present. When pain or tenderness occur they may lead to the
mistaken diagnosis of rheumatism or neuralgia. The condition may arise
as the result of an acute ostitis, in which case patients will be
confined to bed for some time. Actual shortening may vary from one
to one and a half inches, while the limb will be found adducted, the
gluteal region flattened, with a deep curve between the trochanter and
the gluteal muscles.


=Diagnosis.=--The diagnosis is to be made mainly between this condition
and hip-joint disease or misplacement. When abnormalities in the
shape or position of the limbs in the young occur in a comparatively
short time, coxa vara may be suspected, especially in the absence of
that disability which coxitis usually produces. The patient should be
examined in both the upright and horizontal position. Coxa vara may
have an abrupt onset, but it never produces abscess. It is practically
self-limited and will be followed, sooner or later, by spontaneous
cessation of all acute features, while coxitis is progressive, with a
destructive tendency. In coxa vara we do not have the starting pains
nor muscle spasms of coxitis, while the actual shortening is much more
marked. In doubtful cases the cathode rays may be employed and will
often greatly facilitate diagnosis. The condition may be bilateral,
but will still fail to show the muscle atrophy so significant of
tuberculous disease.

As between coxa vara and that senile form of coxitis already described
in the chapter on Joints as arthritis deformans, it should be
remembered that the latter is a disease of advanced life, while the
former occurs rather in its earlier periods. Moreover, in the former
there is no tendency to change in the femorocervical angle, no matter
what changes may occur in other respects about the joint. When in
the senile disease shortening really occurs it results from actual
absorption of bone.

Coxa vara tends usually to _spontaneous cessation_, which may be
considered recovery. Acute symptoms after a time subside, and function
is regained to the full extent permitted by whatever changes have
occurred in the shape of the bone. If symptoms are at all severe they
demand physiological rest in bed, with traction, and the limb should
not be used until pain has entirely subsided. Conspicuous deformity
may call for correction by subcutaneous osteotomy made just below the
trochanter. Only in exceedingly serious cases is exsection of the joint
necessary.


DEFORMITIES CAUSED BY INFANTILE PALSIES.

Deformities induced by more or less acute affections of the cord and
brain, or by hemorrhages, have assumed an ever-increasing importance
in orthopedic work. Most of them resolve themselves into those due to
acute anterior poliomyelitis and those due to cerebral hemorrhages.

[Illustration: FIG. 274

Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing
quadrupedal locomotion. (Gibney.)]


=Anterior Poliomyelitis.=--Anterior poliomyelitis is an acute
inflammation manifested especially in the gray matter of the anterior
cornua of the spinal cord, involving both the neuroglia and the cells,
producing atrophy of the same and consequent paralysis of muscles
supplied by the motor nerves. It may assume an acute febrile type,
with rapid onset of paralysis, or it may be of slower development.
Usually conceded to be of infectious origin, it still lacks the minute
explanation for many of its attendant phenomena. It may appear with
acute symptoms, febrile and convulsive, paralysis appearing more or
less promptly. With the subsidence of other serious symptoms this
paralysis remains. There may then be a period of partial improvement
in the muscular condition, with disappearance of some of the most
pronounced phenomena. Finally with the growth and development of
the child more expressions of damage remain, and produce various
distortions and deformities, varying with the muscle groups affected.
Not only do deformities result, but there is more or less arrest of
development, with disproportion in size between the limbs involved and
those which have been spared. It is the early paralytic features which
may permit diagnosis to be made in the early days of the acute febrile
attack.


=Cerebral Palsies.=--The cerebral palsies, so called, are the result
of hemorrhages or acute disorganization of the brain. The former are
usually unilateral and give rise to a corresponding hemiplegia, with
either paralysis or spastic rigidity, and usually with atrophy. The
paralysis may not be complete, but is rather of the paretic type,
involving the entire limb, the reflexes being increased and the muscles
stiffened rather than flaccid, with loss of electrical reactions.

_A paraplegia points rather to lesion in the spinal cord and hemorrhage
than to cerebral lesion._ Transverse myelitis is rare in children.
Multiple neuritis may produce somewhat similar effects, as may also
the toxic paralyses due either to drugs (especially lead or arsenic)
or that following diphtheria, in which case it is the muscles of the
throat and neck which are likely to be involved. Figs. 274 and 275
portray extreme types which are rare, but instances of minor degree of
affection are frequent.

[Illustration: FIG. 275

Anterior poliomyelitis. Duration seven years. Showing atrophy and
slight lateral curvature of the spine; two and a quarter inches of
shortening. (Whitman.)]


=Treatment.=--As two cases of this kind are seldom alike, treatment
should be planned to meet the indications. Massage, electricity,
hot-air baths, and similar non-operative measures find here a large
field of usefulness, but, save in the milder cases, are insufficient.
In no class of cases do tendon grafting and nerve grafting find a wider
range of applicability, while tenotomy, myotomy, aponeurotomy, and
occasionally osteotomy will permit of atonement for deformity which has
not been treated. These operative measures have been considered.




CHAPTER XXXIV.

FRACTURES.


The term _fracture_ is, in surgery, applied to such injury of bone
and cartilage as effects break in continuity. This injury is effected
instantly, and it is rarely that fracture is produced by any slowly
acting cause, although this latter may so affect or disintegrate
bone as to permit fracture upon the application of a mild degree of
force. Fractures are variously classified and grouped for convenience
of description; thus we speak of _traumatic_ and _pathological
fractures_, implying by the former those which occur by violence in
normal conditions of health, and by the latter those which are produced
only because of some previous disease in the bone. The difference
is that in the former case there is no preëxisting disease, whereas
in the latter it is an essential feature of the case. Fractures
are also classified as _complete_ or _incomplete_, the former term
implying injury to the whole thickness of the bone, while the latter
are separately classified: (_a_) _Fissure_, in which there is a line
of fracture by which there is no complete separation of fragment, it
being essentially a crack; (_b_) the _green-stick fracture_, such as
occurs in the young, where the bone is not thoroughly calcified, but is
capable of bending to some extent, while a portion of it breaks; (_c_)
_depressed fracture_, which is generally produced by direct violence,
and occurs in a flat bone, _i. e._, the skull, the scapula, etc.;
(_d_) _detachment_ of a fragment or separation of an epiphysis; (_e_)
_partial fractures_, corresponding much to the green-stick, but without
deformity or change in shape or position.

[Illustration: FIG. 276

Impacted fracture of the shaft of the femur produced by a fall upon
the knee in a man aged eighty-three years. Illustrating impaction.
(Bryant.)]

Fractures are also described by means of the following adjectives,
which practically explain themselves, for instance:

_A._ _Complete_, _transverse_, _oblique_, _longitudinal_, _dentated_,
etc. _Spiral_ fracture is also described and occasionally seen. It
involves only the long bones, and not only implies a considerable
degree of violence, but is itself regarded as exceedingly serious.

_B._ In number they are _single_, _multiple_, or _comminuted_, as when
there are a number of fragments.

_C._ They are often _impacted_, which means that one fragment is
driven into and more or less embedded in the other. This impaction or
interlocking of fragments occurs usually in the neck of the femur and
the lower end of the radius. In the former locality it is advisable not
to interfere with it; in the latter it should always be dislodged in
order to restore the fragment to its proper position (Fig. 276).

_D._ As to their nature and location, fractures are referred to as
_pathological_, _gunshot_, _intra-articular_, or _extra-articular_,
etc., the latter terms referring to involvement of a joint. If blood
can escape from the site of the fracture into a joint cavity, or if
synovial fluid can escape from the latter into the former, then the
fracture is called _intra-articular_.

_Pathological fractures_ imply preëxisting disease. This may be
constitutional, as in the case of the fragilitas ossium, already
described in the chapter on the Bones, or it may be due to some
secondary deposit of cancer or a primary sarcoma. In adults, especially
those with a cancerous history, any spontaneous fracture, or even
one occurring with trifling violence, should lead to suspicion of a
metastatic focus in the bone at the site of its yielding. The atrophic
changes which notably occur in various bones as old age comes on lead
also to a condition which is pathological, _i. e._, it permits of
fracture from what would appear to be a trifling injury.

_Gunshot fractures are practically always comminuted_, save perhaps
some of those inflicted with the modern military weapons. A Mauser
bullet will frequently make an almost clean perforation, but the
gunshot fractures met with in civil practice are almost invariably
comminuted, especially those of the skull (Fig. 277).

_E._ The term _compound_ is applied to any fracture in which there is
wound of the soft tissues and so located as to permit access of air
to the injured bone. There is a distinction between a compound and a
complicated fracture. A fracture of the femur accompanied by a gash
or extensive wound, so long as air cannot come in contact with the
broken bone, would be described as a fracture of the femur complicated
by a lacerated wound. On the other hand, if through the slightest
puncture of the skin, even at a distance from the fracture, air can
even theoretically enter and come in contact with bone surfaces at the
site of the fracture, such an injury constitutes a compound fracture.
This distinction is not a trifling one, for upon the exclusion of air,
which to a certain extent means the exclusion of germs, depends very
much the rapidity and perfection of recovery. _Compound fractures
are all dangerous in proportion as they permit of infection_, and
while air infection is not necessarily the most serious of any, it
nevertheless is often sufficiently so to set up sepsis and interfere
with consolidation, even if it does not prevent it. Fractures are
made compound by _direct violence_ from the outside or by _indirect
violence_, as where a bone end perforates soft parts and the skin. Even
if a sharp point of bone thus protruded from within is quickly drawn
back again it is enough, since both the skin and the air in contact
with it are sources of germ activity. Thus it may happen that a slight
and apparently trivial injury of this kind is more serious than one
which is extensive.

[Illustration: FIG. 277

Skiagram of compound comminuted (gunshot) fracture of elbow, inflicted
with a Dumdum bullet. Illustrating the extreme of comminution. (Lexer.)]

_F._ _Epiphyseal separations_ constitute a somewhat distinct form of
injury, having at the same time the importance and dignity of fractures
in the truer sense of the term. In the chapter on Diseases of the
Joints will be found a table of the ages at which epiphyses unite. In
childhood and youth a fracture near the joint is most likely to partake
of this character, and it is of importance that it should be recognized
as such when it occurs. Injuries occurring beyond the ages mentioned in
the table are not likely to be of this character unless ossification is
delayed by some morbid process.

By virtue of their occupations and habits men suffer fractures more
frequently than women. Fractures are, moreover, ten times as frequent
as are dislocations. The aged, by virtue of their atrophic changes,
are more subject to fractures than others. Fracture in the vicinity of
certain joints predisposes as well to dislocation of these joints,
and it often happens that the treatment for the dislocation is
reduction and treatment of the fracture. So far as the external causes
of fracture are concerned they are frequently referred to as (_a_)
fracture by external violence, and (_b_) fracture by muscle activity.
The former are easily explained; the latter occur from excessive muscle
action, as in violently throwing a ball, or, as in one case with which
the writer was conversant, where a colored preacher in the vehemence
of his gesticulations fractured his own humerus. Obviously the long
or large bones are more liable to fracture than those which are short
and irregular. Certain bones, especially the clavicle, are peculiarly
exposed.

_Intra-uterine fractures_ have not as yet been mentioned. These occur
during the intra-uterine life of the fetus; this term does not include
such fractures as may be inflicted during delivery with or without
instruments. In a fetus already affected with congenital rickets it
may not require any severe contusion upon the abdomen of the mother to
inflict a fracture. Starvation (_i. e._, scurvy, syphilis, and struma)
in the mother may so disturb nutrition as to weaken the osseous system
of her offspring.

Such previous conditions as ensue from osteomyelitis (_i. e._, caries
and necrosis) may often weaken the bone. Nevertheless with distinct
necrosis there is usually so much new bone formation as to strengthen
rather than weaken the part. Bones may also become fragile as the
result of syphilis, especially when gummas develop within them.

Fractures frequently produce certain _deformities_ which are more
or less conspicuous and easily recognized. They are designated as
_angular_, _lateral_, or _axial_ (_i. e._, when the axes of bone
are considerably displaced, even though they may be more or less
parallel), _longitudinal_ (when ends overlap), _rotary_, etc.; while
by the interposition of muscles and other soft tissues more or less
wide _separation_ may be produced, the same result occurring when the
olecranon or the upper half of the patella is widely separated from the
main bone or portion by muscle pull.


DIAGNOSIS OF FRACTURES.

Fractures give rise to subjective symptoms and objective signs. In
diagnosis the history is also of value, especially in those cases
where it is a question of some constitutional affection and a minimum
or absolute absence of violence. The apparent immunity which the
intoxicated enjoy is in large measure due to the fact that by virtue of
their condition one of the predisposing causes of fracture is avoided.
There can be no doubt but what _muscle tension_, due to voluntary or
instinctive efforts to avoid harm, is a contributing factor in the
separation of many bones or their processes. A patient stupidly drunk
will not make these efforts, and will fall in a relaxed condition,
in which violence will probably be much less extensive, and the
consequences less disastrous than if he made an effort to save himself
from falling.

_Pain and tenderness_ are evidences of injury, and will often serve for
its location; even the reference of pain is somewhat suggestive. It
is stated as a universal rule that when pressure is applied laterally
or in the long axis of a bone and evokes pain, referred to a distance
from the point where pressure is made, it will indicate fracture at the
point to which it is referred. There is always _impairment_, usually
_loss of function_, while effort to move a thus injured limb will give
rise again to localized pain and tenderness. The pain of contusion is
usually diffuse, and that of fracture is referred to a limited area.
The tenderness produced by handling or examination will vary with the
stolidity, the age, and the character of the patient, as well as the
nature of the injury.

Objective signs are _crepitus_, _mobility_, _deformity_, _ecchymosis_,
_redisplacement_. _Crepitus_ means the sensation of grating or rubbing
produced when fractured bone surfaces are moved upon each other. It is
recognized by the sense of touch, sometimes by that of hearing. Its
presence is pathognomonic, but its absence is a negative sign, and
an effort should be made to obtain it. To repeat the demonstration,
especially to demonstrate it to others, means superfluous manipulation,
which is not to the best interest of the patient. Crepitus, then,
should be carefully sought for; once detected it should be sufficient.

_Abnormal mobility_ is explained only by fracture. It is easy to
detect it in the shaft of a long bone, but when near the joint it
is confusing. Its determination by manipulation is not seen in
green-stick or impacted fracture unless these are further broken up
by manipulation. When evident it should serve as a caution against
unnecessary or rough handling, for if it be easily recognizable
crepitus need not be sought.

_Deformity_ is a striking and pathognomonic feature of fracture. It
may be imitated by hematoma or sudden swelling of the soft parts or
of joints. It may consist of shortening or of angular, lateral, or
rotary displacement, or perhaps of depression or indentation. Careful
inspection, then, and palpation should precede other methods of
examination, as they are often sufficient to indicate the location, the
nature, and sometimes even the character of the active causes.

_Inspection of the injured part alone is not always sufficient._
Careful comparison between the two sides of the body should be made
in order that actual measurement or comparative examination may
reveal what mere inspection would not. In connection with inspection
it should be ascertained whether the individual has ever received
previous injuries. The writer recalls a case where a physician claimed
a recovery after fracture of the femur, treated by incompetent method,
yet with ideal result, inasmuch as he said there was absolutely no
shortening. A personal question, however, to the patient revealed the
fact that he had had the other thigh broken some years previously, and
that an apparently similar amount of shortening followed in each case.

The ordinary indications of fracture are frequently followed by
_ecchymosis_. This will appear at a date corresponding with the depth
of the injury beneath the skin (it may occur within an hour or three
or four days). The blood will follow the fascial planes and work its
way to the surface along them. The sign is of the greatest value in the
diagnosis of basal fractures of the skull and certain fractures of the
hip and pelvis. When it occurs after an interval it is a confirmatory
rather than a promptly available sign.

_Redisplacement_ implies that the parts when properly put into
apposition quickly fall out of it unless mechanically supported--that
is, they _do not stay reduced_. This sign is not universally
applicable. It applies especially to the fractures of the long bones of
the extremities, and particularly to the humerus, the femur, or double
fractures of the radius and ulna in the forearm or both bones of the
leg.


=Diagnostic Aid Afforded by the Fluoroscope and the Skiagram.=--Since
Röntgen’s memorable discovery the _cathode or x-rays_ have been of
greater and greater use in the diagnosis and portrayal of injuries and
morbid conditions in the osseous system. To such an extent is this
now true that well-equipped hospitals have ample conveniences for
fluoroscopic and photographic work, while many medical men are doing it
in their private practice. There can be no question but that diagnosis
and methods of treatment have been made more perfect since this new
method of investigation has been made available. On one hand, however,
it has led perhaps to something of neglect of the methods previously in
vogue, which necessitated anatomical knowledge and logical reasoning.
On the other hand, the knowledge thus obtained has been sometimes a
two-edged sword, since the display of skiagrams, or _x_-ray pictures,
in court has too often worked harm or discredit to the surgeon or the
institution with which he was connected. Moreover, even this method of
diagnosis, with its apparent certainties, is not always reliable, and
disappointments have sometimes followed.


=Intra-articular Fractures= are subject to peculiar complications which
enhance the difficulty of treatment and jeopardized the result. Among
the more common of these are the following:

1. Too wide separation of fragments by hemorrhage or distention, with
failure in resorption of fluid before fixation in bad position has
resulted.

2. Complete or partial rotary displacement, preventing proper
apposition of bone surfaces.

3. Interposition of soft or fibrous tissues between fragments by which
bony union is prevented. This is conspicuously common in fractures
of the olecranon and patella, and is of itself sufficient reason to
justify operation in otherwise suitable cases.

4. Separation of a fragment within a joint capsule, by which its blood
supply is cut off, making it essentially a foreign body. This occurs
especially at the anatomical necks of both the humerus and femur.

5. Exuberance of callus with consequent limitation of motion.

6. Insufficient amount or absence of callus, which, when bone ends are
bathed in joint fluids, is not often thrown out.

All of these are _immediate consequences_. The following are among the
more undesirable _remote consequences_ of the same injuries:

1. Exuberant callus, which may be the result of too early attempt to
move the parts, or may result from other causes; it offers more or less
mechanical obstruction to joint movements.

2. Separation of fragments to an extent precluding the possibility of
repair, and interfering with function.

3. Pseudo-ankylosis, as a result of condensation and organization of
blood clot between joint surfaces.

4. Adhesion of tendons to surrounding callus or within their own
sheaths.

5. Displacement and distortion of bone ends with vicious union, for
which the medical attendant is _sometimes_ responsible. Unfortunate
consequences of this kind are generally seen at the elbow after
fractures of the condyles; at the wrist, after incomplete reduction of
Colles’ fracture; at the hip, when insufficient traction has been made;
at the ankle, after the complete form of Pott’s fracture.

6. Exostoses and osteophytic outgrowths, which often complicate
fractures.

7. Absorption of bone, which is usually seen after fractures of the
neck of the femur.

8. Involvement of nerves by pressure of callus, most often seen about
the elbow.

9. Thrombosis leading to obliteration of the deeper and enlargement of
the more superficial veins.

10. Edema, also the result of venous obstruction by pressure of callus.

11. Chronic hydrarthrosis.

12. Arthritis deformans traumatica. This is usually a remote result of
fractures, and manifests itself by slow changes in shape and position,
with deformity and disability. It occurs most often in the aged.

13. Necrosis, which may be the result of failure in the process of
repair and will probably necessitate operation.

14. Malignant changes. These have to do with the occurrence of sarcoma
in bone callus, a complication which is known to occasionally arise.
(See Sarcoma.) It also refers to primary sarcoma, by which bone is
weakened, or secondary carcinoma, which produces the same result.

15. Syphilis. Chronic syphilitic disease is well known to weaken bones
by atrophic processes as well as by the deposition of gumma. It is
known also to delay, or sometimes almost prevent, the process of callus
formation, ossification, and later absorption. Syphilitic patients with
fractures need to be kept under antispecific medicines.


REPAIR OF FRACTURES.

The immediate consequence of a fracture is outpour of blood both from
the broken-bone surfaces and from whatever other tissues may have been
lacerated. This produces, first, a hematoma, which is followed by a
certain degree of local edema, perhaps even of general edema of the
distal parts. The latter will subside with a rapidity proportionate
to the promptness of suitable treatment and the nature of the injury.
The blood begins to coagulate within a short time, while with the
disappearance of the more fluid portion granulations begin to form from
the periosteum, as well as bone surfaces, externally and internally,
and even from the marrow. The clot loses its original characteristics
and is permeated more or less rapidly by granulations. With the site
of the injury wrapped in a mass of granulation tissue we speak of the
so-called _provisional callus_, whose amount will depend upon the
severity of the injury and the accuracy of the replacement of the
parts. If laceration has been but trifling and the bones are accurately
apposed the amount of callus will be small, otherwise it may be
large; so large, in fact, as to be easily palpated and even to cause
edema and pain by pressure. Repair of the fracture is effected by the
gradual conversion of this callus into cartilaginous tissue and then
into bone. So much of it, at least, as lies on the outer side of the
bone and is known as _external callus_ goes through this change. The
_internal callus_, _i. e._, that within the marrow cavity, undergoes a
more direct transformation, which amounts to immediate ossification.
The internal callus usually ossifies completely, and then forms a
_medullary plug_ that serves as an internal splint and affords support
and strength. In time it completely disappears, this time varying in
different cases.

The external callus is converted into bone by passing through the
intermediary condition of cartilage. Between the broken-bone ends
granulation occurs more slowly, and repair at this point is delayed,
partly because of poor circulation and nutrition; but the internal
callus acting as a bobbin within, and the external callus acting as a
solder on the outside, give sufficient support and strength to effect a
final and absolute ossification of all the interfragmentary granulation
tissue. When the time comes when callus is no longer necessary it
begins to disappear by absorption. When everything proceeds normally
callus is absorbed in a proportion commensurate with its loss of
utility. When bone ends have badly united considerable callus remains
permanently. When apposition has been ideal it almost completely
disappears, even the medullary cavity being restored.

Fragments which are completely detached may be reunited by practically
the same primary process, but fragments of considerable size usually
become surrounded by granulation tissue, by which they are nourished
and may be finally reunited, with more or less departure from their
original shape and location. It is in this way that a comminuted
fracture may heal. Fragments that are separated sometimes necrose and
have to be removed.

[Illustration: FIG. 278

FIG. 279

Compound fractures resulting from arm being caught in belting and wound
around shafting. End of radius united to ulna and lower end of ulna to
the radial fragment. Pseudarthrosis of humerus, thrice operated, the
third time in the Buffalo Clinic. (Skiagram by Dr. Plummer.) (Arch.
Phys. Therap., May, 1905.)]

The repair of the flat bones is effected by a similar process, which
is referred to as callus formation. In the skull it is brought about
chiefly through the agency of the diploë, whose powers in this
direction are somewhat limited. Cancellous bone tissue usually throws
out but little callus. Its repair occurs from within. _Cartilage_
heals by a very similar process, though it is not now ossific tissue
but _fibrous_ which reunites the fractured surfaces. Instances of both
kinds can be seen when a fracture has crossed a joint surface.

In a compound fracture much will depend upon the existence or absence
of septic complications. In a clean wound, whence blood and fluid
may have escaped, there will be little but granulation tissue.
Should this wound suppurate the exposed bone surfaces will undergo
at least a superficial necrosis, necrotic particles being removed
by the same granulation tissue which will later bind the bone ends
together. Here, too, the internal callus plays the largest role in the
process of repair. The bone tissue first formed is always coarse and
soft. Complete calcification and restoration of original density and
vascularity occur slowly. Neither cartilage nor bloodvessels alone
appear capable of forming bone; the latter is produced only under the
influence of the _osteoblasts, which penetrate from the periosteum and
the bone itself_ along the course of the bloodvessels.

The process is one of conversion of blood clot into provisional callus,
which then changes into granulation tissue or into cartilage, both of
these materials undergoing subsequent conversion into bone through the
medium of the osteoblasts and osteoclasts (or giant bone cells), the
neighboring bone itself undergoing a rarefying ostitis, to change back
into its original condition with the final changes of the callus.

Repair of intra-articular fractures has already been described as
influenced by the presence of synovial fluid and cartilage. The latter
does not proliferate, and the line of fracture usually appears as a
groove on its surface. At epiphyseal junctions union is usually rapid
and satisfactory, for the changes taking place at this point are in the
direct line of what is needed for repair.


DELAYED UNION; NON-UNION.

The above description refers to the process which is supposed to take
place in normal bone repair. When, however, this is disturbed, as it
may be from a variety of causes, there may be _delayed union_; when it
completely fails we have _non-union_. General conditions have bearing
on these local failures. Whatever makes a strain upon the system may
interrupt the process, _e. g._, pregnancy, lactation, exhausting
hemorrhages, acute diseases, starvation. Again, failure may result from
purely local conditions, such as marked displacement, and particularly
the intervention of some of the soft tissues, or any foreign body.
_Suppuration_ will also frequently cause great disappointment. The
humerus is the bone most often troublesome in this direction; next
the bones of the leg, the femur, and the bones of the forearm. It is
necessary to distinguish between delayed union and absolute non-union.
In the former normal processes may be simply retarded. _When thus
delayed they may be stimulated_ by rough handling, rubbing the bones
together, or by perforating the callus with the point of a drill, from
several directions. This method of drilling was introduced by Brainard,
of Chicago. The existence of syphilis has much to do with delay, and
should be combated by free use of antispecifics. Many patients will be
found to have _phosphaturia_, _i. e._, to be eliminating phosphates
which should go to repairing the bone. Such patients should be given
phosphoric acid, with some of the phosphates, preferably of calcium,
in order to make up for loss in this direction. Much can be done also
by massage, and by everything which stimulates nutrition and general
health (Fig. 280).

[Illustration: FIG. 280

Vicious union with great deformity after fracture, requiring extensive
operation. (Buffalo Clinic.)]

In _non-union_ efforts at repair are at a standstill; the bone ends
become rounded off, the marrow cavity is plugged on either side, while
in time the surrounding granulation or connective tissue undergoes
condensation, as well as organization, and a _capsule_ is formed in
which a certain amount of fluid resembling true synovia collects,
and thus is formed sometimes an almost perfect _pseudarthrosis or
false joint_, whose perfection as a joint must be admired, although
its presence is so deplored. The causes of non-union are now better
understood than formerly, and consist largely in the interposition
of fibrous and muscular tissues, that act as a barrier and keep the
granulation tissue or the callus on one side from coalescing with that
on the other.

_Treatment_ of these cases will vary with their causes. In _delayed
union_ patients should be encouraged to use the parts, thereby causing
greater activity, but in the presence of an actual _false joint_ no
method is of avail except that of actual exposure, by incision, with
removal of all intervening fibrous tissue, and freshening of the bone
surfaces by saw or chisel, the endeavor being to so shape them that
they may lie in contact, and then be so maintained, by some mechanical
expedient, such as a wire nail or suture, an ivory peg, a chromicized
tendon, a bone ring, a small metal brace fastened with screws, or by
any other expedient which may suggest itself to the ingenuity and
the means of the operator. There are, however, occasions when one
deliberately endeavors to secure a pseudarthrosis, as after ankylosis
of the shoulder-joint, if in making powerful effort to break up
adhesions the neck of the humerus should snap it would be better to
prevent union rather than favor it, as in this way something resembling
the original joint, so far as function is concerned, would be obtained.
At the hip, also, after such an accident, the same principles may be
adhered to or more deliberately secured by a subcutaneous osteotomy, as
is sometimes done for relief of deformity.

_Fibrous union_ implies such organization of granulation tissue as
converts it into simple fibrous or ligamentous tissue, the change
stopping here and not going on to formation of cartilage or bone.
There are three localities especially where fibrous union is sometimes
the best that can be obtained and often proves sufficient of itself;
these are the olecranon, the patella, and the neck of the femur.
Even though the halves of the patella be separated by two inches of
ligamentous tissue the patient may still have reasonable use of the
limb. A separation of half an inch to one inch at the olecranon does
not materially disable the arm, while at the hip-joint two or three
inches of ligamentous tissue between the main end of the bone and the
fragment will not totally interfere with locomotion, except so far as
it permits an equivalent amount of shortening of the leg. There are,
then, occasions especially when the hip is involved in elderly and
decrepit people, when ligamentous union is the best that can be hoped
for or attained.


TREATMENT OF FRACTURES.

In principle the treatment of fractures is very simple. It consists
in _putting the parts in apposition and maintaining them there_ for
sufficient time to permit of complete repair. That which is so simple
in theory is often very difficult and sometimes even impossible in
practice, made so by the nature of the injury or the disposition of the
patient. In the aged, who cannot lie long in one position for fear of
pulmonary stasis; also in the insane, in the epileptic, and in those
suffering from delirium tremens, will be met difficulties which are
insuperable. In such instances the first indication is to preserve the
life of the patient, the second is to get a good result, the third
is to do the best we can. Good management is not the least important
feature of such treatment. This will include suitable nutrition,
provision for elimination, prevention of bed-sores or pressure-sores,
and many other less important features.

Diagnosis having been made, the surgeon should study how he may best
carry out the fundamental principle of putting the parts in apposition
and so maintaining them.

The greatest obstacle to reduction and maintenance in position is
_muscle pull_. After an injury of this kind there will be more or less
muscle spasm, the more powerful groups displacing bones in the natural
direction of their pull. In the humerus and femur especially all arm
or thigh muscles will coöperate to produce shortening. As indicated
in the chapter on Joint Affections, nothing so thoroughly overcomes
chronic muscle spasm as _traction_. The principle underlying treatment
by traction is exceedingly simple, but there are numerous ways and
mechanical expedients for effecting it. In the lower limb, whether this
shall be done by anterior suspension, by weight and pulley, by elastic
contraction, or by some of the more complicated splints, matters little
so long as it be efficiently made. Of all these methods it may be said
in general the simplest is the best. In the upper extremity traction
may be made by similar methods with the patient in bed, or the patient
may be allowed to rise and be about with a weight hanging from the
elbow or some simple expedient of this kind.

The method of traction is one to be combined usually with further
protection, by which not only longitudinal but lateral displacement
maybe overcome. This suggests the use of _splints_ in addition to mere
traction methods.

It is not always possible to put in operation at first that method
which we may prefer a little later, as _swelling_ is usually so
pronounced as to make it advisable only to put the parts at rest and
hasten absorption. The same is true of hemorrhage. In rarer instances
it may be a question as to whether the distal parts may undergo
gangrene from the disturbance of circulation. These are matters to be
duly regarded before the later and more complete dressing. _Mechanical
aids_, usually in the shape of splints, are therefore necessary. The
physiological rest which it is so necessary to ensure will lead to a
certain wasting of muscles and stiffening of joints, which are only
temporary, but which by no means lessen disability when splints are
removed. _That splint is best for a given case which best fits it and
permits the surgeon to carry out its peculiar indications._ The writer
is opposed to manufactured splints, as they seldom fit the part. This
can be obviated by packing cotton or other compressible material into
the splint. For temporary purposes they will frequently suffice. For
fixed dressing, however, it is preferable to make a splint which shall
fit the limb to which it is affixed. Immobilization is difficult of
accomplishment and at many points impossible. Thus in fracture of the
ribs or clavicle it is impossible to avoid a certain amount of motion
with each respiratory effort, even though an uncomfortably tight
dressing be applied.

Splints are made of various materials, metal, wood, various
compositions hardened in molds, plaster of Paris, or some of its
substitutes, _i. e._, glue, soluble glass, or a composition like one
made of equal parts of powdered starch and fine isinglass, added to a
solution of potassium silicate, this being allowed to stand for several
days, after which a little fine boric acid powder is added; when this
is painted over gauze dressings it solidifies and forms a light and
rigid splint. There is one objection to all methods which comprise a
solution that hardens slowly--that is, that during the time required
for the purpose redisplacement may occur. It is not advisable to dress
a recent fracture in a wet pasteboard splint or in such a composition
as that mentioned above. Later, when a certain amount of consolidation
has already occurred they may serve a useful purpose.[38]

  [38] Jenkins’ packing, such as is used on some engines, has been
  recommended by Spotswood as a substitute for plaster-of-Paris
  bandages, its advantages being that it is not affected by any
  antiseptic washes as a plaster dressing would be, that it is lighter,
  and that by placing it in hot water it can be molded to assume the
  shape of the limb.

There are two methods of using plaster of Paris: one is gauze bandages
sprinkled with it, rolled, and kept ready for use, to be placed in
water at the time of their employment. A limb may be enveloped in
these, after being covered with a layer of wadding or some other
protective material, by which the plaster shall not come in actual
contact with the skin. It is also a good plan to place a strip of tin
or pasteboard along the exposed surface of the limb, over which the
surgeon cuts to remove the splint. Thus one may avoid any danger of
injuring the skin with the point of the knife. It is also a good plan
to make at least a part of this cut before the plaster has sufficiently
hardened, _i. e._, to do most of the work, leaving perhaps a layer or
two of gauze to be cut through some time later. It is necessary to
impress the fact that when a quickly hardening fixed dressing is used
approximation should be ensured by the greatest attention, maintaining
it until the splint is so hardened that redislocation is impossible.
Another method of using plaster of Paris is by sopping strips of
surgeons’ lint, ordinary canton flannel, or almost any other similar
material, in plaster-of-Paris cream, then molding these to the injured
limb, maintaining the same rigid precaution as to the proper position
of the same while the splint hardens. In this way a splint can be
adapted to the part, and, at the same time, made removable, permitting
as frequent access to it as may be desired.


COMPOUND FRACTURES AND THEIR TREATMENT.

As already stated, it is the communication of fractured bone surfaces
with the external air which makes a fracture compound in the strictly
surgical sense. This may occur through a minute and tortuous opening
or through a large and extensive wound. Although the communication is
with the atmosphere the danger comes not so much from germs floating
in the air as from those on the surface of the body and within the
pores of the skin, or else from foreign material admitted through the
external wound. Obviously the great danger is of septic infection.
Whether the tissues may prove more or less susceptible, and thus
resist or break down, cannot at the outset be foretold. This leaves
but one imperative ride to follow, _to act in every instance as though
serious injection had occurred and to take precautions accordingly_.
Even a small puncture made by a spicule of bone may permit germs to
be withdrawn into the tissues as the bone is replaced. If, then, the
surgeon seals such a puncture he necessarily takes the chances and must
abide the result. Whether he shall do this or not will depend upon the
patient and the injury. At all events, the site of puncture should be
carefully cleansed and disinfected and the case so dressed that it
may be carefully watched. Complete sterilization of every particle of
exposed tissue is absolutely necessary, and for this purpose hydrogen
dioxide or some of its later substitutes will prove effective. A
protruding splinter of bone should be removed with cutting forceps,
unless the wound must be enlarged as a part of the treatment of the
fracture. In most instances it will be safer to pursue this course,
_i. e._, to extend the wound which makes the fracture compound, to a
degree permitting thorough exploration and cleansing. Not infrequently
fragments of bone will be found, which when nearly or completely
detached should be removed. Such a free opening permits also of wiring,
or other means of fastening together bone ends, by which apposition may
be more perfectly secured. _A compound fracture which has been long
unattended may be safely assumed to be septic._ Here free incision,
with cleansing and ample drainage, will be a far safer course than
non-compliance with the general rule.

_Compound fractures of the skull_ are nearly always depressed
fractures, and practically always call for operation. Their proper
treatment will be dealt with when considering Injuries to the Head. A
fracture of the ribs may be made compound by penetration of a sharp
bone end, and such injury to the lung as may permit air to escape into
the pleural cavity. Such a pneumothorax may be followed by a hemothorax
and hydrothorax, and these perhaps by empyema. Compound fractures of
the pelvis are not infrequently complicated by perforation of the
bladder or bowel, or rupture of the urethra, or some other serious
visceral injury which may determine their fate. Compound fractures
are difficult of treatment because they entail frequent changes of
dressing and prevent the use of desirable splints. These fractures
are also sometimes so serious as to necessitate amputation, which may
be necessitated either by such comminution of bone as to make repair
impossible, or such injury to vessels as may determine gangrene. If
the circulation can be shown to be sufficient, either at the time or
perhaps by delay of a few hours or a day, a limb may be saved by the
resection of one or both bones, which in pre-antiseptic days would have
required amputation.

The surgeon does not always see these cases in their recent or
fresh state. He may be called to a case complicated by suppuration,
cellulitis, and sepsis. Here though amputation may be required he may
still delay it, hoping to improve local conditions, and thus to make it
more promising, or he may have to resort to various expedients, such as
suspension with constant irrigation, or temporary packing with yeast,
in order to justify any further attack upon the parts already involved.

In the treatment of compound as of simple fractures we should never
lose sight of the _dangers of too tight bandaging and of pressure
sores_. I have seen both these lead to gangrene, with its necessary
mutilation, in cases where the attendant has forgotten the proneness of
injured parts to swell, and has either not allowed for this within the
dressings or has not atoned for it in time when it has already occurred.

In the treatment of all these cases the operator should never forget
the medicolegal aspects of such a case nor the necessity for constant
attention and caution on his part. He should remember that his minutest
precautions will often be disobeyed. He may, however, be cheered
by the fact that only in cases of carelessness will he incur legal
responsibility.


SPECIAL FRACTURES.

Fractures of the skull and of the vertebræ will be considered under the
respective headings of Injuries to the Head and to the Spine.


FRACTURES OF THE NOSE.

The nose is the most frequently broken of all the bony parts about the
face. One nasal bone or both may be broken, and each may be separated
from its bony supports as well as from the other. The fracture may be
compound in either direction, most frequently so into the nasal cavity,
as a result of which infection may as easily take place from within as
from without. The cartilages may also participate in the injury.

The injury would be easy of recognition were it not for the amount
of swelling that often accompanies it. The signs are mobility and
crepitus, with more or less deformity. So long as the nose can be
grasped between the fingers recognition of fracture is easy. If
swelling prevents this an instrument or the finger can be passed into
one nostril and combined manipulation practised. There is generally
more or less bleeding from the nose, and sometimes considerable
emphysema. Swelling and ecchymosis are also often pronounced. This
will all subside under cool and soothing applications. The most
important indication is to replace the nose and hold it where it should
remain. The difficulty is increased by the efforts which the patient
instinctively makes to dislodge clot or secretion. The importance
of accurate reposition is in some cases sufficient to justify an
anesthetic and instrumental help. This will permit of the application
of such force as may be necessary to elevate or to shift fragments,
while a gutta-percha splint may be molded upon the outside, or a
sterilized pin or needle made to transfix the nose from one side to
the other (Mason), passing behind the fragments and through the septum
in such a way as to keep it from dropping backward. A good plan is to
introduce a tube into each nostril, perhaps a piece of silk catheter,
around which a certain amount of gauze can be packed, and which can
thus be used as an internal splint, while on either side and externally
a little roll of gauze is held in place by adhesive plaster crossing
the cheeks. The operator should take as much pains to see that the
septum is in its original position as in attending to outside and
cosmetic effects. The septum can be controlled by a pair of forceps.

A nose properly held in place will heal within a few days, to a point
requiring little if any support. A transfixion pin should not be
needed, if used, for more than four or five days. An internal splint
should be removed each day, so that the nose may be sprayed with
cleansing solution (Dobell’s) and retained secretions removed.

The disfigurement resulting after this injury is dropping in at the
root of the nose, constituting the so-called _saddle-nose_ defect.
Such disfigurement as results can be later atoned for by subcutaneous
injection of paraffin. (See chapter on Surgery of the Face.)


FRACTURES OF THE SUPERIOR MAXILLA, WITH OR WITHOUT OTHER BONES OF THE
FACE.

The more protected portions of the upper jaw are rarely fractured,
save by extreme violence. The _alveolar process_, with one or several
teeth, may be partially or completely detached. Such fractures are
compound, and after replacement need antiseptic mouth-washes as well as
other attention. Usually the teeth in the fragment can be utilized for
the purpose of fastening it back into place by means of the uninjured
teeth, retention being secured by wire or waxed silk. Extensive
detachment may necessitate sutures through drill holes. The lower jaw
can usually be utilized as a splint for the upper by binding the jaws
firmly together and feeding the patient on fluid food. When one or two
teeth are loosened or displaced it will often be possible, if they
can be promptly secured, to successfully _reimplant_ them in their
sockets. Both the sockets and the teeth should be thoroughly cleansed.
After replacement it will be necessary only to ensure absolute rest and
retention in position.

In regard to other _facial bones_ there is no injury which may not
occur, as the result of direct violence. The _zygoma_ and the _malar
bone_ may be broken away, or the entire collection of facial bones may
be loosened from their connection with the bones of the skull proper.
The margins of the _orbit_, or its walls, may also be injured, and the
sinuses opened, with perhaps more or less entrance of foreign material.
These fractures are generally compound and are accompanied sometimes by
injuries to the soft tissues. It becomes then a question not merely of
cosmetic result, but of avoiding infection and saving life. The latter
is the more important, and measures should first be directed to that
object. Satisfactory results can be attained by drilling and holding
bone fragments together with tendon or other sutures, and by neatly
trimming and cleaning wounded surfaces and bringing them together.
Subcutaneous sutures should be used for this purpose.


FRACTURES OF THE INFERIOR MAXILLA.

This bone is broken nearly as often as the nose, and almost invariably
by direct violence. Here, as in the upper jaw, there may be trifling or
serious fractures of the _alveolar process_, which should be treated
on the same principle as above set forth. Fractures of the rami occur
more often in those parts which are occupied by teeth, or from which
teeth have dropped out by senile changes, the jaw being weakened at
these locations. The most frequent seat of fracture is near the middle
line. Fractures of the _ascending ramus_ and of the upper processes
are rare. Double fractures are not infrequent, the lines of separation
being rarely symmetrical. The gum and the skin are often torn and the
majority of these fractures are compound. The bone is considered to
be weakened at the dental foramen; at all events it often yields in
this vicinity. By fracture with much displacement posterior to this
opening the inferior dental nerve may be injured or torn. The condyle,
after extreme violence, has been known to have been driven up into the
cranial cavity through the base of the skull. _Gunshot fractures_ are
nearly always comminuted (Figs. 281, 282 and 283).

[Illustration: FIG. 281

Use of silver wire in fixation of fragments by utilizing the teeth.]

[Illustration: FIG. 282

FIG. 283

Bandage and splint for fracture of lower jaw. (Bryant.)]

The _signs_ of fracture of the lower jaw are unnatural mobility,
crepitus, displacement, pain, and loss of function. No bone in the
body is more easily investigated by sight and touch, and recognition
of these fractures is usually easy. Pain is provoked by attempting to
move the jaw, even in talking, and depends on the extent to which the
inferior dental nerve is injured. Irregularity in the line of the teeth
will sometimes permit recognition. These fractures furnish excellent
illustrations of the effect of muscles in producing displacement. Those
of the tongue and the floor of the mouth, as well as the anterior
muscles of the neck, will pull the fragments in various directions,
according to the direction of the line of fracture and its location.
This displacement may be trifling or serious. These fractures are
often compound, internally or externally, such injuries constituting
an unpleasant complication, but affording occasionally an opportunity
for fastening fragments by drill or wire suture, which would
otherwise require an opening to be made. In every instance antiseptic
mouth-washes should be frequently used.


=Treatment.=--The treatment is simplified when the dentition is good
and regular so that the fragments may be fastened together with wire
or waxed silk ligature around the adjoining teeth, and then fixation
accomplished with a simple molded gutta-percha or plaster-of-Paris
splint, by which the lower jaw is held firmly against the upper. Such
a dressing is held in position by a four-tailed bandage (Fig. 283). A
silk or wire loop, used for the purpose just mentioned, should include
two teeth on either side of the fracture, for by constant tension the
nearest tooth will soon loosen, and if this were next to the break
the effect of such displacement would be injurious (Fig. 281). When
the line of fracture is oblique there is often greater difficulty in
adjustment.

While the simplest means by which the fragments may be kept in position
are the best, there should be no hesitation in serious cases to resort
to operative measures having for their purpose the insertion of wire
sutures or their equivalent. These are inserted after drilling the bone
at suitable points, and are introduced with a view to their subsequent
removal, the ends being left projecting in order to facilitate this. In
clean cases, where the incision is made in unbroken skin, the ends may
be twisted short and turned in, previously to closing the wound. Such
operative treatment is required when there has been a double fracture,
the central fragment being badly displaced by groups of muscles which
tend to pull it downward and backward.

A dentist should be consulted, as he may be able to make a mold and
then construct a plate or _interdental_ splint, by which a more perfect
reposition may be effected.

Swelling, emphysema, ecchymosis, etc., may be treated in the usual way.
Irritation is likely to provoke free secretion of saliva; this may be
combated by small doses of belladonna. Patients should be fed by fluid
or thin semifluid food, and mouth-washes should be frequently used.


FRACTURES OF THE HYOID BONE.

The hyoid may be broken by direct violence, either locally applied or
by forcing the head backward. Fracture of the bone itself is not so
serious as the lesions which accompany or follow it, either hemorrhage
or inflammation, with _edema of the larynx_, which may impede
respiration or cause strangulation. Fracture produces difficulty in
breathing, swelling, and pain on talking. It is doubtful if bony union
is attained, but fibrous union answers equally well. The treatment
consists essentially of physiological rest. Edema may necessitate
tracheotomy, and dysphagia feeding by an esophageal tube or by the
rectum. Should the fracture be compound, or should a fragment be
displaced so as to be detected, it may be removed through suitable
incision.


FRACTURES OF THE LARYNX.

This may be fractured by injuries of the same character as those which
fracture the hyoid, except that it is more exposed to the direct
violence of a blow, as from a baseball. In elderly people in whom
calcification of the laryngeal cartilages has occurred fracture is
more dangerous than in the young. Injuries which produce these lesions
are of a serious nature, as prompt swelling, either from hemorrhage
or edema, occurs and threatens respiration. For illustration a death
occurred on the baseball field within a few minutes after reception of
a blow upon the front of the neck with laryngeal fracture; the cause of
death was suffocation due to swelling, which might have been averted if
tracheotomy could have been performed. In the milder injuries of this
kind much can be done with sprays of cocaine and adrenalin, to quiet
laryngeal irritation and reduce vascularity.


FRACTURES OF THE STERNUM AND RIBS.

Fracture of the _sternum_ in childhood is exceedingly rare. In adults
it may occur in connection with other injuries or as a solitary lesion.
Such a fracture, of itself, would indicate in most cases excessive
violence. It is usually more or less transverse, the periosteum being
rarely so torn as to permit of much escape of blood. Cases are recorded
in which it has been broken in straining during the act of parturition.
It is most commonly injured by compressing and crushing injuries.

Sternal fractures are followed by much pain, aggravated by deep
respiration and made worse by pressure. Sometimes displacement can
be made out, while crepitus may be detected with the stethoscope.
Occasionally there is sufficient deformity to make the injury apparent
at a glance.

Displacement should be reduced and apposition then maintained by a
plaster-of-Paris jacket or other suitable apparatus. It is advisable in
some cases to anesthetize the patient and to make a sufficient opening
that instruments may be used by which fragments may be lifted or pried
into place. This should be done under aseptic precautions.

_Diastases or separations of ribs or cartilages_ from the sternum
or from each other have essentially the dignity of fractures, are
recognized by the same general signs, and are treated in the same
general way. A cartilage may snap in the young, and in the old, when
calcified, may break as would a bone or even a pipe-stem.

_The ribs_ are usually broken in their lateral aspects, but rarely
between the head and angle. They may be fractured by muscle action or
by external violence, examples of the former being violent efforts at
lifting or sneezing. Violence may be applied in so many ways that it
is not necessary to specify them. Fractures may pertain to one or to
several ribs in proportion to the extent and violence of the exciting
injury. In some crushing injuries an entire section of the chest wall
may be broken loose and depressed, this corresponding to a depressed
fracture of the skull. Rib fractures are usually of themselves
innocent, but may be made serious by _complications_, as when the
pleura is torn, or an intercostal artery bleeds profusely, or when a
jagged fragment of bone first scratches and then perforates a lung.
This will lead first to the outpour of blood and then of pleuritic
fluid, by which in a short time the lung will be separated from the
chest wall. Should infection occur through the injured lung, _i. e._,
entrance of germ-ladened air, then empyema may seriously complicate
matters and later necessitate operation. Even the heart has been
injured, in several reported cases, by projecting fragments of bone.
Gunshot fractures of the thoracic wall imply those features pertaining
to every compound fracture, plus the injury possibly done to the lungs,
heart, or mediastinal contents, such as hemothorax or pneumothorax.

The first and second ribs are so protected and the eleventh and twelfth
so movable that by far the greater proportion of rib fractures pertain
to the eight intervening ribs.


=Symptoms.=--These are often vague, when but a single rib has been
cracked through and not displaced, and comprise pain on pressure,
as well as that provoked by deep breathing, coughing, and certain
other movements. Should this pain be limited, or constant and
made worse by pressure, fracture of the rib may be suspected. If
auscultation crepitus can be heard, diagnosis is at once made. When
abnormal mobility is unmistakable, or when by any means crepitus is
elicited, the signs are positive. Sometimes the patient himself will
recognize crepitus. This may be learned either by auscultation or by
pressure with the flat hand over the affected area. _Emphysema_ is an
unmistakable evidence of fracture with perforation, while the signs of
the presence of fluid in the chest cavity will also indicate fracture.


=Treatment.=--Fracture of one or two ribs with displacement is
ordinarily a matter of trivial import, the adjoining ribs acting as
splints. It necessitates practically nothing but physiological rest,
which may be best afforded by keeping the patient in bed, with _firm
compression_ around the chest, made either with a binder of strong
cloth or a broad piece of adhesive plaster carried nearly around the
body, or in more aggravated cases by a plaster-of-Paris jacket. In thin
individuals the formation of callus can be recognized by the sense of
touch. So soon as this is fairly formed displacement is less likely
to occur and uncomfortable compression may be relaxed. Should there
be external angular displacement this may be corrected by pressure. A
projecting fragment which threatens to perforate should be cut away
with bone forceps through a small incision, taking pains to permit as
little air as possible to enter. If there be a _traumatic pneumothorax_
the air should be removed with an aspirating needle. When it is evident
that there is serious injury to the chest wall and that air has already
separated the lung from it (traumatic atelectasis) the parts should be
freely exposed, to permit the rounding off of bone ends, the seizure
of intercostal vessels, the cleansing out of the pleural cavity, with
perhaps later wiring of fragments or else their complete removal and
closure of the external wound with or without drainage, as may be
required. If blood or air has already escaped into the pleural cavity
the blood should be speedily removed. The same plan is advisable
in fractures of the cartilages. Sedatives to check cough, _e. g._,
heroine, are also indicated.


FRACTURES OF THE CLAVICLE.

The clavicle and the radius are the two bones most frequently broken,
the former more often in the young, the latter in the elderly; the
clavicle yields both to direct violence, as by blows on the shoulder,
and that which is transmitted through the arm from the elbow or hand.
For convenience of description the bone is divided into thirds, the
most common location for fracture being near the junction of the middle
and outer third. Save for epiphyseal separations the extremities of the
bone are seldom broken. In spite of its subcutaneous position and its
proximity to large vessels, compound injuries or other complications
are quite uncommon.

The clavicle is the brace which keeps the shoulder proper from falling
upon and around the thorax. _Consequently when it is broken the
shoulder tends to drop downward, forward, and inward_, except in a
green-stick fracture, while even then there may be some displacement in
these directions. Deformity is usually easily recognized, one or other
fragment projecting beneath the skin in such a way as to be easily
palpated. There is enough spasm of cervical muscles to draw the head
over toward the affected side, while there is loss of function in the
affected arm. Pain is made worse by pressing the shoulder inward as
well as by moving it in any direction.

In young children the bone is often broken with a minimum of
displacement. Fracture of both clavicles is not so very rare. Trouble
may occur later in the course of the case from pressure of exuberant
callus upon nerves and even vessels. This is to be prevented by
foresight and by careful attention to maintenance of parts in proper
position.


=Treatment.=--The multiplicity of dressings which have been suggested
for fractures of the clavicle attest the fact that so long as primary
indications are observed the treatment can be made very simple. These
indications are to _keep the shoulder upward, outward, and backward_,
as it tends to drop in the opposite way. The action of three muscles is
of great importance in considering the proper treatment of these cases,
_i. e._, the sternomastoid and the trapezius, because they tend to pull
fragments upward, and the pectoralis major because advantage can be
taken of its arrangement to overcome upward displacement. It was Moore,
of Rochester, who taught many years in Buffalo, who showed how this
could be done. The fibers of the great pectoral which arise highest,
_i. e._, from the clavicle, are those which are inserted lowest along
the bicipital groove of the humerus, because of the semi-revolution
made by the tendon of this muscle as it passes to its insertion. By
putting the arm in such a position that these fibers are pulled upon
the operator may counteract the upward pull of the other muscles just
mentioned. This is the underlying feature of Moore’s suggestion; to
force the elbow far backward, into a position which is for the time
being uncomfortable, in order thus to pull down fragments which jut
up beneath the skin. Any dressing which permits this position to be
maintained will be equally serviceable. Moore suggests for this purpose
what he calls a double figure-of-eight, which is shown in Figs. 284 and
285. It is put on as follows: A strip of cloth, sheeting, or anything
of the kind, about two yards in length and folded sufficiently to make
a strong strip eight inches wide, is held near its middle over the
surgeon’s hand. This hand is placed beneath the elbow of the injured
side, so that the strip crosses the under surface of the flexed forearm
at the elbow. One end, which should be the longer, lying to the inner
side, is passed upward and in front of the arm, carried over the
shoulder across the back and under the opposite axilla, then over in
front of the sound shoulder, meeting on the back the other end, which
is carried up first over the outside of the forearm, then behind the
shoulder and across the spine. This bandage should be pulled tightly,
while an assistant holds the elbow as far backward and upward as the
patient can tolerate it, as the more the position is exaggerated the
more are the clavicular fibers of the muscle pulled upon and the
better are the fragments held in place. This dressing not only meets
the three primary indications laid down, but gives the added advantage
just described. By it the shoulders are drawn backward and fixed to
each other. The _elbow should be lifted_ as the dressing is applied, so
as to lift the shoulder. Most of the cloth materials used for such a
dressing are more or less elastic, and it may need to be tightened once
or twice a day during the time that it is worn. After a few days, when
consolidation should have occurred, it may be changed for some other
less irksome form of dressing. The hand should be supported in a sling.
This dressing is useful in dislocations of the clavicle, especially of
its outer end, and in every kind of injury in which the indication
is to hold the shoulder upward and backward. In simple cases without
much displacement the primary indications may be more simply met by a
dressing of adhesive plaster, known in the East as Sayre’s and in the
West as Freer’s. It consists of two strips of plaster of about the
width of the arm itself. One of them is wound around the upper end of
the arm, close to the shoulder, in such a way that, as it is passed
around the back and brought over the chest, the arm and shoulder are
pulled backward. The other strip passes from beneath the elbow of the
injured side obliquely up and over the opposite shoulder. When it is
applied the elbow should be _firmly lifted_. After the completion of
either of these dressings the injured shoulder should appear at least
one inch higher than the well one. Should the patient’s arm and chest
be hairy they should be shaved before the application of the plaster
strips. Like other material, plaster will stretch and slip, and these,
like other dressings, should be readjusted every day or two, _for the
shoulder should be kept elevated for at least a week_.

[Illustration: FIG. 284

Moore’s apparatus (back view).]

[Illustration: FIG. 285

Moore’s apparatus (front view).]

When the case is complicated by other injuries necessitating
confinement in bed it is sufficient to keep the patient flat upon
the back and without a pillow. In this position the shoulder falls
naturally in the direction desired, and perhaps no other attention will
be required. Many other methods are combined with a figure-of-eight
bandage, crossing the back and forming a loop over each shoulder, so as
to keep it from dropping forward.

While the results of treatment are nearly always good, if one is
insistent upon a minimum of deformity, confinement upon the back on
a hard bed is the surest way to obtain satisfactory results. Cases
in which there is little or no tendency to deformity need only the
simplest support by which rest may be ensured.

Epiphyseal separations are to be treated as fractures.


FRACTURES OF THE SCAPULA.

The most frequent fracture of the scapula is that of the _acromion_;
this is usually the result of direct violence, such as a fall upon the
tip of the shoulder. Detachment of this fragment permits a peculiar
flattening of the shoulder, but without dislocation. The fragment
can be easily felt, while the deltoid is displaced and its rounded
contour lost. Treatment consists solely in _forcing the arm upward_, by
dressings applied beneath the elbow, thus lifting the fragment into its
place; fibrous union occurring here much more often than osseous, the
latter is possible only in case a good apposition be maintained. Any
form of dressing, then, by which the elbow is crowded upward and rest
maintained will be appropriate.

The _surgical neck_ is occasionally detached, sometimes with and
sometimes without the coracoid process. As the humerus is attached
to it by the capsular ligament the arm drops with the fragment when
the patient is in the upright position, and the elbow will be found
lower than that of the injured side. The arm is unduly mobile, and the
fragment can usually be seized and crepitus obtained within the axilla.
Here it is necessary to hold the arm up, as it controls the position of
the fragment. It is usually sufficient to lift the elbow up and bind
the arm firmly to the side, the scapula being immobilized by broad
straps of adhesive plaster.

The _coracoid process_ is occasionally detached, usually by muscular
violence, _i. e._, it is pulled off by the coracobrachialis and
the coracoid head of the biceps which arise from it. The injury is
recognized by failure to detect the process in its proper place, and
usually by discovery of the fragment at a point below its normal
position, to which it has been drawn out by the muscles arising from
it. Ligamentous union can be secured by relaxing these muscles, which
is done by placing the hand over the opposite shoulder and dressing the
arm firmly against the chest. I have seen paralysis of the arm result
from excessive callus after fracture of the coracoid.

The _spine_, _body_, and the _angles_ of the scapula are occasionally
broken by severe violence. In the aged comminution may occur. Crepitus
can be nearly always obtained. It may be necessary to distinguish
the scapular fracture from one of the ribs beneath it. The treatment
consists in simply fixing the shoulder-blade upon the chest, to which
it is naturally adapted, by firm bandages, which shall immobilize not
only it but the arm as well.


FRACTURES OF THE HUMERUS.

At the _upper end_ of the humerus we deal with fracture of the
processes, _i. e._, the _tuberosities_, which may be torn off by
violent action of the muscles therein inserted; of the _anatomical
neck_, which is rare and occurs most often in the aged; of the
_surgical neck_, which is the most common; or, in the young,
_epiphyseal separation_, which is the equivalent of the last named.
Separation of the tuberosities is diagnosticated mainly by exclusion,
possibly by _x_-rays. The _anatomical neck_ lies within the capsule,
and should the head be thus detached it might remain as a foreign body
in the joint, having no means of securing nutrition. Fractures of
the _head of the bone_ are not classical and are usually the result
of gunshot injuries or extreme violence. In all of these injuries
there will be swelling, loss of function, while crepitus is sometimes
obtained, but is very difficult to locate, even under an anesthetic.
The diagnosis is to be made mostly by exclusion.

The _surgical neck_ is the most frequently broken; the line of fracture
passing below the tuberosities and above the muscles inserted along the
bicipital groove. Therefore the pectoralis and the latissimus muscles
will both conspire to pull the upper end of the shaft toward the thorax
to such an extent that it can be felt in the axilla. This gives its
axis a different direction, while all the muscles extending from the
shoulder to the forearm will tend to produce shortening. Deformity
is usually distinct, crepitus is easily obtained, and undue mobility
is well marked. The head of the bone can be detected in its proper
place beneath the deltoid, but does not rotate with the shaft. In rare
instances a certain amount of impaction may make this evidence of
fracture obscure. _Epiphyseal separation_ will give the same signs and
symptoms.


=Treatment.=--The primary indication here is to overcome muscle pull
by traction in a direction toward the crest of the pelvis of the same
side. At the same time, with a certain degree of coaxing of the upper
end of the shaft outward and a little forward, it may be possible to
so re-apply broken surfaces to each other, and so affix the arm to
the thorax, as to be effective. When serious difficulty, however, is
encountered the writer advises traction, applied to the arm alone, if
the patient be able to be upright, or to the arm and forearm, if he be
confined in bed. It will take considerable stretching to overcome the
combined action of all the muscles which tend to produce displacement.
Along with such treatment a coaptation splint should be applied, the
best being that which can be carefully molded to the parts and adapted
to their needs. For this purpose a molded plaster-of-Paris splint is
preferable to one of metal made to some standard size. In the dressing
it is necessary to include not only the shoulder and arm but also the
forearm, otherwise the principle of physiological rest would not be
enforced. Fig. 286 illustrates the common tendency to displacement in
these injuries.

_Fracture_ of the surgical neck is occasionally combined with
_dislocation_ of the head of the humerus, by which such an injury is
seriously complicated. Reduction may be attempted by manipulation.
Until recently it was generally advised to wait for a week or ten days,
and until consolidation had occurred, and then to make the attempt at
reduction; but Porter and McBurney have shown that it is advisable
to cut down upon the dislocated upper fragment, and, fixing it with
forceps or with an instrument shaped like a corkscrew or hook, to
force it back into place again. If this be done under the strictest
precautions it lends no serious features to the case, while, in most
respects, such a procedure would greatly simplify it, the wound being
closed with or without drainage, and the usual fracture dressing being
applied.

In cases of _old fracture and dislocation_ the head of the bone should
be exsected, the functional result thus obtained being excellent.

_Epiphyseal separation has been too often mistaken for dislocation._
Fig. 287, from Moore, shows how the periosteum is not necessarily
entirely detached, but is stripped up to form a hinge, the fragment
displaced forward, and its outer aspect often turned upward. This
makes traction in an outward direction an essential feature of the
replacement of the fractured surfaces, the manipulation being combined
with fixation of the fragment so far as it can be seized through the
axilla. If the epiphysis is properly slipped over upon the end of the
humerus the case assumes ordinary features, and is to be dressed as
usual.

[Illustration: FIG. 286

Fracture of the surgical neck of humerus. (Hoffa.)]

[Illustration: FIG. 287

Separation of the upper epiphysis of the humerus; displacement forward
of the lower fragment. (Moore.)]

The shaft of the bone is frequently broken, lines of fracture
running in all directions and occurring at all levels. A variety of
displacement may take place. The evidences of fracture are usually
recognizable and diagnosis is not difficult. The brachial artery and
the musculospiral nerve are occasionally involved, either in callus
or by primary injury from a spicule of bone. These fractures are more
liable to delay in union or even to non-union than almost any others.
These occur often without evident cause, while more or less absorption
of bone has been known, by which complications are produced.

In the _treatment of fractures of the shaft_ posture is necessary to
observe, the fragments not only being held in position, but the axis
of the bone being maintained. An external splint, extending up to and
rounded over the shoulder, and an internal splint molded to the inner
side of the arm, taking in the elbow and forearm, and placed at a right
angle, and then the immobilization of the entire arm by its fixation to
the body will give the best result. The writer prefers to make these
of plaster of Paris, by molding strips of surgeons’ lint sopped in
plaster cream, and maintaining the limb in the desired position while
they harden. Should comminution be extreme, or shortening difficult
to overcome, a few days’ confinement in bed, with traction upon the
forearm, either extended or included in the above dressing, by the
usual method, with weight and pulley, will give the best result. So
soon as callus has bound the ends of the bone together the patient may
be released from bed and the arm left in the right-angle position, in
plaster, as above. Or over such a splint as has been described, made
of molded plaster, may be hung by a bandage at the elbow sufficient
weight (a bag containing shot) to maintain constant traction upon the
lower fragment, while the patient is in the upright position, and to
influence for good any overlapping or displacement of any kind during
the critical period when the bone ends are being united by callus.

The _epicondyles_ are occasionally chipped off from the condyles,
the internal being the more frequently injured. These detachments
are extra-articular and are relatively unimportant, the fragments
being kept from displacement by their fibrous investments. If such an
injury should be compound any fragment completely loosened should be
removed. It is sufficient to dress such an injured elbow with cold
wet compresses in the flexed position. _Supracondyloid_ fracture, or
its equivalent in the young (an _epiphyseal separation_) are somewhat
similar, the latter occurring nearer to the articulation than the
former. In each of these injuries the arm is flexed and shortened,
the fragment lying usually in front of the shaft and the olecranon
protruding posteriorly. The more the arm is extended the more prominent
the deformity, while by flexion it is much diminished. Hence the
advantage of dressing it in the position of overflexion sometimes
called Jones’ position.[39] Injury to the vessels at the bend of the
elbow may occur in these fractures. If not dressed in this position
the elbow should be put at a right angle, while a weight is slung over
the elbow, as already mentioned above. Joint function will be greatly
hampered if complete extension and reduction be not effected (Fig. 288).

  [39] In supracondyloid fractures there is almost always posterior and
  upper displacement of the lower fragment. When the parts are found
  in this position, and especially when the skiagram shows the line of
  fracture in the usual location (from above downward and forward), the
  fracture should be treated by flexion of the arm in the so-called
  Jones’ position. By this the fragment is best restored to its proper
  position, being pried there by the muscular cushions of the forearm
  and arm. (Ashhurst.)

[Illustration: FIG. 288

Supracondyloid fracture or epiphyseal separation. (Lejars.)]

In considering fractures about the elbow no greater aid can be obtained
than by a study of the relations of the three prominent or salient
anatomical points to each other. These are the internal and external
condyles and the tip of the olecranon. They afford a key to nearly
all the displacements which may be produced after fracture or even
dislocation, and the only conditions under which they cannot be made
available are those where there has been tremendous swelling before the
case is seen by the surgeon. A fourth prominent feature, the head of
the radius, is also of much assistance, but is less often available,
especially in muscular or swollen forearms. When a normal arm is
flexed to a right angle and viewed from behind the three points above
mentioned constitute the angles of a nearly equilateral triangle.
When seen from the side the point of the olecranon is just below the
external condyle and in the same plane; when the arm is completely
extended and viewed from behind these three points are practically in
the same line. By a careful study of the variations from the above
relations which are produced by injury diagnosis can be greatly
facilitated.

[Illustration: FIG. 289

T-fracture of humerus. (Helferich.)]

[Illustration: FIG. 290

T-shaped fracture of lower epiphysis of humerus.]

[Illustration: FIG. 291

Intracondyloid fracture of humerus. Almost perfect functional result.
(Parmenter.)]

[Illustration: FIG. 292

Gunstock deformity after fracture of internal condyle, illustrating
neglect of precautions mentioned in text. (Beatson.)]

The _condyles_ may each be broken loose by itself, or they may be _both
broken_ at the same time. Fig. 291 illustrates what is known sometimes
as a T-fracture, where the lower extremity is not only separated
from the shaft but is broken into halves; such fractures imply great
violence, and are particularly difficult to treat. Should the condyles
be detached in such a way as to leave the lower end of the humerus in
pointed wedge shape it may perforate or do much harm to the soft parts
(Fig. 290). In these _intercondyloid_ fractures the writer would advise
dressing in the extended position, with a molded plaster-of-Paris
anterior splint and a gentle degree of traction, the patient being
confined to bed for a few days. In applying such a splint the surgeon
should give extreme care to holding the fragments in proper position
while the splint hardens, and in preserving the “carrying function”
(Fig. 291). (See below.)

[Illustration: PLATE XXXIX

Supracondyloid Fracture. (Child, nine years old.) Union with deformity,
fragment so joined to lower end of shaft of humerus at an angle that
when forearm is completely flexed upon this fragment it yet is only at
right angle with the arm. Operation indicated. (X-ray picture.)]

The _external condyle_ when fractured is displaced by muscle pull;
when the _internal condyle_ is broken the tendency is to backward
displacement of the fragment and widening of the joint.

_Fracture of the internal condyle_ is often an exceedingly serious
matter, because it is so often associated with more or less dislocation
and with permanent deformity, as a result of inattention to the
anatomical relations of the bones. The ulna sustains peculiar relations
to the inner condyle; at its upper end it is wrapped around the
process, holding it much as a monkey-wrench can be made to seize an
ordinary object, and being held to it by the internal lateral ligament.
Herein lies the secret of success or failure in treatment, for the
fragment, being so fixed to the ulna, should be controlled by it, _i.
e._, the position of the ulna is the most essential feature of the
treatment of the fracture. The forearm makes an angle with the arm
proper, by which a considerable degree of divergence is maintained.
This has been alluded to by Allis and others as the “carrying
function.” It can _only be estimated in the extended position, and be
accurately judged by comparison with the other arm._ If the arm be
flexed all possibility of estimating it is lost; therefore to _dress
such a fracture in the right-angle position is bad practice_ (Fig.
292). The only position in which the carrying function can be preserved
is the extended, or one a little short of it for the purpose of
comfort. If the ulna is put in the proper position the fragment will be
held equally so or as nearly as possible (Fig. 294).

[Illustration: FIG. 293

Fracture of external condyle. (Lejars.)]

In the _treatment of fractures of the inner condyle_ the patient, if
a child, should be anesthetized, the upper part of the body exposed,
both arms extended, and the injured arm made to correspond exactly with
the other so far as concerns the angle of divergence. Upon the arm so
placed an anterior plaster-of-Paris molded splint should be carefully
applied, extending from axilla to wrist, and then lightly secured with
bandages, the surgeon holding the arm in the proper position _until
the plaster is sufficiently hardened to permit no displacement._ The
arm should be kept in this position for at least ten days, after which
the splint may be removed and gentle motion practised. It may then
be reapplied for two or three days, after which we may begin to flex
the arm, applying either a new plaster splint or any other that seems
suitable, and in such a way that at the expiration of another week the
forearm is brought to a comfortable position of right angle, where it
may be maintained with a light splint or simply with a sling, according
to the age and tractability of the patient. Fig. 294 illustrates the
splint and the position, which is the only one in which the surgeon
maintains his own security and can properly estimate the carrying
function. The mistake has been in dressing this fracture, like most
others at the elbow, in the right-angle position.

In _fractures of the outer condyle_ these anatomical conditions do
not prevail, and these may be dressed in whatever position best meets
the indications of comfort and accurate reduction. _Intercondyloid
fractures_ are subject to the same conditions as those of the
_internal condyle_, plus others which are added, and should therefore
be dressed in the _same position_.

[Illustration: FIG. 294

Molded plaster splint for entire arm, and especially for fractures of
the internal condyle, showing proper position for dressing same.]

_Epiphyseal separations_, as well as supracondyloid fractures, should
be dressed either with traction in a somewhat extended position, or in
that of extreme flexion, called also Jones’ position, according as the
fragments may best fall into place in one or the other.

[Illustration: FIG. 295

Molded plaster splint for arm.]

[Illustration: FIG. 296

Molded plaster splint for forearm.]

The writer has for his own purposes discarded almost all other splint
material for the upper extremity in favor of the plaster-of-Paris
splints already mentioned. Figs. 294, 295 and 296, may illustrate
the method and purpose of their use; many other modifications can be
devised as may be demanded. It is customary, after such a splint is
hard and firm, to remove it for a few moments, trim it, smooth the
edges, line it with a fresh piece of soft lint or its equivalent,
and then reapply it to the arm with a roller or starch bandage, the
arm meantime not having been disturbed, but maintained in its proper
position, and being restored to the splint and made to take its
previous position. Such a splint fits accurately the individual for
whom it is made. It is worthless for anyone else; nor should it ever
be used again, the _intent being to mold a splint for each case which
shall serve its individual purpose and none other_.

Too early passive motion with the intent to regain mobility is
inadvisable and often dangerous. A fractured joint should be kept at
rest until the bone is consolidated. If callus be thus reduced to the
minimum, and consolidation be undisturbed, the patient will, in due
time, recover motion, often to the extreme limit. In fractures of the
humerus five or six weeks are required for the attainment of perfect
union. In spite of precaution callus formation will sometimes be
excessive and interfere with motion. Absorption of exuberant material
then is most desirable. This can be encouraged by constant but gentle
pressure. Thus when callus in front of the lower articular surface of
the humerus obstructs the coronoid process of the ulna and prevents
complete flexion the patient should wear for several hours at a time an
elastic sling, made with a piece of Martin rubber bandage sufficiently
long to make a loop around the neck, into which the hand is passed. It
should be made so tight as to exert gentle but constant pressure; the
result of this will be to cause rapid disappearance of the callus upon
which it is made. Conditions may be reversed when necessary, and the
patient may have some weight affixed to the hand by which, when the arm
hangs down, reversed pressure shall be made, or when desirable these
measures may be alternated. One should not, however, be tempted into
resorting to them too early, since much is done, even in unfavorable
cases, by purely natural processes, this being especially true of
children who are growing rapidly.


FRACTURES OF THE FOREARM; THE ULNA.

At the upper end of the _ulna_ the most frequent fracture is that
of the _olecranon_, whose separation by direct or indirect violence
corresponds to fracture of the patella. The fragment is pulled upward
along the back of the arm by the triceps muscle, and the power of
extension is almost lost. There is rarely any difficulty in diagnosis,
except in conditions of extreme swelling, which of itself would be
suspicious, as under hardly any other circumstances could a joint be so
distended (Figs. 297 and 298).

[Illustration: FIG. 297

Fracture of olecranon. (Erichsen.)]

[Illustration: FIG. 298

Fracture of ulna, upper end. (Lejars.)]

[Illustration: FIG. 299

Fracture of olecranon with fibrous union. (Park.)]


=Treatment.=--The difficulty here, in _treatment_, consists in the
necessity for counteracting the pull of the triceps. The arm first
of all should be dressed in the _extended position_. Sometimes it is
possible, by partly encircling the posterior surface of the arm just
above the fragment with a strong piece of adhesive plaster, to which
is attached some rubber tubing, to make a constant elastic pull upon
the fragment, the tubes being brought down and attached to the sides of
the anterior splint below the elbow. In the absence of swelling this
can often be made quite effective. So long as much fluid is present
no means will be efficient. It may, therefore, be well to wait two or
three days until the fluid has disappeared, aspirating the joint if
necessary. In young and otherwise healthy subjects there is strong
reason for advising _operation_, as only by absolutely approximating
the fragment to the main bone and maintaining it in position can bony
union be secured. In properly selected cases, and when performed
with every precaution, this measure frequently gives ideal results.
A short ligamentous union is represented in Fig. 299. At other times
the fibrous band will stretch out to an inch or more, not completely
disabling the arm but weakening it. The extended position may be
relaxed within a week after operation, but not for at least two weeks
after other treatment. Passive motion should not be begun too early in
the latter cases.

Fracture of the _coracoid process_ is often combined with _backward
dislocation of the forearm_, which is no doubt an incident of the
injury or may occur later by mere muscle pull. The brachialis anticus,
which is inserted into it, will pull the fragment up against the
anterior surface of the humerus. This fracture should be dressed in
the right-angle position, in order to relax the muscle, taking care to
prevent backward displacement, while ligamentous union is ordinarily
all that can be hoped for.

The _ulnar shaft_ may be broken at almost any point, usually as a
result of direct violence. As it is weaker in its lower half the
greater number of fractures occur here. Fracture of the shaft is easily
recognized, crepitus being always obtained, unless muscle tissue has
intervened, this being a condition which will occasionally prevent bony
union. If it can be established by _x_-rays that bony surfaces are
not in contact and cannot be so placed, it is advisable to cut down
upon the site of the fracture, remove the obstacle, and fasten the
fragments together. So long as one bone is broken in the forearm the
other may be relied on to act as a more or less efficient splint. There
is but one position in which any of these fractures can be dressed
with safety, that is _midway between pronation and supination_, _i.
e._, with the thumb pointing toward the patient’s face. Splints used
for this purpose should always be wider than the forearm itself, lest
by pressure the ends be forced toward the other bone. Some hold that
by gentle pressure along the line between the bones, as by a narrow
pad or splint, the muscles may be made to press the injured bone away
from the other; nevertheless only moderate pressure can be tolerated
for this uncertain purpose. It has been generally customary to use two
light wooden splints, one along the palmar, the other along the dorsal
surface of the forearm, padding them properly and securing them in
position by strips of adhesive plaster and suitable bandages. The same
plaster-molded splints mentioned above can, however, be made just as
effective for this purpose, if properly applied.

When either bone is broken near the wrist, and especially when both are
broken, we have to combat the tendency of the pronator quadratus, which
tends to pull the lower fragments together.

The _styloid_ process is occasionally detached, as in violent sprains,
or broken off in connection with other injuries. Inasmuch as it carries
the upper end of the internal lateral ligament its detachment can be
quickly recognized by the abnormal freedom of motion which such an
injury would permit.

[Illustration: FIG. 300

Obliteration of the interosseous space in a fracture of the forearm.]


FRACTURES OF THE RADIUS.

The radius vies in frequency of fracture with the clavicle. The _head_
is seldom broken, its fracture being most likely when the shaft is
driven against the humerus by falls upon the open hand. The _neck_ is
more frequently broken in children than in adults. These fractures have
sometimes to be determined by a process of exclusion or by the use of
the _x_-rays. In muscular forearms they lie so deeply that it is not
always possible to recognize them. Ordinarily, however, if the head
of the bone can be found to remain stationary while the rest of the
bone is being rotated, and if, at the same time, crepitus be felt, the
matter may be regarded as settled. So far as the _shaft_ of the radius
is concerned the remarks made above regarding the ulna mostly hold true
for its fellow-bone. When the neck of the bone is broken the shaft will
be pulled upward by the biceps tendon, while when the shaft is broken
below its insertion the upper fragment is displaced by it. In either
of these cases, then, the forearm should be dressed at a right angle
with the arm in order to relax the muscle. The supinator brevis and
the pronator radii teres should also not be neglected, for the former
will tend to rotate and the latter to more or less displace the upper
portion of a shaft broken high up. With a fracture near the upper end,
in a powerfully muscular arm, diagnosis is not always easy. Fractures
in the lower portion of the shaft are to be treated like those of the
ulna. But those high up should be dressed with the elbow at a right
angle and the forearm supinated. A plaster-of-Paris molded splint here
can be adapted to the needs of every individual case if the surgeon
will give minute care _at the time of its hardening_ to placing the
parts just as he desires them to remain.


FRACTURES OF BOTH BONES OF THE FOREARM.

These are not uncommon, though much less frequent than injuries to
either bone alone. They may occur at the same level or be quite widely
separated. The loss of function is complete in these instances, while
deformity will depend largely upon whether the fractures lie near
together or not. It is of the greatest importance to remember, in these
cases, that the mass of muscles around the upper fragments tends to
crowd them together, while the lower fragments are brought together
especially by the pronator quadratus. Everything then conspires to
convergence of the four fragments, a tendency which it is sometimes
difficult to combat. Every large museum contains specimens showing
a common callus, in which all four bone ends are involved, and
illustrating the permanent loss of rotation that ensues. This is to be
combated, not alone by rest, which tends to limit callus formation, but
by _position with the arm midway between pronation and supination_,
in which the bones are naturally farthest separated, and by _splints_
applied with such gentle pressure as may hold the bones apart. This
pressure should be applied between the dorsal and palmar surfaces,
while the lateral aspects of the forearm should be kept absolutely free
from it (Figs. 300 and 301).

[Illustration: FIG. 301

Fracture of both bones near lower extremity. (Lejars.)]

It is a serious matter to dress any of these injuries with moistened
pasteboard, or other material which does not take its desired shape and
strength promptly, for no matter how carefully the desired position may
be enforced at first the very nature of a material which remains too
long plastic will permit the loss of all that should be maintained. The
writer has seen malpractice suits instituted and men forced out of the
State by inattention to this precaution.


FRACTURE OF THE LOWER END OF THE RADIUS; COLLES’ FRACTURE.

This is perhaps one of the commonest fractures in the body, occurring
at all ages; when seen in growing children it is to be regarded as an
epiphyseal separation rather than as a distinct fracture. It derives
its name from the fact that until Colles, a Dublin surgeon, over one
hundred years ago, described this injury as a fracture it had been
always regarded as a peculiar dislocation at the wrist. It is produced
by falls upon the hand in the hyperextended position, the force
being usually transmitted through the carpus to the radial end. The
name is usually limited to those fractures which occur within one
and a quarter inches of the articular surface (Fig. 303). Here the
structure of the bone is cancellous and impaction may easily occur,
this being a decided feature in many of these accidents, and making
replacement more difficult. The deformity which results from the
fracture is characteristic and more or less uniform. This is called the
“silver-fork appearance,” the lower fragment being so displaced, and
usually more or less tilted, as to raise the tendons and the structures
on the back of the wrist; at the same time it is usually drawn toward
the radial side. The more the fragment is impacted or driven into the
shaft of the bone the less easily is crepitus elicited.

The fracture is more common than is supposed, and there is no doubt but
that many alleged sprains of the wrist illustrate cracks in the bone
without displacement, which, nevertheless, are slow to heal and are
sometimes followed by thickening and impairment of function. (See Plate
XL.)

Along with the radial fracture separation of the _styloid process_ of
the ulna may also occur, or, as Moore has shown, the process itself may
perforate the internal lateral ligament so as to protrude through the
skin; and the surgeon has occasionally to withdraw the styloid from
the ligament which has been impaled upon it. The radio-ulnar ligament
is also frequently injured, and this permits the ulna to become more
prominent than normal. If the styloid has perforated the skin it lends
a compound feature to the case. The interarticular fibrocartilage may
also be displaced.


=Treatment.=--The secret of obtaining a good result and the explanation
for failures lie in the completeness or incompleteness of the
reduction of the fragment. If the latter be _absolutely and accurately
replaced_ it makes but little difference what dressing is applied.
On the other hand any fragment not completely restored will lead to
subsequent deformity and impairment of function. _Successful reduction,
then, is the keynote to success_, and should be accomplished at any
reasonable cost. Sometimes it is not difficult, and then no anesthetic
is required; sometimes it is extremely difficult, and the operator
has to exert all the strength he has in his arms, aided by profound
anesthesia. Moderate cases can usually be dealt with successfully
under nitrous oxide gas. The surgeon grasps the hand as if to shake
hands, _i. e._, with his corresponding hand, the elbow being firmly
held by an assistant. Traction is then made upon the hand to which the
fragment is affixed, while with his other hand the operator makes such
pressure, rotation, or coaxing manipulation with his thumb and fingers
as may assist in restoring the fragment to its place. With whatever
other effort may be made traction should be combined. Forcible swaying
movements, combined with hyperextension, may be necessary to dislodge
an impacted fragment. Any degree of force is preferable to failure in
this respect. Perfect reduction is the key of success; without it, no
dressing is efficient; with it, almost anything will suffice.

[Illustration: FIG. 302

Comminuted but not compound fracture of wrist. (Beatson.)]

Reduction once accomplished it is usually an easy matter to hold the
arm in position. The writer prefers above all other means a molded
plaster-of-Paris splint, which should extend from the line of the
knuckles upon the palmar surface well up toward the elbow. It should
be fitted neatly to the hand and forearm, bandaged comfortably upon
it, while as it solidifies the surgeon should hold the hand slightly
flexed to the ulnar side as well as anteriorly. When the splint is
hardened and bandaged a simple sling will suffice. The hand should be
dressed with the thumb pointing toward the face, while upon the back of
the wrist an ice-bag can be applied. Ecchymosis is sometimes extreme;
I have seen it extend even to the shoulder after an apparently simple
break (Figs. 304 and 305).

[Illustration: PLATE XL

Skiagram of a Fracture of the Lower End of the Radius. (Wharton.)]

I have not described other splints for dressings, at this point, for
two reasons: the dressing given above is ample and sufficient for all
cases, and, aside from it, the number of splints and methods devised is
so large as to be confusing. It is much better to know one method well
than to have a slight working acquaintance with several.

[Illustration: FIG. 303

Colles’ fracture. (Anger.)]

[Illustration: FIG. 304

FIG. 305

Deformity from faulty union following fracture of wrist. Buffalo
Clinic. (Skiagrams by Dr. Plummer.)]

While Colles’ fracture is far more frequent than all other fractures
about the wrist, it is possible to have less-known forms with different
displacements; thus a fracture the reverse of Colles’ has been
described by Barton and by R. W. Smith, being occasionally produced by
falls upon the back of the hand instead of upon the palmar surface.
Figs. 306 and 307, from photographs given me by Dr. Beatson, of
Glasgow, illustrate both the clinical picture and the actual condition
of the bones. Of all these fractures it may be said that accurate
reposition, as in the case of Colles’ fracture, is the key to success.
Once the fragments are reduced the same plaster-of-Paris molded splints
will answer for these as for the others.

[Illustration: FIG. 306

A Barton or Smith fracture at wrist. (Beatson.)]

[Illustration: FIG. 307

Smith’s fracture; reverse of Colles’. (Beatson.) (Skiagram of case
represented in Fig. 306.)]


BENNETT’S FRACTURE.

When considerable force is applied to the distal end of the first
metacarpal, as in striking with the clenched fist, or, as in a fall
upon the outstretched thumb, the first metacarpal is often fractured
transversely at its neck or longitudinally, its interior basal
projection being broken off, both injuries being often associated.
This is a condition lately proved by Russ, of San Francisco, to be
more common than has been generally supposed. It was first described
by Bennett, of Dublin, in 1885, and is known as Bennett’s fracture of
the thumb. Its peculiar features can be best seen in a radiograph.
It produces much pain and swelling of the hand, with tenderness,
especially at the base of the bone involved, _i. e._, at the root of
the thumb. There may be more or less displacement of fragments. The
injured thumb should be treated by traction and with such coaptation
splints as may be extemporized or prepared for the purpose, in the
position of abduction. If accurate coaptation and sufficient traction
be made to overcome both deformity and muscle spasm the result obtained
will be satisfactory. Otherwise more or less loss of function and local
tenderness may long persist.

[Illustration: PLATE XLI

Skiagram of Fracture of the Proximal Phalanx of the Ring Finger.
(Wharton.)]


FRACTURES OF THE WRIST AND HAND.

Fractures of the carpal bones seldom occur, except when the parts have
been crushed. The _scaphoid_ is, however, broken much more often, and
doubtless many cases of so-called severe sprain include this injury.
The use of the _x_-rays has done more to teach the relative frequency
of carpal fractures than was ever previously appreciated. The scaphoid
ossifies by two centres, which do not appear until the eighth year.
When the bone has been thus cracked the usual signs of sprain are
present, which subside and leave a tender wrist and hand whose fingers
can be normally moved, but whose wrist movements are reduced one-half,
while attempts at motion beyond these limits produce great muscle
spasm and pain. Codman and Chase[40] have shown that the sheaths of
the radial extensor tendons are in close relation to the periosteum of
the bone at this point, as well as to that of the radius, so that by
injury here blood may escape into the sheath without appearing at other
parts; the result being a tense, fluctuating, triangular swelling over
the radial half of the wrist, the blood being effused so deeply as not
to discolor, or at least not at first. They regard the presence of such
an engorged bursa as diagnostic of fracture either of the radius or the
scaphoid.

  [40] Annals of Surgery, March, 1905.

While carpal fractures call ordinarily for treatment by absolute rest,
Codman and Chase have advised removal of any loose fragment, especially
of the scaphoid, by incision along the back of the wrist just to the
inner side of the long radial extensor. The annular ligament is to be
divided between it and the long extensors of the fingers, and without
opening tendon sheaths; inasmuch as this ligament does not retract when
divided its borders must be held apart. In this way the joint may be
completely exposed over the proximal half of the scaphoid. The line of
fracture being made out, a blunt hook is introduced into the fissure
and the fragment elevated, loosened by a tenotome, and removed, its
removal seeming nowise to interfere with the function of the whole bone
or the usefulness of the wrist.

The _metacarpal bones_ are frequently broken, usually as the result
of violence, the distal portions suffering more than the proximal.
The diagnosis is best made with the fingers closed, when any lack
of symmetry in the row of knuckles may be seen or any protrusion of
a fragment noted. Here the _x_-rays are useful. Such injury should
be treated by placing the hand upon a palmar splint extending well
up the forearm and maintaining rest by suitable pressure, with or
without traction upon the finger of the bone involved. For this purpose
adhesive plaster may be passed up and down the finger and attached to
an elastic band which is fixed to the end of the splint.

The same is true of fractures of the _phalanges_, which are often made
compound by the injury. Here the danger is not so much to the bone
as to the tendon sheaths or thecæ, along which infection may easily
spread. Widespread and prolonged suppuration might disable a hand thus
injured unless properly and promptly dressed. Ordinarily adjoining
fingers can be utilized for splints, and if the outstretched hand be
fastened upon a palmar splint and the injured finger kept in position
by its neighbors a good result can generally be obtained. Occasionally
distinct splints for one or more fingers are required, and occasionally
also the suggestion made above with regard to traction may need to be
enforced.


FRACTURES OF THE PELVIS.

Fracture of the pelvis may be serious not only in and of itself but
because of frequently accompanying injuries to the various pelvic
viscera. Save in the possible separations that may occur during
parturition it is always the result of direct violence. Such injuries
are usually divided into fractures of the _pelvic girdle_ and those of
the more exposed prominences, such as the _iliac crest_, the _ischiac
tuberosity_, the _coccyx_, etc. Lines of fracture may run at any
point, although it is at the synchondrosis that the pelvis is usually
broken loose from the sacrum. As in the skull and the lower jaw double
fractures or even comminutions may occur. The same considerations
concerning the transmission of serious violence may account for some
of the vagaries seen in these cases. The _sacrum_ is usually broken
as the result of great violence. The pelvic girdle is perhaps weakest
opposite the joints and in the neighborhood of the pubis. Here there
may be a separation of the symphysis, but the break usually occurs a
little to one side of the middle line. In rare instances the head of
the femur has been forced through the acetabulum (Fig. 308).

In a general way fractures of the pelvic girdle can be recognized not
merely by local evidences of injury and shock, but by the resulting
more or less complete loss of function; patients will be disabled
in proportion to the violence and extent of the injury. The more
unilateral the symptoms the easier it is to localize the site of the
injury. Mobility can often be detected upon examination, sometimes
crepitus. This is essentially true of fractures of the pubis.
Occasionally combined manipulation, with a finger in the rectum or
vagina, will permit more accurate localization of the injury. When the
crest of the pelvis is fractured, or any of the parts to which the
abdominal muscles are inserted, then the patient will be still further
disabled in movements of the lower part of the body, while by palpation
the fracture is sometimes easily determined.

Not the least serious features of these injuries are those which
pertain to the viscera. These include not only the ordinary results of
abdominal contusions which may produce all sorts of harm, for example,
ruptures of the kidneys, spleen, or liver, but also more localized
lesions, such as ruptures of the rectum, bladder, or urethra, or
even the pelvic connective tissue. If the urinary passages be torn
there is always opportunity for urinary infiltration and infection.
The same is true of the rectum so far as possibility of infection is
concerned. Therefore one of the earliest maneuvers in dealing with such
a case should be the passage of a catheter, to determine if the urine
be bloody or the urethra obstructed. In such a case, in the male at
least, it will usually be wise to make a perineal section and to open
widely and then drain the bladder. In not a few of these instances the
laceration takes place internally, and a pelvic crushing injury, which
is followed by collapse and abdominal rigidity, without satisfactory
explanation as above, should be _promptly explored_ by abdominal
section, the danger of doing it being considerably less than the risk
of leaving it undone.

[Illustration: FIG. 308

Fracture of pelvis. (Mudd.)]

[Illustration: FIG. 309

Great deformity after multiple fracture of femur, with synostosis.
(From the Buffalo Museum.)]

Some of these fractures are conspicuously _compound_, and the treatment
for the external wound will permit of more careful exploration of the
bone injury, as well perhaps as the insertion of wire sutures or other
means of fixation.

Fig. 309 illustrates a serious complication that ensued in one case
after multiple fractures of the pelvis and hip, with synostosis at the
hip, as well as extensive deformity following fracture of the shaft of
the femur.


=Treatment.=--Treatment of pelvic fractures should comprise, first,
absolute rest. This means not merely confinement in bed, with traction
applied to one or both limbs, but probably fixation of the pelvis
and perhaps the thighs, either in a compressing bandage or in a
plaster-of-Paris double spica, the pelvic jacket running as high as may
be necessary upon the trunk of the body. Cases which seem to permit of
operation and suturing are entitled to it, but they will constitute
but a small proportion of the total. While patients are so rigidly
confined provision should be made for free elimination, and possibly
conveniences provided for receiving the evacuations without possibility
of infection. Recovery is in many instances complete; occasionally it
occurs with considerable displacement. If the viscera escape injury
much may be expected in the way of repair of the bones under suitable
treatment.

The _margin of the acetabulum_ is occasionally chipped off, sometimes
by itself, sometimes as a complication of dislocation of the hip.
The posterior margin of the brim is the part which usually suffers.
Diagnosis should be made by the ease with which such a dislocation
recurs after manual reduction. Sufficient traction to keep the limb
from displacing the fragment, and snug bandaging with pressure,
especially around the injured hip and above the trochanter, is
indicated in such cases.

The _coccyx_ and even the lower portion of the _sacrum_ are
occasionally broken loose, either by external violence or during
parturition. Here the fragment is drawn forward by the levator ani,
displacement is marked, and pain and soreness are great. Should there
be doubt as to the nature of the injury, combined manipulation, with a
finger in the rectum, will make diagnosis positive. Fibrous union is
about all that can be expected in either of these cases. The fragment
may be justifiably removed at any time.


FRACTURES OF THE THIGH.

Fractures at the upper end of the thigh are more common than those at
the lower. At the upper end there may be fractures of the _head_, of
the _neck_, those which pass _between the trochanters_, and _epiphyseal
separations_. All of these are rare except those of the neck.

Fractures of the _neck of the femur_ occur most commonly in those who
have passed the fiftieth year of life. They occur, however, during the
middle period and even in children, and, as Whitman has shown, are by
no means so rare in the young as was until recently supposed.

The shape and structure of this portion of the bone, and the peculiar
changes which occur with advancing years, constitute the explanation
for the frequency of this injury in late life. As the jaw begins to
change in shape, and the teeth to drop out, there occur also unseen
changes within the cancellous structure of the head and neck of the
femur by which the strength of the latter is materially reduced. It
is still further weakened by the change in shape which the bone also
undergoes as it loses its obtuse angle and becomes set more at a right
angle with the shaft. The reduced ability to resist strain produced
by these changes is remarkable, and accounts for the ease with which
fractures occur, even from so apparently trivial an accident as
tripping on the floor. With all the violence directly transmitted there
is usually present an element of twist or torsion by which fracture is
still further favored.

As between so-called _intracapsular_ and _extracapsular_ fractures
surgeons have made distinctions to which unnecessary importance
has been attached. Anteriorly the capsule is attached to the
intertrochanteric line, while posteriorly it does not extend nearly
so far outward; it can thus be seen that many fractures are partly
intracapsular and partly extracapsular. These lines vary in different
individuals, especially that of the posterior insertion; it is not
usually possible to make minute distinctions of this kind. The
principal importance which attaches to them is in the direction of
prognosis, for if the fragment be absolutely intracapsular it can
derive its blood supply only through the ligamentum teres, which
is, to say the least, a precarious method of existence and usually
disappointing. In general it may be assumed that a fracture close to
the head is intracapsular, but that when it occurs well out toward
the shaft it may partake of both characters. In this connection the
_x_-rays will afford, usually, more satisfactory information than can
be obtained by even extensive or rude manipulation.

_Impaction_ occurs with considerable frequency in these cases, and,
unless accompanied by too much deformity or displacement, is rather
a fortunate occurrence, since by it is afforded an automatic splint
which it should be the surgeon’s endeavor to not break apart. There
can be no doubt, moreover, but that trifling degrees of impaction with
incomplete fracture occur, especially in the aged, in many injuries
to the hip. It would be the greatest misfortune to the patient in one
of these cases to complete the separation, and when assured of the
existence of such a lesion it is best to treat the case as though it
were a fracture. I am sure that many cases which have gone into court
have been due to incomplete fractures with impaction, where there has
been later absorption of bone, by which the femoral neck has been much
shortened, so that recognizable deformity as well as more or less
disability have resulted. Other changes comprised among those already
described in the chapter on Joints, under the section on Arthritis
Deformans, may also occur. Callus which has been at one time abundant
may also undergo too great absorption.

[Illustration: FIG. 310

Sections of impacted extracapsular fractures of neck of femur, showing
the degree of impaction and of splintering in different cases.
(Erichsen.)]

[Illustration: FIG. 311

Extracapsular fracture of thigh.]

Fig. 311 illustrates extracapsular fracture and comminution. Figs. 312
and 313, also from specimens in the author’s collection, show some of
the changes described above, including impaction, displacement, and
some osteophytic outgrowth.

[Illustration: FIG. 312

FIG. 313

Impacted fractures of necks of femurs.]

_Signs of fracture of the neck of the femur_ of special import are
_history of injury_, _pain_, _loss of function_, _shortening_, _rotary
displacement_, usually eversion, _crepitus_, _relaxation of the fascia
lata_, and _disarrangement of the lines of triangulation_ between the
bony prominences of the pelvis and the trochanter. Diagnosis should
be attempted with as little manipulation as possible lest impaction
be dislodged. The patient should be placed upon a comfortably hard
surface. Anesthesia will sometimes afford important aid. It should be
ascertained, first, that there had been no previous injury which could
produce shortening. If, then, _shortening_ be apparent it is of itself
almost a diagnostic sign. Such a limb is practically helpless, and
unless the neck be so driven in upon itself as to produce impaction the
foot will be usually everted, while the tension of the fascia lata will
be relaxed and there will be fulness in Scarpa’s triangle. Absolute
inability to use the limb implies fracture without impaction. Should
the patient have been able to help himself or work after the injury,
impaction may be safely assumed. The parts are exceedingly tender and
pain is easily produced. Shortening is to be assumed only after placing
the limbs and body in a _perfectly symmetrical position_ (the pelvis
being at right angle with the spine), after which the measurement
most usually made is from the anterior superior spine to the internal
malleolus. _Nélaton’s line_ is the shortest line which can be made to
pass around the hip, in one plane, from the anterior superior spine to
the tuberosity of the ischium. While the line is curved it should lie
in the same plane. Normally this passes just over the great trochanter.
If there be real shortening the trochanter should rise above this
line to an extent corresponding with the shortening made out by other
measurements. Still another method of measurement is to hold a straight
edge opposite to the superior spine and perpendicular to the surface
upon which the patient is lying; the distance between this edge and
the great trochanter should be as much less than the distance found
by similar measurement on the other side as the amount of shortening
measured by the other methods. This is the easiest way to measure the
lines included in Bryant’s iliofemoral triangle. Both are illustrated
in Fig. 314. Impaction can sometimes be determined by comparing
triangles drawn between three points on either side, these points
being, respectively, the great trochanters, the anterior spine, and the
centre of the pubis, which is common to both. The lower line of the
triangle on the injured side should be shorter than on the other, in
proportion as the head and the end of the shaft have been driven toward
each other.

[Illustration: FIG. 314

Nélaton’s line, dark. Bryant’s iliofemoral triangle, dotted.
(Erichsen.)]

_Crepitus_ is a sign to be elicited with care and gentleness.
Up-and-down movements of the thigh upon the side of the pelvis or
gentle rotary movements, combined with circumduction of the knee, will
yield it if it is to be easily detected. Every effort of this kind
disturbs the injured bone and should be minimized as much as possible.
One other sign of considerable value is the fact that if the patient be
turned upon his face a fractured femoral neck will permit the leg to be
_hyperextended_ to a degree not permitted by the normal condition. In
making this test the pelvis should be held firmly; it should be made
but once, the intent being to disturb the parts as little as possible.


=Diagnosis.=--The diagnosis of fracture is often easy, but in some
cases it is accompanied by many difficulties. It would be better to
give the patient the benefit of a doubt and treat him for a fracture
with rest than to subject him to excessive manipulation. Such an injury
is not likely to be mistaken for anything else save a dislocation
of the hip, although occasionally separation of the margin of the
acetabulum might cause confusion.


=Prognosis.=--The prognosis depends upon the age and vitality of
the patient, the location and extent of the fracture, the method of
treatment, and upon causes which seem at first foreign to the subject.
Patients with pulmonary or cardiac trouble, who need frequent change
in position, or perhaps absolute rest, are likely to develop something
hurriedly which will disarrange ordinary calculations. Sometimes
they die suddenly or they may develop pulmonary edema or hypostatic
pneumonia. The circulation may be so poor as to lead to early
development of bed-sores, while ordinary complications in prostatics,
or habitual constipation in the aged, may make care and treatment
exceedingly difficult. It should be emphasized, then, that treatment
of the fracture alone is by no means all that these patients require,
and prognosis means something more than what may merely happen to the
bone. In this last respect, however, the better nourished the fragment
the more likely is bony union to take place _if_ good position can be
maintained. When osseous union has failed patients get fairly useful
limbs with _fibrous or ligamentous union_, even with one or two inches
of shortening, and such patients may hobble about for years, with a
cane or a crutch, with limbs that are semiserviceable.


=Treatment.=--Of these cases it may be said that interests of life
are paramount to those of limb, and the treatment should be directed
to that which the patient can tolerate. Reasonably healthy, muscular
people can bear the application of adhesive strips and traction such
as the thin and delicate cannot tolerate. The ideal method is that by
which sufficient traction is made to overcome all muscle pull which
shall produce shortening, the measure of weight to be used in these
cases being the effect thereby produced. Thus if twenty pounds be
sufficient, well and good; if not, it should be increased to thirty or
forty pounds, providing that the patient can tolerate it. At the same
time a broad binder around the pelvis may afford sufficient support
with a tractable patient, while many will require a _long side splint_,
extending from the axilla to beneath the foot, to which both body
and the injured limb should be fastened, in order to more perfectly
maintain that physiological rest which is so necessary. This last is
the so-called “Physick” splint, which has been variously modified,
while the method of traction has been usually spoken of as Buck’s
extension. It seems well thus to commemorate the names of the American
surgeons who showed the value of these methods. When a long side splint
cannot be borne, sandbags 15 in. or 20 in. in length and 3 in. in
diameter may be used to give support. Any decided tendency to eversion
of the limb should be corrected as well as the shortening. When the
long side splint is used the foot can be held in place with it and thus
the position of the shaft of the femur controlled. At other times this
may be done by flexing the knee and thus preventing upward rotation.
In all methods of traction it is advisable to _keep the heel free from
the bed_, in order that the effect of the method may not be lost by the
obstruction of the mattress.

[Illustration: FIG. 315

Fracture of upper third of femur. Vicious union.]

[Illustration: FIG. 316

Shortening resulting from overlapping.]

[Illustration: FIG. 317

Overlapping fracture of femur.]

Other methods of treatment of these fractures are common as well to
those of the shaft, and will be considered later. These include the
single and double inclined plane and the method by anterior suspension.
In general the _first indication is efficient traction_. This should be
made as efficiently as possible. When the patient cannot tolerate any
of the usual methods, then the double-inclined plane may be used, the
knee being hung over its apex, or anterior suspension may be practised.
In severe cases patients should be simply made comfortable, with such
local treatment as they can bear. It may be even necessary to place
them in the semi-upright position in bed, in order to free the lungs,
or to frequently change their position to avoid the formation of
pressure sores.

[Illustration: FIG. 318

Fracture of lower end of femur, with great displacement of condyles.]


=Fractures of the Shaft of the Femur.=--Fractures of the shaft of the
femur are usually oblique and accompanied by considerable displacement,
because of the powerful thigh muscles which tend to shorten the limb.
These fractures are often _compound_, and occasionally the femoral
fragment causes serious damage to important vessels or nerve trunks.
When the fracture is just below the insertion of the psoas into
the lesser trochanter this muscle tends to not only pull up but to
externally rotate the upper fragment. Inasmuch as there is no way of
controlling this muscle or the fragment, the fractured limb should be
dressed upon an inclined plane, or in anterior suspension, in such a
way as to make the axis of the shaft fall into line with that of the
fragment. When the fracture is in the middle of the thigh, or lower,
there is sufficient length of the upper portion so that pressure can
be made upon it, or that psoas activity can be overcome. Fig. 315
illustrates the tremendous deformity that may result from neglect of
these precautions. Fig. 316 illustrates a certain degree of overlapping
without conspicuous other deformity. Fig. 317 shows the shortening
which is often inevitable.

_Muscle spasm_ should be overcome as an essential part of successful
treatment, the most important feature in making traction being to use
force sufficient to tire out and overcome the irritated muscles.


=Fractures of the Lower End of the Femur.=--Fractures of the lower end
of the femur are usually the result of extreme violence, and may be
classified as were those of the lower end of the humerus. When there
is a _supracondyloid_ fracture the two heads of the gastrocnemius will
help to displace backward the upper end of the lower fragment to an
extent permitting injury to the bloodvessels, while there is always
marked shortening. Here the patella will be made unduly prominent,
and there will be depression above it. _Either condyle_ may be broken
loose alone, or there may be _intercondyloid_ or T-fractures which are
serious because the amount of force required to produce them may have
played serious havoc with the soft tissues. The joint capsule will
probably be filled with blood, the ligaments rent, and perhaps the
blood supply of the limb compromised. In such a case as this the joint
may be opened, the contents turned out, and the fragments readjusted
and wired or fastened in place (Fig. 318). _Epiphyseal separations_,
which may occur up to the twentieth year, are not essentially
different, although lateral displacement is perhaps more common, while
they are often compound.


=Treatment.=--Oblique fractures of the femoral shaft can be more easily
adjusted under the influence of powerful and continuous traction than
the transverse, where lateral displacement and overlapping tend to
occur. A more general application can be made of the method described
above when dealing with fractures at the upper end of the shaft, _i.
e._, when the upper fragment cannot be controlled the balance of the
limb must be adjusted to it in whatever position it may be required
to maintain. By the use of sufficient traction, combined with molded
or other splints, a fair result may usually be obtained. In stout
individuals it is by no means easy to determine just how the fragments
lie, save by the use of the _x_-rays. If traction be so adjusted as
to maintain the limb at equal length with the other the surgeon may
feel that, with certain coaptation splints, he is doing the best he
can. Application of the same rule given above would lead him to place
the limb on a double inclined plane, in case of fracture near the
knee-joint, in order that in this position the sural muscles (the
calf) may be relaxed and backward displacement of the lower fragment
be adjusted. If the apex of this plane be arranged sufficiently high,
so that the patient’s knee is practically hung over it, and that the
weight of the body makes sufficient _countertraction_, then the use of
weight and pulley may not be necessary. Here, however, pressure which
will be efficient may produce numbness, as will any long-continued
pressure in the popliteal space, and after a few days it may be
necessary to assume some other position. Fractures which loosen the
condyles will need lateral pressure, while the position of each condyle
may be controlled by the position of the leg, through the medium of the
corresponding lateral ligament.

[Illustration: FIG. 319

Extension band and foot-piece.]

[Illustration: FIG. 320

Same, folded and ready for use.]

The standard “Buck’s extension” (for which latter word I prefer to
substitute the term “traction”), by weight and pulley, with the limb in
the extended position, is still the resort of the majority of surgeons,
but combined with other support by long side splints or coaptation
splints as may be needed. Fig. 321 illustrates the method of its use,
except that the ends of the adhesive strips should be extended upward
to a point nearly opposite the site of the fracture. The amount of
weight to be used should be graduated to the effect produced. From
ten to forty pounds, or even more, may be needed. After the muscles
are thoroughly tired the amount of weight may be somewhat reduced[41]
(Figs. 319, 320 and 321).

  [41] Before applying the strips of adhesive, the best for the purpose
  being that made of moleskin spread with material with which zinc
  oxide is incorporated, the limb should be carefully washed and shaved
  and then completely dried. A little cotton should be placed over each
  malleolus, in order to avoid pressure-sores, while the strip of wood
  beneath the foot should be sufficiently wide to prevent or minimize
  this pressure. The heel should be kept off the mattress.

[Illustration: FIG. 321

Mode of applying adhesive plaster. (When the dressings are completed
the limb should not be allowed to rest on the bed.)]

Continuous and anterior traction was devised by Nathan R. Smith, in
the use of a so-called _anterior splint_, which was later modified
and improved in device by Hodgen. The method of its use is shown in
Fig. 322. Adhesive strips are used in this method as well, permitting
the leg and foot to be attached to the lower bar of the wire frame.
The position of the frame which contains the limb, swung within it
upon turns or strips of bandage, is then controlled by a suspension
apparatus, as shown, which tends to constantly pull the frame and
its attached lower part of the limb _away_ from the patient, the
effect being to make a constant but gentle traction. If the point
of suspension were placed directly above the limb there would be no
traction whatever. The essential feature of the method, then, consists
in arranging it as shown, so that the pull shall be oblique, and that,
according to the obliquity of the suspension cords, the amount of
traction shall be regulated.

[Illustration: FIG. 322

The Hodgen suspension splint.]

In this method of treatment there is no violent attempt made at
reduction or overcoming displacement, but dependence is placed, at
least for two or three days, on the effect of the constant pull and
its overcoming muscular activity. After this such added splints or
expedients may be adopted as the case may require. The knee is usually
flexed at a comfortable angle, the intent being not to lift the foot
too high, so as to avoid being compelled to overcome this added weight,
but to regulate the tension by the obliquity of the suspending cord.

[Illustration: FIG. 323

Fracture of the femur in a child treated by vertical extension.
(Bryant.)]

This method has found favor in the West under the enduring influence
of Hodgen’s teaching. In the East it is not so generally practised.
It has, however, several advantages, as follows: (1) Equably perfect
and comfortable extension; (2) easy adjustment; (3) easy exposure
for inspection; (4) when a fracture is compound it permits of easy
application of dressings; (5) adaptability to nearly all fractures of
the femur. It is peculiarly serviceable for feeble and aged patients
who chafe at restraint. If it be desirable to flex the knee to a
considerable degree this can be done, _e. g._, in fractures near the
lesser trochanter.

In fractures of the thigh, patients are frequently disturbed by
muscle spasms occurring during sleep. This can usually be obviated or
minimized by suitable doses of sulphonal, given early in the evening.

Fractures of the femur _in children_ are not uncommon. In those who
still wear diapers, and perhaps in those a little older, these injuries
may be best treated by vertical suspension, with sufficient weight to
overcome all shortening. Here the adhesive strips and the suspending
cords should be attached to both limbs alike, in order to have
sufficient access to the perineum, and in order to judge of the effect
which we are obtaining. Figs. 323 and 324 illustrate this method.

Plaster-of-Paris dressings for fractures of the thigh appeal especially
to those who are most familiar with the use of the material. Some
patients with fracture of the neck of the femur may be early put in
the erect posture, upon an elevated surface, allowing the injured limb
to hang down while the patient rests upon crutches. In this upright
position, with the down-hanging leg, to which traction can be made by
an assistant, a plaster-of-Paris spica may be applied, extending from
the waist-line down to or below the knee. As a limb is thus dressed
so it will heal, and it is of importance that complete reduction be
effected as a part of the procedure.

[Illustration: FIG. 324

Fracture of the thigh; vertical suspension. The fracture is compound in
the patient on the right. (Stimson).]


FRACTURES OF THE PATELLA.

During the active period of middle life the patella is the bone most
frequently broken by muscular violence. In many cases it is practically
cracked over the condyles, as one would crack a piece of wood over the
knee. If direct force be applied, as by a fall, in connection with the
above, the effect is even more marked. In such cases the fracture is
sometimes comminuted (Fig. 325), or the line of fracture may run more
or less perpendicularly rather than horizontally. Ordinarily, however,
these fractures are transverse, while the upper fragment is pulled
upward, sometimes to a considerable distance, by the powerful extensors
of the leg. When the fracture runs vertically the displacement is very
slight. Occasionally these fractures are compound, a most undesirable
complication, since the knee-joint is thus exposed to infection, from
which it suffers unless first attention be prompt and scientific. There
is usually sufficient hemorrhage to distend the joint cavity, and it
may at first be quite impossible to bring the fragments near enough
to each other to get crepitus, but the loss of the power of extension
and the evident gap between the fragments will serve to make diagnosis
positive, at least in all transverse fractures. A _vertical_ fracture
without much separation is a milder form of injury which may be
regarded in a much more favorable light (Figs. 326, 327 and 328).

In these transverse fractures it is rare that bony union can be secured
by non-operative methods. This is not only because of the difficulty
in maintaining parts in apposition, but because it is notably the
case that fragments of periosteum or other tissue drop in between
bony surfaces and tend to prevent their actual contact, no matter how
firmly they may be pressed toward each other. Osseous union then _may_
occur without operation, but is rare. The best that can be expected
is fibrous union, the intervening fibrous band being short or long,
according to the success met with in treatment and to the amount
of strain later put upon it by too early use of the limb. Even with
two inches of fibrous tissue intervening patients are not completely
disabled. The usefulness of a limb under these conditions, however, is
seriously impaired. Something will depend, also, on the extent to which
the joint capsule and the aponeurosis terminating the vasti muscles may
have suffered.


=Treatment.=--The non-operative treatment consists in placing such
a limb upon a single inclined plane, for the purpose of relaxing
the quadriceps extensor group. In this position the limb should be
maintained for at least from ten to fourteen days. Some expedient
should be added, so soon as swelling has subsided, by which the upper
fragment can be coaxed downward toward its fellow. A neatly molded
splint, formed out of gutta-percha or of plaster of Paris, may be
fitted to the thigh above the fragment, held in position, and then
drawn downward by elastic traction on either side of the leg, the
principle of traction being thus given a special application. Something
of this kind should be done if the fragments are to be approximated to
each other.

[Illustration: FIG. 325

Comminuted fracture.]

[Illustration: FIG. 326

Stellate fracture of the patella. (Erichsen.)]

[Illustration: FIG. 327

Fracture of patella, united by ligamentous tissue. (Erichsen.)]

[Illustration: FIG. 328

Side view of same.]

The more completely mechanical method, partaking of the operative, is
afforded by the use of certain _hooks_, whose points are permitted
to pass through the skin above and below the fragments and to engage
in the bone. By a screw mechanism these points are drawn toward each
other, and thus approximation is effected. This method was first
devised by Malgaigne and is usually known under his name, although his
device has been much improved. This is far from ideal, and yet has
given good results in some cases. The surgeon should constantly guard
against infection through the punctures.

By far the most ideal method, when it can be suitably carried out, is
the _open operation_, a transverse incision being made across the front
of the joint, which is completely opened; this affords an opportunity
to empty out clots and to thoroughly cleanse it, which of itself is a
great advantage, since these clots often produce subsequent adhesions.
The exposed surfaces may now be freed from clot and all soft tissue, or
they may be neatly sawed as near to the fractured surfaces as possible,
the intent being to permit them to come into absolute and complete
contact, and to hold them there by wire or other sutures, for a length
of time sufficient for absolute bony union. When properly performed
this operation gives ideal results; it, of course, exposes to great
danger if improperly done.

Treatment by non-operative method rarely affords a useful member
under an average period of from thirteen to fourteen weeks, while the
operative method permits a reduction of this time to less than half.
It, therefore, has obvious advantages for those (_e. g._, laboring men)
to whom time is of great importance. The operation, however, is not
to be practised as a rude emergency affair, but only when we may be
absolutely certain of everything pertaining to aseptic technique. After
operation it is rarely necessary to use a drain, and such a limb can
usually be dressed in a plaster-of-Paris splint. Compound fractures,
however, will probably need drainage at least for a day or two, and
because of this need may as well be operated at once. In _comminuted
fractures_ the method is desirable, since by a loop or by some other
expedient fragments can be held together as in no other way (Figs. 329
and 330).

[Illustration: FIG. 329

FIG. 330

Wiring patella. (Lejars.)]

Injuries to the patellar region, equivalent to fractures, are
_separations_, either of the _tendon_ from the bone, or of the bone
from the _ligament_ which holds it to the tibia. Such injuries can
be recognized by the fact that the contour of the bone itself is
preserved; in the former case it is not drawn up, although the extensor
muscles have lost their power while in the latter it is drawn up,
leaving a well-marked gap below it.

Remarks concerning the treatment of fractures apply equally here.
Choice can be made between the operative and the non-operative
treatment. In well-selected cases the former seems much the more
desirable, the fibrous end of the tendon or ligament being held to the
bone by strong sutures of silk or wire.


THE LEG; FRACTURES OF THE TIBIA.

The _head of the tibia_ is occasionally broken as the result of extreme
violence, the fragment being usually held reasonably in place by one
or other of the lateral ligaments. Hemorrhage into the joint will be
profuse, with swelling extreme, while disability will be complete. Not
a few of these cases justify operation, directed toward opening the
joint, removing all clot, and fastening the fragment in place with
suitable sutures (Figs. 331 and 332).

_Transverse fracture below the tubercle_ is less rare. The insertion of
the terminal ligament of the quadriceps extensor group will, in all of
these injuries to the upper portion of the tibia, tend to pull up the
upper fragment and make it project beneath, even protrude through the
skin. Fractures of the _lower part_ of the tibia are freer from such
distorting influences. Fig. 333 illustrates the distortion produced
as above, while Fig. 335 shows one of the tendencies in fracture of
the lower end of the tibial shaft, which has to be overcome by correct
emplacement of the foot within the dressing. Fig. 334 illustrates
synostosis as the result of fracture of both bones at about the same
level. Torsion is a factor of no small importance in the production
of most of the fractures of the leg, to such an extent as sometimes to
make a completely spiral fracture, a condition generally held to be
more serious than fracture of the ordinary type. The line of fracture
often extends in such a direction as to leave a sharp spicule of
bone close beneath the skin; here rough handling, or carelessly made
pressure in the dressing, may cause a perforation within a few hours or
days after the injury, by which a simple is converted into a compound
fracture. Such a complication should always be avoided.

[Illustration: FIG. 331

FIG. 332

Wiring tibia. (Lejars.)]


FRACTURES OF THE FIBULA.

The lower end of this bone is much more often fractured than the upper,
although it may be broken at any point. Into its upper termination
is inserted the external lateral ligament, and this insertion may be
torn off from the bone in cases of violent sprain of the knee, damage
occurring which is similar to that which happens in injuries about the
ankle. The upper portion of the bone lies well buried beneath muscles,
and fractures here are not so easily recognized. A good maneuver for
their recognition is to seize the bones at the lower portion of the
leg and press them together; if such pressure gives severe pain
above, or if it be shown that the fibula is more movable than natural,
fracture may be practically diagnosticated, even though crepitus be not
detected. A skiagram would, of course, clear up such a diagnosis.

Fractures of _both bones of the leg_ occur almost as frequently as of
either alone, usually as the result of direct violence, with or without
more or less torsion; as, for instance, when the foot is more or less
entangled, and, at the same time, twisted at the time of injury. These
double fractures are by no means necessarily placed upon the same
level; thus the tibia may be broken low down and the fibula high up,
so high indeed that the latter fracture may escape observation. With
fracture of both bones disability becomes complete, while shortening
is very likely to occur, all the muscles passing from the leg to the
foot conspiring to this effect. These fractures, moreover, are often
_comminuted_ and _compound_, sometimes to an extent necessitating
exsection of fragments or of an inch or more from the shaft of each
bone. In exsection of the tibia an equivalent amount should for obvious
reasons be taken from the fibula. Displacements are extremely likely
to occur, and in every compound fracture the presence of the opening
may be utilized for the emplacement of sutures or suitable means for
enforcing approximation. Indeed, other means failing, resort may be had
to this measure in order to secure an ultimately good result.

[Illustration: FIG. 333

Fracture of upper end of tibia.]

[Illustration: FIG. 334

Transverse fracture, with anterior displacement. (From the Buffalo
Museum.)]

[Illustration: FIG. 335

Line of fracture at junction of lower and middle thirds of tibia.]

While wire sutures may be used as freely as may be indicated it will be
well, at least in the majority of cases, to leave the ends protruding
in such a way that they can later be untwisted and removed. The
presence of wire after a certain length of time rather interferes with
the process of ossification than helps it.

Fractures of the _lower end of the leg_ nearly always involve the
joint, to some extent at least, in respect of being accompanied by
sprain if nothing else. They are accompanied by displacement of
the foot, and are produced by violence, which first involves the
foot. The term “_Pott’s fracture_” is meant to include the injury
originally described by Pott himself. In the typical Pott’s fracture,
as shown in Figs. 336 and 337, there are a chipping off of the
internal malleolus, of the outer portion of the articular end of
the tibia, and fracture of the fibula a little above the joint. In
spite of the classical description which Pott gave fractures of the
fibula alone, those accompanied by tearing of the internal lateral
ligament, or chipping off of the malleolus, are frequently referred
to under the same term. The more complete the injury the greater the
possibility for displacement. Eversion and outward displacement, of
course, are conspicuous. Lesser degrees of injury are accompanied
by less displacement, but all of these injuries will be followed by
extreme swelling of the ankle-joint, which may at first make diagnosis
somewhat difficult, because of the extreme tenderness which prevents
the handling necessary for careful determination. It is not always
easy to so completely replace the bones, when we have the combination
of three fractures as above, as to get an ideal result. Nevertheless
with suitable treatment usually very useful limbs are secured. When the
injury has been made _compound_ the difficulties are increased. Such a
result will not be obtained, however, unless the tendency to backward
and lateral displacement be overcome, when the limb is placed in its
permanent plaster-of-Paris splint, as it should be after a few days.
Great care should be given to this point in the management.

[Illustration: FIG. 336

Pott’s fracture. (Hoffa.)]

[Illustration: FIG. 337

Exaggerated deformity in Pott’s fracture.]


=Treatment of Fractures of the Leg.=--Nearly all these fractures are
likely to be followed by swelling, even to a degree which makes it
impracticable to put them up in permanent dressing until the swelling
has subsided. This means a period of two to several days, during which
the limb should be kept absolutely at rest, and the bones maintained
in apposition by side splints, while the limb is restrained within a
folded pillow or other comfortable cushion. More frequently here than
in any other part of the body there will form blebs or large blisters,
which are most liable to occur in alcoholic subjects. The leg should
be scrubbed and shaved before putting on dressings, in order that the
skin may be reasonably clean before its surface epithelium is raised.
Ecchymosis, infiltration, and sometimes general edema may become
somewhat pronounced, and the splint which would be required to fit
a limb under these circumstances would soon be too large when this
disturbance has subsided. The limb should not, therefore, be placed in
a fixed or permanent dressing until it is in every respect ready.

While these disturbances are subsiding, or perhaps being encouraged
to subside by the use of an ice-bag or of cold wet applications,
extreme care should be taken that proper position and apposition are
maintained. This will at times need considerable ingenuity. A delirious
or maniacal patient would need restraint far beyond that required for
one who is rational and docile. Moreover in all of these fracture cases
which entail confinement to bed there is a tendency to deficiency of
elimination which will require judicious use of laxatives and other
eliminatives.

The writer prefers a well-molded set of side splints, properly padded,
to any other first dressing for fractures of the leg. A limb thus
dressed may be supported on a pillow and even made adaptable for
transportation should it be necessary to remove the patient from one
place to another. The fracture box can be well superseded by this
method.

So soon as swelling has subsided, plaster of Paris should be used for a
fixed dressing. The limb should be enveloped in a layer of cotton, by
which the skin is protected, within which swelling may occur without
much strangulation. Over this and down the front of the leg a strip
of thick pasteboard should be placed, which can be moistened and made
to adapt itself, or a strip of sheet tin, an inch wide, which can
be made to fit the part, and upon which one may cut down later in
removing the splint. This refers especially to the use of the roller
bandage saturated with plaster of Paris. Molded splints can be made,
as recommended for the upper extremity, out of surgeons’ lint, canton
flannel, or old blanketing, while at the lower end of these splints
may be incorporated, with the plaster, a strip of bandage or other
material, by which a loop is formed beneath the foot, which may be
utilized for the purpose of traction.

The foot should _always be placed at a right angle to the leg_.
If there be too much muscle spasm to permit this, or make it too
uncomfortable, the tendo Achillis may be divided. This position should
be maintained during the period of repair, in order that so soon as one
resumes the use of the limb the foot may be planted naturally upon the
ground. In addition to this precaution it must be noted that backward
displacement is completely overcome, and that eversion is perhaps a
trifle overcorrected.

In all fractures of the lower end of the leg the foot and entire leg
should be enclosed in a bandage. In fractures near or above the middle
not only the leg but the lower part of the thigh should be immobilized
if the promptest and most satisfactory results are to be obtained.

The limb being immobilized it soon becomes a question as to how quickly
the patient can leave the bed and begin to move about on crutches.
This will depend to some extent on the patient’s temperament. Timid
women are less desirous of getting out of bed than are active men and
children. Some patients acquire facility with crutches very slowly.
Others are so tenderly built that crutches give pain and even produce
crutch paralysis. It is advisable to get patients at least into the
sitting posture so soon as the immobilization has been secured, while
those inclined may be encouraged to use the uninjured limb and move
about with crutches. A foot and leg too long kept off the ground will
swell when again lowered. The later this dependent position is attained
the greater the liability to edema. Patients should be cautioned about
this.

The so-called _ambulatory method of treatment_ has found favor with
some surgeons. This implies something more than merely permitting
motion with crutches; it means really such dressing as to permit use
of the injured limb in locomotion. The various forms of splints used
for immobilizing the limb in hip-joint disease may be used in this way.
A useful splint is made with body and perineal bands, or an inside
steel bar with ischiatic crutch and a cross-bar below the sole of the
foot, on which the weight of the body may be supported. This is to be
combined with a plaster-of-Paris support.

The ambulatory treatment is occasionally of value, but the advantages
claimed for it have not been generally sustained.


FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other tarsal
bones, partly because of their size and partly because they are in the
line of transmission of force as usually directed after accident. When
the posterior end of the calcis is broken off there remains a fragment
which is easily palpated, and which would be displaced backward and
upward by the tendo Achillis were it not for the plantar fascial fibers
which are inserted into it. The bone may also be comminuted, in which
case that part of the foot will lose much of its shape and distinctive
peculiarities. The sole will be flattened, but swelling and hemorrhage
will at first be so great that there will be much difficulty in
recognizing the exact nature of the injury.

The _astragalus_ is usually broken by being caught between the calcis
and the lower end of the leg. It is generally broken through the line
of its so-called neck. Not infrequently one or more of the fragments
is forced out of place, usually beneath the anterior tendons. When
such extensive displacement occurs the fragments should be removed if
the fracture is compound. In both of these bones results are generally
satisfactory when displacement is not marked, also after removal of
the entire astragalus. The foot and leg should be immobilized in the
best possible position, and this can be best accomplished within a
plaster-of-Paris dressing.

In regard to the _tarsal bones_, diagnosis can now be made accurately
by the use of the _x_-rays. These bones, according to Eisendrath, may
be fractured in any one of the following ways: (1) Compression, as when
the weight of the body is violently thrown upon the feet; (2) sudden
dorsal flexion, often with fracture of the inner malleolus; (3) forced
supination or pronation, the interosseous ligaments being stronger, the
bones forcibly pulling the latter apart; (4) violent traction upon the
heel through the calf muscles, by which the tuberosity of the calcis
may be torn from the rest of the bone; (5) extensive crushing injuries,
in which several tarsal bones may be involved; (6) gunshot fractures.
Some assistance in diagnosis may be obtained by computing the distance
from the malleoli to the bottom of the heel, which will be shortened
when the bones are compressed; or shortening of the length of the foot,
or by fixed abnormal positions.

The _metatarsal bones_ are broken by direct violence, the first and
fifth being most exposed. As in other fractures of the foot contusion
will be a serious feature, and swelling and laceration will frequently
seriously complicate, while the fractures themselves may be compound.
The same is true, also, of fractures of the _phalanges_, crushing
and comminution being common. The matter of treatment often includes
an estimation of the blood supply and of the vitality of the distal
portion. The operator may sometimes temporize with an antiseptic
dressing until this matter is settled. Simple fractures require only
immobilization in good position.




CHAPTER XXXV.

DISLOCATIONS.


A sprain has already been described as a momentary change of
emplacement or disturbance of the normal relations between joint
surfaces, which, so far as displacement is concerned, is but a
momentary affair and is promptly overcome. The term _dislocation_
implies something more permanent as well as complete in both respects.
It indicates an absolute and direct separation of articular surfaces
of much more than momentary duration and requiring skilled assistance
for its reduction. It pertains to articular surfaces which are enclosed
within a capsule. The term _luxation_ is synonymous with dislocation.
When the condition is evidently partial or incomplete it is often
referred to as _subluxation_. As compared with fracture dislocations
are about one-tenth as frequent.

Dislocations are described as _compound_ when through a co-existing
wound air may enter the cavity of the joint, and as _complicated_ when
accompanied by other lacerations or injuries. When unaccompanied by
these conditions they are described as _simple_.

To dislocations which result from external violence or from sudden
muscular action is given the term _traumatic_. _Pathological_
dislocations are those which are brought about by slow morbid
processes, muscle spasm being the most prominent factor in their
production. A third variety of dislocations, the so-called
_congenital_, do not belong strictly in this class; by common consent
the term is applied to congenital abnormalities where, from errors in
development, normal emplacements and relations are altered.

The distal bone is the one described as that which is dislocated; thus
we speak of dislocations of the forearm upon the arm, of the leg upon
the thigh, etc.

Subluxations or incomplete dislocations are frequently accompanied by
fracture of a bony prominence, _e. g._, the rim of the acetabulum,
the coronoid process of the ulna, etc. The direction in which the
distal member of the joint has been displaced is indicated by one of
the common terms, as forward, inward. A _consecutive_ or _secondary_
dislocation implies a shifting of position from that at first occupied
by the displaced bone end. These injuries may occur at any age,
although usually during the more active period of life, from childhood
to middle age, when mankind are more subject to injuries.

Certain conditions predispose to dislocations. Abnormalities or
previous injury or disease of joint structures figure especially in
this respect. A joint already relaxed by hydrarthrosis will exercise a
relatively small restraining influence and a subluxation, at least, may
easily occur.

The immediate cause is violence, either from without or within,
generally the former. This may be _direct_, as from a blow, or
_transmitted_, as when the shoulder is displaced by a fall upon the
open hand. It occasionally happens that the component bones of a
dislocated joint were in a position of extreme flexion or extension
at the time of injury. The factors of leverage and spiral tension or
wrenching are also important ones. Luxation from _muscular activity_ is
occasionally met with; most frequently when the lower jaw is dislocated
by the act of yawning or violent laughter. The shoulder has been
displaced in a violent effort at throwing or pitching a ball, or in
wild gesticulation.

A few individuals have been in the habit of exhibiting themselves
whose normal ligament and joint arrangements are so lax that they can
voluntarily displace one or more of them and as easily replace them.
These may be spoken of as instances of _voluntary_ dislocation.

A joint once displaced may never fully recover its normal degree of
tension, and will yield more readily to subsequent similar injuries.
In this way there may occur so-called _recurrent_ or _habitual_
dislocations. Expressions of this kind are seen most often in the lower
jaw and in the patella.

Actual injury to tissues is to some extent unavoidable. In arthrodial
joints the capsule is nearly always lacerated, at least upon one side.
In hinge joints both lateral ligaments are likely to be ruptured. It
is probable, however, that about the maxillary joints the ligaments
may stretch without tearing to any extent. Not only are ligaments torn,
but bony prominences are frequently detached, while sometimes there is
extensive tearing away of tissue.

In connection with these injuries to joints proper other complications
may occur, such as fractures of prominences about joints and epiphyseal
separations, or such injuries as compound fracture of the neck of the
humerus with dislocation of its head. Furthermore, bloodvessels are
occasionally lacerated and nerves are frequently injured. This latter
lesion is liable to occur after shoulder dislocations, the head of the
bone injuring the circumflex nerve, paralysis of the deltoid being the
consequence. This is a feature of the injury, and yet the result has
often been unjustly imputed to the physician in attendance. Even a
momentary contusion of the nerve may be followed by lasting effects,
for which the medical attendant should be held blameless. Other
injuries, _e. g._, contusions or lacerations of nerves, may occur about
any of the joints.

Dislocations of the spine subject the cord to a special class of
injuries which will be dealt with later in this work. In very rare
instances the head of the humerus has been forced within the thorax
or the head of the femur within the pelvis, these, injuries being
practically always fatal.

Compound dislocations rarely occur about the jaw or shoulder. They
pertain usually to the joints below. In every case of such character
the question will be promptly raised whether a more or less complete
exsection of the joint will not be preferable to mere reduction with
the ensuing probability of ankylosis. Such injuries will, under all
circumstances, require aseptic measures.

So far as _repair_ is concerned, dislocations by themselves are so
rarely fatal that there have been but few opportunities for a study
of tissue recovery under these circumstances. It is apparent that
repair is complete, for after almost any simple dislocation there is
restoration of function.

The obstacles to reduction are spasm of muscles pertaining to the
injured limb, by which the dislocated bone end is firmly held in its
abnormal position, and, in those joints provided with a capsule,
the fact that the head of the bone is frequently forced out through
a comparatively small opening, through which it is only with the
greatest difficulty reduced. It is a part of the manipulation in most
cases to enlarge this rent in the capsule, after which reduction is
comparatively easy, although impossible until it is accomplished.

Dislocations which have long gone unreduced are called _old_,
_inveterate_, or _ancient_. By common consent a period of six weeks
has been fixed, beyond which the dislocation is spoken of as old or
ancient; up to that time it is usually described as unreduced. In
proportion to the length of this period the difficulties of reduction
are materially enhanced. So soon as a dislocated joint has been put
at rest, _i. e._, fixed by muscle spasm and by the timidity of the
patient, the blood which has been poured out will begin to coagulate
and conditions are soon favorable for organization of clot and
formation of adhesions in abnormal position. In the course of a few
weeks these adhesions become strong, and in the course of months they
are frequently stronger than the bone itself, which has been disused
and has undergone a certain amount of fatty atrophy. Thus it happens
that even with well-directed effort the bone will yield before the
adhesions, and thus, in spite of every precaution, fracture sometimes
complicates the effort to reduce these ancient dislocations.

So generally is this fact now recognized that surgeons do not hesitate
to make open incisions for the purpose of separating adhesions and
reopening what remains of the capsule in the endeavor to replace the
head of a bone. Nor do they hesitate sometimes to cut down upon the
latter and exsect rather than run the risk of more extensive injury.

Efforts at reduction under these circumstances subject the patient not
only to risk of failure, or of fracture of bone ends, but to rupture
of vessels or laceration of nerve trunks. I recall seeing one case of
enormous traumatic aneurysm of the axillary artery which was brought
about by unsuccessful attempt in this direction.


SYMPTOMS AND DIAGNOSIS OF DISLOCATIONS.

The cardinal indications of a dislocation are _deformity with
alteration in contour and position_ of the affected joint. It usually
happens that the dislocated bone ends cannot be felt in normal
position, but are felt somewhere else in the vicinity. About the
shoulder and hip of stout or fat individuals it may not be easy to feel
the head of the bone, but unless the case be complicated by a fracture
it can usually be detected by aid of anesthesia. The deformity may
include a _lengthening or shortening_ of the limb, apparent or real,
as well as _abnormal eversion or inversion_, or other peculiarity of
position.

Whatever alterations in position appear will be accentuated by _spasm
of the muscles_ which pertain to the movement of the affected joint
or even of the entire limb. These are usually so tightly contracted
as to form a complicating feature of such cases and to lead to that
_loss of mobility_ which is diagnostic of every dislocation. Limitation
of motion is not entirely a matter of muscle spasm. It is not under
voluntary control and subsides only under anesthesia. To some extent
motion may be limited by escape of the head of a bone through a small
rent in the enveloping capsule, by which it is afterward tightly
clasped. This is particularly true of the shoulder and hip. Certain
dislocations of the fingers or thumbs are also made more rigid by
fixation of the tendons, which become tightly stretched within the
neighboring tendon sheaths.

A sort of _crepitus_, which may be easily mistaken for that of
fracture, is occasionally detected during the examination of a
dislocated joint. It lacks the peculiar grating character of true bony
crepitus.

In addition to these features there are certain subjective symptoms,
of which _loss of function_ is the most prominent, while _pain_ is a
more or less frequent but variable accompaniment, and dependent on
the amount of tissue injury or pressure upon nerves. Moreover, the
displacement once completely rectified (“reduced”) does not tend to
recur, as is the case with fractures.


PATHOLOGICAL AND CONGENITAL LUXATIONS.

The statements made above refer almost entirely to recent and traumatic
dislocations.

_Pathological dislocations_ are those which are produced gradually and
through the mechanism of disease affecting the joint structures. The
head of the bone is gradually drawn out of the acetabulum, in tonic
spasm of hip-joint disease, by the continuous action of muscles, the
result being the complete displacement of the bone from its original
socket, or what is known, at the hip, as the _migration of the
acetabulum_, where its upper margin, being softened by disease, is
gradually extended and altered, so that the femoral head rests an inch
or more higher upon the side of the pelvis than is normal. Pathological
dislocations, then, may occur both in the course of the infectious
joint diseases as well as in the neuropathic.

_Congenital luxations_ are those which occur from defect in the
shape or arrangement of joint structures, permitting a departure
from the normal standard. While no joint in the body is exempt from
abnormalities of this description, the congenital hip dislocations
are those which have attracted attention by their frequency and the
disability which they produce.

While the general character of these changes is easily made out by
the ordinary methods of examination, coupled with a suitable history,
a well-made skiagram will tell at a glance a story which it may take
some effort to elicit by other means; hence radiography has here been
of great value to the surgeon. Congenital dislocations are devoid of
nearly all the features which characterize traumatic dislocations, and
their consideration will be found in the chapter on Orthopedics.

_Differential diagnosis as between fractures and dislocations_ is
not always easy. Furthermore it is frequently the separation of a
prominence by fracture which permits of dislocation, this being
particularly true of the elbow and the ankle. The extent of a fracture
may seriously complicate the problem of treatment, as, for instance,
when the head of the humerus is not only dislocated below the clavicle
but separated from the shaft by fracture at the surgical neck. A
dislocation made possible only by fracture will not remain reduced as
will one which is simple and uncomplicated, while it will display even
a greater amount of motility and displacement. Other complications may
occur, many of which are common both to dislocations and to fractures
in the vicinity of joints, such as lacerations of bloodvessels or nerve
trunks, pressure upon the latter, compound injuries with infections,
etc.


TREATMENT OF DISLOCATIONS.

The essential requisite of every case is complete reduction or
replacement of the dislocated bone end. The earlier this is attempted
the better the result. Brief as such a statement is, dislocations
frequently offer considerable difficulties, both in reduction and in
maintenance in proper position with the necessary physiological rest of
the injured part. Thus dislocations of the clavicle, which can hardly
occur without considerable injury to the ligaments, may be reduced with
slight effort, but are kept in place with difficulty. The simplicity of
the after-treatment is proportionate to the difficulty experienced in
reduction, so that while “to put the part in place and keep it there”
sounds very simple, it will often perplex the ingenuity of the surgeon.

Reduction having been effected, rest is the essential feature of the
after-treatment, which should be absolute for a few weeks and relative
for many months. Should reaction be extreme, ice-cold applications will
afford relief.

The causes which prevent reduction of dislocation are either those
attributable to ignorance, carelessness, or failure in diagnosis
on one hand, or, on the other, mechanical difficulties, including
“button-holing” of the capsule around the expanded end of a bone or
the interposition of some of the adjoining tissues. Dislocations of
the class referred to above as unreduced or ancient, offer great
difficulties, proportionate to their duration, which are due to the
formation of adhesions that sometimes take place and become very
dense. Judgment, skill, and effort are needed in their management.
A dislocation which has become unreducible is only to be treated by
arthrectomy and the establishment of a false joint. Nevertheless
in a small proportion of cases, especially of the hip and shoulder
dislocations, the adhesions which first form gradually relax, and
in time there is formed a natural substitute for a joint which may
be regarded as a _nearthrosis_, and which will sometimes prove as
serviceable as any result afforded by arthrectomy. The duration of time
after which reduction is impossible or impracticable varies so widely
with different cases that it can scarcely be stated. It rarely is more
than a few months and often but a few weeks. It is greater when it is a
ball-and-socket joint which is affected.

Nearly everything that has been stated in the previous chapter
concerning compound fractures applies here to compound dislocations.
They are subject to the same dangers, both of infection and of injury
to important adjoining structures. There is the same necessity for
aseptic management if the case be seen early, and for antiseptic
treatment, including drainage, if seen late. In many instances there is
so much liability to subsequent ankylosis that the first treatment may
well be made to include an arthrectomy, or the total removal of a small
bone, _e. g._, the astragalus. Fortunately compound features are less
frequent in dislocations than in fractures.


SPECIAL DISLOCATIONS.


DISLOCATIONS OF THE LOWER JAW.

Unless accompanied by fracture there is but one direction in which
the condyle of the inferior maxilla can be dislocated, _i. e._,
_forward_. One side or both may be affected, _i. e._, dislocation may
be unilateral or bilateral, the latter being more frequent. It is rare
during the extremes of age, and most common during middle life. There
is considerable variation in the degree of tension of the capsule of
the maxillary joint. In some it is so loose that dislocation may occur
during the act of yawning or vomiting. Ordinarily it occurs only as
an expression of violence from without. By a blow which shall thrust
the jaw forward, whether the mouth be closed or open, the ramus may
be made to carry the condyle over the articular eminence. The capsule
is not necessarily torn, but is always tightly stretched, while as
a reflex result the temporal muscle is thrown into a condition of
tonic spasm by which the jaw is fixed and firmly held in its abnormal
position. This produces the symptoms, then, of a more or less widely
opened mouth, with rigidity and inability to close it, with protrusion
of the chin and tense contraction of the temporal muscle, which can be
easily recognized. When the dislocation is unilateral the symptoms are
essentially the same, save that the protrusion is toward the side that
is injured.


=Treatment.=--The method of reduction is simple and consists in
depressing the angle of the jaw, while, at the same time, the chin is
supported and carried both upward and backward. If temporal spasm be
not too pronounced the reduction is rather easy and may be effected
while the patient is seated in a chair, the surgeon standing in front
of him and grasping the jaw with the fingers of each hand, while the
thumb is utilized within the mouth to press the angle of the jaw
downward and backward. At the same time the fingers should lift the
chin. The operator should protect his thumbs by wrapping them with
some material in order that they may not be injured by the patient’s
teeth. Should muscle spasm offer much resistance it would be well to
administer nitrous oxide or one of the other anesthetics, at least to
the point of primary anesthesia, with sufficient relaxation of muscle
to make reduction easy. When once this has been effected the lower jaw
should be bound to the upper and kept at rest for at least two weeks.
When this injury has taken place it is likely to recur with much less
effort until it becomes almost a habit.

[Illustration: FIG. 338

FIG. 339

Reduction of dislocation of lower jaw.]

There is a condition of relaxation of the capsule and elongation, with
abnormal loosening of the interarticular fibrocartilage, peculiar to
this joint, by which it has too free play, to such an extent that a
clicking sound in its movements may be frequently heard by others than
the patient. This condition is either congenital or the result of
previous injury, and is one for which little can be done, although this
explanation should be afforded to all who suffer from it.


DISLOCATIONS OF THE LARYNX.

The _cartilages of the larynx_ are sometimes displaced as the result
of direct violence applied to the anterior region of the neck. Almost
any lesion of this character may take place between the independent
cartilages of the larynx or the attachments of the larynx to the hyoid.
The injury may simply give rise to pain and soreness, or may cause so
much interior damage as to be quickly followed by edema of the glottis
and suffocation. If the latter be impending a quick tracheotomy should
be done, after which time may be afforded for such replacement as may
be required, by manipulation, and subsidence of swelling with relief
from occlusion of the respiratory tract.


DISLOCATIONS OF THE STERNUM.

The various portions of the sternum, especially the upper and the
lower, may be displaced as the result either of direct violence by
forcible backward flexion, or by muscular action accompanied by flexion
of the trunk and neck. When the latter, it is usually forward; when
produced by violence, it is usually backward.

These displacements are sometimes so easily reduced by mere pressure as
to make it almost impossible to retain them. At other times anesthesia
with firm pressure, accompanied by flexion of the trunk backward or
forward, may be required; reduction has been possible sometimes only
through incision and by the use of instruments applied as levers, or
by the use of a screw driven into one of the fragments, thus affording
a handle by which to manage it. Serious dislocations are frequently
accompanied by fractures of the ribs or of the sternum. The same
fixation of the thorax is required as in fractures of these parts, and
should be conducted in the simplest manner possible.


DISLOCATIONS OF THE RIBS.

To displace a rib from its sternal connections requires actual fracture
of bone or cartilage. Forward dislocation at its posterior and spinal
connection, especially of the eleventh and twelfth ribs, has been
described. Considerable effort is necessary for its production, and the
case should be treated on its individual merits.


DISLOCATIONS OF THE CLAVICLE.

Either end or both ends of the clavicle may be dislocated. Its sternal
end may be thrown in any direction but downward; its acromial end in
any direction, although usually upward. Dislocations of the sternal end
can only occur in consequence of serious damage to the sternoclavicular
ligaments, because of which, and in the absence of a socket, it is
extremely difficult to maintain the parts when restored to position.
Violent backward traction upon the shoulder permits anterior
displacement when the joint is thus weakened. Backward displacement is
usually the result of indirect violence when the shoulder is forced
forward and inward, while upward displacement is the result of tilting
which occurs when the shoulder is violently depressed. Respiration
is generally more or less disturbed, while in backward luxations
deglutition may be made difficult and painful.

Reduction is not difficult to effect, but extremely difficult to
maintain. Pressure in the proper direction, accompanied by traction
upon the shoulder, suffices for the former. For the latter there should
be a combination of fixation of the shoulder and arm with proper
traction, and at the same time pressure upon the end of the clavicle.
For all of the clavicular dislocations the dressing and position
advised by Dr. Moore, of Rochester, and referred to in the chapter
on Fractures as his double figure-of-eight, serves admirably for
maintaining the proper position of the shoulder, while pressure can be
made by a pad, retained either by adhesive plaster or by some further
addition to the dressing itself. (See p. 494.) Acromial dislocation is
usually in the upward direction, and is produced by violence upon the
shoulder, which has expended itself in rupturing ligaments rather than
in fracturing the acromion process. The indication here is to keep the
shoulder elevated by any dressing which will accomplish the purpose and
the clavicle bound down.

[Illustration: FIG. 340

Position of clavicle in dislocation of sternal end upward.]

Dislocation of _both ends_, _i. e._, complete loosening of the bone,
occurs occasionally, in which case the indications already given are
reinforced, while the difficulties of treatment are considerably
aggravated. Here the shoulder should be kept upward, outward, and
backward, and the clavicle retained by pressure or some other means.


=Treatment.=--Clavicular dislocations yield fair results to intelligent
treatment. Ideal results are difficult to secure without coöperation
on the part of the patient. Functional results, however, are usually
satisfactory.


DISLOCATIONS OF THE SHOULDER-JOINT.

The upper end of the humerus is attached to the margin of the glenoid
cavity by a capsule which has a certain degree of elasticity, and which
resembles a short section of a sleeve or a cuff. It is sufficiently
loose to permit a wide range of motion, and were it not for the
acromial process above it there would be as much motility in the
upward direction as in any other. It is not the capsule which keeps
the articular surfaces together, but the tension of the muscles which
are wrapped around the shoulder-joint, all of which contribute to
this effect. The glenoid cavity is made a more complete socket by
a fibrocartilaginous rim. Thus a certain degree of subluxation or
displacement may be permitted without very serious damage to this rim
and capsule, but a complete dislocation is hardly possible without more
or less laceration. The prominence and exposure of the joint and its
natural freedom of motion help to account for the fact that more than
half of all dislocations occur here, and that this rarely ever occurs
in children or in the aged, in whom the violence which may be expanded
produces either epiphyseal separations or fractures of the surgical
neck. The relation of structure to function also accounts for their
far greater frequency (_i. e._, four to one) in men than in women. The
influence of atmospheric pressure should not be forgotten, as in the
shoulder this affords a force of some fifty pounds, and in the hip of
nearly double that amount, of pressure.

[Illustration: FIG. 341

  Subcoracoid.

  Subclavicular.

  Subspinous.

  Subglenoid.

Dislocations of the head of the humerus. (Erichsen.)]

[Illustration: FIG. 342

Relation of circumflex nerve to the head of the humerus, explaining
mechanism of deltoid paralysis. (Marion.)]

For convenience of description, and in the order of their frequency,
shoulder dislocations are referred to as _anterior_, _downward_,
_posterior_, and possibly _upward_, when combined with acromial
fracture. Anterior displacements vary in degree, so that they are
described as _subcoracoid_ or _subclavicular_. Complete displacement in
this direction can only occur through a rent in the anterior portion of
the capsule, while the subclavicular muscle is pushed away or torn. The
nearer the head of the bone rests to the sternum the greater the amount
of laceration of the capsule, while its posterior portion is either
stretched tightly or torn. In aggravated cases the tendon of the biceps
is also torn out of its groove (Figs. 341, 343 and 344).

[Illustration: FIG. 343

Subclavicular dislocation. (Lejars.)]

[Illustration: FIG. 344

Subcoracoid dislocation. (Lejars.)]

In the downward or _subglenoid luxations_ the capsule is lacerated
lower down. These displacements occur when the shoulder has been
dislocated with the arm in the extended and elevated position. Here the
head of the humerus is found in the axilla, resting against the border
of the scapula, and the axillary structures, especially the circumflex
nerve, usually sutler, while the external rotators are either ruptured
or their insertions detached (Fig. 345).

[Illustration: FIG. 345

Subglenoid dislocation. (Lejars.)]

The posterior or _subspinous_ dislocation is the least common of all.
In its production the arm is apparently adducted and the elbow raised.
Here the humeral head is found beneath the posterior surface of the
acromion or beneath the spine of the scapula (Fig. 341).


=Symptoms.=--The indications of shoulder dislocation are _pain_;
_flattening of the shoulder_; _undue prominence of the acromion_;
_depression opposite the glenoid cavity_, with loss of the rounded
contour due to the presence therein of the head of the humerus;
_appearance of a more or less globular mass_ in the position now
abnormally occupied by the head of the humerus; _change in the axis_ of
this latter bone; _inability to bring the elbow to the side_; more or
less complete loss of function, and more or less spasm of the muscles
about the joint. Owing to the fact that the thorax presents a curved
or warped surface, to which a straight line can be tangent only at one
point, it results that the _hand of the injured side cannot be made to
wrap itself over the opposite shoulder while its elbow still touches
the chest or side_ (Dugas’ test).


=Diagnosis.=--As between fracture and dislocation the surgeon may
be greatly helped by deciding that the head of the humerus is still
in its proper position; that the deltoid is not flattened as in
dislocation; that the arm is shortened rather than lengthened; that
motility is increased rather than diminished; that bony crepitus is
usually obtainable, and that replacement, which may be comparatively
easily secured, is maintained only so long as the parts are held in
position by the operator’s hands. An additional sign of value is the
fact that a straight edge cannot ordinarily be made to touch the tip
of the acromion and the external condyle of the humerus at the same
time, because of the protrusion caused by the presence of the head of
the humerus in its socket. When the straight edge can be so applied
it must be either because the head of the bone is out of the socket
or the upper end of the bone broken. A still more crucial test which
should, however, only be applied when others prove unsatisfactory, may
be furnished by passing a sterilized hat-pin through the sterilized
skin over what seems to be the displaced head of the bone and into the
globular mass. Rotation of the humerus will then cause its end or head
to make an excursion which will be quite distinctive.

[Illustration: FIG. 346

Exhibits a subcoracoid dislocation and the position of the patient in
his endeavor to find relief from pain. (Mudd.)]


=Treatment.=--Prompt reduction is the only treatment for shoulder or
other dislocations. This may be first attempted without anesthesia.
Should muscle spasm prevent easy reduction it should be relaxed by an
anesthetic, for which purpose nitrous oxide will often suffice. In
the forward or forward and downward dislocations it will sometimes
be sufficient to simply make firm traction in a direction obliquely
outward and upward, with rotation. When this is insufficient it may
be assumed that there is more or less laceration of the capsule and
entanglement of the head of the bone, as well as that it is caught
around the border of the glenoid cavity, against which it is firmly
held.

The above simple maneuver failing, the luxation is to be reduced by a
more scientific manipulation, in which traction figures largely, the
method now generally in vogue being that suggested by Kocher, by which
rotation and leverage are added to traction, and a minimum of power
made to do a maximum of good. Kocher’s method is especially applicable
to the anterior displacements. It consists of a triple manipulation
whose three stages are portrayed in Figs. 347 to 349. The first
procedure is to flex the forearm to a right angle with the arm, apply
the former firmly to the side, and then, while keeping the elbow at the
side, forcibly rotate the limb outward until the forearm points away
from the body (Fig. 348). This having been done the arm is abducted
and the elbow moved upward until the limb is in the horizontal plane
of the shoulder, the scapula being held firmly during these movements,
as shown in Fig. 348. After the arm has been brought to the level of
the shoulder it is rotated inward and brought downward by a process
of circumduction, the elbow being made to describe some part of the
arc of a circle as it comes down. The displaced head should slip into
place during this movement, and will do so unless the capsular tear is
too small. In that case the movements should be repeated, perhaps with
more force, until the opening is sufficiently enlarged to permit the
button-hole in the capsule to slip over the head of the bone.

[Illustration: FIG. 347

First position in Kocher’s rotation method.]

[Illustration: FIG. 348

Arm is being carried forward and upward toward second position.]

[Illustration: FIG. 349

Completion of third movement in Kocher’s method.]

This method of manipulation, with such modification as circumstances
may require, or such addition as pressure with the hand or fingers of
the assistant, has superseded all the older more crude and forceful
methods, and proves sufficiently applicable for all cases. It is
assumed that the operator has sufficient judgment to modify any method
to fit the exigencies of a given case, else he should not proceed
with it. For instance, in the axillary dislocations upward traction
affords valuable assistance. In the subspinous form the arm is raised
to a level while extension is made upward and forward. In other words,
all these methods depend upon the combination of traction, rotation,
and leverage. The old method of Astley Cooper, with the foot in the
axilla, the shoe having been removed, coupled with traction upon the
arm and swaying movements, combined with rotation, abduction, and
adduction, may be made effective, but is not nearly as elegant as the
simpler manipulation above described. On the other hand, old, unreduced
dislocations, complicated with adhesions, are often exceedingly
difficult.

In rare instances dislocations several months old have been reduced
after adhesions have been broken up by more or less violent
manipulations. When forcible efforts of this kind prove futile fair
restoration of function may be obtained by maintaining regular motion,
at first passive, later active, to prevent reformation of adhesions,
the head of the bone gradually forming a new and false socket for
itself. Finally, the method of excision can be employed should occasion
demand. The experience of a number of surgeons has shown that in old
cases, or those impossible of reduction by justifiable force, an open
division of the joint, with severance of those tissues which prevent
reduction, may be profitably, safely, and satisfactorily practised.
Porter and McBurney, among the American surgeons, have devised a
corkscrew instrument which may be driven into the head of the bone, by
which manipulation after arthrotomy is materially facilitated.

The _simultaneous occurrence of fracture and dislocation_ has been
treated of in the previous chapter. When difficulty presents the best
result will be obtained by open incision, replacement of the head of
the humerus, and fixation of fragments by sutures, wire or otherwise.
If seen late the upper fragment should be removed. The possibilities
of aseptic surgery have led to the abandonment of the old method of
first permitting the fracture to unite and then attempting to reduce
dislocation.

Physiological rest is the essential feature of the after-treatment of
all these cases, a sling and a retentive bandage being sufficient for
the purpose. Function should be restored by an increasing degree of
motion.

One of the most serious complications of shoulder dislocations is
_deltoid paralysis_ from injury to the circumflex nerve. The momentary
pressure of the head of the bone upon the nerve is sufficient to more
or less permanently impair its function. In its medicolegal aspect it
should always be maintained that the surgeon is never to blame for the
accident, and is only to some degree blamable in case he has failed
to diagnose the dislocation so soon as opportunity was afforded and
has thus permitted prolonged pressure to possibly intensify the effect
which has already been produced by the injury.[42]

  [42] The shoulder is liable to numerous injuries that produce
  disability. Pain in some of these conditions may be almost constant
  and spread upward to the neck and be aggravated by even passive
  motion. Loss of power varies from moderate paresis to complete
  paralysis. When the circumflex nerve is especially involved it is the
  deltoid which shows the effects. More severe injuries may involve the
  muscles of the arm and the forearm. Muscle atrophy may be greater
  than can ordinarily be accounted for by mere disease. In rheumatic
  patients a dry synovitis may be added to the other complications.
  Most of these features are due to traumatic neuritis. When aggravated
  they may result from rupture of nerves or cicatricial formations
  around them. The best treatment consists of immobilization for three
  or four weeks to favor nerve repair, counterirritation, especially
  with the flying cautery, over the roots of the branchial plexus,
  with massage, electricity, and even deep injections of strychnine to
  stimulate the paralyzed muscles. When paralysis is persistent and
  scar tissue seems to press upon nerves, exposure of the plexus and
  freeing its branches from all source of pressure will be necessary.


DISLOCATIONS OF THE ELBOW.

The irregularities of the elbow-joint have permitted a complicated
dovetailing of its component parts which would seem to make
dislocations almost impossible without fracture. Nevertheless, and
especially in the tender years of childhood, both bones may be
dislocated in either direction, or either bone of the forearm alone in
any direction save toward the other. Diagnosis will be greatly aided by
observance of the anatomical facts stated in the section on fractures
of the elbow-joint and by an estimate of the relative positions
occupied by these bony landmarks. When, however, intense swelling
prevents this then we should either wait for its subsidence or depend
upon a skiagram.

The most common dislocation is that of _both bones backward_, one of
the possible consequences of a fall upon the extended arm and palm of
the hand. The coronoid process may rest beneath the joint end of the
humerus, making the dislocation incomplete, or back of it, making it
complete. If the coronoid process has been broken off the dislocation
can be made and reduced as often as desired. The fan-shaped lateral
ligaments are always more or less lacerated. The arm will be partially
bent and there will be prominent deformity upon the posterior aspect of
the joint while the axes respectively of the arm and the forearm will
be somewhat disturbed. Usually the lower end of the humerus can be felt
in front of the normal situation of the elbow-joint (Figs. 350, 351 and
352).

Reduction is more or less easily accomplished by traction with an easy
movement, by which the upper end of the forearm shall be directed
toward its proper position.

_Lateral displacements_ result also from falls in extreme positions.
Lateral dislocations are rare and the result of violence, and may
compel amputation. In these cases the lateral diameter of the joint is
markedly increased, while the normal relation of the condyles to the
olecranon is greatly altered. In these cases movement is painful and
limited.

[Illustration: FIG. 350

Backward dislocation of both bones. (Lejars.)]

[Illustration: FIG. 351

Outward displacement of both bones. (Lejars.)]

The _ulna alone_ may be dislocated backward, in which case the
orbicular ligament must be lacerated and the upper ends of the
adjoining bones forcibly separated. The olecranon will present back of
its proper position, while the head of the radius will rotate where it
belongs.

[Illustration: FIG. 352

Dislocation forward and outward of head of radius. (Lejars.)]

_Anterior dislocation of both bones_ is exceedingly rare unless
complicated by fractures of the olecranon. When thus injured the
forearm is lengthened and fixed. The posterior surface of the humerus
here has only a skin covering, the condyles are bulging, the olecranon
fossa empty, and the upper ends of the forearm bones felt in front of
the elbow.

The _head of the radius_ alone may be displaced in any direction save
toward the ulna. The _forward_ dislocation is the most common, which
may be produced by a fall upon the overextended and pronated hand.
The orbicular ligament here is lacerated or the head of the radius is
slipped out of it. In the latter case it may be difficult to replace
it. When dislocated _backward_ the capsule is torn posteriorly as well
as the orbicular ligament (Fig. 353).

[Illustration: FIG. 353

Position of the bones in an old unreduced dislocation forward of the
radius. (Erichsen.)]


=Treatment.=--The treatment of elbow dislocations is based upon general
and but slightly differing principles. It consists of a combination
of traction with sufficient force, made with one hand, while with the
other pressure should be made upon one or both bones in the desired
direction; at the same time by a combination of swaying and rotary
movements more or less massage may be given to the parts, by which
complete reduction may be more easily effected. Anesthesia is nearly
always necessary, not alone for the relief of pain, but to produce
muscular relaxation, by which manipulation is materially assisted.

A peculiar form of dislocation of the head of the radius in young
children has received considerable attention. It is produced by a firm
pull upon the wrist or forearm, as in lifting or jerking a child by
the forearm or hand. Pronation of the hand is usually a feature of
the injury. It is probable that the head of the bone is pulled out of
the orbicular ligament and displaced forward. The forearm is slightly
flexed, movements of the elbow are very free, except that supination of
the forearm meets with resistance. The displacement is rectified by a
forced supination with traction. An epiphyseal separation of the head
may simulate this injury. Such cases necessitate a few days’ rest in
a splint, with the arm flexed and supinated, although recovery often
occurs without particular restraint.


DISLOCATIONS OF THE WRIST AND HAND.

Wrist dislocations are rare, the _posterior_ being more frequent than
the _anterior_. It simulates the deformity of a Colles fracture, and is
produced in a similar way. The deformity is more marked, the outlines
of the various bones more distinct, except in front, where they may be
masked by the flexor tendons. There is no alteration in the relations
of the styloid processes. The _forward_ dislocation may possibly
simulate Smith’s fracture, the symptoms being the reverse of those
above mentioned.

Firm traction, with pressure in the proper direction upon the carpus,
will suffice for reduction of these cases. The subsequent dressing may
be practically that of a Colles fracture.

The _lower ends of the ulna and radius_ are sometimes dislocated from
their proper relations. Reduction is easy, but rest and restraint are
required for some time until the ligaments have recovered their tonus.

Of the _carpus_ the _os magnum_ is the only one likely to be displaced,
it being occasionally forced backward so that it forms a projection
on the dorsum of the hand. It requires extreme force to displace the
carpal bones, enough frequently to produce other injuries at the
same time, some of which may be compound. A carpal bone which cannot
be reduced to position by pressure may be safely removed through an
incision.

Of the carpometacarpal dislocations, the _thumb_ is the most frequently
displaced, usually in a backward direction. Traction and pressure
suffice for its reduction. When the bone is forced forward it is
usually as the result of direct violence. Wherever the base of the bone
may rest it is easily detected, while pressure with traction suffices
for its replacement.

Of the dislocations of the _phalanges_ upon the metacarpus those of
the thumb are the more frequent. This may occur as the result of
a fall, by which the thumb is forced backward into a position of
hyperextension. Nearly all of these dislocations are accompanied by a
rupture of capsule. Those of the thumb are difficult of reduction; this
appears to be due to the tendons of the short flexor, which surround
the head of the metacarpal bone. The sesamoid bones also furnish a
source of difficulty, while the long tendons, when contracted by their
respective muscles, increase it (Fig. 354).

[Illustration: FIG. 354

Metacarpophalangeal dislocation.]

Treatment, especially of the thumb dislocations, is facilitated by
first exaggerating the abnormal position, then making traction and
pressure in the proper direction at the same time. Special forceps have
been devised for seizing and holding the digits, or a clove-hitch can
be thrown over the thumb or finger. Extension should not be first made
in the axis of the metacarpal bone, but rather _at an abrupt angle to
it_ in order to relieve the expanded phalangeal end. The majority of
writers concede that in some cases reduction is practically impossible.
When effort has proved futile the parts should be sterilized and
incised, the incision being utilized for open reduction or for
excision, as deemed best.

Dislocations of the other phalanges are usually easily recognized and
treated by traction and pressure.


DISLOCATIONS OF THE HIP.

Hip dislocations constitute about 5 per cent. of the total. As they
are produced by violence they are much more frequent in men, and occur
mostly between the ages of twenty and fifty years. Before the twentieth
year epiphyseal separations often take place, while after the fiftieth
year violence will usually break the neck of the femur. Nevertheless
dislocations may occur at any age. The hip is a ball-and-socket joint,
with a deep socket still further extended by cartilage, in which the
head of the bone is not only retained by the ligamentum teres, but by
atmospheric pressure, which in the natural state furnishes a factor
of perhaps one hundred pounds. The strongest muscles and tendons of
the body envelop the joint. When dislocation occurs the capsule is
usually torn along its inferior aspect. The limb is usually in an
extreme position, or it would require more violence to tear the head
from the socket. The anterior dislocations occur during abduction
without outward rotation; posterior dislocations occur during flexion.
Thus when a person is stooping over in work and a heavy weight falls
upon the back the head of the bone is more easily pushed backward,
especially if the feet be close together.

While hip dislocations are classified for convenience, and because
of their final form, the head of the bone may rest upon almost any
segment of the margin of the acetabulum, though within a short time
it will assume a position justifying a designation as _anterior_ or
_posterior_, meaning thereby in front of or behind Nélaton’s line.
This is, moreover, a convenient distinction, as the symptoms vary
between the two groups. Another classification is into the _forward_,
the _backward_ or _backward and upward_, and the _downward_, which
are again referred to as _iliac_, _ischiatic_, _dorsal_, and
_supracotyloid_ among the posterior, and _perineal_, _obdurator_,
_suprapubic_, etc., among the anterior (Fig. 355).

Allis, however, has simplified the subject by showing that all forms
of dislocation escape primarily from the lower segment, shifting their
position later either upward or downward. He classifies them as follows:

  1. Lower thyroid. } All present the general characteristics of
  2. Middle thyroid.} adduction and rotation outward.
  3. High thyroid.  }

  1. Low dorsal.    } All present the general characteristics of
  2. Middle dorsal. } abduction and rotation inward.
  3. High dorsal.   }

The relation of the so-called Y-ligaments to the successful reduction
of these dislocations, as well as to their formation, is of
considerable importance.

[Illustration: FIG. 355

Upward and somewhat backward on dorsum ilii.

Backward toward sciatic notch.

Downward into foramen ovale.

Forward and upward on the pubic bone.

Dislocations of the head of the thigh bone, according to Astley
Cooper’s classification. (Erichsen.)]

Fig. 356 illustrates the manner in which this ligament receives its
name, it being simply a reduplication of fibers which strengthen the
capsule and which are arranged in the shape of an inverted Y. No
matter how serious the injury it is seldom entirely detached. While it
prevents too great displacement it is of special service in that it
may be made to serve as a fulcrum for the leverage required in certain
manipulations. American surgeons are entitled to the credit for the
establishment of the importance of this ligament in this consideration,
and while Bigelow’s name is most prominently mentioned, the names of
Gunn, of Chicago, and Reid and Moore, of Rochester, New York, deserve
almost equal prominence, not only for their anatomical studies, but
for working out the entire method of manipulation which has completely
supplanted the old and more violent methods in which the use of pulleys
and tackle was not infrequent. The Jarvis “adjuster,” a powerful
mechanism, which was formerly employed for this purpose, is not now
seen except in museums.

[Illustration: FIG. 356

Inverted Y-ligament.]


=Symptoms and Signs.=--These vary decidedly in the different forms.
In every case where the head of the bone rests on a higher level than
the acetabulum there will be shortening. In nearly every instance a
certain degree of flexion is present. In anterior displacements there
is generally abduction and outward rotation. When the head of the
bone is beneath the pubes or in the obturator foramen the limb may
be lengthened as well as flexed, while the trochanter is shifted to
a correspondingly lower position. In most instances the head of the
bone can be felt in its abnormal position, and muscle spasm is always
a pronounced feature, especially when there is actual elongation and
muscles are really stretched. In the backward displacements adduction
and inward rotation are the conspicuous features, the reverse of those
of forward dislocation. When the head of the bone is actually in the
ischiatic notch, and even when it is on the dorsum of the ilium, the
limb is the more flexed, while the trochanter will be found above
Nélaton’s line. Figs. 357 and 358 illustrate the two types of anterior
and posterior displacement, with the usual and predominating postural
features, while Figs. 359, 360, 361 and 362 (from Lejars) portray the
anatomical features of the four principal types in graphic form. By
these can be determined the class to which the dislocation belongs.

[Illustration: FIG. 357

Anterior dislocation of head of femur. (Lejars.)]

[Illustration: FIG. 358

Posterior dislocation of head of femur. (Lejars.)]

This classification into the anterior and posterior seems to the
writer to simplify the general subject and to be serviceable for its
particular purpose and place. Inasmuch as anesthesia is nearly always
required for these injuries it may be expected to clear up difficulties
in diagnosis by its aid.


=Treatment.=--Through the anatomical researches of the surgeons above
named, as well as those of Allis and others, the method of reduction
of hip dislocations is practically always that by _manipulation_,
and is in nearly every instance commenced with _flexion_. In fact a
considerable number of backward dislocations can be reduced almost
alone by flexion and rotation with traction, the patient being upon his
back, preferably upon the floor, and the surgeon standing over him.
While anesthesia is not necessary in all cases it affords sufficient
assistance to justify its general employment.

In the backward dislocations, the patient and surgeon being in position
as above, it is well to employ the Kocher method, which consists of (1)
inward rotation, by which the capsule is relaxed and the head of the
bone carried from the pelvic surface; (2) flexion to a right angle,
preserving the existing adduction and inward rotation; (3) traction, by
which the capsule is made tense and the head of the bone raised to the
level of the socket; (4) outward rotation, by which the posterior part
of the capsule and the outer band of the Y-ligament are tightened and
the head turned forward into the socket.

[Illustration: FIG. 359

FIG. 360

FIG. 361

FIG. 362

Illustrating various types of dislocation at the hip. (Lejars.)]

During the practice of this or any other method the pelvis should be
firmly held in place by assistants, who may seize it with the hands
and hold it down. If the patient lay upon the table the pelvis may be
bound to it. The surgeon may need help in making a sufficient degree
of traction. This can be furnished by a strong loop passed under
the patient’s knee and over the surgeon’s shoulders, the hands thus
remaining free for manipulation, traction being the most important
feature.

Stimson accomplishes the same purpose by placing the patient, face
downward, upon a table, the dislocated limb hanging downward as
represented in Fig. 363. Traction is here partly affected by the weight
of the limb, while in some instances the surgeon has to wait only for
the muscles to relax and the bone to resume its place without much
further effort than a slight rocking or rotation. Stimson claims that
this often succeeds without anesthesia, and sometimes so quietly that
there is scarcely any jar or sound to indicate the effection of the
reduction.

[Illustration: FIG. 363

Reduction of dorsal dislocation of the hip by the weight of the limb.
(Stimson.)]

In those forms of dorsal dislocation which are accompanied by _eversion
instead of inversion_ it is necessary only to convert them into the
ordinary dorsal type before proceeding as above.

In high displacement of the head of the bone traction should be made in
the extended position, by which the head will be brought back of the
acetabulum, and then proceed as above.

Of the _anterior_ dislocations the obturator is perhaps the more
common, while for its reduction the following directions usually
suffice: The limb is flexed toward the perpendicular to disengage the
head of the bone, then rotated inward and adducted while the knee is
carried to the floor. As Bigelow suggested, in this maneuver we may
need the aid of a towel passed around the upper part of the thigh, an
assistant making upward and outward traction while the operator is
bringing the limb downward. Inward rotation is likely to transform the
dislocation into a posterior one. On account of this fact, Kocher would
give the following advice: (1) Flex the thigh to a right angle with the
pelvis, preserving abduction and outward rotation until (2) traction is
made, by which the posterior part of the capsule is tightened and the
head brought nearer the socket; then (3) forcible outward rotation is
made, which should bring the head upward and backward into place.

A _perineal_ dislocation is usually accompanied by laceration of the
capsule. This will permit of easy reduction, which can probably be
effected by traction in the axis of the limb in its abnormal position
and by direct pressure, with some rotation or rocking.

The _pubic and suprapubic_ dislocations require forcible flexion with
traction in the axis of the limb, followed by inward rotation and
circumduction of the knee. Some of these maneuvers are illustrated in
Figs. 364 and 365.

So of the other dislocations of the hip; an application of principles
similar to the above, coupled with such assistance as may be afforded
by manipulation, practised by the operator, or by traction, with the
help of an assistant, will usually suffice.

If a general rule could be formulated covering all cases it would be
of great assistance. I have been in the habit of quoting a rule of
this character, which I first saw mentioned in the American edition
of Bryant’s _Surgery_, edited by Roberts, to the following effect:
(1) Flex the leg on the thigh and the thigh on the body; (2) carry
the knee as far as it will go in the direction in which it already
points; (3) carry the knee to the extreme in the opposite direction and
combine this movement with circumduction and traction. In the backward
dislocations these manipulations should be accompanied by traction
made with one of the operator’s hands in the popliteal space. In the
anterior displacement backward pressure instead of traction can be
made by pressing upon the knee. I have found this an admirable working
direction.

[Illustration: FIG. 364

Reduction of a dorsal dislocation of the hip by traction. (Erichsen.)]

[Illustration: FIG. 365

Reduction of a dislocation by rotation. The thigh is flexed, slightly
adducted and rotated inward, as in the first stage of reduction of a
dorsal dislocation. (Erichsen.)]

The _after-treatment_ of hip dislocations consists mainly in rest
and quiet. These should be enforced, at least by a binder around the
pelvis, and, if necessary, a starch or plaster-of-Paris protection. The
anterior suspension splint affords a comfortable and efficient method
of treating these cases after the first few days. (See Fig. 322.) Very
little liberty should be allowed the patient until the expiration of
the first month.


=Ancient and Unreduced Dislocations.=--The longer a hip dislocation
is allowed to go unreduced the more difficult is its replacement.
The expiration of six weeks will usually make a hip reduction very
difficult, while after a lapse of three or four months it becomes
wellnigh impossible. The longer a limb is disused the more do its
osseous structures atrophy. Therefore a fracture of the neck of the
femur or upper end of the shaft may occur in attempting to reduce
an old luxation. The most marked obstacles are offered by formation
of adhesions about the femoral head in its new position, and the
shrivelling or change in shape of the capsule, whose opening may be
distorted or obliterated, so as to make reëntrance impossible within it
of the head of the bone.

Other things being equal, then, more force and wider range of motion
are necessary in reducing the older dislocations, while success may be
attained only by the expenditure of wellnigh all the muscular energy
of a powerfully built man. Attempts prolonged too far produce serious
laceration, with hemorrhages, which tend to encourage new adhesions
in case of failure. If a dislocated hip cannot be reduced by any
apparently safe procedure the operator should decide whether to leave
it, in the hope of securing a false joint, or to cut down the parts
and make such further division of tissues as may be necessary. Should
this be contemplated it implies, of course, that each case should be
adjudged upon its merits.


DISLOCATIONS OF THE PATELLA.

By various contractions of the quadriceps muscles the patella may be
displaced _outward_, it being practically slipped over the external
condyle. The same result may be produced by a blow from the inward
direction and in the extended position of the limb. These displacements
may be _complete_ or _incomplete_; in the former case the flat plane
and inner edge of the bone are directed forward instead of sidewise.
_Inward_ displacements are unusual and usually produced by direct
violence. Such previous disease as shall have weakened the capsule,
or caused its distention, permits these dislocations to occur with a
minimum of violence. In fresh cases the capsule is usually torn.

_Reduction_ is easily effected by lifting the limb, thus relaxing the
quadriceps muscle and making pressure and manipulation in the indicated
direction. An anesthetic may be given if thought admissible.

When the limb is partially flexed, and a blow is received on the edge
of the patella directly from the front, it is occasionally rotated
on its tendinous axis, so that without being displaced from its
position in front of the condyles its articular surface looks inward
and it rides the knee upon its edge. This is referred to as _vertical
rotation_. It is relieved and replaced by suitable manipulation, a
feature of which may be sudden and forcible flexion with external
pressure.

The patella once displaced the joint structures are left more or
less permanently impaired, and recurrence of the lesion is by no
means uncommon. Some individuals, the young especially, have the
habit of “slipping the knee-pan,” this implying that at least partial
displacement occurs easily with comparatively slight provocation.
Sometimes children become so accustomed to this that they learn how to
care for it themselves.


=Treatment.=--After every knee dislocation protection should be
afforded for a considerable period. In habitual dislocations it may
be justifiable to make lateral incisions and to excise an elliptical
portion of the capsule, by which its dimensions may be reduced and its
undue laxity abolished.


DISLOCATIONS OF THE KNEE.

The _head of the tibia_ is occasionally displaced as the result of
accident, though frequently this is the result of joint lesions. A
traumatic dislocation can scarcely occur without considerable injury
and internal derangement of the joint structures proper. _Anterior_
dislocation may occur when the femur is forced backward or the leg
forward in severe accidents. Here the popliteal vessels may undergo
such pressure and injury as to constitute a serious complication. The
_backward_ dislocations are less common, though likewise the result of
violence. It matters not whether the thigh be fixed and the leg forced
in either direction, or whether the leg be caught and fixed while the
body is made to displace the femur; such injuries are not likely to be
mistaken. They are likely, also, to be accompanied by _displacement of
the semilunar cartilages_. _Lateral_ dislocations are practically the
result of force, often combined with torsion. Injury to the lateral
ligaments, usually extensive laceration, should accompany them.

Dislocations of the knee are more or less easily reduced, in theory at
least, by forcible traction and manipulation, and with the aid of an
anesthetic. Absolute rest, preferably in a plaster-of-Paris splint, is
requisite.

The _semilunar cartilages_ are occasionally torn loose and more or less
displaced, either toward the notch or toward the exterior of the joint.
A cartilage so displaced will project, as a rule, at the upper margin
of the tibia. These injuries may occur alone or as a complication of
more serious forms described above.


=Symptoms.=--These displaced cartilages produce symptoms simulating
those of movable bodies in the joint--that is, disability depending
upon the extent of the original injury and the direction of the
displacement. The movable cartilage may be either pulled into place
by flexion or manipulated until it returns there, but will frequently
reappear when the leg is straightened. It sometimes becomes so
entangled in the joint as to cause almost complete disability. When
movable anteriorly it may be recognized along the upper border of the
tibia. The same sudden disability may be produced here as when there
are other loose or movable bodies in the joint. The patient may be able
to indicate that there is something movable in the joint.


=Treatment.=--Non-operative treatment consists in sufficient limitation
in the motion of the joint with abstention from use of it. In cases
not amenable to non-operative measures the joint may be opened and
the cartilage fastened in place to the head of the tibia either with
absorbable or non-absorbable sutures.


=The Fibula.=--The upper end of the fibula, although firmly bound to
the tibial head, may be dislodged by direct or indirect violence.
Forcible inward rotation of the foot, in full extension, will sometimes
displace it _forward_, while forcible traction on the biceps may
dislocate it _backward_. Displacements at this joint may occur when
the leg bones are broken, while when the tibia alone is broken and
shortened _upward_ displacement may occur in consequence. Should
displacements be discovered it will not be difficult by traction
upon the foot and leg, in the normal direction, and by pressure to
replace them. The backward displacement is the more unstable of the
two. The _lower end_ of the fibula is by itself rarely dislocated or
distorted except in connection with violent sprains, accompanied by the
laceration of ligaments or fracture of one or both bones.


DISLOCATIONS OF THE FOOT.

_Backward_ and _forward_ displacements of the foot are possible without
fracture; as, for instance, when violence is applied to the leg after
the foot is caught and fixed. Even here, however, the lateral ligaments
must suffer partial or complete laceration, while one or both malleoli
may be broken. The most frequent displacements of the foot are those
which accompany and are permitted by fractures of the lower part of the
leg, notably that originally described by Pott, with its troublesome
form of bone lesions. An _inward_ dislocation of the foot is described
as produced by extreme supination and adduction.

It is necessary in studying these injuries to the ankle region to make
out the existence of fracture, if any be present, as the treatment
hinges largely upon such complication.

The _astragalus_ may be dislocated from its relations with the lower
ends of the leg bones, as the result of wrenches or twists or of
violent injuries, as falls or blows upon the feet. When displaced it is
nearly always forward. A backward dislocation is exceedingly rare. The
rest of the foot itself is sometimes dislocated backward beneath the
astragalus, although some portion of its lower surface still remains
in contact with the upper surface of the calcis. These displacements
occur in consequence of combined torsion and excessive violence. The
foot here will be shortened anteriorly. No matter in what direction the
astragalus may be displaced it is easily recognized.


=Treatment.=--Reduction of ankle-and-foot dislocations accompanied by
fracture is not a difficult matter, although their retention may be;
but astragalus dislocations which are complicated are usually difficult
of replacement. They will require relaxation of muscle tension by
anesthesia or tenotomy and forced manipulations. When accomplished good
function results. Better results may be obtained by exsection.

Many of these more serious forms of dislocation are _compound_. In such
cases removal of the astragalus, or a more or less typical resection of
the ankle-joint, may be judicious. In crushing injuries, either primary
or secondary amputation may be necessary.

In general it may be said of the bones of the foot that one which
resists reasonable effort at reduction, when displaced, should be
removed. Various displacements of the tarsal bones, as the result of
direct violence, may occur, as well as of the metatarsal and phalanges.
Many of them may be reduced by judicious pressure and manipulation,
but the violence which inflicts the displacement will frequently make
the injury so compound that excision or partial amputation may be
necessary.




PART VI.

SPECIAL OR REGIONAL SURGERY.




CHAPTER XXXVI.

INJURIES AND SURGICAL DISEASES OF THE HEAD.


THE SCALP.


ERYSIPELAS AND CELLULITIS.

Erysipelas and cellulitis of the scalp are the result of the same
infections and conditions as when encountered in other regions,
but are peculiarly prone to occur here because of the liability to
infection from the hair with the material concealed in and upon the
surface. They frequently lead to suppuration, in which case abscesses
form that may extend inside the cranium, or into the frontal or other
sinuses. These are common about the orbit and in the upper eyelid, and
unless speedily incised may lead to gangrene. Multiple abscesses are
also common. Disturbances of sight and hearing as sequels of these
infections occasionally occur. The principal danger from these purulent
collections pertains to intracranial infection or general sepsis,
usually of pyemic type.

[Illustration: FIG. 366

Pneumatocele of cranium. (Warren’s Surg. Obs., 1867.)]


GASEOUS TUMORS OF THE SCALP.

The most common of these tumors is ordinary emphysema, which may result
from injury to the upper and lower air passages. Thus fractures of the
nasal bones or of the base of the skull may permit of distention of the
subcutaneous cellular tissue by forcible inspiration of air. Emphysema
of the scalp may be a valuable diagnostic feature in certain instances,
as after fractures of the upper bones of the face. When connected
with a wound it should be enlarged in order to permit the escape of
contained air. Otherwise these puffy swellings disappear spontaneously
by absorption of air into the veins. In cases of malignant or
gangrenous emphysema early and numerous incisions are necessary, after
which antiseptic solutions, etc., should be used.


=Pneumatocele.=--A pneumatocele is a chronic gaseous tumor, being a
cavity distended with air which has escaped from the cells of the
underlying bone, bounded on the outside by the scalp and beneath by the
cranium. They are found about the mastoid or the frontal regions. Not
more than three dozen cases are on record. In consistency these tumors
are elastic, while the escape of air upon pressure is sometimes heard
on auscultation. Their explanation is usually a defect of the inner
wall of the mastoid cells, through which air may be forced from the
pharynx through the middle ear by violent effort, or similar defect
in the ethmoidal cells by which air is forced anteriorly. Bony defects
which might permit this condition are seen in a small percentage of
craniums.


=Treatment.=--The best results in the way of treatment have been
achieved by puncture, with the injection of weak iodine solution (Fig.
366).


TUMORS OF THE SCALP.

Tumors of the scalp may be divided into the _congenital_ and the
_acquired_, as well as into the benign and malignant.

Of the congenital tumors the dermoids are of most interest. Originally
the dura and the skin were in contact, and the cranial bones develop
later between them. This explains the occurrence of dermoids either
beneath or outside of the bone or their simultaneous appearance and
possible connection. Many of the so-called atheromatous cysts or
wens are of dermoid origin. Those which are extracranial need only
antiseptic incision or excision. It will often be sufficient to split
such a cyst with a bistoury, after which each half of the sac can
be detached from the bed in which it has lain. Should intracranial
connection be discovered the bone chisel and sharp spoon will be
necessarily called into employment. Some of these dermoids perforate
into the orbit, and may have to be followed into that location.

Most varieties of tumors, benign or malignant, may be met with in this
region. Subcutaneous collections of _fat_ are not so common, nor are
_fibromas_. Various _bony_ growths may be met, while in certain cases
the signs of brain pressure are to be explained only by their extension
within the cranium.

_Malignant tumors_ are common about the scalp and the cranium;
they assume, however, no conventional appearance, and are seen in
any shape or form, those of the scalp alone occurring either as
carcinoma or epithelioma from its epithelial elements, or as sarcoma
from its mesoblastic elements. Tumors primary in the periosteum or
bone are necessarily of sarcomatous nature, while those of the type
which perforate to the surface may be either sarcoma or possibly
endothelioma. The general character of these growths has been referred
to previously. In regard to their extirpation (for there is no other
treatment than this) operations of varying degrees of severity may be
required. (See Cysts and Tumors and Tumors of Bone.)

[Illustration: FIG. 367

Osteosarcoma of the temporal region. Metastatic tumor in the arm and
thyroid. (Parker.)]

The superficial epithelioma should be attacked before it has become
adherent, in which case everything should be removed down to the
underlying periosteum, after which a plastic operation will permit the
repair of the defect, so that primary union of the whole surface may
be secured. Any malignant growth which is adherent to the underlying
cranial bone calls not only for removal of its own substance, but for
that of the bone to which it is attached. To fail in this is to invite
recurrence. This may necessitate more or less extensive osteoplastic
resections of the bone, but the condition permits of no middle course.
Extensive resections of bone have been made with success, and need not
be abstained from unless there be good reason to fear involvement of
the dura or cortex. In this case the advantages and dangers should be
carefully weighed before proceeding to operation. During operations on
the bone great care should be taken, especially in certain regions,
to avoid injury to the intracranial sinuses, although it has been
learned that these may be ligated and intervening portions removed.
But the wounding of the sinus by the point of an instrument or spicule
of bone may lead to a hazardous and annoying complication, and is to
be prevented when possible. A small wound in a sinus may be plugged
with gauze, which may remain for two or three days. There is always a
possibility of air embolism (see pp. 38 and 363) when the sinuses are
opened, as their walls do not easily collapse. Hemorrhage from the
soft parts may be almost entirely controlled by the use of an elastic
tourniquet stretched around the skull. Oozing veins in the diploë or
in the bone may often be secured by pressing the tables of the skull
together with bone forceps, while at other times an antiseptic wax
can be forced into the interstices of the bone and hemorrhage thus
checked. In certain cases where it seems impracticable to slide flaps
and cover defects the desired end may be obtained by skin grafts, after
Thiersch’s method.

A rare and specialized form of blood tumor, seen only on or within
the cranium, is the so-called hernial dilatation of the superior
longitudinal sinus. It may present through openings in the bone;
sometimes pressure upon it will cause vertigo and perhaps greater
prominence of adjoining veins, even of the jugulars.


NON INFLAMMATORY DISEASES AND CONGENITAL CONDITIONS OF THE SKULL.


=Incomplete Formation of Bone (Aplasia Cranii).=--Incomplete formation
of bone is occasionally met with. The bone is a secondary formation in
the skull, the dura and skin being originally in contact; consequently
this condition can be easily explained as a failure to develop bone
where it is normally produced. These defects are most common in the
frontal and temporal regions. The bone may fail also to develop to
ordinary thickness, and may be found as thin as paper or ossifying only
in certain directions. Supernumerary bones may also develop, apparently
to take the place of those previously lacking. _Aplasia_ may also be a
_unilateral_ defect and contribute toward the formation of meningocele.
_Atrophy_ or _anostosis_--_i. e._, complete disappearance of cranial
bones--is occasionally observed. It may be an interstitial or an
eccentric process, and may happen at any point or at several spots.
Up to a certain extent it is the rule in the skulls of the aged, when
the bones become reduced to the thinness of paper or may in certain
places completely disappear. _Senile atrophy_, in other words, is a
normal process, and is to be expected after the sixtieth year of life,
its possibility being not forgotten when operations are undertaken
upon the skulls of those advanced in years. Eccentric atrophy may also
occur from pressure of soft or hard tumors, among them the so-called
Pacchionian bodies. It is also stated that increasing hydrocephalus may
produce an internal and eccentric anostosis.


=Craniotabes, or Cranial Rickets.=--It is particularly in the skull
that the manifestations of rickets are most common, the bone becoming
unduly thick and the general shape being changed. Usually there is a
flattened vertex with delayed ossification, with an abnormally firm
union along the suture lines. In spite of these changes, the bone often
becomes affected by pressure to such an extent that a rachitic or
hydrocephalic child, confined to bed and moving little or not at all,
will develop a skull showing the effect of such pressure. Many rachitic
skulls show areas of atrophic thinning, dispersed irregularly, while
the inner surface may show the markings of the convolutions impressed
upon it by the softness of the bone (Fig. 368). (See Rachitis.)

[Illustration: FIG. 368

Craniotabes (rachitis). (Bruns.)]


SURGICAL AFFECTIONS OF THE CRANIAL BONES.

The acute affections of bones have been considered in Chapter XXXII.
_Acute periostitis_ is, in the main, due either to syphilis or to an
infection following injury. In the latter case it proceeds from the
margin of the wound, and may spread to a considerable distance. It is
in some instances secondary to deeper infection extending from the
middle ear, and then is found posteriorly to the ear and externally to
the mastoid cells. Congenital openings or defects of the sutures about
the mastoid seem to have much to do with the travelling of infectious
lesions in these localities.

[Illustration: FIG. 369

Osteoma of skull. (Mudd.)]

[Illustration: FIG. 370

Same as Fig. 369, seen from below.]


=Acromegaly and Leontiasis= have been considered on pages 437 and 438.


=Acute Osteomyelitis.=--Acute osteomyelitis is due to essentially the
same causes as those just discussed. In this case it is especially in
the diploë that the principal ravages occur. Unless promptly recognized
and relieved by surgical measures this is likely to lead to sepsis
of the pyemic type and at a relatively early period, the venous
arrangement of the diploë favoring such type of disease.


=Necrosis of the Skull.=--Necrosis of the skull is ordinarily the
result, directly or indirectly, of injury, in which case it is usually
of the acute form, a fragment, which has been too much separated
from its surroundings to live, giving evidence of early and easily
recognizable death. This necrosis is mainly confined to the external
table. Necrosis of slow origin is due either to tuberculosis or
syphilis, perhaps more often to the latter. Under a cold abscess of the
scalp or subperiosteal abscess will often be found a small area of dead
external table which needs complete removal. Necrosis has also been
observed to follow severe burns of the scalp. It is usually combined
with caries of adjoining bone. The caries produced by syphilis is
illustrated in Fig. 371.

[Illustration: FIG. 371

Syphilitic caries of cranium. (Bruns.)]


INJURIES TO THE HEAD PREVIOUS TO AND DURING BIRTH.

_In utero_ the head is surrounded by amniotic fluid and is well guarded
against injury. Nevertheless as the result of penetrating wounds or of
falls on the part of the mother real injuries do occasionally occur.
Most of the cases of skull fracture reported as occurring before birth
have occurred during delivery. _Multiple fractures_ of the skull of
either character have been observed.

During the process of parturition there nearly always appears a tumor
of the scalp in the newborn, known as the _caput succedaneum_, at
the point where pressure upon the head has been least. It usually
disappears quickly after birth. It is due to a collection of blood,
partly an extravasation, as the result of compression or injury. It is
composed also of edematous soft tissues of the surface. If incised,
blood-stained serum is poured out. When this fails to rapidly resorb
during the first days of the infant’s existence, and especially if it
fluctuate, it may be incised under antiseptic precautions and blood
clot be turned out. In rare cases it suppurates, by which is produced
an acute abscess, which should be promptly evacuated.

A collection of fluid blood between the periosteum and the bone is
known as the _cephalhematoma neonatorum_, such a lesion occurring on
an average once in two hundred cases. It is generally found over the
fissures, and appears to be produced by the sliding of the bones.
This collection also usually promptly disappears. In case of failure
it may be aspirated or incised. Before resorting to any operative
procedure it would be well to make a careful distinction between a
possible meningocele or encephalocele, as a congenital defect, and
cephalhematoma as an accident of delivery.

[Illustration: FIG. 372

Fracture of right frontal bone in a newborn infant; fracture extending
into orbit. (Bruns.)]

A depression in the skull of a newborn child which does not quickly
right itself or yield to expanding influences from within should not be
allowed to go uncorrected, as serious lesions ordinarily of paralytic
type may result therefrom. In these days of aseptic surgery there is no
reason why such operation as may be necessary to elevate a fragment or
an entire bone should not be performed, with the usual precautions.


IMPORTANT POINTS IN THE SURGICAL ANATOMY OF THE SKULL.

The young and the aged have no distinction of tables of the skull, but
the diploë which separates the two tables is an affair of middle age,
develops slowly, and disappears after the same fashion--sometimes to
such an extent as to leave the skull of almost paper-like thinness. In
all operations, then, upon the young and the old the surgeon should
proceed with extreme caution, as if expecting to find the skull quite
thin. The lower limit of the squamous bone proper is the so-called
mastosquamosal suture, and operations confined to the squamous plate
alone are safe from injuring the sigmoid sinus on its inner side. The
ridge at the posterior root of the zygoma indicates, by its lower
border, the level of the mastoid antrum. A few lines above this is the
level of the base of the brain. The _mastoid_ is present at birth and
appears externally by the second year. Its _antrum_ is present also
at birth, though its air cells do not develop until after puberty,
their location being previously occupied by cancellous tissue. Most of
these cells open into the antrum, a few directly into the tympanum.
They are not always separated from the sigmoid sinus by bone. The
partition between them is perforated by minute veins, forming an easy
communication between the sinus and the antrum. Air escaping from the
mastoid cells into the overlying tissue may cause emphysema from a
basal fracture. In all operations upon the mastoid antrum the operator
should keep to its outer side, and the higher and the more closely to
the posterior zygomatic ridge he makes the first opening the more sure
is he to escape injuring the facial nerve. The _groove for the sigmoid
sinus_ extends to the jugular foramen from a point on the outside
corresponding to the asterion. The _lateral sinus_ may be indicated
externally by a line from the superior border of the mastoid to the
inion--_i. e._, from the asterion to the inion.

The _frontal sinuses_ are usually separated by a septum, which is often
incomplete or wanting. They are variable in size and outline, and do
not develop until after the seventh year. The _infundibulum_, by which
they empty into the nasal cavity, is often so small that when the
lining membrane is involved it becomes closed, and retention, with its
accompanying symptoms--pain, tenderness, swelling, etc.--may ensue.
Ulceration and erosion, however, may cause perforation internally
through the supra-orbital plates, so that pus may penetrate through the
inner half of the orbit.

Aside from its direct communication the superior longitudinal sinus
connects with the basal sinuses through the middle cerebral and the
Sylvian veins, while communications with the middle meningeal veins are
abundant. Where the frontal and diploëtic veins enter the longitudinal
sinus there frequently are dilatations in which marasmic thromboses
often originate. This sinus is also connected with the veins of the
nasal septum, so that a septic phlebitis may be propagated from the
nose. So much of the lateral sinus as is contained in the sigmoid
groove is known as the _sigmoid sinus_, which connects directly with
the exterior through the mastoid and the posterior condyloid veins. In
sinus thrombosis this mastoid vein is likewise affected. One or more
condyloid veins accompany the hypoglossal nerve through the anterior
condyloid foramen, and may also serve for the propagation of infection
or exit of pus.

While septic particles may be carried from any part of the lateral or
sigmoid sinuses--usually through the internal jugular--they may also
be carried by way of the other veins above mentioned or the occipital
sinus, all of which empty directly into the subclavian without passing
through the internal jugular. These sinuses are all rigid tubes, always
open, while the veins are thin and flexible, their caliber constantly
varying with inspiration and expiration. The sinuses contain no valves,
and these are very rare in the cerebral veins.

So far as the _lymphatics_ are concerned there is free and easy
communication between the internal and external plexuses and nodes.
Into the superficial nodes, along the external jugular, outside of
the deep fascia, empty all the external lymphatics of the head.
Intracranial infection shows itself in swelling of the deep cervicals
beneath the deep fascia. Lymphatics are abundant in the dura, and
pathogenic organisms, once housed within the dura, find it easily open
to invasion. The potential interval between the dura and the arachnoid
is termed the _subdural space_, when considerable effusion may occur
without marked symptoms, owing to its easy diffusion, while blood here
poured out may travel even to the lowest parts of the spine and cause
death by pressure upon remote points.

The _arachnoid_ bridges over the convolutions and does not extend into
the sulci. It is not vascular; at certain points it is adherent to the
pia, at others it does not touch it. The _subarachnoid space_ is formed
in the latter way, and within it most of the cerebrospinal fluid is
contained. This space is unevenly distributed over the brain surface,
most prominently beneath the posterior two-thirds of the brain, where
there is a wide interval between the arachnoid and the pia, extending
forward around the medulla and pons and as far forward as the optic
nerves. This space connects with the ventricles by the foramen of
Magendie, as well as with the sheaths of the cranial nerves. Where
these nerves escape from the brain or cord they are covered by all
three membranes, the layers being most distinct along the optic nerves.
Fluid injected into the subdural space may pass along the spinal nerves
as far as the limbs. It is essential to realize this in order to
appreciate how extensive is the surface exposed in leptomeningitis.

Internal hydrocephalus is often the result of closure of the foramen of
Magendie. The cerebrospinal fluid is rapidly reproduced after traumatic
escape. External hydrocephalus or accumulation in the subarachnoid
space, is a condition frequently due to tuberculous infection.

The _pia_ is the vascular coat of the brain, supplied with an extensive
network of fine nerve fibers derived from the sympathetic and the
cranial nerves, having intimate relations with the brain, to such an
extent that leptomeningitis and encephalitis are almost inseparable.
The nerve supply to the cerebral membranes explains the severe pain of
meningitis.


INJURIES TO THE SOFT PARTS OF THE CRANIUM.

In direct connection with what has been stated above it is well to
emphasize that the venous communications between the exterior and
interior of the cranium are numerous, and that the frequency of these
anastomoses explains the ease with which extracranial infections are
propagated within; in other words, these explain the frequency of
septic mischief in the brain after external injuries.


=Penetrating and Incised Wounds.=--Penetrating and incised wounds are
frequent about the head, their prognosis _per se_, as well as their
proper treatment, varying but little from that of such wounds in other
parts, so long as the skull proper and its contents escape injury.
Hemorrhage from scalp wounds may be profuse and even fatal. The most
dangerous hemorrhages occur from the temporal vessels. Penetrating
wounds are short, and the periosteum and underlying bone are usually
also injured. Such small articles as blades of penknives, particles of
dirt, etc., will often be found when the parts are carefully inspected,
a measure never to be neglected. Contusions of the scalp and skull are
spoken of as subcutaneous, subaponeurotic, or subperiosteal, and are
most frequent in the frontal and lateral regions. Ecchymoses following
them may be extensive and discoloration may spread over a large area.
In traumatic hematomas resulting from various injuries incision should
be an early resort should blood clot fail to resorb.


INJURIES TO THE CRANIAL BONES.

All conceivable degrees of injury to the bones, from a trifling
division of the periosteum down to most extensive denudation or
mangling of the external table or the entire thickness of the bones,
may be encountered. These lesions may be spread over a large area or
may be the result of penetrating wounds. In other words, we may have
linear, penetrating, or large surface wounds, with such injury to the
scalp as perhaps to amount to a total loss of covering for the same.
All of these, moreover, may be complicated by fractures of the bone at
the point of injury, with or without brain lesions, or by other and
more remote lesions.

In regard to most of these, it may be said that _non-penetrating
injuries_, when promptly and properly attended to, have, in most cases,
a favorable prognosis. Every _penetrating wound_ of the cranium is a
condition justifying grave prognosis, on account of the great danger of
infection incurred. Other features of these wounds, with more in regard
to prognosis and treatment, will be given under the head of Compound
Fractures of the Skull, etc.

It is necessary, however, to say in this place that penetrating wounds
of the cranium are often received in a way which does not permit
actual diagnosis, as, for instance, when received through the nose
or the orbit. Every wound whose history and appearance indicate that
penetration may have occurred should be subjected to the most rigid
scrutiny and care. Points of fencing foils, umbrella tips, etc., have
been forced into the brain cavity through the orbit and elsewhere in
ways which left little external evidence of the severity of the injury.


FRACTURES OF THE SKULL.

Following the anatomists, and for general convenience, these are
divided into _fractures of the vertex_, of the _lateral region_, and
of the _base_, the former being the most frequent as the vertex is the
most exposed. A fracture in a given region may be confined to that
locality or may radiate widely or extend nearly around the cranium. Of
all the fractures of the bony skeleton those of the skull constitute
about 2 per cent.


Fractures of the Vertex of the Skull.

Fractures of the vertex are, in most instances, due to actual violence,
the force being often expended at the point of application or producing
radiating fractures. Those which are limited to the neighborhood of the
injury are referred to as _direct_ fractures, in distinction to which
we have _indirect_ or _radiating_, often producing remarkable results.
Fractures may vary between the simplest crack or fissure, accompanied
by but trifling brain symptoms and never recognized, to the most
extensive comminution and destruction of cranial bones which can be
imagined.


=Splintered or Comminuted Fractures.=--Splintered or comminuted
fractures refer to the formation of numerous bony fragments, which are
often more or less loosened, sometimes completely so, occasionally
dovetailed together, and often driven in or depressed. Such fractures
are direct. It is possible to have comminution without depression; the
latter makes it the more grave condition.

Fractures with absolute loss of substance may be made by gunshot
injuries or by any extensive splintering or by a penetrating body. It
is possible to have _fracture of one table without that of the other_,
this being often true of the external table. In isolated fractures of
the inner table there is often dislodgement of small fragments which
may injure the dura and possibly produce later epileptic or irritative
disturbance. When the external table is chipped off the diploë is
exposed, and this with its wonderfully fine venous communications opens
up a wide area to infection and subsequent pyemia.


=Gunshot Fractures.=--Gunshot fractures are always depressed and almost
invariably comminuted. The bullet of the modern army rifle possesses
a great initial velocity, and the cranium struck by it will probably
be disrupted into fragments, causing instant death. The majority of
gunshot fractures of the skull seen in ordinary civil practice are due
to revolver or pistol bullets from weapons of the prevailing type.
In these instances there will usually be penetration, perhaps with
perforation of the skull, and the formation thus of one or of two
compound fractures, the wound of entrance being always comminuted and
depressed, while fragments of bone may be scattered along the course of
the bullet, which may also carry infectious material from without, such
as hair, particles of hat, and the like (Figs. 373 and 374). (See also
Figs. 52, 53 and 54.)

[Illustration: FIG. 373

FIG. 374

Gunshot fracture of skull. (Helferich.)]

Whatever may be the wisdom of operating in other cases where there is
room for doubt as to the proper course there rarely is uncertainty as
to the proper treatment of gunshot wounds of the skull, which _should
be invariably subjected to operation_.

It will thus be seen that fractures of the skull may be _simple_ or
_compound_, or _complicated_ with other injuries, or _depressed_,
without any reference to whether they are simple fissures or more
extensive injuries. On the other hand, depressed and comminuted
fractures may occur without being compound in a surgical sense, and
with each one of these injuries there may be accompanying disturbance
of the brain of any degree of severity, from the mildest concussion or
shock up to rapidly fatal compression. Any imaginable complication of
these head injuries is not beyond the bounds of possibility.

The essential features in explaining the _mechanism of fractures_ of
the vertex are the area involved and the violence of the impact. The
skull is often surprisingly elastic, even in the oldest individuals,
and fractures occur ordinarily when the natural limits of elasticity
have been exceeded and bone cohesion overcome. Children particularly
suffer from depression without fracture, which formerly was never
operated upon, but which is now regarded as requiring operation.
On the other hand, certain skulls are _abnormally fragile_ (see
Fragility of the Bones, Chapter XXXII), and among the insane may be
found so porous and yielding as to be easily pressed out of shape. In
injuries of slight extent it is sufficient that the skull be regarded
as composed of an elastic substance, while for injuries produced by
greater violence the skull is to be considered rather as a globe or
arch possessed of high resistance and elasticity, whose shape will
probably yield more or less before a fracture results. Much may be
learned from such experiments as those of Félizet, who filled skulls
with paraffin and dropped them from varying heights, and then divided
the bone, to note in numerous instances that, although the bone had
not been fractured, it had yielded at the point of impact to a degree
producing a marked depression in the paraffin beneath. After various
injuries, especially to the top of the head, the shape of the skull
may be altered and its diameters affected. Many fractures, then, are
the result of a _bursting force_, which may be shown by the fact that
hair has been found included within apparently closed fissures, and
even on the dura. Moreover, particles of bullets have been found within
the skull without any visible opening through which they could have
entered, showing that the bone has yielded under impact for a fraction
of a second. In certain injuries to the head, as when a man is struck
to the ground, there is injury at two points nearly opposite.

Fractures of the skull, especially of the vertex, possess surgical
interest mainly as they are accompanied by more or less evidence of
_intracranial complications_. So long as there is no evidence of
hemorrhage or laceration within they are ordinarily regarded as a
feature of the external wound with which they are usually found, and
unless there be comminution, depression, or some other good reason for
operating they are covered over as the wound is closed and are left to
the natural process of repair by formation of minute callus or by the
ossification of granulation tissue.

It is unfair to contrast the results of the surgery of today with those
of the pre-antiseptic era. Rules then enforced are now abrogated.
One respect in which we violate precedent is in our disregard of the
_periosteum_ or pericranium. This is sacrificed without hesitation
when found to be infected or torn or lacerated beyond repair. A flap
of scalp will adhere as readily to denuded bone as to periosteum, and
skin grafts can be applied and will adhere to this same bone--if not
upon the first day, a little later when granulations have appeared. In
the various plastic operations necessitated about the head we may also
transplant flaps upon otherwise uncovered bone without the slightest
hesitation. Fractures should be treated mainly in accordance with
intracranial complications, or through what can be seen either through
the wound or through an opening intentionally made under antiseptic
precautions for purposes of exploration. It is conceded to be better
policy to remove fragments of bone whose vitality is uncertain and to
sacrifice tissue injured or lacerated to such an extent that sloughing
would probably follow or be so exposed as to have become infected.


=Diagnosis of Fractures of the Vertex.=--In the absence of an open
wound, and unless incision be made, diagnosis of fractures of the
vertex is necessarily conjectural. In the presence of a wound diagnosis
is usually easy. In case of a small puncture it will be better to
enlarge it sufficiently to permit the introduction at least of the
finger. With the finger and the eye we seek to detect differences in
level, depressions, fissures, etc. Mistakes arise from the formation of
an exudate or a clot, by which a depression of the soft parts may be
regarded as depression of the bone. Error occasionally arises from the
existence of previous atrophy of the bone or any congenital defects in
ossification of the skull; also in the skulls of syphilitic patients
where disappearance of a gumma is often followed by absorption of the
underlying bone. In case of doubt exploratory incisions should be made
under aseptic precautions. These should not be made, however, unless
the attendant is ready--_i. e._, has the facilities immediately at
hand--for carrying out any further operative procedure that may be
necessary, as elevation of fragments, removal of foreign bodies, etc.
Error also may arise from mistaking for fracture a deceptive circular
effusion of blood which frequently occurs beneath the scalp after
injury. Areas of bloody infiltration often have abrupt margins which
are calculated to easily deceive. In children, more especially, we
often have a circumscribed bloody tumor which may contain cerebrospinal
fluid rather than pure blood. In some of these cases after exploration
there will be found material resembling brain matter, which, however,
is not always such, although real brain substance may escape, caused
by rupture of the overlying membranes. Should it be noted that the
fluid used for irrigating and cleansing such a wound begins to pulsate,
it will imply connection with the cranial cavity, and, obviously,
fracture. A suture should not be mistaken for a line of fracture. This
mistake is more easy when Wormian bones are present. Blood may be
wiped away from a suture line, but not from that indicating fracture.
It is not often possible to diagnosticate an isolated fracture of the
inner table. It happened, however, once to Stromeyer to notice that so
soon as an injured patient assumed the horizontal position he began
to vomit, and that nausea subsided when he was placed in the upright
position. On autopsy it was found that there had occurred a depressed
splintering of the inner table with perforation of the dura--less
irritation was produced in the upright position than when the
patient was lying down, which accounted for his vomiting when in the
horizontal posture. When a comminution has been produced it is always
of prognostic value if an unbroken dura be found. Prolapse of brain
substance is a serious complication. Escape of cerebrospinal fluid is
relatively rare. _Rising temperature after these injuries is always a
sign of danger._


=Treatment.=--Treatment comprises attention to the local injury and
the suitable dealing with the condition of the brain within when
injured. The treatment of _simple fractures_ is _expectant_. In the
absence of indication for operation it should be simple, and should
consist of physiological rest, aseptic dressings, ice applications to
the head, the administration of such laxatives, diuretics, antacids,
etc., as may be necessary to favor free excretion and to guard against
autointoxication. Whenever there is reason to suspect a depression,
exploratory incision should be made. _Actual depression_, whether the
fracture be compound or not, _requires operation_. This course is
justified by the numerous instances in which later consequences have
been noted, such as traumatic epilepsy, insanity, etc.

_Compound injuries_ should always be operated upon in some manner,
which includes the removal of loosened splinters, the elevation
of depressed bone, the removal of foreign matter, the checking of
hemorrhage, the excision of bruised and lacerated tissue, and the
proper closure of the wound, with or without drainage.

In serious and lacerated cases it is inadvisable to close the wound
with the view of attempting primary union. It should be packed with
gauze and temporarily closed with secondary sutures. These measures
should be seconded by _physiological rest_ (quietude of the head,
which may even be enforced by the posterior plaster-of-Paris splint
to the head and neck), attention to the _primæ viæ_, the avoidance of
transportation, the prevention of auto-intoxication, etc. The surgeon
should use discrimination as to the amount of bone to be removed, the
wisdom of opening the dura when not lacerated, of examination of the
brain with the exploring needle, the matter of drainage, and the time
during which it shall remain. With reference to all these matters exact
rules cannot be given. When drainage is made in recent cases it is
usually sufficient to drain the scalp wound. Only in cases where there
is probability of meningeal infection is it advisable to attempt to
drain the dural cavity. This is better accomplished with gauze, catgut,
or folded rubber tissue than with drainage tubes.

Skull fractures where the injury is limited to a small area are treated
according to a bolder method than was in vogue a number of years ago.
There should be _careful and judicious operating in every case where
distinct depression can be made out_, as well as in every case where
indications point to injury of parts within the bone. The statistics of
trephining in the pre-antiseptic era are valueless as arguments in this
consideration. If done according to aseptic precautions, and if good
surgical judgment be used in every respect, the operation is _per se_
almost devoid of mortality and should not be regarded as a last resort,
but rather in such cases as a first one. I have seen so many instances
of later untoward consequences resulting from delay, which corroborate
the experience of others, that I would not be misunderstood in this
matter. My advice might perhaps be summed up in the following words:
_Where there are no brain symptoms and no skull symptoms, in fractures
of the vertex, let the case alone; when either of these are present,
especially the former, it will always be advisable to operate._


Fractures of the Base of the Skull.

In the majority of these fractures the violence is applied at some
more or less distant point, and, by transmission through the arch-like
structure of the skull, expends itself in fissuring or comminuting
the base. The most frequent location of the indirect injury is upon
the convexity. The mechanism of these fractures has been a problem
for many centuries, but has been cleared up mainly within the past
three decades. Félizet has shown, for instance, how the handle of a
hammer may be forced into its head by striking it in either one of
two different ways, and has compared the mechanism of basal fractures
to this fact. The secret of these fractures probably resides in the
elasticity of the skull, which varies within wide limits in different
individuals, and which breaks, as do the ribs and the pelvis, at points
more or less distant from that at which the injury occurred. Were
the skull everywhere equally thick and elastic, there would be much
less variation in these fractures, but lacerations frequently extend
between the most resistant parts; and when violence is applied upon
the forehead we find that the resulting fissure extends between the
crista and the wings of the sphenoid, upon the same side, in its course
toward the base; that when the lateral region of the skull is injured
the fissure extends between the sphenoidal wings and the occipital
bone; and that when the occipital region receives the first injury the
fracture lies between the pyramid and the occipital crests. The analogy
between fractures of the skull and cracks made in nutshells (cocoanuts,
etc.) when struck with a hammer is too self-evident to be disregarded.
Many years since the French introduced the term _fracture by
contre-coup_ (counter-stroke)--a practical admission of the occurrence
of fracture at a point more or less opposite to that struck.

[Illustration: FIG. 375

Fracture of base of skull. (Bruns.)]

[Illustration: FIG. 376

Fracture of base by fall on vertex. Both condyles broken off and driven
in. Vertex was fissured.]

There is, however, no certainty about these fractures. Extensive
fissures of the vertex are almost always extended to the base of the
skull, while the reverse is seldom true. There are doubtless also
many cases in which a bursting force compromises the bone rather than
mere radiation of unexpended violence; but so long as skulls conform
to no fixed mathematical figures nor proportions, and are composed of
bones varying in shape, density, and strength, it will be impossible
to formulate any laws which are sufficiently comprehensive to be
satisfactory. Fractures in the posterior fossa occur most often through
violence applied posteriorly and from below. There is a ring form of
basal fracture produced mainly by the impact of the vertebral column,
as when an individual falls upon his head the weight of the body
forcing the cranial base in upon the brain.

[Illustration: PLATE XLII

Fractures of the Base of the Skull. Illustrative lines of fissure or
fracture are printed in red.]

Fractures of the anterior fossa may involve the roof of the orbit; even
facial bones may participate in the injury. These considerations are
not without importance, for if a patient presents symptoms of injury of
the petrous bone, and if these be accompanied by injury to the lateral
region of the skull, we are in a position to make a diagnosis of
fracture of the middle fossa. (See Plate XLII, and Figs. 375 and 376.)

By all means the majority of basal fractures are mere _fissures which
open and close instantly upon their production_--close so quickly,
in fact, as scarcely even to include blood between the broken bony
surfaces.


=Prognosis.=--The majority of basal fractures are fatal, either
because of injuries to the brain, or of hemorrhage or violence along
the nerve trunks, or from infection extending along the newly opened
paths. Other things being equal, the longer the fissure the greater the
danger, particularly so when it takes its origin in the vertex, and
because of greater ease of infection. _Air infection_ may occur in any
basal fracture by fissures extending into the various air-containing
cavities--nose, ears, sinuses, etc. They are then practically compound,
though invisibly so. The general prognosis will depend, first, upon
the _injury to the cranial contents_; second, upon _the possibility
of infection_. Statistics are absolutely unreliable, although always
possessing interest. Numerous museum specimens show the perfection with
which bony repair may occur and the admirable way in which compensation
is afforded for defects. Suppuration after basal fractures is mainly
that due to purulent basal meningitis, in which case the brain symptoms
dominate in the clinical picture, while the appearance of a single drop
of pus in the ear or upon the surface is of the greatest significance.
The _conversion of a serous outflow_ (_e. g._, from the ear) _into
purulent fluid_ is also _pathognomonic_. Various _paralyses_,
principally of the cranial nerves, may follow this injury and prove
temporary or permanent. Diagnosis is often made by a study of these
special nerve lesions.


=Diagnosis.=--The most significant diagnostic features are:

1. _Spread of blood from the point of fracture until it appears as an
ecchymosis at certain points beneath the skin_: This will occur early
in some cases and late in others. It may appear beneath the _skin_ or
beneath the _conjunctiva_ or other _mucous membranes_, even in the
pharynx. Occurring about the _mastoid_, it implies fracture of the
middle or posterior fossa; about the _eyelids_, of the anterior fossa.
Beneath the bulbar conjunctiva it means extravasation along the optic
sheath, probably from within the dura. In fractures of the posterior
fossa it will come to the surface of the neck, but only after two or
three days. The ecchymoses about the lids or orbits occurring after two
or three days mean more than those occurring within these days, for the
latter may be caused by external bruising. The globe of the eye may be
pushed forward by blood accumulating within the orbit. _Exophthalmos_
thus produced is therefore most significant, though not common.

2. _Escape of serous fluid, blood, or brain substance from the cavities
of the skull_: Hemorrhages from this cause occur most often from the
ear, the petrous bone being tunnelled with various canals through which
blood may thus escape. The surgeon should, however, assure himself in
every instance that the blood is escaping from the ear and not from
some trifling wound of the external soft parts, the soft walls of the
meatus, or the tympanum. Profuse hemorrhage can probably only come
from a basal fracture. Escape of _serous fluid_ is usually noted as a
sequel to hemorrhage, although it may begin almost immediately after
an injury. Rarely more than twenty-four hours elapse before it begins
to flow. The quantity of fluid discharged is sometimes considerable.
It may occur in frequent drops or during expulsive efforts, like
coughing, or may ooze in such a way as to be insensibly collected by
the absorbent dressings. In average cases the amount in twenty-four
hours is from 100 Cc. to 200 Cc.; 800 Cc. have been noted in occasional
instances, and in a very few still more. Occasionally violent
expiration will increase the flow.

In some cases the fluid may escape through the Eustachian tube into the
pharynx, whence it may escape by the nostrils or be swallowed.

The escape of brain substance is rarely noted, but obviously implies
such serious injury as to make the prognosis of the worst.

3. _Disturbance of function along particular cranial nerves, paralysis
of which is often produced by fractures of the base, especially those
involving the foramen of exit of the nerve involved_: The nerve may be
lacerated or injured in such case by the fragment of bone.

In addition to these distinctive features there will be in the majority
of instances _brain symptoms_, either of _contusion_ or _compression_,
varying in severity within all possible limits, but adding their weight
to the value of the testimony.

Other and unusual signs of basal fracture may occur, such as
communication between the cavities of the petrous bone and the mastoid
cells, leading to the formation of _pneumatocele_ (see page 545), or
_emphysema_ of the overlying soft parts, observed mostly about the
orbits, when the nasal cavity is involved.


=Treatment.=--The treatment of basal fractures is mainly _symptomatic_.
The first effort should be to make antiseptic all those parts of the
skull involved, which means to shave the scalp; to thoroughly cleanse
and irrigate the external ear and the auditory meatus, using a head
mirror and ear speculum for this purpose; to tampon the meatus with
antiseptic cotton; to provide a copious absorbent dressing for such
fluid as may escape and to change this frequently; to cleanse the nasal
cavity as well as the conjunctival sac, for all of which the peroxide
of hydrogen is serviceable. All of this should be done promptly, while
at the same time studying the patient for evidence of brain injury
or of involvement of special nerves. By the time these measures are
thoroughly performed a decision as to the necessity for immediate
operation should have been reached. Evidence of brain compression
wanting, and in the absence of external or compound injury the patient
may be left at rest, with _cold applications_ to the head and active
purgation. In many of these instances benefit follows the application
of a number of _leeches_ to the mastoid region and to the occiput.
_Operation_ is necessary later only when brain symptoms supervene,
these consisting of evidences of compression, either from blood or
from pus, as compression from other causes should have been acting at
the time of the first examination, and should have been recognized at
that time. When direct fractures are evident the possibility of the
entrance of foreign bodies should be also remembered. Thus penetrating
fractures of the base have occurred through the orbit as the result of
accident or assault, and such weapons or implements as foils, ramrods,
drumsticks, canes, umbrella points, etc., have been known not only to
penetrate into the brain, but perhaps to leave some portion of their
substance--_e. g._, a foil tip or an umbrella tip--within the cranium
after their withdrawal.

_Separation of sutures_, known also as _diastasis_ of the same, is the
occasional result of injury instead of, or complicated with, fissures
or other fractures. It is the result of violence, and is virtually
a specific form of fracture, from which it differs in no essential
particular. Diastasis can only take place along lines of previous
suture, but it is possible that Wormian bones may be thus loosened.
Sutures thus separated ordinarily heal by fibrous repair rather than
osseous union. Diagnosis is possible only as they are exposed to view,
although displacement in the middle line or along known suture lines
may be regarded as diastasis. The treatment differs in no respect from
that of other fractures.

_Injuries to the frontal sinuses_ occasionally complicate fractures
of the skull. These sinuses vary in different individuals, are rarely
truly symmetrical, and are not found in the young. They connect
with the nose in such a way that emphysema of the frontal region is
quite possible, while air may be blown beneath the periosteum or may
communicate with the interior of the cranium. In wounds of the frontal
region the sinuses are occasionally opened--a fact of importance, for
infection of the Schneiderian membrane may occur and endanger life,
mainly because of the retention of infectious products within its
cavities. Moreover, by such wounds the _ethmoid_ may also be injured.
Pus which escapes from these sinuses and from the ethmoidal cells is
usually thin and bad-smelling. Long continuation of suppuration after
such injuries probably means necrosis and formation of sequestra.


INJURIES TO THE BRAIN AND ITS ADNEXA.

By better acquaintance with certain portions of the brain whose
function is now generally recognized and described, as well as with the
more exact knowledge regarding the entire encephalon, the outcome of
many recent studies, the teaching of the past in regard to the nature
of various brain lesions has been essentially modified. Especially is
this true in regard to the distinction formerly emphasized as between
_concussion and compression_. In discussing brain injuries we should,
first of all, distinguish between traumatic disturbances of the entire
endocranium and localized injuries to the brain or particular vessels
and nerves entering into its composition. In regard to the first, it
is possible that the entire blood or lymphatic circulation within the
cranium may be affected in such a way as to influence its nutrition and
function, by which means activity and function are mildly or seriously
perverted. The immediate effect of severe injury to any part of the
body is reflex vasomotor spasm, which constitutes the essential feature
of the condition known everywhere as _shock_. It is this condition,
with its marked local expressions, which was formerly known as
_concussion of the brain_. When studied upon its merits it is found to
be _indistinguishable from shock_ produced by injuries to other parts.
The condition for so many years taught and recognized as concussion is
but shock following injury to the head. This makes no further demands
upon the question of pathology than those prompted by any traumatic
disturbance.

Through the mechanism of the cerebrospinal fluid rapid alterations of
pressure and of the volume of the brain are produced. There is an easy
path between the inelastic cranial cavity and the exceedingly elastic
and accommodating spinal canal, which latter serves as a reservoir for
the fluid which may be pressed out of the cranium when brain pressure
is increased. While the subdural and subarachnoid spaces are each
of them absolutely closed sacs and do not communicate one with the
other, there is ample accommodation within each to permit a constant
equilibrium of pressure under ordinary circumstances, as between the
spinal canal and the cranial cavity. The brain expands in volume with
every systole of the heart, while with every diastole it contracts.
Its size is, moreover, modified by the motions of respiration. Under
these extremely accommodating conditions it is scarcely credible that
external injuries which leave no internal evidences of violence should
do anything more than disturb the equilibrium of fluid distribution.


“CONCUSSION” OF THE BRAIN.

We inherit this term _concussion_ from the earlier masters of our art,
by whom, however, it was used in a much broader sense than of late.
Its modern significance was given to it by Boirel, who made it apply
to a group of cerebral symptoms the result of injuries not accompanied
by fracture or perceptible laceration of vessels, symptoms varying in
intensity and duration.

Our present position is practically this: The possibility of pure
concussion of the brain--_i. e._, disturbance of brain function without
gross mechanical lesions--is admitted, but its general frequency is
denied. When present it should either pass away quickly, the condition
being equivalent to that called “stunning,” or, if it assume distinct
form, its _signs and symptoms_ are indistinguishable from those of
shock, consisting essentially of rapid and feeble pulse, quick and
shallow respiration, pallor of the skin, copious perspiration, complete
or partial unconsciousness, muscle incoördination, with lack of
sphincter control, occasional vomiting, the pupils usually reacting in
light.


=Treatment.=--The treatment for this condition is essentially that
for shock, and whatever may be called for in the way of attention to
injuries about the head--_e. g._, sewing up a scalp wound, etc. (See
Chapter XVIII, on Blood Pressure.)


CONTUSION OF THE BRAIN.

The condition of _shock (cerebral concussion)_, when of pure type,
passes away with reasonable promptness, especially when aided by
surgical treatment. _Anything which persists_ in the way of muscle
paralysis, disturbance of function of nerves of special sense, or
_other sign of importance_, indicates something more than mere
vibratory disturbance: it implies mechanical lesion which could be
perceived by the eye were the parts exposed, and constitutes the
condition known as _contusion_. This implies the existence of trifling
exudates, or hemorrhages, which lead not only to absorption but even
cicatrization. _Contusion pure and simple_ differs from ordinary
_laceration_ as a contusion elsewhere may differ from a wound. It
cannot be separated, however, from conditions in which there are
minute separations of continuity and actual lacerations. It may be
divided into three postmortem forms--_general hyperemia_, with or
without edema; _punctate_ or _miliary hemorrhages_; and _thrombosis
of minute vessels_, which may occur separately or together. Moreover,
there may exist similar lesions in the meninges, constituting
_meningeal contusion_. Ordinarily minute vessels of the pia are
ruptured and blood is effused in small and thin patches over various
parts of the brain. The so-called _compression apoplexies_ of certain
authors are inseparable from the conditions above described. Such
minute blood clots are only to be distinguished upon very careful
sectioning of the brain, and are found most often in the region of the
medulla and along the floor of the fourth ventricle. They are probably
caused by the forcing into the fourth from the lateral ventricles of
the fluid contained in the latter.


=Symptoms.=--When the ordinary symptoms of shock, which follow all
severe injuries to the head, especially when the deep lesions are not
too severe, fail to disappear in a short time under proper treatment,
and when new and irregular symptoms are superadded to those of shock
alone, it is reasonable to suppose that the intracranial condition is
one of contusion rather than of shock. When mental agitation changes
into delirium, when the rapid, feeble pulse becomes stronger and
slower, the respiration deeper, the limbs move in incoördinate ways,
the speech disturbed from muscle incoördination, the patient selects
wrong words, or when the mental condition becomes more serious and
stupor or coma take place of the delirium, while external irritants
have less and less effect, and when the pupils gradually enlarge while
failing to respond to light, it may be said that the _condition of
contusion is making itself apparent_. If along with muscle uncertainty
there is also muscle spasm or rigidity, with fixation of the fingers in
the athetoid position, the evidence to this effect is increasing. If
with all this the thermometer fails to show that an active inflammatory
condition--_i. e._, meningitis--is prevailing the diagnosis may be
regarded as certain. Error may possibly arise when there are evidences
of alcoholism. Coma following head injury ought not to be ascribed to
the _alcoholic condition_ except by the strictest process of exclusion.
Temperature alone will be of the greatest service in this direction,
since in _alcoholism_ it is usually _subnormal_. In _apoplexy and
non-traumatic hemorrhages_ it is also usually _subnormal at the
commencement of the attack_, rising to normal, and remaining there
if the patient recover, but _continuing to rise in cases where the
prognosis is bad_.


=Treatment.=--The treatment of brain contusion should be managed
largely in response to special symptoms. Physiological rest, attention
to scalp wounds, fractures, etc., shaving of the scalp, application of
ice to the head, with such stimulation to the heart as may be necessary
in extreme cases by subcutaneous administration of adrenalin, atropine,
etc., by local fomentations over the epigastrium, or by immersion
in a hot bath when surroundings permit it--these in a general way
constitute most of the methods of treatment in contusion. When only
symptoms of diffuse and minute lacerations can be recognized the use of
the trephine is impracticable except when indicated by some external
marking--_i. e._, compound fracture or the like. When _localizing
symptoms_ are present the trephine is, of course, indicated. When
the skull injury is recognized as a basal fracture, venesection or
the application of leeches behind the ears will be most serviceable.
In every such case there is the greatest necessity for _regulating
the excretions_ and preventing auto-intoxication. For this purpose
diuretics and laxatives should be used, often in conjunction with
intestinal antiseptics. The catheter should be employed whenever
indicated by the condition of the bladder, which should be carefully
watched. As the days go by, and patients lie more or less helpless
and inert, the greatest care should be exercised for the prevention
of bed-sores. When mental inertness, muscle rigidity, etc., fail to
disappear, potassium iodide should be used internally.


BRAIN PRESSURE OR COMPRESSION.

That the cranial contents--brain, blood, lymph, and cerebrospinal
fluid--completely fill the cranial cavity has been already amply shown,
as well as that there is no room for anything in the shape of a foreign
body without seriously affecting the equilibrium between the brain and
the contents of the spinal canal. When, however, any foreign substance
exerts pressure upon the brain the results are invariably the same, be
this substance what it may, and _compression signs are always the same,
no matter what the compressing cause_. Reduction in capacity of the
cranial cavity (_i. e._, compression) may be produced--

[Illustration: PLATE XLIII

FIG. 1.

FIG. 2.

FIG. 1. Compound Fracture of Cranium, with Depression; Fracture of
Bones of Face; Extradural Clot from Rupture of Middle Meningeal Artery.

FIG. 2. Horizontal Section of same, showing Depressed Fracture of Bone.
(Anger.)

C, extradural clot; D, laceration of brain substance, with extensive
intracerebral clot; F, same condition produced by contrecoup. Punctate
hemorrhages and minute lacerations at numerous points, characteristic
of contusion of the brain.]

1. By reducing the dimensions of its enclosing walls (_e. g._,
depressed fractures or by direct pressure);

2. By increase in the quantity of cerebrospinal fluid or of the volume
of the brain, which latter may be produced by edema, by serous exudate,
or by actual hypertrophy;

3. By foreign bodies, which may enter the skull from without;

4. By pathological conditions--collections of blood or pus, tumors,
etc., which may be produced either from the brain substance, its
containing bone or membranes, or its vessels.

In every one of these conditions the size and tension of the brain
are affected. _The cerebrospinal fluid is mainly involved in acute
not in chronic conditions._ A slow reduction of the diameters of the
skull produces such slow alterations of pressure as to cause a minimum
of disturbance. So far as compression from traumatic influences is
concerned we distinguish mainly between compression--

1. By extravasation of blood (see Plate XLIII);

2. By fractures of the skull with depression, or by foreign bodies
penetrating from without;

3. By products of acute infectious inflammation due to septic infection
from without.

The result common to all of these is _increase of intracranial
tension_, and its consequence is a less rapid flow of blood and an
altered blood supply to the brain and its membranes.

Experiment has established that in compression of the brain
cerebrospinal fluid is forced by pressure into the spinal canal, whose
membranes are more elastic, and which thus help to accommodate it; it
has been also established that compression of the brain by one-sixth of
its volume, by any material, is fatal, and that much less is at least
serious. That fractures with depression produce sometimes serious, at
other times trifling, symptoms is due to the varying accommodation
of the spinal canal. Both experiment and observation seem to confirm
the view that consciousness pertains to the cortex as a whole, and
that unconsciousness is an inhibitory or paralytic condition which is
produced in compression.

_Temperature_ is a matter of great importance in studying compression
and foretelling its consequences. Elevation of temperature is an
early, continuous, and constant symptom in these cases. If temperature
be subnormal and subsequently rise, prognosis is bad. Variations of
temperature are more reliable guides than conditions of consciousness.
As Phelps has remarked, in no condition except sunstroke is temperature
so uniformly high as in cases of serious encephalic lesions.


=Symptoms.=--As indicated above, the symptoms and signs of compression
are practically identical, no matter what the compressing cause.
When this cause acts instantly there is no time afforded for
differentiation, but when it occurs slowly we note the following
symptoms, and about in the order here presented: Irritability or
restlessness; visceral disturbances; pain; intense cephalalgia;
congestion of the face; narrow pupils; augmented pulse, often seen
in the carotids. If compression occur more rapidly, torpor quickly
succeeds erethism, after which patients vomit, have convulsions or at
least convulsive motions, speech is disturbed, and stupor comes on,
from which they neither awake nor can be awakened until the compression
is relieved. All of these indications refer to involvement of the
cortex, which is generally regarded as the seat of consciousness as
well as of projection and imagination. During the night, of the senses
produced by pressure upon the cortex only the automatic basal apparatus
and that of the spinal cord continue in more or less disturbed
operation. Of all the general functions consciousness vanishes first
and returns among the last. When intracranial pressure has reached a
certain point, epileptiform convulsions result, varying in intensity,
affecting all the limbs, and terminating perhaps with rigidity. These
form an expression of high pressure. Similar convulsions occur in
various head wounds, explanation for which is the result of pressure,
which, though not extensive, may produce alteration in the circulation,
with its disastrous consequences. The later and _constant evidences
of compression, and those which in aggravated cases supervene
at once_, are reduction of pulse rate, due to the action of the
pneumogastric, which suffers first an irritation and later a paralysis.
The pulse becomes not only slackened but full; the respiration rate
is correspondingly reduced, so that breathing during coma is deep,
slow, and often stertorous. This feature of stertor is an expression
of paralysis of the palatal and pharyngeal muscles, which flap, as
it were, in the air current. Vomiting, which may occur before brain
tension has risen high, does not occur in the most serious cases. Coma
is absolute.

Along with these signs the most important other indications are
the _paralyses_, which may consist of monoplegia, hemiplegia, or
paralysis of individual muscle groups, according as pressure is made
upon a limited area or upon an entire hemisphere. By the division of
the cranial cavity by the falx and the tentorium it is divided into
chambers, in any one of which pressure may be more manifest than in
the others. Nevertheless a serious compressing cause will affect the
tension of the cerebrospinal fluid and produce general expression of
pressure. The _pupils_ often vary, and responsiveness to light is
occasionally noted. Nystagmus and ocular rotation may be occasionally
seen. Choking of the optic disk is also a frequent phenomenon, to be
recognized only by ophthalmoscopic examination. This is due to pressure
in the subdural and subarachnoid prolongations along the optic nerve.
In milder cases of chronic compression disturbances of vision are of
very great clinical importance. These pertain especially to diagnosis
of hydrocephalus and of brain tumors. When they occur immediately after
injury and remain, they depend upon laceration or other severe injury
of the optic nerve. Those which quickly disappear depend mainly upon
pressure of blood, which is reabsorbed, while those which are later
in their appearance depend upon later intracranial complications. A
unilateral lesion of the optic nerve depends most often upon injuries
to it within the optic canal. When the lesion is bilateral the cause
lies deep. General paralysis may be of the type of hemiplegia, single
or double--_i. e._, by “double” I mean paralysis of the entire
voluntary musculature of the body, which necessarily implies serious
and often fatal hemorrhage.


=Prognosis.=--This depends in large degree upon the nature of the
compressing cause and of the possibility of its removal. While the
nature of the same may ordinarily be determined, how much can be
accomplished by way of removal may often not be foretold before the
operation at which this should be attempted. In every acute case it
is desirable to make this attempt early, for high pressure, which may
be borne for a short time, is fatal if continued. Compression to any
serious degree is usually fatal. So soon as paralysis of circulatory
and respiratory centres is apparent the beginning of the end is at
hand. Another reason for hastening operation is that acute softening of
brain tissue comes on promptly, as well as _general cerebral edema_,
which has destroyed many a patient during the second to the fourth day
after injury.


=Treatment.=--The treatment of compression is summed up in one
phrase--_i. e._, to remove the cause when possible. The only cases
in which this rule may be safely disregarded are those where the
attempt to remove the cause means more danger than to leave it
unremoved. This is not true, however, in the ordinary cases of bone
depression, meningeal hemorrhage, etc. Before operation, however, or
as a substitute for it in cases of minor severity, it may be well to
assist venous outflow by _venesection_, by which blood pressure is
reduced. In these cases this may be done from the temporal veins or
external jugulars, with the patient in the semi-upright position.
Drastic purgatives may also be employed in order to utilize intestinal
outpour as a stimulation to resorption of cerebrospinal fluid. The
physiological action of cold (ice-bags) may also be secured for the
purpose of contracting the cerebral arteries. But all these measures
are only to be resorted to when there is uncertainty as to the
wisdom of operating, since when operation is indicated it should be
done at once, and _should take precedence of everything else_. This
operation means ordinarily the procedure to which the now general term
_trephining_ has been, by common consent applied, and comprises any
measure by which the skull is opened at a suitable place and the dura
or the underlying cortex exposed to such extent as to permit removal
of the compressing cause. Whether the opening be made with trephine
(annular saw) or with the straight or revolving saw, with bone chisel,
with bone forceps, or with anything else, is a matter of choice on the
part of the operator. So, too, removal of the compressing cause should
include the elevation of depressed bone, the removal of dislodged
particles as well as of all foreign bodies, the cleaning out of blood
clot, the checking of hemorrhage, and the closure of the wound, with
or without drainage or counteropening at some other part of the skull,
as may seem desirable in special cases. This entire procedure comes
now under the name of trephining, and should in most instances be
painstakingly followed.

The operative maneuvers will be discussed in another portion of this
chapter.


INJURIES OF INTRACRANIAL VESSELS AND SINUSES.

Intracranial hemorrhages may occur--

(_a_) From internal sources through the broken bone or between it and
the dura (extradural);

(_b_) Beneath the dura, between or into the membranes (subdural);

(_c_) Into the brain substance proper or the ventricles (subcortical or
intraventricular).

The vessels whose injuries are most often under consideration are
the _meningeal arteries_, the _sinuses_, the _small vessels of the
membranes_, and the _internal carotid_. The arteries, like the sinus
walls, may be ruptured either by substances forced in from without or
by sheer laceration. The _longitudinal sinus_ is most liable to injury
from without. When this sinus is exposed, it may be dealt with either
by suture if the wound be small, or by ligation, or by tamponing with
prepared gauze. Hemorrhage from this source is ordinarily not difficult
to check. Fatal air embolism has resulted through an opened sinus not
properly plugged. The other sinuses are more rarely injured, as by
gunshot wound, fracture of the base, etc. The sinuses have also been
injured by compression of the skull during parturition. Bleeding from a
sinus is usually indistinguishable from that from a meningeal artery,
except that the former occurs more slowly.


=Injuries to the Middle Meningeal Artery.=--Injuries to the middle
meningeal artery naturally occur in the immediate neighborhood of
this vessel, which is not infrequently ruptured by contre-coup. The
artery runs sometimes in a groove of the bone, sometimes in the
dura, and sometimes entirely in the bone. The more it lies within
the bone the more likely it is to be ruptured when this part of the
skull is fissured. Basal fractures often follow the groove for this
artery. The anterior branch is more often injured than the posterior.
Extravasations from this source are more common than from all others
combined, the amount of blood varying within wide limits. 240 Gm. of
blood clot have been known to collect and the dura to be separated
down to the base of the skull. I have repeatedly taken away a small
teacupful of blood clot in such cases (Fig. 377 and Plate XLIII).

[Illustration: FIG. 377

Compression following hemorrhage from the middle meningeal artery.
(Helferich.)]


=Symptoms.=--The symptoms of this hemorrhage are those of compression,
while extravasation may be rapid and quickly fatal, delayed for some
time, or may take place in two stages, the first but slight and
producing no coma. New clots are always dark and disk-shaped, thick
in the middle, with a definite margin. As the clots become older they
become more adherent and difficult to remove. The symptoms of meningeal
hemorrhage consist of an interval of consciousness or lucidity after
injury, followed by epileptic or spastic symptoms, alterations in the
pupils and pulse, unconsciousness passing into coma, and stertorous
respiration. There may or may not be external evidence of head injury.
The character of the _paralysis_ (hemiplegia) may indicate that the
clot is really upon the side opposite to that of the skull which shows
evidence of injury. In this case arterial laceration is the result of
_contre-coup_. According to the rapidity of the symptoms is the extent
of the primary lesion. Meningeal hemorrhages involve immediately the
motor area, which makes diagnosis all the easier.


=Injuries to the Carotid.=--Injuries to the carotid within the cranium
are exceedingly rare. Still, it has been injured in basal fractures and
penetrating wounds.


=Arteriovenous Aneurysm.=--Development of arteriovenous aneurysms after
basal injuries is occasionally noted. They will occasionally give rise
to pulsating exophthalmos. Pulsating tumors within the orbit which push
the eye forward not infrequently occur after serious head injury. Of 77
cases collected by Rivington, 41 had a traumatic origin.


=Subdural Hemorrhages.=--Subdural hemorrhages are not infrequent in
the skulls of the newborn, and constitute the so-called _apoplexia
neonatorum_. They may occasion convulsions and paralyses of irregular
type, while if the extravasations become infected multiple abscess may
result.

In adults subdural hemorrhages are most commonly connected with brain
lesions which have been already spoken of as contusions. They may be
the starting points for pachymeningitis. Their most common results
are disturbances of consciousness and mentality. Paralytic dementia
follows in some of these cases. Extensive subdural hemorrhage may give
a clinical picture corresponding to extradural. Disseminated minute
ecchymoses constitute minute focal lesions, which are, however, usually
so distributed as to confuse and prevent accurate diagnosis. Apoplexy
or intraventricular hemorrhages, especially from the lenticulostriate
artery (Charcot’s “artery of hemorrhage”), have until very recently
never been regarded as warranting surgical interference. Of late,
however, especially in the ingravescent or progressive forms, ligature
of the common carotid has been of some service, though in order to
render this effective ligation should be done early.


=Traumatic Intraventricular Hemorrhage.=--Traumatic intraventricular
hemorrhage occurs in much the same way as meningeal, by contre-coup.
Individuality of symptoms is lost in the general comatose condition of
the patient, but when operation is performed, as it is usually best
to perform it, if no extradural clot be found and if brain tension
be evidently increased, the dura should be opened; after which, if
no subdural clot be seen, the ventricles should be tapped with an
exploring instrument. In this case, if blood be removed by aspiration,
a knife should be passed directly into the ventricle, after which
blood, if present, will promptly escape. Dennis was the first to
diagnosticate the presence of intraventricular clot and to deliberately
incise into it, and I have myself repeatedly imitated this procedure,
both with and without success.

In every case in which superficial or cortical hemorrhage can be
recognized--or even suspected--or intraventricular hemorrhage as well,
one should insist upon exploration. This means trephining, with perhaps
aspiration of the ventricular contents. Tapping of the ventricle is
described under Treatment for Hydrocephalus, while trephining is
described at the end of this chapter.


LACERATIONS AND INJURIES TO THE BRAIN SUBSTANCE.

These have been mentioned under _contusion of the brain_. They may
be divided into those which occur with or without fracture of the
cranial bones. The term contusion was first suggested by Dupuytren.
The condition comprises all degrees of injury, from the most minute
local disturbances to lesions involving the entire hemisphere. The
milder forms show a sprinkling of punctate hemorrhages, numerous in the
centre of the injured area, the surrounding tissue taking on a more or
less diffuse tint, which fades out toward the periphery, discoloration
being due to the imbibition of the coloring matter of the blood. In
more extensive injuries clots as large as peas, or larger, are embedded
at various points, each surrounded by its area of discoloration. When
foreign bodies have been driven into the brain the tissue is also
discolored, while various foreign materials may be met. In instances
of great violence there may occur absolute rupture of brain tissue
extending from cortex to ventricle.


=Prognosis.=--Prognosis depends in large degree upon escape from or
occurrence of infection. In infected cases the principal dangers are
from blood pressure and from later edema or acute softening as well as
from meningitis. Brain lacerations may heal by cicatricial repair, but
usually with some perversion of function.

The possibility of _cystic degeneration of large or small clots_ is
one of great importance. (See Cysts of New Formation in Chapter XXVI,
page 264.) A blood clot within the cranium which fails to resorb is
essentially a hematoma, in whose interior softening and conversion into
a cyst may easily occur. These cysts make room for themselves at the
expense of surrounding brain tissue, and when located in the motor area
give rise to localizing symptoms as well as to epileptic convulsions.
They may be often diagnosticated with certainty after an accurate
history of the case and a study of the phenomena which it presents. As
they grow older their walls become firmer, and it is often possible to
dissect them out.

That _foreign bodies may be encapsulated_ and remain without producing
disturbance is now well known. This is particularly true of bullets.
As a rule, however, though encapsulated, they produce symptoms like
headache, vertigo, etc. (See Plate XLIII.)


=Symptoms.=--The general features of brain lacerations are those of
_contusion_. So long as the disturbances are minute, even if multiple,
or the foreign body small, compression symptoms are not produced, or
at least in very incomplete degree. Minute diagnosis is not easily
obtained. The most essential thing is to decide upon the question
of operative interference. In the absence of distinctly localizing
symptoms or other external markings it is not usually performed.
Upon the other hand a lesion which can be localized is probably due
to extravasation sufficiently large to be easily reached by opening
the skull; and, unless there be other and sufficient reason to the
contrary, this should be done (Fig. 378).

In many instances, however, contractures or paralyses of muscle groups
occur later, and are followed by spastic conditions which may be
permanent. More can be done in these cases by massage, by internal
medication, perhaps with external counterirritation, than by distinctly
surgical procedures. Tendoplastic or neuroplastic measures for their
relief may also be considered. Both albuminuria and glycosuria are
known to be the result of injuries herein described, as well as bulbar
paralysis and disturbances of special senses. More immediate dangers
after these head injuries are those of bronchopneumonia or hemorrhagic
or edematous infiltration of the lower lobes of the lungs--conditions
often spoken of as _hypostatic pneumonia_, much resembling those
produced experimentally in bilateral division of the pneumogastrics.
Some of them are produced by paralysis of the glottis, the result of
which is incomplete closure, with aspiration of fluids and solids
from the mouth, whose decomposition sets up an infection within the
lungs, and is often referred to as _aspiration pneumonia_. Some form of
pulmonary disturbance follows in perhaps one-third of the cases of the
injuries above alluded to, and should be anticipated and prevented.

[Illustration: FIG. 378

Bullet embedded in anterior fossa. (U. S. Army Med. Museum.)]


GUNSHOT WOUNDS OF THE HEAD.

These have already been extensively considered in a previous chapter,
so that but little more need be said of them here. Such wounds in
the scalp are likely to be followed by sloughing. So far as gunshot
fractures of the skull are concerned, there is frequently a marked
discrepancy between the wounds of the inner and outer tables, that last
perforated by the bullet being almost splintered. Penetrating wounds of
the cranium by Mauser and similar bullets are not necessarily fatal.
Many men were shot through the head during the Cuban and South African
wars and yet did not die as a result of the wound. (See Chapter XXII.)


=Treatment.=--So far as treatment is concerned, gunshot injuries of
the skull necessitate trephining or exploration, for checking of
hemorrhage, disinfection of the bullet track when possible, often for a
counterdrainage opening with through drainage either by tube or gauze.
The _bullet_, if it can be found, should be removed. In searching for
it the old porcelain-tipped probe of Nélaton has almost completely
given way to Fluhrer’s aluminum probe, which is larger and longer
and when rightly directed will by slight weight usually glide gently
along a bullet track, thus leading often to the missile, and at the
same time indicating by its direction where the counteropening should
be made. Two other methods of detecting bullets are now in vogue.
Girdner, some years ago, invented a telephone probe, by which, so soon
as the instrument touches the missile, a telephone circuit is completed
and the operator with a telephone receiver applied over his own ear
hears the tell-tale “click” indicating the fact. This has been further
improved by the substitution of a bell or “buzzer,” which tells its own
tale when the probe touches the bullet.

A still more ingenious application of electricity for the purpose is
that afforded by Röntgen’s discovery, and during the American and
English campaigns of the past few years skiagrams of skulls showing
bullets in various locations have become quite common. (See Plate
XIII., p. 229.)


PROLAPSUS AND HERNIA CEREBRI.

_Escape of brain matter beyond its normal level_ is not uncommon in
connection with compound fractures or their sequels. It may be primary,
escaping with the blood at the time of the accident, or secondary,
occurring during the ensuing days. Any lesion of this kind in which the
brain appears or can be handled is entitled to the term _prolapsus_, in
contradistinction to _hernia_, which implies that, though escaping from
the proper cavity, it is nevertheless covered by other textures--_e.
g._, the dura or scalp.

The protrusion may vary in size from a small tumor to one the size
of a fist. It is always the result of uncontrolled intracranial
tension, and may be produced by hemorrhage, by serous imbibition, or
as the result of brain abscess. When immediate it is of the first
variety; when later, of the second or third. When abscess is present
it usually delays protrusion, which is produced by degrees. Prolapse
occurs through large openings, such as those made by gunshot wounds,
the trephine, etc. Prolapse proper implies laceration of the dura. It
pertains obviously to the convexity of the skull, occurring, however,
in exceedingly rare cases into the orbit (Fig. 379).

[Illustration: FIG. 379

Prolapsus cerebri. (Bryant.)]


=Prognosis.=--The prognosis is generally unfavorable. There is always
risk of edema or infection, either of which may prove fatal.

Infiltration, gangrene, suppuration, or repair by granulation may so
disfigure and disguise the real brain substance as to lead to _error
of diagnosis_. It by no means follows that every tumor presenting
through an opening in the skull is of this character. When gangrene
and spontaneous separation occur, spontaneous recovery may follow,
the stump being covered by granulations and finally roofed over by
connective tissue.


=Treatment.=--Treatment in the primary cases should include the most
rigid asepsis with removal of all foreign particles. Localized pressure
does some good, especially in those cases where it can be tolerated.
Signs of abscess should always be watched for, and deep exploration is
often justified or indicated. While excision or cauterization are often
heralded as successful, they are by no means without their dangers.
Nevertheless in selected and suitable cases excision may be freely
practised. Cases that admit of it should wear a protective shield
properly molded to the part. Skin transplantation, or even osteoplastic
repair of the defect, may give good results in favorable cases.


SEPTIC INFECTIONS WITHIN THE CRANIUM.

Under the general term _septic infection_ are included:

  _A._ Abscess;

  _B._ Thrombosis;

  _C._ Sinus phlebitis;

  _D._ Meningitis;

  _E._ Encephalitis.

These are different manifestations of infection, the clinical picture
differing according to the tissues and localities involved. For the
production of these infectious conditions no special bacteria other
than those already catalogued in Chapter III are comprehended. Their
method of activity is there discussed at sufficient length, and we
need here only consider the various _paths of infection_. These may
lie along the _bloodvessels_, the _lymphvessels_, _nerve sheaths_, and
prolongations of the _membranous sacs_ which extend from the cranial
cavity proper.

The most common of all the paths of infection is afforded by the
_middle ear_, especially when involved in a chronic suppurative lesion,
which is by no means necessarily connected with a patulous tympanic
membrane, and which may consequently be undiscovered, though in more or
less constant activity.


A. =Abscess of the Brain.=--This may be _traumatic_ or _non-traumatic_.
The former variety is most often due to the direct result of injury,
infection displaying its consequences promptly or sometimes not until
long periods have elapsed. The ordinary form occurs within the first
two weeks, usually as an acute cortical abscess beneath a more or
less compromised membrane, surrounded by a zone of red softening, and
this by another of brain edema. The _chronic_ traumatic abscesses are
less often cortical, but are deeper. They are marked by prolonged
suppuration of the external wound, but may occur through some mechanism
not understood. Only the chronic abscesses show _encapsulation_, the
capsule partaking of the character of the pyophylactic membrane,
elsewhere described. (See Chapter VIII.) It may cover a long period--to
my personal knowledge at least nine years, while others have mentioned
twenty and more. The _non-traumatic abscesses_ are in the main due
to _middle-ear disease_. When the roof of the tympanum breaks down
it is the middle fossa of the skull which is infected; when the
posterior wall, naturally the posterior fossa. The most common result
of perforation of the tympanic roof is involvement of the mastoid
antrum or the sigmoid groove and sinus. In the former case we have
temporosphenoidal abscess; in the latter, cerebellar, if any. Previous
to actual perforation there is thinning of bone with thrombosis along
the minute veins connected with the sinuses. When the dura is exposed
by the carious process, granulation tissue often protects it against
further inroads, while masses of the same projecting into the tympanum
have been mistaken for prolapse. If the sigmoid groove be the site
of the first disturbance, extradural abscess may form between the
sinus and the remaining bone, the granulating process then involving
the whole bony groove. Its later consequence is _sinus phlebitis_,
_sinus thrombosis_, or _intradural infection_. If there be adhesion
between the dura and the cortex we have actual brain ulceration without
formation of a true abscess; but if once the perivascular sheaths
have carried infection to the substance of the brain there is a rapid
purulent disintegration of the same, and formation of a true subpial
or deep abscess, which latter is in effect a purulent encephalitis.
Macewen has shown how important it is not merely to evacuate such
abscesses, but to eradicate the path of infection from the point of
origin, which is rarely easy.

_Extradural pus_ may escape into the mastoid cells by erosion of their
inner walls. Such pus may escape suddenly, and serious symptoms thus
be mitigated. Even abscess of the bone may thus empty itself by the
process of adhesion and pointing toward the surface. Pus from the
mastoid cells may perforate the temporomaxillary joint or escape along
the digastric groove and form deep cervical abscesses.

When the arachnoidal tissue is involved, both subdural and
subarachnoidal spaces participate in the infection, and the brain
floats upon a pus-bed rather than a water-bed. _Leptomeningitis_ under
these circumstances becomes quickly diffused and fatal. Serous fluid
may accumulate so quickly as to produce death by mere obstruction to
the cerebral bloodvessels, while distention of the ventricles and an
acute infectious internal hydrocephalus is possible. Leptomeningitis
may be propagated wherever anatomical paths may carry it, even to the
cauda equina and along the spinal nerve sheaths.

The pus within cerebral abscesses is often discolored, sometimes
offensive. A greenish color is usually imparted by the Bacillus
pyocyaneus, while the offensive odor comes mostly from the Bacillus
coli. Around such an abscess is a zone of inflamed cerebral tissue. If
within this zone a pyophylactic membrane is produced by condensation
the abscess may become encapsulated and life be prolonged. When a
capsule fails to form, the process being too acute or rapid, death is
the speedy termination of such a case. These abscesses are generally
single, but may be multiple. There is also a metastatic expression of
abscess formation, seen in typical cases of pyemia, where numerous
miliary abscesses are found within the brain. Pressure symptoms are
less likely from abscess than from a tumor of the same bulk, while
there is much greater liability to edema and sudden infection.
Gradually extending paralysis implies pathological activity around the
abscess. Large collections of pus are often met in the least vital
parts of the brain, as in the frontal or temporosphenoidal lobes.


=Symptoms.=--Aside from causal indications (_e. g._, injury to the
head, middle-ear disease, recent operations upon the air-containing
cavities, etc.) the first symptoms may be slight. They consist usually
of headache, often ascribed to cold or trifling injury, becoming
exaggerated, rarely definitely located, radiating widely. In time it
is spoken of as “excruciating,” and may be continuous or intermittent.
Vomiting is not infrequent, rarely accompanied by nausea. Chills come
on early in the history of the case, varying in intensity, duration,
and frequency. The more frequent, the more likely is it that the
abscess results from some general infection. Temperature is seldom much
elevated; it is often subnormal. When exalted it is in proportion to
the degree of meningeal involvement. If pressure symptoms become marked
we get the usual slow pulse due to increased tension. After evacuation
of pus pressure symptoms may subside, but temperature rise. Such
discharge from the middle ear as may have been previously noted usually
diminishes. A history of cessation of discharge and of increased pain
and fever occurring at irregular intervals is very characteristic.

These patients seldom come under the surgeon’s notice until the
condition is serious. If they are still conscious, pain is the
dominating complaint. This may be aggravated by percussion over the
affected region. Rigidity of the sternomastoid on the affected side is
a sign of lesion of the sigmoid sinus. Pain elicited by deep pressure
in the posterior cervical triangle is also significant. There is mental
hebetude, with progressive failure of mental and physical power, as the
stupor increases, or coma becomes marked.

_Abscess_ may be often distinguished from _infectious thrombosis_, as
in the latter respirations are quickened and vomiting occurs when the
patient is in the upright position.

_Vomiting accompanied by cephalalgia is always indicative of
intracranial mischief._ If it be a special feature throughout the case
it may indicate cerebellar lesion. Convulsions are also frequent, but
rarely distinctive. They are the result in most cases of secondary
irritation of motor areas. Paralysis is the consequence of destructive
rather than of irritative lesions.

The ear should be examined, and the use of a probe may give much
information.

_Brain abscess connected with middle-ear disease_ will usually be
found in the temporosphenoidal lobe, but occasionally occurs beneath
the tentorium, in the cerebellum. Many of these cases are connected
with self-evident indications of purulent otitis media and mastoid
disease, and operation for the latter has often to be combined with the
recognition of and suitable treatment for brain abscess. The surgical
treatment of mastoid disease will be discussed in separate paragraphs
and under a separate heading. Whenever there is any reason to suspect
the existence of pus within the cranium the operator should expose the
dura by opening above the mastoid; or his operation may already have
taken him as far as the sigmoid sinus, in which case, with the dental
engine or with other bone-cutting instruments, he may much enlarge the
field of operation and thus make access both to the sinus and to the
brain itself. An extradural collection of pus may be found within the
sinus or above it. Drops of pus may escape as the operator cleans away
or even presses apart the granulations. He has often to decide upon
further exploration, either to open the sinus expecting to find it
filled with disintegrated blood clot and products of decomposition, or
to open the dura proper, expose the cortex, and perhaps explore here
with the aspirating needle for pus located more deeply. In those cases
where evidences of brain abscess are more pronounced, and those of
mastoiditis less so, the lateral region of the skull may be exposed
and the cranium opened with a trephine before working downward and
exposing the mastoid region. In not a few instances both operations are
combined and the area of bone to be cut away is relatively large. Thus
complete _tympanic eventration_, with removal of much of the mastoid,
may be combined with trephining and opening of a brain abscess, or
opening of the sinus, in which latter there may be found such a
condition as to make it advisable to ligate the common jugular low in
the neck, and irrigate from the sinus to the location of the ligature,
where the vein is laid open, or even to pass a small swab upon the
end of a flexible probe. Nothing can more predispose to typical
pyemia than a breaking-down clot within a sinus or vein involved in
thrombophlebitis.

_Temporosphenoidal abscess_ will often be indicated by the escape of
pus through the dura, above the roof of the tympanum. Although such an
abscess might be evacuated by enlarging the tympanic approach to it, it
would ordinarily be much better to open the skull above the ear, and
thus make free access and provision for drainage. In any part of such
an operation when the dura has once been exposed its appearance should
be carefully noted. The coarse of the pial vessels can usually be
traced through it. Therefore when it is sufficiently opaque to prevent
any appreciation of conditions beneath, or sufficiently distended, it
may be opened.

When cerebellar abscess is suspected the trephine should be applied
about midway between the tip of the mastoid and the external occipital
protuberance (inion), _i. e._, one inch beneath Reed’s base-line and
one and a half inches back of the mastoid. The instrument should here
be used with care, as the occipital bone is of irregular and variable
thinness. In a brain abscess which can be freely opened gauze packing
will be found serviceable, even though its use necessitates the
employment of secondary sutures or perhaps leaving the wound open in
order to permit of its removal.

Localizing symptoms are only occasional in connection with cerebral
abscess, because the majority of these lesions are located without
the motor area. Pupillary alterations are indefinite. As an abscess
enlarges the size of the pupil may increase. Infective thrombosis
rarely affects the pupils, save that when located in the cavernous
sinus it may produce ptosis. In _temporosphenoidal abscess_ pain is
usually localized in or near the ear upon the same side. As the motor
area becomes involved there is a gradual development of localizing
phenomena, referred to the opposite side. _Facial paralysis_ is
common in advanced destructive lesions in the mastoid and tympanum.
When produced by cortical lesion it is rarely so pronounced as when
by direct paralysis of the nerve. In _frontal abscess_ there are
few localizing phenomena. Abscess in the _parietal region_ is most
commonly of traumatic origin, and is to be suspected in accordance with
external surface markings. _Occipital abscess_ is exceedingly rare,
and cerebellar abscess furnishes few localizing symptoms. Its most
prominent clinical features are retraction of the head and neck; slow,
feeble pulse and respiration; subnormal temperature; violent yawning;
rigidity of the masseters; slow speech; optic neuritis; vertigo and
vomiting. If accompanied by thrombosis there is pain upon pressure in
the upper part of the neck. In all of these cases _when abscess is
near the surface there is more or less leptomeningitis_, which becomes
diffuse at once when the abscess bursts. If meningitis be present we
have high temperature without marked remissions, rapid pulse, and
general irritability, rapidity of pulse indicating predominance of
leptomeningitis over encephalitis, since the more marked the latter
the slower the pulse. As distinguished from sinus thrombosis we have
in the latter high temperature with marked remission, rapid and weak
pulse, frequent chills, profuse sweats, and often symptoms of pulmonary
infarct or diarrhea, with cervical and submastoid tenderness and
involvement along the jugular vein upon the affected side. _If all
three conditions be associated the symptoms of thrombosis usually
prevail_, although there may be retraction of the head due to basilar
meningitis. As between tumor and abscess we have in the former absence
of explanation of infection, slow progress of symptoms, more definite
localizing phenomena, progressive involvement of nerves, pronounced
optic neuritis, absence of chill, and alternating periods of mitigation
of symptoms. Temperature and pulse afford little help, save that
subnormal temperature points rather to abscess.


=Prognosis.=--From every direction come statements that the tendency
of cerebral abscess is invariably toward fatality. No matter what the
cause, unless relief be promptly afforded, death is the sure result. Of
the acute cases those not promptly operated usually die within a few
weeks. The more chronic or prolonged cases rarely come under surgical
treatment; most of those which do are the result of disease in or about
the middle ear. Were it possible to early diagnosticate formation of
these abscesses prognosis would be much more favorable. When seen
before necessarily fatal complications have arisen, in instances where
the position can be reasonably well determined, surgical attack is
likely to give good results. After proper evacuation even complete
mental and bodily recovery is possible. Anchoring of the brain by
adhesions may leave a train of disquieting symptoms, which, however,
are not so bad as fatality. Abscesses may remain for a long time
encysted, and yet be a fruitful source of danger. Multiple abscesses
may complicate both the diagnosis and the treatment and produce a
condition beyond help.

The operative treatment of these cases will be discussed by itself.


B. =Sinus Thrombosis.=--The sinuses are predisposed to thrombosis
by virtue of their size, inflexibility, shape, and the fact that
they are not emptied during respiration, all of which tend to retard
blood flow. If to these be added defect in the blood supply, then
everything predisposes toward _marasmic thrombosis_. This occurs
much less frequently than the infective form, is mostly confined to
the longitudinal sinus, is noted mainly at the two extremes of life,
and is often seen in cases of death following exhausting diarrhea in
children. In the _marasmic form_ the clots are dense, firm, stratified,
and non-adherent; they rarely occupy the whole caliber. In old cases
the clots may be tunnelled sufficiently to permit reëstablishment
of circulation. Their principal evil consequences are edema of the
frontal lobes and serosanguineous effusion into the ventricles or
orbits--in the latter case producing exophthalmos. Sometimes epistaxis
is produced. Strabismus, tremor, muscle rigidity, or contractures are
more often seen conjoined, especially in children, with convulsions,
sometimes unilateral, and choked disk.


=Diagnosis.=--The diagnosis in adults is difficult, but in children,
when convulsions occur after exhausting illness, with the signs just
noted, marasmic thrombosis may ordinarily be diagnosticated.

_Infective thrombosis_, the other variety, is due exclusively to the
invasion of pyogenic organisms. It is observed mostly in the basal
sinuses; its origin is local, and it is always secondary to some
external infection. Its most frequent cause is middle-ear disease;
consequently the sigmoid sinus is the one most often involved. It may
follow carbuncle, erysipelas, or cellulitis of the external parts, or
nasal ulceration, as well as dental caries, suppuration of the tonsils,
etc. Infection may be propagated by tissue continuity, or through the
circulation.


=Symptoms.=--Infective thrombosis presents few distinctive symptoms.
Local ischemia, perversion of function, extracranial edema are too
vague. Headache is nearly always constant and vomiting is frequent;
temperature runs high, with marked remissions; the pulse is small
and rapid, and remains so even under an anesthetic. _Chills_ are
frequent, of the pyemic type, and are followed by copious sweats.
Should pulmonary infarct occur there will be typical thoracic signs,
although at first physical examination may give negative results.
Later, however, we get prune-juice expectoration, putrid sputum, etc.
Cerebral function is disturbed late rather than early. The duration of
the disease ordinarily is from two to four weeks. Should _meningitis_
complicate the case there is more violent headache, persistent high
temperature, great excitement, muscle spasm, strabismus, delirium, and
coma; if the sigmoid sinus be involved there is usually retraction of
the head. Should leptomeningitis extend down the spine, complaint of
girdle pains will be made.


=Differential Diagnosis.=--The two conditions which are most likely to
be confused with sinus thrombosis are meningitis and brain abscess.
In _thrombosis_ there are pain and tenderness over the mastoid,
extending down the neck. Fever is high, pulse rapid, respiration not
affected, rigidity not usually present. Chills are frequently followed
by profuse perspiration. The general picture is one of sepsis and the
typhoid state. There are no special eye symptoms. Death is finally
due to pyemic processes. In _meningitis_ pain is an early, constant,
and severe symptom. Headache is frontal or general, fever is not
characteristic, pulse is rapid until the accumulation of pus causes
slowness by pressure, breathing is short and rapid, and finally of the
Cheyne-Stokes variety. Rigidity of the neck and back, with retraction
of the head, is nearly always present, with spasmodic contractions or
convulsions about the neck. Chills are not so pronounced, vomiting is
almost invariably of the projectile type, optic neuritis is frequent,
and the intellect is early impaired. In _brain abscess_ pain is at
first localized and severe, extending and becoming excruciating. This
increases on pressure, and does not disappear until relief is obtained
or the patient becomes unconscious. Temperature is normal or subnormal
until the abscess ruptures. The pulse is slow, as in compression from
other causes; breathing is slow and stertorous. Rigidity and vomiting
are like those of meningitis. Eye symptoms are almost always present,
photophobia at first, later inequality of pupils, with dilatation on
the affected side, optic neuritis and irregular movements of the eye
and lids. Drowsiness, dizziness, and impaired intellect are features
when the abscess is in the cerebellum. Death occurs in coma unless the
case be complicated by meningitis.

We may also have _exophthalmos_ on one side or both, with conjunctival
injection, edema of the lids, and disturbances of vision, due to
thrombosis of the cavernous sinus and stasis in the ophthalmic vein.
In thrombosis of one transverse sinus only the internal jugular on
that side will carry less blood. So long as that on the other side is
free it will take that which cannot pass through the obstructed one.
Consequently the jugular on the other side will carry more. But if
the contained clot extend so far that direct communication with the
internal jugular is interfered with then the internal jugular of the
affected side will be almost empty, while the external of the same side
will be the more distended. When the eye is protruded and the frontal
vein distended it is evident that the cavernous sinus on that side is
involved. If the superficial veins of the scalp be distended it is
the superior longitudinal sinus which is at fault. When the veins of
the mastoid region are involved, we may locate the thrombus in the
transverse sinus; when there are no localizing symptoms, it can only be
said in a general way that thrombosis has occurred.


=Prognosis.=--Prognosis is always unfavorable, though recovery is not
impossible. The therapeutics are in the main prophylactic. By actual
physiological rest the possibility of pulmonary complications can be
diminished. The treatment, aside from this, is purely operative, and
will be discussed elsewhere.


C. =Sinus Phlebitis.=--This may be the result--

  (_a_) Of thrombosis; or,

  (_b_) The continuation of suppurative processes from neighboring
  tissues.


=Symptoms.=--The symptoms are seldom diagnostic. Sinus phlebitis
is often accompanied by meningitis, even encephalitis. The first
symptom is usually severe headache, often localized, made worse by
pressure. Anorexia with early mental disturbance and often delirium
follows, with vomiting, restlessness, and mania, changing to stupor
and coma. _Rigidity_ or spasm of _cervical muscles_, or of those of
the extremities, followed by paralyses, is often seen. Evidences of
_irritation of special nerves_, particularly the oculomotor or the
vagus, are not rare. When pyemic symptoms occur they are vague and are
most conspicuous in the lungs and liver. Taken in conjunction with
aggravating brain symptoms they make prognosis unfavorable.

Symptoms will in large measure depend upon the sinus most involved.
They are characteristic if this be the _cavernous_ sinus. There are
disturbances in the eye on the same side, congestion of orbital veins,
pain and photophobia, and, later, cloudiness of the cornea and edema
with exophthalmos. Finally the pupil becomes paralyzed and dilated, the
cornea loses its polish, the upper lid cannot be raised, and, if the
case persists, the cornea ulcerates. Along with these local evidences
there will be complaint of frontal pain, usually with paralysis of
the hypoglossal nerve and consequent thickness of speech. When the
_transverse_ sinus is involved there are, first, vagus irritation,
then paralysis with paralytic sequences in the muscles of the jaw, the
tongue, palate, pharynx, etc. Diaphragmatic motions are interfered with
and the character of the respiration altered. As the trouble extends to
the internal jugular we have further paralysis of accompanying nerves,
especially of the hypoglossal. As the irritation extends down the vein
there will be tenderness, rigidity, and often swelling. The local signs
and symptoms vary obviously as the lesion extends from one sinus to
the other, for when one cavernous sinus is involved the trouble nearly
always extends to the other, and local symptoms are repeated upon the
opposite side.


D. =Meningitis.=--The dura has a duplicate anatomical character. Its
outer surface, having the structure of periosteum, functionates as
such; its inner surface, being lined with endothelium, partakes of the
nature of a true serous membrane. When the former texture is mainly
at fault we have pachymeningitis externa, or endocranitis, which is
rarely a primary, but usually a propagated lesion met with after injury
or external infection. It may lead to infiltration with purulent
products, and, if speedy exit for pus be not provided, to involvement
of the pia within. _Extradural suppuration_ without external injury
is very rare, but should there have been a subdural hemorrhage with
external lesion the blood clot may become infected and break down.
_Pachymeningitis externa_ is most common after chronic lesions of
the cranial bones--_i. e._, caries and necrosis. _Symptoms_ are not
characteristic and often not distinguishable. When chronic there will
be local tenderness, evidence of the presence of pus, with focal
symptoms.


=Treatment.=--The treatment is always surgical, save possibly in
certain cases due to syphilis, where delay may be justifiable for the
purpose of testing the action of antispecific drugs.


=Pachymeningitis Interna.=--Pachymeningitis interna is often confounded
with chronic hydrocephalus. It is frequently the occasion of a firm,
membranous exudate upon the internal surface of the dura, which forms
in time a new membrane rich in small and extremely friable vessels,
from which hemorrhages easily occur, thus giving rise to the condition
of pachymeningitis hæmorrhagica. Trifling hemorrhages will produce
little or no disturbance; when of greater extent they may give rise to
localizing brain symptoms. These extravasations may absorb or undergo
fluidification--_i. e._, produce localized or cystic collections of
fluid. The condition sometimes occurs after other acute infections,
especially pneumonia, pleurisy, typhoid, whooping-cough, etc. Recovery
is possible, but usually at the expense of adhesions, which lead to
subsequent complications.

The _symptoms of pachymeningitis hæmorrhagica_ are headache, which
will increase in intensity with every new escape of blood, usually
localized in the vertex, with more or less paralysis following each new
extravasation. The final result may be atrophy. Absence of disturbance
in the cranial nerves points to lesions in the convexity rather than
basal or ventricular. In chronic cases there is optic neuritis, and
toward the end coma, usually coming on slowly. Dennis has recommended
trephining under these circumstances, and has practised it with great
benefit.


=Treatment.=--The treatment should be in a large degree surgical, for
little short of eradication will bring about the desired result.


=Leptomeningitis.=--This term refers to inflammation (_i. e._,
infection) of the pia mater, in whose texture we encounter tissue
quite different from that composing the dura, and in which, when
inflamed, distinction as between the arachnoid and pia has disappeared.
_Leptomeningitis suppurativa_ is an exceedingly common expression of
intracranial infection, and may result not merely by extension, but as
a primary infection. When begun it spreads rapidly, the fluid contained
within the meningeal cavities, mixed with pyogenic agents, helping to
disseminate the active agents to the ultimate limits of the membranous
involvement. Consequently basilar meningitis usually extends down the
spinal canal. Next to injury the most frequent cause is _middle-ear
disease_, with its infectious complications and extensions. Next to
this come sinus phlebitis and endocranitis. Infection from the teeth
and the nasal cavity may occur. It is also known to result from
panophthalmitis: in traumatic cases, when primary, it sets in early,
even from four to thirty-six hours after injury. So rich is the pia in
loose connective tissue that even from the outset the inflammation may
assume the phlegmonous type. The cerebrospinal fluid, as well as that
of the ventricles, becomes cloudy, contains numerous flocculi, and is
often blood-stained.


=Symptoms.=--When the disease is limited to the vertex and follows
several days after injury it usually begins with chills and malaise,
with increasing temperature; after which the symptoms assume the
pyemic type, distinguished from true pyemia by their comparatively
early onset. The pulse becomes frequent, first full and then small;
patients are disturbed, restless, or uncontrollable, and complain of
headache, moan, grate the teeth, become delirious, with glistening
eyes and congested face. After a while delirium subsides into stupor
and restlessness into insensibility. The pupils contract and remain
inactive to light. Paralyses and cramps are not infrequent. _Traumatic
basilar leptomeningitis_ occurs often with fracture of the base.
Signs and symptoms are less distinctive here; paralyses occur more
easily and are less distinctive, save those which involve the special
cranial nerves. When _ptosis_ occurs with dilatation of the pupils and
glossopharyngeal paralysis we should be quick to suspect extension of
the process along the brain. Cramp or stiffness of cervical muscles
mean the same thing, and are signs of grave import which may be
considered pathognomonic. Albuminuria is frequent, with marked increase
of phosphates in the urine.

_In the non-traumatic cases the symptoms of leptomeningitis are
those of increasing brain pressure and temperature._ The disease
usually commences with headache followed by vertigo, hyperesthesia,
restlessness, delirium, insomnia followed by somnolence, muscle spasm,
paralyses, coma, and death. If the disease extends from the middle ear
there is frequently facial paralysis before the meningeal symptoms
appear.

The type of fever is one of gradual increase, though before death
temperature often falls even below the normal. Pathognomonic fever
should not be mistaken for the elevation of temperature which often
accompanies absorption of intracranial hemorrhages. In these latter
cases temperature may mount to 39° C., but if rising higher than this
meningeal complications should be suspected.


=Diagnosis.=--The diagnosis as between sinus phlebitis and
leptomeningitis depends principally upon the existence of pyemic
symptoms. When the latter are entirely wanting we may at least say that
the predominating symptoms of sinus phlebitis are absent.


=Prognosis.=--The prognosis is unsatisfactory. Many cases end in
forty-eight hours; others may live for two weeks or more.


=Treatment.=--Treatment seems almost futile, though one should
endeavor by energetic purgation, venesection, etc., to do what he can.
The only prospect or hope comes from the possibility of relieving
the compression from effusion of purulent fluid, and of irrigating
and draining what is now an enlarged abscess cavity. Since we do
not hesitate to open and wash out other serous cavities when thus
affected--_e. g._, peritoneum, pericardium, joints, pleura--we should
no longer hesitate to open the dura and wash out the subdural space,
even though this necessitate more than one trephine opening. The
measure was suggested by S. W. Gross, in 1873, when he reported cases
thus treated with success, and has since been practised by other
surgeons, among them by Souchon, who has advised multiple puncture with
the small drill and irrigation and disinfection through numerous small
openings. Of 11 cases collected by Gross more than twenty-five years
ago, 45 per cent. recovered.


E. =Encephalitis.=--The etiology of this condition is practically
that of leptomeningitis. It may proceed from sinus phlebitis or from
the veins emptying into the sinus, infection travelling backward
rather than forward. In many cases the primary infection occurs from
without, as in gunshot fractures. It is also transmitted along the
lymphatic channels, since I have operated on abscess in the frontal
lobe following intranasal operation. It assumes practically always the
suppurative type, and may run either an acute or a chronic course. When
acute the lesion is usually limited in area, and the result is an acute
abscess with irregular boundaries. It may be distinguished from uremic
coma by examination of the blood (leukocytosis) as well as that of the
urine.


OPERATIVE TREATMENT OF INTRACRANIAL SUPPURATIONS.

In dealing with pus the surgeon can never follow a safer rule than
to go according to this dictum: _i. e._, that pus left alone is a
greater source of danger than the surgeon’s knife judiciously used.
Consequently _ubi pus, ibi evacua_, applies to intracranial collections
as well as others. For its detection and evacuation operations are now
regarded as not merely justifiable, but indicated whenever there is
presumption of its presence. Discussion now hinges entirely upon the
wisdom of exploration when absolutely no diagnosis can be made. Save
where an opening already exists, trephining is a necessary preliminary.
Among other _indications_ is _spontaneous escape of pus_ through a
previous opening or any of the natural outlets of the cranium, with
or without localizing phenomena. _Further indications_ are those
pertaining to the bone--_i. e._, loosening of pericranium; or to the
scalp--_i. e._, edema, puffy tumor, etc.; and certain other indications
are those of a more general character, chills and pyrexia. When the
dura is exposed much can be determined by the existing brain tension,
it being now well established that brain pulsation is often intensified
by the presence of pus beneath the dura. The most feasible method for
detection of subdural or deep collections is the use of the aspirating
needle--a method now generally in vogue and everywhere accepted.


MASTOID DISEASE AND THE MASTOID OPERATION.

In all cases of infection and suppuration of the middle ear the
adjoining portions of the cellular structure of the mastoid undoubtedly
participate. Fortunately morbid activity is usually so limited that
the clinical evidences of what is called _mastoiditis_ occur in a
relatively small proportion of cases, but otitis media purulenta is so
common that mastoiditis is consequently a complication of sufficient
frequency, and occasionally of such severity, that it is as likely
to come under the supervision of the general surgeon as that of the
specialist. Moreover, the region affected is such common ground, as it
were, between the broad field of the former and the restricted field of
the latter that it seems to me that every general surgeon or student of
general surgery should be familiar with the condition and its surgical
treatment.

Several of the specific germs, of diseases like pneumonia, la grippe,
etc., are known to set up acute mischief within the tympanum as well
as the commonly known pyogenic organisms. They have easy access to the
middle ear through the Eustachian tube, as well as by the deeper blood
and lymph channels. The nasopharynx is never free from the presence of
organisms, while the specific fevers, like scarlatina, and notably such
infections as diphtheria, predispose to germ activity in the region
into which the inner end of the Eustachian tube opens. The Schneiderian
membrane, which is practically continuous from the ethmoid cells to
the membrana tympani, affords easy travelling, and in all directions,
for infecting organisms. The violence of reaction will depend upon two
uncertain and indeterminable factors, the virulence of the organism and
the susceptibility of the patient. To what extent the mastoid cells
and antrum, around an infected tympanum, shall participate may be, to
a considerable degree, a matter of their anatomical arrangement. When,
however, they do participate to any great extent the fact is made known
by symptoms of unmistakable character. These constitute the added
features of what is known as _mastoiditis_.

The cavity in the mastoid known as the _mastoid antrum_, no matter
what may be the arrangement of the other cells, is always present, and
in the presence of deep disease the antrum should be first opened. In
close proximity to the antrum are cavities like the sigmoid sinus,
the horizontal semicircular canal, the facial canal, and the interior
of the cranium. While opening the antrum care should be taken to
avoid encroachment upon the other cavities or structures, except in
those instances where there is evidence of intracranial mischief, in
which case it may be desirous to expose the sinus wall, or even a
considerable area of brain surface. The mastoid prominence varies in
different individuals, extending outward to accommodate the sigmoid
groove for the lateral sinus.

According to the intensity of the process the pathological condition
of the mastoid may vary between an empyema of its cavities, an
osteomyelitis of its osseous structure, or osteoperiostitis of its
external surface. Nevertheless all three of these may be combined in
the same case.


=Symptoms.=--The symptoms of mastoiditis are _pain_, referred to the
mastoid, as well as to the region around it, although when pressure is
not made by retained pus pain may not be intense; local tenderness is
present in nearly all cases, and will depend upon the proximity of the
trouble to the surface. This tenderness is evoked by gentle pressure,
which will sometimes produce pitting, or by tapping lightly with the
finger. When the trouble is superficial there will often be _edema_,
with all the local evidences of suppuration. In addition to this there
will be coincident symptoms of _disease of the middle ear_, with
discharge, earache, etc., and frequently edema or actual phlegmon of
the auditory canal.

The different directions in which destructive processes may extend, and
their consequences, are as follows: (_a_) Externally, with well-marked
local evidences of the proximity of pus; (_b_) anteriorly into the
meatus, with phlegmonous appearances in that canal; (_c_) upward,
through the roof of the tympanum or the antrum, with disastrous
cerebral symptoms or extradural abscess; (_d_) inward, toward the
sinus, with consequent thrombophlebitis, extradural abscess, and
perhaps cerebellar abscess; (_e_) downward, and away from the mastoid,
with phlegmon deep in the neck.

The first appearance of symptoms of any of these complications should
awaken apprehension and demand scrupulous attention. Any collection of
pus along the auditory canal should be promptly incised, and the first
indication of mastoid tenderness or inflammation should cause a prompt
application of leeches, followed by antiseptic irrigations. In this way
it may be possible to avert serious symptoms, provided these measures
be instituted early.

But with either the access of local symptoms indicating the presence
of pus, or of more general symptoms, elevation of temperature,
acceleration of pulse, headache, or anything else suggestive of dural
irritation or cerebral complication, no time should be lost in making
free and radical operation. The _mastoid operation_, so called, is
then demanded in these cases. When thus indicated the first objective
point should be the _antrum_. In order to reach this the customary
incision of many writers, back of and parallel to the posterior convex
border of the ear, is insufficient and uncertain. The antrum lies
within what Macewen has described as the _suprameatal triangle_, and
is to be regarded as the key to the situation. It is necessary to
recognize the posterior zygomatic root, which projects behind and
above the ear, as well as the tip of the mastoid process, and then
to make a perpendicular linear incision, about a quarter of an inch
behind the posterior border of the external osseous meatus, extending
from this posterior root down to or nearly to the mastoid tip. The
surgeon should cut down directly upon the bone, without dissecting or
scratching his way through the different tissue layers. The posterior
auricular attachments are thus fully exposed, and should be reflected
forward, so that the posterior aspect of the external meatus is fully
exposed. After thus exposing the bone the surgeon notes the position
of the superior meatal triangle, which is formed by the posterior
zygomatic root, the upper posterior segment of the external osseous
meatus, and an imaginary line uniting these two, extending from the
most posterior portion of the osseous meatus to the zygomatic root.
Within this triangle the mastoid antrum may be entered, its depth being
proportionate to the depth of the middle ear from the surface. So long
as care is exercised the sigmoid groove will not be injured. The depth
at which it lies from the surface varies. It is more superficial in
children, while in adults with chronic ostitis of the region it may
have a thick covering. When opened it should be thoroughly cleansed,
for it may contain not only pus but granulation tissue or masses
of cholesterin. After cleansing the antrum the passage between it
and the middle ear should be noted, as well as the position of the
facial canal, which traverses its inner side obliquely from without
inward as it passes into the inner wall and roof of the tympanum. It
is recognizable by a ridge of harder osseous tissue. If changes have
occurred in the surrounding bone it may not be recognized. If the
operator keeps to the upper and outer part of the antrum he will avoid
the nerve. Any injury to it will produce facial twitching. The bony
canal may be eroded by granulations, so that the nerve itself may be
exposed when the antrum is being cleansed.

The _mastoid cells_ lie posteriorly and below this antrum, and should
be exposed, when cleaning out their morbid contents, by removing the
external mastoid wall. In this part of the operation the _sigmoid
groove_ should not be forgotten, as it may have been disintegrated by
granulations which have extended into the fossa and separated the dura
from the bone. When granulations have thus formed there is usually more
or less thrombosis of the sigmoid sinus in addition to the localized
pachymeningitis.

The instruments which may be employed during this work are a matter
of choice. It can be done with the ordinary bone instruments of the
general surgeon, which should, however, include gouges and curettes of
small size as well as delicate chisels and mallet. A dental or surgical
engine is advisable, which will serve admirably and for the desired
purpose. Just what instrument should be used and how manipulated will
depend upon the more or less pneumatic (_i. e._, cellular) character of
the bone. Some mastoids are richly cellular. Pus or granulation tissue
should be followed wherever it may lead.

When both mastoid cells and tympanum participate in the morbid process,
and are practically filled with pus, debris, or granulations, there
may then be added to the operation those features which entitle it
to be called _tympanomastoid exenteration_, as devised by Schwartze,
Zaufal, Stacke, and others, and frequently described under their names.
It is an extension of the measures already described, and results in
converting the mastoid cells and antrum, the tympanic cavity, and the
auditory canal into one common cavity. Not only is the bony barrier
between the antrum and the tympanum removed, but the ossicles as well.
This leaves a large cavity, which should be partially closed and
lined by granulation and cicatricial tissue, epithelial lining being
furnished so far as it may extend from the exterior.

The operation may be begun practically as already described, the
incisions being more extensive and the auricle more freely detached,
so as to be reflected forward. There need be no particular effort to
save the periosteum over the area of the attack, although there is no
objection to reflecting it with the softer tissues. Some operators
prefer to detach the cartilaginous meatus and the ear from its osseous
insertion and to shift them all farther forward. The antrum and the
mastoid cells having been exposed, opened, and cleaned out, the
surgeon next passes forward and upward to the external wall of the
epitympanum, and the dividing barrier of bone between the tympanum and
the mastoid. This cavity being uncovered, the incus, if present, may
be lifted out of its position, or all of the ossicles removed in as
gentle a manner as circumstances will permit. All the bony prominences
and partitions between the tip of the mastoid and the anterior wall of
the tympanum are then smoothed off with a curette, or surgical engine,
while granulation tissue is followed in to any recesses which may be
occupied by it, or along any of the cranial outlets which it may be
seen to traverse. One gives the greatest care to avoidance of injury to
the horizontal semicircular canal, to the aqueduct of Fallopius, or to
inadvertent puncture of the sigmoid groove. The Fallopian aqueduct, or
canal, lies in the ridge between the mastoid and the meatus, along the
floor of the aditus, and it should be spared in the process of cutting
away the bone.

If the membranous portion of the meatus has been split, as advised by
some operators, its margins may be brought together with chromic gut.
At all events the auricle should be brought back into place after the
cleansing is finished, where it should be fastened and retained by
sutures as well as by the dressings. Should there be insufficient skin
to cover the opening thus made, slide a flap, or even cover the exposed
raw area with a skin graft. The former will usually be the better
plan. The cavity left after such closure should be packed with gauze,
on which balsam of Peru should be used. This may be left for two or
three days, after which a daily dressing, with irrigation or suitable
cleansing, will suffice.

Most of the mechanism of the middle ear is apparently destroyed, but
loss of hearing is not complete.


CEPHALOCELE.

The term _cephalocele_ is applied to tumor of the endocranium,
presenting through defects in the cranial bones, of essentially
congenital origin, and containing more or less of intracranial
contents. It comprises--

A. _Meningocele_, which means a tumor consisting of a membranous
protrusion and containing cerebrospinal fluid; and,

B. _Encephalocele_, referring to tumors which contain also more or less
of actual brain substance.

[Illustration: FIG. 380

Occipital cephalocele.]

Such tumors of non-traumatic origin can only be explained by the
existence of congenital defects which permit the escape of that which
the normal bone retains within normal limits. In most instances the
defect is in the middle line, at either one or the other extremity of
the skull. In some instances the arches of the atlas, or even of other
cervical vertebræ, are lacking. The most common cephaloceles are the
occipital, which are known as inferior when below the occipital spine,
or superior when above it. Those appearing anteriorly are known as
sincipital, and are met with most often at the root of the nose, where
they may communicate with the orbit or the nasal cavity. Other and
irregular forms are laterally or unsymmetrically located (Figs. 380,
381 and 382).

_Cephaloceles_ have an elastic feeling, many of them an exquisite
fluctuation. Sometimes by touch alone we recognize both their fluid
and solid contents. A meningocele with thin walls is _translucent_. By
pressure they can be _reduced in size_, such pressure usually producing
brain symptoms, often paralysis or convulsions. Many children thus
affected cannot lie upon the tumor without becoming restless. When the
patients cry or make violent straining efforts it becomes larger and
its covering more vascular, while during quiet sleep it is usually
reduced in size or tension.

[Illustration: FIG. 381

Sincipital meningocele.]

A large proportion of patients with these congenital defects die
shortly after birth. The tumor, when large, may be ruptured during
delivery. Occasionally the sac ruptures spontaneously, which accident
is usually followed by purulent meningitis from infection, though it
may possibly lead to spontaneous recovery. The principal danger is the
liability to such accident.

[Illustration: FIG. 382

Sincipital hydrencephalocele; two views. (All of these from the Buffalo
Clinic.)]

The _encephaloceles_ are divided into the _cenencephaloceles_,
containing solid brain substance, and _hydrencephaloceles_, consisting
of the protrusion of a dilated brain cavity--_i. e._, a thin area of
brain enclosing fluid communicating with one of the ventricles. Most of
the large tumors pertain to the latter class. The more brain material
such a tumor contains the more it pulsates, especially if the patient
cry or strain; the smaller, too, is the skull--_i. e._, the greater the
tendency toward microcephalus.

_Congenital cysts_ of brain and membranes, in a measure traumatic, are
classified by Rawling, as follows:

1. According to situation: (_a_) within the calvarium, subosteal,
subdural, subarachnoid or intracerebral; (_b_) projecting through an
opening in the skull, with or without ventricular communication.

2. According to origin, _i. e._, whether they arise from blood clot or
other causes.

3. According to contents, whether they contain clear fluid, altered
clot, or brain substance.

Cysts of this character are to be differentiated from the cephaloceles
already considered because there is about most of them the element
of traumatism, although this may have been intra-uterine or produced
during parturition. Those which are associated with premature
synostosis and microcephaly, with hydrocephalus, with marked deformity,
or situated below the external occipital protuberance, are generally
considered inoperable, while those considered operable consist of
limited protrusions without any of the above defects. This practically
excludes the greater proportion of these cases from operation, which is
always dangerous. Nevertheless if success is to be achieved the risks
should be taken. Osteoplastic methods of closing cranial openings may
be perhaps of value in rare cases, although in the young the skull is
too thin to furnish an external table which can of itself be detached.
In inoperable cysts of this kind, with a tendency to increase, while
the rest of the brain lags behind in the rate of growth, the edges of
the opening become everted, and operation is thus made more difficult
and less desirable.


=Treatment.=--Treatment should, first of all, be protective, by
a shield of some device held in place by a suitable bandage or
dressing. _Compression_, with or without puncture, has given at times
satisfactory results, but not much should be expected from any method
or combination. Most of the cases are such that extirpation would seem
applicable, but the impossibility of absolute asepsis in young infants
and the liability to fatal shock preclude many of these attempts. In
some instances ligature of a meningocele has been successfully applied.
_Operation_ may be attempted in young children in selected cases.
Plastic operations may be resorted to, or plastic maneuvers combined
with extirpation. It may be possible by the insertion of a celluloid
plate to atone for a small defect in the skull after extirpation of a
tumor of this kind. I have successfully practised this method in spina
bifida.


HYDROCEPHALUS.

This term is applied to abnormal collections of cerebrospinal fluid
within the cranial cavity. We speak of--

A. _Hydrocephalus ventriculorum_ or _internus_, when the fluid is
confined to the dilated ventricles of the brain; or of--

B. _Hydrocephalus meningeus_ or _externus_, when the fluid collects
between the brain and the dura.

The former condition is much the more common. The cause of
hydrocephalus in the young is essentially congenital, and inseparable
from imperfect development within the cranium. The forms are
occasionally combined. At the time of commencing trouble the skull may
be of natural size, but yields to the accumulation of fluid within
until it attains relatively enormous dimensions. Most children thus
affected die early, some shortly after birth. It is most common in
rachitic children. Hydrocephalus developing in the adult is the result
almost solely of atrophy of the brain. _Pachymeningitis interna_ (see
p. 572) may also produce subdural exudate leading to _hydrocephalus
externus_. Encapsulated collections of cerebrospinal fluid due to
pachymeningitis interna are known as _hygromas_ of the dura. A
_ventricular_ form of hydrocephalus may also result from meningitis and
tuberculous disease. The condition is essentially chronic, the fluid
collecting in the dilated lateral ventricles, though the third or forth
are sometimes also distended: 4000 Cc. of cerebrospinal fluid have been
found in more than one instance. As the result of the presence of the
fluid there is _atrophy of brain_, with _arrest of development_, to
such an extent even that the hemispheres are changed into great sacs,
being merely spread out upon the outer wall of cystic cavities; all the
surface markings are lost, and gray and white substances are scarcely
to be differentiated.

In the cranium itself the bones of the vertex separate, and instead of
sutures there is a tightly stretched membrane. There is also congenital
or acquired _aplasia_--_i. e._, absolute defect of bone between the
dura and pericranium. All these changes give to hydrocephalic heads
a distinctive appearance. Other developmental defects--hare-lip,
club-foot, etc.--are common in these patients. Many infants thus
affected die during delivery unless skilful help is at hand. The
resulting disproportion between the enlarged head and the small face
is most distinctive. Children in this condition suffer from disturbed
digestion, are emaciated, with rachitic curvatures of the long bones;
special senses are seldom developed perfectly; strabismus and nystagmus
are frequent, while cramps and stupor are by no means infrequent.


=Prognosis.=--While spontaneous recovery is possible, as already
stated, the tendency is always toward fatality.


=Treatment.=--Treatment by compression of the enlarging skull, with
elastic bandages or their equivalent, is an abandoned method since
compression which can be effective is too great to be tolerated.
Treatment by mere aspiration is also useless. Tapping is an old
operation long discontinued, recently revived, but again proved
disappointing. The establishment of _permanent drainage_ is a more
recent suggestion. It depends upon the demonstration of the fact
that the tension of the cerebrospinal fluid and of the blood in the
cerebellar veins is the same, and that intracranial pressure forces
fluid into the veins and away from the skull. Thus subdural or
_autodrainage_ was suggested. Sutherland and Cheyne, in 1898, were
the first to operate in this manner. They opened the dura near the
lower angle of the anterior fontanelle, through the opening carried a
strand of catgut into the ventricle, and passed the outer end beneath
the dura; but the method again proved disappointing. Mikulicz passed
a gold tube into the right ventricle, leaving its outer end in the
subcutaneous tissues about 5 Cm. from the middle line. After being
three weeks in this position it ceased to drain, and was then inserted
into the other ventricle. The child died, unbenefited, in six weeks.
In another case he used a glass-wool drain, making it subdural rather
than subcutaneous. This case seemed to be benefited. Senn has modified
the method by making a large pocket in the subcutaneous tissues of
the cervical region, inserting one end of a rubber tube into it and
carrying the other into the ventricle between the temporal and frontal
bones. Even this proved disappointing. I have twice tried conducting
fluid by a small rubber tube from the ventricle into the cellular
tissue in the neck, passing the tube beneath the skin by suitably
curved forceps. This method, however, showed no advantage over the
others mentioned above. Taylor has endeavored to make a permanent
fistula between the ventricles and the subdural space by passing
chromicized catgut into the ventricle and letting it drain into the
latter. His results, however, were not encouraging, in spite of the
plausibility of the theory upon which they were based. Drainage through
the spinal canal into the abdominal cavity has also been practised by
a very few surgeons. The ingenuity and theory of the method are most
attractive, though but very few little patients are in condition to
bear the abdominal section which is necessitated for the purpose.[43]

  [43] In March, 1906, Cushing informed me that his present routine
  in effecting such drainage was to make a laminectomy and expose the
  spinal canal from the rear, then to do a laparotomy, and, exposing
  the bodies of the vertebræ, pass through from in front backward a
  silver tube, whose end should reach into the spinal canal, draining
  it into the abdominal cavity, the posterior wound being always snugly
  closed. The spinal canal is thus exposed in order to ensure the
  accurate performance of the other part of the operation.

Permanent drainage, then, has been a most disappointing procedure,
although there need be no hesitation in tapping the lateral ventricles
when there is indication for it. This can easily be done at any time by
an opening about 3 Cm. behind the external auditory meatus and the same
distance above the base-line of the skull. By directing the puncturing
instrument to a point on the opposite side, 6 Cm. above the meatus,
the lateral ventricle will be entered. (This same general direction
will serve for opening an abscess in the temporosphenoidal lobe.) The
best results in hydrocephalus seem to have been obtained by _lumbar
puncture_, as first suggested by Quincke, the method being the same as
that now in general use for intraspinal cocainization. As directions
for entering the spinal canal with the aspirating instrument would
be identical with those mentioned in the chapter on Anesthesia, when
describing intraspinal cocainization, the reader is referred to that
section for further direction (p. 208). The only case of well-marked
hydrocephalus which I have ever apparently cured was one repeatedly
tapped in this fashion, a considerable amount of fluid being withdrawn
at each little operation.


SURGICAL TREATMENT OF DEFECTS OF INTRACRANIAL DEVELOPMENT.

There are numerous causes which produce _imbecility_ and _kindred
conditions_ in the young. Some are in effect congenital, some are
postnatal. Within the past few years a number of these cases have
been subjected to surgical operation, in many instances with more or
less success. Mental defect may occur from injuries at the period of
birth--mainly hemorrhages, more commonly cortical, though sometimes
deep. In either case the clots thus formed frequently undergo cystic
alterations. The term _porencephalon_ is modern, and applied to changes
comprising disappearance of real nerve tissue with partial substitution
by connective tissue, often with other degenerations, the result being
atrophic alterations which apparently permit of no remedy. In a case of
true porencephalon the outlook for operation is not at all encouraging,
nor is it in any cases which are accompanied or caused by a genuine
arrest of cerebral development. On the other hand, when the mental
condition can be ascribed to the result of injuries, to hemorrhages, to
meningeal irritation, to premature ossification, or too early closure
of the fontanelles, or when it is accompanied by evidence of meningeal
irritation or symptoms which point to a definite area of the brain as
being the site of the principal disturbance, operation as a _legitimate
experiment_ may be conscientiously suggested and performed.

[Illustration: FIG. 383

Lines of removal of bone as practised by the author, by Lannelongue,
and by others.]

[Illustration: FIG. 384

Defective cerebral development. (Buffalo Clinic.)]

The _operation_ is usually described as _craniotomy_ or _craniectomy_,
and is apt to be successful in many cases of microcephaly combined with
idiocy. An _acquired form_ will give a better prognosis than will the
_congenital condition_. The danger of the operation is often great, and
especially so since it is called for in puny, ill-nourished, and badly
cared-for children. To be successful it ought to be _extensive_. It
should vary in character and degree--from simple division of the skull
along the middle line, from near the root of the nose to the occiput on
one or both sides, to the formation of large bone flaps by cutting away
a wide groove of bone so as to relieve pressure upon the hemispheres.
Fig. 383 presents the various ways of performing the operation.

It can usually be made bloodless, or nearly so, by an elastic
tourniquet around the skull. The incision in the skin should not
correspond to the groove in the bone, but should overlap it some
little distance. For my own part I prefer to do most of these
operations in two sittings. I would advise, as a rule, to prepare the
scalp carefully for operation, to divide the skin along the proposed
line, separate it from the pericranium and check all oozing; then,
after opening the skull with the trephine, to cut away with proper
forceps (rongeur) along the desired line, or, if provided with it, to
remove the bone by some surgical engine or revolving saw operated by
electricity. The strip of bone thus removed should be at least half
an inch wide, and the overlying periosteum should be removed with it,
as only in this way can the undesirably rapid regeneration of bone be
prevented. By this means the dura is exposed, but not opened. In some
cases this will be sufficient.

In many others, however, it will be insufficient; and, could this be
foreseen, it would be well to combine the above measures in one as a
first operation, and then, a few days later, to open the dura as the
second procedure--this, however, only on the discovery by careful
inspection that the wound is absolutely free from possibility of
infection. Could infection be prevented, this is certainly the safer
procedure, since in weak, puny young children to make a long scalp
incision, to remove a long strip of bone, and then to widely open the
dura is more than can safely be done in the majority of instances.

It should have been carefully explained to those interested in the case
that improvement will in all probability be extremely slow, and that
little or nothing is to be expected at first, even if prompt recovery
from the operation ensue. Neither would I advise any one to perform the
operation unless parents are willing to assume all risks and abide by
the results.


SURGICAL TREATMENT OF EPILEPSY AND THE PSYCHOSES.

Operations for relief of _epilepsy_ seem to date back even to the
prehistoric era, and were for centuries done as a purely empirical
measure; later, to have been practised with more or less plausible
reason; then to have fallen into discredit for long periods of time,
with occasional revivals of the practice, until within the past
twenty-five years the operation has been again revived upon its merits
and upon the recognition of more or less accurate indications.

Operations of this character are based upon two fundamental facts:
the first, the widespread experience that after various operations
epileptic patients have been benefited; and, second, that a certain
proportion of these cases, especially those of traumatic origin, are
characterized by a localized and definite aura, and by a systematic and
practically invariable order of muscle involvement, according, it would
seem, to some fixed law, and pointing definitely to a certain area of
the brain from which apparently the irritation arises and spreads. This
form of epileptic seizure is that generally known as the _Jacksonian_,
and is that in which operation is most often of real service. The
statements of patients regarding these phenomena should never be
accepted; only those made by a trained observer (nurse or physician)
are reliable.

_In spasms of the Jacksonian type_ there is a _certain order of
progression_ which is scarcely ever violated. Thus, irritation
beginning in the leg centre can hardly reach the face centre without
traversing that of the arm. It is possible also to have sensory
equivalents for _Jacksonian_ attacks, as when they commence with
peculiar sounds indicating irritation in the centre of hearing, or
with optical phenomena, or with disturbances of smell or taste, the
former indicating occipital irritation, the latter irritation in the
temporosphenoidal region.

The surgeon will often be consulted as to the wisdom of operation
in the presence of this condition. In brief, and in a general way,
the following statements may be made: It is necessary, first of all,
to establish a traumatic origin, and epilepsy which has preceded a
severe head injury can in no sense be ascribed to it. If it can be
clearly established that it has followed injury, and if a distinct
scar--especially a scar which is adherent--or depression can be
discovered, or any area which is always irritable and which seems
epileptogenic when irritated; or if, again, by close study of the case
it can be determined that the aura and the initial muscle symptoms
arise always in the same part--as, for instance, a finger, thumb, foot,
etc.--and proceed according to a constant program--then it may be said
that operation is not merely justifiable, but advisable. On the other
hand, when neither distinct scar nor history of localizing phenomena
can be obtained operation should rarely be attempted.

Again, in epilepsy of the non-traumatic type, operation may be advised
when it assumes the distinctly _Jacksonian_ form--_i. e._, when
everything points to irritation proceeding from a localized portion
of the brain. In the absence of Jacksonian symptoms operation is even
more of an experiment than in the traumatic form. Such cases should
be studied a long time on their merits before a decision is made to
trephine.

The _operation_ itself is directed to excision of irritable scars,
to exposure of the dura at the point of opening, to the detection
and suitable treatment of depressed fragments, dural adhesions,
tumors, foreign bodies, etc. It is essential in every case that it be
represented to those interested that the operation itself removes the
_cause_, but _cannot_ be, _per se_, expected to _complete the cure_,
especially in cases of long standing, and that the final cure must
depend in large measure upon the avoidance of subsequent irritation,
upon the establishment of perfect habits of diet and excretion, which
are often perverted, and perhaps upon the long-continued administration
of drugs, of which the bromides are those most constantly given. The
reader need not be reminded that _old cases are the least favorable_,
and that recent cases are the most so for operation, and that the
longer the diseased condition has existed the harder it will be to cure
by any method.

Besides these direct operative attacks it has been suggested by
Alexander to tie the vertebral arteries (now practically abandoned)
and by Jonnesco to excise the superior and middle cervical sympathetic
ganglia. This seems to me particularly indicated in those cases where
a convulsion can be aborted by prompt administration (by inhalation)
of amyl nitrite as soon as the preliminary aura is recognized. The
operation is described in the chapter on Surgery of the Cranial and
Cervical Nerves. Many encouraging results of this treatment have been
reported.

_I believe thoroughly in operating in selected cases._ I am
equally confident that indiscriminate operation must lead only
to disappointment and to occasional disaster. In the presence of
long-standing lesions, like bone depressions, cystic degeneration of
old clots, etc., the brain may have been so long pressed upon as to
have become atrophied.

The whole subject of the modern surgical treatment of epilepsy is
inseparable from the topic of prompt and efficient treatment of all
head injuries. Were the indications in these always met at the time
of the accident we should have a much smaller proportion of cases of
traumatic epilepsy.

Inasmuch as one object of many of these operations is to break up
adhesions between the dura and the pia, there is generally anxiety
to know the result after such operations as to whether they do not
speedily form anew. There is always this theoretical danger, and it
is my custom in such cases to insert beneath the dura, at the point
where such adhesions have been divided or torn, a piece of delicate
gold-foil, duly sterilized, in order that it may separate these
surfaces and prevent the recurrence of the old condition. Foil used
for this purpose is harmless, and I have numerous patients in whom it
has been used, apparently without producing the slightest disturbance.
(Foils of silver or aluminum answer as well or better.)

_Mental and psychic disturbances after head injuries_ have been
long known and the suggestion to operate upon the skull in cases of
so-called _traumatic insanity_ is not new. In a general way it may be
said that whenever distinct mania follows a recognized lesion of the
vertex of the skull, and fails to subside within a reasonable time and
under proper treatment, there are the best of reasons for raising the
scalp, trephining, and exploring as to the deeper conditions. Patients
might be released from asylums who have long been inmates had this
measure been practised at the beginning of their mental alienation.

The same measure will give relief in certain cases of _cephalalgia_,
or headache, where the pain is always ascribed to a particular region,
and especially when there is tenderness over this region. These
operations are, of course, _empirical_, yet, as the result of altered
nutrition and allayed irritation, relief follows in a fair proportion
of instances.


INTRACRANIAL TUMORS.

Until within recent years these were regarded as having interest mainly
for the pathologist and clinician, but as essentially hopeless so far
as surgical help is concerned. Recent discoveries in the field of
cerebral localization and recent experience with extensive openings
into the cranium have shown, however, that a small proportion of
intracranial tumors are of such a character and so located as to make
them amenable to surgical relief. These tumors occur with about equal
frequency in childhood and adult life. In the order of frequency they
stand about as follows: Tuberculous gumma, glioma, sarcoma, cysts,
carcinoma, and syphilitic gumma, with a small proportion of fibroma,
etc.

Of 100 cases of brain tumor selected at random not more than 5 to 7
per cent. are so placed as to justify surgical attack. In as many
more, at least, the tumors are so located as to justify opening the
cranium for mere relief of pressure without any notion or endeavor to
attack the tumor itself. _Before opening the cranium_ diagnosis should
be made as carefully as possible--first, as to _location_; second, as
to whether _cortical_ or _subcortical_; third, as to the _number of
tumors present_; fourth, as to their _general character_. Location is
determined in the main by study of pain complained of, by watching
patients during convulsive seizures, by determining the extent of local
or general paralysis, by careful history which shall reveal the method
and rate of extension of these symptoms, and by the study of the optic
disks, of vision, and by noting the presence or absence of stupor,
nausea, coma, slow pulse, or other compression symptoms.


=Symptoms.=--A brief epitome of the principal features attending cases
of brain tumor will include:

1. _Pain and headache_, rarely localized with much accuracy; the former
sometimes increased by percussion or pressure, occasionally periodical
and usually intense. The location of the pain sometimes corresponds
with that of the tumor.

2. _Vomiting_, usually without pain or nausea, and often projectile. I
have repeatedly seen obstinate constipation in brain-tumor cases which
has gone almost to a degree of acute obstruction, and which has caused
serious error in diagnosis.

3. _Vertigo_, independent of indigestion or the condition of the
stomach or bowels. It is most frequent in cerebellar tumors, but occurs
in about 50 per cent. of all cases. It is sometimes quite severe.

4. _Eye symptoms_ such as optic neuritis, choked disk, usually double,
indicating pressure, but telling little or nothing as to the location
of the tumor causing blindness. Ophthalmoplegias are of little value by
themselves as symptoms. Hemianopsia, when homonymous, usually indicates
a lesion of the cuneus of the same side, the blind half, according to
the patient, indicating the side.

5. _Localizing symptoms_ which may be due to the destruction of
brain tissue or to indirect pressure. Those of importance comprise
paralysis or spasms, indicating involvement of the motor area; sensory
aphasia, indicating trouble in Broca’s area, ataxia or staggering,
due to cerebellar lesions; loss of sense of position, sometimes seen
in lesions of the parietal regions; anesthesia, which is rare unless
the internal capsule is involved. Other symptoms are: word-deafness,
which indicates a lesion of the posterior part of the first temporal
convolution; agraphia, indicating deep lesions under Broca’s speech
centre, and alexia, usually produced by lesions of the lower left
parietal lobe. Tumors in the sensory zone affect vision and speech, and
reveal themselves by irritative symptoms. For instance, a patient with
verbal deafness and marked hemiplegia probably has tumor involving the
left superior or dorsotemporal gyrus, which, as it grows, would involve
loss of muscle sense and anesthesia on the opposite side of the body.
A patient with headache, vomiting, choked disk, stupor, increasing
hemianesthesia, lateral hemianopsia, without spasm or hemiplegia,
probably has a tumor in the white substance of the occipital lobe. If
hemianopsia alone be present there is almost always a tumor upon the
inner aspect of the occipital lobe, on the side opposite to the dark
half-fields, which by downward growth may cause cerebellar symptoms.
Psychic and mental disturbances are present in many cases, but not in
all; most frequently in frontal lesions. They are met with in about
one-third of the cerebellar tumors and two-thirds of the temporal
tumors; they assume the epileptic type, with hallucination, mania,
or sometimes convulsions of Jacksonian type, the latter, of course,
indicating lesions of the motor area.

6. Finally there are frequent _constitutional_ disturbances, including
anomalies of thirst and appetite, and disturbances of heart and
respiration. In two or three instances the writer has seen such
serious obstruction of the bowel as to lead to mistake in diagnosis,
the obstruction in each case being finally fatal, but apparently not
justifying operation.

The above symptoms pertain to the brain tumors in general. When it
comes to tumors of the cerebellum these constitute, in a measure, a
class by themselves. Those which are operable comprise tumors located
in one lateral lobe, or invading the vermis or middle lobe, or those
found at the junction point of the cerebellum, medulla, and pons,
those first mentioned being by far the more favorable for attack. It
is not relatively difficult to decide upon the presence of a tumor in
the cerebellum, but to minutely locate it is extremely difficult. In
addition to the symptoms already rehearsed above the following features
may be mentioned: Headache is often intense, sometimes agonizing.
While usually referred to the back of the head it is occasionally
frontal. Nausea and vomiting are generally present, at least for
a time. Sometimes they subside to recur later. Optic neuritis and
choking of the disk occur earlier and oftener than in other tumors.
Blindness sometimes comes on promptly. Vertigo, as in other brain
tumors, is commonly due to irritation of those branches of the fifth
nerve which supply the inner surface of the dura, this irritation
being reflected to the bulbar nuclei of the fifth, and thence to the
nuclei of the pneumogastric. This is partly true of those growths
which are in relation with the dura, though sometimes it is true of
tumors which make pressure at the base of the brain. It is important to
distinguish, if possible, between mere vertigo and cerebellar ataxia.
The more directly focal symptoms are: nystagmus, which may be present
when the eyes are quiet or only when they are in use; paralysis, when
the pyramidal tracts are involved; muscle weakness, seen more often in
the legs, which is nearly always a cerebellar symptom; and sometimes
a peculiar posture of the head, where the spinal column becomes
concaved toward the affected side, the face looking almost backward.
Incoördination is a common indication; in about four-fifths of the
cases patients stagger in their gait.

To determine whether a given tumor is an irritative or destructive
lesion special study should be made of the spastic or non-spastic
condition of the limbs, and note to which side the eyes are turned.
Tonic spasms and contractures are rare in cerebellar tumors. A tremor
of the head and upper part of the body is not infrequent, and muscle
sense is rarely lost.

Between cerebellar tumors and those of the parietal region the chief
diagnostic points are muscular and cutaneous sensibility in the
former, with nystagmus and peculiar and extreme vertigo. From frontal
growths they may sometimes be differentiated by the clearness of
the mental processes and the absence of those symptoms which point
especially to involvement of the temporocortical region, _e. g._,
aphasia. In cerebellar tumors convulsions, one-sided or general, are
not infrequent, and incontinence of urine and feces is often noted.
The convulsions are accompanied by subjective sensations and noises,
vertigo, and by sudden blindness, with loss of consciousness, while
such tonic spasms as occur are generally of the extensor type, and last
from one to ten minutes.

_Basal tumors_ of the cerebrum produce a collection of symptoms which
sometimes are significant. Owing to their location they involve the
functions of several of the special nerves. In tumors in the _anterior
fossa_ there is involvement of the optic, the oculomotor, and the
first branch of the fifth. In tumors of the _pituitary body_ there is
involvement of the optic, the chiasm, the oculomotor, and the first
branch of the fifth, as well as the abducens. In tumors resting on
the _middle fossa_ and situated above the dura the oculomotor, the
patheticus, and the chiasm are involved. If situated beneath the dura
there is paralysis of the three ocular nerves and also the fifth nerve.
In tumors of the _posterior fossa_ there is involvement of the facial,
the trigeminus, the auditory, the glossopharyngeal, the vagus, the
accessorius, and the abducens.


=Neurofibroma of the Acoustic Nerve.=--Fränkel and Hunt have recently
shown that basal tumors spring from the acoustic nerve, which are
essentially _neurofibromas_. They have their site upon the nerve at the
point where it merges from the junction of the pons and the medulla; in
other words, where the function of the nerve is more or less disturbed,
and the patient thereby made to complain of deafness, tinnitus, and
vertigo. They slowly displace surrounding tissues. They vary in size
from a cherry to that of a robin’s egg, are loosely attached, and when
exposed easily enucleated. Their general symptoms are those common to
all brain tumors, but focal symptoms may include ataxia, paralyses
(especially of the fifth, sixth, and seventh nerves), inequality of the
pupils, and loss of coördinate movements of the eyes; these symptoms
are in addition to those of the auditory already mentioned.

Access to these tumors is a serious matter. It should be undertaken
in two stages: the first including a large lateral exposure, with or
without an osteoplastic flap, comprising the lower portion of the
squamous, a part of the occipital, and perhaps even the posterior
aspect of the mastoid. Drainage will be required for a few hours as in
other similar operations.

As to _depth_ and _number_ the former may only be learned by studying
the nature and location of the signal symptoms, the presence and order
of appearance of the same, presence or absence of headache, and local
changes in temperature. Tumors occurring in tuberculous individuals are
probably _multiple_. When different centres or systems are involved
multiple lesions are usually present.

It has been held that the three cardinal symptoms of brain tumor
are _optic neuritis_, _headache_, and _vomiting_; and while each of
these is significant, and all of them are corroborative, they are not
necessarily present nor does their absence exclude possibility of
tumor. _Other signs indicating the presence of tumor, it is a mistake
to wait for the development of these three._ The most distinctive
feature of intracranial neoplasms is the _progressive character_ of
such symptoms as are present.

There is but one form of brain tumor which is amenable to internal
treatment--namely, _syphilitic gumma_; and in case of doubt it may be
justifiable to keep the patient actively under the influence of iodides
for a reasonable length of time. This, however, need never be prolonged
beyond six weeks, after which time, should no improvement occur,
operation should not be delayed.


=Operation.=--Brain tumors are operated for two purposes: First, for
relief of pain and other distressing symptoms in incurable cases;
second, for radical cure. Operation is justifiable in any case when
pressure symptoms become severe, particularly so when pain is localized
to a reasonable extent. Choking of the optic disks is not infrequently
relieved and threatened disability postponed. The complete operation
consists in the _exposure_ of the tumor and in its _removal_.

The osteoplastic method should be used in exposing the tumor, by which
a bone flap is raised, along with the overlying scalp, from which it
is not detached. The centre of this flap is supposed to be calculated
to overlie the centre of the deep lesion which it is proposed to
attack. In many instances the operation should be divided into two
distinct procedures, the first consisting in removal of the bone and
exposure of the dura; this exposure should be ample, including the
whole lateral region if necessary, as Horsley has shown; the second, a
week or two later, comprising the balance of that which is to be done.
But comparatively little shock attends removal of the tumor in the
second stage of such a divided operation. After removal of the growth
its cavity is best packed with a gauze tampon, after prompt ligation
of all bleeding vessels within the field of operation, although it is
usually required merely on account of venous oozing, as it is often
possible to cut to the depth of an inch in the brain without a single
artery spurting except those in the pin. The tampon is of value if
allowed to remain for forty-eight hours, as preventing filling of the
cavity with clot or excessive bleeding during the vomiting which may
follow the administration of the anesthetic. The vasoconstricting
properties of adrenalin may prove of great service here; it should be
used in the standard 1 to 1000 solution, diluted 1 to 3. I have no
hesitation in spraying this upon the brain or in saturating tampons
with it, which may be left _in situ_ so long as necessary. A number of
the old-fashioned small serrefines, properly sterilized, can also be
resorted to, if needed, for securing vessels, which may not be easily
tied. They can be left in place along with the tampon and all may be
removed together.

Next to the danger from hemorrhage is that of rapid edema of the
brain, which may result from increased tension in the arteries or
through venous stasis, which later produces lymph stasis, by which
fluid collection in the tissues is still further facilitated. Another
reason for using tampons is to prevent such relaxation of veins as may
predispose to this edema. In most respects the operations for removal
of brain tumors differ slightly from those whose general principles
are elsewhere mentioned in this work. I am greatly in favor of using
secondary sutures (_i. e._, those tied with bow-knots), which may
be loosened on the second or third day, permitting the raising of
the flap, removal of tampon, etc., and I employ them largely after
all sorts of operations upon the cranium. If we desire to prevent
any attempt at union of wound margins we may employ the green silk
protective introduced by Lister, which should have been previously
carefully sterilized by boiling.

The _operative treatment of cerebellar tumors_ is made doubly
difficult by their protected position and the large sinuses with
which this part of the brain is surrounded. The cavity is restricted
in size, intradural tension is greater than above the tentorium, and
there is no room for easy displacement or retraction of parts. The
occipital bone varies much in thickness and at points is somewhat
thin. Operation which is begun either as an exploration or with a
fixed purpose may prove palliative, even should the original purpose
fail of accomplishment, as relief may be afforded by reducing tension,
such relief consisting perhaps in freedom from headache, vomiting, and
vertigo. Incision should extend from the tip of the mastoid process, a
little above the superior curved line, to beyond the median line, with
a vertical median incision by which a flap sufficiently large may be
reflected downward. It is best to reflect the periosteum with the other
soft tissues in order to expose the bone. The bone should be bitten
away with forceps or removed with a reliable engine as rapidly as
possible, hemorrhage being controlled with Horsley’s wax.

The operation may be divided into two stages, confining the first stage
to the exposure of the cerebellar surface, or the operator may attempt
all at one time.

The second stage consists in raising a dural flap, by which the
cerebellar surface is exposed for inspection. It will protrude promptly
through the opening, so that, with the finger, it may be possible to
detect a tumor by the sense of touch. If no tumor appear on or near the
surface deeper exploration should be made, with the aid of a retractor
and by removal of a portion of the cerebellar hemisphere. This may
require further exposure of the lateral region of the skull. Tumors
situated deeply or at the junction of the cerebellum and pons require
all the room that can be afforded from the outside, and are better
approached from the lateral region than from above or below. It is
comforting to realize what considerable portions of the cerebellum can
be removed without serious or extensive disturbance, but as the medulla
and pons are approached there is need of great care. The opening may
be extended across the middle line, and either the lateral or the
longitudinal sinus, or both, may be doubly ligated and divided. The
tentorium may also be divided nearly to the petrous portion, after the
lateral sinus has been thus divided, and so better access given to the
deep location.

These remarks apply especially to operations for tumors of the
cerebellum. The other features of such operative attack are those
common to brain tumors in any location.

In all operations for brain tumor, but particularly for cerebellar
tumor, it will prove of the greatest advantage to have the operating
table so inclined that the patient’s head will be three or four feet
above his heels. In this position the veins are drained by gravity,
and the operation is complicated by but little venous oozing. _Crile’s
pneumatic suit_, or at least the lower part of it, should be worn, and
an assistant should watch and report on the blood pressure. These two
precautions permit such an operation to be conducted with an ease and
safety hitherto unknown.[44]

  [44] New York Medical Journal, February 11 and 18, 1905.

Cushing, dealing especially with a group of brain tumors in which
radical procedures are impossible, where nevertheless relief from
symptoms would prove a therapeutic desideratum, has proposed to afford
this by removal of a portion of their bony covering, in order to allow
a part of the brain to protrude, and thus provide a means of relief for
the constantly increasing pressure. The incomplete union of the bones
in _infancy_ permits something of this kind to occur through natural
causes, but after fusion of the elements of the cranial vault it is
no longer possible, save in those rare cases where an opening results
from the process of slow pressure absorption, which comes only when the
tumor is in actual contact with the bone.

It would be mechanically ideal if, during adult life, a dislocation
of cranial sutures could be produced similar to that observed in very
small children. The dangers of such operation are many, among them
being the possible injury to the functions of that portion of the
cortex which protrudes through the opening thus made, by which, for
example, preëxisting paralyses might be aggravated. For this reason it
is preferable to establish the hernia over some “silent” or unimportant
part of the cortex and to avoid making it unnecessarily large. Cushing,
after various trials, recommends to make the bone defect under the
temporal muscle, which not only affords a certain degree of protection,
but exposes an area where few important motor centres are involved. He
has reported several cases, with gratifying results, with a minimum of
undesirable sequels.

Obviously in tumors below the tentorium the opening would best be made
in the suboccipital region. Nevertheless, Cushing believes that even
here the final result would be no more effectual than were the defect
placed elsewhere.

Beck has called attention to the value of the temporal fascia as a
substitute for the other firm coverings, by which the brain should be
left enclosed after exposure, and when these latter are not available.
For the purpose he would fold over a flap made from the temporal muscle
and the adjoining periosteum in such a manner that fascia originally
external should now be placed deeply and in contact with the cortex.

[Illustration: PLATE XLIV

FIG. 1

Topographical Anatomy of Cortex. Localization of Functions. (Ziehen.)

FIG. 2

Topographical Anatomy of Inner Surface of Right Hemisphere.
Localization of Functions. (Ziehen.)]


OPERATIONS UPON THE CRANIUM.

The _fissure of Rolando_ is the anatomical landmark whose position it
is important to determine with reference to a number of modern surgical
procedures, for around it cluster most of the motor areas or centres.
It commences at the middle line about 56 per cent. of the distance
backward from the glabella (root of the nose) to the inion (occipital
protuberance), and, passing downward and forward, makes with the middle
line an angle of 67 to 69 degrees. For most purposes it begins half
an inch back of a point midway between the glabella and inion. It may
be easily found by _Chiene’s method_, which consists in folding a
square piece of paper diagonally and folding this again; after which
it is three-quarters unfolded, the acute angle then representing
67¹⁄₂ degrees. If this be properly applied to the skull, one edge of
its surface can be made to fall directly over the Rolandic fissure.
The fissure may also be located by a simple instrument known as the
cyrtometer--a gauged metal strip having a sliding arm upon it, which,
when the long strip is placed over the longitudinal sinus (_i. e._,
the middle line of the skull), can be made to fall directly over the
fissure. While neither of these methods is invariably and minutely
exact, either of them is sufficiently accurate for all practical
purposes.

The _fissure of Sylvius_ may be indicated by a line drawn from a point
3 Cm. behind the external angular process to a point 2 Cm. below the
most prominent part of the parietal eminence. The short and ascending
limb of this fissure is of relatively small importance in this
connection.

_Reid’s base-line_, so called, is a line drawn from the inferior margin
of the orbit backward through the centre of the external auditory
meatus. It is a line often alluded to in cranial topography. The
colored plate (see Plate XLIV) will indicate with reliable accuracy
the relations of the motor centres to each other and to the principal
fissures and convolutions. It pertains merely to the left hemisphere
of the brain, in whose third frontal convolution is placed Broca’s
centre for speech, the corresponding area upon the right side having no
exactly corresponding function. The centre for vision, it will be seen,
is located in the cuneus, the most basal portions of the hemispheres
being the seat of the special senses of taste, smell, and hearing.


=Operation.=--The word _trephine_ is at present used both as a noun and
as a verb, the older term _trepan_ being now wellnigh discarded. The
instrument consists of a section of a tube, one of whose extremities
is arranged with sharply cut saw teeth, the whole provided with a
grip or handle, which revolves in a plane parallel to that in which
the saw teeth cut. The best instrument is that arranged in a slightly
conical manner, so that it may less easily burst through the skull
and do harm to parts within. The trephine proper is manipulated by
the hand. A variety of substitutes have resulted from applications of
human ingenuity to the problem of opening the cranial bones. Some of
these are operated by foot or hand power, with reduplicated mechanisms,
and others by electricity. The more complicated the mechanism the
more likely it is to get out of order, and there are but few of these
substitutes which give anything like lasting satisfaction.

The operation of trephining is made to include any method by which an
opening is made in the uninjured cranium or by which an opening already
existing is enlarged and made to subserve the surgeon’s purpose. Aside
from the saws already alluded to, there are in use a variety of cutting
bone forceps, rongeurs of various device, and a variety of chisels,
which are to be used in connection with the mallet or hammer. In order
to use any of the latter instruments to advantage the first attack
should be made with a trephine of reasonable size, say 2 to 3 Cm. in
diameter, after which forceps, chisel, or saw may be used. Straight
saws also are of occasional usefulness. I do not favor the use of the
chisel and mallet, feeling that the concussions resulting from blows
of the hammer add to the shock of the operation. The common trephine
is provided with a centre pin, which can be withdrawn after a shallow
groove has been cut. To prevent slipping of the centre pin the point to
which it is to be applied should be marked by cutting a nick with the
point of a chisel.

The _Gigli saw_ should be in every surgeon’s outfit. It consists of a
piece of steel wire having a thread cut around and along it by a die,
by which it is made as effective as a series of saw teeth. Two small
trephine openings are made, and it is then passed into one and out
of the other, the dura protected by depressing it, and the wire then
handled as though it were a chain saw. It can thus be made to cut its
way quickly through the bones of the skull.

Other aids in mechanical procedures are revolving small saws and the
surgical engine.

[Illustration: FIG. 385

The Powell electric saw cutting a “trap-door” in the skull.
(Illustrating the operation upon a cadaver.)]

In the absence of a wound a flap of scalp is raised before applying
the instrument. This flap is ordinarily of horseshoe shape, and should
be made with its convexity pointing toward the occiput, as drainage is
best afforded later by this arrangement. The old crucial incisions are
now wellnigh abandoned. The pericranium is detached, after incision,
with the periosteum elevator, and it should be turned up with its
overlying scalp without completely separating it. The scalp flap can
be held out of the way by temporarily sewing it to some other part of
the scalp, every portion of which should be previously shaved closely
and thoroughly scrubbed. The operator has his choice--to seize vessels
as they bleed or to make the operation in large degree bloodless by
applying an elastic tourniquet tightly around the scalp above the
eyebrows and beneath the occiput, the ears preventing it from sliding.
If the tourniquet be used the vessels will often bleed in an annoying
way after the wound is closed. If the operation be performed for
fracture of the skull, should there be an opening already made by the
depression of fragments, it may not be necessary to use the trephine,
but with suitable bone forceps fragments may be removed or detached.
In this case, however, there are often sharp points of bone which
will require removal by cutting bone forceps, for the surgeon should
leave the margin of the bone opening comfortably round and smooth.
Should there be no opening into which the point of an elevator or of
bone forceps can be inserted, then one should be made; it is for this
purpose that the trephine is mainly used in cases of fracture of the
skull. It should now be applied upon a firm and undetached surface of
bone, one which will bear the pressure necessary in the process of
perforation. As used for this purpose it should be so applied that at
least two-thirds of the circle cut by its teeth will be upon unbroken
skull; the remaining segment of the circle may be over the fractured
area. After it has begun to cut a distinct groove the centre pin should
be withdrawn and the instrument maintained in its position during its
work by a firm and steady hand, which will force it evenly through the
bone and not exercise undue pressure. As the diploë is perforated the
bone-dust becomes soft and bloody and the resistance is diminished. As
the instrument sinks deeper the operator should frequently intermit its
use, and determine his position by means of the irrigator and of the
probe or other instrument. The nearer the inner surface is approached
the more caution must be exercised, remembering that the bone is
likely to be of unequal thickness. When the skull has been completely
perforated at one or two points around the little circle the operator
should introduce the point of an elevator and pry up the disk of bone,
or by rocking the handle of the trephine he may be able to remove the
button with that instrument. When the operation is performed in the
ideal manner the dura is scarcely touched, certainly not raggedly
injured by the teeth of the instrument (Figs. 386, 387 and 388).

[Illustration: FIG. 386

Construction of an osteoplastic flap; bone is exposed; first openings
are made with a hand trephine or burr. (Marion.)]

[Illustration: FIG. 387

Division of bone by use of hammer and chisel. (Marion.)]

Before opening the dura every loose particle of bone and every splinter
should be removed, depressed fragments should be picked out, and those
which are semidetached should be raised to their proper level. Through
the opening thus made the dura is carefully examined; extradural
collections of blood are recognized instantly, while some idea as to
the amount of intracranial tension may be secured, even through a small
opening. Absence of pulsation means probably the presence of cyst,
tumor, or abscess deeper. Edema of the membranes usually subsides
after nicking or opening them. A yellowish discoloration of the dura
often indicates the existence of a tumor beneath. Nothing abnormal
being discovered outside of the dura, should brain tension be great
or should the dura be discolored, as by blood beneath, the membrane
should be opened, by a triangular or horseshoe flap, and the subdural
condition accurately estimated. In some cases of meningeal hemorrhage
clots will be ejected with some force the instant the dura is opened.
In other cases of intracranial pressure, either from tumor or from
intraventricular hemorrhage, the brain will instantly protrude to such
an extent as to make its reposition difficult or even impossible.
Horsley’s dural separator is exceedingly useful, both outside and
inside the dura, for detecting and separating adhesions, and as a
retractor.

Incisions in the dura should be made, so far as possible, parallel with
its vessels rather than across them. When accessible, dural vessels can
always be secured and tied. Vessels of the pia can also be picked up
and secured with fine catgut ligatures. When the brain tissue itself is
diseased it should be carefully excised. The cortex itself is not so
vascular as to afford much trouble. Upon any portion of the membranes
or cerebral surface a sterilized solution of adrenalin can be sprayed
or applied without hesitation. In all deliberate operations sinuses
are avoided. When exposed or when necessary to attack them they may
be ligated and divided, or may be packed with tampons of sterilized
gauze, or may be seized with serrefines or light hemostatic forceps,
which may be left for a day or two included within the dressings.

Any of the exposed motor areas or centres can be stimulated, when
desired, if the patient be not too deeply anesthetized, by the faradic
current of mild degree, applied to surfaces which have not been bathed
with antiseptics, nor long exposed to the vapor of the anesthetic,
through a double brain electrode made for the purpose, or by sterilized
probes connected with the battery.

Buttons of bone or chips of the skull may be replaced after suture of
the dura, when desired, though this is seldom advisable. When fragments
are thus to be replaced they should be placed in warm sterile salt
solution at once after removal, and kept warm. When a button is thus
put back the periosteum may be sewed over it with buried catgut sutures.

The dura should be stitched with fine catgut as closely as possible. I
have often placed beneath the dural opening a piece of gold, silver, or
aluminum-foil, carefully sterilized, with a view to preventing dense
adhesions between the dura and the membrane or cortex beneath. I have
never known it to do harm.

[Illustration: FIG. 388

Exposure of cortex or of cerebellum after division of dura. (Marion.)]

[Illustration: FIG. 389

Osteoplastic resection after Wagner. (Chipault.)]

Drains and drainage are to be avoided when possible, and should be
removed early, except in cases of abscess. They may be made of catgut,
horse-hair, gauze, rubber, or even of glass, like those short ones
which Kocher inserts after extensive operations, their outer ends
flanged to prevent their slipping beyond control.

_Opening the skull_, or, in general terms, _trephining_, is at present
_resorted to for the following purposes_:

1. _For relief of compression_--

  (_a_) By depressed bone, as in comminuted or gunshot fracture;

  (_b_) By removal of clot or ligation of vessels;

  (_c_) By evacuation of pus, either from the meningeal cavity or from
  a deeper abscess;

  (_d_) By the removal of serous effusions, either extraventricular or
  intraventricular.

2. _For removal of foreign bodies._

3. _For relief of intracranial irritation_--_e. g._, epilepsy, the
psychoses, etc.

4. _For removal of tumors._

5. _To compensate for defective development._

6. _For exploratory or purely empirical reasons_, including the making
of “relief openings” for relief of pain, etc.

Aside from the ordinary methods of trephining as applied for common
conditions, modern surgery comprises the resort to essentially new
methods for raising areas of skull of considerable size and then
restoring them to their previous position. These are ordinarily spoken
of as _osteoplastic resections_, and have added very materially to the
art and resources of the surgeon. These consist, in a general way, of
the formation of a window, as it were, in the vertex or lateral region
of the skull by outlining a quadrangular or horseshoe flap of scalp,
which is detached only for a slight distance around the incision,
after which, by use of the revolving saw or by chisel and mallet, a
groove is cut through the bone running parallel with the margin of the
scalp-flap, but perhaps a centimeter within it. After this bone area is
completely cut through on three sides it is then sprung up or elevated
in such a way as to be broken across the base of the bone-flap. It
is not at all detached nor separated from the scalp, and so when
subsequently lowered into position retains its vitality by virtue of
its vascular connections.

When some particular measure seems indicated in order to atone for
a large defect in bone it has become quite customary to insert some
_artificial substitute_, mainly either _celluloid_ or a thin aluminum
plate, previously absolutely sterilized and cut at the time into such
shape as may be called for, but a trifle larger than the real defect,
being let in or sprung in, as it were, either completely beneath the
bone or into the bony opening, so as not to be easily detached or slip
out of the way. By this _heteroplastic_ method most admirable results
have been achieved. I have used celluloid for this purpose in the
spinal column also, closing with it the defect which remained after the
extirpation of the sac of a spina bifida. It is rarely _necessary_ to
resort to this practice in the skull, as dense fibrous tissue in due
time firmly protects the endocranial contents from external harm (Figs.
386, 387, 388 and 389).




CHAPTER XXXVII.

THE ORBIT AND ITS ADNEXA; THE EXTERNAL AUDITORY APPARATUS; THE
ACCESSORY SINUSES; THE CRANIAL AND CERVICAL NERVES; THE ORBITAL
CONTENTS AND ADNEXA.


INJURIES OF THE ORBIT.

_Intra-orbital hemorrhage_ is not uncommon after injuries to the head.
It may result from rupture of orbital vessels proper or by escape of
blood from within the cranium, either outside or beneath the dural
prolongation which constitutes the sheath of the optic nerve. When
extensive it may produce a pulsating tumor, and this may, in time,
become practically a traumatic aneurysm. After basal fractures blood
frequently will escape forward so as to appear beneath the conjunctiva.
Collections of blood in the orbit may also interfere with the return
circulation in such a way as to lead to extensive chemosis of the
conjunctiva or edema of the lids and orbital contents. Pressure may
cause temporary disturbance of vision. Should there be absolute
blindness it may be inferred that there has been injury to some part of
the optic tract. Protrusion of the globe is an indication of the degree
and amount of extra-ocular hemorrhage, which may be very pronounced.
When visual symptoms are bilateral, while external evidences are
confined to one orbital region, it may be assumed that there has been
intracranial disturbance as well, with laceration along the optic
tract. Such immediate damage will in time be followed by the ordinary
symptoms of neuroretinitis and atrophy.

The more external the injury the more quickly will it yield to ice-cold
applications. There are times when incisions for relief of tension may
be desirable. An extensive clot in the orbit which seriously displaces
the eyeball, and which does not quickly absorb, should be evacuated by
an incision, either directly through the lid or beneath the lid and
outside of the globe.

_Penetrating injuries_, like gunshot wounds, are usually easy of
recognition. If vision be instantly and completely lost the harm done
to the optic nerve or the globe will probably prove irreparable.
Foreign bodies penetrate from various directions, and sometimes to
such a depth that they are difficult to find. I have seen a large chip
of wood completely lost within the orbit, and such bodies may enter
either from outside or from within the nasal cavities. A foreign body
will nearly always limit the motility of the globe and usually displace
it. If its presence can be ascertained or revealed before operation it
should be sought and removed at the expense of almost any and every
other indication. If its presence be suspected it may be sought for,
even though a skiagram fail to reveal it. When the usefulness of the
eye is destroyed it will be advisable in such case to remove it in the
progress of this search.

Aside from the traumatic hematomas above mentioned extravasation
occurs, due to constitutional or vascular disease, as atheroma,
especially when coupled with violent straining efforts. Subconjunctival
effusion and exophthalmos, with limitation of motion, will be unfailing
expressions of such damage. _Orbital aneurysms_, spontaneous or
traumatic, are occasionally seen. They will cause a more or less
pulsating exophthalmos, while, in some instances, a bruit may be
detected with the stethoscope. Cases may be imagined where it would
be suitable to cut away the external wall of the orbit and expose
such a tumor. Ordinarily, however, ligature of the internal or common
carotid will be required. _Angiomas_ occur also in the orbit, producing
exophthalmos, usually without pulsation. Such tumors will prove
compressible and the globe may be gently pressed backward into the
orbit to immediately protrude again when pressure is removed. These
lesions will prove very difficult, usually impossible of treatment, and
no general rule can be made therefor.

_Orbital cellulitis_, _i. e._, infection of the cellular and other
tissues in the orbit, may occur, either from without or from within,
but usually in connection with some traumatism. Sometimes this
involves first the cornea or the structures of the globe; at other
times infection is by a more direct method, through the conjunctival
sac or the orbital coverings. It varies in intensity between extreme
limits. It may even be bilateral. While cases occasionally undergo
resolution it usually terminates by formation of abscess. It is met
with in the infectious fevers, in facial erysipelas, by extension
upward of infection from diseased teeth, after primary infection of
the ethmoidal or sphenoidal sinuses, or by extension from external
phlegmons. There will be edema of the lids, usually with chemosis,
fixation and protrusion of the eyeball, commonly with divergence. In
proportion to the severity of the lesion there will be present septic
symptoms, with deep-seated pain and headache. Vision is disturbed
in proportion to the pressure upon the nerve and globe, as well as
the involvement of the ocular structures proper. When the disease is
begun within the eye it will usually terminate by a combination of
panophthalmitis with orbital abscess.


=Treatment.=--The application of the compound ichthyol or Credé’s
silver ointment, with ice, preceded perhaps by the use of leeches,
will be suitable local treatment unless the presence of pus be
distinctly made out or until tension threaten serious harm. In either
of these events, however, free incisions are required at points of
greatest tension, the knife being so directed as to avoid the globe.
These incisions should be free and sufficiently deep. Should there
be accompanying panophthalmitis the eyeball itself should be freely
incised through its anterior aspect and its contents completely
evacuated. Such emptying of the contents of the sclerotic is called
_evisceration of the globe_. While theoretically indicated, experience
has shown that it is a disastrous practice to enucleate the eye at such
a time; _evisceration first and enucleation later_, should it prove
desirable.


TUMORS OF THE ORBIT.

The orbit is the site of many primary tumors which originate within its
proper tissues as well as those which encroach upon it from neighboring
cavities or from the face. Prognosis is better in the former than in
the latter, but unfavorable in all malignant cases.

Of the primary _cystic tumors_ there may be nearly all the known
varieties, including those of parasitic origin. The pseudocysts of
the cranial cavity sometimes project into the orbit, forming _orbital
encepholacele_. _Dermoid cysts_ are not at all uncommon. Around
the bursæ of the orbital muscles exudation cysts occur, while the
retention cysts, including the cholesteatomas, are not infrequent. The
true dermoid cysts may contain all the ordinary epithelial products,
just as in any other part of the body. _Parasitic cysts_ include the
echinococcus and the cysticercus, the latter being rare, while the
former may extend into the frontal sinus or cranial cavity. It produces
almost constant ciliary neuralgia. _Vascular tumors_ of all types
are found in the orbit and the various expressions of telangiectasia
of the lids and orbit are often seen. These are always of congenital
origin. Of the more simple types of mesoblastic tumors the osteomas
are perhaps as common as any. These assume all the types described in
the chapter on Tumors, and are of all degrees of hardness. _Sarcoma_
and osteosarcoma, originating within the orbit, are unfortunately
too common. Naturally they spread to and involve all the adjoining
structures. True _endothelioma_ is rarely recognized as such until
after removal and microscopic examination. _Epithelioma_ commencing
upon the surface of the eye, or about the skin and spreading inward, is
also quite common.

Exophthalmos is an expression of intra-orbital tension common to all
forms, while by the extent of protrusion and its direction the site
of the tumor may to some extent be determined. Other disturbances
of position, with limitation of motion and consequent diplopia, are
further expressions of pressure and dislocation. Ptosis, or drooping
of the upper lid, is a feature of tumors which proceed from the upper
part of the orbit. The vascular tumors, as already mentioned, produce
more or less pulsation. Ocular tension is usually increased, and when
circulation and enervation have been seriously affected necrosis and
even perforation of the cornea may occur. Pain is a variable feature,
but is sometimes pronounced. An exploring needle may be passed into
a tumor which seems to be cystic, but it should be done with every
precaution, both against infection and injury to the eye.

_Tumors of the optic nerve_ proper originate more often in its
sheath than in its true neural tissue. They may occur at any point,
but usually within the orbit. These tumors are usually of the
sarcomatous, gliomatous, or endotheliomatous type. Cystic changes are
not infrequent; they occur usually in the young. All of these tumors
will involve the optic nerve in such a way as to produce signs easily
recognizable with the ophthalmoscope, such as optic neuritis and nerve
atrophy. Moreover, they affect or completely destroy vision. They are
not so painful as most of the other intra-orbital tumors, and, while
causing a direct forward protrusion of the eye, affect its motility
less than other forms. Nevertheless they grow with great rapidity and
evince destructive tendencies. In theory the treatment for all tumors
of the orbit is complete extirpation, while the malignant tumors
require emptying of the orbital contents. Benign tumors and cysts
are usually successfully treated by this method. Of most malignant
tumors it may be said that the prognosis is unfavorable. The lymphatic
and vascular connections are so free, and extension into surrounding
cavities so easy, that recurrence takes place in the larger proportion
of cases. Too often by the time a patient is willing to sacrifice the
eye and the orbital contents it is too late to effect a radical cure.


EXOPHTHALMOS.

The term _exophthalmos_ simply implies protrusion of the eyeball
beneath and even between the lids. Usually it is in a downward and
outward direction. In some cases the displacement is accompanied by an
easily recognizable pulsation, and occasionally by a bruit or audible
sound. The latter instances are spoken of as pulsating exophthalmos.
They are connected in most cases with vascular tumors or intra-orbital
aneurysms, although sometimes the aneurysm may be primarily
intracranial. For instance, arteriovenous aneurysms, by communication
of the internal carotid artery with the cavernous sinus, will produce
pulsating exophthalmos. Whatever be its cause exophthalmos is an
expression of pressure from behind. This is true even of the ocular
symptoms accompanying Graves’ disease or exophthalmic goitre, only here
the protrusion is permitted by general fulness of the vessels and undue
vascularity of the orbital tissues.

In proportion to the amount of projection there will be swelling and
edema of the upper lid, the skin being more or less shiny and the veins
distended. In extreme cases the lids are everted and the conjunctiva
extremely chemotic, while by exposure of the cornea it becomes
vascular, infected, and often necrotic. Should it be possible to
replace the globe by pressure it will protrude so soon as pressure is
removed. In vascular cases a bruit may be heard and pulsation detected
with the finger. Audible sounds are lost by making firm compression
on the common carotid of the same side, and return instantly when
this pressure is removed. By the ophthalmoscope both arterial and
even venous pulsation may be perceived at the fundus. Vision is only
slightly affected by a well-marked protrusion, especially when the
latter has occurred slowly. The pulsating forms will frequently give
subjective symptoms of sound and sense, _e. g._, vertigo.

A history of injury, coupled with external evidences, may give a clue
to some of these cases as an indication of traumatic aneurysm or
communicating vascular tumor. Soft and vascular tumors, without history
of injury, are usually malignant, this being true also of multiple
growths.


=Treatment.=--The treatment of exophthalmos should depend entirely on
its nature. When due to arteriovenous aneurysms, or to the consequences
of injury alone, a ligation of the common or of the internal carotid
will give the best result. When compression of the carotid gives
temporary relief to at least some of the features of the case its
permanent ligation is indicated. Bilateral exophthalmos implies a
more serious condition, especially in Graves’ disease. When thyroid
symptoms are prominent a thyroidectomy is indicated. When the thyroid
participates but slightly such a case may be treated by excision of the
cervical sympathetic on both sides.


INTRA-OCULAR TUMORS.

These tumors may assume most of the known types and may spring from
practically all of the tissues of the eye.

From the _iris_ there may develop _cysts_ of traumatic or even of
congenital origin. In the former such a foreign body as an eyelash may
be found, having entered through an external wound of the cornea.
Vascular tumors are occasionally met with, many of which are full of
pigment, while melanomas, with a minimum of vascular structure, are
also observed. The actively malignant tumors of the iris usually assume
the sarcomatous or endotheliomatous type, and when melanotic assume
an exceedingly rapid and serious phase and course. In the iris, also,
tuberculous or syphilitic granulomas are occasionally encountered.

In the _choroid_ are seen expressions of tuberculosis, especially the
more acute, as a complication of tuberculous meningitis. The most
common malignant tumor here is sarcoma of the melanotic variety. Of
the _retina_, glioma is the most common as well as the most malignant
tumor, occurring usually in the young. All of these tumors when
malignant spread from their primary site to the adjoining tissues.
When extremely malignant they kill too quickly to show many metastatic
expressions. At other times they will appear in other parts of the body.

All intra-ocular tumors tend to impair, and the malignant to quickly
destroy vision. Tension is increased and the natural contour of the
globe may be lost. Fixation to and involvement of the surrounding
orbital tissues depend in some measure on the rapidity of growth and
its location. They occur sooner or later in malignant cases.

A malignant growth of any part of the globe calls for enucleation of
the eye, as well as removal of the orbital contents. When the orbital
tissues are thus involved it is too late to secure more than temporary
benefit. If the eyelids are involved they should also be sacrificed and
the orbital opening covered by some plastic procedure.


PANOPHTHALMITIS.

The term _panophthalmitis_ implies a phlegmonous process involving the
entire contents of the sclerotic, by which the eye is destroyed. It is
usually traumatic in origin, but may occur as an extension of infection
from ulcer and abscess of the cornea, or from thrombotic or metastatic
processes. Its course is usually rapidly destructive, while it is
accompanied by more or less orbital cellulitis. These signs, therefore,
are not confined to the orbit proper, for the lids become edematous,
the conjunctiva chemotic, and there is more or less purulent discharge
from the entire conjunctival sac, which will escape beneath the lids.
If the cornea is at first clear it rapidly becomes cloudy, and to the
signs of intra-orbital mischief are added all those above described
under the heading of intra-orbital cellulitis. The sclerotic is an
unyielding membrane; hence pain in these cases is usually intense,
while septic features are added according to the nature of the cause.
When the lesion has begun in the cornea it usually ruptures early and
the ocular contents may escape in this way.


=Treatment.=--Panophthalmitis is dangerous to life as well as to the
eye when not promptly treated. The same rule prevails here as well as
elsewhere in the presence of pus. Prompt evacuation offers the greatest
safety and relief. _Evacuation of the entire contents_ of the eye
through a free incision and by means of a sharp spoon, with antiseptic
irrigation, affords the only safe measure in these cases.

As previously remarked, the general consensus of opinion among oculists
and surgeons is that, under these circumstances, enucleation should
never be done, the danger being that of a purulent meningitis or
thrombosis by extension backward along the sheath of the optic nerve.


SYMPATHETIC OPHTHALMITIS.

This, too, is a matter of interest common to the eye specialist and
the general surgeon. The term refers to lesions of one eye which
follow sooner or later upon injuries or infections of the other. These
expressions of so-called sympathy occur in irritative or inflammatory
lesions. The former are more or less neurotic and include pain, often
referred to the region beyond the orbit, photophobia, blepharospasm,
too free lacrymation, and various subjective phenomena of impaired
vision. These features will be accompanied by more or less tenderness
of the globe, with ciliary neuralgia and injection. These may subside
under treatment, but will recur when the eye is again used.

Contrasted with these lesions is another form whose features are most
pronounced along the uveal tract, though the retina may also suffer.
Its subjective features are those of _uveitis_, to which are added
actual exudates in various parts of the globe, some of which may be
seen with the ophthalmoscope, with intra-ocular tension, which reduces
the anterior chamber, and with partial or complete loss of sight
that may end in total atrophy. In some instances these lesions occur
rapidly; in others the course of the disease is chronic.

The oculopathologists have striven hard to explain these phenomena.
Most of them believe in the continuity of the subdural or subvaginal
sheath of the nerve from one orbit around into the other, and believe
that the germs passed along this subway. Involvement of the yet
unaffected eye may follow the entrance of foreign bodies, occurrence of
traumatisms, punctures, existence of corneal lesions as minute ulcers,
constant irritation of the presence of an artificial eye upon the
stump, the performance of some of the common operations upon the globe,
and even the much less frequent conditions of pathological changes in
the choroid, the ciliary body, the optic nerve, or the existence of
intra-ocular tumors. A recognition of the possibilities in these cases
will lead to more radical treatment of the lesions which may produce
them. Even a minute foreign body should be promptly removed and an
ulcer of the cornea should not be regarded as a trifling lesion. Under
all circumstances the surgeon, as well as the general practitioner,
should be alert to the possibilities of these lesions, quick to
recognize the symptoms, and prompt in urging the only satisfactory
relief. It will be seen that the earliest suggestive features are those
of involvement of the uveal tract.


=Treatment.=--There is usually but one efficient method of treatment
for these cases, and this consists of _removal of the injured_ or
_diseased other eye_, more particularly if it be more or less already
impaired by the consequences of the original lesion. The exceptions
to this statement occur in the event of well-marked sympathetic
inflammation, as it may be possible that there will be better vision
in the originally injured eye than in that secondarily infected; but
so long as it is a matter of simple sympathetic irritation enucleation
is the proper course. While this is extremely radical there is no
satisfactory substitute for it. The only excuse for delay should be
threatening phlegmonous processes by which communication posteriorly
might be afforded. Bull has laid down the following indications for
enucleation of the first eye before the outbreak of sympathetic
inflammation in the other eye:

1. When the wound is in the ciliary region, and so extensive as to
greatly damage or entirely destroy vision;

2. When the wound is in the ciliary region, and is already accompanied
by iritis and cyclitis;

3. When the eye contains a foreign body, and attempts at its removal
have proved futile;

4. When the eye is atrophied or shrunken and tender on pressure, or is
continually irritated.


ENUCLEATION OF THE GLOBE OF THE EYE.

The conditions which justify enucleation of the eye have been pointed
out. For the operation, which is usually done under general anesthesia,
the lids should be widely separated with the ordinary eye speculum or
by suitable retractors. A circular incision is then made through the
conjunctiva, around the margin of the cornea. This is carried down
to the sclerotic at a little distance from the corneal margin, by
which Ténon’s capsule is opened; then a strabismus hook is inserted
in each direction and the tendon of each muscle raised upon it and
divided close to its insertion. By pressure upon the surrounding
tissues the eye is now made to protrude. Should the globe have been
already collapsed it should be drawn forward with forceps, one blade
of which may be thrust within it. After thus firmly withdrawing it a
blunt-pointed, curved scissors is passed behind and around it, the
blades being made to open in such a way as when closed to divide the
optic nerve at a little distance from the globe. After this enucleation
by pressure is easy, and any further tissues requiring division may be
readily cut. The principal source of hemorrhage is the artery extending
through the nerve, but this is readily controlled by pressure.

Should there have been any inflammatory or septic condition about
the orbit or the conjunctival sac the parts should be cleansed with
hydrogen peroxide or other antiseptic. Sutures are seldom required.
A compress should be applied outside the eyelids, removing it
sufficiently often to be certain there is no retention of fluid or
blood.

Recovery is usually rapid. Granulation tissue sometimes forms at the
bottom of the conjunctival sac and becomes exuberant. In this case it
should be removed with scissors and cauterized, after which it rarely
recurs.


SYPHILITIC AFFECTIONS OF THE EYE AND THE ORBIT.

As already described, many expressions of the various stages of
syphilis pertain to the eye. Thus there may be _chancre_ upon the
eyelid or conjunctiva, or ulceration of the same; syphilitic iritis
as a secondary expression; syphilitic retinitis, neuroretinitis,
choroiditis, as tertiary lesions; and the formation of gummas in the
later stages of the disease, and in almost any imaginable locality,
especially the uveal tract. _Syphilitic tumors_ are seen upon the iris
more often than anywhere else within the eye. Outside of the globe and
within the orbit the ordinary expressions of syphilitic periostitis
and of gummatous tumors occur. These constitute also the more common
intra-orbital expressions of this disease.

The _symptoms_ of syphilitic lesions in this location do not vary from
similar lesions elsewhere, save so far as they involve special tissues
or disturb the special sense of sight. The _prognosis_ in nearly all of
them is relatively good if suitable and active _treatment_ be promptly
instituted. It is, however, too much to expect that annular destruction
of areas of the retina or choroid can be completely repaired.


CATARACT.

Cataract is a subject of primary interest to the general surgeon only
so far as it pertains to the consequences of injury to the orbital
region. The term implies opacity of the lens or of its capsule, or
both, which may be partial or complete. Its pathognomonic feature is
slow and progressive failure of vision. Examination by direct as well
as bilateral illumination will show the opacity to be located behind
the iris. Everyone should be able to recognize it; its excision should
be relegated to the trained specialist, since it is one of the most
delicate special operations.


GLAUCOMA.

The term _glaucoma_ implies a collection of more or less variable
pathological conditions within the eyeball which lead to increased
intra-ocular tension. Because of this increased pressure, with its
disturbance of circulation and the peculiar coloration often given to
the cornea or the pupil, the disease has received this name. Among
its symptoms are pupillary changes, including both size and mobility
of the iris; turbidity of the cornea, as well as the fluid humors
of the eye; pain, corneal anesthesia, impairment or final loss of
vision, engorgement of the visible vessels of the globe, and a peculiar
cupping or excavation of the optic disk. Unless checked by operative
intervention the course of the disease is steadily toward blindness. It
varies in acuteness, the favorable cases being the acute ones, in which
early operation can be practised. It admits of no other treatment.


=Treatment.=--The operation almost universally practised by the oculist
is either iridectomy or sclerotomy. The condition is briefly mentioned
in this place for the double reason that the student may be made
aware that the condition may follow certain injuries to the eyeball
or the head, and that the more chronic forms have been successfully
treated by _excision of the cervical sympathetic_, on one side or both,
the operation being based upon anatomical and physiological facts
pertaining to the distribution and function of those sympathetic fibers
which pass to the orbit from the cervical trunk. The operation is
described in the section on the Cranial and Cervical Nerves.


AFFECTIONS OF THE IRIS AND THE CILIARY BODY.

These lesions are frequently the result of blows and of penetrating
injuries, as well as of syphilis. Moreover, motility of the iris is so
essential to the normal function of the eye that where it may possibly
be effected the surgeon should protect against those adhesions between
the iris and the lens or cornea, which are very likely to occur, by
instillation of a sufficiently strong solution of atropine, a ¹⁄₂ to
1 per cent. solution being usually sufficient for this purpose. These
adhesions are referred to as _synechiæ_, and are anterior when the iris
becomes affixed to the cornea, or posterior when affixed to the lens.
They occur easily after minute punctures of the cornea, the result
being a limited mobility or a dislocation of the pupil, along with
opacity of the cornea, all of which work to the detriment of vision.

The iris is so visible that the mechanism of an exudate on or in it can
be observed almost from beginning to end when it occurs in the form of
iritis. Occasionally an exudate will merge into an actual collection
of pus which will gradually fill up the anterior chamber, and which is
then spoken of as _hypopyon_. Under the most favorable circumstances
a disappearance of this pus by absorption may be noted. It may prove
destructive or may necessitate evacuation.

The iris and the ciliary body are intimately connected, and
inflammation beginning in one point may easily spread to and involve
other tissues. These structures with the choroid constitute the
so-called _uveal tract_, and when they participate in inflammation it
is called _uveitis_.

The _symptoms of iritis_ consist of pain, lacrymation, photophobia,
which is often intense; increasing turbidity of the aqueous humor,
as well as of the cornea, by which vision is impaired; visible
discoloration; irregularity and sluggishness in movements of the iris,
and circumcorneal injection. A congestion which assumes an annular form
about the cornea and does not involve the conjunctival sac indicates
trouble in the ciliary region, while a true conjunctivitis is limited
only by the extent of the membrane itself.

Iritis due to syphilis, whether assuming the plastic or the gummatous
form, requires the most active antisyphilitic medication, in addition
to local treatment. The non-specific and traumatic forms need absolute
rest in a dark room, with cold applications about the eye and the
free use of atropine, to completely dilate the pupil and prevent the
formation of synechiæ.


THE CORNEA.

The cornea being the most exposed part of the eyeball will be
frequently subjected to minor or serious injury in connection with
violence to the orbital region. It is an exceedingly sensitive
membrane, whose reflex excitability is heightened by the presence of
a small foreign body, this accident being one of frequent occurrence.
It is a lesson in neurophysiology to watch the relatively local and
general disturbances which the presence of a minute speck of foreign
material embedded in the cornea may cause. Every extraneous body
should be removed at once, the procedure being now facilitated by the
local use of cocaine, for any abrasion or serious injury of the cornea
occurring in surgical cases offers a possible source of infection
to the deeper ocular structures. Careful attention should be given
to the use of antiseptics of suitable strength in the conjunctival
sac, whenever this region is involved. This statement cannot be made
too positive. There is danger both to the cornea and to the iris
in perforating ulcer or traumatism of the cornea, and there is as
much occasion for the use of atropine in these instances as in those
pertaining to the iris proper. To the protrusion of the cornea, which
is produced by weakening of its structure and tension from within, is
given the name _staphyloma_. It is frequently combined with adhesions
of the iris and dislocation of the pupil. It constitutes not only a
cosmetic disfigurement, but a serious impediment to vision.

[Illustration: PLATE XLV

FIG. 1

Lacrymal Fistula on the Right Side; Ectasia of the Lacrymal Sac on the
Left; Bilateral Epicanthus. (Haab.)

FIG. 2

Dacrocystitis. (Haab.)]


THE CONJUNCTIVAL SAC.

The mucous membrane lining the conjunctival sac is perhaps the most
exposed to irritation and even infection of all mucous surfaces. It
is not strange then that conjunctivitis is the most common of all eye
affections. Whether irritated by constant exposure to dust and dirt,
or raw and cold winds, or by the heat of a blast furnace, by the
dazzling brilliancy of electric lights, or contact with bacteria, it
displays a surprising degree of accommodation and resistance. It has
peculiar susceptibilities, particularly to the germs of _gonorrhea_
and _diphtheria_. To these it is peculiarly sensitive, and under their
influence it may quickly succumb. The harm done in either of these
conditions is by no means limited to the conjunctiva, but may extend in
such a way as to eventually cause loss of vision.

Nowhere else may the phenomenon of hyperemia be so easily studied as by
watching the ocular conjunctiva for a few moments after the occurrence
of irritation. The rapidity with which the vessels dilate and become
visible, the occurrence of the consequent redness and swelling, and the
reflex phenomena attending it become appreciable within a short time.
In the chronic conditions the tissues become thickened and less mobile.
A chronic conjunctivitis is the constant condition in certain laborers
whose eyes are exposed in their occupation.

A peculiar granulomatous condition of the conjunctiva, especially the
palpebral, is that known as _trachoma_, which appears to be due to a
specific form of infection that leads to exudation, organization and
thickening, intensified in punctate areas, and giving the surface the
appearance of an ordinary granulation. This condition has assumed
such importance as to be sufficient for the exclusion of aliens and
immigrants.

The milder conditions of acute or subacute conjunctivitis subside
under cold applications and mild antiseptic and astringent eye-washes
or collyria. These should be frequently instilled, beneath the lid
whenever this area is involved as a complication of injuries to the
head or face. In acute cases of the infectious type, such as the
gonorrheal or diphtheritic, atropine should be used locally, so that
the iris may be drawn out of harm’s way and the pupil left free
should resolution and recovery ensue. Individuals suffering from
either gonorrhea or diphtheria should be cautioned and protected from
possibility of conjunctival infection. The eyes of the newborn are not
infrequently infected during the process of parturition. The parturient
canal of women suspected of having an infectious lesion of this kind
should be cleansed before the passage of the fetal head, and in all
suspicious cases instant and constant attention should be given to the
eyes of the newborn infant.


THE LACRYMAL TRACT.

The _lacrymal gland_, though situated in the anterior and upper part
of the orbit, and beneath the upper lid, where it is ordinarily well
protected, is nevertheless liable to both acute infections and chronic
irritations. When acutely inflamed it usually goes on to abscess
formation. We have then acute _dacryo-adenitis_, which will produce
the ordinary symptoms of phlegmon, with the added ocular features of
vascularity and chemosis of the conjunctiva and more or less edema
and immobility of the upper lid. Displacement of the eyeball may be
produced by great inflammatory swelling. These abscesses tend to
discharge either through the skin near the external angle or sometimes
through the conjunctiva. While in the former case a scar results, it
nevertheless is a preferable point either for spontaneous opening or
for incision. If the case be seen in time it will be advisable to make
this incision early and so limit destruction. (See Plate XLV, Fig. 1.)

The lacrymal gland suffers occasionally in instances of constitutional
syphilis, undergoing chronic and obstinate enlargement. It may also be
the site of tumors either non-malignant, usually adenoma, or cancerous,
most instances of the latter being expressions of extension.

The _tear passages_ proper are composed of the canaliculi, the lacrymal
sac, and the duct. These are altered, occasionally, in their relations,
or absent, as the result of congenital defects. The passages proper
frequently become obstructed, as the result of any chronic irritation
which produces thickening of the conjunctiva, and in many laborers
and others who are exposed to dust, dirt, or cold winds there will be
a more or less constant stillicidium or overflow of tears. In some of
these cases it is sufficient to slit up one or both canaliculi with a
fine probe-pointed bistoury.


DACRYOCYSTITIS.

The _lacrymal sac_ proper is frequently the site of both acute and
chronic disease, known as _dacryocystitis_, which is the result of
infection spreading from the conjunctival sac, rarely from the nose,
or the exaggeration of conjunctival thickenings, like those mentioned
above. The first symptoms are overflow of tears, accompanied by
swelling or enlargement in the region of the sac. By pressure upon this
a mixture of water, mucus, and sometimes pus may be expressed. As the
disease goes on the fluid becomes purulent. If the sac, by pressure,
can be emptied into the nose the nasal duct may be regarded as patulous
and the treatment is simplified. If not there is stricture, usually at
the upper end of the duct, which requires division and dilatation. The
more chronic forms of trouble in this region are frequently intensified
into acute phlegmonous lesions which, if neglected, will lead to
spontaneous perforation and the formation of a _lacrymal fistula_ at a
point below the inner angle of the eye. (See Plate XLV, Fig. 2.)


=Treatment.=--The treatment should consist of exposure of the sac by
incision of the canaliculi and its irrigation by means of a syringe and
antiseptic fluid. Unless this fluid passes easily into the nose the
stricture should be divided and Bowman’s probes passed, the principle
of treatment being the same as that in treating urethral stricture.
This part of the treatment should be referred to an oculist.

In acute dacryocystitis with suppuration the sac along the natural
passages should be opened. When a diagnosis of an acute lesion of this
kind is made nothing but the most radical treatment is advisable.


THE LIDS.

Congenital deformities of mild degree are not infrequent about the
eyelids.


EPICANTHIS.

Epicanthis is a term implying folds of redundant skin extending from
the internal end of each eyebrow to the inner canthus and over the
lacrymal sac. It varies much in degree, is a more or less hereditary
feature in certain families, and is not infrequently associated with
other defects. The palpebral fissure varies in length in different
individuals, giving a longer or shorter window through which the eye
proper shall appear. Sometimes the fissure is much too short and
requires division or extension, which is easily made by incision at the
outer angle.


COLOBOMA.

Coloboma is a term applied to various lesions of the eyelid, the iris,
and the choroid, implying a defect in structure, which, in the eyelid,
leaves a V-shaped deficiency, corresponding to harelip, whose edges may
be brought together by a simple operation.


STYE; HORDEOLUM.

The eyelids are subject to certain painful or disfiguring lesions,
which frequently come under the notice of the general surgeon. Of these
the most common is _stye_, or _hordeolum_. This is a phlegmon of one
of the minute glands along the margin of the lid, which has become
infected and violently reacted. It forms a miniature furuncle, often
associated with conjunctivitis, and giving a disproportionate reaction.
So soon as the presence of pus can be detected a puncture should be
made and the contained drop of pus exvacuated. Threatening suppuration
may sometimes be aborted by local use of 1 or 2 per cent. mercurial
(yellow) oxide ointment.


CHALAZION.

A somewhat similar but non-inflammatory cystic distention of one of
the Meibomian glands, which pursues a slow and painless course, is
called _chalazion_. It presents rather beneath the mucous surface, but
is often visible through the skin. Its contents are mucoid or dermoid.
When it attains troublesome dimensions it should be exposed through a
small incision, usually external, and thoroughly extirpated.


XANTHELASMA.

Small, elevated areas of dirty-yellow color are met with in the skin
about the eyelids, more often near the inner angle. Such a lesion
is called _xanthelasma_, the lesion being a fatty metamorphosis of
a portion of the skin structure. While harmless, it is amenable to
excision for cosmetic effect.

Any of the ordinary tumors which affect similar tissues elsewhere may
be seen about the eyelids. The more common are the vascular tumors,
especially small nevi. Epithelioma occasionally commences along the
palpebral margin, but is more often an extension from neighboring
tissues.


BLEPHARITIS.

The margins of the lids are frequently involved in a mildly infectious
inflammatory condition called _blepharitis_, in which nearly all the
structures participate; when the borders alone are involved it is
referred to as _blepharitis marginalis_. The condition is largely due
to dirt, and to irritation in which the Meibomian ducts seem to share.
It is accompanied by chronic conjunctivitis. The condition is seen
more often in the ill-nourished, the rickety, and the tuberculous.
The best local treatment consists in the use of an ointment of yellow
oxide or yellow sulphate of mercury. The former may be used in 2 per
cent. strength, and the latter not stronger than 1 per cent. This
should be applied along the lid margins at night, and thoroughly rubbed
in. A commencing phlegmon and stye may be aborted by one of these
preparations.


TRICHIASIS.

Another very annoying complication, and usually the sequel of the
condition already mentioned, is _trichiasis_, or turning inward of the
eyelashes. Chronic irritation and cicatricial contraction on the inner
aspect of the eyelids, or a chronic blepharospasm, which may be the
result of corneal infections, serve to draw the lids inward, especially
with the margins of the hair follicles, so that the eye-winkers grow
toward the ocular surfaces, which they constantly irritate. The result
is a vicious circle, each morbid condition intensifying the other.
In time there is produced a condition of _entropion_, which is to be
remedied only by operation. It is not sufficient to treat trichiasis by
epilation, as the hairs will grow again and continuously cause trouble.
The cause should be removed and the effect treated.


ENTROPION.

By this term is meant a condition of inversion of the margin of one or
both lids, by which the external surface is brought into actual contact
with the surface of the eyeball. It is a chronic condition brought
about through the action of several contributing causes. Any condition
of the cornea or deeper portion of the eye which leads to photophobia
and spasmodic closure of the eyelids will produce in time hypertrophy
of the orbicularis, with corresponding strengthening of the muscle and
exaggeration of its activity. Chronic blepharospasm will thus in time
lead to a mild degree of entropion, while any affection of the inner
palpebral surfaces which leads to cicatricial contraction will still
more intensify it. So soon as trichiasis or irritation by the eyelashes
is added to what has gone before, every feature is exaggerated and the
cornea is made to lie practically in contact with the skin surface
of the eyelid. A further consequence is corneal disease, often with
ulceration and opacity, with even worse structural changes.

The condition is really a serious one and is to be treated not alone
by operation upon the lid, but care should be given to all the
contributing features. So far as the lid condition alone is concerned,
I have found the operation suggested by Hotz the most satisfactory of
any, at least in average cases. An incision is made from one end of the
lid to the other, along the distal border of the tarsal cartilage, and
down to it. Through this a bundle of those orbicularis fibers which
run parallel with the incision is dissected away. In extreme cases the
tarsal cartilage, which is incurved as the result of the old condition,
may be either incised or a strip excised from its structure. Sutures
are then inserted which include not only the borders of the skin
incision, but the exposed border of the tarsus and the tarsoörbital
fascia. By applying the central suture first, and then one on either
side, it will usually be found that as the sutures are tightened the
edge of the lid is drawn outward and the desired effect obtained.

The large number of operative methods which have been suggested for the
cure of entropion bespeak the variety of causes which may produce it
and the many devices to which different ingenious ophthalmic surgeons
have resorted.

[Illustration: FIG. 390

Arlt’s operation for ectropion. (Arlt.)]


ECTROPION.

This condition is the reverse of entropion, and implies eversion of the
margin, or of a considerable portion of a lid, with consequent exposure
of its conjunctival surface, which undergoes changes in consequence
of which it becomes thickened, contracted, and irritated. Ectropion
may possibly be produced by violent orbicular spasm, especially in
children, the lids being so tightly shut as to be everted. Ordinarily
it is the result of external lesions which produce cicatricial
contraction, like burns, or of chronic ulcerative lesions along the
palpebral border, such as are met with in tuberculous and syphilitic
disease. The lower lid is much more frequently involved than the upper.

For the relief of ectropion plastic operations are practised, usually
on the lower lid. The milder cases require a V-shaped incision, its
apex downward, with free dissection of the integument up or near to the
margin of the lid, by which it is released from the scar tissue which
has bound it down. Fig. 390 illustrates the general principle of such
an operation. The lower portion of the V-shaped defect is then brought
together with sutures, the triangular flap being fastened in a position
much higher than that in which it originally rested.

All of these operations upon the eyelids are included under the term
_blepharoplasty_, of which the above is the most simple. When necessary
new flaps may be raised from the temporal region, from the forehead
or from the cheek, as may be required, and turned into place, their
pedicles being so planned as to carry a sufficient blood supply for
nourishment of the same. If this supply be properly provided these
operations are practically always successful. It is necessary only to
make the transplanted flap at least one-third larger than appears to
be necessary, judging from mere size of the defect, for experience
shows the necessity of allowing at least one-third for primary and
cicatricial shrinkage. A _heteroplastic_ operation is occasionally
performed for this purpose, by which the flap of skin is detached from
an entirely different part of the body, or from the body of another
individual. Skin thus transplanted should be prepared by removal of
all of the fat upon its raw surfaces, skin alone being desired and not
other tissue. Figs. 391, 392, 393 and 394 illustrate blepharoplastic
operations of various types, which may be modified or made more
extensive. These are but a few of the various plastic devices, and are
intended to serve merely as suggestions or examples rather than methods
to which one is limited.

[Illustration: FIG. 391

Richet’s operation for ectropion. (Arlt.)]

[Illustration: FIG. 392

Fricke’s method of blepharoplasty. (Arlt.)]

[Illustration: FIG. 393

Dieffenbach’s method of blepharoplasty. (Arlt.)]

[Illustration: FIG. 394

Arlt’s method when a portion of the eyelid is to be sacrificed. (Arlt.)]


INJURIES OF THE EYEBALL AND ADNEXA IN GENERAL.

This topic has already been considered. It seems advisable, however,
to summarize some of the results of such injuries in order to call
attention to their dangers and methods of treatment. Burns of the
orbital regions, for instance, are liable to cause not only opacity of
the cornea following ulceration, but adhesions between the conjunctival
surfaces and the palpebral margins. The term _symblepharon_ is
applied to those lesions where the lids are more or less fixed upon
the globe and their motility partly or completely impaired. When the
edges alone of the lids have grown together the condition is known as
_ankyloblepharon_. Both of these conditions are the result of adhesion
of granulating surfaces and of cicatricial contraction, and should be
avoided.

By a concussion of the orbital region, and especially of the eyeball,
all sorts of injuries may be inflicted, from those involving the cornea
to deep lesions which leave little or no superficial evidences, but
cause partial or complete blindness. _Detachment of the retina_, for
instance, is one of the possibilities of such conditions. _Intra-ocular
hemorrhages_ or _dislocation of the lens_, with traumatic cataract, may
also occur.

The _sclerotic_ may be ruptured with or without the presence of a
foreign body, in which case the contents of the eye may have partially
or completely escaped. An eye which has collapsed from these causes
offers an almost hopeless field for the general or special surgeon,
and little can be done, save possibly for cosmetic purposes. There is
danger of sympathetic ophthalmia, and it may be a question whether
evisceration, _i. e._, completion of the evacuation, may not be the
wiser course.

Perforating wounds, even when inflicted by minute bodies, have dangers
of their own, including the possibilities of infection. The interior
mechanism of the eye is so easily disturbed, and its transparent media
so easily clouded, by the results of accident or hemorrhage, that even
apparently trivial injuries may be followed by disturbances of vision.


=Treatment.=--The general principles of treatment of all such injuries
should include, first, the removal of every detectable foreign body,
followed by the application of cold, and the use of antiseptic
eye-washes, which, however, must not be used too strong lest they
irritate. Saturated boric-acid solution is perhaps as strong as
anything which is permitted, while even this may occasionally require
dilution. In addition to this the use of atropine solution is always
indicated. It has the double effect of soothing and allaying pain and
of dilating the iris into a narrow ring. With such measures as these it
may be possible to save vision; at all events it will limit reaction
and prevent harm.


DISTURBANCES OF INNERVATION.

The nerves which supply the eye and its adnexa may undergo injury,
either within the orbit or within the cranium, or in their course
from one to the other. The _paralyses_ may be caused by syphilis, by
intracranial tumors, or by injury. A careful study of the areas and
nerves involved will sometimes lend considerable help in diagnosis,
both in traumatic and pathological cases. Thus diplopia, or double
vision, may be caused by paralysis of the external rectus on one side,
by which its antagonistic internal rectus is permitted to swerve the
eye too much to the inner side and away from the normal axis of vision
required for single sight. When there is complete paralysis of the
third nerve there may be drooping of the eyelid, called _ptosis_,
with impaired motion of the eye, upward, inward, or downward. The
eye will roll outward because the external rectus is supplied by the
sixth nerve. There will also be dilatation of the pupil, with loss
of accommodation. When the upper lid is raised there is also double
vision. This third-nerve paralysis, however, is not always complete,
and diplopia may result only when the eye is directed in a certain way.
When the sixth nerve is paralyzed the eye is rolled inward, and again
there is diplopia. When the fourth nerve is paralyzed the eye is but
slightly displaced upward and inward. When the sympathetic nerve is
involved there will be protrusion of the globe with dilatation of the
pupil. This will be accompanied by flushing of the face.


MUSCULAR AND ACCOMMODATIVE DEFECTS.

Detection of errors of accommodation is practically a specialty within
a specialty, while the various forms of strabismus, or deviation of
the eyes from their normal axes, depend largely upon regulation of
accommodative errors.


REGION OF THE EXTERNAL AND MIDDLE EAR.

The region of the ear is subject to _congenital malformations_,
deviations, and defects, which include anomalous shapes of the auricle,
malpositions of the organ, defects in the cartilaginous structure
with resulting deformity, and congenital excesses or redundancies
by which there are made to appear supernumerary auricles or portions
thereof. These latter have been described by Sutton and treated in his
work on _Comparative Pathology_. They bear relation as well to the
branchial clefts, and are of great interest from a phylogenetic point
of view. Some of these defects result from absolute arrest or excess
of development, others from injury during intra-uterine life; some are
accentuated by lack of care during the early months of infancy. The
most common deformity of the ear is that by which it is made unduly
prominent and deflected outward or forward, the cartilage being thick
and abnormally curved. Such _overlapping_ or _overprominent ears_ can
be made to assume their proper position on the side of the head by
the excision of an elliptical piece, either of skin or of skin and
cartilage, at the point of junction of the ear and the scalp. The
amount to be removed should be proportionate to the desired effect. The
parts may be brought together by sutures, and the auricle should then
be bound upon the head.

Fig. 395 illustrates a common form of defect, inherently of the
cartilage and of the overlying skin. This is but one illustration of
many, two cases being rarely found exactly alike. Not infrequently
these arrests of development include the structures of the middle ear
as well. The auditory meatus may be entirely covered and concealed, or
may be absent, having failed to develop.

[Illustration: FIG. 395

Developmental defect of external ear. (Broome.)]

_Supernumerary auricles_ are usually found as small tags of skin and
cartilage in front of or below the ear. They are easily removed and
leave no disfiguring scar.

The external ear is also exposed to injury, which it frequently
receives in the way of contusions and lacerations. It is occasionally
detached. The ordinary wounds of these parts require only the
conventional treatment, while it may be possible, by replacement and
approximation of a completely detached portion, to see it re-adhere.
This happened to the writer after his horse had completely bitten a
piece out of the ear of his groom. Here, as with detached finger-tips,
cleanliness is necessary, and the parts must be kept warm and protected
after dressing. The cartilage of the ear is covered by a perichondrium
which corresponds to the periosteum. Beneath it, or beneath the skin
alone, blood may be extravasated as the result of contusions. When such
collections fail to promptly resorb they should be incised and the
contained blood released. Such lesions are referred to as _traumatic
othematomas_.

A peculiar lesion of this general character occurs occasionally in
the insane. If due to injury the latter is but trifling. It makes a
conspicuous tumor, involving usually the lower end of the auricle, and
is known as the _othematoma of the insane_. It is scarcely amenable to
surgery, nor does it often need it, but it constitutes a disfigurement
which is not only easily apparent, but diagnostic as to the cerebral or
mental condition.

The ear is the site of many _neoplasms_, both innocent and malignant.
Small papillomas are common, while fibrous tumors are likely to
develop, especially about the fibrocartilaginous lower end of the
auricle, where the ear has been pierced for ear-rings. Keloid tumors,
of still more conspicuously fibrous nature, are common about the
ear, especially among negroes. All innocent tumors may be excised,
through incisions which should be so planned as to leave a minimum of
disfigurement. (See Fig. 397.)

Of the malignant tumors epithelioma is perhaps the most frequent. It
pursues a course here similar to that which characterizes it elsewhere,
save that the dense structures of the cartilaginous ear yield but
slowly to its encroachment. The form known as “rodent ulcer” is slower
here than elsewhere. Fig. 396 illustrates a case under the writer’s
care, showing complete destruction of the external ear by a growth of
this kind, which had attained a degree and extent that did not permit
of successful treatment, and which eventually proved fatal. When
growths of this character have not progressed too far they should be
radically removed, the question of cosmetic effect being secondary to
that of their eradication. By a well-planned plastic operation much can
be done to atone for disfigurement resulting from radical operation.

[Illustration: FIG. 396

Complete destruction of auricle by rodent ulcer. (Buffalo Clinic.)]

[Illustration: FIG. 397

Congenital lymphangioma of ear. (Lexer.)]


FOREIGN BODIES IN THE EAR.

All sorts and descriptions of foreign bodies may enter the ear. Young
children have a tendency to introduce all kinds of bodies into the ear,
as into the nose, and sometimes intrude them to such a distance that
their removal is made difficult. Living insects make their way into the
meatus auditorius and even deposit their larvæ, which may subsequently
go through their developmental phases and fill the passage-way with
young insects. Among the inanimate materials which children introduce
are small buttons, pebbles, beans, peas, beads, etc. Such a foreign
body may not be at once discovered, and some of those which easily
undergo decomposition, like fresh vegetable substances, may not be
detected until they have set up trouble by decomposition. Therefore
it may be hours or days before its presence is recognized. Sometimes
it may be easily seen, again it may be concealed. When the auricle is
drawn upward and backward the external meatus is somewhat straightened,
and bodies within it are more easily made visible, especially by
reflected light. Therefore the head mirror is usually required for
their detection and removal. The substance may be one which is easily
seized and withdrawn, after certain turning or shifting motions have
been attempted, or it may be impacted so as to offer considerable
difficulties. It should never be pushed farther in, for injury might
thus be done to the membrana tympani, and the effort should be to
remove it with the least possible damage to the lining of the canal.
So essential is it to have the head kept perfectly still during these
maneuvers that it will be advisable, with young children, to administer
an anesthetic. Instances occasionally occur which necessitate incision
and liberation of the auricle, with its deflection forward, and the
consequent more complete exposure of the auditory canal. Forceps of
various fashions may be used, or occasionally a blunt hook may be made
with a probe, which may be used to advantage.

Of living foreign bodies information can be obtained more promptly,
as the annoyance caused by their movements will at once disturb the
patient.

Relief has often been promptly afforded by filling the meatus with
water or glycerin as warm as can be borne, by which the insect is
killed, after which it may be removed by irrigation or by forceps,
assisted by good illumination.

That which is essentially a foreign body may be produced by an
_accumulation of cerumen_ in wax-like form within the auditory canal.
Neglectful patients sometimes allow this to accumulate until it
constitutes not only a source of irritation but an obstacle to hearing.
Its removal is not ordinarily accompanied by difficulty, but requires
patience and often considerable effort, not only with instruments, but
with irrigation, especially with an alkaline solution, by which the
waxy substance is softened.

A phenomenon noted in many of these cases, where instrumentation has
to be practised within the vicinity of the middle ear, is coughing or
sneezing, sometimes to a degree which interferes with the work to be
done. This is a reflex to be explained through connection with the
pneumogastric nerve.


THE EXTERNAL AUDITORY CANAL.

In the fibrocartilaginous as well as in the more richly cellular
portions of this passage-way small phlegmonous processes frequently
occur. They give rise to an amount of suffering, and even of
sympathetic reaction, disproportionate to the extent of the difficulty.
They are called furuncles, or boils, sometimes occurring singly, often
in groups. A commencing process of this kind may be cut short by the
use of an ointment of 1 to 2 per cent. yellow sulphate of mercury,
but after the furuncle is well developed it is best treated by free
incision, which can be made with the freezing spray, and without much
pain to the patient.

More extensive phlegmonous destruction, assuming even carbuncular form,
is occasionally met with in this region. There will be more or less
necrosis of tissue in such cases, which will require removal, usually
with the sharp spoon. These cases are not without their danger, since
the veins connect so freely with the interior of the cranium.

_Hyperostosis_ and _exostosis_ produce either a narrowing of the
auditory canal or its complete obstruction, and sometimes even the
formation of an osseous tumor of considerable size. A thickening and
even new formation of bone may be the result of the chronic irritative
processes which frequently occur in the middle ear, but many of these
conditions occur in the newborn, in whom they are to be regarded
as congenital excesses and in whom they frequently cause permanent
impairment or loss of hearing. Some of the osteomas in this region are
of bone-like hardness, their density being sufficient to dull or even
to break the finest tempered steel instruments.

A small exostosis may be removed with the ordinary instruments of the
surgeon or the dental engine, but the larger and more dense growths
offer formidable difficulties for the operator and uncertain results
for the patient. When growths of this kind attain considerable size
they should not be attacked through the natural passages, but the
auricle should be separated and pushed forward and the auditory canal
opened.


THE MIDDLE EAR.

The middle ear has for its external boundary the membrana tympani,
which, for clinical purposes, constitutes a limit beyond which the
general surgeon should not trespass, the structures within being those
within the field of the aural surgeon. Nevertheless the student of
surgery should realize that the membrane of the drum may be ruptured in
consequence of a blow upon the external ear, or perhaps by the sudden
condensation of air produced by explosions, etc. It may, moreover,
be lacerated in consequence of various injuries to the head, basal
fractures, etc., even those involving the opposite side of the head;
it may also be injured by foreign bodies, introduced usually from
without and through the canal. While this membrane has normally an
opening by which air pressure is equalized on either side, this seems
to play but a small part in the liability to or exemption from injury
such as just described. The membrane has its own blood supply, which
can become congested to a degree permitting considerable escape of
blood after laceration. It does not follow that bleeding from the ear
is necessarily an indication of basal fracture, after injuries of the
head, unless the hemorrhage is continuous and considerable, in which
case it may be stated that the injury must be deeper and more extensive
than one of the membrane alone. If, however, cerebrospinal fluid can
be detected as escaping with and diluting the blood, or escaping
independently, then the diagnosis of basal fracture may be regarded as
certain.

After such injuries as lead to hemorrhages from the ear the external
auditory canal, should be irrigated and protected against infection by
light tamponing, etc.

It is the writer’s opinion that the general surgeon should abstain
from operative intervention in the ordinary diseases of the middle
ear, save in the presence of symptoms which accompany mastoiditis,
acute infections of the sinuses, or even of the brain itself. When it
comes to an extensive operation, such as is often required in such
instances, including not merely opening of the mastoid antrum and
cells, but exposing the dura and judging of the condition of the sinus,
with perhaps the simultaneous ligation of the jugular in the neck
and washing out of the intervening portion, then these are measures
requiring such surgical judgment and operative skill that it would seem
that the general surgeon should be peculiarly equipped for this task.
But the ordinary office operations should be left to those who make a
specialty of these diseases.

When the cavity of the tympanum is involved in a suppurative condition,
with caries of the surrounding bone and extension into the spongy
tissue of the adjoining mastoid, this abscess cavity should be cleaned
out. Therefore the more radical operations of the aurist, by which the
membrana tympani is destroyed, the ossicles of the ear removed, etc.,
are but applications of broad surgical principles to a limited region
of the body, but made justifiable by their results. Moreover, in a
more chronic type of cases, where the tympanum is filled by redundant
granulation tissue and by polypoid formations, which are producing
more or less circumscribed caries or necrotic processes in the bone,
by which bony partitions between the cranial cavity and the ear proper
are gradually thinned or lost, and by which encroachment on the
intracranial sinuses with all its dangers is incurred, they are still
to be subjected to the same general radical methods of treatment, no
matter whether it be carried out by a specialist or a general operator.


THE ACCESSORY CRANIOFACIAL SINUSES.

While these cranial cavities are connected with the respiratory tract
there are, nevertheless, good topographical and physiological reasons
for considering their lesions in this place. There is free venous
communication between each of them and the cranial cavity, and free
lymphatic communication as well from at least three of them. Infection,
therefore, may and often does travel from the smaller to the greater
cavity, and thrombophlebitis, brain abscess, or purulent meningitis may
be the ultimate result of apparently trifling infection of one of the
sinuses.

They are four in number--the _frontal_, the _ethmoidal_, the
_sphenoidal_, and the _maxillary_, or antrum of Highmore. They are
all connected with the nasal cavity, and all lined with the same
Schneiderian membrane, which affords a continuous pathway of infection.
At least two of them are cellular in character, much resembling the
mastoid cells. Their means of communication with the nasal cavity are
small, and often obstructed by catarrhal swelling and inspissated
discharge. If thus plugged their retained contents may undergo
decomposition and intensify the trouble. It has been shown that the
effect of inward currents of air through the nostrils is to suck
out from these sinuses more or less of their secretion. In this way
perhaps may be accounted for the strings of tenacious mucopus which
slowly make their way out of especially the anterior sinus openings.
Some surgeons believe that if one sinus is affected all the others on
that side of the head are more or less involved; while this may be
true in many cases, and is easily explained on anatomical grounds,
it is not strictly true of all instances, least of all in cases of
chronic empyema of the antrum, which often long remains simple and
uncomplicated.

Surgical lesions within the accessory sinuses result from infective
processes, proceed often to suppuration, often, too, with caries
of the surrounding spongy bone as well. These conditions may result
from the ordinary acute catarrhs, or follow the more specific fevers,
like influenza and the exanthems, and frequently follow diphtheria.
Traumatic causes may also conspire to produce the same effect. In the
maxillary sinus disease is often due to extension upward from carious
teeth. In syphilitic and tuberculous patients these affections will
partake to a greater or less degree of the specific nature of these
diseases.

_Symptoms_ differ according to location and are often obscure enough to
make diagnosis difficult. Perhaps the most prominent symptom is _pain_,
either deep-seated, vague, or disquieting, located in the neighborhood
of the diseased sinus; or intense and neuralgic in character, radiating
from the source of the trouble. Its severity is proportionate to the
acuteness of the case. When the frontal and maxillary sinuses are
involved there occur external swelling and tenderness. If the sinus
openings be patulous there will be more or less purulent discharge
into the nasal cavity, that which comes down from the upper sinuses
appearing beneath the middle turbinate body. Transillumination by means
of a small electric light, passed into the nostril, will demonstrate
an opacity in the region of the affected sinus which does not appear
on the healthy side. The condition is frequently associated with
nasal polypi, small or large; while granulations in time spring up
within these cavities and may even escape therefrom as these become
filled. The general clinical picture is one of nasal obstruction, with
more or less constant discharge, sometimes mucopurulent, sometimes
offensive, which perhaps may be favored by certain positions of the
head, this being especially true of the maxillary antrum. Along with
these features go a degree of headache, of local pain, and even of mild
or severe febrile disturbances, proportionate to the severity of the
lesions which produce them.

When the anterior ethmoid cells are involved pain is usually referred
to the temples rather than the forehead, though both may suffer alike.

_Treatment_ should be based upon the fact that we have affected and
infected cavities whose interiors are diseased, and whose outlets are
blocked. The more free and thorough the drainage and the cleansing
which can be given, the more prompt the results. In all well-marked
cases, then, radical treatment is indicated. The ordinary treatment by
sprays, inhalations, etc., is useless, as the source of the trouble is
not reached.

Special treatment for each sinus will now be considered.

_Frontal Sinus._--Most of the symptoms of affection of the frontal
sinus are objective, and there is frequently external swelling, with
tenderness and edema. For its relief intranasal methods will often
suffice. In almost all cases we may expect to find hypertrophic
conditions within the nose. When empyema exists there is often a
deviated septum. It is impossible to avoid the conclusion that there is
a strong relation between hypertrophic lesions and sinus retention. The
difficulty may arise from many causes, most of which lead to sneezing,
coughing, and hacking, by which the mucous membrane of the nasopharynx
is both thickened, loosened, and predisposed to polypoid changes. The
irregularities thus produced harbor more germs than usual and their
effect is, in a measure, proportionate to their numbers. For the
examination of the upper part of the nasal cavity Killian’s speculum is
of great help.

The frontal sinus differs very much in shape and size, not only in
different individuals but on opposite sides of the same individual.
It may be rudimentary upon one side and large upon the other. It
is usually more capacious in those individuals who have prominent
foreheads and resonant voices. Here, as elsewhere, it will usually
be found that the most radical operation is the best, although one
endeavors naturally to preserve cosmetic features of the nose, so
far as he can, without sacrificing the patient’s interests. The
nasopharyngeal duct is so often connected with the ethmoidal cells, as
well as the frontal, that the former may be easily affected when the
frontal sinus is diseased.

In case of sinus disease, especially when the frontal sinus is
involved, it is better to encourage patients to snuff materials back
into the throat rather than to forcibly blow the nose or expectorate
them, as the latter would tend to force into the sinus that which it
would be better to have aspirated out of it.

The frontal sinuses may be attacked from within the nose or externally.
It is perhaps the least open to mild and conservative treatment, as it
is the most difficult of access by non-operative methods. The anterior
ethmoid cells are usually connected with it and infection rarely spares
one part to involve the other alone. Therefore if it be necessary to
operate on the frontal sinus the anterior and upper cells should be
exposed at the same time. Thus operations which have for their object
continuous drainage have usually as an objection the necessity for
wearing the drainage tube for months. After opening the sinus from
without the nasal duct may be enlarged to any size and desired degree,
and a tube inserted which shall afford ample drainage downward. This
may be covered with a flap and allowed to remain for a number of weeks.
Nevertheless it is a foreign body which has to be subsequently removed
from the nose. Killian’s method is doubtless the best for most cases,
as the most anterior of the ethmoid cells, and those which extend over
the orbits, cannot be easily reached through the nose, and if disease
involve the posterior ethmoid cells its extension to the sphenoid may
be expected. The operation includes an incision from the temporal end
of the shaved eyebrow, along its curve to the side of the nose, and
down to the middle of the nasal processes. The periosteum is divided
along a line a little higher, and again in the centre of the frontal
process, the intent being to so remove it that a bony bridge may be
left after removal of the anterior lower wall of the sinus. The first
periosteal incision should correspond to the upper border of this
bridge, either above or below it. The sinus is opened at first with
a chisel, afterward with bone forceps or surgical engine. It is then
completely scraped out, leaving the supra-orbital ridge for a bridge.
Its floor is resected along with the frontal process of the superior
maxilla. Through this opening the anterior and middle ethmoid cells may
be reached and cleaned out to the middle turbinate. The ethmoid cells
may then be attacked, the sphenoidal cells inspected, and also attacked
if necessary. The opening into the nose should be made free, and a
flap should be formed from the nasal mucoperiosteum, so that there
may remain a permanent opening of sufficient size. This method may be
modified to suit various needs. After doing all the work necessary the
external wound is closed, with a tube for drainage, while the formation
of the bridge above alluded to prevents much of the sinking in of the
anterior wall of the sinus, which would otherwise occur. If the little
pulley over the superior oblique muscle has been interfered with in
the operation or loosened from its attachment there will be at least
temporary and perhaps permanent diplopia. This should be carefully
avoided. There is also danger of injury to the contents of the orbit.
For some time after the operation there will be some drooping of the
upper lid. Nevertheless the results are usually satisfactory. After the
operation the patient should be permitted to lie upon the healthy side
and be forbidden to blow his nose; he should rather attempt to aspirate
the fluid from the wound. If necessary both sinuses can be attacked at
the same time and after the same fashion, the septum being removed.

Here as with the other sinuses the test of the efficacy of the
treatment will be furnished by relief of the headache, pressure, and
pain. Should carious or necrotic bone be exposed, or should there be
indications of malignancy, much more radical surgery would be indicated.

_The Ethmoidal and Sphenoidal Cells._--For the exposure of these,
especially the latter, it is necessary to make room for work. This
would be true even in normal cases, and is still more so when the parts
are hypertrophied and the passage-way is obstructed. It is necessary
at least to remove all deviated portions of the nasal septum, and to
clear away not only all hypertrophies of the turbinates, but to remove
more or less of these bones. With a free passage-way it is possible
to expose the opening of the sphenoidal cells, whose anterior wall
may then be broken down, after which granulations may be removed with
an appropriate small spoon, or the purulent contents cleaned out with
swabs.

In dealing with the ethmoidal cells by intranasal methods it is
necessary to break down the slight compartments between them, one after
another, because of the fact that they all constitute foci of disease.
An opening at least 2 Cm. in length will usually be required, and can
be comfortably made, under suitable illumination, if all obstructions
have been removed; after this a probe is gently passed upward and
alongside of the nasal septum until it rests against the ethmoid, then
passed backward until it meets the posterior wall, which will be in the
immediate neighborhood of the sphenoidal opening, through which, by
gentle manipulation, it may be passed. At this point the presence of
polyps or a greatly thickened mucosa may be detected by palpation with
the finger within the nasopharynx, while should pus be removed by the
end of the probe it would indicate empyema of this cavity.

In all these accessory nasal sinus examinations and operations the
greatest aid will be afforded by cocaine solution, which has the
double advantage of not merely abolishing sensation, but of contracting
and rendering anemic the mucous membranes, and thus to a certain extent
shrinking them. When necessary for this latter purpose, or for the
control of hemorrhage, adrenalin may be added to the cocaine. For all
these purposes a spray of a mild solution may be first used, for its
general benumbing effect, after which it would be advisable to use a
strong solution, even saturated, very sparingly, applying it by the aid
of illumination just to the area where the effect is desired, and not
allowing it to come in contact with other parts of the nasal cavity;
this is done to avoid unpleasant symptoms from cocaine absorption.
Another benefit obtained from the use of cocaine is in thus abolishing
sensation to an extent which does away with reflex vasomotor symptoms,
shock, etc. Therefore even when a general anesthetic is used it will be
well to use at least a small amount of it for this latter purpose.

The question of instruments and of methods will depend much on the
equipment of the operator and his expertness in the necessary technique.

_The Maxillary Antrum of Highmore._--This is the largest of the
accessory sinuses, the most easily approached, and the one whose
disturbance is most quickly and easily appreciated. It may be infected
by continuity, along the Schneiderian membrane which lines it, or by
extension upward of disease from carious teeth, as well as after a
variety of injuries involving its integrity. So long as its opening
into the nose be not plugged it will, when involved in catarrhal or
suppurative inflammation, discharge into the latter a characteristic
fluid, which is especially likely to escape when the head is held
downward and to the opposite side. Any statement of this fact,
coupled with evidences of local inflammation, should enable an easy
recognition of antral disease. In more chronic cases it becomes blocked
by thickening of its membrane, the production of granulations or of
polypi, which sometimes completely fill it. When thus plugged and
filled there is a tendency to protrusion of its anterior outer wall and
floor, while the overlying cheek may become somewhat edematous, the
parts at the same time being tender. The pain from a diseased antrum
will often induce the patient to go to the dentist for extraction of a
molar tooth, which, however, affords little relief.

The relief for chronic antral disease is surgical, as in the case of
the other sinuses. Opening the antrum through a tooth socket would
seem judicious only when a diseased tooth is the cause of the lesion.
It is useful only for such otherwise uncomplicated cases. The argument
usually used in its favor is that it affords better drainage. This,
however, is not the case, since the position assumed by the head for
the greater part of the time does not locate such an opening in the
most dependent part of the cavity. Moreover, the discharge is not
always fluid, nor does it flow freely; on the contrary it is often
thick, and so adherent to the wall or roof of the cavity that it takes
a strong irrigating stream or swab to dislodge it. If the antrum is
to be opened through the mouth it would seem more surgical to open it
widely, cleanse it, and then either drain it or close it again. Other
things being equal, the best method is that which permits of both
examination and subsequent treatment. Jansen’s method is frequently
most serviceable. It includes careful cleansing of the teeth, with
disinfection of the mouth, and walling off the area to be exposed
by gauze strips in order to prevent hemorrhage into the throat. An
incision is made through the anterior mucoperiosteum, beneath the floor
of the antrum, from the first incisor to the first molar. Its edges are
then separated and the entire front wall of the antrum removed. Through
such an opening its interior can be carefully inspected and cleansed.
Should it seem desirable to go farther the inner wall may be removed
by forceps, and through this opening the ethmoid cells can be seen and
curetted up to the insertion of the middle turbinate. Then the sphenoid
surface can be inspected and the lower portion of the sphenoid cells
resected. Finally a good-sized counteropening is made inward, onto
the floor of the nose, the antrum is loosely packed, the ends of the
gauze extending into the nose, and the mucoperiosteal wound closed, in
order to secure primary union. All bone edges should be made smooth and
non-irritating; the sphenoidal cells should not be packed, but left
open for subsequent treatment.

In the presence of bone disease, malignant growth, etc., it may not be
possible to shut off the mouth again from the antral cavity. In such
cases the packing may be made more snug and the granulation process
will have to be substituted for sutures.

Special flaps or plastic methods should be devised for special cases,
as, for instance, the formation of a mucoperiosteal flap from the outer
side of the antral wall and its union posteriorly within the cavity
of the antrum with another made from the antral floor. By turning
the latter in the necessary direction a line of suture may be made
through the mouth. Any such cavity, long diseased, will call for a
radical method of attack and opening, which latter can be maintained
to permit of subsequent treatment, as an early closure would sometimes
be undesirable. Antral cavities thus left more or less open should
be treated with cleansing sprays or applications, and with such
stimulating applications as silver nitrate in various strengths of
solution, or similar antiseptic stimulants.


THE CRANIAL NERVES.

While most of the affections of the nerves are considered to be
non-operative, and to belong rather to the internist than to the
surgeon, there are, nevertheless, some nerve lesions which are only
to be relieved by surgical intervention. These may be divided into:
(1) _Wounds and injuries._ (2) _Morbid conditions_, such as (_a_)
_neuralgia_, and (_b_) _muscle spasm_.


WOUNDS OF THE NERVES.

Wounds of nerves have been considered in the chapter on Wounds, and
the possibility of nerve regeneration and repair therein discussed.
In every division of a nerve trunk of importance or size the nerve
ends should be trimmed and reunited by a suture, passed either through
the sheaths or through the nerve itself. The ends should be brought
together securely and the tension should not be too great. If this be
promptly done the best of results may be expected. This is equally true
of cranial and peripheral nerves. Clinical experience has long since
established the necessity of this procedure after all such injuries,
and _nerve suture_, or _neurorrhaphy_, is now a standard operation.
Later there was added to this measure the analogous one of _nerve
grafting_, and it has been found that nerves can be juggled with
just as can tendons, as described in the section on Tendon Suture.
Indeed the methods of nerve suture and _nerve grafting_ are strikingly
similar to those employed with tendons, where can be made either
end-to-end junction, lateral implantation, or a more properly termed
_grafting_, a trimmed end of one nerve being inserted into another. In
the arm, when the ulnar nerve has been caught in callus and completely
destroyed, both the upper and lower portions may be grafted into one
of the adjoining nerves, _e. g._, the median; this procedure seems to
reëstablish communication and serve the double purpose, in a manner
corresponding to duplex or quadruplex telegraphy over one wire. Nerves
which have been divided and entangled in scars may be disengaged, their
ends trimmed off and approximated, success being proportionate to the
length of time during which nerve degeneration may have been taking
place.

Another operation is practised on nerves, solely for the relief of
painful or disturbing symptoms, _i. e._, _neurectomy_. In cases of
intractable and hopeless neuralgia, where other measures fail, sensory
or complex nerve trunks are divided, a portion of the continuity being
resected. This operation is practised more often upon the trifacial
nerve than upon all others. It is generally successful, but in those
cases where pain is due to some central lesion it is often palliative
rather than curative. In the case of the trifacial nerve the operator
endeavors to be as radical as possible in its practice, and to remove
the Gasserian ganglion rather than portions of any of its branches.

The neuralgia for which these operations are performed may be due
either to central or constitutional causes, as well as to local
irritations, compressions, or degenerations. The term neuralgia itself
is so vague and covers such widely differing changes that nothing which
can be said in this place would clear up the problems of its pathology;
consequently attention will be directed here solely to its surgical
relief in connection with the various nerve trunks which are usually
attacked.

One other operation is practised upon nerves for the relief of pain
and spasmodic affections--namely, _nerve stretching_, or nerve
_elongation_. This is practised more often upon the sciatic than upon
any other nerve, but has been done for the relief of choreic spasm of
the arm and shoulder, by exposing and stretching the various cords of
the brachial plexus, for the relief of spasmodic torticollis, and in
various other places. Nussbaum was the first to note that obstinate
intercostal neuralgia was relieved by accidental stretching of an
intercostal nerve, and introduced the procedure.

[Illustration: FIG. 398

Various incisions for reaching different branches of the trifacial
nerve: _a_, supra-orbital; _b_, external nasal; _c_, Bruns’ incision;
_d_, inf. dent. at mental foramen; _e_, internal nasal; _f_,
infra-orbital; _g_, Carnochan’s incision. (Marion.)]

Operations upon nerves, then, include _suture_, _grafting_,
_stretching_, _division_, and _resection_. After any operation upon a
nerve trunk the parts pertaining to it should be placed in a position
of rest; and, furthermore, such position as will prevent stretching and
favor relaxation of the sutured trunk should be maintained. The writer
is credited with the first primary suture of the sciatic nerve, which
was done immediately after its accidental division, during the course
of an extensive operation. Recovery was prompt and complete. The limb
was immobilized in the extended position and physiological rest thus
maintained.

Nerves can be stretched, it has been found, to one-twentieth of their
length. Nerve trunks have much more strength than has been generally
appreciated. The sciatic trunk of a full-grown individual will bear
a stress of more than eighty pounds, while even six pounds’ pull are
necessary to tear the supra-orbital nerve. The benefit which follows
nerve elongation is ascribed to the improvement in its nutrition
produced by the damage done to its substance, and the consequently
enhanced blood supply, as well as to the severing of adhesions between
the sheath and its surroundings and between the nerve bundles within
the sheath.

The operation of nerve stretching consists simply in exposing the
nerve at a site of election, detaching it from its surroundings, and
then hooking either the finger or some smaller instrument beneath it
and pulling firmly, yet gently, in both directions; in the case of the
sciatic, for instance, the entire limb should be lifted from the table,
and even this does not entail upon the nerve trunk anywhere near a
breaking force.

The _cranial nerves_ are sought, found, and treated as follows, in
their respective cases:

The _supra-orbital nerve_ is attacked at its exit from the
supra-orbital notch, which can usually be felt, or foramen, when such
exists, either by a straight incision made directly over it, where it
can be felt, or by a curved incision through the region of the eyebrow,
which should have been shaved for the purpose, the resulting scar being
hidden by the hair as it grows again.

The _infra-orbital nerve_ is similarly treated at the infra-orbital
foramen, where it lies under the levator labii superioris. It may be
exposed by either a curved incision, parallel to the orbital margin, or
by a vertical incision, which will leave a more disfiguring scar.

The _second branch of the fifth nerve_ may be attacked from the front
by Chavasse’s modification of Carnochan’s original method, consisting
of a T-shaped incision from one corner of the eye to the other, the
vertical branch extending from its middle well down to the mouth.
After the infra-orbital nerve is identified it is secured with a piece
of silk. The anterior wall of the antrum is then removed, the cavity
opened, and a small trephine applied to its posterior wall. The nerve,
being exposed in its canal or groove, is divided anteriorly, pulled
down into the cavity by means of a ligature previously applied to it,
and now made to serve as a guide into the sphenomaxillary fossa. Here
it may be followed directly into its connection with Meckel’s ganglion,
which may also be extirpated. The nerve trunk is forcibly pulled out
of the foramen rotundum, through which it escapes from the Gasserian
ganglion.

Horsley does not open the antrum but lifts the orbital contents,
including the periosteum, follows the nerve along the canal by means
of sharp-pointed bone forceps, and thus follows it up to the foramen
rotundum, where it is evulsed as above. (See Fig. 399.)

Luecke years ago devised a method of lateral approach, attacking
the ganglion and the nerve from the temporal region. An incision is
made from the external angle of the orbit straight downward in the
direction of the molar teeth, where it is met by another extending from
the middle root of the zygoma, downward and forward. Through these
incisions the zygoma is exposed and divided. Thus an osteoplastic flap
is formed which is laid up over the temporal region, the divided piece
of bone being raised with the overlying skin and not detached. This
exposes the temporal and zygomatic fossæ. The temporal muscle is then
drawn backward with a hook, the fatty tissue which fills these fossæ
cleaned out, and the nerve sought for in the sphenomaxillary fossa,
where both it and Meckel’s ganglion may be extirpated. The flap is then
turned down and fastened in place (Fig. 400).

[Illustration: FIG. 399

Branches of the inferior maxillary nerve which most concern the
surgeon: _a_, auriculo-temporal; _b_, inf. dental; _c_, buccal.
(Marion.)]

[Illustration: FIG. 400

Exposure of Meckel’s and the Gasserian ganglia by temporary resection
of the zygoma; Luecke’s method. (Marion.)]

The _inferior dental, or third division of the fifth nerve_, may be
reached in several ways: Its terminal portion where it escapes at the
mental foramen; its upper portion by an incision two inches along
the lower border of the jaw and above the angle, the masseter muscle
being separated from the jaw, and the ascending ramus opened with a
³⁄₄-inch trephine at a point 1¹⁄₄ inches above the angle, its upper
edge ¹⁄₄ inch below the sigmoid notch. The nerve is here exposed before
it enters the canal. The lingual nerve may also be found resting upon
the internal pterygoid muscle. A ligature tied around each nerve, for
traction purposes, permits easy tracing of their trunks to the foramen
ovale, where, after vigorous stretching, they are divided. They should
then be traced downward and at least one inch of their trunks removed.


=The Gasserian Ganglion.=--When all three branches of the trifiacial
nerve are involved in painful _tic_, or when operation has already
been practised upon one or more of them and the tic has recurred, it
becomes necessary to attack the Gasserian ganglion itself.[45] This
may be approached by either one of two methods. Both are difficult
and serious, having a mortality of from 15 to 20 per cent. As Cushing
has pointed out, however, its mortality rate is scarcely as great as
the death rate by suicide in neuralgic cases of this kind. The attack
from below was first carefully worked out by Rose and then by Andrews,
and is begun in much the same way as the operation for the removal
of Meckel’s ganglion by resection of the zygoma, described above. A
flap is laid up, larger and wider, including the zygoma, with the most
complete possible exposure of the zygomatic fossa. The coronoid process
is drilled in two places, divided between the openings, which are to be
used for subsequent suture, and the temporal muscle pushed upward and
forward, out of the way, with the upper fragment. The foramen ovale is
then identified by following into it the inferior maxillary nerve, the
base of the skull being cleaned away in that neighborhood, and a small
trephine opening made between it and the foramen rotundum, connecting
these two openings by a much larger one. Through this opening the
ganglion is exposed and destroyed piecemeal or extracted as completely
as possible. The operation is exceedingly difficult, and hemorrhage,
especially from the middle meningeal artery at the foramen spinosum,
maybe so troublesome as to make it impracticable unless the carotid
be tied. I have preferred in doing this operation to make preliminary
ligation of the common carotid, which facilitates the balance of the
procedure. The exposure by this method, however, is not as satisfactory
as by that next to be described.

  [45] _Osmic Acid and Other Treatment of Trigeminal Neuralgia._--While
  it hardly pertains to operative surgery, it may be worth while to say
  that it seems to me that no case of trifacial neuralgia should be
  subjected to radical operation until at least two or three remedies
  have been given a fair trial. One of these is _castor oil_ its use
  being based upon the theory that such neuralgia is of toxic origin
  and that a prolonged evacuant treatment should benefit it. This
  would mean the administration of two or three good-sized doses of
  castor oil every day for a period of two to three weeks. It is not
  such a drastic remedy, thus given, as would appear, for after the
  oil has once thoroughly produced its laxative effect it ceases to
  distress, but serves as a very effective eliminant. The second remedy
  is _gelsemium_, the best preparation being the tincture of the green
  root. It seems to exercise a selective affinity for the trifacial
  nerve. It should be given in large doses, pushed to the physiological
  limit, _i. e._, until the patient begins to see everything in yellow
  colors. Its effect on the heart must also be guarded. Fifteen drops
  of the green tincture given every two hours, and for a few days, will
  usually suffice to thoroughly test its efficacy.

  _Osmic acid_ is used only for _intraneural injection_, its efficiency
  now being under trial. Ten to twelve drops of a 2 per cent., freshly
  prepared aqueous solution are directly injected into the nerve trunk
  after its exposure. Murphy has been its particular advocate, and
  has reported relief of pain in a number of cases thus treated. It
  seems to depend for its effect upon two factors--the destruction of
  nerve filaments and their substitution by connective tissue. All the
  nerve branches that can be exposed should be injected; the palatine
  and lingual through the mouth; the intra-orbital and supra-orbital
  by incisions upon the face; orbicular-branches, as well, should be
  injected, if possible. Most of those who have used it advise also
  to inject a few drops into the foramina of exit, around the trunks,
  which are thus infiltrated with the solution. The procedure is
  painful and usually requires a general anesthetic, but it seems to
  be free from danger. While the treatment has been successful in some
  cases it has been equally disappointing in others, and the method
  will scarcely supplant the more radical method of ganglion exsection.

Hartley and Krause, about the same time and independently, devised a
method of attacking the ganglion, after raising an osteoplastic flap
from the side of the skull, which affords a better exposure and a more
satisfactory method.

Within reason the larger the osteoplastic flap the easier the balance
of the operation. Whether it be square or horseshoe in shape, whether
it be made by chisel, by Gigli saw, or by surgical engine, matters
little. In fact experience has shown that the conservation of the bone
is not a matter of serious import, and there is no good reason why
there should be any hesitancy to remove the bone should the formation
of such an osteal flap present too many difficulties. After the dura
is completely exposed it is to be separated from the base of the skull
until the foramen spinosum and middle meningeal artery are reached.
It is better to do this quickly and with the finger than slowly with
instruments. After this separation the brain with its dural covering
is lifted by a spatula or retractor, so as to afford a good view of
the region of the ganglion. It will be necessary to double ligate the
middle meningeal artery unless preference has been given to make a
preliminary temporary or permanent ligation of the carotid. Should
this artery have been injured in raising the flap it should be secured
before going any farther, either by plugging the opening or canal with
gauze or with antiseptic wax (Fig. 401).

The upper surface of the ganglion is adherent to the dura, and these
adhesions should be separated. The second and third branches should
be identified and divided near their exit. The first branch is in too
close relation with the cavernous sinus to justify much interference.
The ganglion itself is then seized, after complete isolation, with
forceps and evulsed, with as much of its longer and shorter roots as
possible. Hemorrhage is checked by adrenalin or by pressure with gauze,
as may be required. If gauze be used for the purpose it may also be
utilized for drainage. The brain is restored to position and the flap
sutured in its proper place.

Before doing either of these operations I should prefer to place the
patient within the Crile pneumatic suit and then tilt the body to an
angle of at least 45 degrees, thus prompting emptying of the cranial
and cervical veins by gravity, while at the same time blood pressure is
maintained by the pneumatic pressure (see p. 180).

Abbe has endeavored to lessen the shock of the operation by not
formally tearing out the ganglion, but by taking out a section of
the nerve trunks between it and their foramen of exit, and then
interposing a piece of thin, sterile, rubber tissue, inserting it in
such a way that it shall effectually prevent regeneration of nerve
trunks across the interval, this rubber being intended to remain and
become encapsulated. This method of Abbe seems to have made operative
attack upon the Gasserian ganglion less formidable and less dangerous.
It remains to be seen whether it is permanently as effective as more
complete extirpation.


=The Lingual Nerve.=--In some cases of cancer of the tongue there is
such intense pain that not only has the lingual artery been tied but
the lingual nerve been stretched or exsected. It can ordinarily be
reached where it lies on the floor of the mouth beneath the mucous
membrane, at the fold between it and the tongue, where it can be felt
if the tongue be forcibly stretched. Through a small incision a blunt
hook may be passed and the nerve thus secured. Close to the first lower
molar the nerve lies in the tongue near the surface, where it can also
be found.


=The Seventh or Facial Nerve.=--This nerve has sometimes to be
stretched for spasmodic affections. When the desire is simply to reach
its trunk it may be sought through an incision behind the ear, by which
the posterior border of the parotid is exposed, the sternocleidal
insertion identified, the nerve lying in the interval between these two
landmarks. A more easy method of reaching it would probably be by an
incision in front of the ear just before its main branch divides as it
enters the parotid gland. If necessary this may be followed backward
until the main trunk is reached.

[Illustration: FIG. 401

Intracranial exsection of Gasserian ganglion; dura open, brain lifted
up. Hartley-Krause method. (Marion.)]

[Illustration: FIG. 402

Relations of the facial and spinal accessory nerves: _a_, carotid; _b_,
int. jug.; _c_, facial nerve; _d_, transv. proc. atlas; _e_, spinal
acces.; _f_, stern. mast. muscle. (Marion.)]


=Neuro-anastomosis for Facial Palsy.=--In view of the hopelessness
of facial paralysis, when resulting from destructive injuries to
the nerve trunk, the introduction of anastomotic methods has marked
a very distinct advance. Ballance, in 1895, was the first to apply
neuro-anastomotic methods to the facial nerve. He attached the
facial to the spinal accessory. His own experience, as well as that
of half-a-dozen later operators, proved that nerve regeneration is
possible, but that in this particular instance voluntary movements of
the face were often accompanied by distressing and unsightly associated
movements of the shoulder, and _vice versa_. Hence, Taylor and others
suggested the use of the hypoglossal instead of the spinal accessory,
the former being a purely motor nerve running near the facial,
intimately associated with it in function, and arising by nuclei, which
are equally closely associated in the cranial centres. The operation
is indicated in all cases of paralysis caused by lesion of the nucleus
within the brain, or the nerve trunk at the base of the brain, or along
its course. It is justifiable in Bell’s palsy, when there is complete
reaction of degeneration in the facial nerve after several months of
treatment (Fig. 402).

The steps of the operation are practically as follows: Incision is made
along the anterior margin of the mastoid and the sternomastoid muscle,
and the parotid gland is retracted forward and the posterior belly
of the digastric is exposed. It should then be pulled downward and
backward and divided if necessary. The styloid process is identified,
and the facial nerve which emerges from the stylomastoid foramen near
its base is then sought and isolated. It should be separated as high as
possible and divided close to its exit, so that one-half inch of its
free trunk may be secured before it enters the gland. Two fine silk
sutures are then passed, one on either side, through the peripheral end
of its sheath and tied, the ends remaining long, to be subsequently
used. This nerve end should be trimmed to a wedge shape. Next the
transverse process of the atlas is identified and the deep cervical
fascia divided. This will expose the internal jugular, which should be
separated and held out of the way. There will now be seen the spinal
accessory nerve, which runs obliquely downward and outward, sometimes
in front of and sometimes behind the jugular (Fig. 403). When the vein
is held forward and the fascia well retracted both the hypoglossal
(Fig. 404) and the pneumogastric nerves are seen, with the internal
carotid to their inner sides. The former may be identified either by
the electric current, which will cause contractions in the muscles
supplied by it, or it may be followed down to where it turns forward
around the occipital artery and gives off the descendens noni. Here it
should be separated until its trunk is sufficiently free, so that the
facial stump can be inserted into it without tension. The nerve being
elevated by a hook a slit is made in it, about ³⁄₄ inch long. Into this
the wedge-shaped end of the facial trunk is introduced, and held there
by utilizing the sutures which have already been passed through its
sheath. When the nerve is thus firmly held in the cleft, with its end
turned toward the direction of nerve supply, a little cargile membrane
may be wrapped around the junction and the wound closed.[46]

  [46] Taylor and Clark, New York Medical Record, February 27, 1904, p.
  321.

Nerve regeneration has been known to follow this procedure in a number
of cases, and it has given encouraging results. Considerable time,
however, is required, and the patients should be warned that results
are not to be quickly expected.

[Illustration: FIG. 403

Exposure required for anastomosis of facial and spinal accessory
nerves: _a_, facial nerve; _b_, sp. acces.; _c_, int. jug.; _d_,
digastric muscle; _e_, atlas, trans. proc. (Marion.)]

[Illustration: FIG. 404

Exposure required for anastomosis of facial and hypoglossal nerves:
_a_, facial nerve; _b_, sternomastoid; _c_, digastric; _d_, parotid;
_e_, hypoglossal. (Marion.)]


=The Spinal Accessory Nerve.=--The principal reason for attack
upon this nerve is spasmodic torticollis, or _wryneck_. It is
exposed through an incision along the anterior border of the
sternocleidomastoid muscle, extending two inches downward from the ear.
The nerve is found a little above the level of the hyoid bone; or,
again, it may be found by an incision along the outer border of the
muscle, opposite its centre, just above which it will be detected (Fig.
405).


=The Deep Posterior Cervical Plexus.=--When operation upon the spinal
accessory has failed to relieve long-standing and serious spasmodic
torticollis, Keen has suggested to divide the first, second, and third
cervical nerves. The operation is difficult and not always successful;
still it is worth trying. A transverse incision is made below the level
of the lobe of the ear, the trapezius being divided and dissected up
until the great occipital nerve is found. It is followed after the
necessary division of the complexus until its origin from the posterior
division is reached. The suboccipital or first cervical nerve, which
lies in the triangle close to the occiput that is formed by the two
oblique muscles and the posterior rectus, is excised. The exterior
branch of the posterior division is found lower down, and should be
divided close to the bifurcation of the main nerve (Fig. 406).

[Illustration: FIG. 405

Exposure of the spinal accessory nerve alone: _a_, digastric; _b_,
jugular veins; _c_, sternomastoid muscle; _d_, spinal accessory.
(Marion.)]

[Illustration: FIG. 406

Incisions through which the various nerves in the neck may be sought:
_a_, facial; _b_, facial and hypoglossal; _c_, facial and sp. acces.;
_d_, spinal accessory; _e_, cervical plexus; _f_, brachial plexus.
(Marion.)]


=The Cervical Sympathetic.=--The cervical sympathetic is a most
complicated nerve trunk, furnishing fibers of various functions
to the skin, and to the deeper parts fibers which are vasomotor,
vaso-inhibitory, pilomotor, and secretory in function. It supplies
the various glands, the upper viscera, the heart and bloodvessels,
and connects with nerves below, which supply even the genital organs
and the non-striped muscles of the body. The upper part has a very
important oculopupillary function, as it supplies the dilator pupillæ,
the non-striped part of the elevator of the upper lid, and the orbital
muscle of Müller, _i. e._, a small bundle of non-striped muscle which
lies behind the globe and projects across the sphenomaxillary fissure
at the back of the orbit. (By contraction of this muscle the eye may
be pushed forward.) It also supplies the submaxillary gland, the
cutaneous bloodvessels, and the sweat glands of the head and neck.
The pupil dilating fibers arise in the medulla, run backward in the
lateral columns of the cord to the ciliospinal centre, emerge through
the anterior roots of the first and second dorsal segments, and enter
the inferior cervical ganglion, thence passing upward through the
sympathetic trunk to the orbit. Therefore ocular and other symptoms are
produced not only by lesions of the external trunk, but also by lesions
within the cord at the level of the upper dorsal segments. These nerves
may be injured anywhere in the neck, or compressed by inflammatory
deposits or new-growths, or even by cicatricial tissue at the apex
of a tuberculous lung. Many cases of phthisis show inequality of the
pupils. One nerve may be injured in operations on the neck, the result
being slight drooping of the lid and flushing of the face, as well as
excessive perspiration on the injured side; the corresponding pupil
being smaller than the other because of paralysis of the dilators, but
contracting to light, as the third cranial nerve which supplies its
sphincter is unaffected. The eye will then sink back somewhat, owing to
paralysis of Müller’s muscle, and thus permit a nearer closure of the
lids. These oculopupillary symptoms are pathognomonic of paralysis of
the cervical sympathetic. Cocaine will not dilate a pupil whose dilator
has thus been paralyzed. The area of skin supplied with sweat fibers by
the cervical sympathetic includes the corresponding side of the head,
neck, shoulder, and upper part of the trunk (Fig. 407).

When the cervical sympathetic is unduly stimulated we have dilatation
of the pupil, exophthalmos, widening of the palpebral aperture, delayed
descent of the upper lid when the patient looks downward, all of which
can be imitated or produced by dropping into the eye a solution of
cocaine, which stimulates the nerve.[47]

  [47] Stewart, Some Affections of the Cervical Sympathetic, The
  Practitioner, February, 1905.

The surgical sympathetic is attacked surgically for three widely
variant conditions: _epilepsy_, _glaucoma_, and _exophthalmic
goitre_--the first, because of its vasomotor control of the vascular
supply of the brain; the second, because of the relation of the nerve
to the orbital circulation and nutrition; and third, because of its
relations to the thyroid and the heart. In the latter case it is
especially desirable to remove the lower cervical ganglion and the
first dorsal, if it can be reached, although the procedure here is
exceedingly difficult.

The tachycardia of Graves’ disease is due apparently to irritation of
the accelerator nerves of the heart, which come from the sympathetic,
or else to paralysis of the regulator (pneumogastric) supply. The
former spring from the lower part of the cervical cord and the upper
dorsal segments, and pass to the third cervical ganglia and to the
first dorsal, terminating in the cardiac plexus.

The operation described below is practically that advised by Jonnesco,
more or less modified by other operators, and may be varied to some
extent to meet the exigencies of particular cases. Thus whether it
shall be done through one or two incisions will depend on the will of
the operator. It is made about as follows: A long incision is made
along the posterior border of the sternomastoid. The latter may be
either retracted forward or its fibers separated, in order that the
fascia on its inner side may be reached and separated from the deeper
muscles. This fascia should be divided as high as the base of the
skull. The upper ganglion of the cervical sympathetic lies on the
inner side of the anterior tubercle of the transverse process of the
second and third vertebral processes, resting upon the muscles covered
by this fascia. The ganglion, being recognized by its shape, and the
sympathetic trunk being thus identified, the nerve should be divided
and made free, as high as possible and just beneath the base of the
skull. (See Fig. 408.)

[Illustration: FIG. 407

Diagram to illustrate the relations of the cervical sympathetic and the
mechanism of the various disturbances following lesions of its trunk.
(Stewart.)]

The lower end is to be exposed by continuation of the first incision,
or by another beginning 1 Cm. above the clavicle and extending along
the posterior border of the sternomastoid for 4 or 5 Cm. The platysma
should be entered and the tissues separated upward until the fingers
can meet in a channel thus made by connection with the upper incision.
The tissues should also be loosened downward until a point has been
reached behind the clavicle. They then should be widely retracted and
the inferior thyroid artery sought. The middle cervical ganglion is
found inside of its curve. Occasionally this ganglion is replaced by a
plexus, or the main trunk may pass behind the artery. At this level it
is to be seized and its upper divided end pulled down and out through
this opening. The nerve trunk should then be followed downward. The
artery should be freed from any plexus of sympathetic fibers around
it, all of which should be destroyed, and especially those fibers which
constitute the middle cardiac nerve, which pass to the inner side. The
main trunk is to be drawn down beneath the artery and then followed
downward and outward to the lower ganglion, where it lies behind the
clavicle, on the neck of the first rib, between the scalenus anticus
and the longus colli. The ganglion and the trunk should be separated
from the efferent and afferent branches which connect with it, as well
as from the vertebral artery; being thus made free it is again drawn
outward. Here one should divide especially the cardiac branches which
form the lower cardiac nerve, as well as the vertebral branches which
have so much to do with controlling the supply through the vertebral
artery. The ganglion, after being identified, should be finally
removed. The nerve should be traced still farther down to the first
thoracic ganglion, which has much to do with supplying the heart, and
this also should be separated and destroyed (Fig. 409).

[Illustration: FIG. 408

Sympathectomy. Exposure and removal of middle and upper ganglia.
(Marion.)]

[Illustration: FIG. 409

Sympathectomy. Seizure and removal of inferior ganglion. (Marion.)]

It is rarely necessary to provide for drainage after the operation,
unless the retraction and laceration of tissues have been very great.
My own preference is to make one long incision along the posterior
border of the sternomastoid, by which the dissection is facilitated
and the operation made less complicated and difficult. When done for
glaucoma on one side it will be sufficient to attack one nerve, but
when for epilepsy or for exophthalmic goitre the operation should be
bilateral. When for epilepsy or glaucoma it is not so necessary to
remove the lower cervical ganglion; this is indicated rather in those
cases where it is desirable to control the accelerator nerves to the
heart. The operation has given good results in all three affections
named, yet it is one of considerable difficulty. It would be made
extremely difficult by the presence of a large goitre, and in such case
it would probably be better to extirpate the thyroid rather than to
attack the nerve. (See Glaucoma, Epilepsy, and Exophthalmic Goitre.)




CHAPTER XXXVIII.

THE SPINE, THE SPINAL CORD, AND THE PERIPHERAL NERVES.


SYRINGOMYELIA.

The term _syringomyelia_ implies irregular dilatation of the central
canal of the spinal cord, having a congenital origin, tending to
relative increase later in life, with corresponding disturbance of
function, the latter including paresthesiæ, loss of sensibility to heat
and cold, more or less motor impairment and disturbances of nutrition,
more noticeable in the region of the joints than elsewhere, the latter
having been already considered in the chapter on the Joints. The
dilatation is by no means regular, may occur in various regions of the
cord, and attain a size permitting encroachment upon, and even atrophy
of, the structures of the cord itself. When functional disturbance,
especially paralytic, has become very pronounced a few surgeons have
ventured to expose the cord by a laminectomy, and endeavored to make a
more or less permanent opening with drainage of the dural cavity. Thus
Keen has operated twice, Abbe once, and Munro three times, including
twice on the same patient. Only in this last instance was any permanent
relief obtained, and this was at the expense of a second operation. It
is doubtful if any of the peculiar joint lesions of this disease will
be in any way affected by operation for this purpose.


TUMORS OF THE SPINAL CORD.

Tumors of the spinal cord may be classified as follows (Krauss):

1. Tumors springing primarily from the envelopes of the cord: (_a_)
Tumors of the vertebral column, and (_b_) tumors of the meninges, the
latter including those arising from the external surface of the dura,
or from the periosteum of the spinal canal, _i. e._, extradural tumors,
and those from the inner surface of the dura and the other membranes,
that is, intradural tumors.

2. Tumors developing in the cord proper, intramedullary. These are
generally gliomas and do not present so much the symptoms of cord
tumors as of syringomyelia.

Vertebral tumors may be carcinoma (secondary), endothelioma, sarcoma,
osteosarcoma, as well as the non-malignant and cartilaginous or osseous
tumors, and parasitic cysts, _i. e._, echinococcus. The sarcomas are
the most common of all.


=Symptoms.=--The symptoms of tumor of the spinal cord depend upon
the part involved and differ according as it involves the cervical,
thoracic, or lumbar portions or the cauda equina. They are to be
classed as _root symptoms_ and _cord symptoms_. _Root symptoms_ include
pain, paresthesia, and hyperesthesia. The pain is usually persistent,
burning, and severe, affecting one side or the other, if the tumor
be laterally placed, or both sides if central. The pain follows
the distribution of the spinal roots rather than the course of the
intercostal nerves, _i. e._, is more horizontal and less oblique. These
pains persist and have the characteristic feature of not presenting
painful points on pressure. They are commonly referred to the abdomen,
and may thus give rise to serious mistakes in diagnosis, _e. g._, they
have been regarded as due to hepatic colic, dry pleurisy, appendicitis,
etc. Pain may assume the girdle character, which is usually accentuated
by movement, and is frequently accompanied by herpes zoster. The
greater the involvement of the posterior roots the more painful the
condition. When the anterior sensory roots are involved pain may be
wanting and the disturbance assume a type of paresthesia, with final
anesthesia, in which case the patient would at first complain of
numbness and prickling sensations. There is sometimes noted a zone
of hyperesthesia on the proximal side of the anesthetic area, or
this zone, if not hyperesthetic, may be replaced by a condition of
uncertainty of sensation.

The _cord symptoms_ are the reliable ones, varying according to the
segment involved. The portions of the cord where lesions can be best
localized are, for instance, the third to the fifth cervical, including
the origin of the phrenic nerve; the fifth to the seventh cervical,
where the posterior thoracic nerve comes off; the seventh to the eighth
cervical and first thoracic segments, where originate the dilator
nerves of the pupil. The upper border of the anesthetic area points to
a lesion of the next or second higher spinal segment than the level
really represents. The lowest level of the lesion corresponds to the
highest level of the sensory disturbance. The level of the segment
area of the skin of the back does not correspond to the level of the
spinal segment involved, the latter being higher up. The point of
greatest sensitiveness over the spine is in many cases a good guide
to the segment involved, but is applicable only where the lesion is
posteriorly placed. The absence of pain or tenderness along the spine
means little or nothing, but their presence has great significance.


=Diagnosis.=--The diagnosis of a cord tumor covers, according to
Krauss, a first or subjective period, indicative of irritation along
the posterior roots, and is characterized by pain and paresthesia.
This is followed in time by a second or objective period which points
to invasion of the spinal cord, characterized mainly by weakness and
later by paralysis, with disturbed tendon reflexes. Diagnosis early
is extremely difficult, for pain and disturbances of sensation are
produced in many ways.


=Treatment.=--The treatment of spinal-cord tumors is purely surgical
and should be instituted promptly so soon as diagnosis has been made.
Only in tumors of syphilitic origin will internal treatment be of any
avail. The therapeutic test having been made, should it seem wise,
and proved futile, the case should be regarded at once as surgical.
According to Krauss’ statistics nearly 40 per cent. of all operated
cases have resulted in recovery, while in 35 cases of sarcoma 8 have
resulted in recovery and 6 in improvement. This is really a more
gratifying statement than can be made with regard to brain tumors, and
should be regarded as lending encouragement to surgical procedure.

The operative details will be discussed later in this chapter.


THE PERIPHERAL NERVES.

The remarks made concerning the surgical affections of and operations
upon nerves contained in the previous chapter, pertaining to the
cranial nerves, will apply equally well to the peripheral nervous
system.

_Constant pressure_ as well as contusions of nerves will cause more
or less paralysis. The surgeon occasionally sees manifestations of
this kind in the so-called “crutch paralysis,” due to pressure upon
the brachial plexus by the use of crutches, and in another form so
generally associated with administration of an anesthetic as to be
called “ether paralysis.” It is another form of pressure paralysis due
to indifference in letting the arm, for instance, hang over the edge of
an operating table during anesthesia or operation. It does not call for
operation so much as for electricity, massage, and similar measures.
Extreme consequences of nerve and vessel injury are portrayed in Fig.
410.

_Tumors of nerves_ are both benign and malignant, the former assuming
the fibromatous type oftener than any other, and frequently involving
more than one nerve trunk, attaining also considerable size and
impairing or destroying function by pressure. In addition to the
true fibroma of nerve sheaths we have the peculiar type of _fibromas
of nerve stumps_ seen after amputations, and the multiple neuromas,
again largely of the fibromatous type, which involve many and in
rare instances nearly all the peripheral nerves. Cases are on record
where as many as 1600 small and large tumors have been found, strung
like beads upon wires, along all the peripheral nerves throughout
the body. Another variety of fibromas of nerves involves those of
the skin and produces small _painful subcutaneous nodules_, although
these may attain a considerable size. Within the past few years there
has been a much better familiarity with that form of growth known as
_plexiform neuroma_, in which entire nerve trunks are involved, so
that they become elongated, thickened, and tortuous, and resemble a
varicose condition of the veins. The plexiform neuromas are found in
any part of the body; they produce little or no pain, but lead to
disturbances of function, as well as to peculiar irregular swellings
that may be mistaken for lymphangioma, and which are often accompanied
by pigmentation of and growth of hair upon the overlying skin. (See
chapter on Tumors.)

For the various purposes already mentioned different nerve trunks and
plexuses are made accessible for operation by the following methods.


=The Brachial Plexus.=--The brachial plexus is reached through an
incision similar to that for ligation of the subclavian artery. After
opening the deep fascia the nerves are sought and found behind the
subclavian vein and lying around the artery. This plexus is stretched
especially for the relief of choreiform spasm or painful nervous
affections. The various nerves of the upper extremity, after leaving
the brachial plexus, are made accessible to operations for grafting or
suture as below. (See Fig 406.)


=The Median Nerve.=--The median nerve lies in front of the brachial
artery and is exposed through an incision as if the artery were to
be tied in its course. It may also be found on the inner side of the
tendon of the palmaris longus, where it lies beneath the deep fascia.


=The Ulnar Nerve.=--The ulnar nerve is reached through practically the
same incision as the median, when it is sought in the middle of the
arm, but is farther back. It lies near the surface, just behind the
inner condyle, between it and the olecranon, and at the wrist it is on
the radial side of the tendon of the flexor carpi ulnaris.

[Illustration: FIG. 410

Gangrene (mummification) of arm resulting from injury to nerves and
vessels. (Preindlsberger.)]


=The Musculospiral Nerve.=--The musculospiral nerve is found between
the heads of the triceps, where it lies in the groove which winds
obliquely around the humerus.


=The Radial Nerve.=--The radial nerve lies to the outer side of the
radial artery, three inches above the wrist. Should any of the nerves
of the arm or forearm have been cut by an accident which has produced
an incised wound they should be sought for in the wound if fresh, and
in the neighborhood of the scar if older, and should be reunited by
suture, as already described.


=The Great Sciatic Nerve.=--In the lower extremity it is the great
sciatic nerve which is usually made the subject of operation. An
incision midway between the great trochanter and the tuberosity of the
ischium, by which the lower border of the gluteus muscle is exposed,
will enable the surgeon to identify the biceps, to divide the deep
fascia, and find the sciatic nerve at the outer border of the muscle.
It is sought for the purpose of nerve stretching, and it may be pulled
completely out of the wound, while the entire weight of the limb may be
suspended by it.


=The Tibial Nerve.=--The tibial nerves may be exposed through incisions
identical with those indicated for ligation of the tibial arteries.


=The Anterior Crural Nerve.=--The anterior crural nerve lies in
Scarpa’s triangle, near Poupart’s ligament, on the outer side of the
femoral artery.

Tetanus should be treated by injecting antitoxin into the main nerve
trunks, as well as into the spinal canal. The individual nerve trunks
of the brachial plexus may be exposed in the upper arm, where the point
of the hypodermic syringe needle may be inserted into their substance.
The same expedient may be employed with the sciatic or anterior crural
trunks, through the incisions just described. The same measures may be
used in cocainizing the nerve trunks, as suggested by Crile and others,
and described in the chapter on Alterations of Blood Pressure (p. 181).

Abbe has suggested to treat certain cases of inveterate neuralgia of
the peripheral nerves by an intraspinal division of the posterior nerve
roots.

There has been added to the standard operations on nerves another
measure. This consists of _grafting_ by means of foreign material;
using a section of nerve trunk removed freshly from some animal,
or inserting catgut loops between nerve ends which shall serve as
trellises upon which the growing nerve tissue may arrange itself.
Powers, of Denver, has, for instance, reported the implantation of four
inches of the great sciatic nerve of a dog into the external popliteal
of a man. The results seemed to be good so far as sensation was
concerned, but negative as regards motion. Probably no method of nerve
grafting will give so good results as the utilization of a part of the
nerve itself to be operated upon, by partially detaching and turning
back a portion of its central end and uniting it to a similar flap
made from the other end. Various operators have made use of different
materials for the purpose of forming a tube around the nerve ends, and
thus excluding other tissues. For this purpose cargile membrane is
perhaps as serviceable as any. When all other measures fail the method
by long catgut sutures may be adopted.


DISLOCATION OF NERVES.

A few of the nerve trunks may be displaced by injury in such a way
that they are liable to subsequent redislocation. The condition is
recognized by the mobility of the nerve trunk under the skin, by
peculiar sensations when the trunk is irritated, and often by tingling
sensations referred to its distribution. The condition is most common
in connection with the ulnar nerve, just behind the inner condyle.
Should nothing else give relief the trunk should be cut down upon and
retained in place by suture or by fixation of other structures around
it.


WOUNDS OF THE SPINE AND CORD.


=Penetrating Wounds.=--Penetrating wounds of the spine occur both
in military and in civil practice. Sometimes the vertebræ alone are
injured; occasionally the spinal canal will be opened, with little
injury to the bone, only the cartilage suffering. All such injuries are
serious in proportion as the cord itself may be injured. Such injuries
may be direct or indirect. Should a large vessel have been divided the
cord may suffer from pressure of clot, and should this injury occur
high in the spine, death may be caused by pressure. The severity of
such an injury is generally estimated by phenomena pertaining to the
nerve supply of parts below the wound. Should anything indicate partial
or complete division of the cord, or that a single nerve trunk has been
divided, then an operation is indicated for relief of symptoms, and for
nerve or cord suture except in those instances where destruction seems
to be too complete to warrant it.


=Gunshot Injuries.=--Gunshot injuries vary from small punctures and
penetrating wounds to extensive laceration. The lower the injury the
lower the mortality, other things being equal. Such injury to the
cervical region generally proves quickly fatal. The symptoms here are
not essentially different, save that the bullet may have done still
more harm by passing beyond the cord, and that to the signs of a
penetrating wound may be added those of a traumatic hemothorax or some
other serious complication. It is necessary to distinguish between
mere stiffness of the back and disinclination to use certain groups
of muscles and absolute loss of motility. The former may indicate
contusion and the latter severance or pressure. After some perforations
cerebrospinal fluid will escape. In one instance I opened a spinal
canal for perforating gunshot wound with complete paralysis, and found
not only that the bullet had divided the cord but had passed through
the vertebra into the lung beyond. A very curious phenomenon presented
in this case is that when the passage was well opened air passed
backward and forward through the spinal wound, the patient thus partly
breathing through his back.

[Illustration: PLATE XLVI

Intraspinal Hemorrhage, mostly Subdural, with Minute Subpial
Ecchymoses.]

The effect of _pressure from hemorrhage_ is practically the same
whether it be intradural or extradural, or occurring within the
structure of the cord itself. The presence of blood in the spinal
canal is known as _hematorrhachis_, and when occurring within the cord
itself is termed _hematomyelia_. The typical symptoms of sensory and
motor paralysis, which serious pressure upon the cord always produces,
occur when produced by mere presence of fluid more slowly than when due
to the introduction of a foreign body or to comminution of the bone.
Diagnosis is then much facilitated if by the personal history it can be
learned that there was an interval after the reception of the injury
and before the occurrence of paralysis, during which the patient had
reasonable use of the parts later paralyzed. This interval may be one
of but a few minutes’ duration or may have extended over several hours.

When, on the other hand, such an interval lasting several days has
been noted, then the intraspinal lesion must be either one of acute
degeneration or of suppurative character. (See Plate XLVI.)

The question of _operation in spinal hemorrhages_ will frequently be
raised, and is to be decided in part by the intensity of the symptoms
and in part by the character of the injury. Incomplete paralysis would
indicate a lesser degree of pressure and justify a hope that the
outpoured blood may be resorbed. This hope may be further encouraged
should symptoms improve. On the other hand symptoms of complete
paralysis, indicating serious and extensive pressure upon the cord,
would justify a laminectomy, and make it even more encouraging than
though it were done for a crushing injury. The more serious cases,
then, of spinal hemorrhage would seem to justify exploration.

Until very recently it has been held that a complete cross-division of
the spinal cord must necessarily be followed by a hopeless paralytic
condition, plus the changes due to ascending degeneration of the
upper segment. The results of laboratory experiments have made this
quite plain, and therefore it was a startling innovation in surgery
when Harte could report an experience contradicting all that we had
learned to believe in this regard. In spite, then, of the fact that
experimental suture of the cord after its division had not been
successful in animals we are now confronted by three more or less
successful cases reported by American surgeons, Estes, Harte, and
Fowler, where the spinal cord was sutured after division, with at least
partial recovery of function. In Harte’s case the operation was done
three hours after injury; in Fowler’s case ten days had elapsed. Fowler
used chromicized catgut sutures in the cord itself, with separate
sutures of the dura with the same material, the principle here being
the same as in nerve suture, and the effort being to do as little harm
as possible with the needle and the suture material. After a simple
division there is but little tension, and the ends of the cord are
easily approximated.

It has thus been proved that there is at least some possibility of
regeneration of the cord after such destructive lesions; but the cases
which permit of or justify this measure will be rare, although it is
gratifying to learn that there has been so much encouragement afforded
by experiences reported.


THE SPINAL COLUMN.


SPINA BIFIDA; SPINAL MENINGOCELE.

Spina bifida is the result of a congenital defect in the construction
of the spine with incomplete closure of the spinal canal. The defect
lies in the posterior arches of the vertebræ; the bodies are rarely
involved. For this reason these lesions are centrally placed, _i.
e._, in the middle line. The essential feature of a spina bifida is
protrusion of the spinal membranes, and they are, to all intents and
purposes, spinal meningoceles. These tumors sometimes have only the
thinnest of skin coverings; at other times they will be covered by
considerable masses of overlying fat or fibrous tissue.

These congenital tumors when more definitely described should be
classified as--

1. _Meningocele_, where there is simply a protrusion (hernia) of the
dura, which may be lined with some branches of the vertebral nerves;

2. _Meningomyelocele_, where some portion of the spinal cord proper is
included within the sac;

3. _Syringomyelocele_, where the central canal of the cord is dilated
into a cyst of some size, over which the structures of the cord proper
are more or less thinly spread out, the whole being covered with the
spinal dura.

The first form is by far the simplest and most amenable to treatment.
The other forms are much more serious, and the third form is hopeless
so far as operative surgery is concerned.

The greater proportion of these cases occur in the lumbar region, at
least 70 per cent. being met with in the lower region of the spine,
including the sacrum. It occurs occasionally in the neck and in the
mid-dorsal region.

Fig. 411 illustrates the general appearance of such a tumor. The
opening of communication may be very small or may involve the arches of
several vertebræ. So with the tumor itself, it may be small and almost
imperceptible, or it may attain almost the size of a child’s head. The
overlying skin is rarely absent; it is usually covered with a growth of
hair, and its presence in the region of the spinous processes, coupled
with the presence of any perceptible tumor, should cause suspicions of
the so-called _spina bifida occulta_.

[Illustration: FIG. 411

Spina bifida. (Bradford.)]

These tumors are situated in the middle line or very near to it, and
are compressible in proportion to the thinness of their coverings. When
small they can be collapsed by pressure, the same not infrequently
causing pressure symptoms, as the fluid is forced into the cranial
cavity, such as coughing, vomiting, vertigo, etc. If the fluid can
be easily expressed from the sac the opening may be regarded as
relatively large. If pressure makes no alteration in the size of
the growth the case should then be regarded as one where the small
original communication has been closed by natural processes. Some of
these tumors have more or less of a pedicle and others are broadly
sessile. The tendency is ever toward increase in size, being rapid or
slow according to the thickness of the protecting membranes and the
size of the opening. While spontaneous occlusion may occur there is
practically no spontaneous repair of the bony defect. _The surgeon
should beware of a tumor of congenital origin situated in or near
the middle line, anywhere from the root of the nose, over the head,
and down to the tip of the coccyx._ Such a tumor should be regarded
with suspicion until shown to be harmless. Many cases of spina bifida
are accompanied by other congenital defects, such as club-foot, or
hydrocephalus. Symptoms may or may not be present. When present they
will be of the paralytic type and affect those parts of the body below
the level of the growth. They are due to the involvement of the cord or
the nerves. The ever-present danger in such cases is of rupture with
escape of the contents, with its proportionate reduction of intraspinal
pressure, and the possibilities of infection, with rapid death from
meningitis. Inasmuch as some of these cysts have such thin walls that
transillumination is possible it will be seen how great may be this
danger.


=Treatment.=--Treatment should be made to meet the indications. Only
in cases which are deemed inoperable should some protection be relied
upon and worn. This may be afforded by a common surgical dressing or
by means of a plaster-of-Paris or waxed gauze. A molded shield may
be prepared and so arranged upon a band or girdle as to protect the
cyst from external harm. Efforts to reduce the size of the tumor by
pressure are futile and useless. The skin may be protected by covering
with collodion.

The _radical treatment_ of spina bifida should only be attempted
in favorable cases, but in such instances can be made exceedingly
satisfactory and successful. A tumor with a small pedicle may be
treated by ligation, the skin being divided by elliptical incisions,
the pedicle proper being surrounded by a chromicized or silk suture
and the sac then excised. When the pedicle is too large to be treated
in this way and yet not very large, it may be closed by sutures after
removal of the sac, and dropped downward into the spinal opening, and
the adjoining tissues made to close over it by buried and superficial
sutures. It is the larger and more sessile sacs which give rise to the
greatest difficulties. The attempt may be made to excise a greater
portion of the sac, to fold in its edges and to approximate these
with sutures of fine chromic catgut. The fold thus formed may be laid
downward and upon the spinal groove, the aponeurotic and other firm
fibrous tissues in the neighborhood being loosened sufficiently so that
they may be brought together by buried sutures, and the balance of the
wound closed. I have a number of times been able to introduce either
strips of metal foil or thin pieces of celluloid, or, better still,
ivory trimmed to fit the bony defect, and so arranged as to be sprung
into grooves made on either side of the osseous canal. If ivory be used
for this purpose the thin small sheets which are used by miniature
painters should be procured.

Such operations should be made at the earliest practical moment; in
infants especially, but probably with all young patients, the head
being maintained at a much lower level than the sacrum in order that
only the smallest quantity possible of the cerebrospinal fluid may
escape. I have also used a small amount of weak cocaine solution after
exposing the cord in the spinal canal, in order that reflex impressions
may be avoided so far as possible and shock thus prevented. With a
young patient the amount of cocaine to be thus used should not exceed
more than 2 or 3 Mg.

Osteoplastic methods have also been devised for the purpose and may be
practised in cases permitting them.

Many of these cases do not come to operation until the skin is
excoriated or ulcerated. It is exceedingly difficult under these
circumstances to make an aseptic operation. The subsequent difficulties
of maintaining asepsis should also be foreseen, especially when lesions
are located low in the spine and in little patients, as soiling from
diapers and discharges is so easy. After such operations oiled silk,
or gutta-percha tissue should be fastened around the pelvis by rubber
cement, in such a way as to make a water-tight covering for the deep
surgical dressings, and this line of junction should be scrutinized
frequently. These operations often give satisfactory results.


CYSTS AND COCCYGEAL TUMORS.

Many congenital tumors are met with about the region of the sacrum
and coccyx, some of which have the essential characteristics of
meningocele, while others are rather of the dermoid or embryonal
variety. Tumors of great size develop from the region of the coccyx,
and many are of interest to the pathologist.

True dermoids often begin to develop within the pelvis and then escape
therefrom in this vicinity, some of them containing soft epithelial
products, others being dense and hard. (See Figs. 72 and 73, p. 266.)

[Illustration: FIG. 412

Sacral cyst, showing defect in sacrum. (Warren Museum.)]

Every tumor of this general character and in this location should be
removed as early as possible unless it can be determined that it is
not only cystic but dangerously large. Of even these, however, it may
be said that to leave them is to expose the patient to more danger of
infection than is incurred during a legitimate surgical operation.
There should be, then, about such a case serious complications and
perplexities, which would tend to make a competent surgeon decline to
operate (Fig. 412).


SPRAIN OF THE SPINAL COLUMN.


=Concussion of the Spine; Railroad Spine; Litigation Spine.=--In 1866
Erichsen published a series of lectures dealing with “Certain obscure
injuries of the nervous system commonly met with as the result of
shock received in collisions on railways.” In 1875 he expanded these
lectures into his celebrated monograph on _Concussion of the Spine_, a
work which served first to arouse the greatest interest in a hitherto
neglected subject, and which has unfortunately served in later years as
a basis for many a damage suit. The injuries described by him may occur
as the result of railway accidents, hence the name often applied to the
condition which they cause--_railway spine_. Cynical observers have
noted the frequency with which these cases appear in court and have
stigmatized the condition with the name _litigation spine_. Erichsen’s
original work is now superseded by much better monographs, although
his clinical descriptions were full and complete. Nevertheless he had
no knowledge of minute changes in the nervous system and many of his
explanations were based upon theories then prevalent but now abandoned.

These injuries involve the spine as a whole, and the spinal column
is so firmly held together by powerful ligaments, and so abundantly
protected by muscular and aponeurotic coverings, that its contents
are exempt from injuries which would easily involve those of more
exposed joints. An injury which would cause serious disintegration
within the spinal cord must be so severe as to inflict other and
well-marked damage upon the surrounding structures. Consequently a
large part of the injury received consists in what may well be called
strain and wrenching of all of these component structures. These may
be accompanied by minute hemorrhages into the cord, with or without
laceration, while exudates may result therefrom which may press upon
the spinal nerve roots or cause adhesions within or without their
sheaths, all of which may lead to signs and symptoms which may persist
for a long time. But the theory to which too many have held in time
past, that a mere concussion of these parts, without other injuries,
can be followed by such extensive and durable lesions is not tenable.

Obviously these cases are of a character frequently to appear in court.
Unfortunately the signs and symptoms are so vague, so variable, and
the latter so subjective that opportunity is afforded for deception,
_opportunity of which both dishonest patients and dishonest lawyers
too frequently avail themselves_; this to an extent which has almost
brought the condition into disrepute among the better class of
practitioners and caused it to be in some sense neglected. That serious
lesions do follow injuries to the back is undeniable; that many of the
resulting conditions can be simulated is unfortunately too true.

Nervous demoralization and more or less chronic invalidism frequently
follow these injuries, producing symptoms which are mainly functional
and maybe grouped among the _traumatic neuroses_. These symptoms are
mostly ill-defined, often contradictory, and accompanied by very few
objective features.

If _malingering_ can be excluded the best way to regard these clinical
pictures is to consider them as indicating a _traumatic neurosis_--that
is, a nervous disturbance, with perversion rather than abolition
of function, comparable with similar conditions from other causes.
As Angell has said, its symptomatology is largely built up of the
emotional features, with such grotesque nervous disturbances as to be
quite inconsistent with any true organic malady. In the latter there
will always be definite indications with positive changes and normal
reactions, while each segment of the spinal cord will have its own
definite features. Quite the reverse is the case in a so-called railway
spine, where paralyses are incomplete, where loss of sensibility
fails to correspond with anatomical relations, where the reflexes are
contradictory and the complaints out of all proportion to the injury
received. Such a condition is, therefore, a psychosis or neurosis
rather than a somatic disease. (Angell.) As a mental perversion it
is often dependent upon the dominating influence of an imperative
conception, which may or may not have an honest basis. Even if a
patient be not tempted to malinger or simulate, his troubles may be
exaggerated by expectant attention, which of itself has nothing to
do with the injury, but rather with his mental attitude. This is a
predominant feature of those cases which go to trial, and while it may
persist after a settlement is reached, it should be admitted that the
morbid condition usually subsides when litigation is terminated.

These imperative conceptions are intensified by emotion, fear,
sympathy, or anxiety, while attention becomes more and more
self-centred, the condition finally terminating in a more or less
self-induced hypnotic state--a species of autosuggestion. Similar cases
of non-traumatic origin are frequently observed, which are then called
neurasthenia or hysteria. When in an individual already neurasthenic
injury occurs it almost invariably produces exaggerated symptoms.
To use Angell’s own expression: “Railway spine is a convenient and
picturesque term which hypnotizes juries, even as shock has hypnotized
patients. It is dramatic, but not accurate. The damage is not to the
spine nor to the spinal cord, but to the mind. It is a psychical
disorder, not a physical one, although it has a physical expression in
its symptomatology.”


=Treatment.=--Viewed in this light it will be seen that there is the
greatest value attaching to physiological rest, beginning immediately
after the injury and continuing until the subsidence of the symptoms.
This should be combined with measures which improve elimination and
nutrition. Confinement to bed or the room will reduce elimination,
which should never be allowed to decrease in any way. Bodily and mental
rest, combined with the above features, followed later by massage,
cold spinal douche, electricity (either for its actual or suggestive
value), and mental encouragement, constitute the principal methods of
treatment. A case of this kind tinctured by a hope of securement of
ultimate damages will be not only resistant but difficult of successful
treatment.


INJURIES TO THE SPINE.

The principal injuries to the spine proper to be considered here
consist of:

  1. Fractures;

  2. Dislocations, or their occurrence together;

  3. Injuries to the cord and spinal column;

  4. Rupture or injury of the muscles, ligaments, and aponeuroses.


FRACTURES OF THE SPINE.

[Illustration: FIG. 413

Fracture of body of the vertebra. (Warren Museum.)]

[Illustration: FIG. 414

Crush of cord and its membranes. The result of a fracture of the spine.
(Erichsen.)]

The spinal column is so strongly put together and its bones so
protected that fracture of any one of its component parts is
inconceivable except as a result of violence. This may occur by
objects falling upon it or by the body falling a distance, or from
violent twisting or wrenching. These injuries constitute but a small
percentage--about 3 per cent.--of all fractures. They occur more easily
and commonly in the upper portion than in the lower, where the vertebræ
are larger. As a result of their occupations adult males suffer much
more frequently than women or children.


=Diagnosis.=--The diagnosis of fracture of the vertebral column is
rarely difficult. The disability produced is instantaneous if the cord
itself be compressed. If the cord escape pressure there may be serious
symptoms, but without paralysis. The most serious feature, then, of
any fracture of the vertebræ is the amount of damage done to the cord
proper. The so-called gunshot fractures of the spine have already been
partially treated of above and in the chapter on Gunshot Wounds. They
constitute a somewhat different class of lesions, but have, in common
with those above alluded to, the actual fracturing of the bone and the
question of damage to the cord. In most respects they may be considered
with the non-penetrating injuries. Fractures of the spine, therefore,
may be divided into (_a_) fractures with injury of the cord, and (_b_)
fractures without such injury. In many cases it is difficult to state
whether the cord is crushed or simply more or less compressed by bone,
fluid, or exudate, until the spinal canal has been opened and explored.

When the cord is totally destroyed there will be total loss of
reflexes, with motor and sensory paralysis complete. (See Fig. 413.)

In some instances there is visible or palpable _deformity_. This is
by no means necessarily the case. It is more likely to be noted in
the upper portion of the column, where the vertebral spines are more
easily palpated. If sufficient time have elapsed there will often be
ecchymosis. The principal feature, however, of spinal fractures is the
_paralysis_, which results in most instances as above. Its careful
study is requisite both for minute diagnosis and localization of the
injury. _Paralysis, then, whether of motion or of sensation, along
with the condition of the reflexes_, deserves careful consideration in
each instance. It is of the greatest importance, because by it, rather
than by other causes, death is brought about in the majority of cases
which outlive the first twenty-four hours after injury. Even injury low
down, which causes paraplegia with loss of control of the bowels and
bladder, may terminate fatally in time, through an ascending infection
of the urinary passages, which may finally lead to pyelonephritis
and death. This has often occurred as the result of inattention to
precautions in the use of the catheter, and to carelessness on the
part of the patient. Death, then, may be caused by roundabout methods
of infection which have only accidental connection with the original
injury. Other cases die of septic infection in consequence of lack of
proper attention to bed-sores. Again, with cord involvement high up
in the dorsal region there is very likely to occur a rapid ascending
degeneration, by which, one after another, the roots of the phrenic
nerves are involved in their order from below upward, until finally
the patient dies of asphyxia from paralysis of all the respiratory
apparatus (Fig. 414).

Aside from such evidences as actual displacement of the vertebral
spines may afford the localizing diagnosis is made mainly by a study
of the paralysis. In regard to this paralysis it should be remembered
how it is produced from the very nature of the injury itself. That
occurring within from a few minutes to a few hours after the injury
is due to hemorrhage; that which occurs still more slowly is due to
exudate or the presence of pus; while a late paralysis may result
from poliomyelitis. The first form of paralysis may be produced by
hemorrhage either within the central canal (hematomyelia) or hemorrhage
within the membranes or structure of the cord itself (hematorrhachis).

There is another form of paralysis due to embolism which, however,
has but little to do with the ordinary injuries. The following table,
inserted by the courtesy of Dr. Dennis, will assist in localizing the
lesion by a study of these paralyses and reflexes due to spinal injury:

_Paralyses and Reflexes due to Spinal Injury._

    _Spinal_          _Motor_
    _Nerve._       _Paralysis._      _Anesthesia._       _Reflexes._

           {  1. Death from
           {     pressure of
           {     odontoid.
           {2-3. Death from
           {     paralysis of
           {     diaphragm.
           {  4. Deltoid muscles   Upper shoulder,   Pupil.
           {     of upper arm.     outer arm.
  Cervical.{  5. Supinators of     Outside of arm    Pupil, scapular,
           {     hand.             and forearm.      supinator, triceps.
           {  6. Biceps, triceps,  Outer half of     Pupil, scapular,
           {     extensors of      hand.             triceps, post.
           {     wrist.                              wrist.
           {  7. Pronators of      Inner side of arm Pupil, scapular,
           {     wrist, latissimus and forearm.      post. wrist, ant.
           {     dorsi.                              wrist, palmar.
           {  8. Flexors of wrist, Inner side of     Scapular, post,
           {     hand, muscles.    hand.             wrist, ant. wrist,
           {                                         palmar.

           {  1. Thumb.            Ulnar supply to   Scapular, palmar.
           {                       hand.
           {2-12. Muscles to back  Skin over the     Epigastric, 4-7;
  Dorsal.  {     and abdomen.      back and abdomen  abdominal, 7-11.
           {                       in areas corre-
           {                       sponding to
           {                       distribution of
           {                       spinal nerves.

           {  1. Psoas and         Groin.            Cremasteric.
           {     sartorius.
           {  2. Quadriceps ex-    Outside of thigh. Cremasteric,
           {     tensor femoris.                     patellar.
           {  3. Abductors and     Front and inside  Cremasteric.
           {     inner rotators of of thigh.
  Lumbar.  {     thigh.
           {  4. Adductors of      Inside of leg,    Gluteal.
           {     thigh, tibialis   ankle, and foot.
           {     anticus.
           {  5. Outward rotators  Back of thigh and Gluteal.
           {     of thigh, flexors leg; outside of
           {     of knee and       foot.
           {     ankle.

           {1-2. Muscles of foot,  Outside of leg.   Plantar.
  Sacral.  {     peronei.
           {3-5. Perineal muscles. Perineum, anus,   Ankle clonus.
           {                       sacrum, genitals.

Injuries low in the lumbar segments cause incontinence of urine and
feces because of the location of the centres for the rectum and bladder
at this level. Injuries higher up cause retention by paralyzing the
expulsive muscles of the abdomen. The reflexes which most interest the
surgeon and which are of importance to him in diagnosticating these
and other traumatic conditions are the following, with their method of
detection (Bradford):

  Pupillary:       Dilatation produced by pinching side of neck.
  Scapular:        Scratching skin over scapula causes muscles to
                   contract.
  Supinator:       Tapping tendon at wrist causes flexion of arm.
  Triceps:         Tapping tendon at elbow causes extension of arm.
  Posterior wrist: Tapping tendons causes extension of hand.
  Anterior wrist:  Tapping tendons causes flexion of wrist.
  Palmar:          Scratching palm causes flexion of fingers.
  Epigastric:      Stroking mammæ causes retraction of epigastrium.
  Abdominal:       Stroking abdomen causes retraction.
  Cremasteric:     Stroking inner side of thigh causes retraction of
                   scrotum.
  Patellar:        Striking patellar tendon causes extension of leg.
  Gluteal:         Stroking buttock causes dimpling in gluteal fold.
  Plantar:         Stroking sole of foot causes flexion and retraction
                   of leg.
  Ankle clonus:    Forcible extension causes rhythmical flexion.

Much will depend upon the minute character of the injury, its location,
and the amount of displacement of fragments. Fracture of a spinous
process causes irregularity of the tips of the spines, with frequently
the displacement of a fragment which may be moved beneath the skin,
with or without crepitus. Fracture of one or both laminæ will permit
mobility of the spinous process, with perhaps displacement. It is
difficult to elicit crepitus. The neural arch may thus be broken
without serious involvement of the body of a vertebra. On the other
hand, the body itself may be fragmented, compressed out of shape, or so
loosened as to permit of easy displacement.


DISLOCATION OF THE SPINE.

A limited proportion of serious and paralyzing injuries to the spine
consists of dislocation of some of its component parts without
fractures. These may be considered as pure types of dislocation,
but they constitute less than one-fourth of such cases. In a large
proportion of these spinal injuries the actual lesion consists of the
combination of fracture with the displacement which it permits. Such
conditions are referred to as _fracture dislocations_. Unilateral
dislocation in the cervical region produces a distortion of the neck
simulating wryneck, the face being turned to the opposite side. Except
in very fat individuals irregularity will be perceived in the line
of the cervical spines. When high up dyspnea is a constant feature.
Traumatic dislocations are sharply differentiated, so far as the
treatment is concerned, from those of slow production as the result of
cervical spondylitis. In the acute cases the muscles are spasmodically
contracted on the dislocated side. Irregularity of contour may be
detected with the finger in the pharynx.

[Illustration: FIG. 415

Fracture dislocation with great displacement--patient almost completely
recovered. (Buffalo Museum.)]

In the lower portions of the spine, which are both larger and more
protracted, are more frequent combinations of both injuries and fewer
instances of the single type of either. Except in the cervical region
it is exceedingly difficult to distinguish between these lesions, for
the question of operation or no operation is decided by other and more
conspicuous features (Figs. 416 and 417).

[Illustration: FIG. 416

Dislocation between the fifth and sixth cervical vertebræ. (Erichsen.)]

[Illustration: FIG. 417

Dislocation of the spine forward (Bryant.)]


=Treatment.=--The injury having been localized, so far as deformity
and careful study of its paralytic features will permit, the questions
of prognosis and treatment become insistent. In the pure type of
dislocation the prognosis will depend, first, upon whether reduction
can be accomplished, and, secondly, upon the amount of damage suffered
by the cord previous to such reduction. Every injury of the cervical
spine is of most serious import because of the possible damage to the
phrenic nerves. Rapidly ascending changes may terminate life in two
or three days even though reduction be accomplished. The injuries to
the lower part of the spinal column which produce paraplegia threaten
life much less directly, but too frequently terminate fatally after the
lapse of weeks or months, as the result of infections from spreading
bed-sores, or infections through the urinary tract permitted by the
constant necessity for and carelessness in the use of the catheter. The
prognosis, then, in almost every case of these severe spinal injuries
is unfavorable, at least if it be let alone (Fig. 415).

It becomes, then, a question of what can be done to improve the local
conditions. Certain cases of cervical spinal dislocation have been
reduced by forcible traction upon the head, assisted by rotation
and manipulation with the hands in the direction indicated by the
displacement of the patient’s head, as well as by such indications as
may be secured in the pharynx. A considerable degree of traction may
be necessary in this effort, and there is the possibility not only of
failure but even of serious harm, and perhaps immediate death, since a
fragment loosened may be made to produce promptly fatal pressure upon
the cord. Such a measure, then, should be undertaken with the greatest
care, and not without a complete understanding with those interested
regarding its dangers (Fig. 418).

[Illustration: FIG. 418

Method of reducing dislocations of the cervical vertebræ by
manipulation. (Lejars.)]

In most cases it is impossible from the exterior to estimate either
the damage to the cord or the amount of fluid outpour until the spinal
canal be opened. If there be complete loss of reflexes, with absolute
insensibility and motor paralysis, then complete transverse destruction
of the cord may be inferred. In these instances it may be decided not
to operate. On the other hand it may be felt that unless the damage
appear irremediable an open operation for inspection and relief should
be performed at the earliest possible moment, since pressure on the
cord allowed to persist even for a few hours causes damage for which
there is no compensation. These cases may then be viewed in this
light--if left to themselves they are almost hopeless. It therefore is
a question simply of what can be accomplished by operation. On one hand
the patient’s condition _may_ be materially improved; on the other it
is scarcely possible to make him worse. The dangers of such operations
inhere especially in the anesthetic and in the possible introduction of
sepsis; not that the operation itself cannot be properly conducted, but
that it is often difficult to keep these cases free from contamination
during the subsequent course of events. To operate through bruised or
infected skin would probably be fatal. These operations, then, are
begun as explorations intended to reveal deep conditions. When one has
freed the spinal cord from pressure and has removed the products of
hemorrhage he has done nearly all that can be accomplished in such a
case.

Until recently it has been supposed that complete transverse division
or crushing of the cord was necessarily hopeless and fatal. As
previously mentioned, Estes, Harte, and Fowler have reported instances
of complete division of the cord, with subsequent approximation by
suture and with at least partial restoration of function, that have
lent an element of hope to cases previously regarded as hopeless.

For my own part, although I regard these cases as discouraging, I
do not feel like withholding from patients the only possibility of
improvement which can be offered them, but I am more and more impressed
with the necessity for prompt intervention if this benefit is to be
obtained. To wait a few days, then, until it has been made evident that
nothing can be done, save by operation, or until a tardy consent is
obtained, is to rob the patient of the hope which it may afford. The
operative treatment should be begun immediately after the diagnosis
is made, providing that this be promptly done. Delay is more than
inexpedient--it is absolutely dangerous. As Burrell has pointed out
it is scarcely fair to decide upon a course of treatment from a study
of statistics alone, as lesions vary within widest limits, as do also
results of individual operators. Let each case, then, be decided upon
its merits, _but let whatever is done be done promptly_. If there be
excuse for delay it is in those cases where paralysis is incomplete and
where the cord apparently has not been seriously compromised. But these
would afford the most promising results after operation.

The operation itself will be described at the conclusion of this
section, and in connection with other operations practised for exposure
of the cord when involved in other lesions.


HEMATORRHACHIS AND HEMATOMYELIA (INTRASPINAL HEMORRHAGES).

These occur, as do hemorrhages within the cranial cavity, with or
without serious other lesions of the investing structures. They are
expressions, of course, of transmitted violence, depending so far as
known essentially upon injury, whether the hemorrhage occurs within the
central canal of the cord, within its structure, or within the subdural
or even extradural spaces. Everywhere within these regions bloodvessels
abound, from which may occur sufficient outpour of blood to make
pressure upon the cord to a degree producing complete paralysis. The
duration of time between reception of injury and the occurrence of
diagnostic paralysis will be to some degree a measure of the rapidity
of such outpour, while a study of the paralyses themselves will permit
of localizing the injury. The symptoms consist mainly of pain in the
spine radiating to some distance, often referred to the distribution of
the nerves most involved. This pain is often associated with muscular
spasm, while paralysis may be a very early or somewhat tardy symptom.


=Treatment.=--Once the fact of pressure upon the cord is established
these cases come under practically the same rule as above. While there
is a possibility that a moderate amount of bloody outpour might be
absorbed there is nearly as much danger of its organization and of
permanent involvement of the cord. In fact there is more reason for
operating in cases of spinal hemorrhage than in cases of fracture,
since it may be possible to thereby accomplish more.

The _non-operative treatment of fractures or dislocations_ consists
mainly in external support, preferably by a plaster-of-Paris corset
properly applied, and by maintaining elimination and nutrition, while
affording physiological rest for a sufficient length of time. These
cases will need massage and electricity, _i. e._, stimulation of
the compromised muscles, and _extreme care should be given to the
prevention of bed-sores_, to which they are peculiarly liable. _Every
precaution should be taken also against any possible retention of
urine or feces. The incontinence of an overdistended bladder should
not be mistaken for that of paralysis of its sphincter apparatus._
The specimen of dislocation from which Fig. 415 was taken was removed
from a patient who almost completely recovered from the effects of the
injury, but who became careless about the condition of his bladder and
who suffered an ascending urinary infection that terminated his life.

Of these cases it may also be said, then, that a much better prospect
of exact diagnosis and atonement for harm done is afforded by
exploration, since as between compression of the cord by clot or by
bone there is little essential difference.

The subjoined table may afford assistance in the diagnosis of the
injuries above considered:

_Differential Diagnosis of Diseases and Injuries of the Spine and
Spinal Cord._

                           _Fracture._   _Dislocation._ _Hematomyelia._

  _Onset._                Immediate.     Immediate.     Immediate.
  _Anesthesia._           Immediate.     Immediate.     Immediate.
  _Paralysis._            Hemiplegia or  Hemiplegia. In Paraplegia.
  (Is of hemiplegic type  paraplegia.    partial dis-
  when compression is                    location may
  unilateral, paraplegic                 be absent.
  when bilateral, and
  local when single nerve
  roots are involved.)
  _Deformity._            Usually        Present.       Absent.
                          present.
  _Temperature._          Rises after    Same.          Same.
                          second or
                          third day.
  _Bowels and Bladder._   Paralyzed.     Paralysis      Same.
                                         usual.

                          _Hematorrhachis._  _Acute Poliomyelitis._

  _Onset._                Progressive.       Slow.
  _Anesthesia._           Incomplete.        Absent.
  _Paralysis._            Hemiplegia or      Paraplegia.
  (Is of hemiplegic type  paraplegia.
  when compression is
  unilateral, paraplegic
  when bilateral, and
  local when single nerve
  roots are involved.)
  _Deformity._            Absent.            Absent.
  _Temperature._          Same.              Precedes the paralysis of
                                             degeneration.
  _Bowels and Bladder._   Affected late if   No paralysis.
                          at all.


COCCYGEAL OR PILONIDAL SINUS.

In the neighborhood of the coccyx, usually below its tip, between it
and the anus, sometimes above the tip, a small depression or sinus
mouth is occasionally seen. This is usually known as the _pilonidal
sinus_. It is the persistent remnant of the original fetal termination
of the spinal canal. It varies in size from a mere dimple to a
cul-de-sac, in which sebaceous matter, with any other epithelial
products, hair, etc., as well as foreign material and dirt from the
skin, may collect and excite suppuration. In this way an abscess of
considerable size may form. Sometimes its contents will be found to be
principally hair; hence the name pilonidal. Frequently this sinus can
be traced down to the periosteum and into the remains of the original
neurenteric canal. When it is distended so as to give trouble it needs
only to be freely incised and thoroughly cleaned.


CONGENITAL COCCYGEAL TUMORS.

In the region of the coccyx and lower part of the sacrum there appear
tumors of congenital origin which are often present at birth or may not
develop until later. These assume various sizes and aspects, varying
from mere protuberances to large pendulous tumors. While covered with
integument their internal structure varies within wide limits, and
they are usually made of such a mixture of embryonal elements as to
entitle them to be considered true teratoma. Even organized tissues or
rudimentary organs may be found therein. They are rare and constitute
practically surgical curiosities. Such a tumor, if troublesome,
calls for removal, which should be accomplished with the strictest
precautions, as the spinal canal may perhaps be opened during the
procedure and most inflammable tissue thus exposed to infection from
the perineum.

The sacrum, like the coccyx, is also the site of numerous congenital
cysts and tumors which may appear posteriorly or anteriorly.
Occasionally they form within the bone itself. Cysts that connect with
the spinal canal will be found filled with cerebrospinal fluid, and
some of them are essentially _spina bifida occulta_. The sacral region
is also the site of predilection for those teratomas which consist in
whole or in part of vestiges of an attached fetus. The advisability of
operation must be determined for itself in each of these cases. (See
Fig. 412, p. 627.)


COCCODYNIA; COCCYGODYNIA.

Under this name are included severe and chronic neuralgias of the
coccygeal region, including its joint, which occur most often in women,
and usually as the result of contusion or direct injury. Occasionally
it results from an injury inflicted during parturition. It gives rise
to a degree of pain and tenderness which sometimes is almost disabling.
Because of the insertion of the levator ani into the tip of the coccyx
defecation may become distressing, to an extent which leads to fecal
impaction in the rectum from postponement of evacuation as long as
possible. The symptoms are subjective, but the tenderness is frequently
exquisite.

In regard to treatment subcutaneous division of the tissues around the
bone may afford relief, but in most instances, particularly those of
traumatic origin, an excision of the coccyx will afford the only cure.
(See below.)


OPERATIONS ON THE SPINE.

These are included under the general heading _laminectomy_, which is
used in a comprehensive sense, as is also the term trephining.

In a general way the measure is about as follows: Through a long median
incision over the spines of the region where the lesion is localized
their tips are exposed, while the muscle groups on either side and
posterior to the laminæ are separated by the knife and by retractors.
Dense fibrous bands may be nicked. In this way the posterior aspect of
the neural arches is exposed to the desired length. The exposed spines
should be removed by cutting them off at their bases with bone forceps,
although they may be left and later removed with the posterior bony
arches. To clear them away, however, affords a better view of the field
of operation. The ligamenta subflava are then divided transversely
at their upper and lower margins, after which, either with cutting
forceps, saw, or chisel, the laminæ are divided on either side, and the
section which is loosened pried out from the bed in which it rests.
More or less fatty tissue will be found outside of the dura and in this
tissue veins, sometimes of considerable size, freely ramify. These may
be seized and divided, those of considerable size being tied. Great
care should be given during the procedure to avoid perforation of the
spinal membranes by the points of the instruments used. The cutting
forceps are preferable to the saw or chisel, except for work in the
lower lumbar region, where the parts are stout and strong. Especially
in case of fracture, and at the upper end of the spine particularly,
care should be given, with the force used, that no loose fragment be so
handled as to increase the damage already done to the cord.

The dura being thus exposed and the blood cleared away, inspection may
or may not reveal the nature of the lesion. A probe, gently handled,
passed upward and downward into the canal, will reveal whether the
cause of the pressure has been cleared away or not. According to
the nature of the lesion it can then be decided whether to open the
dura. To open it is to pave the way for fatal infection, unless the
strictest aseptic technique has prevailed. On the other hand, to leave
it unopened is to fail to appreciate the actual condition of the cord
and to leave an important matter still undetermined. The dura if opened
should be closed by suture.

Reference has already been made, in three cases now on record,
to suture of the cord as a whole. Such sutures may be applied,
if necessary, in a manner to do the least possible damage to the
structures of the cord. If cerebrospinal fluid escape too freely the
patient may be operated in a position with the head lower than the
trunk, avoiding leakage.

_Osteoplastic methods_ of temporary resection of the posterior arches
of the vertebræ have been devised and practised, but they offer no
particular advantages, and are attended by disadvantages which have
caused them to be almost abandoned, save in rare instances and by
individuals of large experience. (See Plate XLVII.)

In regard to wiring fragments of a fracture or displaced spine, Hadra,
of Texas, was perhaps the first to carry out the measure. It comprises
simply the fixation of fragments by wire sutures or ligatures which
bind them together after they have been replaced through a more or less
open wound, such as is included in the term laminectomy. But resort to
wire is to be left to the judgment of the operator and the needs of the
case. There is no reason, however, why it may not be used here, as in
other fractures which are thus made compound, if there would seem to be
prospect of benefit attaching to its use.

[Illustration: PLATE XLVII

Osteoplastic Resection of Posterior Vertebral Arches. (Urban.)]

_Laminectomy_ is practised also in _Pott’s disease_, with the hope
of relieving pressure upon the cord, due to the deformity or to the
presence of tuberculous foci. It is possible that in some of these
cases an incomplete operation will serve the purpose. Sufficient should
be done, however, to relieve pressure if such a measure be indicated.

When laminectomy is practised for the purpose of attacking a _tumor
of the spinal cord_ the exposure of the cord should be followed by
the removal of the tumor. Some of these are so placed as to make
the procedure simple, while at other times it will be exceedingly
difficult, if not impracticable. If the growth has so extended as to
involve the bones themselves, then the measure will be futile and
should be abandoned; but an isolated tumor, either within or without
the dural space, in or on the substance of the cord, can usually be
removed by a process of blunt dissection. Sometimes the small wounds
thus made will ooze considerably and hemorrhage may prove troublesome;
it should be checked before the parts above it are closed. Pressure
forceps and ligatures and the occasional use of adrenalin solution will
afford the necessary means for combating bleeding.

For nearly all of these operations upon the spine the chisel and the
cutting forceps will suffice. Some operators, however, prefer a small
saw, like that suggested by Doyen, which has a guard that can be so
set as to determine the depth to which the instrument may pass. No
matter what instrument be used, great care should be taken lest it pass
through and beyond the bone in such a way as to lacerate the dura or
the plexus of veins outside of it.

The _sacrum_ is rarely attacked except in connection with some of those
tumors already described.

The _coccyx_ is easily removed through a median incision, the parts
around it being entirely separated and the bone thus freed removed at
the joint with stout scissors or cutting forceps. The instruments used
should be kept in contact with the bone and not allowed to injure the
veins between it and the rectum. Such a wound should not be closed
completely, as a cavity always remains, which it is better to pack and
permit to heal by granulation. (See Coccodynia.)




CHAPTER XXXIX.

THE FACE AND EXTERIOR OF THE NOSE AND MOUTH.


Monsters are born with almost complete absence of the face, which is
called _aprosopia_. They have also been observed with double faces.
Again a condition of congenital hypertrophy is known involving one or
both sides. On the other hand congenital atrophy is also occasionally
noted, affecting one or both sides. The former is likely to be of
syphilitic origin (hereditary), in which case it will be accompanied by
other indications such as corneal opacity, irregularity of teeth, or
other evidences of its luetic origin.

Among the most interesting congenital defects are those connected with
_imperfectly closed branchial fistulas_ and the various outgrowths
therefrom. These may lead to fissures extending from the ear to the
mouth. Fibrocartilaginous growths occur along the regions of the
original branchial clefts, either as tags of skin upon the face or
so-called _supernumerary auricles_ or auricular appendages. While these
are covered with skin they usually contain a cartilaginous nucleus.
They are most common in front of or on the tragus. They may be single,
multiple, or symmetrical. They sometimes increase in size and at others
remain stationary.

Fissures are seen more often upon the central portions of the face,
especially in the nose or between it and the cheek. About the root
of the nose and the orbit dermoids are somewhat common. They may be
connected with fissures or fistulas, and extend upward and involve the
dura.

Absence of the mouth is known as _astomia_, and of the lips as
_acheilia_. These malformations are exceedingly rare. Atresia, or
narrowing of the mouth, is more common. While the lips and mouth may be
apparently well formed there may be imperfections. These conditions of
narrowing call for division on each side and union of skin to mucous
membrane. _Fistulas of the lip_ are extremely rare, but are found
occasionally, especially opening upon the lower lip. Branchial fistulas
opening upon the lips have also been observed.

A condition of arrest of development of one or both jaws leads to
unnatural smallness of the mouth known as _microstoma_. The opposite
condition, _macrostoma_, is produced usually by fissure of the cheek
on one or both sides, extending upward and backward from the labial
junction and due to incomplete closure of a branchial cleft. The
most common congenital defect of the lip known as _hare-lip_ is a
median fissure involving the upper lip. This occurs in all degrees,
from a trifling notch at the vermilion border to a hideous defect,
in which, through a wide cleft, projects a relatively overdeveloped
intermaxillary bone, with a small downward projection of skin, known
surgically as the philtrum. This defect may involve much more than
the lip alone, for there may be failure to unite, along the median
line between the lip and the uvula, of those portions of the superior
maxillary which should develop symmetrically, and coalesce as they are
formed from the rudimentary maxillary processes. Any portion, then, of
the hard or soft tissues may show failure to unite in the middle line.

Hypertrophy of a lip is known as _macrocheilia_. It is not uncommon in
strumous subjects. Another form is known as mucous ectropion. (See p.
373.)

The chin may be malformed in the direction either of atrophy or the
reverse, as in the so-called double chin. A deviation forward, known as
_galoche chin_, is also recognized. A peculiar malformation, consisting
of the implantation of a supernumerary inferior maxilla by its own
symphysis upon that of the subject, is known as _hypognathy_. Such
a tumor will occasionally develop to considerable size, with cystic
degeneration or other irregular changes.

Aside from the common forms of hare-lip most of the congenital defects
that occur about the face are to be explained through incomplete
closure of the branchial clefts or the development of dermoid cysts
and tumors therefrom. Deviations rather than defects appear more
commonly about the nose than anywhere else. They produce disfigurements
known as pug-nose, saddle-nose, parrot-nose, etc. Again, double noses
exist, each being more or less well formed. In such a case the surgeon
should endeavor to remove a part of each and unite the remaining
portions in one, unless one of them be placed away from the middle
line, in which case it may be extirpated.


ACQUIRED MALFORMATIONS OF THE FACE.

These are usually the result either of mutilation or of some ulcerative
morbid process. Injuries of the face, unless extremely carefully and
promptly attended to, are commonly followed by scars, which may cause
great disfigurement. This is invariably true of severe burns, which, by
subsequent contraction, draw features badly out of shape, and sometimes
close the mouth or pull the lower jaw down upon the neck and the chin
upon the chest. Serious contused wounds are frequently accompanied
by fracture of parts beneath, and should be treated as a compound
fracture. Considerable portions of the facial mask are sometimes torn
away, producing hideous appearances. By punctured wounds the maxillary
sinus, orbit, or brain cavity may be perforated and foreign bodies
carried in. A wound may be so placed as to sever Stenson’s duct. All of
these injuries may be accompanied by serious brain disturbance, as the
result of the contusion. Gunshot wounds will present either punctures
or extensive lacerations, according to the proximity and the weapon.
In no part of the body are gunpowder stains more observable or more
deplored than upon the face. In order to prevent them each grain of
powder must be picked out with a small spud or needle, after a careful
scrubbing of the face. Every grain of gunpowder allowed to remain will
produce a minute area of staining.

Injuries to the nose may require plastic reconstruction or the
formation of a new nose by one of the rhinoplastic methods later
described, or an artificial nose, carried by spectacles, may be worn.
The cartilages of the nose are frequently dislocated, thus producing
deformity, and the same result may follow fractures. As already
indicated in the chapter on Fractures, prompt and complete replacement
with support are usually sufficient to give a satisfactory result.

Deviations of the nose, and especially cosmetic defects which result
from injuries or disease, producing the so-called saddle-nose, when
not extreme, may often be remedied by the injection of paraffin, the
patient being either under cocaine or general anesthesia.

Burns, injuries, and serious ulcerations about the cheeks and lips
produce conspicuous disfigurement (perhaps none more so than a serious
form of cancrum oris) with a considerable loss of substance. In this
way may be produced an acquired microstoma, or adhesion of cheek to
jaw, which is known as _syncheilia_. More superficial lesions may
produce ectropion or eversion of the lips, or acquired macrostoma.
Cretins, idiots, and patients with facial paralysis acquire gradually
a chronic swelling of the lower lip with drooling of saliva. The lip
may enlarge to such an extent as to ulcerate as the result of exposure.
_Frostbite_ also produces serious deformity by ulceration of the skin.
When a puncture of the cheek occurs at the opening of Stenson’s duct,
_i. e._, opposite the second upper molar tooth, there may occur a
salivary fistula. In a recent clean wound the duct ends may be stitched
together. In old wounds Souchon recommends to introduce catgut into
the distal end, and then by pressure on the parotid to discover the
proximal end and stitch it with the catgut in the divided portion; or
the wound may be enlarged and the proximal end turned into the mouth
and there retained.

Considerable emphysema may follow contusions of the face, especially
those causing fracture of the nose. In this way a face may be so
distended as to produce almost a caricature of its former appearance;
this, however, will subside within a few hours.

By virtue of its extreme vascularity wounds and injuries of the face
heal with a surprising degree of promptitude and certainty. This
affords the reason for the satisfactory results of extensive plastic
operations. For the same reason secondary hemorrhages may easily occur
and additional precautions should be taken. Exact hemostasis, before
closure of wounds, will afford protection as against this event. Wound
edges should be neatly trimmed and _subcutaneous sutures_ may often be
used to advantage to minimize the resulting scars. A lesson “how not
to do it” may be learned from the faces of German university students
who have indulged in the common but senseless sport of duelling, and
who are said to rub salt and alum into their cuts in order to make the
scars as conspicuous as possible.


NEUROSES AND CONSEQUENCES OF INJURIES OF NERVES OF THE FACE.

Anesthesia of parts supplied by the trifacial necessarily follows
division of its various portions. It may also occur as the result
of a deep-seated or central lesion. In course of time more or less
sensibility will return, apparently due to an anastomotic process.
_Facial paralysis_, so-called Bell’s palsy, may be of central origin,
or be due to the effects of a “cold” following exposure, apparently
with inflammation of and an exudate around the trunk of the facial
nerve as it passes through its bony canal in the temporal bone. It
is also the result of a division of the nerve trunk either outside
of the bone or in the bony canal, where it is occasionally wounded
in operations upon the mastoid or in removal of the parotid for
malignant tumor. _Facial neuralgia_ is an affection of one or more of
the branches of the fifth nerve, and, when assuming a spasmodic and
intermittent type, is often spoken of as _tic douloureux_. Its exciting
cause may be a carious tooth, even though it give no pain, while other
causes are lesions in the neighborhood, such as callus, foreign bodies,
tumors, bone disease, and the like. Its special treatment has already
been indicated in the chapter dealing with the Cranial Nerves. Many of
these cases of neuralgia gradually diminish the patient’s strength.


ULCERATIVE AND GANGRENOUS LESIONS OF THE FACE.

The serious ulcerative lesions of the face are usually due to
_tuberculosis_, _syphilis_, or _malignant disease_. In all of these
conditions there will be enlargement of the neighboring lymphatics.
This is true also of the lesions of _actinomycosis_, which should
not be forgotten as a possible cause. The free border of the lips
is occasionally ulcerated in patients with pulmonary tuberculosis.
Otherwise tuberculous lesions are uncommon upon the lower lip, while
in the upper lip they show a tendency to invade and spread. Syphilitic
ulcers may be either primary chancres, which are most common on the
lower lip, or the results of mucous patches, or other secondary or
tertiary lesions. Of the cancerous ulcerations, which tend always to
break down and spread, without any tendency to healing in the centre,
_epithelioma_ is the most common form. It is a frequent disease in men,
occurring much oftener on the lower than upon the upper lip. In women
it is exceedingly rare at this point. The difference is explained by
the liability to constant irritation incurred by those who smoke pipes
or are particularly careless about their teeth. Of epithelioma there
are, as is well known, various types, including the so-called rodent
ulcer, which, however, is less frequent here. The location of the
lesion subjects it to constant irritation, as well as maceration from
the moisture of the mouth. Such a growth may be superficial and raw,
or it may be covered by scale or crust. It will nearly always have an
indurated and raised periphery. A papillary form, with non-indurated
edges, is also known, as well as a diffuse form, where several minute
lesions seem to coalesce, with elevation of the central portion.
This is perhaps the most malignant of all, as it has no well-defined
boundaries. In nearly every well-marked case involvement of the
submaxillary lymphatics can be detected. All of these cancers of the
lip and face should be removed, with plastic re-arrangement of the
parts. Growths of this kind seen early, before much tissue is involved,
can be removed with permanent success. Error is made on the side of not
doing sufficient rather than doing too much. (See Chapter XXVI.)

_Cancrum oris_ has already been described in the chapter on Gangrene.
The extensive destruction which it may cause is also described there.
The condition, when seen and recognized early, has been successfully
treated by local applications of bromine and the actual cautery. It is,
however, a destructive and unpromising condition with which to deal,
as it rarely occurs in healthy children, but usually in those with a
constitution already vitiated by heredity or environment. (See p. 75.)


TUMORS OF THE FACE.

The parts described in this chapter may be the site of almost every
tumor which is met with in any other part of the body; in addition
to which there are two which are peculiar to the nose and adjoining
tissues. These are _rhinophyma_ and _rhinoscleroma_. They have both
been described briefly in the chapter on Tumors, and each is to be
differentiated from the other, having a very different etiology.

_Rhinophyma_ consists of vascular engorgement, with hypertrophy,
especially of the glandular and connective-tissue elements of the
skin, which begins about the tip and the alæ of the nose, and produces
disfiguring deformity. It is, however, at first, quite innocent in
its character. It occurs most often in hard drinkers, and is to be
regarded as an overgrowth, coupled with a large amount of secretion,
of the sebaceous glands of that portion of the skin. This secretion
is often so great as to escape and lead to the formation of scabs,
as it dries, until more or less ulceration takes place. The nasal
enlargement is rarely symmetrical, and is nearly always lobular, so
that the overgrowth may consist of a series of nodules whose escaping
secretion becomes offensive. The parts are often discolored, even to a
purplish color, in consequence of venous stasis. Frostbite frequently
predisposes toward it.

[Illustration: FIG. 419

Plexiform angioma of face; cirsoid aneurysm. Not benefited by ligation
of external carotid. (Lexer.)]

[Illustration: FIG. 420

Illustrating ravages of rapidly growing vascular sarcoma of face,
involving all the cranial and facial cavities. (Lexer.)]

Treatment in incipient cases may consist of a sort of massage, by
which the overloaded glands are emptied. In more serious instances the
diseased tissue should be extirpated, and either left to granulate or
be covered by a plastic operation.

_Rhinoscleroma_ is a serious and fatal lesion, consisting of a
parasitic invasion by a peculiar bacillus. It begins as a painless
induration, either at the edge of the nostril or upon the upper lip,
grows slowly, the tissue affected becoming firm and dense. The growth
is usually lobulated, with fissures or excavations between the lobules,
which may crack and give rise to a yellowish discharge that dries
into crusts. While the affection may begin in the deeper parts of the
nasopharynx its occurrence there is usually the result of extension
from the anterior growth. The disease may occur either in the young or
in the adult. A case illustrated elsewhere (see p. 55), for which I
am indebted to Dr. G. W. Wende, proved fatal after a couple of years.
In this country it is rare, but occurs frequently in some portions of
Russia.

For treatment there is but little encouragement, least of all for
operative intervention. Growths nearly always recur after removal.

In the cheek _cysts of Stenson’s duct_ and _dermoid_ tumors and cysts
have often been observed near the parotid region. The so-called “fatty
ball of Bichat” is occasionally the site of an angioma, which may
press upon Stenson’s duct and be accompanied by calculus in the parotid
gland, the superficial veins being much dilated. (Souchon.)

Fatty tumors, as well as sarcoma in this same tissue, are prominent.
The most frequent tumors of the face are the _epitheliomas_ of the lip,
nearly always of the lower lip, occurring oftener in men than in women.
A growth of this character at this site is regarded as an expression
of the result of irritation, which may be produced by a carious tooth
or by constant friction of a pipe-stem, or from many other causes.
It frequently develops at the site of an old chronic fissure. These
growths spread from small beginnings, and if, when small, they were
extirpated there would be fewer cases of cancer of the lip spreading
to and involving the face and neck. Every ulcer of the lip whose
base becomes indurated, and from which the syphilitic element can be
excluded, should be excised, the ensuing defect being repaired by a
plastic operation. (See above.)

[Illustration: FIG. 421

FIG. 422

FIG. 423

FIG. 424

FIG. 425

FIG. 426

FIG. 427

FIG. 428

FIG. 429

FIG. 430

FIG. 431

Utilization of rectangular flaps.]


OPERATIONS UPON THE FACE AS A WHOLE.

The tissues composing the face are extremely vascular, hence hemorrhage
is profuse and hemostasis should be exact. By virtue of this same
rich blood supply the process of repair is prompt and satisfactory,
if sources of infection be avoided. Patients here, more than anywhere
else, desire a minimum of scar. Incisions, then, should be so planned
as to permit the utilization of the natural folds or grooves of the
face. They should also be so made as to avoid injury to main trunks
of vessels and nerves, as well as to Stenson’s duet. Sharp knives and
the least possible bruising of the tissues help to ensure the desired
result. When possible a subcutaneous suture should be employed. When
this is not sufficient fine needles and fine suture material should be
used. A reasonably short, clean wound upon the face, especially in
the neighborhood of the mouth, should be protected from the air until
it is dry, using a dusting powder and then covering with collodion. In
extensive operations provisional or permanent ligation of the carotid
may be necessary; usually the external branch will suffice. In every
instance plastic repair should be made, as it will always be required
after the excision of growths involving the surface.

Space does not permit of detailed or specific directions for all
possible methods of plastic repair of facial defects, but Figs. 421 to
441 illustrate the principal methods which may be utilized in planning
and sliding flaps which shall serve this purpose. These may be modified
or combined to meet special indications.

[Illustration: FIG. 432

FIG. 433

FIG. 434

FIG. 435

FIG. 436

FIG. 437

FIG. 438

FIG. 439

FIG. 440

FIG. 441

Sliding rectangular flaps into desired position.]

It is often necessary to intermit the anesthetic because the operator
must displace the mask in order to do his work. Souchon advises an
apparatus by which most of this delay can be avoided. By means of a
rubber bulb a current of air is passed through the bottle containing
the anesthetic and then directed through a tip which is passed down in
the pharynx through a nostril. This may be connected, if so desired,
with a bag of nitrous oxide gas, which is illustrated in Fig. 442, and
its use in Fig. 443.

Ligation with excision of a section of the external carotid has been
suggested by Dawbarn as a means of cutting off the blood supply in
_cases of inoperable malignant tumors of the face_, thus reducing their
rate of growth. In tumors of the jaw, for instance, he would also tie
the inferior dental artery, with its mylohyoid branch, just before it
enters the inferior dental canal. He advises, also, the removal of one
inch of the inferior dental nerve, thus avoiding pain and distress,
occluding the artery on the less diseased side first, waiting for two
or three weeks before attacking the more diseased side, for should
there be noticeable benefit after operation on the more affected side
many patients would be unwilling to be again subjected to the other
operation. Other operations include those made upon the various nerves
for relief of neuralgia or for nerve suture of divided trunks. These
have been described in a previous chapter.

[Illustration: FIG. 442

FIG. 443

Souchon’s intranasal inhaler.]


OPERATIONS ON THE NOSE.

Plastic operations upon the nose appear to have been practised early
in the history of surgery. The East Indians had a method by which the
skin of the forehead was made to furnish a flap from which a new nose
was created. This was known as the Indian method. It has been somewhat
modified of late years by raising with the skin flap the periosteum,
or, as suggested by König, the outer table of the frontal bone, with
the intent and hope that something resembling the nasal bone might
be secured. The so-called Italian method (named the Tagliacotian
operation, after Tagliacozzi) consists in utilizing the skin of the
arm, which is loosened according to a pattern previously made, leaving
it connected only by a pedicle through which its blood supply is to be
afforded. This flap is usually cut out and perfectly formed, then left
loose upon the arm for about fifteen days until its viability has been
thoroughly proved and its under surface is granulating. Then the edges
of the defect in the nose are pared, as well as those of the flap, and
the arm is brought into such position as to allow fitting the latter
to the former, where it is held by stitches. The arm is held in proper
position by cushions and by bandages of plaster of Paris until union
has taken place, after which the pedicle is severed and the arm then
released.

[Illustration: FIG. 444

“Saddle-nose” due to syphilitic destruction of bone. (Lexer.)]

Lesser deformities of the nose may be remedied or repaired in various
ways. Angular deformities may be excised, while a sunken bridge may
be raised, as Weir has suggested, through a bevelled incision at the
junction of the nasal and maxillary bones, they being held in place by
a transfixion pin. One of the most common and objectionable deformities
is the so-called _saddle-nose_, which may be treated by Weir’s method,
or which has afforded satisfactory results after the injection of
paraffin. Roe, of Rochester, New York, has succeeded in remedying many
of the more trifling nasal deformities by operation from within the
nose, as, for instance, in case of _pug-nose_, where he dissects from
within superfluous fat and connective tissue (Fig. 444).


HARE-LIP AND OPERATIONS UPON THE LIPS.

_Hare-lip_, or _coloboma of the upper lip_, is due to a failure in
coalescence of the developing maxillary processes, which should unite
early in fetal life to form the lip, alveolar process and roof of the
mouth. This failure may involve but a trifling part of this line of
normal junction or may be complete. Thus anywhere along it defects may
be noted, such, for instance, as a little notch in the lip, a small
opening in the hard or soft palate, or a bifid uvula. The defect in the
lip alone is known as hare-lip because of its normal occurrence in the
hare, and occurs on either side of the median line, absolute median
fissure being extremely rare. It may occur alone or in combination with
deeper fissures which involve the gum or the alveolar process alone or
the entire palate. In extensive fissures of this character development
is rarely symmetrical, and one side is usually not developed
sufficiently to match the other. This makes operative treatment the
more difficult. The more complete and extensive fissures are often
complicated by excessive development of the intermaxillary bone,
apparently from lack of pressure. This permits a projection of the
septum, and especially of the central portion of the alveolar process,
with a small part of the skin and connective tissue, which should
have been blended into the lip proper. It represents the original
intermaxillary bone with the portion which should have been developed
downward from the nasal process of the midfrontal region. This gives a
snout-like appearance to the face, and nearly always necessitates doing
an operation for closure of the lip in two sittings. In Figs. 445 and
446 will be seen wide clefts with projecting intermaxillaries, while
Fig. 447 illustrates a much more complete coloboma of the face, with
complete bilateral fissures. Figs. 448 and 449 show the double form
with philtrum or snout. Figs. 450 and 451 give the palatal conditions
of irregularity and projection of the intermaxillary bone. (See Cleft
Palate.)

[Illustration: FIG. 445

Incomplete hare-lip.]

[Illustration: FIG. 446

Complete fissure in double hare-lip.]

[Illustration: FIG. 447

Complete bilateral fissures (coloboma) of face. (Guersant.)]

All forms of hare-lip call for operation not alone for cosmetic
purposes, but so that patients can nurse, drink, eat, and talk to
better advantage. Obviously the earlier such operations are done,
other things being equal, the better the results. When the cleft does
not include the deeper tissues it may be closed within the first week
or two of infancy. When the roof of the mouth is involved the surgeon
is perplexed in deciding which is the better of two courses--to operate
or to wait. Unquestionably by early closure of a fissured lip a gentle
but constant influence is maintained to press the divided upper edges
together, or at least to influence their more rapid growth toward each
other. For this reason it would be desirable to operate early. On the
other hand with a bad palatal defect it is a difficult thing to operate
until, with the increasing age of the child, the mouth has attained
a size which will permit the manipulations required for the purpose.
Nevertheless, unless there be some special reason for delay it would
appear wise, at least as a general rule, to operate early. (See Cleft
Palate.)

[Illustration: FIG. 448

Double hare-lip with philtrum or snout.]

[Illustration: FIG. 449

Complete fissure, with labial defect and projecting intermaxillary.
(Bruns.)]

[Illustration: FIG. 450

Illustrating the osseous (palatal) defect in complete fissures.
(Bruns.)]

[Illustration: FIG. 451

Projecting intermaxillary bone. (Bruns.)]

The underlying principle of these operations is easily and briefly
stated. The edges of the defect should be freshened and brought
together by sutures. Extreme care should be taken that the vermilion
border of the lip be maintained. A little particle of mucous membrane
in the lip of an infant, dislocated to a level higher than that where
it belongs, will appear later in life as a reddish patch upon the skin,
which will prove quite a disfigurement. Simple fissure of the lip is
easily managed by Nélaton’s procedure (Figs. 452 to 457). The deeper
and more extensive the fissure the more plastic reconstruction is
required.

[Illustration: FIG. 452

Malgaigne’s operation: the incision.]

[Illustration: FIG. 453

Malgaigne’s operation: the sutures in position; the lower sutures tied.]

[Illustration: FIG. 454

Nélaton’s operation: the incision.]

[Illustration: FIG. 455

Nélaton’s operation: the sutures.]

Incision, when necessary, may be extended around the angle of the nose
on one side or both, and the lip should be dissected away from the
bone sufficiently to make it movable. Operations by which a certain
dovetailing of the little flaps is performed afford more security than
a perfectly straight incision, but the resulting scar is rather more
marked. The more perfectly the mucous membrane can be preserved upon
the under side of the lip the better will be the result.

[Illustration: FIG. 456

The operation for double hare-lip.]

[Illustration: FIG. 457

Operation for double hare-lip: the sutures in position.]

Hare-lip pins have been abandoned. Sutures only are used, which may be
of thread or horse-hair, catgut absorbing too rapidly. It is my custom
to pass a retaining suture of stout silk through the cheek on either
side, at a distance of one inch or so from the wound margin, to bring
this forward in front of the alveolar process, and, by using a plate
and shot on either end, to prevent tension upon the line of junction.
This is very important, for children will fret and cry in a manner
to tear out many a stitch not thus fortified. After operation young
children should be snugly enclosed in a protective bandage around the
chest, by which it shall be made impossible for them to get their hands
to their mouths. It is vitally necessary to maintain absolute rest of
the face and protection from any possible source of harm.

[Illustration: FIG. 458

FIG. 459

Line of incision, according to König.]

_Fissures of the lower lip_ are surgical curiosities. Should one be met
it may be treated on the same general principles.

[Illustration: FIG. 460

Cheiloplastic operation on lower lip. (Tillmanns.)]

The other _cheiloplastic operations_ upon the lips are those made
necessary by excisions of malignant growths, or by deforming cicatrices
such as follow burns, syphilitic lesions, and the like.

[Illustration: FIG. 461

FIG. 462

Estlander’s cheiloplastic operation.]

Fig. 460 illustrates one method of filling a defect of the lower lip,
while Figs. 461 and 462 indicate a method of bringing down a flap from
the upper lip for the same purpose.


THE SALIVARY APPARATUS.


FOREIGN BODIES IN THE SALIVARY DUCTS.

Foreign bodies occasionally enter the salivary ducts, especially
Stenson’s and Wharton’s, where they may set up an inflammation known as
_sialoductilitis_. These may consist of bristles, fish-bones, and the
like. Abscess, in consequence, may form in the gland or between it and
the foreign body. Calculi also lodge in the ducts, where they remain
as foreign bodies, producing sometimes a disproportionate amount of
irritation.


FISTULAS OF THE SALIVARY DUCTS.

Fistulas of the salivary ducts involve Stenson’s duct. They open on the
inside of the buccinator muscle, back of the orifice of the duct, which
is opposite the second upper molar tooth. These fistulas of the parotid
gland may be recognized by the passage of a probe from within the
mouth. When they open externally they result nearly always from injury,
and it is only the external forms which are troublesome. One may resort
to the mildest measures first, and experiment with cauterization of the
orifice or compression by occlusion. These measures will be ineffective
if there be no opening upon the inside of the mouth, in which case
one must be made by reëstablishing the original canal or forming a
substitute. For this purpose a suture may be passed around the duct,
back of the fistula, using a curved needle, and making it come out near
the point of entrance. It should hold the duct in its loop. This suture
may then be tightened and the distended duct punctured on the inside
of the cheek. When once the flow of saliva is diverted to the mouth
the edges of an external fistula may be pared and closed. In obstinate
cases which have resisted all other methods it has been suggested to
remove or destroy the gland which connects with the duct at fault.
Even this is not an easy matter, but it can be done in the case of the
parotid by careful dissection, with separation of the branches of the
facial nerve and removal of the greater portion of the gland itself.

Congenital anomalies of the salivary glands are rare and of small
import. Any one of them may be displaced, or either of them may connect
with an accessory gland separated from it by an appreciable interval.
Abnormal duct openings have also been noted.


INFLAMMATION OF THE SALIVARY GLANDS.

Inflammatory affections of the salivary glands give rise to
_sialoadenitis_. Among these by all means the most common is
_parotitis_ (_mumps_), which often occurs in epidemic form. It is an
infectious and probably contagious disease, usually attacking the
young, though no age is exempt. The period of incubation is about
fourteen days. The condition begins with a stomatitis and with swelling
of the affected parotid, with edema of the overlying tissues. It is
accompanied by moderate fever. Swelling may be extensive and involve
the entire neck region. The parotid on the other side becomes affected
within a few days, although usually not to a similar extent. The other
salivary glands occasionally participate. The febrile stage lasts for
about a week, after which the swelling recedes and is gone within from
two to four weeks. Occasionally the affected glands suppurate, in which
case the condition may be very serious, since it may simulate Ludwig’s
angina, or may be followed by sloughing and gangrene.

Save when abscess threatens the treatment should consist of
warm antiseptic mouth-washes and the external application of an
ichthyol-mercurial ointment or of Credé’s silver ointment. When
suppuration threatens early incision should be made for the relief of
tension and prevention of destruction.

A frequent and important _complication of parotitis is orchitis_, or
swelling of the testicle. This is an unexplained feature of these
cases, and occurs mainly in sexually mature individuals. It is the
testis proper which suffers and not the epididymis. Suppuration here
is rare. More or less atrophy is a remote consequence in many cases,
estimated at about one-third. When both testicles are affected to
a marked degree impotency may follow. Treatment of this orchitis
consists in absolute rest in bed, with elevation of the parts affected,
often with the application of an ice-bag. Painting the scrotal skin
with guaiacol in small amount will often relieve pain. A similar
complication occurs in the female, the _ovary_ being involved.
Aside from this, other complications may occur in the breast, the
vulvovaginal glands, the prostate, the heart, the eye, and the ear.

Apart from this somewhat specific affection the parotid and the other
salivary glands may become involved in swelling and inflammation on
account of surrounding local infections, or the presence of foreign
bodies, stones in the ducts, etc. Metastatic abscesses, especially in
the parotid, are not uncommon. Considering the open pathways offered
it is surprising that these glands are not oftener involved in septic
conditions of the mouth.


MIKULICZ’S DISEASE.

Mikulicz has described a not very infrequent simultaneous affection
of two or more of the salivary glands, occurring in middle age,
characterized by uniform swelling which may involve even the palatine,
labial, and buccal glands. It is spoken of in German literature
as _Mikulicz’s disease_. The swelling progresses slowly, so that
the glands reach a varying size in the course of years. Thus the
parotid glands may attain the size of the fist, and other glands a
corresponding increase. Sometimes the adjoining lymphatics are also
involved. The enlargements are not tender, but may interfere with
movements of the tongue and jaw. These tumors have been known to
recede after an intercurrent acute disease. Nothing is as yet known
of the cause or nature of the affection. In its treatment arsenic and
potassium iodide have given perhaps the most favorable results.

The salivary glands, especially the parotid, are as likely to be
involved in the manifestations of tuberculosis, actinomycosis, and
syphilis as are the other structures of the body. Lesions of these
various natures will be appreciated without further description.


TUMORS OF THE SALIVARY GLANDS.

Tumors of the salivary glands are not uncommon. The parotid is more
frequently affected than either of the others. These tumors may be of
cystic character, either large from obstruction of the excretory duct,
or small and numerous. Almost all the tumors described in Chapter
XXVI may be found in this region. Simple adenomas are common and the
parotid especially is often the site of tumors of mixed character, in
which the various mesoblastic elements mingle in a confusing manner.
Cartilaginous tumors here are frequent. The presence of cartilage is
to be explained on Cohnheim’s hypothesis. Endothelioma, sarcoma, and
carcinoma are also common, especially as primary tumors in the parotid.
Any or all of the glands may also suffer by extension of malignant
disease from primary foci in their neighborhood (Figs. 463 and 464).

[Illustration: FIG. 463

Mixed tumor of the parotid. (v. Bruns.)]

[Illustration: FIG. 464

Mixed tumor of the submaxillary gland. (v. Bruns.)]

Cancer of the parotid is especially serious and discouraging, because,
while radical removal is necessary, it is impossible to effect this
without destroying the facial nerve and producing consequent paralysis
of the face on that side. Such an operation should not be made without
explaining to the patient beforehand its inevitable result. Only when
seen in their very early stages can these tumors be so effectually
removed as to not leave the patient liable to secondary or metastatic
affections. This also should be explained to them in order that the
surgeon may protect himself from blame.


SALIVARY CALCULI.

Calculi which form either in the substance of the glands, or much
more commonly in their ducts, by precipitation of those salts held in
solution by the saliva, are of the same character as the accumulations
of the so-called tartar upon the teeth. They are met with frequently in
Wharton’s duct and occur more often in men than in women. They may vary
in size from that of a rice-grain to a stone more than one inch long.
They are always ovoid in shape and with a rough exterior. They are
believed to grow much as do gallstones, as the result of some previous
infection, a clump of bacteria perhaps affording the nidus on which
calcareous material is deposited. The affection may be spoken of as
_sialolithiasis_.

They usually give rise to pain and swelling, and lead occasionally to
the formation of abscess and fistulous openings. They may be revealed
by the _x_-rays, or the operator may search for them as for stone in
the bladder, with a small probe passed through the duct opening. The
discharge of mucopus or blood into the mouth would suggest infection of
this kind. They may also be recognized by thrusting a needle through
the overlying tissues in the direction of the swelling which they
produce. Their removal through the smallest incision on the interior of
the mouth which will suffice for the purpose is indicated. No attempt
need be made to close the opening.

Operations on the parotid region are difficult and severe. In case
of large tumors the external carotid and the common carotid may
be ligated. By separating the patient’s jaws the parotid space is
increased and deep dissection is more easily made. Caution should be
taken not to open the maxillary joint. Souchon has called attention to
the fact that the safest plan is to proceed so long as the surrounding
tissues are easily removed _en masse_, and to stop when they become too
resistant as the deep surface is approached. Then the portion of the
tumor which has been cleared should be cut off. The stump thus left
will, in growing again, become more superficial, and it is sometimes
possible to effect a radical removal by a second operation.




CHAPTER XL.

THE MOUTH, THE TONGUE, THE TEETH, AND THE JAWS.


CONGENITAL DEFECTS.

Aside from anomalies due to incomplete closure or erratic development
from the branchial clefts, the principal congenital defects of
the regions included in this chapter are as follows: The mouth is
essentially a coalescence of the upper end of the foregut and a recess
known as the stomodeum, which are at first separated by membrane, the
latter disappearing early in fetal life. Some remains of it, however,
may produce a narrowing of the oral fissure and cause one form of
_microstoma_. Some of these facial defects are due to formation of
amniotic bands and adhesions, which restrain or interfere with the
normal development from the branchial fissures. Malformations of the
_tongue_ may accompany other anomalies. A _median cleft_, called also
a _bifid tongue_, and defective development and undue adhesions to the
floor of the mouth, are known, whose most trifling expression may be
seen in the so-called _tongue-tie_, where the frenum is too short and
needs to be divided in order to release the tip and more movable part
of the organ. Adhesive bands may also attach the tongue laterally to
the cheek, bands between the cheek and the gums being also occasionally
seen. An extreme type of tongue-tie is known as _ankyloglossum_.
Abnormally long tongues are also met, and cause an actual menace
from danger of the tip being swallowed, as children have suffocated
from this cause. _Congenital macroglossia_ has been described; it is
usually due to lymphangioma of the tongue. A condition known as _lingua
plicata_ is characterized by moderate enlargement of a number of either
longitudinal or transverse folds or rugæ. The covering mucosa, however,
is normal. _Complete absence of the tongue has been noted._

Aside from malformation of the upper jaw, _cleft palate_, there are
arrest of development in one or both sides of either jaw and a failure
of union in the two halves of the lower jaw. Anomalies about the
temporomaxillary joint interfere with its function and may prevent
separation of the jaws.

_Malformation and misplacement of the teeth_ are extremely common.
Thus a tooth may develop in an abnormal position by displacement of
its body, or it may project in an abnormal direction; while teeth may
be lacking in number or in eruption, so that a given tooth, usually
a molar, completely fails to appear. Absence of a number of teeth is
more rarely noted. Numerous cases are on record where a third set
of teeth has succeeded the second instead of the latter remaining
permanent. Abnormalities of tooth formation extending to the dignity
of tumors of the dental tissues have been referred to in the chapter
on Tumors, under the head of _Odontomas_. Cysts of congenital origin
not infrequently develop around unerupted or misplaced teeth, and
constitute tumors which at birth are scarcely noted and which may not
develop until later in life.

Persistent remains of the _thyroglossal or thyrolingual ducts_ may be
seen early in childhood, or not until late in life. Their consequence
is occasionally noted in the existence of _fistulas_, but more often
of _cysts_ or _dermoid tumors_, which, though having their origin in
the middle line, may become displaced to one side, and when seen by the
surgeon have a lateral position.


CLEFT PALATE.

Cleft palate is a congenital defect due to failure of coalescence
between the nasal and maxillary processes, which, proceeding from
either side, should meet and unite in the middle line. The defect may
be so slight as to produce only a small notch in the alveolar border,
or a small opening in the roof of the mouth, or it may be so complete
as to constitute a separation with the formation of but a small part
of the roof of the mouth, leaving but little tissue serviceable for
any possible operation. The relation between the products of lateral
growth and the downward projection and formation of the _intermaxillary
bone_ by the midfrontal and nasofrontal processes is too complex to
be described here (Fig. 465). In some instances there is but little
evidence of the formation of such a bone, while at other times it has
not only bone formation but is relatively overdeveloped, in such a way
as to make the lower anterior angle of the septum and its own part of
the alveolar process project far beyond the level of the surrounding
tissues, thus producing a snout-like appearance, which not only
makes the case more disfiguring, but seriously complicates operative
procedure. Usually the lower border of the nasal septum will be found
attached to one side of the cleft (Fig. 466). The soft palate presents
the same fissure, and the uvula is often neatly separated into halves.

[Illustration: FIG. 465

Double cleft palate.]

[Illustration: FIG. 466

Left-sided cleft palate.]

The _coincidence of cleft palate with hare-lip_ has been described.
(See p. 645.) While they often are combined, either may occur without
the other (Fig. 467).

[Illustration: FIG. 467

Left-sided hare-lip and cleft palate. Marked displacement of
intermaxillary bone. Boy, aged six years. (Bevan.)]

No matter how incomplete the palatal cleft may be the nose and the
mouth are converted into a common cavity. Suction, as from the breast,
is impossible. Infants with this defect should be carefully fed by
hand; as they develop, food passes readily from the mouth to the nose,
while there is corresponding difficulty in swallowing. With lapse of
time speech becomes defective or almost unintelligible. There is,
therefore, every reason for any possible closure of such defects.
Against the mechanical difficulties on one side should be weighed the
desirability of such closure on the other. One argument advanced in
favor of operation on hare-lip is that the influence of the pressure
thus afforded will tend to hasten the natural attempt on the part of
the halves of the upper jaw to grow toward each other instead of in the
opposite direction. On the other hand, by closure of the labial defect,
the space within is materially diminished and manipulation made more
difficult. It then becomes a serious problem _when to operate upon a
given case of cleft palate_. The operation itself is usually one of no
small mechanical difficulty, the space required for manipulation is
most restricted, the procedure relatively a long one because of the
anesthetic, and necessity for its frequent suspension in order that the
operator may proceed, and, because of these difficulties and delays,
the attendant shock to the patient. A puny child, unable because of the
defect to take sufficient nourishment, is then in far from a favorable
condition for a serious operation. Without a general anesthetic
no child will endure it, while local anesthesia in the young is
insufficient on account of their timidity and involuntary resistance.
When to operate, then, should depend upon the condition of the child,
the dexterity of the operator, and the width of the cleft--that is, the
amount of work to be done.

Brophy, of Chicago, has taken a radical and advanced position in this
matter, and believes that these operations should be performed in
early infancy, a fact which his own large experience would appear to
demonstrate. Yet this same experience has developed in him a facility
possessed by few, and that which such an operator may do with impunity
can be duplicated by but few. He finds, however, unanswerable argument
in this: that in infancy the bones of the jaws are scarcely developed,
are not only friable but very flexible and yielding; that even in the
very young the tissues unite kindly, and that very young infants seem
to be less liable to extreme shock than those several months old;
that the earlier the muscles of the palate are brought into contact
and action the better performed are the functions of deglutition and
of speech, and that if they are not used they atrophy; that the teeth
are more likely to erupt normally, and that the extreme liability to
pharyngitis produced by such wide-open fissure is obviated. To all of
these statements no objection can be raised, and the only argument
which can be adduced against Brophy’s position is the actual danger of
the operation.

In the matter of time it may be said that in extremely competent hands
operation in infancy is the ideal method, but that when children reach
the age of two or three years and still have very small mouths, not
much is lost by waiting until they are five or six years of age, while
considerable room is gained for ease of manipulation. Much depends
also on the temperament and obedience of the child. These children,
like most of those born with congenital defects, are usually pampered
and spoiled by indulgent parents, so that at a time when implicit
obedience is most needed it seems almost impossible to do anything with
them. In dealing, therefore, with such a child one should insist upon
its being thoroughly disciplined, and, at the same time, accustomed
to manipulation within the mouth, as the presence of a finger, tongue
depressor, etc., so that when need comes for their use the child
shall not be totally unaccustomed thereto. Every case should also be
prepared so far as possible by antiseptic and astringent mouth-washes.
A nasopharyngeal catarrh which shall compel such a patient to be
constantly swallowing and spitting may defeat the object of the
operation itself.

The terms usually used in this connection are _uranoplasty_, which
means closure of the hard palate, and _staphylorrhaphy_, which means
the closure of the soft palate.


=Operations for cleft Palate.=--The responsibility of the anesthetist
in these cases is great. Considering that he has to work through the
same cavity as the surgeon it is sometimes very difficult to keep the
child in a consistent state of narcosis. The inhaler devised by Dr.
Souchon serves an admirable purpose. (See p. 644.) I regard chloroform
as the safest of the anesthetics, as it is less irritating and provokes
less flow of saliva. It is a good plan to cocainize the parts previous
to incision, in order to so benumb them as to make reflex impressions
less pronounced.

The theory of these operations, like that for hare-lip, is simple. It
consists in freshening the edges of the cleft, bringing them together
and holding them in position; this requires clean work and a mouth kept
clean--in other words, it calls for efficient antisepsis, for strict
asepsis is impossible. All carious teeth should be removed or put in
good condition, and large tonsils, with their distended crypts and
reservoirs of decomposing material, and all adenoid tissue should be
removed.

Owen has shown the benefit in nursing infants of using an old-fashioned
“slipper bottle,” having a soft giant teat with a hole on the under
surface. As the infant sucks from this the teat fills the cleft, and as
the child compresses it in sucking the milk is directed downward. When
this does not suffice milk may be given in a warm teaspoon, passed far
back over the tongue, or from a medicine dropper.

Owen sustains Brophy in the contention that the most favorable time
for operating on a cleft palate is between the age of two weeks and
three months, there being at that time less shock, and the bones are
extremely flexible. Accepting this statement as authoritative the
operation upon young infants will be described.

Previous to the operation a warm, nourishing, and stimulating enema
should be given the patient. After the infant is anesthetized the
tongue is drawn forward by a long suture and the mouth kept open by a
mouth-gag. The edges of the cleft are then pared with a sharp knife,
after which effort should be made to press the upper maxillæ together,
in order to test their flexibility and the possibility of approximating
them in this manner. This will rarely be sufficient, however, and
it becomes necessary to raise the cheek, on each side, toward the
posterior extremity of the hard palate just behind the malar process,
and pass a knife through the outer bony surface, making a sufficient
division of the antral wall through a minimum of opening. Rather than
cut too much bone at first the knife may be re-introduced. The actual
approximation of the maxillæ is produced by silver-wire sutures. A
firm, stout needle carrying a thick, silk pilot suture is passed
through at the point above mentioned and made to appear in the fissure,
where the loop may be pulled down, after which it may be again passed
through the other side and made to emerge at a point corresponding to
that at which it entered. The suture thus passed in one way or the
other is made to carry a strong silver wire from one side across to the
other, on a level above the hard palate, emerging on each side within
the cheeks. Another wire suture is similarly passed more anteriorly.
Two small oblong leaden plates, 1.5 Cm. in length and 35 or 40 Cm. in
width, drilled with two holes, are then provided, one of them laid
along the outside of each maxilla, the wire sutures passing through the
holes which they contain. On one side the ends of the wire are then
twisted firmly and cut short, thus forming a complete grip upon the
plate on its side; then the jaws are pressed firmly together, while the
wire sutures on the other side are similarly fastened over the lead
plates and twisted tightly to make permanent the effect produced by
pressure with the fingers. These sutures should be made sufficiently
tight to permit of approximation of the borders of the mucoperiosteal
surfaces, already freshened, in such a way that they may be held
together with fine wire or horse-hair sutures and without undue tension.

The lead plates are left _in situ_ for three or four weeks. If
necessary the wire suture may be tightened to allow for relaxation
produced by pressure effect. Some ulceration may occur beneath the
plates, but this heals after their removal. Theoretical objection
to this method may be made because of the tendency to narrowing of
the upper jaw. In fact, however, it is only restored to its proper
dimensions, as that part of the face has been previously widened by
the width of the cleft. Irregular eruption of teeth or irregularity of
development may be treated by a dentist.

When the vomer affixed to the intermaxillary bone projects in a
snout-like manner it is necessary to remove a V-shaped section from it,
the base of the triangle being along the margin of the cleft, in order
that the projection may drop backward and the corresponding part fall
into line with the rest of the alveolar process. This is best done as a
preliminary and distinct operation.

_Uranoplasty in older patients_ consists essentially of forming two
anteroposterior mucoperiosteal flaps, from the hard and soft palates,
on either side of the cleft, with their inner edges neatly pared,
which should be separated from the bony roof of the mouth, and slid
toward each other until they can be held together by sutures. These
operations are best performed with the patient’s head hanging over the
end of a table, so that blood may not find its way into the trachea or
stomach, but be sponged away. This is the position of the so-called
“down-hanging head” described by Rose. In fat-necked individuals it
may be impracticable. After paring the borders adjoining the fissure
an incision is made just within the alveolar border, close up to the
teeth, parallel to the former, of sufficient length to permit of
the formation of the flap above mentioned; then with raspatories or
elevators it is detached from the hard palate. In a mouth with a gothic
arch or roof it is often easier to form these flaps and to bring them
together than in others. It may be possible in such cases to not only
suture the edges, but also some portion of their raw surfaces, thus
ensuring better union. (See Fig. 468.)

Branches of the anterior palatine artery will bleed freely during
this part of the performance. Firm pressure and the use locally of
adrenalin solution will usually overcome this difficulty. As the
incision is extended backward the posterior arteries will cause the
same difficulty. The wider the defect the farther backward should the
lateral incisions be extended. Here the principal obstacle to easy
approximation of edges is the activity of the levator and tensor palati
muscles. Formerly it was a part of operations to divide the tendon
of the latter as it passes around the hamular process. It has been
found, however, that this is often unnecessary. A tenotomy of this
tendon, however, may be made just as that of any other tendon with the
expectation that the gap thus made will be filled with fibrous tissue.
While, on one hand, it is of great advantage to spare this tendon, on
the other hand its muscle may be the principal factor operating to pull
apart those surfaces which have been neatly brought together.

Fergusson and Langenbeck have not hesitated to make _osteoplastic
flaps_ when necessary, dividing the hard palate along the line of the
lateral incisions with a fine chisel. This is not often required, and
complicates the case to an undesirable extent, although it may be
necessary in wide fissures with a minimum of tissue (Fig. 469).

Sutures are best made of fine silver wire or of black silk, as the
ordinary silk is usually too absorbent, and permits infection of the
stitch holes. These sutures are introduced with any one of a variety of
needles devised for the purpose. A complicated needle is not necessary
for this purpose, for with an adequate needle holder even the ordinary
needles can be used. Silver wire may be fed directly into the needle or
through a hollow needle devised for the purpose, or sutures of silk may
be passed, by which a wire suture is pulled after them.

Great assistance can be obtained from packing strips of gauze between
the flaps and the bone from which they have been detached. These may
be inserted for pressure effect and prevention of hemorrhage during
the operation, and later may be substituted by smaller packing of
antiseptic gauze left for the purpose of helping to minimize tension,
flaps being crowded toward each other by their use.

[Illustration: FIG. 468

Uranoplasty, showing incisions. (Tillmanns).]

[Illustration: FIG. 469

Staphylorrhaphy, sutures placed. (König.)]

The parts being approximated and the wound suitably tamponed it is
necessary to keep the patient as quiet as possible. Young infants
tend to keep up a constant sucking motion with the tongue, which may
interfere with the quietude of the palate. Small doses of bromide or
chloral may be administered either by the mouth or rectum, for every
effort at crying, coughing, or vomiting tends to make a stress upon
the line of sutures. Vomiting immediately after the operation is not
necessarily serious, and yet should be avoided. Patients sufficiently
old to talk should be cautioned not to converse. Water is better for
the patient than milk, as the latter does not allay thirst so well and
may form curds. Most of the nourishment for the next few days should
be administered by the rectum, giving only water through the mouth.
Children should be watched continuously lest they get fingers or toys
into their mouths, and fretfulness should be guarded against. Thread
sutures should only be removed with scissors and forceps after the
expiration of five or six days. A useless suture is a foreign body
which does more harm than good. When lead plates are used with strong
wire sutures they should remain from two to four weeks. In young or
undisciplined children it may be necessary to give an anesthetic for
removal of the sutures. The tampons or pledgets of gauze should be
removed from day to day. An antiseptic mouth-wash or spray should be
frequently used.

The two results most desired are prevention of passage of food from the
mouth to the nose, which is always commensurate with the success of the
operation itself, and improvement in speech and voice. The earlier the
closure the more natural the voice. Patients in adolescence or adult
life rarely note much gain in this respect, while those operated in
early childhood may learn to talk almost perfectly.

There are cases, especially those which have gone for years unattended,
where the arch of the mouth is of such gothic shape and the defect so
wide that disappointment is sure to follow in at least one of the above
respects. The art of the dentist has now reached a point where plates
or obturators may be constructed for unsuitable cases, which will give
better functional and vocal results than any which the surgeon can
produce.

Another form of palatal defect is the result of the late manifestations
of _syphilis_, and small and large perforations may occur, usually in
the hard rather than in the soft palate. They are to be dealt with
surgically, but not until after the patient has been subjected to a
course of antisyphilitic treatment.


THE MOUTH IN GENERAL.

The mouth more than any other part of the body is the habitat of a
large fauna and flora of minute organisms. Over one hundred different
kinds of bacteria from this region have been identified by Miller,
and it will be easily seen how prone fresh wounds or old lesions may
be to infection from these sources. Fortunately but few of these
microörganisms have decided pathogenic propensities. They lurk
especially in two localities--the crypts of the tonsils and along the
gingival borders and alveolar processes. Along the gingival border of
the teeth _tartar_ accumulates, by a precipitation of mineral salts
from the saliva, where by irritation, coupled with germ activity, the
gum is loosened from the teeth beyond the level of the enamel, and the
sockets thus exposed to various kinds of infection. In consequence the
teeth thus undergo _dental caries_, become loosened in their sockets,
while, at the same time, infection travels along lymph paths until
the germs are filtered out in the adjoining cervical lymph nodes,
which thus suffer enlargement and often suppurative destruction. An
_interstitial gingivitis_, therefore, is always a serious menace to
the integrity of the teeth. This will furnish another argument for a
semi-annual inspection of the mouth by a competent dentist, that he may
clean away all tartar accumulations and treat the gums in such a way
as to prevent disintegration. In elderly people, especially, there is
a marked tendency toward _retrocession of the gums_. In young or old,
when this condition is noted, it may be treated by applications of zinc
iodide, either of the dry, minute crystals or of a saturated solution,
which may be used daily or weekly. By such precautions the teeth may
be preserved to old age, the importance of which is not generally
appreciated, since the teeth are necessary for suitable mastication
of food which the enfeebled stomach of an aged person can more easily
digest.

Infection may also occur during the period of eruption of teeth in
young people, and serious trouble sometimes accompanies the appearance
of temporary or permanent teeth. Gingivitis of toxic origin is not
uncommon, as among the possible effects of overdosage of _mercury_ and
_phosphorus_.

All that has been said of the teeth and their sockets is in the main
true of the tonsils, which afford numerous crypts or lacunæ in which
germs may be harbored for a long time. The explanation of probably
75 per cent. of enlarged and tuberculous lymph nodes is afforded
by infection spreading from the tonsils and teeth. It may not be
tuberculous at first, but it becomes so later.

In the mouth may be seen expressions of _actinomycosis_,
_tuberculosis_, and especially of _syphilis_, among the more chronic
lesions, as well as of diphtheria, erysipelas, and the result of the
_oidium albicans_ of _thrush_. Tuberculosis is more common in the
pharynx, while the syphilitic infections may appear anywhere and in
any form, as chancre on the tonsil or the lip, mucous patches of the
tongue, destructive lesions of bone, all of the earlier and most of the
later expressions of the disease offering serious dangers of contagion.

_Stomatitis_ is a term generally applied to the lining membrane of the
mouth and indicates little regarding its nature or seriousness. It may
be of traumatic origin, as when strong caustics have come in contact
with the mucosa. _Ulcerative stomatitis_ is a disease of childhood, due
to the activity of the _oidium albicans_ or some kindred microörganism,
it being usually a more serious expression of the condition known
as “thrush.” Washing the mouth frequently with dilute solutions of
hydrogen peroxide or of tincture of iodine will usually be all that
is necessary. Resistant ulcerations may be treated with 10 per cent.
solution of silver nitrate. _Stomatitis gangrænosa_ is another name
for _noma_, or _cancrum oris_, which was described in the chapter
on Gangrene. In these cases the surgeon should hasten the tedious
separation of sloughs by use of scissors, curette, or the actual
cautery (Fig. 471).

_Blastomycetic lesions_ of the mouth, and especially of the lips, have
been recognized. Bevan has reported extirpation of granulomas provoked
by the blastomycetes, or yeast fungi, which are known to produce
similar effects elsewhere (Fig. 471).

[Illustration: FIG. 470

Misplaced and imprisoned tooth. (Forget.)]

[Illustration: FIG. 471

Destruction of cheek the result of cancrum oris. (Tiffany.)]

Severe infections of the mouth may also involve the tongue and thus
produce acute glossitis or may spread to the connective tissue, or the
submaxillary region, and there produce that type of phlegmon called
_Ludwig’s angina_, described in the chapter on the Neck. The source of
infection in most of these cases is a tooth or tooth-socket.

_Injuries and wounds of the mouth_ are _liable to septic infection_,
whether they occur from mechanical, chemical, or traumatic causes.
Injuries inflicted by the mouth, or rather by the teeth, _upon others_
constitute infected wounds of a serious type. Burns, scalds, and
similar lesions inflicted by violent caustics, such as carbolic or
nitric acids, may be followed by cicatricial contraction and produce
serious consequences. So far as the latter can be foreseen they should
be prevented, while for their more extreme results various plastic
operations may be performed.


THE TONGUE.

What has been said above with regard to the possibility of infected
wounds in the mouth applies also to the _tongue and other parts_. It is
often lacerated by being caught between the teeth in falls and blows
and is sometimes bitten by epileptic patients during their convulsions.
Free hemorrhage from such wounds may occur and may require ligation of
vessels at the site of the wound, or of suture of tissues _en masse_
with catgut, or ligation of the lingual artery just above the hyoid
bone. Lacerated wounds should be closed with sutures, and antiseptic
mouth-washes should be frequently used.

_Glossitis_, or inflammation of the structures of the tongue, may
appear in either acute or more chronic form. To some extent it is a
part of a general stomatitis, but no matter in what form occurring
it is an expression of infection from a source easily recognized,
and may be limited to one side of the tongue. Its principal features
are swelling, which may be so extensive as to prevent movement of
the tongue, infiltration of the floor of the mouth, and extension of
a phlegmonous type down the structures of the neck. The swelling
may also involve the epiglottis and larynx, causing edema and even
suffocation unless tracheotomy be performed. Thus acute glossitis
may frequently lead to _abscess_ formation either in the tongue or
the adjoining tissues. When swelling is extreme its formation may be
anticipated, and free incision should be promptly made to permit of
its evacuation. Naturally the region of the large vessels should be
avoided, and, after external incision the focus should be reached
by blunt dissection. Some of these cases are due to extension of an
erysipelatous process commencing externally. Even _hemiglossitis_ may
be accompanied by serious swelling and high fever. One form of this
affection is supposed to be analogous to herpes zoster. The relation of
phlegmonous glossitis to _Ludwig’s angina_, the latter being described
in Chapter XLI, may be readily appreciated. Sometimes it is due to the
entrance of foreign bodies, as fish-bones, bone-splinters, and the like.

Most urgent danger is that of asphyxia from pressure, and of
inspiration pneumonia, for the infected saliva in these cases will
trickle down within the larynx and trachea. Even _gangrene of the
tongue_ has been observed as the result of pressure, while the teeth
will leave their impress upon the sides of a swollen tongue.

The more _chronic infections of the tongue_ are _syphilis_,
_tuberculosis_, and _actinomycosis_. Syphilis may assume a primary type
and occasionally typical chancres may be seen on the tongue. It is
frequently the site of mucous patches and of other ulcerative lesions.
Tuberculous ulcerations of the tongue assume less indurated and
irregular borders, and may be suspected in connection with well-marked
tuberculous lesions of other parts of the respiratory tract, being
particularly common in consumptives. These ulcers yield best to
cauterization and antiseptic mouth-washes, whereas syphilitic lesions
rarely disappear without active antispecific medication. Both syphilis
and tuberculosis produce gummatous tumors, the former more frequently
than the latter. The former will disappear equally readily under
suitable treatment.

Actinomycosis of the tongue is rare in man. It constitutes a granuloma
which may soften and present a ragged, ulcerated surface. (See
Actinomycosis, Chapter VIII.)

_Leukoplakia_ implies the appearance of opaque, white patches upon the
mucous surfaces of the tongue as well as on the lining membrane of
the mouth, lips, and palate. They are far more frequent, however, on
the tongue and generally appear there first. Here they appear almost
as if thin scales could be separated from the surface upon which they
lie, but this will not be found possible when the effort is made. The
patches are irregular, but sharply outlined, occasionally confluent,
involving the entire upper lingual surface; while the plates become
harder and more roughened as they grow older, and furrows, subsequently
ulcerating, may appear between them. The affection is chronic and
intractable. It occurs often in the mouths of smokers during middle and
advanced life. While its etiology is unknown it may be due to chronic
irritation.

_Between leukoplakia and epithelioma_ of the part involved there
seems to be a strong relation, and the former is often regarded as a
precancerous stage of the latter. Epithelioma is a frequent terminal
feature of leukoplakia. There often seems, moreover, a predisposition
to it in syphilitic individuals. It is mainly to be distinguished
from secondary syphilitic lesions, which may be done by recalling its
chronicity and its obstinacy to the treatment which would disperse the
latter.

In the way of _treatment_ smoking must be prohibited, antiseptic
mouth-washes often used, with cauterization to a mild degree. These
methods, however, suffice only for the milder cases. If any caustic be
used it may be either 10 per cent. chromic acid, chemically pure lactic
acid, or nitric acid, caution being used in their application. The more
serious forms of leukoplakia will usually yield to local anesthesia,
followed by curetting of each patch until the raw surface beneath is
exposed, and then the application of the actual cautery. Rigorous
treatment is necessary when ulcerated and fissured patches are present.

The _benign tumors of the tongue_ include nevi, often in connection
with single or multiple papilloma, or which may assume the type of
multiple papillomas, each of which is extremely vascular. Occasionally
the tongue will be seen almost covered with these small growths. This
condition is noted usually in young children, and is practically of
congenital origin. It frequently subsides spontaneously, but may
require the actual cautery or something equally radical. The other
benign tumors are of occasional occurrence, even an enchondroma having
been occasionally seen. Much more common are the _retention cysts_,
especially that particular form of cyst occurring beneath the tongue
or at its base, known as _ranula_. This term is vaguely applied to
cysts produced by obstruction of one of the salivary ducts or by cysts
of congenital origin. It is caused mainly by incomplete obliteration of
the thyroglossal duct. A so-called ranula may contain colorless fluid,
more or less thick, and mixed with epithelial or dermoid products.

[Illustration: FIG. 472

Macroglossia. (Tillmanns.)]

It is possible to extirpate nearly all of these growths through the
mouth, with aseptic precautions.

_Macroglossia_ is a condition of congenital enlargement of the tongue,
due mainly to a form of lymphangioma, which may be accompanied by
vascular papillomas or alteration of the mucous covering. Such a
growth will produce enlargement of the tongue to an extent that does
not permit of its retention within the mouth. Excision of a V-shaped
portion sufficiently large to reduce the tongue to proper dimensions is
usually requisite in these cases (Fig. 472).

Of the _malignant tumors of the tongue epithelioma_ is by far the
most common. It is rarely seen in women, and not often before middle
life. Here more than in almost any other part of the body the possible
causative factors of irritation and trauma are present, jagged teeth
furnishing the usual source of each. It is known also to be a frequent
sequel of _leukoplakia_ and of various chronic ulcerations and other
lesions. Other benign growths occasionally alter their type and
become epitheliomatous. It occurs usually on the exposed surface,
and tends quickly to an ulceration whose border is indurated and
often fissured. It is ordinarily distinctive in its appearance, but
occasionally needs to be differentiated from lesions of syphilis,
tuberculosis, and actinomycosis. Lymphatic involvement occurs early
in each of these conditions and may be confusing. A suspicious
ulcer which tends constantly to deepen and increase in dimensions,
accompanied by marked induration and lymphatic involvement, and not
benefited by antisyphilitic treatment, will generally prove to be
epitheliomatous. As the lesion extends there is involvement of all the
surrounding structures--the floor of the mouth as well as the pharynx,
the salivary glands, and even the lower jaw itself. When pain is
felt it is usually referred to the region of the ear. There will be,
naturally, interference with all the functions of the mouth, as well
as with speech, while starvation, septic infection, and hemorrhage may
terminate the case.

In no part of the body is prognosis more unfavorable. Recurrence, even
after early and radical operations, is usually unavoidable, and it is
doubtful if 10 per cent. of cases of epithelioma of the tongue are free
from disease at the expiration of three years after removal.

Treatment should be prompt and radical. It consists of _extirpation_,
which must be extensive to be effectual. A small cancerous ulcer on one
side of the tongue may justify removal of one-half of the organ, but,
under nearly all circumstances, it is best to make a complete removal
of the tongue. This may necessitate a formidable operation, and may
be expected to materially interfere with speech; but that it does not
prevent it is shown by the fact that in medieval days, when tearing out
the tongue was a means of punishment or torture, men were often still
able to speak intelligibly.

Inoperable cases should be made comfortable with cleansing mouth-washes
and applications of local anesthetics, coupled with such anodynes as
it may be necessary to administer. Resection of the lingual nerve will
sometimes relieve the intense pain, while proximal ligation of the
lingual artery may arrest rapidity of growth. It is in these inoperable
cases that Dawbarn’s suggestion of the extirpation of the external
carotid artery, first on one side and then on the other, may be put
into practice, the intent being to so completely shut off circulation
as to check growth. In some forty cases or more it has given results as
satisfactory as could be expected.


OPERATIONS UPON THE TONGUE.

Operations upon the tongue include _partial excision_ and _complete
extirpation_, perhaps with much of the adjoining tissues. Here, as
in every operation, the mouth should be thoroughly cleansed. Before
extensive operations a preliminary ligation of the lingual artery
should be made on both sides, just above the hyoid bone. (See p. 352.)

A small lesion at the tip of the tongue may be excised by a wide
V-shaped removal of the anterior part of the tongue, under cocaine
anesthesia, the edges of the opening being brought together with
sutures of silk or of chromic catgut, for ordinary catgut would be too
quickly macerated when thus soaked in the mouth. The lesion may be so
placed as to not permit of this V-shaped opening being symmetrically
placed. The same rules, however, will apply, the operation being
performed with a sharp-bladed bistoury or with sharp scissors, bleeding
vessels being seized with forceps as they are cut. These clean removals
give more satisfactory results than the old operations performed with
the écraseur or cautery. A _complete excision of the lateral half_ of
the tongue is easily made through the mouth, the organ being controlled
by a stout suture passed through the other portion. The vessels
and lymphatics of the tongue do not cross its septum, and all the
hemorrhage that need be anticipated will come from the side attacked;
but when it is necessary to remove an entire half of the tongue the
case has usually progressed to such an extent that its complete removal
will be usually indicated and will be more effectual.

Of the various complete operations upon the tongue but three will be
described here.

_Whitehead’s_ operation comprises an almost total extirpation made
through the mouth, without division of cheeks or lips. The patient
is placed in a semi-upright or upright position. The mouth is held
open with a mouth-gag, for which purpose none serves better than the
O’Dwyer gag used for intubation. The operation is begun under brief but
complete anesthesia, and is usually completed before the patient has
recovered from it.

The tongue being secured with a stout suture passed through it, its
frenum and its attachment to the fauces are divided, along with
all other reflections of the mucosa. Vessels which spurt should be
caught at once. General oozing may be disregarded. After being thus
freed the tongue is pulled forward, a strong suture passed through
the glosso-epiglottidean fold, and then with sharp, slightly curved
scissors the entire organ is cut away from its base, the lingual
arteries being seized the instant they are divided. The operation
is bloody for the few minutes required for its performance, but is
quickly done and with a minimum of disfigurement. By the last-mentioned
suture the stump can be pulled forward, should the epiglottis tend to
drop backward and disturb respiration, or should hemorrhage require.
After its conclusion, and during the after-treatment, frequent warm,
antiseptic solutions should be used for washing the mouth, and it is
the practice of some to paint the raw surfaces with a styptic varnish,
made of balsam and saturated solution of iodoform in ether. In order to
avoid the passage of saliva downward the patient is encouraged to sit
up and to expectorate freely rather than swallow infected saliva.

The _Regnoli-Billroth operation_ is performed by turning down a
horseshoe-shaped flap, its convexity being taken from the symphysis of
the jaw, and thus opening into the mouth from below. After making the
opening sufficiently wide, the tongue, through which a traction suture
has been passed, is pulled through the submental wound and its base
divided with scissors. Should it be difficult to locate bleeding points
in the stump a finger may be hooked in the pharynx and the latter
pulled forward. The submaxillary wound is then closed with sutures,
with one drain.

[Illustration: FIG. 473

Lines of incision for total excision of the tongue. (Chalot.)]

The most complete of these operations is that described by Kocher.
It permits of removal of the tongue, of the floor of the mouth, of
all infected lymphatics, and even of a portion of the jaw if this be
necessary. A line _A-B_, Fig. 473, may offer sufficient exposure by
incision, but the line _C-D-E-F_ will permit more complete attack.
Through this incision a flap is raised, the facial vessels being
ligated. All lymph nodes are extirpated, as well as the salivary
glands, if necessary. After separating the mylohyoid from its insertion
in the inferior maxilla the mouth is opened and the tongue drawn out
through the incision, where it may then be kept under perfect control.
It will facilitate matters if the lingual arteries be secured before
the entire tongue is cut away. In some cases a preliminary tracheotomy
is considered advisable, largely because the performance of the
operation interferes with the administration of the anesthetic in the
ordinary way. Should it be done the pharynx should be tamponed until
the conclusion of the operation. The trachea tube may be immediately
removed or left, as seems advisable, while the patient is fed for
several days with a stomach tube.

Operations suggested by Sédillot and Langenbeck include division of
the lower jaw in such a way that by separation of its portions a more
complete exposure of the floor of the mouth is afforded. They are at
present rarely adopted, unless extension of the disease to the bone
should necessitate excision of some portion of the jaw itself.


THE TONSILS.

The tonsils are the most conspicuous portion of the ring of lymphoid
tissue which extends completely around the original opening connecting
the exterior of the face with the upper end of the neurenteric canal.
This tissue is particularly inflammable, and this may account for the
frequency with which severe infections of the tonsils occur, and the
marked toxemia which complicates even mild degrees of the same. In this
lymphoid, or, as it is usually called, “_adenoid_” tissue, crypts and
follicles abound, and in these latter all sorts of infectious materials
accumulate. Thus acute infections, as well as chronic hypertrophies due
to pressure and irritation, are extremely common.

The various forms of _angina_, _i. e._, _sore throat_, have to do
largely with expressions of these infections in varying degrees
of severity. The adjoining mucosa and other tissues frequently
participate, and it is possible to produce a painful degree of
chemosis of the membranes involved in a short time. Adjoining lymph
involvement, with discomfort or even distress in the region of the
throat, and sometimes pronounced general malaise, are extremely common
accompaniments.

The “cynanche tonsillaris” of the older writers implied an acute
expression of this kind, often with more or less exudation, which,
accumulating upon the exposed surfaces, produces there a membrane, the
condition being most noticeable in the pronounced types of diphtheria.
At other times activity is manifested rather in the peritonsillar
structures, and acute and suppurative types of cellulitis, leading
either to abscess in the tonsil or deep in the neck, are the result. A
surprising degree of toxemia accompanies these lesions and sometimes
severe and fatal general septic infection, perhaps with endocarditis.
_Abscess of the tonsil_ may produce so much occlusion of the pharynx as
to make breathing difficult and even almost impossible, perhaps even
to a point requiring tracheotomy. Tonsillar abscesses usually evacuate
themselves in time; if they are opened by the surgeon relief comes
promptly, with evacuation of pus, no matter how brought about.

Many such abscesses could be easily recognized and incised were it
not for the surrounding inflammation, which prevents the patient from
opening the mouth sufficiently wide to expose the pharynx. Suffering in
these cases is acute.

A swollen and fluctuating tonsil, if it can reached, is easily
perforated by a sharp, straight knife. Erasion and fatal perforation
of the carotid artery has been known to be a sequel of such a case
unrelieved. Again, pus having its source within the tonsil may burrow
in such a direction as to produce a retropharyngeal abscess.

The tonsil is rarely the site of primary _syphilitic_ lesions, more
often of the secondary, and occasionally of _tuberculous_ lesions.

The most common chronic affections of the tonsils result from failure
of absorption of inflammatory products after acute inflammations, which
leaves a permanent enlargement, and which is constantly irritated and
provoked into further growth by the retained contents of the tonsillar
crypts. It is in this way that _chronic hypertrophy_, or the so-called
_enlarged tonsils_, result. These conditions are especially common in
children, presenting the milder forms of the status lymphaticus. (See
Chapter XIV.) These enlargements are seldom seen alone in the tonsils.
Similar involvement of the lymphoid or adenoid tissue in the vault of
the pharynx, and even at the base of the tongue, is quite common, the
entire original lymphoid ring being more or less involved.

The consequences of chronic enlargement of the tonsils have much to do
with the subsequent welfare of patients. Not only is speech interfered
with and made peculiarly “throaty,” but, owing to encroachment upon
the natural breathing space, children suffering in this way contract a
habit of carrying the head forward and stooping the shoulders, in order
thereby to increase the dimensions of the nasopharynx; thus they become
“mouth-breathers” and hard of hearing, which is deleterious to their
intelligence as well as to their physical well-being. Such children, in
time, become stupid, unintelligent, and defective in many ways. There
is, then, every reason for removing these obstructions to respiration
and for doing it early.

Children thus suffering will present such peculiarity of voice as to
suggest immediate examination of the oropharynx, while the posture
above described and the existence of the mouth-breathing habit should
also prompt investigation. An instant inspection through the widely
open mouth should permit the detection of this condition. Should it
be desired to estimate it more thoroughly it may be done with the
finger, although it will provoke the act of coughing or vomiting and be
resisted by most children. Frequently the enlargements can be felt from
the outside. There is but one suitable treatment for such a case, _i.
e._, _tonsillotomy_.

Tonsillotomy may be effected with any one of several different patterns
of tonsillotomes on sale in the instrument stores, most of which are
neat and speedy in their work, but the surgeon need not refrain from
the purpose of removal because of the lack of such an instrument, as
it may be easily accomplished without one. Young and timid children
are probably best anesthetized, although if one can establish perfect
confidence it may be possible to do it by the aid of local anesthesia.
In adults the latter will always be sufficient.

An anesthetized patient should be placed in a chair or semi-upright,
and the mouth widely opened. The circular loop of the instrument
should be fitted over the tonsil, this, if necessary, being drawn into
its grasp by a small hook or forceps, after which by a quick motion
of the cutting blade the projecting mass is removed. All instruments
are made to be used with either hand and to cut on either side. The
practised operator will, therefore, use his left hand when operating
on the right tonsil of the patient, and _vice versa_, it being best to
adopt this order, for should he be a little clumsy with his left hand
and the patient be thereby somewhat disturbed, the right hand may more
dexterously perform the excision on the other side. The surgeon should
be thoroughly familiar with his tonsillotome before using it. It is
not, however, necessary to employ such an instrument, and it will often
be more satisfactory to grasp the projecting tonsil in the bite of a
suitably constructed tenaculum forceps, or even hold it with a common
tenaculum, while with blunt scissors, long handled and curved upon the
flat, the tonsil itself is cut away.

None of these methods gives promise of complete extirpation of the
tissue, which is often chronically diseased, and it is often well,
therefore, to complete the extirpation with the sharp spoon or even
to use the finger-nail as a curette. Hemorrhage will be active for a
few moments, but is nearly always controlled with either iced water
or water as hot as can be borne. Only rarely does it give rise to
serious trouble. In such cases adrenalin may be used. Cases are on
record where it has been necessary even to tie the carotid, but such
instances are mostly bugbears which need not deter one of good judgment
from a properly devised operation. Antiseptic gargles, and avoidance of
speech and swallowing of hard food, will be all that are needed in the
after-management.

The young and the timid will need complete anesthesia, which should be
complete in order to abolish reflexes, and cocaine locally to ensure
this condition. Many of these subjects are, however, those presenting
minor degrees of the _status lymphaticus, to whom anesthetics should
be administered with caution_. In such children tonsillotomy should be
combined with the erasion and removal of other involved adenoid tissue
in the nasopharynx. Inquiry should be made as to whether the patient
bleeds unduly freely after minor injuries. In a bleeder it would be
well to proceed with caution or abstain from operating.

_Foreign bodies in the tonsil_ are as often fish-bones as any kind;
they all give rise to serious irritation. True _calculous formation_
in the tonsil is known. Every foreign body which can be detected and
exposed should be removed.

_Tumors of the tonsil_ are usually of the malignant type, either
epitheliomatous or sarcomatous. A cancer of the tonsil should be
recognized as such very early if operative or other relief is to be
effectually afforded, and if operation is made it should be done more
thoroughly than can be done through the mouth.

_External pharyngotomy_ is the measure usually required for this
purpose. This is usually performed by making a long incision along the
anterior border of the sternomastoid muscle, and, after retracting
it, making careful and blunt dissection down in the direction of
the tonsil, separating tissues which are evidently not involved,
but excising everything in which infiltration can be recognized.
An extensive operation of this kind would justify preliminary or
provisional ligation of the common or at least the external carotid
artery. Care should be taken to avoid wounding the nerve trunks,
especially the hypoglossal.

_Subhyoid pharyngotomy_ is performed by a transverse incision just
below the hyoid bone, with division of the platysma, the omohyoid,
the sternohyoid, and the thyrohyoid muscles, leaving enough of their
insertion into the bone to permit of subsequent reunion by suture.
The thyrohyoid membrane is then divided in such a way as to also
permit of its reunion by sutures. Then the mucous membrane, which will
probably now protrude into the wound, is caught and divided, retraction
sutures being inserted in the edges of the wound. The epiglottis may
be retracted or a suture may be passed through it, to be used as a
retractor. The lower portion of the pharynx is now exposed and through
this opening the tonsil may be removed. After completion of the deeper
work the different layers of the tissues are reunited with chromic gut
and the deep wound is drained.

_Transhyoid pharyngotomy._ Vallas has suggested a central method
of approach to the pharynx by a median incision, through which the
mylohyoid muscles are separated, the body of the hyoid exposed, and its
division effected with stout scissors or with cutting forceps. When its
two halves are retracted a space over an inch long is made, through
which the mucous membrane of the pharynx may be opened, this being done
by making it protrude with the finger passed into the throat, which
shall thus serve as a guide. In closing the wound it is not necessary
to make suture of the hyoid bone.


THE TEETH, THE ALVEOLAR PROCESS, AND THE GUMS.

The alveolar process, which furnishes the actual sockets for the
teeth, and which carries that peculiar fibrous texture with its mucous
covering known as the gum, is a frequent site of ulcerative disease
and fertile source of infection. While the toilet of the mouth is
much more generally attended to at present than in times past, the
majority of people are extremely inattentive and indifferent to the
condition of the teeth and the gingival borders. As elsewhere stated
the mouth is the habitat of an extensive flora and fauna, and deposits
of tartar along the gingival border afford excellent hot-beds for their
development and growth. This accounts for the marginal ulceration
of the gum, or _ulcerative gingivitis_, seen in so many mouths, and
it may be regarded as the beginning of a disease process, _pyorrhea
alveolaris_ (Rigg’s disease), that will eventually cause the loss
of the teeth and extensive infection of the lymphatics in the neck.
In almost every mouth where such accumulations of tartar have taken
place the expressions of local infection may be traced by a bluish or
purplish line along the gingival border, with some degree of sponginess
and mild ulceration.

The enamel covering the teeth is extremely resistant, but when the
dentine is exposed below the enamel line, as happens in such instances
as those just described, bacteria may easily enter the dental tubules,
and _dental caries_ or _alveolar suppuration_ is the result. In order
to prevent such disease the services of the dentist should be secured
at least as often as every six months, in order that all tartar may be
removed and the gums placed in a healthy and resistant condition.

For the marginal ulcerations thus produced there is no better
treatment, after removing tartar, than the local application of zinc
iodide, either in fine crystalline form or in saturated solution. It is
not so much the visible surfaces which need such application as does
the gingival tissue in concealed locations and between the teeth. Zinc
iodide is not only an excellent antiseptic, but a powerful astringent,
and meets a double indication. It may be applied once a week or
oftener.

The dental enamel is the protective medium which, being once injured,
exposes the dentine beneath to the possibility of infection. Such
injuries are mechanical, but usually minute. The practice of putting
hot food into the mouth and immediately following it with a drink of
iced water is calculated to crack the enamel on a tooth as it would on
any other material. Such a crack, although microscopic in dimensions,
permits the entrance of bacteria into the dentine, in whose tubules
they multiply and produce minute amounts of lactic acid. The enamel
will resist this acid almost indefinitely, but the softer dentine is
dissolved by it, and in this way cavities are formed within the teeth,
and the condition known as _dental caries_ is engendered. While it
requires the special art and training of the dentist to cope with
such conditions, every general practitioner should be familiar with
the circumstances under which these lesions are produced. Congenital
defects of the enamel afford also the same opportunities for infection.

When infection has extended to the delicate pulp cavity and when one
of the terminal fibers becomes exposed the condition is accompanied by
more or less distress, and when the alveolar socket becomes involved
the tooth is loosened, either temporarily or permanently, according as
the condition is treated. Thus a small _alveolar abscess_, referred to
as “gum-boil,” may result. In the former case there is usually a small
sinus which leads down to the root of the tooth, either through the
spongy bone or alongside the tooth itself.

Plate III illustrates the conditions in teeth undergoing various
forms of caries, there being numerous bacterial forms responsible for
different types of the disease.

_Treatment_ here does not differ in principle from that for treatment
of caries in bone. Its essential feature is actual removal of all
infected dental tissue, with a combination of protection against
further infection, and that substitution for lost tissue which is
effected by the use of gold, amalgam, or some of the other fillings
in common use among dentists. American ingenuity has reached its acme
in the discovery of means and methods for atonement of tissue thus
lost by disease, and American dentists certainly lead the world in
the mechanics of their art. They go much beyond the mere filling of
diseased teeth, but have devised substitutes for teeth actually lost,
and much of the plate work of the past is now substituted by what is
known as _crown and bridge work_.

Dentistry as a part of oral surgery has now become a specialty by
itself. A competent dentist, therefore, is a necessary coöperator in
the treatment of all diseases of the teeth.

It is mainly when disease has spread from the teeth to the surrounding
bone and tissues that the surgeon as such intervenes. _Caries and
necrosis_ of a small or large part of either jaw may be the result of
extension of disease processes having their beginnings as above. In the
chapter on the Neck, when dealing with the subject of tuberculosis of
the lymphatics, it is stated that a large proportion of such cases due
to the propagation of infection from the oral cavity and often from the
teeth.

There are two substances used in medicine and in the arts which
have a proclivity for the tissues of the mouth and jaws. These are
_phosphorus_ and _mercury_, the former usually affecting the bone and
the latter the softer tissues. Before legislation had been enacted
by which the young were prevented from working in match factories
phosphorus necrosis of the lower jaw was not uncommon. Today it is
rarely seen. Again, in the older days when mercury was given in large
amounts, and its effects were not as well guarded against as now,
_mercurial stomatitis proceeding to ulceration_ and even loss of teeth
was not an uncommon event. Now it is seen only in those who have
an idiosyncrasy which makes them peculiarly liable to its effects.
The mechanism of phosphorus necrosis is supposed to be an ossifying
periostitis, with formation of small osteophytes in the alveolar
periosteum, which lower tissue resistance and permit easier invasion of
bacteria from the mouth. (See p. 428.)

The extension of disease from the teeth, especially of the upper jaw,
upward into the _antrum of Highmore_, with its consequent infection, is
elsewhere discussed, and the reader will find the treatment of _empyema
of the antrum_ considered in Chapter XXXVII.

The teeth are also subjects of certain tumor formations which in
general are spoken of as _odontomas_, and have been mentioned in the
chapter on Tumors. (See p. 281.)

Teeth, moreover, show at times excessive development or marked
displacement or defects of development. Thus they erupt in abnormal
positions, or fail completely in eruption, or they project in abnormal
directions or are sometimes amalgamated. The art and science of the
dentist permit of wonderful control of abnormal development of those
teeth which once appear upon the surface. Children whose teeth are
irregularly placed, or which are abnormal in any respect, should be
placed under the care of a competent specialist. The most serious
_tumors of the teeth_ are those connected with _cyst formation_, which
may assume considerable size. A _dentigerous cyst_ is proper material
for the surgeon rather than for the dentist, inasmuch as while the
operation can be usually done through the mouth it may require external
incision and removal of a considerable shell of bone, perhaps with
plastic restoration of tissues.


THE EXTRACTION OF TEETH.

The general practitioner has often to remove diseased teeth as well as
the surgeon. The theory of tooth extraction is simple. Its performance,
especially when the tooth is diseased, may be exceedingly difficult,
for such teeth may be crumbled in consequence of the force needed for
their removal.

_Forceps_ of different shapes are required for the various teeth. At
least half a dozen different patterns are requisite. A form of elevator
is also of use in elevating stumps which may lie beneath the alveolar
border.

The tooth to be removed should be seized along the fang and beyond the
crown. The blades of the forceps should be pressed firmly down and
along the tooth, in order to separate from it the softer tissues of the
gum and the firmer tissue of the alveolar socket. This is thinner upon
its outer aspect than its inner, save in the location of the wisdom
tooth, and it is the outer border which is more easily broken away by
force applied toward the cheek rather than toward the interior of the
mouth. Using first one blade of the forceps and then the other to split
the socket and separate the osteofibrous tissues, the tooth being then
firmly grasped between them, the operator makes a series of rocking
movements, by which it is itself loosened and its further attachments
torn, until by a lifting effort it can be extracted from the socket. In
this minor operation the head must be firmly held with the disengaged
hand, or better between the forearm and the operator’s body, while with
that hand he supports and manipulates the lower jaw, if it be a lower
tooth which is to be removed.

The operation is painful for the moment. With timid patients local
anesthesia may be produced with cocaine or one of its substitutes, the
solutions being sterile, and either locally applied around the socket
or injected into the surrounding tissues with the ordinary hypodermic
syringe needle. Such attempts are not without their own danger, for
I have seen serious infection follow the introduction of unsterile
solutions by dentists not familiar with aseptic technique. Again,
nitrous oxide gas may be administered, it being usually necessary to
employ a mouth-gag. Recovery from anesthesia is prompt and muscle spasm
may not be entirely abolished; therefore, the gag should be inserted
before the gas is administered. It may be sufficient for the purpose to
employ a good-sized piece of cork, to which a cord should be attached
in order that it may not disappear down the patient’s throat during a
violent effort at inspiration. The horizontal position is the safer for
this purpose.

It is especially the removal of fangs or roots which gives the greatest
trouble in these cases. For this purpose special forceps are devised,
but for their use it is necessary to clear away the gum and periosteum
and to cut away a portion of the alveolar process. Such broken
fragments of teeth allowed to remain give rise to curious reflexes,
such as convulsions, neuralgia, etc., all of which makes it apparent
that the extraction of a tooth being undertaken it should be thoroughly
performed. After its removal the patient should rinse his mouth
with water as hot as can be borne, to check hemorrhage. The removal
of the tooth having left an open pathway for infection, antiseptic
mouth-washes should be frequently used and the socket packed with
antiseptic gauze. Except in rare instances granulation tissue fills the
cavity and the process of repair is rapid.

Among the _accidents which may follow extraction of teeth_ are
_hemorrhage_, which may be checked by plugging and the use of
adrenalin. Adjoining teeth are occasionally injured in clumsy
efforts at extraction, while not infrequently a patient who has not
sufficiently described his symptoms has indicated to the dentist the
wrong tooth, whose consequent extraction has, therefore, not relieved
him of his difficulty. Some teeth have such spreading roots as to make
their removal extremely difficult, and even careful operators have
occasionally inflicted fractures, especially of the lower jaw. The
treatment of such an accidental fracture will not be different from
that of fractures otherwise produced. Such an accident as forcing a
tooth upward into the antrum of Highmore should be followed by its
removal, even at the expense of further operation, while excessive
tearing of the alveolar border, or especially of the gum, may be
treated by suitable packing or by suturing. The accident of aspiration
into the larynx of part or all of a tooth just removed has been known
to be followed by suffocation. The operator, therefore, should not
release the tooth from the grasp of the forceps until the latter are
entirely out of the mouth.

By accident or from indifference it may happen that a healthy tooth has
been removed instead of one diseased. Should this happen the tooth may
often be _re-implanted_ after being cleansed, and will usually resume
its previous position and function. So feasible is such re-implantation
of teeth that they have been frequently removed or transplanted from
one mouth to another, for a compensation, a new socket being made for
the reception of the healthy tooth just removed from the mouth of the
individual willing to part with it.


THE JAWS.

While the jaws are not subject to affections peculiar to these parts,
there may be seen in them peculiar expressions of general conditions,
made so by virtue of environment or complexity of tissues. Most of the
acute infections of the jaw bones are propagated from the teeth or the
tooth sockets. There may be _periostitis_ and _osteomyelitis_, and
these may be followed by a sclerosing process or acute suppuration.
The jaws are prone to be thus affected in consequence of the acute
exanthems and the infectious fevers, while the effects of mercury and
phosphorus have been mentioned. The treatment of the inflammatory
affections here is the same as elsewhere, _i. e._, early incision and
complete evacuation of pus, with removal of necrotic bone or other
tissue. Many sequestra may be removed from within the mouth in such a
manner as to avoid disfiguring scars. When external sinuses complicate
the case, incisions through the skin should be made. These may be so
planned as to coincide with the natural wrinkles or folds of the face.

The _temporomaxillary joint_ is a locality of considerable interest.
_Dislocations_ take place here in consequence of blows or of violent
muscular effort, and are easily recognized because of the fixation
and displacement which they produce. Ordinarily they are easy of
replacement. These luxations may be unilateral or bilateral. As
the result of violence the condyle has been driven upward through
the base of the skull, the violence producing such injury usually
being fatal. Aside from these injuries to the grosser structures
the temporomaxillary joint is not infrequently the site of _acute
synovitis_, or more extensive inflammation, usually propagated from
surrounding tissues, but sometimes the result of distant infection.
In phlegmons of this region the structures of the joint rarely escape
a sympathetic participation, while parotid abscess and similar
collections of pus may penetrate the joint and destroy it. Again it
is occasionally the site of a _postgonorrheal arthritis_, or it may
suffer as do other joints after the exanthems and acute fevers. It
also occasionally becomes involved in the disturbances accompanying
irregular eruption of the last molar, _i. e._, the wisdom tooth; in
other words, it may suffer just as may any other joint in the body, and
from similar causes.

_Ankylosis of the temporomaxillary joint_ is an infrequent result of
its involvement in serious disease, or may result from lesions of the
adjoining tissues, as from the cicatricial deformity following noma,
burns, and the like. Thus we may have either a true or a spurious
ankylosis of this joint, in either case the resulting condition being
intractable and exceedingly difficult to manage. When it can be
foreseen as a consequence of extrinsic disease it may be prevented by
the insertion of a mouth-gag, and more or less frequent and forcible
stretching, or by wearing some suitable apparatus between the teeth
which shall keep the jaws apart, and which may be used at night. A
pseudo-ankylosis produced by cicatricial bands, and long neglected,
will become genuine, and require as radical an operation as though it
had been interosseous from the outset.

For the relief of such conditions various operations have been devised,
in each of which the formation of a false joint is contemplated,
it depending upon the exigencies of the case whether this shall be
produced by the _division of the horizontal ramus in front of the
masseter_, or of the _ascending ramus behind the masseter_, or whether
there shall be actual _resection of the temporomaxillary joint_, with
division of the neck and removal of the condyle. The latter procedure
is the more ideal, at the same time the more difficult, and the more
likely to permit injury to the branches of the facial nerve, with
consequent paralysis of the orbicularis and the facial muscles.

I have elsewhere described a peculiar condition of _relaxation of the
temporomaxillary ligaments_, by which there is a recurring subluxation
of the joint, noticed most often during eating and accompanied by
a snapping sound. This is usually unnoticed by the patient, but is
often observed by others. It is painless, harmless, and not ordinarily
amenable to treatment. (See p. 528.)

_Tumors of the jaws_ proper include mainly _cysts_, which are often
connected with odontomas, _benign tumors_, such as fibroma, chondroma,
and osteoma, most often of mixed type, and the _malignant tumors_, _i.
e._, sarcoma, carcinoma, and endothelioma. Malignant tumors primary
to the bone are usually of sarcomatous type, though these may include
the endotheliomas. Carcinoma and epithelioma do not originate in bone
texture, but may easily spread to and involve it. Thus many cases of
advanced epithelioma of the lip involve the bone as well as the other
neighboring tissues.

_Epulis_ is a somewhat vague term, which has been applied to tumors
which spring from and mainly involve the fibrous texture of the gum
and the periosteum covering the alveolar process. The term itself
simply implies a tumor upon the gum. Microscopically these tumors are
usually of the giant-cell type of fibrosarcoma, and are among its least
malignant varieties. They pursue a slow course, gradually loosening one
tooth after another as they invade the tooth sockets, show very little
tendency to spread rapidly, and are usually sharply circumscribed
growths, tending to ulceration. They seem to be products of irritation.
When removed they rarely recur. The surgeon should excise involved
tissue in order to be on the safe side, sacrificing teeth, gum, and
alveolar process as widely as necessary for the purpose. Formerly
the _epulides_ were made to include different expressions of fibroma
and sarcoma involving the gum, but the name is so vague that it
would be better to speak of each of these cases as its histological
characteristics may indicate.

Benign tumors involving the entire bone may necessitate its removal,
but most of the dentigerous bone cysts may be laid open, their contents
evacuated, their size reduced, and the remaining cavity allowed to fill
with granulation tissue; while malignant tumors call for sacrifice of
every portion of tissue involved, often including the skin, and in the
upper jaw much of the complicated structure of the nasal cavity, or in
the lower jaw the loss of the tongue or a large portion of the floor
of the mouth. A cancer of the lower jaw may be removed, with permanent
good result, but a true cancer of the upper jaw should be seen early
and mercilessly extirpated if the result is to be more than temporary.


OPERATIONS UPON THE JAWS.

Aside from those already mentioned the principal operations upon the
jaws consist of _partial_ or _complete excision_.

_Removal of the upper jaw_ is a rather formidable procedure, frequently
made so by extent of the disease which requires its performance.
The presence of an extensive and ulcerating tumor, by which normal
anatomical outlines are obliterated, will cause mechanical difficulties
as well as unusual liability to hemorrhage. During some portion of its
performance a temporary control of the vessels of the neck may be of
assistance. This can be usually afforded by external digital pressure.
In serious cases a ligation of the external or the common carotid
may be of assistance. If soft, vascular tumors protrude into the
nasopharynx a _preliminary tracheotomy_ should be performed, tamponing
the pharynx in order to prevent escape of blood down the throat. The
position of the patient with the down-hanging head may be also of
assistance in these cases. Of the various incisions employed one should
be selected according to the nature of the case. Most of the operations
include a splitting of the upper lip near the middle, with continuation
of the incision along the margin of the nose, upward toward the
orbit and outward along the orbital border, as originally suggested
by Fergusson. This permits of completely raising the cheek from the
underlying bone in one extensive flap and turning it backward, with
complete exposure of the anterior surface of the superior maxillary.
The operator next proceeds according to the desired extent of removal.
If the roof of the mouth is to be sacrificed the osteoperiosteal and
soft tissues composing the palate should be divided as far from the
middle line as may be permitted, then reflected, and the bone divided
with chisel or with cutting forceps. It may be necessary to remove one
of the incisor teeth to permit the insertion of the chisel for division
of the anterior part of the jaw. Bone forceps or a chain or wire saw
will serve for division of the zygoma and the external or lower wall
of the orbit, while with chisel or forceps the nasomaxillary region
is divided. The loosened bone can now be seized with strong lion-jaw
forceps and wrenched from its attachments, which may then be divided
with scissors or knife as they are encountered (Fig. 474).

[Illustration: FIG. 474

Resection of superior maxilla. (Farabeuf.)]

Hemorrhage will be profuse at this juncture, when the internal
maxillary artery is, with many of its branches, thus torn across or
severed. The surgeon should be ready with tampons and forceps to check
the bleeding and secure the vessels. The complete Fergusson operation
includes removal of the entire upper maxilla, but oftentimes much less
than this will suffice. On the other hand it is necessary sometimes
to go still farther and remove more bone from the orbit or the nasal
cavity, or perhaps to clean out the orbit entirely. A case which
necessitates one of the more formidable operations is too unpromising
to make it often judicious to perform it.

When the tumor involves the overlying skin this should also be
sacrificed, and a plastic operation should be made to cover the defect.
The skin flaps required for this purpose may be taken from the temple,
the forehead, the neck, or adjoining parts of the face.

Bardenheuer has suggested the raising of osteoplastic flaps for removal
of tumors lying within the jaw, and their replacement at the conclusion
of the operation. He has also devised ingenious methods of making
immediate plastic repair which are worthy of study, but which are so
seldom required as to not justify description in this place.

After operation the bleeding should be checked by torsion, by ligation,
by sutures _en masse_, by application of hot water, and by securely
tamponing with antiseptic gauze, by whose pressure oozing is checked
and protection from infection afforded. The patient is allowed to sit
up as early as possible, meanwhile being made to lie upon the affected
side in order to avoid danger of aspiration pneumonia, and using an
antiseptic mouth-wash with relative frequency.

It is sometimes possible to perfect an artificial substitute for
tissues removed, which can be inserted after the operation. The loss of
tissue will cause more or less disfigurement by sinking in of the cheek
and side of the face. After the parts are healed an apparatus made of
gutta-percha or metal, and adapted to each case, by which most of the
lost symmetry may be restored, should be worn, in the same manner as an
artificial denture.

The _lower jaw seldom requires complete removal_. It is rarely
necessary to go so high as the joint or the coronoid process, although
occasionally the condyle must be avulsed and the coronoid either cut
away or its temporal tendon detached. Most of the exsections in this
location are confined to some portion of the horizontal ramus. Except
in rare instances it is not possible to make a complete excision
of the lower jaw through the mouth, and nearly all operations are
practised through external incision, carried along the lower border for
a sufficient length, and extended upward along the posterior border
beyond the angle, if necessary. In most instances the facial vessels
are directly exposed and should be secured before division. Masseteric
attachments are separated and the instruments are kept as near to the
bone as the circumstances of the case will justify. In well-marked
ulcerating cancer, however, the surgeon should go nearly an inch beyond
its apparent border and remove still more if it be visible, taking
everything which seems involved. Here the bone is usually divided with
a chain saw, although stout cutting forceps may suffice. It may be
necessary to remove a tooth in order to clear a place for the action of
the chain saw. Growths involving the skin necessitate not merely linear
incisions, but extensive oval excisions of the overlying tissues.
All the involved structures should be removed in one mass; if it be
necessary to remove the floor of the mouth the divided bone section is
seldom cut away until it can be removed with the rest of the tumor.
The healthy mucous membrane should be preserved and brought together
with catgut sutures at the conclusion of the operation, as the more
carefully the cavity of the mouth can be shut off from the balance of
the wound the more prompt and satisfactory the healing (Fig. 475).

[Illustration: FIG. 475

Resection of inferior maxilla. (Farabeuf.)]

In a few cases it may be possible by the use of stout silver wire, or
some other substitute, inserted between bone ends to keep them apart
and thus nearly preserve the contour of the lower part of the face; but
this can be expected to succeed only when the cavity of the mouth can
be completely closed, so that the wire or other material may be quickly
incorporated in granulation tissue, where it is expected to remain.

When it is necessary to remove the joint end of the bone the operator
should work carefully along the bone toward the joint in such a way
as not to injure the facial nerve, the external maxillary artery, or
Stenson’s duct. With a sharp separator it is possible to thus expose
the joint, and after opening it to avulse the articular surface. In
operating for necrosis the healthy periosteum should be preserved,
while in the removal of cancer it should be sacrificed to the same
extent as the bone itself.

The same rules apply here as above with reference to the closure of the
wound and the construction of flaps; an extensive plastic operation
being sometimes necessitated, as when a large portion of the lower
lip, the chin and the bone are removed for extensive epithelioma. Dead
spaces should be avoided, any cavity should be packed sufficiently,
opportunity for drainage afforded, and the mouth cavity closed.
Mouth-washes should be frequently used.

These cases should be prepared for operation by a careful cleansing
of the mouth and the local use of antiseptics. During any of these
operations, diseased teeth which may require it should be removed,
whether they occupy the site of the operation or some other portion of
the jaws. The cleaner the mouth the more prompt will be the healing
process.




CHAPTER XLI.

THE RESPIRATORY PASSAGES PROPER.


MALFORMATIONS OF THE RESPIRATORY PASSAGES.

The _congenital malformations_ of the upper respiratory passages
pertain mainly to the nasal septum and the interior of the complicated
nasal cavities, which are rarely symmetrically arranged, and which
often differ considerably. The _nasal septum_ is frequently deviated
or warped to one side, often to an extent making one nostril too
restricted for easy breathing purposes. The _nostrils_ are occasionally
seen to be abnormally retracted. Malformations of the _pharynx_ are of
rare occurrence. The _soft palate_ is occasionally found to be more of
a diaphragm than is natural, and _imperforation_ is sometimes seen.
_Pharyngeal fistulas_ have been mentioned in connection with incomplete
closure of branchial clefts. They occur more commonly on the right than
on the left side, and are usually incomplete. A _fistula_ placed in the
middle line and opening into the larynx or trachea is also occasionally
seen, its inner opening being generally found on the side of the
pharynx and just below the tonsil. This is not necessarily a persistent
remains of the thyroglossal duct, but may have a different origin.
_Cystic distentions_ not infrequently occur along these fistulous
tracts. Malformations of the _larynx_ are rare and consist mainly of
narrowings or stricture formations.

_Acquired malformations_ of the respiratory passages are common and
are the result usually of previous disease or injury. They may assume
the _obstructive type_, as when the tonsils or the other adenoid or
lymphoid tissues of the nasopharynx become hypertrophied, or they
may assume the _constrictive type_, as when strictures result from
ulceration, produced either by disease or by caustics. Such diseases
as diphtheria cause not only paralyses, through the nervous system,
but cicatricial deformity in consequence of ulceration. The latter is
also true of burns, while fractures may permanently displace parts,
this being particularly true of the nose, but holding good also for the
hyoid, and even for the larynx. Nearly all these malformations permit
of more or less surgical improvement by operations, some of which are
simple and easy of performance, while some will need the highest degree
of trained skill.


=Ozena.=--Ozena is a general term applied to ulcerative lesions,
especially involving the Schneiderian membrane in the nose, and
causing more or less discharge of mucus, pus, and crusts, nearly
always offensive, and accompanied by evidences of deeper ulceration,
involving the fragile nasal bones or the nasal septum, and constituting
expressions of caries or necrosis in this region. Ozena may be the
consequence of a milder catarrhal inflammation, occurring in patients
of vitiated constitution and bad habits of life, with insufficient
attention or no care whatever. Another type of ozena is from the
beginning of _syphilitic_ origin, and it is especially the syphilitic
cases which present the most offensive types of lesions, yet which are
the most satisfactory to treat, because of the relative certainty with
which they yield to properly directed treatment. Any case characterized
by profuse and offensive nasal discharge, in which by suitable
illumination and examination ulcerations can be detected, should be
considered ozena.


=Treatment.=--The treatment for all these cases should consist of
local cleanliness, alkaline solutions in spray or by irrigation
being especially indicated because of their cleansing properties.
Warm sterilized salt solution may also be used for the same purpose.
All visible ulcerations should be treated by local applications of
mild silver nitrate solutions, or some other combined antiseptic and
stimulant; or these may be alternated with local applications of an
ointment of the yellow oxide of mercury in strength of 0.5 to 1 per
cent. Local treatment, however, is but a part of that which should
be instituted. In every case where the syphilitic element can be
recognized, or where there is good reason for even suspecting it,
vigorous antisyphilitic treatment should be begun and prosecuted.
While these cases nearly always need one of the iodides, administered
internally, there is no way of so quickly bringing them under the
desired influence as by inunction with the ordinary mercurial
ointment. Both measures should be carried along simultaneously until
the combination proves to be too active, when the inunction may be
discontinued.

In addition to these measures such cases need improvement of
elimination and of nutrition, and the best restorative tonics may be
combined to advantage with any other special medication which may seem
to be indicated.


FOREIGN BODIES IN THE RESPIRATORY PASSAGES.

Nowhere, except perhaps in the ear, are foreign bodies more likely to
find entrance, and become impacted, than in the respiratory passages.
They are introduced either through the nose or the mouth. They consist
of almost all imaginable substances, introduced either by accident or
design, and belonging to all three kingdoms--animal, vegetable, and
mineral. According to their nature, size, and lodging place, symptoms
of more or less severity will ensue. Migratory bodies, especially small
insects and parasites, may escape from the nasal cavity into one of
the accessory sinuses, where they will give rise to great irritation,
and necessitate perhaps serious measures for relief. The presence of
a foreign body is not always promptly recognized. In some instances
it is discovered only by accident, as when, having been present for
some time, it has produced irritation, with or without ulceration and
offensive discharge. Thus a shoe-button may have been pushed up the
nose of a little child, and remain there undetected for some time,
perhaps to be spontaneously extruded in the act of blowing the nose.
The presence of a foreign body in the nasal passages, then, will be
manifested by symptoms of obstructed nasal respiration and by other
evidences of local irritation, with pain, tenderness, swelling, and
discharge.

An object easily seen is ordinarily easily removed, unless it has some
peculiar shape which impedes its easy withdrawal. Local cleanliness is
the first prerequisite, and then in most instances local anesthesia,
which may be produced with cocaine or one of its substitutes. After
this a probe, bent into the shape of a blunt hook, or forceps of
various patterns and shapes may be required, and will usually suffice
for all ordinary cases which can be detected by inspection through the
nostrils or with the rhinoscope. In more difficult and unusual cases
the fluoroscope or the skiagram may be made to render great service.
Should some larger object be found, particularly in the antrum, deeply
within the cranium, then a more formal operation will be demanded,
whose details should be made to suit the needs of each individual case.
When a mass of inspissated secretion or of granulation tissue more or
less conceals the outline of the foreign body, everything should be
cleaned away with irrigating spray, or with cotton wrapped around a
probe or held within the forceps.


=Calculi.=--A rare condition of _calculus formation_ is occasionally
met with in the nose, the concretions being formed by precipitation
of the mineral elements from the nasal mucus, and constituting the
ordinary _rhinoliths_. These become, in effect, foreign bodies, and
are to be recognized and treated as such. After syphilitic ulceration
portions of bone may be loosened spontaneously, and dropped into
locations where they are caught instead of being spontaneously expelled.

It is known, also, that, especially in tropical climates, there are
several species of _insects_ which enter the nostrils and there deposit
their _eggs_, which later are hatched into the resulting _larvæ_, the
latter sometimes being expelled, or perhaps developing and burying
themselves further within the nasal recesses. Any living organism may
be killed by administration of chloroform or ether, and then expelled
as an ordinary foreign body; or, in most cases, such larvæ or eggs can
be washed away with an irrigating stream to which a little extract of
tobacco should be added. Thus maggots have been found buried within
the nasal mucosa, and requiring extraction by means of forceps. When
larvæ have invaded the sinuses the case becomes more serious, for it
will require free exposure by perhaps a somewhat formidable operation
on the interior of the sinus, which should then be carefully cleansed
and suitably drained. Living organisms within the nasal cavity or the
sinuses will cause headache, lacrymation, sneezing, nasal discharge,
perhaps with epistaxis, and almost every possible expression of local
discomfort.


=Foreign Bodies in the Pharynx.=--Foreign bodies in the pharynx are
usually, when small, lodged in the neighborhood of the tonsil, or
caught in the lymphoid tissue of the tonsillar ring. According to their
size they may become impacted at almost any point, and may even cause
suffocation. They may be detected sometimes by the finger alone, or,
at other times, only with good illumination and local anesthesia. The
irritation which they produce leads to frequent acts of swallowing, the
latter always exaggerating the former. Such objects as small fish-bones
and the like, which may cause irritation, may easily escape or defy
detection; moreover, such objects may be multiple.

For the sake of comfort pellets of ice may be frequently swallowed and
cocaine may be used locally. Their _extraction_ should be promptly
practised. In rare instances emergency may call for prompt tracheotomy,
but this is rarely the case unless the object be impacted below the
epiglottis. Curious instances of impaction in the nasopharynx, of
strange foreign bodies, have required the administration of anesthetics
and even serious cutting operations for their removal, by combined
manipulation through the nostril and the oropharynx. Such bodies,
however, can be in some way always removed.

Liquids may be aspirated through the nose, and cause strangling attacks
of coughing. They are then more easily drawn into the larynx or
trachea, where they will cause reflex phenomena and actual obstruction,
according to their nature. Again by free inhalation of steam, natural
or superheated, burns and scalds of the respiratory passages may
be produced, which will be followed by edema of the glottis or by
pneumonia. The inhalation of extremely strong vapors, like that of
ammonia, may cause spasm of the glottis. The entrance of blood, as
from rupture of an aneurysm, or of pus, as from a bursting abscess, or
the escape of pus from one side of the chest into the other lung by
way of the trachea, may cause serious symptoms or may produce actual
suffocation. In operations for pyopneumothorax, for instance, with one
side of the chest well filled with pus, one should be careful to avoid
turning the patient in such a way that pus may run over into the other
lung and thus suffocate him. I have seen death occur on the operating
table from this cause, in spite of every precaution, when the accident
itself had been anticipated.

Solid objects may be of all shapes, sizes, and materials; living
insects are occasionally aspirated and may not be at once killed, the
local irritation caused by their presence producing intense spasm of
the glottis. I have personally known of two cases of suffocation in
restaurants, where men eating hastily died as the result of impaction
of pieces of meat within the rima glottidis. Again, bodies may pass
beyond the glottis proper and enter the trachea, or even one of the
great bronchi; shoe-buttons, for instance; and in one case in my
knowledge a small hat-pin passed down and was only removed after a
low tracheotomy and careful search, aided by a skiagram. Owing to the
anatomical arrangement the right bronchus is more frequently entered
than the left. Immediate danger of suffocation, of obstruction, or
spasm having passed, there is still serious menace from _pneumonia_,
with or without abscess or gangrene of the lung. Such condition
occurring in a young child, in the absence of the history of passage of
a foreign body, may cause some difficulty in diagnosis. The greatest
help would be afforded by the use of the Röntgen rays, although the
laryngoscope alone will sometimes be sufficient. To use the latter to
advantage it will probably be necessary to allay local irritation with
the cocaine spray. (See Figs. 476 and 477.)


=Treatment.=--Treatment should be operative, although in some cases
it is sufficient to invert the patient and slap him on the back. With
an object impacted in the glottis relief may be afforded with the
finger, but this may be exceedingly difficult, for in the later stages
of suffocation the jaw may be convulsively shut and it will be almost
impossible to effect entrance. In such case the jaw should be hastily
pried open and the index finger carried down behind the base of the
tongue, lifting the epiglottis and dislodging the object. If this fail
and respiration have ceased, attempt should be made to hastily open the
trachea, even with the blade of a penknife, and to follow this with
artificial respiration. Under these circumstances the vessels of the
neck will be engorged with venous blood, which will escape freely; this
may, however, be disregarded, the primary indication being to get into
the trachea, which may be held open by turning the knife-blade at right
angles, while artificial respiration is practised, and until a couple
of hair-pins, for instance, can be secured, bent into shape of blunt
hooks and made to act as temporary retractors. This is an illustration
of what may be done in emergencies.

[Illustration: FIG. 476

Toy-pin (actual size) removed by external pharyngotomy from pharynx and
esophagus of a two-year-old child. Recovery. Skiagram by Dr. Plummer.
(Buffalo Clinic.)]

[Illustration: FIG. 477

Skiagram of Fig. 476.]

On the other hand these operations should, when possible, be done
deliberately and with local anesthesia. Foreign bodies should be
located with the laryngoscope, after which they may be removed with the
aid of the illumination thus afforded, or by mere sense of touch. _An
object impacted in the larynx proper_ may be extracted by _thyrotomy_,
whereas when it has passed below the larynx it will be necessary to
open the trachea, perhaps even low down, making more than an ordinary
opening for purposes of manipulation. Numerous forceps have been
devised for these purposes. Roaldes reports having removed a piece
of impacted iron from the bifurcation of the trachea, by means of a
powerful _electromagnet_.

In the ensuing chapter there will be mentioned a method of exposing
both the trachea and the esophagus by posterior incision or resection
of the thoracic wall.

[Illustration: FIG. 478

Tack in bronchus of young child, removed after a low tracheotomy. Case
of Dr. Parmenter’s. Skiagram by Dr. Plummer. (Buffalo Clinic.)]


INJURIES TO THE RESPIRATORY PASSAGES.

Besides those inflicted by _foreign bodies_ injuries may be produced
here from external conditions, _gunshot wounds_, _fractures_, and a
variety of causes which need not be specified. The inhalation or the
entrance of violent _caustics_, either fluid or volatile, may produce
edema at least, or actual destruction of tissue. The glottis, being the
narrowest portion of the respiratory tract, offers the greatest danger
under conditions of obstruction, and fatal dyspnea may ensue. Thus, for
instance, _burns_ caused by inhaling _steam_, or hot vapors or _flame_,
will be followed by most intense reaction, often extending beyond the
trachea and to the air cells. Edema will be prompt, while pain, shock,
dyspnea, and loss of voice will be instantly produced. If the patient
survive the early complications he may succumb to pneumonia or other
disastrous sequels in the lungs.


=Wounds of the Larynx.=--Wounds are nearly always complicated by other
injuries of the neck or face, which may involve vessel or nerve trunks
of primary importance. Moreover, such wounds are mostly infected and
lead to extension of phlegmonous involvement, which may later cause
mediastinal or deep cervical abscesses, and all sorts of septic and
pyemic complications. Even when recovery ensues cicatricial contraction
may produce laryngeal or tracheal stenosis, with defective voice, or
sometimes _fistulas_, connecting usually with the trachea.


=Treatment.=--In the treatment of such wounds provision should be
made for drainage, and it is seldom advisable to make too accurate a
closure lest its very intent be thereby defeated. Unless the patient
be suffocating the first indication is to check hemorrhage, then to
cleanse the wound, and later to make such approximation of its surfaces
as the case may permit. Occasionally in order to obtain a good result
in the upper part of the respiratory tract it would be good practice
to make a tracheotomy below. At other times an O’Dwyer tube may be
inserted.

The occurrence of edema may be prevented, or at least its severity in
a measure controlled, by the use of adrenalin solution, 1 to 10,000,
while the local use of mild cocaine solutions will be frequently
indicated, in order to check irritability and the reflex phenomena to
which it will lead. Local symptoms may also be combated by inhalation
of vapor, with soothing solutions, such as weak preparations of
cocaine or of one of the opiates, followed by mild astringents and
antiseptics--tincture of benzoin or oil of eucalyptus, or some of their
equivalents, being nebulized and used in a spray. Opiates internally
should be prescribed; while with delirious, drunken, or maniacal
patients every effort should be made to secure physiological rest and
to subdue restlessness or frenzy.


=Fracture of the Larynx.=--Fracture of the larynx is a somewhat
uncommon accident, due to direct violence, which may instantly
precipitate symptoms of the greatest severity. It may be simple or
compound, the thyroid being obviously most often involved and the
cricoid next. These injuries will occur more frequently in the aged,
in whom the external cartilages of the larynx are prone to calcify and
thus become more brittle. A fracture of the larynx precipitates extreme
danger of suffocation, either from displacement or edema, and will
usually require a prompt tracheotomy, which may be performed with a
penknife in the absence of any better instrument. It may be indicated
also by expectoration of bloody mucus, with froth, with stridulous
respiration, dyspnea, pain--which is increased by pressure or motion,
as in swallowing--and the local indications of injury. Thus death has
occurred upon the field during a game of baseball, from a direct blow
of the ball upon the larynx, no one who knew sufficient to perform it
reaching the patient in time to do an emergency tracheotomy as above.
Edematous laryngitis, which is not sufficiently serious to call for
operation, is characterized by dyspnea, aphonia, dysphagia, cough,
laryngeal irritability, and by more or less chemosis and congestion of
the mucosa. The specialists treat certain of the milder forms of this
condition by local scarification (_i. e._, with a knife made for the
purpose), in order that by considerable local hemorrhage the vascular
engorgement may be relieved.


NASAL DEFORMITIES.

These consist in large measure of deviations of the nasal septum,
with or without turbinate hypertrophy, due to previous disease of
the Schneiderian membrane, and followed by thickening and structural
change. Nasal deviations are either of _congenital_ or _acquired
origin_. An absolutely symmetrically arranged and divided nasal cavity
is a rarity. Thus, though one side is rarely a replica of the other,
deviations which are sufficiently marked to cause nasal obstruction
are commonly the result of rapid or slow disease. They will be seen in
connection with other body deformities by which the head is habitually
held in an abnormal position, so that growth in one direction is
thereby favored. Such conditions may be caused either by irregularities
of vision, by enlarged tonsils, or by spinal deformities.

The _acquired deviations_ are frequently the result of injuries, not
necessarily of those sufficiently severe to produce fractures. The
nasal septum proper is made up of the cartilaginous or purely nasal
portion, the vomer, and the perpendicular plate of the ethmoid, any
one of which may be separated from its connections or warped from its
perpendicular plane. Dislocation of the cartilages may also occur in
the young, and, having once taken place, is rarely reduced unless
treatment has been both prompt and scientific.

_Angular deviation_ to an extent which often produces a _spur_ is not
necessarily of serious inconvenience unless it protrude sufficiently
from its proper plane to come in contact with one of the turbinates,
in which case a nearly complete obstruction may result, with symptoms
of constant nasal irritation. Absolute symmetry being rare, and
mild deviations being very common, it is only those which produce
either visible deformity or local irritation which require surgical
treatment. Obviously after injury to these parts attention should be
given to overcome present and prevent further dislocation. This may be
conveniently done by the introduction of small, tubular, nasal splints,
of celluloid or caoutchouc, made for the purpose. In their absence
short pieces of a stout, silk catheter may be used, one inserted on
either side of the septum, and packed around with a light tampon of
antiseptic gauze. All intranasal splints, no matter how made, will
cause considerable local irritation, with tendency to discharge, and
will need to be renewed every day or two.

Deviation having resulted in permanent deformity, no matter how
produced, it can be relieved by operation. Except in the young this
may be performed under local cocaine anesthesia. These measures fall
under two heads--those made for _removal of projections_, or spurs, and
those directed to _straightening of warped or deviated septa_, which do
not show much thickening.

For the treatment of projections caustics and the actual cautery
were formerly much in use. They have been now almost abandoned for
the use of instruments, such as a strong knife, a small intranasal
saw, or cutting forceps of various patterns, adapted for use within
the nose. Only these latter means will be mentioned in this place.
Cutting instruments may be actuated by hand or by electric motors. When
the field of operation is small cocaine anesthesia is nearly always
sufficient. Extensive operation involving both nasal cavities may often
be better performed under a general anesthetic. The nasal cavity should
have been previously thoroughly cleansed by the aid of irrigation with
alkaline solutions, and then just previous to operation with hydrogen
peroxide. Instruments should be absolutely clean and sterile. When
local anesthesia is complete it is sufficient to seat the patient
with the head supported, opposite to the operator, to illuminate the
nasal cavity with the head mirror or some substitute therefor, and to
introduce the knife, saw, or forceps in such a way that the removal may
be effected with one movement, while injury to surrounding tissues is
avoided. An intranasal saw should be blunt-pointed, and should never be
pushed so as to touch the posterior wall of the pharynx. After division
of bone the final detachment of the mucosa should be made with scissors
or knife. Bleeding after these operations is rarely severe, although
free at first, and may be controlled by a tampon made of a narrow,
continuous strip of antiseptic gauze, either packing it into the
nostril and occluding it, or inserting a nasal tube and packing snugly
around it. Only in rare instances is it necessary to tampon the nose
from the pharynx by the use of the Bellocq cannula. (See below.)

Warped and deviated septa, without angular projections, may be
sometimes successfully treated by dividing the septum, either with
knife or scissors, or with cutting forceps whose blades make a stellate
incision, by which the curved surface is so much weakened that it can
be pressed back into normal shape, where it is retained by tamponing
the nostril on the affected side. The pressure required for this
purpose is, however, sometimes irksome or even intolerable. A method
of using a long pin, like a small hat-pin, has been suggested, it
being passed through one nostril into and out of and again into the
septum, in such a way that it serves as a splint, to keep it straight
for a sufficient length of time. Later this pin may be removed without
difficulty, its enlarged head lying meantime concealed within one of
the nostrils.


SUBMUCOUS RESECTION OF THE NASAL SEPTUM.

This was first suggested by Killian as affording a method not subject
to the objections of the older authorities. It may be performed under
cocaine anesthesia, each side of the septum being swabbed with a 20 per
cent. cocaine solution. A semilunar incision made through the mucous
membrane and perichondrium on one side is the more convenient. Through
this opening the coverings are separated from cartilage by means of a
sharp and a plain elevator. Unless the perichondrium be itself elevated
the mucous membrane will be torn in the pressure of loosening. The
cartilage is then cut through with suitable instruments or burred away
with a dental engine, the instrument being guarded by a finger in
the opposite nostril, which acts as a guide, it not being desirable
that the membrane on that side shall be cut through. In this way any
spurs or ridges may be removed submucously with such instrument as the
operator may select. The separated membranes then fall together and may
be retained by light gauze packing without any suture.


NEOPLASMS OF THE NASAL CAVITIES.

Of true neoplasms in the nose the most common are those myxomatous or
fibromyxomatous developments from the Schneiderian membrane, which are
called _nasal polypi_. Histologically most of these are of myxomatous
character. Clinically, however, they seem to be in large degree
products of inflammatory and irritative conditions. At all events they
constitute sessile and later pendulous outgrowths, occupying different
areas or occurring in clusters, those from the upper part of the nose
being covered with columnar cells, while those of the lower pharynx
are covered with flat epithelium. They are firm or soft, according to
the amount of connective stroma which they contain. They are poorly
supplied with blood and their contained fluid is largely composed of
mucin. When involving a considerable area the condition is referred
to as _polypoid degeneration_. They are observed at all ages and in
both sexes. Their most common seat is the middle turbinate, toward its
posterior extremity, and they also hang from the septum, but may be
found in any part of the nasal cavity. From it they may spread to fill
the adjoining accessory sinuses, even producing absorption of their
bony walls by pressure. They also produce distortion of the nose, with
such obstruction as to prevent nasal respiration. They may involve
one side or both, and may hang so loosely attached that a flapping,
valve-like sound is heard on respiration.


=Symptoms.=--They produce nasal obstruction, with irritation; more or
less discharge of watery or acrid mucus, the latter sometimes leading
to excoriation; while by pressure they produce headache, especially
when located high in the nose, or deafness, as when they press upon the
Eustachian outlets, or symptoms of sinusitis according as they invade
one or other of the sinuses. Other reflex symptoms, such as facial
neuralgia, reflex cough, lacrymation, and conjunctivitis, frequently
accompany them, and mouth breathing and snoring are almost inevitable
consequences. The voice becomes impaired, as does occasionally the
sense of taste.

In most cases they are easily revealed by artificial illumination
and exposure with the nasal speculum. In color they are usually
pinkish, and may be seen to move with the respiratory effort. While
it is usually easy to see at least some of them, when present, it is
difficult to detect their exact point of origin. With the rhinoscopic
mirror they may be seen projecting into the nasopharynx. Occasionally
one will be detached by violent effort at sneezing or blowing the nose.

[Illustration: FIG. 479

Jarvis snare.]

Aside from the danger of retained secretion, which they may bring
about, and that attending their extension into adjoining cavities,
there is in elderly people at least an actual possible danger of their
undergoing _malignant transformation_, although this is not common.
There is, however, good reason for their removal, and none for allowing
them to remain, for they are always both irritant and obstructive.


=Treatment.=--Almost every other method of treatment has yielded to
that of removal by the Jarvis snare, or its equivalent, supplemented
by the occasional use of forceps. In order, however, to expose them
sufficiently to permit of removal it is often necessary to cut away a
portion of the middle turbinate. In extensive polypoid disease this
would be practically always required, and it should be done thoroughly,
for nasal polypi tend usually to recur unless radically attacked. Local
anesthesia is sufficient for the majority of cases, but an aggravated
instance will call for complete anesthesia and thorough work,
especially if the accessory sinuses have been infected.

The snare figured in Fig. 479 is a type of instrument which can be
used to great advantage in dealing with these cases. When, however, it
cannot be made effective by being applied around the actual base of
each growth its use should be supplemented by that of the curette. No
actual assurance can ever be given that there will be no subsequent
development of polypi. Nevertheless it does not follow that new
polypoid development is of the actual nature of recurrence. It may
occur independently from the same causes that produced its first
appearance.

It should hardly be necessary to insert here the caution that no
operation of even this degree of simplicity should be effected without
careful cleansing of the nasal cavity.

Of the other tumors that may occur within the nasal cavities none can
be said to frequently occur here, but all varieties may be encountered.
Of the more benign tumors the most common are the vascular growths and
the fibromas, or mixed form of fibromas and papillomas. Epithelioma and
sarcoma occur occasionally.


FIBROMA OF THE NASOPHARYNX.

Fibroma of the nasopharynx is much more common than in the nasal cavity
proper. Here it assumes its usual characteristics as a more or less
firm and dense tumor, growing slowly, sometimes from a large base and
again in pedunculated form. A form occasionally met with springs from
the periosteum of the base of the skull and slowly extends into the
nasopharynx, causing in time a complete obstruction, with disappearance
of the surrounding structure by its pressure effects. Some of these
growths are of a considerable degree of vascularity. When arising from
the base of the skull they become almost inoperable after obtaining
considerable size. I have seen death upon the operating table, in one
of the foreign clinics, from uncontrollable hemorrhage occurring during
the removal of one of these growths. A growth thus situated should
be attacked with extreme caution, and preferably after easier access
has been made to it by division of the soft palate, and removal of a
portion of the hard, or perhaps by a temporary or permanent resection
of the upper jaw; the route being left in each case to the decision of
the operator. Provisional ligation of the carotids may be also made.

The same is true of the other tumors of the nose and nasopharynx. The
less malignant they are the more they justify radical attack. By the
time a sarcoma or adenocarcinoma of deep origin has declared itself it
is usually too late to justify its removal.


ADENOIDS OF THE PHARYNX.

A new-growth of different form, occurring in the vault or around the
outlines of the pharynx, is frequently seen in the shape of great
_hypertrophy or overgrowth of the lymphoid tissue_, already and
elsewhere alluded to as composing a part of the original lymphoid
ring which marks the site of the embryonic nasopharyngeal canal. This
lymphoid hypertrophy, whose commencing expressions are seen in the
tonsil, is referred to as _adenoid growth_. Associated with it occurs
more or less hypertrophy of the other tissues, fibrous, etc., according
to whose proportion the growths will be soft and spongy or more dense
and resistant. The so-called _adenoids_ occupy more or less of the
nasopharynx proper, reducing its dimensions, encroaching upon the
vault of the pharynx, materially reducing the breathing space, thus
leading to the establishment of the mouth-breathing habit, as well
as to alteration of voice and the accompanying disagreeable features
of increased secretion of the parts. It leads to characteristic
appearances which may be recognized at a distance, consisting of a
mouth habitually open, with more or less projecting teeth, pinched
nostrils, Gothic roof of mouth, stooped shoulders, deformed thorax,
loss of hearing, irritative cough, and possibly remote reflex effects,
such as laryngeal spasm, general neuroses, chorea, and epilepsy.
The effect of these changes is to give not merely an appearance of
stupidity, but actually to interfere with mental development. Save in
exceptional instances, a child with the mouth-breathing habit, and
with that peculiarity of voice which indicates nasal obstruction, will
nearly always be found to be defective in cerebral activity, if not
actually stupid. The longer the condition is allowed to persist the
greater the permanent alterations and damage permitted.

Pronounced degrees of the condition may be easily recognized by the
habitually open mouth and the character of voice. A moment’s inspection
will usually reveal the character and the degree of involvement. When
adenoids in the nasopharynx attain a size sufficient to produce these
results the tonsils are also usually involved, and the clinical picture
is thereby made more pronounced. The rhinoscopic mirror, if it can be
used, will give a picture of the condition, while the finger-tip passed
upward behind the soft palate will give an idea as to the extent to
which the cavity is filled.

By virtue of the interference with the vital function of respiration
thus produced, and because of the retention of secretion and the
greater exposure to irritation through the constantly open mouth,
individuals with this condition are usually anemic, while many of them
give evidence of the _status lymphaticus_, to which attention has
been called in the preceding pages. _To such an extent is this true
that the administration of an anesthetic is frequently attended by
extra danger, and the operator should give the necessary relief only
after careful preparation._ This should consist not only of general
measures, by which the condition of the patient may be improved, but
by local cleansing of parts; and finally, as a preparation for the
anesthetic, of the local use of a weak cocaine solution, by which
reflex excitability may be controlled. Just before administering
the anesthetic in these cases it is well to spray into the nostrils
and pharynx a weak cocaine solution, after which the anesthetic
may be administered. In most instances it would be better to use
ethyl chloride or ether than chloroform, not because the latter is
necessarily more dangerous, but because one is placed less upon the
defensive in case of accident, owing to the belief that it is not so
safe as some other anesthetics. (See p. 164.)


=Operation.=--Local applications being of small avail in producing
either condensation or resorption, the treatment of this condition is
essentially surgical. With children an anesthetic is always necessary.
With adults cocaine may be sufficient. The best position for the
patient is that with the down-hanging head (Rose’s), as blood is not
swallowed nor passed into the lungs, but may be removed as fast as it
collects. The hemorrhage in these operations is generally profuse but
of short duration.

Adenoids are removed either with a _snare_, the _curette_, or by
special instruments constructed on the type of a tonsillotome, and
having a concealed blade. The curette is also used as _forceps_. Two or
three curettes and forceps are sufficient for nearly all purposes. In
operating the instruments are guided entirely by the sense of touch and
the operator’s knowledge of anatomy, for he relies upon his finger-tip
for information as to whether the tissue has been completely removed or
needs further attention. These instruments are used until the entire
vault of the pharynx and its openings into the nasal cavities (choanæ)
are freed from all hypertrophied tissue or excrescence. The posterior
wall of the pharynx should be scraped until it is smooth. In addition
the tonsils should be removed if it be necessary, while the lingual
tonsil may be also removed with curette or forceps if it be involved.
For a few moments there will be a free flow of blood through both nose
and mouth. In some instances there will be indications for cutting
away hypertrophied turbinates and removing nasal polypi. Hemorrhage,
at first profuse, quickly subsides. A mixture of 1 per cent. cocaine
solution with a little adrenalin is the best hemostatic for local use.
The nostrils may be packed if the turbinate has been cut away, or the
entire passage-way may be left open for the purpose of permitting the
later use of an irrigating stream, by which blood clot may be washed
away and antiseptics applied. While using and relying upon instruments
for the greater part of this work there is no better curette for
concluding the work than the finger-nail of the index finger. The
finger being introduced recognizes the degree of relief afforded, and
the finger-nail may be used to scrape away any remaining projecting
tissue.

Various operators have devised formidable operations, varying from the
temporary resection of one upper jaw to Cheever’s ingenious method of
dividing and separating both upper jaws in one piece from the cranium,
and thus exposing the nasopharynx from in front and above. Such
operations are rarely performed.

Other neoplasms in this region are _cysts_ and _dermoids_ of congenital
origin--those involving the original craniopharyngeal canal, and those
produced from pharyngeal diverticula. These produce only the ordinary
manifestations of tumor and are of pathological rather than surgical
interest.


EPISTAXIS (NOSE-BLEED).

The escape of a small amount of blood from the nose, especially in
childhood, is a common occurrence, and may occur in consequence of
slight traumatisms or even spontaneously. The so-called nose-bleeding
of children, then, is scarcely of sufficient importance to justify
consideration here, nor would it were it not for the fact that it
may become severe and even dangerous. Children in whom it frequently
recurs will lose sufficient blood to become anemic, while the effect
of its frequent occurrence may bespeak a depraved condition of the
blood as well as of the tissues which permit of its escape. A history
of repeated nose-bleed should prompt an investigation into the general
condition of the patient as well as a local examination of the nasal
passages, where some explanation may be afforded. For instance, a
polypus may be found whose removal will then be indicated, or an
exceedingly spongy and vascular area may be revealed, which will call
for a touch of the actual cautery or the use of the curette.

Besides the frequent expressions of this kind in childhood, some
of which may occur during sleep, there are other forms of nasal
hemorrhage. A vicarious menstruation is known to assume this type,
individuals thus losing blood every month. This is a rare but
well-known phenomenon. A plethoric individual may suffer serious
epistaxis at any time, and this may be beneficial unless it be too
extensive. Nasal hemorrhages may occur with certain fevers. Individuals
with a hemorrhagic diathesis are peculiarly liable to it, and it is
seen in connection with purpura hæmorrhagica. When this occurs in
the debilitated or dissipated it may be fatal. Thus epistaxis may
terminate fatally in spite of all that can be done. This statement
requires some explanation. The nasal cavity may be tightly plugged,
but such plugging cannot be made permanent because of decomposition of
products thus retained and their absorption, with consequent septic
infection. Nasal tampons should be removed every day or two, for the
purpose of cleanliness, although their removal is contra-indicated
when the necessity for physiological rest of the part is realized. The
treatment, then, of epistaxis may be trying, at least, and in rare
cases will prove absolutely disappointing and ineffectual. I have even
been compelled to tie the common carotid to save life.


=Treatment.=--The ordinary nose-bleed of a young child will usually
subside with the application of cold to the nose, elevation of the
arms, or firm pressure upon the upper lip just below the nasal septum.
It may be also checked by an irrigating stream of cold water, or by a
spray of cocaine or weak adrenalin solution. A 5 per cent. antipyrine
solution also makes an excellent styptic for the purpose. Within a
day or two after a serious hemorrhage, after the remaining clots have
been cleaned away, a thorough inspection of the nasal cavity should be
made in order to reveal the source of the hemorrhage and permit local
treatment.

Nasal hemorrhage may be subdued by _plugging the anterior nares_ with
strips of gauze, or, better still, after the introduction of a tube
through which air may pass freely, and around which packing may be
firmly inserted. The ordinary dry styptics should not be used, for
they may produce such a crusting of tampons as to make it difficult
to remove them. More efficient materials can be used in solution. No
tampon should be introduced into the nostrils which is not tied with
a ligature of silk in such a way that it may be by it more easily
withdrawn, and, at the same time, prevented from going too far. If the
source of the bleeding be in the anterior part of the nasal cavity
anterior packing may be sufficient. The surgeon should not, however,
be deceived by the apparent cessation of bleeding, which cannot escape
through the nostrils under these circumstances, but may continue into
the nasopharynx, the patient swallowing the blood as it trickles down.
Inspection of the pharynx should be made after the use of tampons. A
much greater degree of safety is afforded by _posterior tamponing_ of
each side of the nasal cavity, which is most easily effected by means
of the little instrument known as _Bellocq’s cannula_, whose use is
illustrated in Fig. 480.

[Illustration: FIG. 480

Plugging the nares with Bellocq’s cannula. (Fergusson.)]

It is, however, by no means necessary to have this special instrument
in order to accomplish the purpose. A soft catheter may be passed
backward through the nostril until its end appears in the nasopharynx,
where it is caught with forceps and drawn into the mouth. Here, by
means of a needle or knot, a piece of silk is fastened to this end.
When the catheter is drawn out from the nose it pulls up after it and
out through the nostril this bit of silk, to whose middle is tied a
tampon, made of a sufficient amount of gauze or similar material,
folded or rolled into the desired shape. By combined manipulation, as
the silk thread is drawn upward and outward through the nostril, it
pulls up the tampon into the nasopharynx, where it should be guided
into its place by the tip of the index finger of the disengaged hand.
If necessary this procedure is then repeated upon the other side, and
thus a complete double tamponing can be effected. If the procedure
be made difficult by the extreme sensitiveness of the part this can
be overcome by local anesthesia. The tampon may be saturated with a
weak adrenalin solution if desired. Ordinarily such a tampon can be
easily disengaged and removed by again passing the finger up behind the
soft palate and dislodging and withdrawing it, using curved forceps
for the purpose of securing it. A tampon inserted for the control of
hemorrhage should be left _in situ_ for at least forty-eight hours,
possibly longer. The case should be watched for a while after its
removal, lest it might require re-introduction. This maneuver is made
easier by fastening the tampon in the middle of a long piece of silk as
described; one end being brought out through the nostril is tied to the
other portion, which is allowed to come out of the mouth. The latter
will provoke some discomfort, and patients should be cautioned not to
disturb it, its purpose being explained to them.

Mulford, of Buffalo, has suggested a method of dealing with cases of
epistaxis by injecting two or three drops of reduced adrenalin solution
into the tissues at the base of the upper lip, in close proximity to
the course of the arteries which pass upward on either side and supply
the septum. The injection should be made in the fold of the mucous
membrane just beneath the septum of the nose.


RETROPHARYNGEAL ABSCESS.

This has already been referred to as the product of tuberculous disease
in the upper cervical vertebræ, or in the neighboring lymph nodes,
or as the possible sequel of more acute infections occurring in the
upper portions of the neck, proceeding usually from infected tooth
sockets or other lesions within the nose and mouth. Collections of pus
in this location may be circumscribed or may be extensive and rapidly
assume serious phases. A chronic abscess is essentially a tuberculous
expression. Acute abscesses, either in the tissue behind the pharynx
or to either side of it, may be seen in cachectic children and assume
serious phases.

The first evidences in these cases are those of pharyngitis,
but swelling and edema occur rapidly, septic indications become
unmistakable, and, finally, almost complete nasopharyngeal obstruction
may occur. The discovery by the palpating finger of a fluctuating
swelling will make the presence of pus practically positive. If the
operator be still in doubt he may use the exploring needle. The
experienced practitioner will at once plunge the point of a knife into
such a swelling, and, at the same time, plan his opening in such a way
as to afford the best possible drainage.[48] For the purpose it may be
necessary to have the patient in the position of down-hanging head, or,
in extreme cases, the patient may be almost inverted in order that pus
as it gushes forth may escape through the mouth rather than into the
larynx or down the esophagus. The operation should be done without an
anesthetic. The mouth may be opened with the O’Dwyer mouth-gag, or it
may be forced and held open with the ordinary tongue depressor. When
pus has travelled to such an extent as to give the case the importance
and aspect of a deep cervical phlegmon, such as described in the
chapter on the Neck, then anesthesia is necessary in order that by
external, combined with internal, incision, escape of pus and provision
for drainage may be permitted.

  [48] Nevertheless in one instance an eminent American practitioner
  thus hastily incised a fluctuating intrapharyngeal swelling and
  found, to his dismay, that he had opened a carotid aneurysm, the
  patient dying within five minutes.

Two dangers attend inexcusable delay in such acute cases--one is
of suffocation from pressure or from sudden spontaneous rupture of
abscess; the other is of invasion of large blood trunks in the vicinity
and possibility of hemorrhage after erosion, either into the abscess
cavity or directly into the outer world.


THE UVULA AND SOFT PALATE.


ELONGATION OF THE UVULA.

As the result of constant irritation by coughing, or other reflex
motions of the pharyngeal muscles produced by local irritation, the
uvula frequently becomes elongated to a point which permits it to rest
upon the base of the tongue and there to produce still more irritation
and reflex phenomena. Patients suffering in this way will be noticed
to make frequent attempts at swallowing and coughing, which may be
depressing, and may lead to disturbed sleep and even an asthmatic
form of breathing. The uvula is a useless organ when it has attained
such dimensions, and its amputation, or at least its shortening, are
indicated in all such cases as those above described. Local anesthesia
is sufficient. Its tip is caught with a pair of forceps and it is
clipped off, not too near its base, by long-handled and sharp scissors.
This is a much neater and more expeditious method than to include it
within the grasp of a wire snare and somewhat slowly crush it off.

Upon the uvula, as upon the soft palate, papular lesions of _syphilis_
are frequently seen, rarely the primary chancre, but very often mucous
patches or the deeper ulcers, which characterize the secondary and
tertiary lesions. _Gummas_ also may form within the thickness of
the palatal tissues, which will in time break down and form ragged
ulcers, while the destruction may extend to the bony portions, either
of the nose or roof of the mouth, and then necrosis will be added
to the evidences of ordinary ulceration. The rapidity with which
these specific lesions will disappear under prompt and vigorous
constitutional treatment, along with that local cleanliness which
should include removal of necrotic tissue, is surprising and gratifying.


THE EPIGLOTTIS.

The epiglottis is composed of yellow elastic cartilage and it does
not tend to calcify during the later years of life, as does the white
or fibrocartilage of the balance of the larynx. Thus its elasticity
and flexibility are fortunately maintained throughout life. It may be
sometimes injured by the incised wounds elsewhere described under the
term “cut-throat,” and is at least often thus exposed when not actually
injured.

The epiglottis seems to be exempt from most of the primary diseases,
but is occasionally involved in lesions of surrounding tissues, in
which it may then participate. Thus it may be deformed by cicatricial
tissue and unduly bound down, or it may succumb to advancing ulceration
of syphilis, tuberculosis, or cancer. Injuries which break the
laryngeal box rarely affect the epiglottis because of its elasticity.

While an extremely useful portion of the body, the epiglottis is not an
absolute necessity, for even after its removal individuals can swallow,
although the act requires some extra care. Should the epiglottis become
involved in cancerous disease it should be removed with the rest of
the diseased tissue, while syphilitic and tuberculous lesions will
usually prove amenable to a combination of local and general treatment.
New-growths in this region are extremely uncommon, but will prove
relatively easy of removal when present.


THE LARYNX.

The laryngeal cartilages, save the epiglottis, are composed of white
fibrocartilage which manifests a tendency in the later years of life to
undergo calcification. This makes the organ less elastic, changes the
tonal qualities of the voice, and makes it more brittle and subject to
possible fracture by external violence. _Fractures_ of the organ, as
of the adjoining _hyoid bone_, have been elsewhere discussed, with the
indications which may make an emergency tracheotomy necessary because
of hemorrhage or edema of the narrow laryngeal passage.

Of the inflammatory affections of the cartilages _chondritis_ and
_perichondritis_ are most common. These are usually seen in connection
with other expressions of tuberculous, syphilitic, and malignant
disease. Nevertheless they are known to occur as sequels of the
exanthems and ordinary infectious fevers. They may be followed by
destructive ulceration, which will lead to a necrosis of the cartilage
corresponding closely to death of bone under similar circumstances.
In due time there may form a cartilaginous sequestrum, and this
will require removal as though it were bone. Dangers attend these
lesions in two peculiar directions. The very condition which produces
the destructive inflammation may also produce either _hemorrhage_
or _edema_, with suffocation which can usually be prevented by
an emergency tracheotomy. On the other hand, when repair follows
spontaneous recovery or successful treatment, it may be accompanied by
such cicatricial contraction as shall materially change the shape and
impair or possibly destroy the function of the larynx itself. In this
case either thyrotomy, tracheotomy, or laryngotomy may be called for,
the opening thus made being expected to permanently remain.


STRICTURES OF THE LARYNX.

Various forms of _stricture of the larynx_ may be similarly produced.
Such strictures, then, are due to previous disease or to injuries,
and here as elsewhere stricture is a consequence rather than itself a
disease. It occurs in consequence of syphilis and of the destruction
following laryngeal diphtheria.

What is, in this respect, true of the larynx is also true, though
less often, of the trachea, where constrictions may occur at various
points, with reduction of caliber or such distortion of shape as to
produce partial or even finally complete obstruction. The peculiar
scabbard-shape which the trachea may be made to assume by compression
between the lobes of a growing goitre has been elsewhere described.
While the trachea itself is in this case free from disease the
obstruction is none the less pronounced. Similar effects are produced
by pressure, as from aneurysms or tumors, even at a distance. Loss of
voice, shown to be due to paralysis of one or both vocal cords, should
always prompt an examination of the chest, in order that the presence
of an aneurysm or other tumor making pressure upon the recurrent
laryngeal may not be overlooked.


=Symptoms.=--Symptoms of laryngeal and tracheal stricture comprise
(1) those of the primary and active disease which produces them; (2)
those of obstruction; (3) those of suffocation in emergency cases. The
earlier symptoms are those of increasing _dyspnea_, which may vary
in rapidity and extend over weeks and months, or which may become
most pronounced within a few hours. There is also a change in the
character and sometimes complete loss of voice, hoarseness of the
speaking voice changing into a whisper. The condition is frequently
complicated by attacks of serious dyspnea, often at night, which are
due to an added spasmodic feature, and in which death may suddenly
occur. Usually, however, with asphyxia comes muscular relaxation,
and individuals may pass through a large number of these attacks,
which are accompanied with extreme mental and physical suffering, in
which death is only avoided by final relaxation. Again the heart may
suddenly give out, and then the case becomes practically hopeless. In
recognition of causes and location of such troubles it may be held that
when hoarseness precedes dyspnea the lesion is in the larynx; when the
reverse, it is in the trachea. Careful auscultation of the chest and
thorough laryngoscopic examination will usually enable the lesion to
be recognized. The lower the location of the stenosis the worse the
prognosis, because of its inaccessibility. So long as the trachea below
the stricture can be opened life may be prolonged indefinitely; but
when due to a mediastinal tumor or an enlarged thymus, the case assumes
desperate aspects and may baffle the best-directed efforts.


=Treatment.=--Strictures in the larynx proper may be treated by
dilatation, as by the introduction of intubation tubes of increasing
size, a method which ordinarily gives satisfactory results.
Nevertheless such laryngeal strictures manifest an almost permanent
tendency to recontract, and whatever measures are addressed to them
have to be frequently and thoroughly practised and over a long period.
Fortunately, however, these patients are able to wear an O’Dwyer
tube nearly all the time. When these internal operative methods fail
there remains only an external opening, which may be made through the
larynx proper (thyrotomy), or a low tracheotomy, which may require
the insertion of short or long tubes, according to circumstances.
Long trachea tubes are made, their lower portion being composed of
rings fastened together in such a way as to cause them to be called
lobster-tailed, and such a long tube may be passed through a low
tracheotomy opening and made to extend beyond the point of pressure
produced by an extrathoracic or an intrathoracic tumor. By the use of
such an expedient life may be prolonged, although the exciting cause
may prove fatal.


TUBERCULOSIS OF THE LARYNX.

Tuberculosis of the larynx may appear in a generally disseminated form,
involving nearly all the structures, or in circumscribed localized
form, as a tuberculous ulcer, which may produce symptoms depending
upon its exact location. Laryngeal tuberculosis may, moreover, be but
a local expression of the disease, apparently primary, or as often
happens, it may be an accompaniment of pulmonary tuberculosis, the
laryngeal trouble appearing as a local infection, taking place by the
constant passage over the surface of tuberculous sputum which the
patient is expectorating at frequent intervals. Thus, clinically, we
may have a miliary, an ulcerative, or a gummatous form of the disease.

The condition is frequently referred to as _laryngeal phthisis_,
and is mainly to be distinguished from syphilitic laryngitis, or
occasionally from commencing malignant disease. _Local symptoms_
include those of chronic laryngeal catarrh, with hoarseness, impairment
of voice, sensation of dryness within the larynx, and frequent short,
hacking, unsatisfying cough. To these features are later added more
or less pain, especially in deglutition, while aphonia will finally
succeed dysphonia. When the epiglottis and the structures near it are
involved there are more irritation and pain. Dyspnea is a measure of
the encroachment upon the breathing space left by the progress of the
disease. Infiltration of all the parts within and later of those around
the larynx finally takes place, and with further implication nervous
reflex symptoms are added to those above mentioned. Cough is usually a
distressing feature; the sputum varies in amount; saliva is increased
in flow, and the expectoration is frequently streaked with blood. In
advanced disease the sufferings of the patient become excessive, while
constitutional symptoms keep pace with those of the local disease.
Thus anemia, emaciation, debility, insomnia, and general malaise cause
the patient great discomfort, and, coupled with his terminal local
symptoms, make death an absolute relief.

With the laryngoscope varying pictures may be seen, either of
ulceration or of general involvement of the entire interior of the
larynx, which will be tumefied, irregularly swollen, ulcerating here
and there, while the vocal bands show thickening and roughenings as
well as ulcerations. Gummatous outgrowths may be seen at almost any
point and in various stages of ulceration. A more distinctly _lupoid
form_ of tuberculosis is also occasionally seen in the larynx, where
it assumes more of the nodular appearance characteristic of lupus, the
nodules coalescing or disappearing by ulceration, which may leave a
dense, cicatricial tissue after healing. Primary lupus of the larynx is
rare.

Tuberculous lesions of the larynx are mainly to be recognized with the
laryngoscope, but they, like all other local diseases in this location,
produce alteration and final loss of voice, with difficulty of
breathing, reflex cough, and are accompanied by general constitutional
symptoms, according as the disease is purely local or an expression of
a general affection.


=Treatment.=--Treatment should be both local and general. The latter
may be summarized by stating that all measures, including proper
climatic environment, which are found to be of advantage in ordinary
tuberculous disease, will prove of equal advantage here. There should
be avoidance of exposure to all irritation--coal gas, tobacco smoke,
vitiated air, etc.--while absolute rest of the vocal organs should
be prescribed and all attempts at singing or unnecessary speaking be
prohibited. All measures regarded as of value in general tuberculosis
will find an equally wide field for their activities.

_Local treatment_ is directed toward amelioration of discomfort
and improvement of local lesions. The former may be afforded by
steam inhalations with some soothing, volatile antiseptic added to
the spray, such as methol, oil of eucalyptus, some gentle opiate,
or anything that may give local anodyne effect. Cough may also be
treated by the milder anodynes, of which cocaine or heroine will serve
for most instances. Sleep is to be secured by some of the ordinary
hypnotics. Local applications may be made by an applicator guided by
the laryngoscopic mirror, by the medical attendant, or through watery
or oleaginous solutions in a spray. For absolute local relief a mild
cocaine solution, followed by the use of a very weak solution of silver
nitrate, lactic acid (C. P.), or even the more thorough treatment of
local ulceration by means of the laryngeal curette or touching with
the point of the galvanocaustic loop, may give relief. The treatment
of laryngeal tuberculosis rarely comes within the domain of surgery
proper, until the disease has reached a degree necessitating some
radical measure, such as thyrotomy, with erasion of the affected
tissue, or possibly a laryngectomy, with complete removal of an organ
which is too thoroughly diseased to warrant hope of repair.


SYPHILIS OF THE LARYNX.

Syphilis of the larynx is more common than tuberculosis, the lesions
usually belonging to the later stages of the diseases, including
especially mucous patches, and the ulcerative expressions, with
or without the formation of small gummatous tumors. The loss of
voice is rarely as pronounced, and the entire course of the disease
is accompanied by less irritative and offensive features than is
tuberculosis. Diagnosis will be materially assisted by the discovery
of suggestive expressions of syphilis, either in adjoining or distant
parts. Thus if mucous patches appear within the larynx they will also
be seen within the mouth. Ulcers which are produced by syphilis have
well-defined edges, and are rarely multiple; while those produced by
tuberculosis are more often multiple, are seated upon an anemic base,
produce more distortion of laryngeal structures, and more residue of
cicatricial tissue at points where healing has occurred.


=Treatment.=--The treatment of laryngeal syphilis is essentially
constitutional, for nearly every local expression will clear up under
the influence of properly directed remedies. However, when local
symptoms are uncomfortable or depressing they may be treated as are
those of tuberculosis, by soothing sprays and the local application of
anesthetics, astringents, and the like.


INTRALARYNGEAL AND INTRATRACHEAL TUMORS.

Within the larynx tumors may occupy the space beneath the glottis,
where they are referred to as _subglottic_; they may grow from the
structure of the vocal cords and become _intraglottic_, or they may
spring from above the glottis and from the aryteno-epiglottic fold.
Certain forms of benign tumor are relatively common in this location,
while others are almost unknown. The former include cysts, papillomas,
fibromas, angiomas, and adenomas, as well as the ordinary granulomas.

A nodular lesion seen upon the vocal cords, especially in singers,
which is hyperplastic in character, irritative in origin, and often
called “_singer’s node_,” is frequently found upon the edges of the
cords, either as a single or bilateral lesion. The adjoining structures
are usually quite vascular. These lesions occur in those who abuse
their voices, as, for instance, in amateur singers and newsboys. The
nodules themselves vary in size from that of a pin’s head to that
of a split pea. The condition produces hoarseness and impairment of
the voice, is recognized with the laryngoscope, and is amenable to
treatment, which should consist in absolute rest from vocal effort and
gentle astringent and stimulating applications. If the node project
very far it may be removed by the intralaryngeal guillotine.

_Laryngeal polypi_ include the forms of benign tumor above mentioned,
most of which assume in time a polypoid form, and cause impairment of
function according to their location.

[Illustration: FIG. 481

Multiple papilloma of larynx. (Bergmann.)]

_Papilloma_ is by all means the most common of these growths, and may
present either the vascular type, bleeding easily and growing rapidly,
or the firmer and denser type from admixture with fibromatous tissue.
It occurs frequently in the young, and may even be present in the
newborn. Here it can scarcely be detected with the laryngoscope, but
may be felt with the finger. _Cysts_ take their origin from the mucosa,
save those which, possibly of embryonic character, protrude into or
encroach upon the larynx from without (Fig. 481).


=Symptoms.=--The symptoms of benign intralaryngeal growths are largely
irritative, including cough, with hoarseness and change of voice, and
going on to production of dyspnea in proportion to the size which they
attain. Later complete aphonia, with spasm of the glottis, may be
the result of their presence, while pedunculated growths, or polypi
with long pedicles, may cause aggravated symptoms by circumstances
of position, the patient being much of the time relatively free.
Hoarseness, dyspnea, and cough, without other evidences of inflammation
or epidemic disease, should always lead to careful inspection with
the laryngoscope, and this will reveal the size and situation of
the growth. These examinations can be made with cocaine and give
satisfactory information. Only in young children are they difficult, or
sometimes impossible. Even in an infant with a hoarse cry and spasmodic
or suffocative attacks the condition may be suspected.


=Prognosis.=--The prognosis will depend upon the character of the
tumor and the local conditions--_i. e._, size, fixation, location,
etc. In the young it is serious because of the danger attending its
removal. Rational adults can be usually put in excellent condition for
endolaryngeal operation by the aid of local anesthesia, and expert
specialists become dexterous in their manipulation of the specially
shaped forceps, curettes, and the like which are required for removal
of these growths. As elsewhere a truly innocent tumor in this location
does not recur after complete extirpation.


MALIGNANT TUMORS OF THE LARYNX AND TRACHEA.

Of these tumors the most common is _epithelioma within the larynx_.
_Sarcoma_ occasionally originates from the vocal bands, true or false,
and will usually form a nodular tumor, of rugose surface, until it
begins to ulcerate. Once it begins to break down it is difficult to
distinguish from the other varieties without the aid of the microscope;
but epithelioma may be met with in any part of the larynx, generally
arising from the ventricular bands. Here, as ordinarily upon mucous
surfaces, it begins as a small nodule with a definite zone of
infiltration about it; if seen early it may be mistaken for innocent
papilloma. As infiltration progresses the hoarseness resulting from its
presence will change to loss of voice, because of the fixation of the
tissues whose mobility is essential to voice production. Pain may be an
early feature, depending upon ulceration and exposure of sensory nerve
endings. Later when the ulcerated surface has become deep, irregularly
covered with fetid discharge, and more or less concealed by edematous
surroundings, the picture is more complete in one respect, although
the details may be obscure. From the mucous and softer tissues the
disease will spread and invade the cartilages themselves, as well as
the tissues outside, and so with the progress of the cancer the entire
larynx becomes fixed in a bed of infiltrated tissue extending in all
directions, involving the upper part of the trachea, the epiglottis,
and the base of the tongue. Meantime the loss of voice, the distressing
cough, and the other evidences of local invasion will have kept pace
with the progress of the disease, and dyspnea will come on sooner or
later as the passage-way becomes blocked, while from sudden, violent
efforts at coughing acute attacks of edema, which may result fatally,
are liable to occur.

_Tumors of the trachea_ proper are far less common. They may be benign
or malignant. In either event they will prove to be of about the same
type as those already discussed above as occurring within the larynx.
They cause less interference with speech, but as much or even more
difficulty in respiration.

When tracheotomy was a frequent resort in croup and diphtheria a
peculiar form of new formation in the trachea was occasionally
encountered, resulting from the irritation of the trachea tube, whose
presence sometimes provokes excessive formation of granulation tissue,
whose subsequent contraction brings about not only the formation of
a dense granuloma, but cicatricial contraction. Hence in the older
literature references to _granulation stenosis_ were common. Now
that intubation has almost completely replaced tracheotomy for these
purposes the latter is rarely performed, and tubes are seldom left more
than a day or two _in situ_, so that this kind of local provocation,
with its consequences, is rarely encountered.

It may be possible by expert use of the laryngoscope to see a tumor
located within the trachea. If the patient cannot tolerate its use the
parts may be made tolerant by the use of a weak cocaine spray. Such a
growth, if accessible from above, may be removed through the glottis
by forceps. Most operators, however, prefer to make an opening through
the trachea and thus profit by the larger surgical opportunities thus
afforded. Such an operation should be made with the patient’s head low
in order that blood may gravitate to the pharynx rather than to the
lungs.


OPERATIONS UPON THE LARYNX.

Cancer of the larynx was regarded, until the last quarter of the
previous century, as an absolutely hopeless condition for which
nothing could be done until it became necessary to do a tracheotomy,
this simply affording relief from some of the distressing features,
but aiding nowise to check the progress of the growth. The first
demonstration of the possibility of successful removal of the larynx
was made by Czerny, in 1870, upon dogs. Watson, of Edinburgh, had
removed a syphilitic larynx _in toto_ in 1866, but this summary
operation only became known to the world through a publication of
Foulis in 1881. Meantime, Czerny’s experiments were so successful
that Billroth was induced to attempt the removal of the entire larynx
in a case of cancer, with results which astonished the profession
of that day. Thus introduced, nevertheless, the mortality rate was
great, the principal cause of death being inspiration pneumonia--that
is, rapid infection of the lung through the widely opened trachea and
the entrance of saliva and fluids from the mouth. Hahn, of Berlin,
undertook the improvement of the technique and was able to reduce the
mortality from this cause. Meantime another radical method--namely,
_thyrotomy_, _i. e._, opening the laryngeal box--had not fared much
better than the measure just mentioned. Thus until about twenty-five
years ago the radical treatment of laryngeal cancer stood in an
unpleasant light, partly because diagnostic methods were unsatisfactory
and our general knowledge of the disease incomplete, partly because
operation was always delayed until late, and because operative measures
had yet to be much improved. Tremendous impetus was given to the
whole subject by the celebrated case of the Emperor Frederick, and
the acrimonious criticisms concerning its conduct were not without
benefit, since they led to a careful re-study of the whole situation,
with its numerous subsidiary questions, among which was the possibility
of transformation of a benign into a malignant tumor. At present,
largely through the labors of Hahn and Billroth, in Germany, and Semon,
in London, the question of operative procedures is fairly settled,
everyone now believing that the disease should be radically attacked at
the earliest possible moment, opinions differing only in regard to the
route which the surgeon should adopt, _i. e._, whether he should make
an intralaryngeal operation, as is now favored in Germany; a thyrotomy,
as preferred in Great Britain, or a laryngectomy, as some of the
general surgeons in all parts of the world prefer.

The different methods of attack upon the larynx for cancer may then
be summarized as including _intralaryngeal extirpation_ through the
natural passages, _thyrotomy_, and partial or complete _laryngectomy_.

The _intralaryngeal method_, seen from the general surgeon’s
view-point, can only be suitably applied to a limited class of cases
which are recognized early, and may be best performed by an expert
laryngologist, _i. e._, one accustomed to instrumentation within the
pharynx and larynx. It includes the use of various instruments for the
excision of small areas, for the application of the galvanocautery,
etc. The writer agrees with Semon in regarding it as irreconcilable
with the principles which should guide us in dealing with malignant
growths, the fundamental one being the removal not only of the growth
itself but of an area of surrounding tissue. This intralaryngeal method
may then be satisfactory in the removal of benign growths, but will
seldom appeal to the operating surgeon when he deals with cancer.
Epithelioma may commence at the accessible tip of the epiglottis, but
intrinsic cancer of the larynx should be dealt with in a more radical
manner. Thyrotomy is the operation of choice, especially among the
British laryngologists. It seems rational to believe that in cases
where diagnosis is made early a thyrotomy, with removal of the growth
and a wide area of surrounding tissue, including portions of cartilage,
if necessary, may prove the ideal operation, while vocal results are
better than after extirpation. It is necessary, however, that diagnosis
should be made early and that operation be made thoroughly; while if,
after opening the thyroid, it should appear that complete extirpation
of the growth is otherwise impossible, then the operator should make a
complete laryngectomy.

All of these operations are best preceded by use of a cocaine spray, by
which extreme irritability of the interior of the larynx is allayed,
and the reflex lowering of blood pressure prevented. (See p. 178.)

_Thyrotomy is performed as follows_: The patient is preferably in
the position with down-hanging head. An incision in the median line,
about three inches in length, is made from the upper border of the
thyroid cartilage down to a point below the cricoid. With but slight
separation of the tissues it is made to extend directly down upon the
abrupt ridge-like anterior border of the thyroid cartilage, below
which will be exposed the cricothyroid membrane. Into this the knife
may be inserted and made, with cutting edge up, to split the halves
of the larynx exactly in the middle line, the blade passing between
the vocal cords, unless they have been much distorted by the growth.
In that case the dissection may be made more deliberately. The larynx
being thus split, the cricoid should be divided, after which, with
suitable retractors, the interior is exposed to such an extent as to
permit both inspection and palpation. Through the opening thus afforded
all suspicious tissue should be removed, from one side or both, the
primary question being not what will be the resultant effect upon the
voice, but how best to completely eradicate the cancerous tissue. With
the patient’s head hanging downward there is less likelihood of the
entrance of blood into the trachea. Nevertheless the _tampon cannula_
should always be accessible so that it may be inserted should it be
required. The tampon cannula is a trachea tube around which there is a
small rubber bag, with a tube through which it may be inflated, so that
after the cannula is introduced into the trachea it may be tamponed by
air pressure in such a manner as to permit no passage of blood.

In the absence of one of these specially designed tubes an effective
substitute may be made by the ordinary trachea tube wrapped with a
covering of antiseptic gauze, the latter held in place by a few turns
of fine silk or catgut.

The thyrohyoid membrane bears the superior laryngeal vessels and
nerves, and it should be entered through the middle line in order
not to disturb these. Whatever operation may be required upon the
tissues within the laryngeal box may be conducted with knife,
scissors, curette, and the fine point of the actual cautery. The
interior of the larynx should be cleaned, leaving it simply as a part
of the respiratory tube, without reference to what may become of the
structures within it devoted to voice production. The cartilaginous
shell, with or without a part of its previous contents, having been rid
of the suspicious tissue within, it may be held together by one or two
sutures of silver wire or by superficial sutures of chromic gut, while
the trachea tube which may have been used may be left for a day or two,
or removed at the time. Ordinarily the latter course will prove the
better.

_Laryngectomy, or total extirpation of the larynx_, is the most
severe procedure of all, but will be requisite when there is evidence
of escape of malignant growth from within the true confines of the
laryngeal box. Not only the larynx but more or less of the surrounding
tissue may be removed, with infected neighboring lymphatics, the upper
portion of the trachea, and the base of the tongue.

The operation may be preceded by a low tracheotomy or otherwise. If
necessary this should be done several days in advance, in order that
the patient may have become tolerant of the tube and of the new method
of breathing. If requisite the ordinary trachea tube may be substituted
for the tampon tube above described, in which case it will not be
necessary to lower the patient’s head. Otherwise the operation is
perhaps best performed with the head and neck in the Rose position.

The incision is a long median division of tissues from above the hyoid
to an inch or more below the cricoid cartilage. Through it the anterior
border of the thyroid should be easily exposed. It is then necessary
to separate on either side the sternohyoid and sternothyroid muscles,
the lateral mass of the thyroid body being drawn to either side along
with the musculature, the isthmus having been previously doubly ligated
and divided for this purpose. Now as rapidly as may be the larynx is
completely isolated from all the structures around it, the dissection
being bluntly made. After freeing it on both sides it is drawn forward,
first to one side, then to the other, so that on either side the
superior laryngeal artery may be exposed and secured, the superior
laryngeal nerve being necessarily divided. The cricothyroid branches
need also to be secured, as well as any other vessels which may spurt
blood. Circumferential isolation of the larynx is now completed by
dividing the inferior constrictor of the pharynx and separating it
from the side of the thyroid, keeping close to the cartilage. After
this isolation is completed the surgeon has the choice of first
dividing the respiratory tube either above or below the larynx. This
will depend largely upon his own choice, but usually the procedure is
easier when the first division is made either through the cricothyroid
membrane or between the cricoid and the upper ring of the trachea or
even below this point, if necessary. With a low division first the
patient will immediately begin to breathe through the opening thus
made unless a previous tracheotomy has been done. Ample time will be
afforded for the introduction of a trachea tube and protection around
it to prevent entrance of blood, when the larynx may be lifted and
separated with knife or scissors from the tissues remaining attached.
The esophagus begins at the level of the cricoid cartilage, and if
the cricoid is to be removed the esophagus should be separated from
it; otherwise it is not disturbed. Last of all, in this order, the
thyrohyoid membrane will require division, and then the extirpation is
completed.

The wound is large, the communication with the oropharynx is
unobstructed, and there will be constant escape into the newly formed
cavity of secretions from the nose and mouth. At first the patient
will be unable to swallow, although there may be constant desire to
reflex attempts in this direction. The questions to be decided are the
management of the wound in gross and the suitable treatment of the
upper end of the trachea, as well as of the esophagus, if this has been
touched. The greatest danger is that of inspiration pneumonia. Other
consideration should be secondary to that of prevention of the escape
of fluids down the trachea and the consequent production of pneumonia.
General experience is rather to the effect that the best results are
obtained with a minimum of sutures, the large cavity being lightly
packed with absorbent material, while the upper end of the trachea
should be sewed to the skin as high as possible on either side, the
esophagus being allowed to take care of itself. The patient should
wear a trachea tube for several days after the operation. Through the
exposed upper end of the esophagus a tube may be passed three or four
times a day, and sufficient nourishment be thus introduced into the
stomach. The patient may be kept lying upon the side for the greater
part of the time, so that saliva may escape from the mouth.

The question comes up later as to what substitute, if any, may be
afforded for the lost larynx. Gussenbauer devised an improvement on
what was called the “artificial larynx,” devised originally by Foulis
and then modified by Hahn, which afforded an ingenious mechanical
substitute for the larynx, permitting the production of voice by
vibration of a metallic reed, such tone as it produced being, like that
produced by the vocal cords, modified by the vocal organs above into
perfectly intelligible speech, but always in a monotone. It consisted
of a tracheal tube through whose external opening another tube could
be passed upward to a point where it lay beneath the epiglottis, if
this were left _in situ_, or behind the base of the tongue, if the
epiglottis had been removed. Through this the patient could breathe
under ordinary circumstances. By a little device at the external
opening the touch of the finger upon a spring would throw into the air
current a thin, metallic reed, by whose vibrations tone was produced,
to be modified as mentioned above. This was the principle of the
_artificial larynx_ which was worn by many patients and which in many
gave good results. One patient of my own wore one for seven years,
although he discontinued using the reed because the peculiarity of
the tone attracted more attention than did the loud “stage whisper”
which he had cultivated. Around the instrument there is always more or
less moisture or discharge, and there are many disagreeable features
attending its use, even though it permit the act of swallowing without
any difficulty.

Solis Cohen introduced a method of treating these cases by fastening
the trachea to the external wound and permitting the cavity above to
close as rapidly as possible. In this way the trachea is permanently
terminated in the middle of the neck and patients breathe through
this opening. It has been found that with practice they can retain
sufficient air in the mouth and pharyngeal cavity to permit them to
whisper several words at a time. This simplifies the procedure, and is
now usually adopted after extirpation of the larynx.

_Partial laryngectomies_ have been practised through external openings,
one lateral half or more of the larynx being removed. These operations
have been few in number and often unsatisfactory. They should be
reserved for cases with favorable indications. When required they are
performed on the same principles as those already outlined, only the
extirpation is incomplete. Certain modifications have been proposed
by individuals, as, for instance, the suggestion made by Gluck, to
suture the opening in the trachea to a buttonhole opening made in
the overlying skin, by which means he thought to prevent inspiration
pneumonia.


OPERATIONS UPON THE TRACHEA.

Tracheotomy is the general term made to cover any opening into the
lower air passages between the larynx proper and the upper end of the
sternum. Laryngotomy, cricotracheotomy, tracheotomy, etc., may be
described as implying by these names the exact location of the opening.
The principle is, however, the same, and the details of the operation
vary but little.

[Illustration: FIG. 482

Position of patient for tracheotomy. (Wharton.)]

Tracheotomy as a deliberate operation is different from tracheotomy
as it was formerly practised for diphtheria, and as it is yet done in
emergencies, some cases being so serious that suffocation will occur if
the opening be not promptly afforded. In the former case preparations
can be made; in the latter, operation may have to be done with the
blade of a penknife. It makes considerable difference also whether an
anesthetic can be used. To administer chloroform to a child with a
heart already weakened by the toxins of diphtheria is almost to invite
disaster, and yet to do the operation without an anesthetic is perhaps
impossible.

The _middle line is the line of safety_ in all of these operations.
The danger of heart failure from the anesthetic, or of suffocation
from tardiness of relief, being passed, the other principal danger is
that of hemorrhage. The isthmus of the thyroid may be divided, but
always with preliminary ligatures, or it should be caught between
the blades of pressure forceps on either side before dividing it. A
patient with a short, fat neck, whose cervical veins are dilated and
engorged with venous blood owing to partial asphyxia, makes a difficult
and undesirable subject. The trachea lies nearer the surface at its
laryngeal end than in its lower portion--_i. e._, if the operation be
low in the neck deep search will have to be made for the tube. The
first incision should be made sufficiently long, never less than two
inches, and should be so planned as to bring the operator down upon the
tracheal rings. By this time sufficient engorged veins may have been
divided to cause a serious oozing of dark, venous blood, by which the
field of vision is much obscured. Except in emergencies the surgeon
may wait for this engorgement to be relieved. The trachea, being
recognized by the finger-tip, is seized with a tenaculum, by which
it may be held forward, and then at least two of its rings divided
with the knife-blade. The instant the opening is made, if the patient
be still breathing, bloody foam and frothy blood will be ejected,
and for a moment or two the bleeding may be uncontrollable. Under
these circumstances the normal blood color soon returns. Artificial
respiration should be practised at the same time. Supposing this to
be an emergency case, with little or almost nothing at hand, sutures
should be passed through the tracheal opening and through the skin
margin on either side. If no other retractor be at hand the suture
materials may be left long and tied behind the back of the neck,
sufficient tension being made to prevent the wound edges from coming
together. Formerly when the surgeon was called to do this operation
with little or no help the writer has extemporized a couple of
retractors out of hair-pins, bent for the purpose, hooked into the
tracheal wound, then tied with tapes, which were united behind the
neck, while the wires were kept from being pulled out of place by a
skin suture on each side. There is now less occasion for these crude
methods since the introduction of O’Dwyer’s intubation.

With _tracheotomy done deliberately_, and at the point of election,
usually above the thyroid isthmus, with or without division of the
cricoid, the vessels may be secured as they are exposed or bleed, and
the trachea should not be opened until all oozing from its exterior has
been checked. For this purpose the patient is placed upon the back, the
shoulders raised, the head thrown backward, and the neck exposed, a
pillow being placed beneath. (See Fig. 482.) The operation may be done
under cocaine local anesthesia or with a general anesthetic. Incision
in the middle line, below the lower border of the thyroid cartilage,
is made two inches or so downward, the fascia beneath being divided in
the same line and the tissues retracted to either side from this median
exposure. Thus one makes access to the cricothyroid membrane, the
cricoid, the upper tracheal rings, and the thyroidal isthmus. According
to the size and location of the latter (it usually lies in front of
the second tracheal ring) it may be retracted or doubly ligated and
divided in the middle. The difficulty now afforded is from the upward
and downward play of the larynx, which may occur during forced efforts
at respiration. To steady it a tenaculum should be introduced just
above the cricoid, a little to one side of the middle line, firmly
fastening it. With this held in the left hand, thus steadying the
parts, a sharp-pointed knife is so employed as to divide the cricoid
and one or two upper rings of the trachea, being cautious not to wound
the posterior wall. The opening thus made should be about one-half inch
in length. Through it a second hook is now passed into the other side
of the cricoid and the incision held open by their agency while the
trachea tube is introduced.

This procedure may be modified in accordance with any local
indications, and may be made according to the needs of the case. When
the opening is made into the trachea below the isthmus it is called a
low tracheotomy. Here the anterior part of the trachea lies free from
the skin, but may be covered with a plexus of veins connecting with
the inferior thyroid. Farther down the _arteria thyroidea ima_ may be
encountered. There is always reason for operating as high as the case
will permit. The trachea may itself be displaced by the growth which
compresses it and necessitates the operation. Thus it may be crowded
to one side, other anatomical relations being disturbed, or it may be
compressed into scabbard shape, and thus be difficult to find or to
open.

The moment the trachea is open more or less marked expulsive efforts
will drive blood and foam in all directions, and may for a moment
obscure the field of vision. Every precaution should be taken to
prevent the entrance of blood into the trachea. Pressure of the
tracheal walls against the tube to be inserted may check hemorrhage
from its margins. The operator should be ready to suspend all other
procedures and make artificial respiration, and he should also be
prepared to open the trachea suddenly, should impending suffocation
require it.

In a general way, then, the _indications for tracheotomy_ are symptoms
of rapidly or slowly threatening obstruction to respiration from causes
either within the larynx--_e. g._, diphtheria, foreign bodies, tumors,
and the like--or causes external to it, such as tumors, phlegmons,
cicatrices, etc. Any cause which interferes with the free play of air
through the respiratory tube, which can be either relieved or atoned
for by the operation, will always justify it.

_Tracheotomy tubes_ are mechanical devices for not only keeping the
tracheal wound open but permitting the unobstructed passage of air.
They are made of various materials, of which silver is the most
satisfactory, as aluminum is too easily acted upon by the fluids of
the body, and rubber occupies too much space. The tracheotomy tube
is a double tube, the inner one slipping easily into and out of the
outer, and being necessitated by the ease and abundance with which
secretions may collect and dry, and thus obstruct. Were it necessary to
remove the entire tube for each cleansing, difficulty might be met in
re-introducing it, whereas the inner tube is easily removed, quickly
cleansed, and restored to place within the outer without disturbance or
pain to the patient.

Aside from the tracheal tubes ordinarily used there are others made
exceptionally _long_, and with flexible lower ends, which may be used
in case of tumor low in the neck or high in the mediastinum--for
instance, in cases of enlarged thymus, where it is necessary to go
beyond an obstruction.

In the _after-care_ of these cases it should be remembered that air
passes directly into the lung without being warmed, or moistened, by
passage over the mucous membrane of the upper respiratory tract. The
patient, therefore, should be kept in a warm room, and the air should
be kept moist by the use of a croup kettle or a spray machine. The
inner tube should be kept unobstructed, the length of time during
which it should remain depending on the nature of the case. So soon
as its usefulness is passed it should be removed. A tracheotomy wound
kept open but for a day or two will quickly close, but one which has
remained open for weeks may close with difficulty, and then there may
be trouble from granulation stenosis or cicatricial contraction. (See
above under Stricture.) In instances where a permanent opening is to be
maintained it is desirable to remove the tube as early as circumstances
may permit.


INTUBATION.

The perfection by Joseph O’Dwyer of a method, at which others
had worked, of substituting intubation of the larynx for the old
tracheotomy, not only shed the greatest luster upon his own name, but
has afforded a speedy and bloodless method of accomplishing much more
than had been previously possible by the older procedure. The method
comprises the emplacement of a suitably sized and shaped tube within
the larynx, by a manipulation guided almost entirely by the sense of
touch, for the relief of suffocative symptoms due to disease at this
level, and leaving the tube _in situ_ for a sufficient time to permit
morbid activity to subside and justify its removal.

It is advisable to have a half-dozen tubes, varying in size from 1¹⁄₂
inches to 2¹⁄₂ inches in length, and of corresponding increase in
other dimensions, each of which affords a passage-way for respiratory
purposes, and is also provided at its upper end with a flange, which
shall rest upon the false vocal cords and prevent the descent of
the tube into the trachea below. The complete set of instruments as
now furnished by all the manufacturers provides an assortment of
these tubes, with a scale indicating which one to use upon a patient
of a given age, and includes a mouth-gag, which may be used for
many purposes, and two handled instruments--one intended for the
introduction, the other for the extraction of the metal tubes.

[Illustration: FIG. 483

O’Dwyer’s laryngeal tube and introducer.]

[Illustration: FIG. 484

Mouth-gag.]

[Illustration: FIG. 485

Extractor.]

[Illustration: FIG. 486

Intubation of the larynx.]

[Illustration: FIG. 487

The tube in the pharynx.]

A suitable tube having been selected, a strong thread is passed through
a small opening near its head, thus affording means for withdrawing
it should there be need before it is finally left in its resting
place. The particular obturator meant for the tube to be used is then
firmly fastened upon the handle and over it the tube is slipped. The
instrument should then be tested to make sure that disengagement of the
tube will easily take place. Everything being ready, the patient is
then held in the arms and on the lap of an assistant, in the position
indicated in Fig. 486. The individual holding the patient should be
perfectly reliable in the matter of presence of mind and self-control,
for a great deal depends upon having a child firmly and properly held
during the moment of intubation. The arms and hands of the patient
should be well wrapped with a towel and firmly held by the side of the
chest, for the temptation is inevitable to put the hand to the mouth
and interfere with the operator. A second assistant should stand above
and behind, holding the mouth-gag in position, as represented, and
steadying it as well as the head. It is necessary that the mouth-gag be
held firmly in place, for if it should become disengaged the child may
bite the operator’s finger.

[Illustration: FIG. 488

The tube penetrates the larynx. (Lejars.)]

[Illustration: FIG. 489

The stem is withdrawn while the finger fixes the tube. (Lejars.)]

Standing in front of the patient the operator identifies the tip of
the epiglottis with the forefinger of the left hand in the pharynx,
this finger being used at the same time to raise and fix the epiglottis
and also to serve as a guide to the tip of the tube, which is passed
downward alongside it, by a maneuver similar to that by which the
laryngoscopic mirror is used in the pharynx (Fig. 487). When the tip
of the tube reaches the location behind the epiglottis the finger may
be passed a little farther downward, plugging the entrance to the
esophagus, while at the same time the handle of the instrument is so
manipulated as to bring the tube forward. With gentle movement in
the right direction it passes into the larynx (Fig. 488). It is then
pressed downward until the flanged upper end has passed the epiglottis,
after which the tube is disengaged, the handle and the obturator
withdrawn, and the upper end of the tube pressed gently into place by
the finger which still rests in the pharynx (Figs. 488, 489 and 490).
During the manipulation there is almost complete obstruction of the
glottis for two or three seconds. The effort, therefore, should be
to shorten the procedure, and at no time should it occupy more than
two or three seconds. If the landmarks are not easily recognized,
and the tube is not placed at the expiration of three seconds, the
operator should discontinue for a few more seconds in order that a few
inspirations may be taken, after which he should try again.

[Illustration: FIG. 490

The finger pushes the tube into place. (Lejars.)]

[Illustration: FIG. 491

Withdrawal of the thread. (Lejars.)]

When the tube is in place there will come ease of respiration, at the
same time violent coughing efforts, because of the irritation thus
suddenly produced. So soon as it is apparent, both to the finger in
the pharynx and from the relief of obstructive symptoms, that the tube
is in its proper place, the finger may be once more passed into the
pharynx, the tube pressed down, while the silk thread is withdrawn,
since it is not intended to leave it for more than the time necessary
to be assured that the tube will not have at once to come out again
(Fig. 491). Before removing the thread the gag should be removed for a
few moments, so that the effect of the excitement may pass, after which
it may be re-introduced for the purpose of withdrawing the thread.

The procedure is by no means a simple nor necessarily easy one, and
it should be practised with the instruments upon the cadaver before
resorting to it on the living child.

The tube being placed it will remain to be decided by the subsequent
course of events how long it should be allowed to remain--in some
cases a few hours, in others a few days. With young children it should
remain for at least a week. The time having arrived for its _removal_,
the procedure is similar to that required for its introduction. The
assistants hold the child in the same position as before, while the
operator substitutes the extractor, guiding its tip again by the sense
of touch along the left index finger, which, passed down into the
pharynx, is made to discover and identify the upper end of the metallic
tube. So soon as the point of the extractor is engaged within the tube
the blades are separated and it is then drawn out, while the finger
is withdrawn along with it in order to make its removal easier and to
prevent its loss should it slip off the instrument. Unless the patient
struggles violently the whole procedure should be conducted so as to
scarcely cause the slightest staining of the expectoration with blood.

_Various causes may require abrupt removal of the tube._ Thus it
is possible for its caliber to be become occluded with tenacious
secretion. This may produce a violent fit of coughing, during which
there may occur spontaneous expulsion of the tube. At any time, when it
is seen that asphyxia is increasing, or when violence of respiratory
effort would indicate obstruction within the tube, it should be
removed, cleaned, and re-introduced. After its introduction and removal
the operator should remain within easy reach for a short time, to be
sure that no unpleasant effects result and that no re-introduction
may be suddenly required. Should obstructive efforts occur the child
should be held head downward and be slapped vigorously upon the chest.
This may loosen membrane or it may permit dislodgement of the tube and
its spontaneous expulsion. The latter may also occur during the act of
vomiting.

The above description is meant especially to apply to intubation
as performed upon young children for the relief of the laryngeal
obstruction consequent upon diphtheria. It has given better results
than tracheotomy, which was the only resort previous to O’Dwyer’s
device. It is usually performed easily, and is devoid of the horrors
frequently attendant upon an emergency tracheotomy. But intubation is
not necessarily limited to children nor to cases of diphtheria. The
emplacement of such a tube may be called for at any time in cases of
threatening or actual _edema of the glottis_, as, for instance, from
inhalation of steam or flame. It may be advisable in other forms of
intralaryngeal disease, both acute and chronic, while individuals
suffering from laryngeal stricture or stenosis find that they can wear
an O’Dwyer tube almost constantly, not only with relief, but that they
are thereby saved from the more serious measure of opening the trachea
or removing the larynx.

Impending suffocation having been relieved by intubation, the question
of feeding arises. The principal disadvantage attendant upon the use
of the tube is partial or complete inability to swallow, for the
epiglottis does not always easily close over the tube and prevent
entrance of fluid into the larynx. It is necessary to feed patients,
especially the young, with extreme care. For this purpose there is no
food better than ice-cream, while little children should be placed upon
their backs, with the head lower than the body, and made to swallow
in this position, at least until they have been accustomed to the
presence of the tube and instinctively learn how to avoid irritation by
involuntary regulation of the act of swallowing.




CHAPTER XLII.

THE NECK.


CONGENITAL ANOMALIES OF THE NECK.

These consist largely of defects due to arrest of development along
the lines of the branchial clefts. Necessarily of embryonic origin,
they do not reveal this until varying periods after birth, sometimes
not until old age. They consist of fistulas, opening either externally
or internally, or more commonly of cystic dilatations of the interior
portions of the original fissures. External openings are usually seen
along the sternomastoid, either in front or back of it, or between
the larynx and the clavicle. Vestiges are also present in the shape
of little tags of skin containing portions of cartilage or bone. They
frequently occur together, the tag indicating the location of the
fistula, whose opening may be found obstructed with crusts. Internally
the openings are usually found in the pharynx, perhaps in the larynx or
trachea, generally near the tonsil and base of the tongue. An external
fistula may be tested for its completeness by injecting a colored fluid
and inspecting the pharynx. The fistulous portion is usually marked
by a cord-like mass which extends inward, usually toward the hyoid
bone. Internal blind fistulas may gradually expand and constitute one
variety of the so-called pulsion diverticula of the pharynx and upper
esophagus, their dilatation being due to accumulation of food, and
gradual stretching in this way.

All of these embryonic relics are of interest because from their small
beginnings large growths may take place, constituting even serious
surgical problems. These growths may present in almost any region of
the neck and frequently extend into the mouth, where they give rise to
certain forms of _ranula_. Almost every cystic tumor beneath the tongue
or jaw is open to the suspicion of having an embryonic origin. Most of
these vestiges are amenable to surgical treatment should they give rise
to discomfort or trouble. The operations required are sometimes quite
extensive, as any tumors of branchiogenic origin are especially liable
to adhesions to the large vessels; moreover, they are nearly always
firm and the dissection thus made difficult. A dermoid cyst may be
evacuated and its wall or sac destroyed or dissected out. It may then
be made to heal by packing.


=Treatment.=--In the treatment of fistulas of the neck, König has
advised that a curved probe be passed through the tract to a point
close to the tonsil, at which point on the inside of the mouth or
pharynx the mucous membrane is incised, a silk thread is fastened to
the end of the probe, pulled out with it, then made to pass to the
external end of the fistulous tube, which is then invaginated and
pulled back into the mouth, where it is reduced to a short stump which
is fastened to the margins of the opening of the mucous membrane. The
external wound is then made to heal as usual. This treatment suffices
for blind internal fistulas of the cervical region.

It is a matter of great surgical importance and interest that certain
branchiogenic remnants persist in a perfectly harmless manner until
advanced life is reached, after which there take place therein
cancerous changes which convert them into the so-called _cancers of
branchiogenic origin_. These are too often of hopeless character by the
time they are seen by the surgeon.

Other congenital defects consist of atrophies, such, for instance,
atrophy of the sternomastoid muscle, or of certain hypertrophies which
may be unilateral or symmetrical.


WOUNDS AND INJURIES OF THE NECK.

The neck is everywhere exposed to incised and perforating wounds,
partly as the result of pure accident, too often as the result of
homicidal efforts. The most exposed parts are supplied with veins of
large caliber which connect directly with the heart, and whatever
danger there may be of _entrance of air into the veins_, under any
circumstances, is in this region enhanced. This entrance of air has
been regarded as a serious and often fatal accident. The writer’s
experience and research have shown that it may often occur in mild
degree with but little temporary disturbance. Should it occur the fact
will be indicated by a slight gurgling sound, with tumultuous action of
the heart, dilatation of the pupils, embarrassed breathing, and every
indication of lowered blood pressure. Every competent operator will
secure these large veins before dividing them, but if anything of this
kind should be noted during an operation, pressure or plugging of the
wound, with artificial respiration, perhaps even massage of the heart,
and tracheotomy if necessary, should be practised until the patient
has revived. If in the course of an exceedingly deep dissection the
accident can be foreseen it may be avoided by keeping the wound filled
with warm sterilized salt solution. This, however, will seriously
embarrass the operative work, as it obscures vision.

The lower in the neck a serious wound be received, other things being
equal, the more dangerous it becomes. Thus penetrating wounds above
the larynx are of less importance than those below it. All injuries or
wounds about the larynx are not only likely to dislodge its interior
cartilages, but are especially likely to be followed by pressure of
effused blood, or the consequences of a rapid _edema of the glottis_,
which may prove fatal unless the trachea be opened below. It is this
fact which makes fracture of the larynx so dangerous an injury.

A _wound of the trachea_ rarely occurs by itself, as it lies deeply,
and it may be especially serious if vessels in this neighborhood
have been so injured that blood may be easily poured or escape into
the lungs. If the trachea be completely divided its ends will be
separated and gap, while the lower end will be drawn out with each deep
inspiration. In this way suffocation may quickly occur. In all such
cases the head should be placed lower than the body (Rose’s position),
the lungs emptied completely, the wound enlarged, and the tracheal
wound be sutured or else a tube be inserted. The treatment must
largely depend upon the number of hours which have elapsed since its
infliction, and the condition of the wound itself. In these cases it
may be assumed that such a wound is infected, therefore it should not
be closed without provision for drainage.

Any injury to the respiratory tract proper will be indicated by the
character of the expectoration and the sounds heard on auscultation.
Such injuries are likely to be complicated by a subsequent bronchitis,
pneumonia, deep abscess, or various other undesirable sequences. Under
the suggestive term “Schluck-pneumonie” the Germans have described a
condition which we describe in the term “inhalation pneumonia.” It
implies a septic type of pneumonia caused by the passage downward of
foreign material, including septic wound secretions, which, not being
expelled promptly, cause a type of inflammation, with consolidation,
which will give most of the ordinary physical signs of pneumonia.

A rather distinct type of incised wound is that included in the term
“_cut-throat_.” It implies a homicidal, usually suicidal, attempt on
the part of the ignorant to sever the large vessels in the neck. This
is but rarely accomplished, the injury being done to the larynx and
the trachea and the tissues anterior to the vascular trunks. Usually
inflicted with the right hand, one side of the wound may be deeper
than the other. While the trachea is usually cut and often divided,
the injury may be to the larynx instead. At all events, a wide gash is
made and there is considerable hemorrhage, the external jugulars being
nearly always severed. By the time such a wound is seen by the surgeon
it is an infected wound and it should not be closed too tightly. The
trachea may be sutured by itself, but it will be best to place therein
a tracheal tube. Ample provision should also be made for drainage. In
some instances the wound may be left open, at least for a few days,
until it is granulating, and then be closed by deep sutures. Care
should always be given to those of desperate suicidal intent and to the
maniacal, that they do not reopen the wound in continuation of their
previous efforts. This requires careful watching.

_Rupture of the trachea_, either due to violent coughing or straining
efforts or to external violence, is known. It will call for
tracheotomy, because of the emphysema which will ensue. Penetrating
wounds of the large arteries and veins are always serious. When not
extensive they may be followed by diffuse or circumscribed hematoma
or by aneurysm. Nélaton is reported to have stated that it takes four
minutes for a man to bleed to death from the carotid artery, and
that two minutes should suffice for its ligation. Any injury to the
vessels should be followed by their exposure, and probably by ligation
or suture, in order to prevent the conditions above mentioned. If the
wound be low in the neck it would be proper to remove the upper end of
the sternum or to divide the sternomastoid sufficiently to expose it.

The _vertebral artery_ is occasionally injured, mostly in the osseous
canal through which it passes. At the base of the neck a wound at or
near its origin is an exceedingly serious injury. The same rules apply
as above.

_Wounds of the large veins_ are supposed to be of a more serious
nature because of the possibility of inspiration of air, _i. e._, air
embolism. These vessels are occasionally injured during removal of
deep-seated and adherent tumors. It has been possible in some instances
to make a _lateral suture of the jugular vein_ at the point of injury,
providing this be not too extensive. Effort at reunion of this kind
is always legitimate if the operator feel himself equal to the task.
The jugular vein is also occasionally exposed and tied low down, then
opened above the ligature, for the purpose of cleaning out its upper
portion when filled with infective thrombi, a condition occasionally
seen with mastoid abscess, etc. To open it before tying would be a
surgical mistake. By this process it is practically obliterated as
recovery ensues.

If such a muscle as the sternomastoid be partially or completely
divided muscle suture should be practised and the head and neck kept at
rest for the ensuing few days.

_Injuries to the cervical nerves_ may be followed by peculiar and
interesting features. That of the recurrent laryngeal will cause
paralysis of the laryngeal muscles on one side, with consequent
difficulty in speech; injury to the cervical sympathetic will be
followed by dilatation of the pupils and protrusion of the eyeballs
with flushing; of the spinal accessory, by mastoid and trapezius
paralysis; of the phrenic, by paralysis of the diaphragm on one side;
and of the pneumogastric, by embarrassment of respiration, with
pupillary and abdominal symptoms, which are variable. Of all of these
injuries that to the phrenic is probably the most serious. Some years
ago I tabulated the then recorded cases of injury to the pneumogastric
and was able to show that only about 50 per cent. of such cases were
immediately or tardily fatal. The phrenic nerve is then the only one
within the neck which can scarcely be spared. Any of these nerves when
divided should be reunited by sutures, as elsewhere described.

When any portion of the _brachial plexus_ has been injured a
corresponding paralysis of the arm will follow. Wounds of these nerves
should be sutured at once. A distinction should be made in all cases
between hysterical anesthesia, malingering, and the actual paralysis
of injury. Sometimes the amount of callus thrown out after a fracture
of the clavicle will include a nerve of sufficient size to produce a
neurosis, usually neuralgia, or possibly a paralysis. Excessive callus,
or, in effect, the bony tumor which is thus produced, may be removed by
operation, and any entangled nerve should be hunted out and liberated.

Pressure of a tumor upon a nerve will cause paralysis corresponding to
its degree. When this comes on gradually, even though it involve the
phrenic nerve, the consequences are not so serious. Repeated irritation
or pressure may cause paralysis, as in the cases of the strap of
letter-carriers or those who carry burdens slung from the neck.

_Injuries occur to the cervical muscles during parturition and a
hematoma_ of the sternomastoid in the newborn is described. The
muscle is contracted and the head bent over. It usually disappears
by resolution within a short time. This muscle is also ruptured by
violence in the adult; again, hematoma is the result, with at least
temporary torticollis, pain, and tenderness. When an abrupt division
can be recognized, exposure of the ends and muscle suture would be
indicated. At any time, in the presence of clot, it would be proper to
cut down and turn it out.

_Syphilitic myositis_ is often seen in the sternomastoid, where it may
affect the entire muscle, transforming it into a cord-like mass, or
where it may occur as gummatous infiltration. These cases occur without
pain and without known cause save the disease itself, whose possibility
should be established by the history of the case. Again, these
muscles are sometimes contracted because of reflex excitement from
adjoining inflammatory foci. Such an affection subsides shortly after
due attention to the exciting cause, unless it has been allowed to
continue too long. _Inflammation_, even of the destructive type, may be
propagated to the muscles by continuity from a neighboring suppurating
focus.

Serious _phlegmons of the neck_ may be followed by phlebitis of the
internal jugular vein, which may be recognized by the presence of a
palpable cord-like clot within its lumen. Such a condition is serious
because of the ease with which pyemia may ensue. It would be better to
expose the vein, to tie it low down, to freely excise and turn out such
a clot, than to leave it to create serious disturbance a little later.

Of the _posterior portions of the neck_ we have fewer injuries, and
these less serious, excepting those by which the vertebral column or
the enclosed spinal cord are injured. These injuries have been referred
to in the chapter on the Spine. A high perforating injury of the cord,
especially if it involve the medulla, is promptly fatal. Infanticide
has been produced by a long needle driven between the occiput and
the vertebræ, corresponding to the pithing of small animals in the
laboratory. An injury above the origin of the phrenic, on one side, is
not necessarily fatal. Injuries to the posterior portion of the high
cervical cord, as well as to the membranes, may be followed by more
or less atrophy of the genital organs, with corresponding impotence,
Larrey claiming that this may take place even when the cord itself is
not affected.

_Ruptures of muscles_ and _separations from their insertions_ or
origins are occasionally noted. The scapular muscles are occasionally
torn loose. A reflex spasm of the trapezius which follows some of
these injuries will produce a posterior form of acute torticollis
(wryneck) described in the chapter on Orthopedics (XXXIII). The
resulting deformity and stiffening might be confounded with arthritis
of the upper vertebral joints. It is to be overcome by traction and by
suitable apparatus, save in extreme cases, when division or excision of
a sufficient portion of the muscle may be practised.

[Illustration: FIG. 492

Carotid aneurysm successfully treated by complete extirpation.
(Author’s Clinic.)]

Of great interest are the _blood vascular tumors_ of the neck, both
those of spontaneous and of traumatic origin. Large angiomas, either
of the arterial (cirsoid aneurysm) or of the mixed or venous type, are
seen about the neck. Here more than anywhere else are found peculiar
_venous dilatations_, especially of the smaller veins, which form
cavities in a tissue that becomes thereby almost erectile. Should these
tumors connect with the arteries they will pulsate. If composed of
larger veins they will prove quite compressible. These tumors should
be extirpated, care being taken to place a provisional or permanent
ligature upon the large vessels connecting therewith before the
tumor itself is attacked. Occasionally the ampullæ of these growths
become sufficiently large to entitle the growths to be considered
as _sanguineous cysts_. The neck is also frequently the site of the
smaller varieties of these growths which constitute the ordinary nevi.
(See chapter on Tumors.)

_Aneurysms of the cervical vessels_ are more frequently of spontaneous
than traumatic origin. They may, however, result from contusions or
penetrating injuries. While no vessel in the neck always escapes, it is
the common carotid which is more frequently affected than the others.
The general subject of aneurysm has been considered. Care should be
taken not to confuse the vascular and pulsating goitres, or other
pulsating cysts of the thyroid. It is necessary also to distinguish
aneurysmal pulsation from that which is transmitted through a tumor
overlying the vessels or which may be seen in some of the extensive
malignant tumors of the neck. When the diagnosis of aneurysm is made
the surgeon should decide what vessel is primarily affected. This,
however, is not always possible, as an aneurysm of the vertebral artery
projecting forward is liable to be mistaken for one of some other trunk.

Aneurysm in the neck, unless very deep, and in a very unfavorable
subject, is always an indication for operation. While operation
necessarily includes ligation, either on the proximal or distal side,
if this can be practised the sac itself may be treated just as though
it were a tumor of any other character, and extirpated. I have myself
had satisfactory results by the last-mentioned procedure (Fig. 492).
The existence of laryngeal paralysis, especially unilateral, which is
not easily accounted for in other ways, should excite a suspicion of
aneurysm, with consequent pressure upon the recurrent laryngeal nerve.
Its possibility should be excluded as part of the diagnosis.

_Wounds of the subclavian vessels_ give rise to serious hematomas which
may be converted into spurious traumatic aneurysms of arteriovenous
character. When such a tumor pulsates it is probably connected with the
subclavian artery, which should be ligated. It may be possible to make
this ligation above the clavicle, but a portion of the sternum should
be removed as well as the inner end of the clavicle for a more complete
exposure. On the right side at least the artery can only be reached
above the bone after dividing the scalenus anticus, where a provisional
ligature may be placed. After this the sac should be incised and the
vessel ligated, on either side of it, so that the provisional ligature
may be removed. On the left side it is safe to ligate the second
portion of the artery at once. The clavicle should be divided to afford
better exposure, and its ends reunited with silver wire (Fig. 493).

[Illustration: FIG. 493

Traumatic aneurysm of axillary artery.]

Any open wound of the subclavian vein is a serious affair, as bleeding
will be profuse, and there is also danger of air embolism. Immediate
occlusion with an antiseptic dressing would probably afford better
prospect than any attempt to enlarge the wound and secure the divided
vessel. If the vein be thus attacked its proximal portion should be
first secured in order to avoid the entrance of air. Meantime much of
the hemorrhage from the distal end may be prevented if pressure be made
in the axilla upon the axillary vein. If the vessel be secured both
ends should be tied.

In instances of accidental injury, or that included in the removal
of large and deep tumors, the _thoracic duct_ on the left side and
the _lymphatic duct_ on the right have been injured or divided. It is
one of the possible dangers in performing extensive operations on the
root of the neck, especially on the left side. Its occurrence would
be indicated by oozing of the milk-like lymph. The accident has not
been frequently reported. It would render closure of the wound without
drainage impracticable, but it has been found sufficient to place a
deep packing and to rely upon the natural healing process (granulation)
by which such a wound would be gradually closed.

It may be said of vascular lesions that when it appears to be necessary
the upper part of the sternum may be resected, as it adds little to
the danger and exposes the operative field in a more desirable way.
There is no better operative method for ligation of the innominate
artery than that which includes removal of the upper end of this bone.
Incidentally it may be added that this is also justifiable in certain
penetrating wounds of the trachea and in attacking retrosternal goitres
or lesions of the thymus.


PHLEGMONS OF THE NECK.

_Phlegmonous affections_ in the region of the neck are serious because
of the complications which may ensue. The more deeply they lie the
greater this danger. This comes not only from septic processes which
may follow veins and lymphatics, but from burrowing of pus along and
between the deeper muscle planes, which may carry it into one of
the mediastinal spaces or within the thorax. These phlegmons may be
primary, or may follow infection spreading through the open crypts of
the tonsils, or the open pathways afforded by diseased teeth and by
superficial ulcerations. An infection of a tonsil may cause an abscess
which presents beneath the jaw, while a deep axillary abscess may be
the consequence of a phlegmon beginning in the neck. Not infrequently
they come about through the mechanism of infected lymph nodes, which
may sometimes produce multiple or extensive single abscesses. These
phlegmons occasionally follow the exanthems, especially scarlatina,
and the variety of directions in which infection may spread from the
middle ear is well known, since it may cause phlegmon in the neck
or empyema of the mastoid antrun and even fatal disturbance within
the cranium. When the resulting pus travels downward in front of the
thyroid and sternum it will appear upon the thoracic wall; when behind
the trachea and the oesophagus, or along the large vessels of the
neck, it will be seen either within the thorax or at the root of the
neck, possibly opening into the esophagus or spreading to the axillary
space. _Retropharyngeal abscesses_ are often the result of caries of
the vertebræ, but may occur in consequence of a deep cellulitis caused
by extension from some focus within the nasopharyngeal cavity. This is
an illustration of the rule that pus travels in the direction of least
resistance.


=Diagnosis.=--The _diagnosis of cervical phlegmons_ is usually not
difficult, especially when they are superficial. The ever-present
indications of redness and edema of the surface, pitting upon pressure,
tender swelling, and loss of function of the surrounding parts, often
with fixation through muscle spasm, coupled with the general systemic
disturbance, and, in desperate cases, the indications afforded by
the blood and the urine, will enable a diagnosis to be made, usually
without the use of the exploring needle. This, however, may be employed
if necessary. The same is true in lesser degree of tuberculous
collections of pus and pyoid, which have been earlier described as
“cold abscess.” Only in the beginning of its course can any doubt arise
concerning the nature of a _carbuncular process_.

A somewhat typical type of deep phlegmon is often referred to as
_angina_ and _Vincent’s angina_. Semon regards these manifestations
as expressions of an acute septic cellulitis which has been described
as abscess of the larynx and as erysipelas of the larynx, and which
other writers refer to as cynanche tonsillaris, acute peritonsillitis,
etc. The disease may occur in healthy individuals, more often in the
diabetic. A violent sore throat is followed by serious dysphagia, with
considerable edema of the pharynx, whose surface is of a dark-blue
color. Patients may become unable to swallow, while hoarseness with
aphonia will result from edema of the glottis. The epiglottis will be
darkly discolored, greatly tumefied, and nearly obscuring the entrance
to the larynx. Dyspnea may necessitate tracheotomy. A light-colored
false membrane may be seen in the throat. There is always marked
lymphatic involvement. The disease may be more confined in some
cases to one side. Vincent has described a particular spirillum or
bacillus which he found in some of these instances. The infection
here doubtless proceeds from the mouth or the tonsils, its activity
being due to symbiosis of various organisms. It is to be distinguished
from Ludwig’s angina, which is rather a submaxillary affection than a
retropharyngeal. It infrequently leads to retropharyngeal abscess.

_Ludwig’s angina_, also called _infectious submaxillary angina_, is
an infectious cellulitis of the mouth. The tongue is swollen and
immovable; the mouth more or less fixed, with difficulty of swallowing,
and the condition is one of extensive infiltration, with formation of
pus, which is likely to burrow. In some of these cases the Micrococcus
tetragenus is the organism at fault. In my experience when present it
leads to a brawny infiltration which is slow to subside or disappear.


=Treatment.=--The early recognition and evacuation of pus are called
for in all cervical phlegmons. The presence of pus may be assumed
before it can be recognized from external evidence. Therefore when
swelling begins to mask anatomical outlines, or to produce difficulty
of swallowing or breathing, free external incision, with deep
dissection, will prove much safer than to leave such a case to itself.
Retropharyngeal abscesses, or such collections as may be recognized
in the tonsil or in the pharynx, may be opened from within the mouth.
That there should not be too much haste in this direction, however,
was indicated to me when a well-known surgeon plunged a bistoury into
what he supposed to be an abscess of the tonsil and found it to be an
aneurysm, the patient dying within five minutes in his office.

Early and free incision will relieve tension, and do good by a certain
amount of bloodletting, even if pus is not reached, while an easier
outlet for it will be afforded when it does form. However, the surgeon
will rarely fail to find it if he goes sufficiently deep or in the
right direction, when the existing symptoms and signs are of serious
import.

The operator should incise freely in the beginning, after which deep
dissection is best effected with some blunt instrument. The exploring
needle may afford valuable information, but if the deep tissues
be edematous we may feel quite sure of the presence of pus in the
neighborhood. Souchon has described a method of guided dilatation which
requires a series of dilating instruments, and which will give good
results. Search for pus can be made without them by using the blade of
a dissecting knife or hemostatic forceps, or the blades of a pair of
scissors to stretch a small opening. The less tissues are cut and the
more they are thus separated the better.

_Perilaryngeal_ or _peritracheal abscesses_ are likely to cause dyspnea
and show a tendency to extend downward along the trachea into the
thorax. In these locations they produce a peculiar diffuse cellulitis,
which was described by Dupuytren. Such phlegmons may extend from the
ear to the clavicle or from the back of the neck to the larynx. Pus
will collect in many small interspaces, and purulent infiltration will
affect many of the tissues, and may produce gangrene. This condition
has also been described by Gray-Coley and by Hannon. The surface
not infrequently seems to be involved in erysipelas. In fact it is
doubtless true that most of these affections are of the streptococcus
type, where it is impossible to distinguish between erysipelas and
cellulitis. Tracheotomy as well as the other free incisions may be
indicated. _An early tracheotomy should be made whenever suffocation
threatens from any swelling or edema._ The latter occurs so suddenly
that a tracheotomy should be made early rather than wait for its
necessity, especially when patients cannot be kept under constant
observation. The operation may be done under cocaine, while the
presence of the tube will then permit the administration of one of the
ordinary anesthetics without embarrassing respiration.

All of the other phlegmons, no matter what type they assume, are to
be treated on the same general principles. If seen, however, before
incision and drainage appear these cases may be treated locally with
the compound ichthyol-mercurial ointment, or with Credé’s silver
ointment, re-inforced by hot external applications; and the mouth
should be frequently rinsed with warm antiseptic solutions. Any lesion
within the mouth should receive its own proper treatment.


=Carbuncles.=--Carbuncles, which appear perhaps more frequently upon
the back of the neck than elsewhere, should be treated by the radical
method, _i. e._, excision of all tissue which is evidently so involved
that it will subsequently slough. Even an extensive carbuncle several
inches in diameter, with numerous crater-like openings, and presenting
large amounts of already necrotic tissue, is best treated in this same
way. The more quickly the dead and dying tissues are removed the better
for the patient. Such an operation requires an anesthetic and the free
use of scissors and a sharp spoon, even the scalpel. After being freed
of necrotic tissue the exposed surfaces should then be dressed with
brewers’ yeast. In general, of all these phlegmons, it may be said that
nowhere does the general rule elsewhere laid down in this work better
apply, _i. e._, that pus left to itself will always do more harm than
will the surgeon’s knife if judiciously used.

The various fixations of the neck by muscle spasm or muscle
infiltration due to these phlegmons, _i. e._, the temporary forms of
wryneck, will nearly always subside as infiltration disappears. Some
degree of permanent contracture may follow neglected cases and may call
for massage, stretching, and the use of a suitable brace.


AFFECTIONS OF THE CERVICAL LYMPH NODES.

The cervical lymphatics are abundant in number, as they need to be to
serve their purpose, considering the variety and extent of the possible
sources of infection, both from within and without. They become
enlarged even in a trifling case of tonsillitis, while in more serious
infections they participate with the surrounding tissues, but sometimes
suppurate independently of them. They are involved in nearly every case
of constitutional _syphilis_, and serve as an index of the saturation
of the system with the specific poison. Treatment for the same should
never be discontinued so long as they are perceptibly enlarged. They
participate, then, in both the local and the constitutional infections.

In no respect is this more true than in local tuberculous infections,
or in others which have become tuberculous through the process of mixed
or secondary infection.

_Tuberculosis of the cervical lymphatics_ is then one of the results
of previous mild or severe infections. They constitute the so-called
“scrofulous glands” or swellings of writers of the past generation.
There may be seen repeated within these structures those processes
which in the lungs cause at one point softening, at another caseation,
and at another sclerosis. An acute suppurative process may also be
going on, or there may be found, in broken-down cavities, that pyoid
material which is often seen in cold abscesses, and to which elsewhere
in this work is given the name archepyon, indicating that it was
originally of a truly purulent type, which it has lost in course of
time.

[Illustration: FIG. 494

Cluster of tuberculous lymph nodes removed by dissection, and showing
the usual and various changes. (Lexer.)]

Tuberculosis of the cervical lymph nodes may be a limited and almost
single expression of disease, or one involving both sides of the neck,
and to a degree that may produce large and disfiguring swellings. It is
nearly always a secondary infection, the original lesion being found
upon the surface of the skin, more frequently in the middle ear, the
pharynx, the tonsils, the nose, the teeth, or other parts within the
mouth. The first measure in every instance should be to trace this
source of the infection, since to leave it uncared for is to invite
a continuance of the disease. The course of events often is an acute
exanthem, a chronic tonsillitis, a mildly septic involvement of the
lymph nodes, followed later by tuberculous invasion through a port of
entry opened by the previous process (Fig. 494).

Most of the acute septic infections of these lymphatics will be
followed by local abscess and by one of the extensive phlegmonous
manifestations described above. This usually means an acute abscess
formation, which should lead to early incision and speedy recovery.
It is the more chronic and less suppurative types which cause serious
trouble. They occur more frequently in the young. There is a distinct
form, however, occurring in the aged, which is called _senile
tuberculosis_. Its pathology nowise differs from that of the type
occurring in the young, although it has a different clinical expression.

When the lymph nodes are but recently involved they are simply so
encapsulated as to be easily shelled out from their beds; but when
degenerating and slowly suppurating they become so firmly embedded in
the surrounding tissues by dense infiltration that their extirpation
is exceedingly difficult. This condition has been spoken of as
peri-adenitis, a bad term, because nowhere in this work are lymph nodes
spoken of as “glands.” Not infrequently the operator will find large
masses affixed to the carotid sheath, or surrounding the vessel and
nerve trunks, so that it is almost impossible to separate them. During
the dissection the internal jugular may be torn, or one of its branches
severed at its base, while an important nerve trunk may be so lost in
the mass that it is almost impossible to distinguish it, and it may not
escape injury.


=Treatment.=--Search should be first made for the source of the
infection, since to attack the consequences of the disease and to
leave the cause untouched would be a mistake. If it be a chronic
nasopharyngeal catarrh it will require considerable local treatment.
If an enlarged tonsil this should be removed. If due to dental caries,
or ulceration in connection with faulty dentition, or to pyorrhea
alveolaris, the patient should be sent to the dentist; if the trouble
be in the middle ear, to the aurist; if the infection come from the
skin, as in various ulcerating skin diseases, again appropriate
external measures should be adopted. When the patient is otherwise in
good condition and freed from liability of further infection, then
the question of surgical intervention is to be decided. Decision will
rest somewhat upon the general condition of the patient and the extent
of the lesions. A consumptive patient, for instance, is not a good
subject for surgery, and it may be held that the lymphatics will be
benefited by such change of climate as is indicated for his tuberculous
lungs. A puny or anemic subject is not a favorable one for an extensive
surgical operation, such as the removal of a large mass of those
nodes often necessitates. It may be deemed advisable to delay while
the patient is temporarily sent to the mountains, or is placed upon
treatment, including arsenic as an alterative, and the best restorative
tonics. Some cases not favorable for operation are benefited by x-ray
treatment. This should be judiciously administered, in such manner
as not to produce a dermatitis nor increase the infiltration in the
tissues of the neck. It is to be advised rather in cases considered
inoperable than in those favorable for operation.

Excision is the measure usually resorted to because of the promptness
of its effect, as well as the extent. Excision, however, necessitates
an exceedingly careful and tedious dissection. When the whole side of
the neck is involved I would advise an S-shaped incision, by which a
double flap, with much better exposure, is afforded. There may perhaps
be found two quite different sets of involved nodes, the superficial
lying rather to the outside and to the front of the sternomastoid,
which will be adherent to the carotid sheath, and a deeper set lying
back of the sternomastoid whose removal will usually take one down to
the transverse processes of the cervical vertebræ. In an average case
there may be found all possible combinations of degeneration, with
softening and cold abscess on one hand, and caseation and calcification
on the other. Proceeding more deeply masses will be found whose
existence had not been appreciated from the surface. Nevertheless, such
cases usually do well and often recover. Thus a wound extending from
the mastoid to the clavicle may be entirely healed within a week if the
wound has not been infected by fresh pus. Such extensive wounds should
be treated with at least one drainage provision, a drain being brought
out through the wound or a special opening made for it, at a point
where the resulting cavity will empty itself with the patient lying
upon his back in bed.

For all these operations the patient should be prepared in the best
possible manner. It will be of advantage to send patients to the
woods, while, under any circumstances, they should be kept under
those surroundings most favorable to tuberculous individuals, where
hypernutrition, lively elimination, and oxygen fulfil the general
requirements. They may also take such alteratives as arsenic, and such
drugs as creosote or its derivatives, which are supposed to have more
or less specific effect.

A distinct type of involvement of the cervical lymphatics is seen
in connection with the spread of _malignant disease_ from adjoining
structures. Nowhere is this more marked than in epithelioma of the
lip, but it may be seen in cancer spreading upward from below, as in
connection with cancer of the breast. When the cervical lymph nodes are
involved in a case of cancer of the breast a hopeless aspect is thereby
put upon it. Although operation may be justified for temporary relief
it should be so understood.


TUMORS OF THE NECK.

_Aeroceles_ of the neck are sacs formed by air distention of an
adventitious pouch, and constitute a species of local emphysema, due
to weakening and yielding of some portion of the respiratory tract,
produced by such strains as cough, labor, etc. A congenital dilatation
of a laryngeal ventricle may produce the same effect. It may also
follow a distinct wound of the trachea, or the expansion of a cavity
in one of the mucous glands produced by its ulceration or breaking
down. They may also result from abscess cavities opening into the
respiratory tract. According to their location they may be referred
to as _laryngoceles_, _tracheoceles_, etc. The term _pneumatocele_
implies a protrusion of the pleura and the lung into the region
above the clavicle. It will give distinct signs here on percussion,
will disappear under pressure, and quickly recur as the result of
forced expiration, coughing, etc. It may even follow the respiratory
movements. This latter form is scarcely amenable to treatment unless
tissues can be brought together over it and the opening closed. The
other aeroceles are more or less amenable, according to their location
and exciting cause. It is rare that there is any contra-indication to
their exposure and extirpation.

Of the many true _cysts_ of the neck a large proportion are due to
_incomplete closure of some portion of one or more branchial clefts_.
These have already been mentioned in the chapter on Tumors. The lesions
vary from trifling submaxillary dermoid tumors to extensive hydroceles
of the neck, such as those illustrated in Figs. 495 and 496. Not
every congenital tumor, however, is of branchial origin. There is a
possibility of the development of others along the thyroglossal duct,
along the great vessels, and in the neighborhood of the pharynx and
larynx. _True bursal cysts_, as well as true _atheromatous cysts_,
also develop at various ages. The former will be found filled with
serous fluid. They occur on the anterolateral aspect of the neck and
generally on the left side. _Dermoid cysts_ also abound here. They
have an epithelial lining, which always indicates their congenital
origin. They frequently do not develop until puberty. They may contain
various epithelial products, which may escape by suppuration or
perforation. These growths sometimes extend into the mediastinum. A
form of _median thyrohyoid cyst_ of this character often grows rapidly
after confinement. Such a cyst if incompletely treated will be followed
by persistent fistula. All of these growths should be thoroughly
extirpated if attacked at all, or widely opened and packed, and then
made to heal by granulation. Fig. 497 illustrates another type of
cystic growth of the neck connecting freely with the lymph spaces and
vessels and regarded as a congenital lymphangioma.

[Illustration: FIG. 495

Congenital multilocular serous cysts (hydrocele) of neck.
(Lannelongue.)]

[Illustration: FIG. 496

Branchial cyst. (Case of Dr. Parmenter.)]

Still another type of cystic growth is connected with the anterior
jugular vein. It contains sanguineous fluid, and sometimes true venous
blood. Connection with the vein may be determined by making pressure.
A growth easily emptied and rapidly refilling will be distinctive. It
should not be mistaken for an aneurysm, as it does not pulsate. It is
known as a _sanguineous cyst_.

[Illustration: FIG. 497

Branchial cyst or hydrocele of neck. Baby six weeks old. (Case of Dr.
Parmenter.)]

The difficulty of distinguishing between dermoid cyst and dermoid tumor
has been mentioned in the chapter on Tumors. The distinction is one of
small importance, for no matter what its character such a growth calls
for extirpation. A similar dermoid in the course of the thyrolaryngeal
duct is represented in Fig. 498.

[Illustration: FIG. 498

Dermoid (ad-hyoid) cyst at base of tongue. (Marchant.)]

[Illustration: FIG. 499

Diffuse symmetrical lipoma, multiple. (Lexer.)]

In the neck, more often than in any other part of the body, may be seen
well-marked cases of diffuse lipoma. These are painless overgrowths of
fatty tissue, unencapsulated and consequently liable to spread to an
unlimited extent (Fig. 499). They form disfiguring clinical pictures,
but cause no unpleasant symptoms. They are scarcely to be attacked
surgically, as they have no anatomical limit. They are rarely operated.
More circumscribed growths can be more or less easily removed.

Of the true tumors of this region little need be said here. There is
a form of fibrochondroma, springing from a branchial cleft, which
occupies the external orifice of a congenital fistula a little above
the clavicular joint. This makes it of interest, and, at the same time,
distinctive in character.

Any of these growths may give rise to serious pressure symptoms and
may be so located as to make tracheotomy difficult. They often extend
downward behind the sternum, in which case the upper part of that
bone should be removed in order that they may be safely followed.
Such a tumor, if it so extends and is a true cyst, should be treated
by free incision and packing; but when solid, no other resource than
extirpation is left. On their posterior aspect the greatest caution
should be exercised, and it may be well to leave a part of their
posterior walls to avoid the danger of injuring the large veins.

The majority of tumors that present on the floor of the mouth which
are not of malignant type, nor adenomas of the salivary glands, are
embryonic relics, a type alluded to above. A small vestige of this kind
may long remain dormant and then suddenly assume a rapid growth.

Of the _malignant tumors_ there are many expressions in the neck of
endothelioma, of sarcoma, and of carcinoma, the latter only arising
from epithelial structures like those of the skin, the glands, or the
mucous membrane. They may extend in all directions. Many cancers of
the neck are metastatic, the primary growth not necessarily being in
the immediate neighborhood. A distinct form of cancerous degeneration
of embryonic vestiges is known under the name of _branchiogenic
carcinoma_. It is seen usually in elderly people and along the line
of the branchial clefts. If possible it constitutes a more hopeless
variety than others, because of its origin and depth. Certain sarcomas
of the neck are prone to assume the type of fungus hematodes. Any tumor
of this character should be attacked with spoon and cautery, for the
vessels which bleed so easily are only those of the growth itself,
those which lead up to it and around its margin not being enlarged.


THE CAROTID BODY.

The carotid body seems to have been first described by Haller, in
1743, although his description has attracted but little attention.
In 1833 Mayer recognized that, aside from the well-known cervical
ganglia, there was met at the bifurcation of the common carotid a
small, so-called glandular structure, about the size of a grain of
rice, red, firm, and vascular, much resembling the superior cervical
ganglion, which receives sympathetic filaments as well as branches from
the vagus. Luschka, in 1862, spoke of it as a glandlike appendage of
the sympathetic system in the neck. It is usually wrapped in a sheath
from the adventitia of the carotid and perhaps by more or less fat, the
former having to be divided before the gland becomes visible. It seems
to be a common meeting-place for fibers from the superior laryngeal,
the glossopharyngeal, the sympathetic, and certain ganglion nerve
fibers. It is not always present and may vary in position, lying either
below the division of the artery or considerably above it upon the
external carotid. In any case it is enclosed by a sort of capsule.

Its principal surgical interest obtains in that it is the occasional
site of tumors, which as they grow will have intimate and perplexing
arrangements to the surrounding tissues, which may necessitate most
painstaking dissection, or may call for sacrifice of the large vessels.
In one case reported by Scudder the tumor became larger and more tender
whenever the patient caught cold. Such a tumor will not of itself
pulsate, but will transmit pulsation from the carotid in a perplexing
manner. They move sidewise, but not vertically. When vascular they
may diminish upon pressure, or they may pass in between the other
tissues in a way to simulate collapse on pressure. They lie in front
of the sternomastoid, above the level of the thyroid cartilage, are
usually of slow growth, and are sometimes accompanied by such vasomotor
disturbance as flushing of the face and irregularity of the pupil. They
are likely to be mistaken for tuberculous lymph nodes, or for common
tumors of the neck. While views concerning their absolute malignancy
differ, one may be certain that at least they rest upon the border
line, and should in all cases be removed. Instances are reported,
however, where the tumor has shown an extremely malignant tendency.


THE THYROID AND THE PARATHYROIDS.

By virtue both of its complex functions and complicated affections the
thyroid is an object of surgical interest. Between it and some of the
most important body changes there is intimate relation, and its effects
on disposition, mentality, voice, general appearance and behavior,
sexual function and the development of the sexual organs are matters
of common knowledge. The latter features are abundantly illustrated by
the effect upon these parts of removal of the thyroid. Embryologically
it develops from the floor of the pharynx, between the upper branchial
arches. Within it there forms a duct, known as the _thyroglossal
duct_, whose glossal portion opens upon the base of the tongue, where
it is of great surgical importance, because of growths of embryonic
origin occurring along its path, and because downward growth of cancer
of the posterior portion of the tongue usually takes the same course.
In the early days of its existence it contains no iodine, at least in
mankind, this lack of iodine being supplied from the mother’s milk, the
babe thus receiving from its mother that which its own thyroid at first
fails to supply.[49]

  [49] This may afford an explanation of the unsatisfactory character
  of artificial foods, as well as of cows’ milk, since, unlike the
  babe, the calf is born with a functionating thyroid. Cows’ milk does
  not contain in this respect that which is found in human milk, all
  of which may afford a reason for adding minute amounts of thyroid
  extract for a short time to artificial foods for children.

That the thyroid normally produces substances of vital import in the
human economy is shown both by the bad effects of their overproduction,
as in tetany and certain spasmodic affections, with final clonic
rigidity, and in thyroidism or the hyperthyroidism of Graves’ disease
or exophthalmic goitre, with its tachycardia, mental depression, and
numerous other symptoms, and by those of its underactivity, as in
myxedema, cretinism, cachexia strumipriva, and certain of the toxemic
neuroses.

The relations between the thyroid and the genital organs, especially
in the female, are in many instances pronounced. Menstrual suppression
and pregnancy are often followed by thyroidal enlargement, and nearly
every woman having a goitre notes its temporary enlargement with each
menstrual epoch, and its permanent enlargement with each succeeding
pregnancy. The most specific constituent of the thyroglobulin, which
is supposed to be the substance formed within the thyroid, is iodine,
which is present in variable amounts.

In general it may be said of the thyroid: (1) That it secretes some
material requisite for normal nutrition; (2) that it has much to
do with the assimilation of oxygen by the tissues as well as with
phosphorus metabolism; (3) that its peculiar secretion has a marked
effect in lowering blood pressure and quickening the pulse, in the
former respect being the direct antagonist of adrenalin.

The _parathyroids_ have only recently assumed importance either in
surgery or pathology. Their existence as separate structures with an
identity of their own was first demonstrated by Sanström in 1860. Up
to his time they had been assumed to be small accessory thyroids.
In 1884 they were described by Horsley. Since that time they have
been an object of the greatest interest to experimenters. They are
of different character from the thyroid proper. Nevertheless the two
are not absolutely independent of each other, for removal of either
one causes changes in the other; the symptoms caused by removal of
the parathyroids, especially, including tremors and various nervous
symptoms, of which tachycardia and sometimes exophthalmos are the most
prominent. Experimental animals will usually survive removal of the
thyroid alone, but to take away all four of the parathyroids is almost
invariably fatal. Anatomically they consist of two pairs of small
bodies, with an average diameter of ¹⁄₂₅ inch, having color and texture
much like the thyroid in gross appearance, but containing epithelioid
cells, lying in man in close relation to the lateral lobes of the
thyroid, behind them and to their inner sides. In minute structure
they resemble that of the pituitary body. Their relatively trifling
size and deep position in man have caused them to be neglected in
pathology, and to be seldom recognized during operations or except by a
careful dissection made for the purpose. The present trend of opinion,
especially among the experimenters, ascribes to them an important role
in the production of exophthalmic goitre, it being made to appear that
by some neglect of duty their function of indirectly regulating the
heart and controlling the sympathetic system is not properly performed.


CONGENITAL AFFECTIONS OF THE THYROID.

Congenital affections of the thyroid may assume the type either of
defect or of absence of the organ, or an hypertrophy which may involve
one side or both. Presumably when the thyroid is lacking its function
is to some extent assumed by the thymus and perhaps by other portions
of the body.

Anatomical alterations are met in the so-called _supernumerary or
accessory thyroids_, which may be due to separate development of one of
the original lobules, or they may arise independently. These vary in
size, location, and importance. They may be seen as high as the base
of the tongue or as low as the upper end of the sternum or behind it.
Tissue of this kind has been seen in the body of the hyoid bone. These
accessory masses are subject to the same type of affections as those
which involve the principal thyroid, and thus tumors may develop in the
anterior region of the neck, which may cause some perplexity.

An extraordinary feature of thyroidal tissue is that when affected
it may infrequently produce _metastases_, even to distant parts of
the body. Thus cases are on record of benign goitre, with universal
metastases, and, on the other hand, of numerous metastases without any
noticeable thyroidal enlargement. They occur frequently in the osseous
system, and in the lungs, and when the thyroid is the site of a colloid
type of goitre. The same is equally true of the malignant growths of
the same tissue.

The immediate results of a total removal of the thyroid, as by
operation, are _myxedema_, or _cachexia strumipriva_, conditions which
require a few weeks for development and which may be preceded by an
acute mania. These conditions are indicated by anemia with weakness,
defective circulation, swelling of the extremities, usually first in
the fingers, the swelling being of a hard, inelastic type, and not
pitting on pressure, appearing later in the face so that the features
become altered. Later appear also muscular tremors, with tetanoid
convulsive attacks. These results of thyroidectomy may be combated by
feeding thyroid extract, or by transplantation of thyroid tissue from a
sheep into the tissue of the body or into the abdominal cavity. While
Horsley and others have been successful with the surgical procedure,
it is usually now sufficient to resort to continuous administration
of thyroid extract, this being indicated only in cases where thyroid
activity is defective and being contra-indicated in instances of
overactivity, such as exophthalmic goitre.


THYROIDITIS.

Thyroiditis as a more or less acute affection is occasionally noted,
being due to one of the infectious fevers, or occasionally following
dermatitis, local infections, etc. It may assume a hemorrhagic type and
be followed by production of hematoma. It may also assume a suppurative
type and lead to the formation of abscess. This, if impending, is
always of a serious nature, as it is sure to be followed by local
cellulitis, perhaps with serious pressure symptoms, and escape of pus
along the deeper fascial planes into the thorax.

_An acute idiopathic hypertrophy_ in children has been noted by the
writer in one instance, in which the enlargement was rapid, occupying
but a few days, and had already caused such compression of the trachea
when the case was first seen that even a tracheotomy promptly performed
did not serve to save the patient’s life.

_Intra-uterine hypertrophy_ of the thyroid is also known. There
are at least five cases on record of this condition following the
administration of potassium chlorate to the mother during pregnancy. In
one case reported the tumor attained a size sufficient to constitute a
serious complication in delivery of the child.

Among the special symptoms produced by these acute affections are:
difficulty of swallowing, which may lead to great thirst; head symptoms
due to obstruction to the return circulation, with congestion of the
face and epistaxis; while pressure upon the pneumogastric may cause
nausea or vomiting. The treatment of such a case when seen early should
consist of wet and ice-cold applications for several hours; but when
seen later, especially if suppuration be already threatening, pus
formation and its localization may be encouraged by hot applications,
followed by free incision, thus relieving tension and evacuating pus.

Thyroiditis occurring in goitrous thyroids is usually referred to as
strumitis, as the enlargement itself was formerly known as struma; it
follows the exanthems and fevers, and may cause sudden and distressing
complications.


TUMORS OF THE THYROID.

Aside from those thyroidal enlargements to be considered under the
heading of goitre may be met tumors of congenital origin, especially
the simple or complicated cysts, which may grow slowly or rapidly,
or may not appear at all until puberty or adult life. An apparently
innocent cyst may suddenly increase in size and produce serious
symptoms, or hemorrhage may occur into it, or it may rupture, in either
of which instances severe pressure symptoms will ensue. All cystic
tumors of the thyroid should be enucleated, an operation usually easy
of performance unless the collection be multilocular and extensive.
If an entire thyroidal lobe be occupied by growths of this character
it may be assumed that its function has been so much impaired that it
should be completely removed.

The thyroid body is occasionally the site of teratomas, _i. e._, tumors
containing tissue of each blastodermic layer. No two such tumors are
alike. They may assume various sizes and shapes, growing in various
directions, and will hardly define themselves until removal.

The benign solid tumors consist mainly of the various types of goitre.

Of the _malignant tumors_, _sarcoma_ is perhaps the most frequent, and
is met here in all its varieties. _Endothelioma_ occurs here also,
while true carcinoma can hardly be primary in the thyroidal tissue, but
may frequently extend to it and invade it, thus seriously complicating
a case already made desperate by its presence in the neck. Metastatic
forms of true cancer may also occur here as elsewhere. For a growth of
this kind there is but one resort, _i. e._, extirpation, but this will
be difficult and usually inexpedient.


GOITRE; STRUMA; BRONCHOCELE.

The enlargement or hypertrophy of a part or the whole of the thyroid,
now known universally as goitre, has been known also as bronchocele
and trachelocele. The condition is one of unilateral or symmetrical
affection, met with much oftener in women than in men, and particularly
in certain regions. It is most prevalent in Switzerland and in Upper
India. It is occasionally known to assume an endemic or epidemic form,
the affection disappearing from the region of the country concerned
after a period of some years. Practically nothing is known of its
cause. Many theories have been advanced, that which finds perhaps
widest acceptance referring to the character of the water supply.

For present purposes goitre may be understood to include the following
forms:

  Simple hypertrophy, the so-called parenchymatous form;

  Thyroid adenoma;

  Cystic goitre;

  Exophthalmic goitre (Graves’ or Basedow’s disease).

The _parenchymatous_ form consists essentially of an overgrowth of
the ordinary thyroid tissue. It is diffuse and unencapsulated, all
the thyroidal tissues participating in its structure. Sometimes
whole families suffer from this form of goitre, and occasionally an
apparently hereditary influence may be traced. The tumor thus produced
may attain great size. According as it involves one side or both
will it be symmetrical or otherwise. It is elastic, smooth, rounded,
sometimes apparently subdivided by furrows which mark the original
lobar arrangement. It displaces the structures around it, and may
attain a large size without producing serious pressure effects. When
these occur they assume the type of dyspnea, dysphagia, and laryngeal
paralysis. The growth is insidious, usually increases markedly with
each pregnancy, and may spontaneously recede. Within it changes may
occur which lead either to cystic softening and formation of cysts,
or fibrous trabeculæ may appear and thus make it more firm and dense.
The denser the growth the earlier the pressure symptoms appear.
Occasionally the isthmus alone will appear involved, in which case
there will be a central growth.

The so-called _thyroid adenoma_ (the term adenoma being used on the
supposition that thyroidal tissue is true gland tissue) is often of
cystic type. It consists of more or less isolated tumors of general
thyroid character, but circumscribed, often encapsulated, perhaps
undergoing cystic degeneration, occurring frequently in multiple form,
and producing cysts of all sizes. Such a growth will displace the other
thyroidal tissue and may give a decidedly irregular aspect to the
resulting tumor. The cysts often contain cholesterin. In recent cases
the capsule is thin; in old tumors it may be calcified, and so may be
the tissue within the capsule. These growths are seen in successive
generations of the same family. They have their beginnings usually in
the earlier years of life.

Similar growths may also arise from the outlying portions of the
thyroid, or from _accessory thyroids_, so that they may be found back
of the sternum, or lying deeply in the neck or near the base of the
tongue. If near the surface and cystic they give a sense of fluctuation
which the harder forms do not afford.


=Endotracheal Goitre.=--A recent study of Enderlen has shown that
small, goitrous growths make their appearance within the trachea more
commonly in females than in males, and in patients of middle age.
The known duration of growth has varied from a few weeks to fifteen
years. He believes the majority of the cases begin to grow at the
age of puberty. These growths have been found on the posterior wall
of the larynx or in the trachea itself. They have usually rounded
bases and broad implantation, with smooth surfaces, covered with
intact mucosa. In most instances the thyroid itself is also enlarged.
The only recorded symptom is dyspnea, proportionate to the degree
of obstruction. They are probably to be explained by the inclusion
theory, some thyroidal rest being disintegrated and so entangled as to
grow in this direction. The only satisfactory treatment is ablation
of the tumor, after tracheotomy, as endolaryngeal operations are more
dangerous.

These constitute the ordinary types of goitre. _Diagnosis_ is not
difficult, as the resulting tumors are more or less prominent,
involve the region of the thyroid, and rise and fall with each act
of swallowing. When the entire organ is involved the tumor may
have a horseshoe shape. Large veins appear upon the surface, while
pressure symptoms will correspond with its size and location. They
pursue an irregularly slow course. Many patients attain old age and
a considerable size of growth without such discomfort as to require
operation. Any goitrous enlargement in which considerable softening
occurs, with formation of colloid material, is entitled to the term in
frequent use, “_colloid goitre_.” By accident of location any growth of
this kind behind the sternum may cause serious pressure effects before
attaining large size. In symmetrical enlargement of both lobes the
trachea may be so compressed as to be narrowed and to entitle it to the
term _scabbard trachea_.

Iodine has been used externally and sometimes with benefit. The favored
method in India is to use an ointment containing one grain of red
iodide of mercury to the ounce. This is daily rubbed over the goitre
and then the parts exposed to the bright sunlight for an hour or more.
Iodine has also been used by parenchymatous injection. It is mainly
used, however, by those who object to operation or do not dare perform
it. The iodine treatment, whether externally or internally used, is
usually disappointing. So also is that by the Röntgen rays, and, for
that matter, all other non-operative measures. Operative relief alone
is complete and final. It is described below.


EXOPHTHALMIC GOITRE.

As a clinically distinct type of disease this was first described
by Graves, of Dublin, in 1835, and five years later by Basedow, of
Magdeburg; hence it is frequently called by their names. Although the
thyroid participates in the clinical picture it cannot be stated that
it is primarily at fault. Three marked objective features characterize
pronounced cases--_thyroidal enlargement_, more or less pronounced
_tachycardia_, and _exophthalmos_.

So far as known there is an essentially toxemic feature behind these
lesions, which is mysterious, nor is the nature of the toxemia certain.
No constant lesions have been found in the nervous system, although
the sympathetic nerves are always involved when the heart and the eyes
are affected. The three cardinal symptoms or signs above mentioned
are nearly always associated; but with pronounced rapidity of the
heart’s action there may be but little involvement of the thyroid or
slight protrusion of the eyes. Whatever the original toxemia, or its
source, a prominent feature of the condition is _hyperthyroidism_--_i.
e._, hypersecretion of the substance which regulates nutrition--whose
overproduction materially disturbs the heart and vasomotor nerves. It
stands in strong contrast to myxedema and cachexia strumipriva, which
are considered to be due to hypothyroidism or diminished secretion.
Consequently it is not to be treated by feeding thyroid extract. A
recent view which has much to support it is that at the basis of this
condition the parathyroids are so concerned that any operation which
includes their extirpation would be a serious menace. At present it
may be held that the parathyroids are intermediate factors between the
primary toxemia and the hyperthyroidism.

Aside from mere thyroidal enlargement, which is influenced by pressure
and shows an increased pulsation, always palpable, sometimes visible,
there occur increased heart activity, with a rapid and easily
influenced pulse; widening of the palpebral fissures, the upper lid
not following the motions of the globe, with defective convergence;
rhythmic muscular tremors; increase of general sensibility; insomnia,
with disturbed sleep; psychical disturbance, sometimes amounting to
melancholia or mania; digestive disturbances, including diarrhea,
vomiting, and thirst; cough, with frequent and shallow respiration;
loss of hair and nails; sweating, flushing of surface and sometimes
leukoderma or pigmentation of the skin. Terminal symptoms consist
of all those mentioned above, with acute mania, high temperature,
vomiting, profuse sweating, dermatitis, jaundice, and final convulsions
with exhaustion, all these resembling those of death in experimental
animals after the removal of the parathyroids.

A sign recently described by Teillas, which he considers pathognomonic,
consists of deep-brown pigmentation of the outer surface of the
eyelids, the color being evenly diffused, bounded above by the eyebrow,
below by the margin of the orbit, the conjunctiva being not affected.
Its effect is to apparently increase the degree of exophthalmos and to
intensify the fixity of gaze observed in these subjects.


=Treatment.=--This is not the place in which to consider in detail
either the pathology or the drug treatment of this affection. By
many surgeons it is regarded as a surgical disease, _i. e._, one to
be treated by one of two operative methods, either thyroidectomy
or excision of the cervical sympathetic. When such measures as
electricity, Röntgen rays, and hydrotherapeutic treatment, and such
drugs as belladonna, sodium phosphate, arsenic, iodine, phosphoric
acid, etc., have failed, and when the antithyroidal serums or
preparations, such as thyroidectin and antithyroidin have proved
insufficient, then surgery remains a last resort. Unfortunately this is
too long delayed. To remove the thyroid so soon as it is shown to be
producing an injurious amount of oversecretion is neither a difficult
nor a dangerous procedure, but to wait until the heart beats 150 times
a minute and the patient is nearly maniacal is to wait until he is
almost moribund and until it is too late. Nowhere does the remark,
“The resources of surgery are seldom successful when practised on the
dying,” apply more forcibly than to such cases as these.

As between _sympathectomy_, already described, and _thyroidectomy_
(see below) it may be difficult to choose. By the time such a case
comes to operation each will present its distinct difficulties. The
question is mainly one of choice. A large tumor will obscure access
to the sympathetic trunk in the neck, while, on the other hand, the
neurectomy itself is probably a less dangerous procedure. The decision
should be based on the predominance of the features due to vasomotor
disturbances. Thus when the eyes are prominent, the pupils dilated, the
palpebral fissure widely open and difficult of closure, there is reason
for attacking the middle and upper cervical ganglia, which are not so
difficult of access. Again when the heart is affected there would be a
special indication for extirpating the inferior cervical ganglion, as
well as the first dorsal; but the former will always be difficult in
the presence of a thyroidal tumor, and the latter wellnigh impossible.
When, however, thyroidal symptoms are pronounced, with difficulty
in respiration or other purely pressure effects, thyroidectomy is
indicated. This should be performed as described below. An effort
should be made to preserve the capsule, at least on the inner and
posterior aspect of the thyroid, in order that the parathyroids which
lie in close relation to it may not be disturbed. Operations upon the
vessels for the purpose of controlling the circulation are rarely
practised, and the question in these cases is as between partial and
complete extirpation.

Curtis has recently collected from the statistics of two German and
two American operators 136 cases of exophthalmic goitre treated by
thyroidectomy, with 17 deaths, chiefly from acute thyroidism. The most
marked improvement realized was disappearance of tremor, nervousness,
and insomnia, and of a feeling of anxiety, so common to the disease.
To these may be added the more extensive experiences of Charles Mayo,
which present extirpation as an almost ideal method of treatment.

As remarked above, all attempts at feeding with thyroid extract should
be avoided, the case being one already suffering from hyperthyroidism.
It should be noted that in few instances the thyroid seems to suffer
from its own overactivity, and passes into a stage of physiological
atrophy, with more or less subsidence in volume. In such a case the
symptoms of Graves’ disease would gradually change into those of
myxedema.

The thyroid itself is extremely vascular under all circumstances,
particularly under these, to such an extent that pulsation becomes a
prominent feature. This, however, should not be mistaken for that form
of ordinary goitre in which the vessels undergo increase in dimensions
and in which sometimes a loud _bruit_ may be heard.

_Malignant goitre_ implies a generalized involvement of the thyroid in
one of the malignant forms of neoplasm. (See below.) It is of rapid
growth, with more or less infiltration of surrounding tissues, which is
evidently not of inflammatory character but more distinctive.


THYROIDECTOMY.

This may be partial or total. It is important to leave a portion of the
thyroid in order that the patient may not suffer from the consequences
of _athyroidism_, _i. e._, _cachexia strumipriva_. It is generally
understood that if one-sixth or one-seventh of the total mass can be
left _in situ_, with sufficient blood supply, it will suffice. Thus
it may be possible to leave the isthmus, after removing both lateral
lobes, or a portion least affected of one of the latter may be left in
place.

The character of the incision will depend on the size and position
of the enlargement. For complete thyroidectomy a horseshoe-shaped
incision, convexity downward, should be made, extending along the
anterior border of the sternomastoids and then across the neck. This
should be carried through the platysma and superficial fasciæ, the
anterior jugular veins being secured when cut. The flap thus made is
then raised, after which a large part of the subsequent procedure is
made by blunt dissection, and separation of the surrounding muscles,
which are held aside with retractors. When the tumor is so shaped and
placed as to make it possible it is well to approach it laterally
and secure the upper and lower thyroidal vessels on one side or
both, dividing between double ligatures. If this be done the mass
can be drawn forward in such a way as to avoid injury to the nerves
and vessels, the operator keeping in close contact with the capsule,
or, for reasons specified above, perhaps dividing and shelling out
the mass from within it. Although the tumor may be occupied by large
vessels, those which lead up to it--_i. e._, the thyroids--are rarely
much enlarged. Nevertheless it is wise to secure them first. While
the anterior muscles may, in many instances, be separated and the
tumor mass exposed between them, there are cases which will require
transverse division of the sternohyoid and sternothyroid, in which case
they should be subsequently sutured.

One of the complications is to find the tumor mass extending down
behind the sternum or the clavicle. From these locations it should be
separated by cautious blunt dissection, else the pleura or one of the
deep veins might be wounded. The former accident would be instantly
denoted by the passage of air and its entrance into the thorax, the
latter by severe hemorrhage.

In exophthalmic cases it may be held to be especially desirable
to enucleate the thyroid from within its capsule. This makes the
performance easier in some respects and more difficult in others.

Extreme caution should be taken in two particular respects: First,
that the trachea be not compressed, nor its caliber interfered with,
by the traction efforts used in removing the mass. The second caution
necessary in exophthalmic cases is to _make the least possible amount
of pressure upon the thyroid during the operative procedure_, since, as
mentioned above, its secretion is depressing to the heart, and it would
complicate matters to force more of this material into the circulation
at a time when everything conspires to reduce blood pressure and the
reliability of the heart’s action. A certain amount of manipulation
is unavoidable, but this should be made as gentle and as slight as
possible. Moreover, these cases are to be drained to permit of free
escape of thyroidal secretion. (Mayo.)

In performing thyroidectomy for Graves’ disease advantage should be
taken of the pneumatic suit devised by Crile, and the patient placed
in the semi-upright position. These are advisable precautions to take
in every such operation. The position allows more natural emptying of
the veins at the base of the neck and the suit permits of the blood
pressure being maintained by mechanical means. In order to use the suit
to best advantage the blood pressure should be noted throughout the
course of the operation.

The enucleation or extirpation concluded, hemostasis should be
observed, as with returning cardiac vigor secondary hemorrhage is by
no means an impossible event. Every vessel which can be recognized
should be carefully tied, and tissues which ooze should be caught
up with suture and tied _en masse_. All the deeper portions of the
wound should be brought together by buried sutures in such a way
as to leave no dead spaces. Cases where a retrosternal pit has been
left, by removal of a low-lying growth, should be drained to avoid the
accumulation of blood. Where doubt exists as to security from secondary
hemorrhage it is the writer’s custom to place secondary sutures, and
to pack the cavity with gauze dipped in balsam of Peru, leaving this
packing in place for two days, then removing it and closing the wound
by utilization of the sutures.

Shock after these operations may be extreme, and is to be combated
by transfusion or infusion of salt solution, with small amounts of
adrenalin.

Should the surgeon attack a so-called malignant goitre he must be
prepared to meet with greater difficulties and perhaps to abandon the
operation before its completion. Death on the table is not unusual in
such cases.

Operation under cocaine local anesthesia is often most advantageous,
and is the rule in such clinics as that of Kocher, in Berne. The
patient should be well narcotized with morphine, after which a weak
cocaine solution is injected along the proposed line of incision. The
pain produced by the balance of the work is not beyond endurance, while
the dangers are certainly minimized, especially in cases where there is
compression of the trachea or excessive heart action, the latter being
particularly true in Graves’ disease. There is less fulness of veins,
and there is neither coughing nor vomiting. The operative features
are the same as those described. As the anterior thyroid artery is
approached all possibility of including the recurrent laryngeal nerve
in the ligature is avoided by having the patient talk, injury to the
nerve producing instant hoarseness. If the growth extend low and into
a pit behind the sternum it may be possible to extirpate it from above
downward, and finally to lift it from its bed, securing its base or
pedicle with an elastic ligature.

[Illustration: FIG. 500

Patient placed in semivertical position, and enclosed in Crile’s
pneumatic suit, as recommended for many cases of goitre, brain tumor,
or other serious operations about the head and neck. (Crile.)]

A danger common to all thyroidectomies is that of injury to the
trachea. This is avoided when there are no abnormal adhesions, but when
the growth surrounds the trachea, or is firmly fastened to it, such an
accident may happen in spite of the greatest care. According to its
size and location the surgeon may endeavor to close the opening with
sutures, or he may insert a tracheotomy tube or leave the wound open
sufficiently to pack it snugly, preventing entrance of fluid into the
trachea, at the same time expecting the wound to be subsequently closed
by granulation tissue.

Sympathectomy as a measure directed toward the treatment of
exophthalmic goitre, as well as of glaucoma and certain forms of
epilepsy, has been described in Chapter XXXVII.


STRUMITIS.

Strumitis is a term applied to actual inflammation of an already
goitrous thyroid. It may follow such infectious diseases as typhoid, or
it may be an apparently spontaneous infection without known cause. It
may run an acute course, tending rapidly to suppuration, in which case
there will be not only pain and tenderness in the thyroid itself, but
all the local evidences of pyogenic infection, with infiltration and
rapid formation of pus, perhaps with widespread phlegmon of the neck.
This is a serious condition and may call for early and free incision
of the infected area. A hemorrhagic form of strumitis is also known.
The thyroid may also be the site of metastatic abscesses in cases of
pyemia, in which case there will be but few local indications.


THE THYMUS.

The thymus figures but rarely in surgical interest, but when seriously
affected it causes most pronounced symptoms. Its principal activity
is shown previous to birth and during the earliest months of infancy,
and it should have disappeared by the age of puberty. Instead of
atrophying, as it should, it may undergo _hypertrophy_, by which, on
account of its location, serious pressure is made upon the trachea and
the base of the neck. This may occur suddenly, so that a tumor in its
location rapidly develops and will prove fatal unless surgical relief
be afforded. This constitutes an acute hypertrophy of the thymus, which
is more than a mere surgical curiosity. In one case seen by me a long
trachea tube was with difficulty inserted just in time to prevent death
by asphyxiation. In case of such tumor the upper end of the sternum
should be removed and the tumor enucleated, or the thymus should be
sewed up to the sternum and the tumor thus raised out of its bed.

The thymus is of special interest in connection with the _status
lymphaticus_, which has been referred to in a previous chapter. Its
connection in such cases with hypertrophied lymphoid elements all over
the body, and especially of the adenoid tissues of the nasopharynx,
was therein described, and the seriousness of the condition, with the
menace which it offers to anesthesia, as well as the extreme cautions
to be observed, were fully rehearsed. The significance of laryngismus
stridulus and its relations thereto were also mentioned. All this is of
extreme importance to the surgeon, as every child with so-called thymic
asthma, and with symptoms of lymphatism, should be watched carefully
and anesthetized cautiously. (See Chapter XIV.)

_Acute inflammation of the thymus_ as well as hemorrhages within it
have been observed. It may also be the site of cystic tumors, perhaps
of hemorrhagic origin. Suppuration in these cases is possible. In
brief, the thymus, when acutely inflamed and suppurating, may be
excised, when the tumor may be removed; but when simply somewhat
involved, as in the status lymphaticus, it is best let alone, except in
the presence of urgent indications to the contrary.




CHAPTER XLIII.

THE THORAX AND ITS CONTENTS.


MALFORMATIONS OF THE THORAX.

[Illustration: FIG. 501

Congenital malformation of chest. (Sayre.)]

Congenital malformations of the thorax are not uncommon, yet but few
of them permit of surgical remedy. One or more of the ribs may be
absent or defective in formation and produce lateral distortion of
the spine. The clavicle also may be defective on one or both sides,
or absent. This is a defect which causes but little inconvenience, in
spite of its prominence. The chest as a whole may develop defectively
or irregularly, some of these conditions being expressions of
intra-uterine rickets and others being due to unknown or uncertain
causes. Thus we have the absolutely flat chest seen most often in
connection with an unduly rounded back, the flattening appearing rather
in front, while perhaps the anteroposterior diameter is actually
increased. As Hutchinson has shown, this may be a persistence of the
fetal type of chest. _Pigeon-chest_ or _keel-shaped chest_ may be
regarded as a reversion to a more primitive type, the anteroposterior
diameter being increased at the expense of the lateral. The reverse
of this deformity is the so-called _funnel-shaped chest_, where
the sternum is depressed and the lateral dimensions increased. In
addition to the defects thus noted in the ribs and sternum, absence
of a vertebra has been known, the condition not producing deformity,
but rather an appreciable shortness of the spine. Malformations are
seen frequently in the _sternum_, which may be _fissured_ in either
direction, or may present _perforations_. With these similar defects
of the ribs may also be seen, even to a degree permitting congenital
hernia of the thoracic contents.

_Supernumerary developments_ find their expression usually in an
_added rib_, either in the _cervical_ or in the _lumbar_ regions.
This condition is practically never noted at birth and may pass
unnoticed. Nevertheless a _cervical rib_ may, in adult life, produce
discomfort or actual interference with function, partly by pressure
upon the subclavian artery or the brachial plexus. When found it is
in relation with the seventh cervical vertebra, and the space between
it and the first dorsal rib is occupied by muscle developed for the
purpose. The scalenus anticus may be inserted into its anterior edge.
When sufficiently prominent to produce troublesome symptoms it may be
recognized by palpation, and cases of doubt may be made clear by a
radiograph. Should it prove troublesome it may be removed, an operation
requiring considerable caution, because of its close relation to the
pleura, which might easily be opened. It may be exposed by such an
incision as would be used for ligation of the subclavian artery.

The _thoracic muscles_ occasionally show anomalies, either in
arrangement or by their absence, the pectoralis major being
occasionally wanting in whole or in part, and furnishing the most
frequent illustration of these defects, which are usually unilateral.
(See Fig. 502.)

_Congenital luxations of either extremity of the clavicle_ are
also occasionally seen, particularly of the inner end. A peculiar
displacement and relaxation are thereby permitted, with some degree of
functional loss.

The _acquired malformations_ of the chest may be produced from a
variety of causes. Thus in connection with non-closure of the foramen
ovale and the consequent disturbance of heart action, with its
overdevelopment of the right auricle, the left side of the chest may be
pushed forward and the apex beat found far below its normal position.
_Asymmetry_ in the young may also be produced by several different
intrathoracic conditions, the most common being pleurisy and empyema,
with their consequent distention of the pleural cavity, and later
a tendency to cicatricial contraction. In this way marked forms of
lateral curvature are produced. In a previous chapter it was stated
that overgrowth of lymphoid tissue in the nasopharynx, ordinarily
spoken of as adenoids, with consequent embarrassment of respiration,
leads in time to stoop shoulders and poor development of the thorax.
Deformity may also be produced by such defective vision as shall compel
a peculiar or abnormal position of the head.

In _chronic emphysema_ there is noted a peculiar _barrel-shape_ of the
chest, which is also to be regarded as an acquired deformity. Paralyses
of the internal thoracic muscles will also permit of asymmetrical
growth, and projection of the lower angle of the scapula, giving it a
wing-like aspect.

[Illustration: FIG. 502

Congenital absence of the pectoralis major muscle of right side.
(Richardson.)]

The most common cause of thoracic asymmetry or deformity is _rickets_,
which may be an early or a late manifestation. By the ordinary changes
permitted in the epiphyses and along the costochondral junctions is
produced the peculiar appearance known as “rickety rosary.” In these
cases the effect of the weight of the upper part of the body upon the
soft and changeable structures of the osseous and cartilaginous ribs,
as well as the vertebræ and the sternum, are to be noted. Pronounced
types of deformity result from such changes, producing extreme cases
of _pigeon-breast_, or of hollowing in front known as _birds’ nest
deformity_, while alterations occur in the vertebræ, producing various
expressions of kyphosis and scoliosis. (See Fig. 504.)

These deformities of the back thus produced require to be
differentiated from those produced by Pott’s disease, the former being
unaccompanied by symptoms and occurring slowly, while the latter are
usually accompanied by pain and are progressive in character, as well
as more or less disabling. With a softened skeleton in a rapidly
growing child such trifling influences as the position assumed in the
nurse’s or mother’s arm, or that habitually taken in sleep, may affect
and modify symmetrical growth. Rickety deformities of the spine and
thorax, if not too far advanced, permit of being checked and much
improved by braces, along with the measures indicated in rachitis.
Without the latter, however, the former would be almost ineffectual.

[Illustration: FIG. 503

Malformation of chest following empyema. (Sayre.)]

[Illustration: FIG. 504

Deformity of the thorax, the result of rickets. (Gibney.)]

_Malformations may also be produced by injuries_ or certain
_occupations_. Extensive burns may cause cicatricial contraction;
contusions may produce paralyses, and more serious lacerations may
leave extensive scars, which will gradually warp the chest out of
shape. Burns, for instance, which may involve the axilla and the upper
arm, may be followed by such dense scars as to limit the motion of the
arm. Skin grafting should be resorted to early in the treatment of
lesions thus produced.

_Tight lacing_ is the source of a mild form of thoracic deformity, by
which the chest capacity is reduced, the respirations made peculiar in
character, the liver displaced downward, and the general welfare of the
individual materially affected. Influence of the right-hand habit is
frequently quite apparent in that the right side of the chest becomes
overdeveloped as compared with the left. This may be seen in a large
number of workmen who use heavy tools especially with the right hand.
Certain occupations, as well as sports, lead to constant assumption of
the stooping position, with the inevitable round shoulders and drooping
head so apparent in bicycle riders.

_Tattooing._--As a local expression of a bad habit, or in some
instances almost of a criminal instinct, _tattooing_ may be mentioned.
This is seen usually upon the chest and arms. It is a prevalent custom
among sailors, and is regarded by alienists and anthropologists as a
habit indulged in by criminals and the insane. La Cassagne has spoken
of tattooing as “an uninterrupted and successive transformation of an
instinct.” Among the inhabitants of the Pacific Islands it is almost a
mutual practice, and among them the tattoo marks are often found upon
the back and upon the sexual organs. The materials usually employed
are lamp-black, indigo, and India ink for the black or blue tints, and
cinnabar or carmine for the red. Practised as it is by the unschooled
and the ignorant it may be followed by all forms of local infection,
while syphilis has been thus transmitted.

For the _removal of tattoo marks_ many methods have been suggested,
but few have been found satisfactory. The minute particles of pigment
have become so deeply lodged that, like powder marks, it requires
infinite patience in their detection with the lens and individual
removal, or those portions of the skin must be destroyed which contain
them. Mechanical methods should be limited to localized stains, unless
a plastic operation is preferred, and, after removal of the affected
area, healthy skin may be transplanted by one of the plastic methods
or we may resort to skin grafting. Actual cauterization with strong
caustics or with the actual cautery will be followed by superficial
sloughing, which may remove the disfigurement. It is questionable,
however, if the resulting scar will be considered much of an
improvement upon the previous condition.


INJURIES TO THE THORAX AND ITS CONTENTS; CONCUSSION OF THE CHEST.

As a result of a severe blow made by a blunt object there may result
a form of _concussion_ or commotion, similar in its results to the
conditions which were formerly described in the cranial cavity as
concussion of the brain, but which are now known to be due to reflex
vasomotor disturbances, by which blood pressure is seriously affected
and extreme degrees, perhaps fatal, of shock or collapse produced.
It is possible for fatal injuries thus produced to leave little or
no evidence that may be discovered at the autopsy. Hence the term
_concussion of the chest_ may be retained as descriptive of what has
taken place, and implying serious symptoms produced through the agency
of the nervous system, especially through its sympathetic plexus. In
such instances the heart is seriously affected and may continue to beat
feebly for some time, as in shock from other injuries.

Severe blows upon the chest also disturb the function of respiration,
and it is possible that asphyxia, even to a fatal degree, may result
from a momentary paralysis of the entire respiratory apparatus thus
produced. In such cases artificial respiration will be required. In
many instances patients will complain of not merely distress, but
severe pain, which may require local anodyne measures as well as the
administration of an opiate.

_Contusion of the chest_ leaves more visible and lasting effects upon
the tissues of the chest wall. Thus extensive hemorrhages may result
and hematomas form, or ribs may be broken, with or without injury to
the pleura, or internal hemorrhages may occur, as from a ruptured
intercostal or internal mammary artery, the consequences of such
injuries not necessarily appearing at the time, but developing later.
Along with these injuries to the chest there may occur other injuries
to the abdominal viscera or to other portions of the body. Something
will depend upon the distention or relative emptiness of the lungs at
the time of injury, and whether there may have been at the same time
a sudden closure of the glottis, in which case, by an external blow,
something resembling an explosive effect may be produced within the
air passages. The degree of stomach distention may also have its own
effect. _Laceration of lung_ tissue will usually be shown by appearance
of bloody froth at the mouth, as well as by more or less dyspnea.
Rapidly developing symptoms of pressure upon the lung would indicate
the accumulation of blood within one pleural cavity and cause the
ordinary physical evidences of the presence of fluid. The _diaphragm
may be ruptured_, and the proper viscera of one cavity be displaced
into the other. When emphysema of the tissues of the chest occurs it is
usually safe to assume that a rib has been fractured, even though the
injury cannot be located or even otherwise recognized.

A series of later lesions may result from such contusions, which may
be of serious character. Thus there has been described a so-called
_contusion pneumonia_, whose symptoms are similar to but milder than
those of the genuine disease. It is a result of inflammatory and
hemorrhagic infiltration. It may lead to a pleuropneumonia, with
subsequent hydrothorax or pyothorax, or these may take place more
directly and without its occurrence. The products of this disease
afford foci in which, later, tuberculous expressions are commonly met.
It has been shown experimentally that the blood serum of animals
subjected to severe injuries of the chest and abdomen has well-marked
toxic properties. Thus the appearance of sugar or albumin in the urine
or of other toxemic indications may be perhaps explained.


=Treatment.=--The _treatment of these injuries_ should include the
relief of pain; the performance of artificial respiration, along with
the inhalation of oxygen; the customary treatment for shock, with the
use of adrenalin, when needed, for raising blood pressure; absolute
rest, and especially the enforcement of local physiological rest by
bandaging or the application of broad strips of adhesive plaster about
the thorax. In addition to these general measures special indications
should be met when they arise. The occurrence of phenomena indicating
the development of pneumonia or collection of fluid should be noted, as
the latter may call for removal, with perhaps ligation of a vessel, if
it be bloody, or later evacuation, should it be serum or pus. External
extravasation will usually disappear under soothing, warm, and moist
applications. No hesitation need be felt in opening a hematoma which
does not show a disposition to prompt resolution. Other non-perforating
injuries include, for example, severe burns or scalds, which may need
the same treatment as when occurring in other parts of the body. Fluid
may accumulate within the chest when there has been any such serious
external disturbance.


PENETRATING WOUNDS OF THE CHEST.

Penetrating wounds of the chest are generally inflicted by stab
or gunshot injury. Two serious elements of danger accompany these
injuries: the first immediate, that of _hemorrhage_ from division of
some vessel of importance concealed from sight; the other that of
_infection_, for either by the penetrating object itself or by air or
clothing which may follow it, infection may ensue, which may result
in septic pneumonia, pyothorax, or some deep phlegmonous process,
with always dangerous and sometimes fatal results. _Gunshot wounds_
vary, and according to the character of the missiles and the weapons
from which they are discharged. Those occurring during warfare and
made by bullets of the Krag or Mauser type are usually driven with
such velocity that they produce a minimum of laceration, even though
they pass through the chest. Such injuries have in the late wars in
different parts of the world been frequently observed, and have shown a
surprisingly low mortality rate, providing only that the heart itself,
the pericardium, the large vessels, and the spine be not injured.
Stories of the battle-field afford abundant illustration of men shot
through the chest being scarcely affected by the injury, but continuing
in action, at least for some time, and finally recovering. On the other
hand, the ordinary revolver or pistol, with which most affrays in civil
life are terminated, does not drive its bullet with nearly the same
velocity, and is more likely to inflict a serious or even fatal wound.
(See Plate XLVIII.)

A bullet or a stab wound almost invariably so opens the thorax as
to permit the immediate entrance of air. In theory this should be
followed by prompt collapse of the lung; in fact, however, this is only
partial, and often surprisingly so. If such a bullet wound be occluded
the air thus admitted is more or less absorbed, disappearing into the
bloodvessels, and the lung once more expands to its natural dimensions.
Much will depend, therefore, on the size and character of the wound
as to whether occlusion may occur spontaneously, or may be practised
through the first-aid dressing or its equivalent.

The entrance of air may be recognized by a certain degree of
embarrassment of respiration, by alteration in the percussion note, and
often by its passage to and fro through the opening.

The principal indications of possible injuries, in addition to those
just noted, will be the occurrence of _paroxysmal coughing_, with
inspiration of blood, and the added physical signs of the presence of
blood in the pleural cavity. Thus dulness on percussion, with the line
of dulness altering with position, will indicate the presence of fluid,
and should this occur soon after the injury it can only be regarded as
an evidence of hemorrhage into the pleural cavity. A combination of
abnormal tympanitic condition, as above, with the physical signs of
fluid beneath, will indicate a condition of pneumohemothorax. These
signs will change from hour to hour or from day to day in accordance
with altering internal conditions. If they become rapidly more
pronounced they indicate a condition which will probably call at least
for free incision, evacuation of blood, and very likely determination
of the source of its escape and proper attention thereto.

[Illustration: PLATE XLVIII

Radiograph of Chest, showing Mauser Bullet.

(From Plate X, “Use of Röntgen Ray by the Medical Department of U. S.
Army in the War with Spain, 1898.”)]

An intercostal artery is of itself a small vessel, but when cut across
by the edge of a knife or torn by the passage of a bullet it may pour
sufficient blood into a pleural cavity to cause serious dyspnea and
perhaps fatal result. To discover at the coroner’s inquest that a
patient has been allowed to die because no one had the judgment to
enlarge the wound and assure himself whether such a hemorrhage was not
occurring is not at all creditable to those in charge of the case.
The combined dangers of infection and of collapse of the lung are not
so great as those of possibly fatal hemorrhage, or intrinsic disaster
through septic infection from neglect of this kind.

Aside from the injuries thus produced to the respiratory apparatus
there are those especially involving _the heart_. It has been supposed
that gunshot wound of the heart was necessarily fatal. There is now
reason to think that this is not invariably true, even in individuals
not promptly operated upon, while the resources of modern surgery have
enabled the surgeon to save a number of cases of absolute gunshot
injury to the pericardial sac and even to the heart itself. (This
subject has already been considered in the chapter on Surgery of the
Heart and Great Vessels.) Every case which is not promptly fatal is
worth attempting to save, if suitable help be at hand, by a resection
of the chest wall, exposure of the pericardium, and of the heart
itself, with the introduction of sutures or the use of the ligature
wherever these may appear to be needed.

The occurrence of more special forms of traumatic lesion may be
indicated by particular features. Thus if the _esophagus_ has been
wounded the patient may expectorate or vomit blood, whose presence in
the stomach could not be explained by other features of the case. On
the other hand blood which comes into the mouth from the _lungs_ may be
swallowed and its appearance in the ejected materials thus accounted
for. A violent disturbance of cardiac regularity or evident paralysis
of the diaphragm may be accounted for by injury to the _pneumogastric_
or _phrenic nerves_.


=Treatment.=--In regard to the general _treatment_ of these injuries
the use of the _probe_ should not be encouraged, at least in the way in
which it was formerly used. It is a serious matter to stir up clot or
to open up a wound with a probe, thus inviting free entrance of air.
Nearly all the information desired may be more accurately obtained by
careful physical examination and study of symptoms. It should never be
used except with aseptic precautions. It affords little information
as to the course, and practically none as to the location of a bullet
which has penetrated the chest wall. It may possibly be of service
in searching for a bullet in the muscles of the back, but the only
information it is capable of furnishing is afforded by a skiagram.
Miscellaneous probing should be condemned, and in these injuries is
rarely justifiable.

The first measure to adopt in cases of gunshot wound of the chest
is to determine that the heart has not been disturbed; the next to
estimate what injury may have occurred to large vessels, then a
general determination of the other surgical features of the case. The
patient who shows no depressing symptoms nor develops them during the
ensuing few hours may be left with only a temporary occlusive dressing
placed over the wound; but increasing embarrassment of respiration,
or weakening and increasing rapidity of pulse, should be carefully
watched to guard against internal hemorrhage. If it be learned that
there is such internal bleeding prompt action should be taken for
its control. This means anesthesia and perhaps _thoracotomy_, with
resection of one or two ribs, in order to afford space through which
to practise deep suture or ligation. So long as one side of the chest
alone is involved--_i. e._, one lung thus exposed--the surgeon may
widely open the chest and meet every surgical indication without the
necessity for artificial respiration or the use of the Fell apparatus.
It is, however, advisable to have this at hand for such work, while
cases demanding such extreme measures can scarcely be made worse by the
performance of a tracheotomy and resort to some means for forced and
artificial respiration.

To simply enlarge a small bullet opening or punctured wound, in order
to be sure that an intercostal artery has not been injured adds but
little to the danger and much to the security of such a case. _In case
of doubt give the patient the benefit of that doubt and operate_ to any
necessary extent. When hemorrhage is slight and not alarming it may be
sufficient to make the occlusive dressing include a tamponing of the
opening between the ribs, gauze being packed in the opening in such a
way as to prevent hemorrhage.

A study of the escaping blood will permit of differentiation between
arterial and venous hemorrhage, that which escapes from the lung being
ordinarily of the latter type. Richter has suggested an ingenious
method of deciding whether hemorrhage comes from an intercostal artery
or lung tissue, by introducing a sterilized piece of pasteboard,
similar to a visiting card, rolled up in the form of a circular tube
and flattened with a crease; should blood flow out along the groove it
shows that it is an intercostal artery which is bleeding; but if it
flows out of the wound through the tube the source of the bleeding is
the pulmonary tissue itself. (Dennis.)

The question of the _presence of a foreign body_, bullet or otherwise,
is important. This is less so when it is a question of the bullet
itself than of driving in some fragment of rib or of foreign body
introduced from without. A bullet, a broken knife-blade, or anything of
such character will be revealed by an _x_-ray picture. The probe will
rarely give this information. Clothing, objects carried in the pocket,
or various other foreign material may escape detection.

The first measure of importance is the determination of the occurrence
of serious _internal hemorrhage_, the second is the emergency
_treatment of the injury itself_, which should include primary aseptic
occlusion, to be followed later by other measures. A withdrawal of
fluid is also indicated. Escaped blood may be contaminated and produce
later a pyothorax. As the result of a traumatic pleurisy serum may
collect within the ensuing few days, and it too should be removed. It
should be first found with the exploring needle. If seen to be free
from pus it may be withdrawn by the aspirator; but if it be destined to
become pus, then the sooner it is evacuated by incision the better.

Increasing embarrassment of the heart’s action, which is not caused by
the collection of blood, may be due to _pyopericardium_. So soon as
the physical signs indicate gradual enlargement of the cardiac area
the exploring needle should be used. A _traumatic pericarditis_ may
simply require aspiration of the pericardium, whereas the presence of
pus in the pericardial cavity will not only necessitate aspiration, but
occasionally open _incision_, with or without drainage. The appropriate
manner of affecting these procedures will be found more fully discussed
in the section on the Heart.


INJURIES TO THE THORACIC VISCERA.

In general, and without regard to the nature of the accident,
_injuries_ to the _thoracic viscera_ include wounds of the _pleura_,
the _lung_, the _diaphragm_, the various large and small _vessels_, the
_pericardium_, the _heart_, the _thoracic duct_, and the _nerves_.


=Wounds of the Pleura.=--Injuries to the _pleura_, including rupture,
are produced by severe blows which do not inflict fractures, although
these are rare in the absence of such injuries. They are usually
not accompanied by external markings, but are indicated rather by
dyspnea and cough, with involuntary limitation of respiratory motions
and by the physical signs of escape of blood (hemothorax) or air
(pneumothorax), or by some crepitation at the site of fracture, which
may be recognized with the stethoscope. In many instances lacerations
of the pleura are accompanied by more or less injury to the lung,
perhaps with perforation of air cells or small bronchi and the
inevitable pneumohemothorax. With a wound situated near the twelfth
rib the lung, which extends normally only to the tenth, may escape
injury. A small wound of the pleura is of little consequence. By itself
it is of serious import only as it is accompanied by more serious
disturbances of the lung which it envelops, or the heart which it
contains.

When air passes freely to and fro through the opening in the chest
wall, without expectoration of froth or bloody mucus, it may be assumed
that the lung itself has not been injured. To this condition the name
_traumapnea_ has been given.

Uncomplicated cases of _pneumothorax_ usually take care of themselves,
the air being gradually absorbed by the bloodvessels. In certain cases
this air may be withdrawn by the aspirator. A small amount of _blood_
within the pleural cavity is usually absorbed. An amount sufficient to
embarrass respiration should be withdrawn either with the aspirator
or by incision. For the latter purpose the wound may be utilized when
properly situated.


=Wounds of the Lung.=--Wounds of the lung are made immediately
dangerous by injury to its bloodvessels or are given a serious aspect
by the possibilities of various forms of infection, including septic
pneumonia. In serious cases this may proceed to _abscess_ formation
or _gangrene_. Should either of these be sufficiently localized no
surgical procedure directed to evacuation or to excision or removal of
the gangrenous tissue can be more dangerous than the condition left to
itself. The surgeon may, therefore, be impelled to perform a pneumotomy
or a pneumectomy.

When the lung tends to protrude or prolapse through an external
injury the condition is referred to as _pneumocele_, or sometimes as
_hernia_ or _prolapse of the lung_. This is rare, and occurs usually
in connection with punctures or stab wounds placed anteriorly and
generally low. The lung may be entangled, after having been forced
out by violent coughing, and the external portion has been known to
be strangulated in such a way as to slough off. Should this occur
the mass may be permitted to slough, or it may be removed by cautery
or by ligature, the wound being left to heal by granulation. In rare
instances the pneumocele has been covered by the parietal pleura, as is
abdominal hernia by parietal peritoneum.

Another form of pneumocele is the later consequence of injury, the
soft, crackling, or crepitating tumor presenting beneath the skin and
returning the usual breathing sounds when auscultated. It may increase
and diminish in size with the respiratory movement. Such a hernia may
occur beneath a scar or through ruptured intercostal muscles. It is of
small surgical consequence, and, if troublesome, may be retained by a
suitable pad.

The lung is occasionally _ruptured_ by a violent concussion of the
chest, as is also the heart. Its consequences will be emphysema,
pneumohemothorax, with vomiting of blood, and later infection.

The later consequences of hemothorax, simple or uncomplicated, may
be troublesome pleuritic adhesions, by which freedom of respiration
is impaired, and, it may be, chest motions interfered with and chest
development limited. The pleural surfaces are usually gradually drawn
toward each other by the development of granulation tissue and its
subsequent contraction and condensation.


=Wounds of the Diaphragm.=--The diaphragm may also be lacerated by
the compressing effects of violent blows, either upon the chest or
abdomen. In consequence there may be passage of viscera (_hernia_)
from either cavity into the other. Accurate recognition of these
cases will scarcely be possible, but the development of distinct
abdominal symptoms or noticeable displacement of the heart or of the
abdominal viscera may lead to exploratory section, which shall reveal
the location of the rent and possibly permit of appropriate repair or
suture.


=Injuries to the Thoracic Duct.=--The thoracic duct is occasionally
injured by penetrating wounds, while, at the base of the neck, it has
been known to be divided in the course of the removal of deep and
adherent tumors. In the latter case the escape for a short time of
the milk-like _chyle_, which it carries, will give evidence of the
injury. Several cases on record show the comparatively innocent nature
of the injury and its tendency toward spontaneous recovery without the
necessity for further intervention. The very low pressure of the fluid
in the duct is a contributing cause to this exemption from serious
harm. Should the duct become obliterated near its upper end doubtless
collateral circulation will enable the right and smaller duct to take
up its work and continue it.


=Injuries to the Upper Nerve Trunks.=--In regard to injuries of the
upper nerve trunks in the chest it is necessary to add but little to
statements made regarding injuries to the same nerves in the neck.
The writer has collected over fifty cases of destructive injury to
the pneumogastric, in over one-half of which recovery followed. It
has been shown that unilateral resection of the vagus is almost
devoid of danger, though when it is required the nerve is rarely in a
normal condition. Unless the nerve be attacked or involved below the
branch which forms the recurrent laryngeal, laryngeal symptoms may be
certainly expected. Irritation to the cervical _sympathetic_ is usually
followed by dilatation of the pupil, widening of the palpebral fissure,
some degree of protrusion of the bulb, and paresis of that side of the
face, while absolute sympathetic paralysis, such as follows division,
will produce dilatation of the pupil, ptosis, and increased flushing of
that side of the face. The sympathetic nerve may have to be extirpated
in certain cases of excision of malignant tumors. Again, it has been
deliberately resected, as recommended by Jonnesco and others, for the
cure of epilepsy, of exophthalmic goitre, and of glaucoma. This will
demonstrate the fact that injury to it is not necessarily of itself a
severe accident.

In certain injuries to the chest branches of the _brachial plexus_
will be divided or compromised, or displaced by fragments of bone or
otherwise. When nerve pressure can be recognized the compressing cause
should be removed. If a nerve be divided every attempt should be made
to suture it.

Partial or complete division of the large _vascular trunks_ is usually
too promptly fatal to justify much consideration here. On the other
hand, injuries to the _intercostal_ and _internal mammary_ vessels
are not uncommon and should not be fatal if only they can be properly
recognized and treated. It is stated that even an intercostal artery
may pour four pounds of blood into the pleural cavity in case of
gunshot or stab wound. The presumption would be that one of these
vessels, if injured, is wounded at the site of the evident puncture.
While this is usually true it is possible that a bullet penetrating
may have divided an intercostal on the opposite side. If a ligature is
to be applied it should be done on each side of the wound, whereas a
tampon used to check hemorrhage may be packed in such a direction as to
completely meet the indication. While many methods have been suggested
for arresting bleeding, the surgeon will enlarge the puncture, seek
out the source of the hemorrhage, and then resort to ligature or to
tamponing, as the case may indicate. When the tampon is used it is well
to push ahead of it a piece of gauze like a glove finger and fill this
with the tampon, in order to ensure complete removal of the whole mass
at the proper time.

This is true also of injuries to the _internal mammary_. Dennis
mentions five cases, quoted to him by Langenbeck, of perforation of
the chest with a sword-blade, as the result of duels among university
students of Göttingen, of which number two died. The latter also stated
that up to 1876 there never had been a successful ligation of this
artery. The vessel, leaving the subclavian between the two heads of
the sternomastoid muscle, lies in its course just to the inner side of
the sternum, with the vein on its inner aspect. Near the clavicle it
lies on the pleural sac, where if injured the pleura will not escape.
Lower down the pleura is not necessarily opened, although it rarely
escapes. As Dennis shows, the inference from this is that tamponing
the wound in the two upper intercostal spaces is impracticable, while
below these it might succeed, as the triangularis sterni lies between
the pleura and the artery. The mortality of the injury has been stated
to have been nearly 70 per cent. Diagnosis is not difficult so long
as the blood escapes externally. With a wound properly situated and
rapid accumulation of blood within the chest, and increasing collapse,
assumption of the injury or provisional diagnosis will scarcely prove
fallacious.

The _internal mammary_ when injured should be secured. The operator
need never hesitate to resect a portion of the sternum, or the rib ends
or cartilage, in order to expose it, since no danger can be so great
as that of not finding it. Incision may be made along or between the
ribs, parallel to them, or over the known course of the artery. After
retracting the tissues down to the bone a sufficient amount of the
bone should be removed to afford space for the examination. The pleura
should be first separated, care being taken not to inflict upon it more
than a minimum of injury. A T-shaped incision will afford more room
when the case is complicated. The ends of the vessel having been found
and secured, it becomes then a question of emptying the chest of the
blood already accumulated. This is preferably done by incision placed
laterally and sufficiently low, with the introduction of a drainage
tube. Should the blood be already coagulated the incision should be
made sufficiently wide to permit of breaking up the clot and completely
removing it.


=Treatment.=--In general, with regard to the treatment of all these
injuries, it should be said that, in addition to whatever local
measures may be indicated, general rest of the parts should be secured
by as complete immobilization of one or both sides as can be effected.
This should be made a part of the treatment of all fractures, simple or
compound, as well as of all perforating injuries. Anodynes, hypnotics,
and the like need to be used both to restrain motion and to allay
cough, either of direct or reflex origin, by which harm is always done.


THE THORACIC WALLS.

The complex structure of the thoracic walls is not exempt from
the infections and other diseases which may involve skin, muscle,
cartilage, and bone. Thus upon its surface all sorts of phlegmonous
lesions may occur, assuming carbuncular or localized type, or
occasionally ending in widespread gangrene, usually of that particular
type which is due to the morbid activity of the gas-forming bacilli,
whose first expression is a _gangrenous emphysema_. These infections
occur not only in consequence of some external irritation, but are
seen after the infectious fevers, as well as in connection with
syphilis, tuberculosis, scurvy, actinomycosis, and other forms of
infection. Tuberculous disease beginning on the exterior of the
chest wall may spread to the interior and even deeper, and, _vice
versa_, tuberculous lesions beginning within the chest spread to the
adjoining bone, producing caries, and then to the exterior surface, the
resulting sinuses being irregular and sometimes opening at a point at
considerable distance from the origin of the trouble.

All the infectious processes, whether slow or rapid, need radical
attack, including free incision, curetting, removal of diseased bone,
cauterization of the affected area, and suitable dressing and packing.
_Carious ribs or portions of the sternum_ may be removed without fear,
it being necessary in certain advanced cases to remove nearly the
entire sternum. Any concealed focus of disease is sure to spread and do
more harm than will a well-directed attempt to eradicate it. Infection
originating within the bone may spread in either direction, and may
give rise to pleurisy, with adhesions, and possibly even subsequent
abscess of the lung. The same is true of the diaphragm, while products
of infection travelling in the proper direction may cause the beginning
of an extensive subphrenic or hepatic abscess.

[Illustration: FIG. 505

Erosion of sternum, the result of pressure of an aneurysm. Wood Museum.
(Dennis.)]

[Illustration: FIG. 506

Erosion of vertebræ, the result of pressure of an aneurysm. Wood
Museum. (Dennis.)]

The pressure of advancing tumors will sometimes cause surprising
changes, not so much the result of ulceration as of mere absorption
in the path of the advancing mass. Thus _aneurysms_ will gradually
erode the sternum or the ribs, and in time form bulging projections
from within the chest, which may ultimately rupture and thus terminate
the case. Even upon the vertebral column the effects of such pressure
are pronounced. Figs. 505 and 506 illustrate what may happen under
circumstances just detailed.

Remarkable expressions of subcutaneous _emphysema_ may be seen in
certain cases of fracture of ribs, with perforation of the lung, air
escaping into the tissues and puffing up the whole upper part of the
body and neck, giving it an appearance and shape very different from
the original. For this condition there is no particular treatment,
save immobilization, by which respiratory efforts shall be limited.
Ordinarily the tissue distention quickly subsides. Should, however,
putrefactive organisms enter with the air there may arise emphysema,
terminating in gangrene, with fatal septicemia.

Painful affections of the thoracic walls are associated with lesions,
either of the intercostal nerves or the ganglia or special nerves
with which they are connected, which produce _intercostal neuralgia_
of various types, including that with its peculiar eruption known
as _herpes zoster_, or as the laity call it, “shingles” (being a
corruption of the Latin _cingulum_, meaning a girdle). Neuralgia may
also be caused by inclusion of nerve branches in callus which is
formed around a badly united fracture of the ribs. The diseases of the
vertebræ which lead to softening and changes of shape will also permit
of pressure upon nerve centres and trunks, which cause more or less
pain, referred more often to the distribution of the nerves involved
than to their origin. Thus the referred pains of spondylitis (Pott’s
disease) are to be thus explained and are sometimes very pronounced.
We give the term “neuralgia” to those painful affections for which
there is no satisfactory explanation, and thus we are told that in
intercostal neuralgia there are three points of tenderness, known as
those of Valleix, whose determination confirms the diagnosis--the first
being at the point of exit of the spinal nerve from the vertebral
canal, the second in the axillary line, and the third close to the
costosternal articulation. Abrams has shown that if a freezing spray be
applied over the first spot the neuralgia will at once subside if it
be of peripheral, but not if of central origin. Again, if one pole of
the galvanic current be placed on the affected side and the other upon
any one of the above spots the pain, if neuralgic, will disappear. If
the current employed be the Faradic, and the pain subside, its cause is
located in the muscles, as the induced current does not influence the
pain of a genuine neuralgia. (Dennis.) So far as the treatment of these
painful affections is concerned it is rarely surgical; although it was
the relief afforded by the accidental stretching of an intercostal
nerve which first suggested to Nussbaum the utility of nerve
stretching as a more general procedure, and it was thus introduced to
the profession. The treatment of _herpes_, _i. e._, of that form of
neuralgic affection which is characterized by the appearance of papules
which soon become vesicular, which collect in clusters and appear along
the course of certain intercostal nerves, is rarely surgical. It is
not difficult to distinguish this from ordinary eczema, which does not
follow the nerve distribution and is not accompanied by the severe pain
of herpes.


THE MEDIASTINUM.


MEDIASTINITIS.

The principal interest attaching to diseases in either mediastinum
pertains to the consequences of spreading infection, which will be
practically always of the phlegmonous type, and which will produce
clinical expressions varying much with its location and the direction
of its course. These are included under the general head of acute or
chronic _mediastinitis_, which might be the result of an extension
from above, as from cervical abscesses, spondylitis of the cervical
vertebræ, deep cervical phlegmons, and the like; or the result of
perforation, or of foreign bodies impacted in the esophagus or
elsewhere; or may again come from the osseous structures of the chest
proper, spine, ribs, and sternum. Doubtless certain cases of subphrenic
abscess are the result of suppuration begun in the mediastinum.
Instances are also occasionally seen after typhoid and the other
infectious and contagious fevers.

The _indications of mediastinitis_ consist of intrathoracic soreness
and pain, increased upon coughing and deep inspiration, difficulty
of deglutition, disturbances of respiration and of heart action.
Any irregularity of the pupils is evidence of irritation along the
sympathetic nerves. Displacement of the heart means accumulation in its
neighborhood and pressure disturbance. The lesion which will produce
this will probably give dulness on percussion, and alterations of the
ordinary chest sounds. With trouble high in the thorax the recurrent
laryngeal may be involved, with the inevitable change in the voice. If
the pneumogastric be compressed there will be rapid and irregular heart
action. If the esophagus thus suffer dysphagia will result. Should the
presence of pus be suspected a differential blood count may do much
to clear up the diagnosis. Should pus come near the surface it will
probably give the ordinary surface indications which one should be
quick to appreciate and to relieve. Collections of pus within the chest
tend always to migrate and pus may burrow to a considerable distance.


=Treatment.=--The treatment of phlegmonous mediastinitis mainly depends
upon recognition of the lesion and its degree of accessibility. Certain
deep forms are hopeless, since they tend to kill before even pus can be
located and evacuated. So soon as there be found any surface indication
surgical attention should be promptly given. Any of these cases may
be complicated by septic conditions within the lung or accumulations
within the pleural cavity. The latter at least may be recognized and
relieved. The proper use of the exploring needle may afford much
information, and, in the presence of suitable indications, the sternum
should be trephined and exploration made behind it. The main thing in
all these cases is to distinguish between pressure effects produced by
phlegmon and those due to aneurysm or tumor. Only rarely, and then only
by surgeons of wide experience, should radical measures be attempted
for the latter. Chronic processes, of tuberculous character and leading
to formation of cold abscesses, will usually produce symptoms much less
urgent, while the nature of the relief to be afforded will scarcely be
left in doubt.

[Illustration: PLATE XLIX

Neurofibroma of Skin.]


TUMORS OF THE THORAX.

_Primary tumors of the chest wall_ constitute less than 1 per cent.
of those occurring in general practice; this, of course, not having
reference to secondary developments from cancer in the breast, which
are somewhat frequent. Of the benign tumors those which most frequently
appear upon the surface are the _lipomas_, which are seen either in
circumscribed or diffuse form, as illustrated in Figs. 507 and 508.

[Illustration: FIG. 507

Circumscribed lipoma of back. (Dennis.)]

[Illustration: FIG. 508

Congenital diffuse lipoma of back. (Mixter.)]

They are sometimes multiple and perfectly innocent, save as they
may attain large size or ulcerate from surface irritation. The
_granulomas_, especially those of syphilis and tuberculosis, are
common, appearing either as superficial tumors which ulcerate, or as
deeper ones which may break down in the course of months or years,
after perhaps involving the ribs or a considerable portion of the chest
wall. _Actinomycosis_ is perhaps as often seen in this region of the
body as anywhere.

The _fibromas_ are seen more commonly in the axilla and beneath
the thoracic musculature. The chest is a frequent site for those
pedunculated fibromas which have been described under the term keloid.
A most striking case of neurofibroma of the skin is portrayed in Plate
XLIX.

_Chondromas_ of the chest are slow-growing, usually painless, may
involve a considerable area, both of bone and cartilage, are not
infrequently the seat of cystic changes, and often undergo a final
sarcomatous degeneration. All this is true in lesser degree of the
_osteomas_, which are of the cancellous type.

The malignant tumors of the thorax proper are mostly _sarcomas_ which
assume various types, according to their cellular characters, the
round-cell sarcomas growing rapidly, becoming extremely hemorrhagic
and fungous, and tending to kill early, while the larger and more
spindle-cell and the giant-cell forms grow relatively more slowly, and
may even be successfully removed (Figs. 509 and 510.)

[Illustration: FIG. 509

Sarcoma of rib and pleura, result of injury by a base-ball. (Dennis.)]

_Carcinoma_ of the chest wall is generally the result of extension from
cancer of the breast or of some other epithelial structure. Advancing
carcinoma spares nothing, and may not only perforate the chest but
involve the lung beneath, with or without later ulceration, and the
occurrence of pneumothorax.

[Illustration: FIG. 510

Skiagram of a large sarcoma of the thorax and humerus, whose
bloodvessels were injected previous to taking the _x_-ray picture.
(Lexer.)]

While these are the more common forms of tumor of this region there are
no known growths which may not occasionally be met here.


=Treatment.=--The treatment for all these tumors is _extirpation_. With
benign growths outside of the ribs proper this is usually a simple
matter. When the whole or nearly the whole thickness of the chest wall
is involved it becomes then a serious problem how far to proceed in the
effort to extirpate. This is true alike whether sternum or ribs are
involved. The entire sternum may be separated from its surroundings and
lifted out of place, and this would be justifiable when dealing with
an osseous or cartilaginous growth. If, however, it were distinctly
sarcomatous it would be hardly worth while. If in such an operation
the pleura be spared and air not admitted to the pleural cavity
almost anything is allowable. If, however, it appear that it will be
necessary to open the pleural cavity caution should be observed. Of
late years, however, less hesitation has been felt in this regard,
and Parham and others, including myself, have shown that extensive
portions of the thoracic wall may be resected without the necessity
for employment of the elaborate operative methods suggested by some
recent experimenters. For instance, Sauerbruch has devised a “pneumatic
cabinet,” the patient’s head resting outside when the anesthetizer
administers the anesthetic. The balance of the body rests within the
cabinet, which is sufficiently large to accommodate the operator and
two or three assistants, and which, being closed, is subjected to a
lowering of atmospheric pressure equivalent to 10 Mm. of mercurial
column, or to a difference in atmospheric level of 1000 to 1200 feet.
The patient breathing air at external pressure does not suffer the
collapse of the lung, thus exposed, which would otherwise take place.
The operation being completed within the cabinet, the dressings are
applied and hermetically sealed, and the door then opened and pressure
equalized. Subsequent dressings can be made in the same way. Thus has
been afforded a scientific method of doing that which the experience of
many American surgeons has shown to be only theoretically indicated.
Sauerbruch’s device is ingenious in theory and complicated in operation.

A simpler method is to apply the Fell-O’Dwyer apparatus over the face
and thus keep up artificial respiration. It is not, in theory, so ideal
as to open the trachea and practise this procedure as is done in the
experimental laboratory, but is much simpler and will usually suffice,
should anything of the kind be required.

A malignant tumor of the chest wall whose overlying skin is seriously
involved, and whose removal would leave a defect which it would not be
possible to cover with integument, should not be disturbed. It might be
possible in certain cases to partially transplant the breast in such
a manner as to permit closure of a defect thus made. Nevertheless it
is questionable if any cancer advanced to the extent of requiring this
procedure is to be considered operable.

Nor should any malignant tumor of the chest wall be operated if, in
addition to its own presence, there be indication of the involvement of
the lymphatics or other structures within the chest, such indications
including, for instance, cough, loss of voice, dyspnea, dysphagia,
disturbance of pneumogastric control of the heart, displacement of the
latter, or great accumulation of fluid in any of the chest cavities.
The only exception to this statement is possibly when the lung has
attached itself to its interior surface, but yet not so extensively but
that removal of a small amount of lung tissue will not interfere with
extirpation of the growth. Cases of recurring carcinoma where the chest
wall is completely involved rarely justify operation.


TUMORS OF THE LUNG.

Tumors of the lung proper might be made amenable to surgery, in certain
instances, if an exact diagnosis could be made. Occasionally this is
possible, though but very rarely. Particles of lung tumor have been
expectorated and their minute character recognized, so that actual
diagnosis has been made. As in the abdomen, cancer of the thoracic
viscera will usually lead to an accumulation of serous fluid, and, in
both instances, thus obscure rather than simplify recognition. Quincke
has shown that the presence in such pleuritic effusions of fat cells
(hydrops adiposus) is significant, since they rarely if ever occur in
any other exudates.

Primary tumors of the lung are usually _sarcomas_ or _endotheliomas_.
_Carcinoma_ is exceedingly rare, save as secondary to cancer in the
breast. Even sarcoma is itself usually secondary to disease in some
other part of the body, metastasis having occurred through the blood
channels, instead of through the lymphatics, as is the case with
carcinoma. Tumors arising in the pleura may be of endotheliomatous type
and are usually accompanied by the presence of bloody serum. Extremely
rare tumors within the chest are those of _dermoid origin_, connected
more often with the pleura than with the lung proper. These may
suppurate and communicate either externally or internally. One known
case mentioned by Dennis was that in which such a tumor communicated
with a bronchus, so that the patient coughed up hair. _Syphilitic
gummas_ are also found in the lung, either in multiple small form or in
masses of considerable size. They are slow in development and may give
rise to no special disturbance. Dennis has described instances in which
these growths have become encapsulated.

Two other forms of tumor are not very rare in this situation: one is
that produced by _actinomycosis_; the other occurs in _echinococcus_
disease and in the formation of _hydatid cysts_. The former, developing
within the lung proper, tends to migrate toward its surface, to include
the pleura, and finally to invade the chest wall. Such a tumor when
exposed in either location can scarcely be differentiated from a
breaking-down sarcoma, except by the recognition in it of the small,
calcareous particles which are so pathognomonic of this disease. (See
Actinomycosis.) In the living patient the sputum will frequently
contain these particles, while under the microscope the peculiar
club-end, thread-like fungus formation may be recognized. The disease
is usually of slow development, but occasionally, especially when mixed
with a secondary infection, may be rapid. Significant tumors may also
occur in other parts of the body. Actinomycotic tumors upon the surface
may be attacked with curette and cautery. Injections of iodine are also
of value. For actinomycosis of the lung proper potassium iodide and
Lugol’s solution are indicated as well as copper sulphate.

_Hydatid cysts_ occur within the lungs in about 10 per cent. of cases
of echinococcus disease. Their contained fluid is alkaline, of low
specific gravity, colorless, and contains the characteristic hooklets
which are pathognomonic of this disease. A circumscribed collection
of fluid within the chest, shown to be due to this condition, may
be tapped or incised and drained. When occurring in the lung it not
infrequently leads to secondary pyothorax, while operation for the
latter may reveal the existence of the former. Any hydatid cyst of the
lung which can be recognized, or be made accessible, may be treated
by incision and drainage, the lung, if not already adherent, being
first fastened to the chest. Inasmuch as the condition develops in the
lower lobe and on the right side this is occasionally a practicable
procedure. As the diagnosis is usually made only after the primary
cyst has ruptured and small cysts are cast off, producing more or less
pleuritic effusion, the attempt may still be made to do this by a free
incision of the chest wall, perfecting the diagnosis and completing the
procedure at this time.


THE HEART.

There is but little to be said about the heart in addition to that
elsewhere stated, where such injuries as gunshot wounds, stab wounds,
etc., are considered. _Rupture_ of the heart without external injury is
possible under conditions of fatty degeneration or softening produced
in consequence of embolus or thrombus. _Aneurysms of the heart_ are
also known by which it is weakened and permitted later to give way.
The final rupture is usually the consequence of some emotion or extra
exertion, although it may occur with injury to some other part of the
body, as after a blow upon the abdomen. Death may be instantaneous, or
occur more slowly as the result of filling of the pericardial sac and
rapidly increasing embarrassment of heart action.

_Wounds of the heart_ produce syncope and shock, restlessness, extreme
anxiety, with dyspnea and such disturbance of heart activity as to
materially change the sounds heard on auscultation.

The treatment of such cases not primarily fatal should include opium
narcosis, but not stimulants intended to excite the heart to extra
activity. The operations justified under these conditions are elsewhere
described.[50]

  [50] Borchardt has collected 83 cases of operations upon the
  heart, of which 78 included heart suture. Of these 78, 46 died and
  32 recovered. He quotes a statement of Billroth, made when this
  surgeon was sixty years of age: “Paracentesis of the pericardium
  is an operation which, according to my view, closely approaches to
  what might be considered a prostitution of surgical art, or, as
  some surgeons would call it, a surgical frivolity, an operation
  which altogether has more interest for the anatomist than for the
  physician. Possibly a later generation will regard it differently.
  Internal medicine is constantly becoming more surgical, and those
  physicians who concern themselves especially with internal medicine
  will find themselves compelled to make the most daring operation.”
  The rapid advances made in surgery during the past three decades
  cannot be better illustrated than by contrasting Billroth’s statement
  of a few years ago with the standard practice of today.

_Pericarditis_, either of idiopathic or traumatic origin, may produce
a degree of distention, either _hydropericardium_ or _pyopericardium_,
calling for surgical intervention--in the former case with the
aspirating needle, in the latter either with the needle or the knife.
When a pericardium is greatly distended with fluid there is marked
change in the position of the apex beat, with embarrassment of heart
action, accompanied by distress and distention of the veins of the
upper part of the body, as well as much alteration of the ordinary
physical signs, the area of dulness being correspondingly enlarged and
the lung sounds being lost over the area occupied by the distended sac.
Great distention, with marked precordial trouble and distress of heart
and lung function, always requires _paracentesis_.

_Paracentesis pericardii_ is performed ordinarily by puncturing (a
previously sterilized area) 3 to 5 Cm. to the left of the left border
of the sternum, and in the fifth intercostal space, with a sterilized
needle. Here are found the internal mammary artery and the pleura. Too
rapid withdrawal of fluid may lead to syncope. It should, therefore, be
allowed to escape slowly. Should it prove purulent it may be incised,
passing the knife-blade along the needle; or the sac may be emptied,
when, if fluid re-collect, a free incision should then be made. Roberts
has shown that recovery follows in at least 40 per cent. of cases
of empyema of the pericardium thus treated. Gauze drainage may be
provided, but irrigation of the cavity should not be practised.

Allingham has suggested to open the pericardium from below by an
incision three inches in length, carried along the lower margin of
the seventh left costal cartilage, to separate the cartilage from the
abdominal muscles, pull outward and upward the lower surface of the
diaphragm, expose the cellular interval between its attachment to
the cartilages and to the tip of the sternum, to expose and enlarge
by blunt dissection, until there appears a mass of fat which belongs
above the diaphragm in the interval between the pericardium behind,
the sternum in front, and the diaphragm below. When this is removed
the pericardium is exposed and can here be opened. Throughout the
procedure injury to the pericardium which lines the upper surface of
the diaphragm should be avoided. By this method the pleura need not be
opened and better drainage may be secured. (Dennis.)

_Abscess in the heart wall_ is an exceedingly rare lesion, usually
accompanying pyopericardium, but occasionally met without it. It
was the writer’s experience in one case, in puncturing for what was
supposed to be a pyopericardium, to withdraw pus and give temporary
relief. Later postmortem examination showed that this pus came from a
large abscess in the wall of the heart, which had been thus entered by
the aspirating needle without immediate bad consequences, but, on the
contrary, with temporary relief.


THE LUNGS.

In the fact that the lung never completely fills the pleural cavity
we find explanation for the kindred fact that small effusions produce
little if any compression symptoms. Collapse of one lung after opening
the chest is never _complete_ if the other lung be uninjured and
functionating. Moreover, a partial collapse on the affected side will
be quickly atoned for when the pressure of the external atmosphere is
taken off.

Two or three serious pathological conditions of the lung occasionally
require surgical intervention.


HYDATIDS OF THE LUNG.

Hydatids of the lung have been mentioned (see above). Seventy-five per
cent. of these cases terminate fatally without surgical help, and in
reality more prospective benefit can be offered by it than without it.
Serious and even fatal collapse has attended the sudden withdrawal of
fluid from hydatid cysts in this location. Aspiration may be made, but
even this is scarcely less dangerous while it is less satisfactory than
free exposure and drainage.


ACTINOMYCOSIS OF THE LUNG.

Actinomycosis of the lung may be recognized by the sputum and also by
the pus discharged from any breaking-down cavity within the affected
area. (See section on the Pleura.) If a localized focus could be
diagnosticated or recognized after exposure the portion of the lung
thus involved might be removed.


ABSCESS OF THE LUNG.

Abscess of the lung is always the result of some local or distant
infectious process. The mechanism of production of the multiple
metastatic abscesses which characterize pyemia has been described in
the earlier portion of this work. For such conditions surgery affords
no aid. Circumscribed abscess may be the result of the presence of a
foreign body--_i. e._, a bullet or a parasite--or it may result from
embolism with infarct, in consequence of such affections as ulcerative
endocarditis, puerperal septicemia, sloughing fibroid, an otitis media,
or a septic pneumonia produced from any cause. It may be the result of
extension from an osteomyelitis of some portion of the bony wall of
the thorax, which itself may result either from injury or from local
infection. Abscess of the lung is seen not infrequently in connection
with _empyema_, and often results from suppurating tuberculous
_bronchial nodes_. It may be produced, also, by extension of trouble
from below the diaphragm, as hepatic abscess, subphrenic abscess, and
the like. It is always a secondary rather than a primary affection.

Such abscesses are to be recognized by the character and offensiveness
of the sputum, the pus discharged being colored green or brown,
containing shreds of tissue, with masses of bacteria and crystals of
fat. Some believe the presence of elastic fibers to be pathognomonic.
When pulmonary abscess is diagnosticated it is necessary, in addition,
to determine whether multiple lesions or a circumscribed collection
are to be dealt with. In the former instance it is of little avail
to intervene. In the latter the physical signs will usually furnish
evidence of adhesions between the lung and the chest wall, by whose
presence the operative procedure is simplified.

The term _pneumotomy_ is applied to the exposure and evacuation of pus
in the lung, whether it be found in connection with an ordinary abscess
or a suppurating hydatid cyst. It is essentially a thoracotomy, plus
the added measure of whatever may be done to the lung itself, and will
be described in connection with other operations upon the chest.

If a tuberculous abscess could be located it also might be treated upon
the same general principles. Thus Lane and others have suggested early
operations for relief of tuberculous lesions. For obvious reasons,
however, the method has not found general acceptance.


GANGRENE OF THE LUNG.

Gangrene of the lung is the terminal stage of a local infection, and
unless relieved may prove fatal to the patient. It is due to the causes
above mentioned as producing abscess in the lung, while to them may
perhaps be added a few others, especially expressions of embolism or
thrombus of the pulmonary circulation by which, the blood supply being
cut off, death of tissue occurs before there is time for phlegmonous
development. Thus it is met with occasionally after the acute exanthems
and the infectious fevers and after violent pertussis. When diffuse
it is of the miliary type. When circumscribed it may be due to more
localized causes. In any event it is more frequent in the lower
portions of the lung.

Pulmonary gangrene may be recognized by the extreme condition of the
patient, offensive odor of the breath, and expectoration of sputum
which may at first be frothy and bloody, but becomes rapidly purulent
and finally necrotic in type. Meantime, the function of the lung being
materially interfered with, respiration is rapid and there will be more
or less cough, pain, and finally collapse. When the sputum is allowed
to stand in a test tube there will form an upper layer, opaque and
frothy; a middle, more frothy layer; while the lower and denser portion
will be of a dirty green color and contain shreds of dead tissue with
bacteria, crystals of triple phosphates, fat debris, and pus. According
to the nature of the case the cavity or the area of dead lung may be
outlined by physical signs. There is a form of _fetid bronchitis_ which
has been mistaken for pulmonary gangrene, but the character of the
sputum and the progress of the case will be quite different.

Gangrenous areas of limited size have in certain favorable cases
cleared up and the patients have recovered, but ordinarily for this
condition surgery affords the only prospect of relief, the operation
being begun with a _thoracotomy_ and completed by the _removal of the
gangrenous lung tissue_. The operative procedure is essentially the
same as that for abscess and above described.

_Septic pneumonia_ is the term applied to those forms of pneumonitis
which occur in connection with septic lesions in other parts of the
body, or with the less typical forms--_e. g._, aspiration pneumonia,
due to the passage into the finer bronchioles of material from the
mouth or nose. It gives rise to the same physical signs, though it is
perhaps more often irregularly located than is the consolidation of
the ordinary lobar pneumonia. Viewed in this way it will be regarded
as a serious complication of various other conditions, many of which
are surgical, and it is frequently a primary expression of infection.
The physical signs by which it may be recognized are scarcely different
from those of ordinary pneumonia, except that, in addition to the
latter, there may be distinct expressions of general septic infection
and of profound toxemia, and that the disease may progress to the point
of producing pulmonary abscess or gangrene. While the milder types of
septic pneumonia are not necessarily fatal, it is always a serious
complication, and, as such, dreaded by the surgeon. It is not, however,
essentially a surgical complication, but calls for the treatment
generally given to pneumonia, plus whatever may be needed for the
primary condition behind it.


CHYLOTHORAX.

This implies a collection in one of the pleural cavities, usually the
left, of fluid which is practically unchanged chyle, which has probably
escaped from the thoracic duct. The number of cases on record is not
over fifty, of which about one-third have followed unrecognized injury
with probable rupture of the duct. Most of these cases have occurred in
connection with fracture of the spine. The duct may be opened by the
progress of ulcerative disease, and carcinoma is often the predecessor
of chylothorax. Rupture may also occur in connection with tuberculous
lymphatics about the course of the duct, and when the condition occurs
in children this is the usual explanation. It should be differentiated
from so-called _chyloid effusions_ into the pleural cavity, which are
more often seen in connection with cancer than tuberculosis, the fluid
in this case being mixed with fat and degenerated leukocytes or cells.
Pure chyle contains sugar, while chyloid fluid contains but a trace of
it. The former also is thicker, and compares with the latter as does
cream with skimmed milk.

The prognosis is not usually favorable. Nevertheless recovery has
ensued without operation. Mere pressure of the effusion may occlude the
opening through which it occurs until the latter shall heal. When the
fluid gives rise to severe symptoms the chest should be aspirated.


HYDROTHORAX; HEMOTHORAX; PYOTHORAX.

Under these terms are included the presence of fluid in the pleural
cavity, between the lung and the chest wall; this fluid, in the first
instance, being _serum_, which may be slightly admixed with pus and
blood; in the second, _blood_; and in the third, _pus_.

Hydrothorax may be a primary condition, the result of pleurisy with
effusion, or of pleuropneumonia. It may also occur as does a similar
collection in the abdomen, as the result of disease of the chest wall,
the lung itself, or in consequence of serious cardiac or renal disease,
with tendency to dropsical accumulations in various parts of the body.
Thus it is seen in connection with tuberculous disease or cancer of
the lung, as well as cancer of the chest wall. There is, moreover, a
miliary expression of tuberculous pleuritis in which hydrothorax is
always a complication.

The serious features of hydrothorax result from the compression which
it may make upon a lung with consequent embarrassment of lung function
and from the possibility of infection by pyogenic organisms and the
consequent conversion of a hydrothorax into a pyothorax.

Collections of serum within the pleural cavity which manifest a
kindly tendency to disappear by resorption do not require surgical
intervention, but all such accumulations which do not quickly evince
this tendency should be removed by the operation of paracentesis,
which, applied to the thorax, is called _thoracentesis_, _i. e._,
aspiration through the hollow needle. No lung should be allowed to have
its capacity long reduced by compression.

_Hemothorax_ may be idiopathic or traumatic. In the former case it is
an expression of malignant disease, or of advanced septic lesions which
have permitted erosion of bloodvessels and escape of blood. It may also
result from rupture of an aneurysm, and will then prove fatal. It is
seen in surgical cases in connection with injuries to the chest wall or
its contents, as in compound fracture of a rib or perforation of a rib
fragment into the chest, with injury to the lung.

In case of the sudden escape of fluid into the chest, with symptoms
of collapse and lung compression, it may be assumed that an acute
hemothorax affords the explanation. Fluid accumulating _rapidly_ under
any circumstance is more likely to be blood than serum. The exploring
needle may be relied on to furnish the deciding test, in addition to
the ordinary physical signs afforded by auscultation and percussion.

_Pyothorax_ is frequently referred to as _empyema_, the latter term
indicating a collection of pus in a previously existing cavity, and,
by common consent, made to refer to the pleural cavity unless some
other be mentioned. Empyema is seldom a primary condition. Generally it
is the result of a hydrothorax, which has become contaminated either
by direct or by indirect access of germs. Under these circumstances
it indicates the conversion of a relatively innocent collection of
serum into a collection of pus, with all its attendant dangers. It may
be looked for in cases of perforating injury of the chest, _e. g._,
compound fracture of the ribs, gunshot wounds, and the like.

While returning the ordinary physical signs met with in fluid
collections in this location, and being discoverable with the exploring
needle, empyema has this additional feature, that the pus may, when
long retained or accumulated in large amount, burrow and attempt to
escape through whatever path may offer least resistance. In this way
strange freaks will occur, as when it escapes behind a mammary gland
and pushes the latter forward, thus forming a large retromammary
abscess, which requires not merely the ordinary incision, but a
thoracotomy and ample drainage as well. It may penetrate at other
points and thus escape. The most remarkable illustration that the
writer personally has known of this travelling of pus was in a colored
man, in whom it perforated the diaphragm, then separated the peritoneum
from the abdominal wall over a large area, collected in large amounts
between the peritoneum and the abdomen in front, and even extended
down into the pelvis. This man had such a peculiar abdomen that he
was supposed to have dropsy. When the trocar was inserted there was a
discharge of over a pailful of almost pure pus.

In addition to the ordinary embarrassment which a considerable amount
of pus thus collected causes, there should be reckoned the peculiar
septic and toxic features, which can be easily accounted for by
the nature of the contained fluid. Pyothorax will nearly always
have septicemic in addition to local features, which give it an
individuality of its own.

The operations practised for relief of these conditions are discussed
at the conclusion of this chapter.


THE ESOPHAGUS.

Anatomically, the esophagus is a musculomembranous tube with downward
projection into the thorax, its uppermost portion blending with the
lower constrictor of the pharynx, the tube proper beginning at the
level of the cricoid cartilage, and opposite the sixth cervical
vertebra. Its conclusion opposite the tenth dorsal vertebra marks the
cardiac orifice of the stomach. In its upper portion it is placed
centrally, then inclines a little to the left, and, at the level of
the third dorsal, lies about half an inch to the left of the middle
line. This furnishes the reason for approaching it upon the left side
in doing external esophagotomy. From here it passes to the middle line
again until opposite the ninth vertebra, where it once more inclines
a little to the left. It has an anteroposterior curve corresponding
to the shape of the spine. Between it and the trachea, in the neck,
lies the recurrent laryngeal nerve. Its nervous supply is derived from
the sympathetic and the pneumogastric, and its lymphatics connect
with the mediastinal nodes, the latter point being of importance
in connection with cancer of the esophagus. Its average caliber is
about three-quarters of an inch, save where it is crossed by the left
bronchus and at the diaphragmatic opening. There is also a slight
constriction at its upper opening.


CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.

Congenital malformations include its absence, at least throughout some
of its course. Communication between it and the treachea, so-called
tracheo-esophageal fistula, has been noted. Its upper portions, into
which may open the incompletely closed branchial clefts, are also
subject to malformations with incomplete obliteration of the latter
and consequent diverticula. Irregular dilatation is also occasionally
of congenital origin, as well as acquired, in the latter case being
due to fatty degeneration of muscle fibers. These dilatations should
be differentiated from those which are mostly found on the proximal
side of any constricted tubular passage, and which are produced by
accumulation and distention from behind of whatever should be passed
through it.

The most common _malformations_ of the esophagus which are not of
the stenotic character are so-called _diverticula_, which appear in
two forms--namely, _distention_ and _traction_, these being both
acquired forms, while congenital formations of this character are also
occasionally met.

_Congenital diverticula_ may appear anywhere along the course of
the tube, but are probably more common in its upper portion. They
constitute more or less irregular tubular sacs which lie alongside
of and parallel to the main tube. The openings by which they connect
may be large or small. These saccular defects, always small at first,
may assume increasing proportions, because of the entrance therein of
food and their consequent distention by foreign material, as well as
by products of decomposition of the same. Thus slowly and insensibly a
very mild form of such defect may in time assume serious proportions.

The _acquired diverticula_ of the _distention_ type are usually met
with in the upper part, and are practically hernial protrusions of at
least the mucosa through the fibers constituting the muscular portion
of the tube, and cannot occur save by some preceding pathological
change. _Traction diverticula_ are the results of adhesions to
breaking down lymph nodes or other pathological conditions, by
which the esophageal wall is first pulled out of position, then
gradually sacculated, and the condition still further aggravated by
accumulation therein of foreign material. The acquired diverticula
attain considerable size, and when emptied one may be astonished at the
accumulation which has occurred. Such a tube having been completely
emptied may be again filled by the first food which is subsequently
taken. After being filled, the balance of the food may then pass into
the stomach, with partial or complete comfort or satisfaction to the
patient.

The principal indication of an esophageal diverticulum, beside
dysphagia, is regurgitation or vomiting of food. When food which has
undergone decomposition is occasionally rejected, and when, at the same
time, the stomach is shown to be not dilated and not at fault, the
suspicion of a diverticulum may be considered well founded. Its opening
into the esophagus may be so placed as to always engage the instrument
which may be passed down for examination, either bougie or stomach
tube. Should this be a constant phenomenon the diagnosis may be easily
established. In such a case it may be possible to first empty and then
distend the sac with food mixed with bismuth subnitrate, or perhaps
to inject it with an emulsion of the same. If this can be done, the
fluoroscope or a good radiograph will show a distinct shadow, and in
this way a pictorial outline of the condition may be obtained.


=Treatment.=--The treatment of these diverticula is of great
difficulty, especially when the sac has attained a size which permits
of retention of material. Sacs which contain decomposing matter should
be emptied by the stomach tube and washed out at frequent intervals.
If it be then possible to pass the tube beyond them the patient should
be fed through it, or it may be possible to place the patient in the
recumbent position, with the head lower than the body, and cause food
or fluid to be swallowed in this attitude. It will then probably enter
the stomach instead of the sac. Such measures as these failing, and
nothing else affording relief, operations are occasionally undertaken.
Much will depend upon the location of the sac, especially its height.
A diverticulum in the neck may be more easily reached than one in
the chest, and Richardson and myself have had remarkable success in
the relief of aggravated cases of this kind. Cushing has shown the
advantage of the administration of atropine before these operations,
in order to limit the flow of saliva and keep the parts dry. The sac
having been exposed by a long incision in front of the sternomastoid,
it may be filled with a solution containing methyl blue, by which
it may be identified, or it may be filled with paraffin, which,
solidifying, will serve admirably for its identification. It then may
be attacked as would be any solid tumor. The sac having been identified
and extirpated its opening into the esophagus is then closed by sutures
and the neck wound cared for as usual, with provision for drainage
(Figs. 511 and 512).

[Illustration: FIG. 511

Diverticulum freed from its attachments and delivered from the wound.
(Richardson.)]

[Illustration: FIG. 512

Shows the external layers of the esophagus closed by interrupted
Lembert suture of silk. (Richardson.)]

Traction diverticula may be amenable to surgical intervention. Should
the esophagus be diverted by adhesion to an advancing aneurysm nothing
should be attempted. Among the operations which may be practised upon
the thorax there may be mentioned a method of posterior exposure and
attack upon some of these conditions which may or may not afford
advantages, according to the nature and location of the various
conditions.

_Cardiospasm_ (see chapter on the Stomach) produces a sacculation
of the gullet often mistaken for diverticulum, and requiring to be
differentiated from it.


FOREIGN BODIES IN THE ESOPHAGUS.

Foreign bodies may be lodged in any portion of the esophageal tube and
cause a variety of troubles, according to their size, shape, location,
and nature. There is scarcely any conceivable object which may be
introduced into the mouth which has not been known to be impacted
in the esophagus and produce more or less serious symptoms. Young
children, imbeciles, and the insane may suffer unwittingly in this way,
while the condition is usually accidental and unintentional.

The accompanying figures (Figs. 513 and 514), portraying in one case
a jackstone lodged in the esophagus, a coin in the other, a case of
my own, will furnish illustrations of what has just been said. (See
also page 674.) The young and the insane may make no statement which
will furnish a clue for the distress caused in attempts to swallow or
the actual impossibilities of the act. In most instances, however, a
history of impaction and a statement as to the nature of the foreign
body may be obtained. The _symptoms_ produced are those of partial or
complete inability to swallow, of more or less pain accompanying the
act, and of the regurgitation often of blood or of bloody mucus. The
object may be sufficiently large to produce dyspnea and suffocative
symptoms, _e. g._, a plate with false teeth.

[Illustration: FIG. 513

Jackstone lodged in esophagus. (Phelps.)]

[Illustration: FIG. 514

Coin lodged in esophagus, successfully removed by external
esophagotomy. From the Author’s Clinic. (Skiagram by Dr. Plummer.)]

The condition being suspected or made known, the location of the
foreign body may be determined by the esophageal bougie and by the use
of the _x_-rays. With certain irregularly shaped objects the latter
prove a desirable help, especially when irregular plates containing
false teeth, or toys have been passed into the esophagus. They afford
an indication not only as to their exact situation and emplacement, but
also as to the best method of attack, that is, whether from without or
within. Considerable distress may be produced by even small particles,
as chips from an oyster-shell, small pieces of glass, and the like.

[Illustration: FIG. 515

Esophageal forceps.]

[Illustration: FIG. 516

Horse hair probang, expanded and unexpanded.]


=Treatment.=--A foreign body which produces the slightest discomfort
or recognizable symptoms should be removed. Only occasionally can this
be done by making the patient endeavor to swallow something else, this
being too uncertain a method of procedure; although I have known a
peach-stone impacted in the esophagus to be pushed into the stomach
by the passage of an esophageal bougie. The situation and the nature
of the object being known, one then decides how best to proceed. The
available methods of operation are:

  1. The introduction of a bougie and the enforced passage of the
  object into the stomach (questionable).

  2. The use of the esophageal snare.

  3. The use of the esophageal forceps or similar means of extraction.

  4. The more directly operative methods by external incision.

The _esophagoscope_ is an instrument of comparatively recent device
and perfection. We owe it largely to the ingenuity of Mikulicz. It
is to the esophagus what the endoscope is to the urethra, and may be
regarded as essentially an enlarged endoscope. Its introduction is
comparatively easy, but its retention is distressing to the patient,
so that opportunity may thus not be afforded for profiting by its
use. The employment of cocaine anesthesia, and perhaps of morphine
hypodermically, will sometimes enable it to be used satisfactorily.
It may also be used for exploratory purposes previous to commencing a
formal operation under general anesthesia. There are furnished with the
instrument itself forceps and extractors, by which it may be possible,
when the object is once seen, to grasp and withdraw it. The use of the
esophagoscope is, moreover, not limited to these lesions, since it
can be used in revealing the character of strictures, small wounds,
diverticular openings, and the like. Endeavors may be first made to
locate the body by those possessing such an instrument and expert in
its use.

The _esophageal snare_ is a simple instrument which, after being
introduced, is shortened in such a way as to cause to protrude a
basket-like meshwork of bristles in which, as the instrument is
withdrawn, a small object may be entangled and so withdrawn. In the
same way an ingeniously made _coin catcher_ is furnished, which, in
cases of impacted coins or similar shaped objects in the esophagus, may
be introduced beyond them and then withdrawn, the object being caught
in a miniature cradle, from which it cannot escape until brought up
into the pharynx. Esophageal forceps are made with long blades, curved
like all the instruments used within the pharynx, and serving admirably
for grasping objects impacted high in the tube (Figs. 515 and 516).

Dislodgement being impossible by either of the above-mentioned
expedients, recourse may be had to the operation of _external
esophagotomy_. This may require to be done as an emergency measure,
but is practically always indicated when an impacted object cannot
be otherwise removed. A dangerous location for a foreign body in the
esophagus is at a distance of about nine inches from the upper incisor
tooth, at which point it will be located directly behind the arch of
the aorta, at which level ulceration would perhaps result disastrously,
as Richardson has shown. The operation was devised by Goursault, in
1773, and has proved a satisfactory surgical measure. It is performed
upon the left side of the neck. The incision is made along the anterior
margin of the sternocleidomastoid from the middle of the neck downward.
The larynx and trachea are separated to the inner side, the muscles
and the large vessels to the outer side, the omohyoid divided, the
descendens noni and the recurrent laryngeal nerves, which lie in the
groove between the trachea and the gullet, are protected from injury,
and the esophageal tube thus exposed. The surgeon will feel more secure
in opening it if he now pass downward through the mouth a bougie or
instrument upon whose beak or tip he may cut down. The esophagus being
opened, the margins of the wound are secured by sutures which serve
as retractors, and the interior of the tube is then subjected to the
necessary manipulation. Even now it may not be an easy matter to
dislodge a pointed object, which may have become partially impacted.
Thus it may be dislodged at first by pushing it down a short distance
and turning it, the direction having been already indicated by an
_x_-ray picture. The manipulation should be as gentle as possible.
Extraction having been accomplished, the esophageal wound is closed by
the sutures introduced for traction purposes. Over this the external
wound is closed, with suitable provision for drainage, as it is almost
certain to have been infected during the procedure. In rare cases it
has been necessary to combine a _gastrotomy_ with this operation, in
order that by combined manipulation a peculiarly shaped object may be
dislodged.

_Gastrotomy_ will be necessary in but few instances, as, for instance,
when an object known to be one which cannot pass through the pylorus
has been dislodged into the stomach by pressure from above--as plates
containing false teeth, and various similar objects. It will probably
be safer to open the stomach and remove the object than to leave a
patient to his otherwise uncertain fate. On the other hand objects
which are sure to be in time dissolved or disintegrated by the stomach
juices may be allowed to remain to await this event.


WOUNDS OF THE ESOPHAGUS.

Wounds of the esophagus occurring in other ways than those above
indicated may be the result of gunshot and various perforating
injuries. The tube may be also partially cut across in so-called
_cut-throat_.

Any external wound of the esophagus which can be recognized should be
closed with sutures, and the parts brought together, if possible, with
provision for drainage. Those lacerated wounds constituting some forms
of cut-throat, however, permit of very little in this direction, for
when seen they are too infected. Through an esophageal opening thus
inflicted the patient may be fed for a time by a tube, the wound being
left to close later by granulation or by a secondary operation. When
the esophagus has been anywise injured it would be better to abstain
from feeding or else to introduce food through an esophageal tube.


RUPTURE OF THE ESOPHAGUS.

Rupture of the esophagus has been known to occur in consequence of
severe vomiting, there being some twenty-five cases of this character
now on record. (Dennis.) A tear is rarely complete, but it may be
followed by hernia and formation of a diverticulum. The accident will
be indicated by violent pain following severe vomiting in connection
with an effort to dislodge a foreign body. There will be more or less
shock and perhaps collapse, with escape of blood. Emphysema of the neck
and upper part of the chest may result and the injury prove fatal. The
condition being suspected, it would be advisable to do an external
esophagotomy or else to carefully introduce a stomach tube and leave it
_in situ_.


PERFORATION OF THE ESOPHAGUS.

Perforation--_i. e._, rupture _without traumatism_--may result from the
existence of ulcers or from the advance of malignant disease. It may
occur in either direction. Thus while the mediastinum may be infected
from entrance of septic material into it the direction may be reversed
and an abscess or other lesion of the surrounding tissues may evacuate
itself into the esophagus. Should this prove to be an aneurysm the
patient will die with uncontrollable escape of blood. The treatment of
such a case, if any be permitted, will depend entirely on the nature of
the exciting cause. Perforation has also followed injudicious use of
bougies when exploring or treating strictures (especially cancerous) of
the esophagus.


ESOPHAGISMUS.

Esophagismus, or spasmodic contraction of the esophagus, is usually
an expression of hysteria, or else is a reflex spasmodic effect due
to the presence of some neighboring irritation. In the esophagus, as
in the urethra, there may be spasmodic stricture, which will afford
considerable obstruction. Thus I have seen it as a functional neurosis,
absolutely without explanation, in an apparently healthy workingman.
It is noticed also in connection with hemorrhoids and with hepatic
lesions. It is seen in pregnancy, and a certain degree of it will
complicate many cases of gastric ulcer, gastritis, or esophagitis such
as is produced by swallowing mild caustics. While producing dysphagia
and obstructive phenomena it is intermittent and interposes little
real obstacle to the passage of a full-sized bougie or tube. It is
frequently accompanied in the hysterical by globus hystericus, and by
regurgitation of whatever food the patient attempts to swallow.

The local treatment consists of dilatation by the passage of full-sized
instruments at frequent intervals. If a neurosis the patient may
require other treatment, addressed either to the nervous system or to
any well-marked constitutional condition.


STRICTURE OF THE ESOPHAGUS.

Stricture of the esophagus has an etiology practically identical with
that which pertains to stricture of any other passage of the body. It
may be due to extrinsic or intrinsic influence. Among the former may
be mentioned the presence of tumors, either benign or malignant, or
of cicatricial tissue, while among the latter should be mentioned the
injuries resulting from the presence of foreign bodies, the extensive
ulcerations due to the swallowing of various caustic fluids, and the
cicatricial contraction which may follow other lesions like ulceration.
Those cases which are due to serious congenital defects will usually
die early. Of the ulcerative lesions which lead to stricture the most
common are the cancerous. Syphilitic and tuberculous ulcerations may
occasionally produce the same effect. By far the most common causes are
the traumatic, which are connected either with foreign bodies or with
the unfortunate accidental use of caustics.

_Esophageal strictures_ are recognized by the difficulty in swallowing
which they produce and the later dilatation of the esophagus above,
which is the frequent result of their long existence. The degree
of difficulty experienced by the patient in deglutition is to a
considerable degree a measure of the extent of contraction. It may
be nearly always assumed that such a stricture as is produced by
the swallowing of caustic fluids will leave a tortuously contracted
passage-way, and the instrument passed for its recognition, while
arrested in its upper portion, may give little or no correct idea as to
the arrangement below. In some instances it may be possible here, as in
the case of diverticula, to introduce sufficient bismuth emulsion into
the esophagus to make it cause a shadow in an _x_-ray picture, and in
this way to give pictorial information not otherwise attainable.

The surgeon should distinguish between hysterical spasm or esophagismus
and cicatricial stenosis. The former will offer but little obstacle
to the passage of a full-sized bougie. In fact it will be frequently
benefited, usually cured by it, while in the latter instance this is
almost impossible.

[Illustration: FIG. 517

Stricture of the esophagus. (Dennis.)]

[Illustration: FIG. 518

Esophageal bougies.]

Fig. 517 shows the possibilities in a case of actual obstruction, and
how different such a condition is from mere esophagismus or globus
hystericus. It has been recently shown, especially by Dennis, that
during or just after typhoid fever, ulcers occur in the esophagus
which may produce serious stenosis. At present writing I have under
observation a little girl of nine years who has an extreme condition
of this kind. It is with difficulty that she can swallow fluid
nourishment, and she was so nearly starved that her life was only saved
by a gastrotomy. Those congenital defects which may produce esophageal
stricture are usually of such a serious and extensive character as to
afford no opportunity for relief.

The location and caliber of these strictures may be ascertained by the
use of esophageal bougies, such as represented in Fig. 518. These are
made of various sizes, and are fastened upon the end of a flexible
rubber handle, which affords a degree of elasticity in manipulation.
_They should be used with care and caution_, as minor degrees of injury
produced by them may cause a spreading infection, while still more harm
may be done by rupture of an ulcerated area, or perhaps the perforation
of an aneurysm.

The patient should sit before the surgeon, with the head thrown
backward, the mouth comfortably widely opened, while the surgeon,
standing, introduces the left forefinger into the pharynx and with
it depresses the tongue and guides the tip of the instrument, be it
bougie or tube, along this finger, which serves as a guide. Unruly or
hysterical patients will not only gag, but may attempt to bite the
operator’s finger. To prevent such accidents a metal thimble is made,
which, being inserted between the teeth, protects the finger, but makes
the manipulation more awkward. Should the patient show any tendency
to folly of this kind, it should be remembered that when the finger
is forced back into the pharynx the mouth is instinctively opened.
If necessary, at the same time, the nostrils may be grasped and held
closed, in which case the patient is sure to open the mouth widely and
thus release the finger. After the tip of the instrument is engaged in
the pharynx it sometimes assists in the manipulation if the patient’s
head be now tipped a little forward. This manipulation is not very
different from that by which a small and long flexible rubber tube may
be inserted through the nostril into the stomach for the purpose of
feeding, as is frequently done with the insane who refuse to eat, or
may be done in the presence of certain diseased conditions.

The intent in this exploration is to determine the distance from the
upper incisor teeth of the obstruction, as well as its caliber. When
the instrument is withdrawn the surgeon marks the location of the
teeth by grasping it at this point with the thumb, and the distance is
measured off afterward so that it may be read in inches if desired. The
caliber is determined by the success or non-success met with in passing
an instrument of given diameter. The size with which the attempt should
be made may be determined largely by the history and statement of the
patient. With a patient who cannot swallow no ordinary bougie should
be expected to pass, while a small solid instrument might produce a
perforation. Flexible bougies are also provided by the instrument
makers, made as are the silk catheters, some of them being loaded with
small shot in order to give them a certain degree of weight. A small,
soft, flexible instrument may be thus passed when the ordinary probang
would fail. Here, as in the urethra, an olivary bougie may pass, after
which the same sort of resistance will be offered upon its withdrawal.
In this case the stricture is passed twice, going and coming. A
slight degree of constriction is met opposite the cricoid cartilage
at the entrance to the esophagus. This should not be mistaken for a
pathological condition. Information may be afforded by material brought
up by the instrument, such as shreds of tissue, blood, etc. A small
bougie coated with sponge may be used for the purpose of retaining and
bringing back such material as it may engage.

It will be of assistance to let the patients dissolve in the mouth
a tablet containing a little cocaine and swallow it, or to spray or
gargle the pharynx with a weak solution. It prevents the gagging and
discomfort of an operation which otherwise is almost painless.


ESOPHAGEAL HEMORRHAGE.

Esophageal hemorrhage occurs especially in connection with cirrhosis
of the liver. Stockton and others have called attention to a peculiar
varicose condition of the esophageal veins in certain of these cases,
and the possibility of repeated hemorrhages which may terminate
fatally. The same is true of obstructive jaundice with Riedel liver.


CANCER OF THE ESOPHAGUS.

Cancer of the esophagus may be either primary or secondary, and may be
either sarcoma or carcinoma. Its first expression will be ulcerative
or stenotic, according as it originates on the inner surface or not.
Sooner or later it will produce stricture, with the ordinary evidences
thereof, and is to be detected in the same way. Cancer is usually of
the carcinomatous type or squamous epithelioma. The disease is more
common near the lower than the upper end of the canal. The disease
spreads and involves the adjoining lymphatics, as well as various other
structures. In addition to the ordinary evidences of stricture it is
accompanied by a certain degree of pain, which is likely to be referred
to the _interscapular_ region or the back of the neck. The emaciation
which always accompanies it is not merely an expression of the disease
itself, but of the starvation which stricture in time produces.
Frequent expulsion of bloody mucus or shreds is extremely indicative.

Esophageal cancer admits only of esophagectomy, as a very unusual
method of relief, or gastrostomy, which is a palliative measure
intended to prevent death from starvation, but not affording exemption
from the advance of the disease.


OPERATIONS UPON THE ESOPHAGUS.

Operations upon the esophageal canal include:

  1. Dilatation;

  2. Internal esophagotomy;

  3. External esophagotomy;

  4. Esophagectomy.

1. _Dilatation_ is practised ordinarily with olivary or conical-tipped
bougies. The former are usually metal or ivory tips fastened to a
firmer handle, while the latter are fashioned like silk catheters
having more or less conical tips. These are introduced until they
are engaged within the stricture, after which the amount of pressure
or force used should be graduated to the character of the trouble,
the density of the tissues, and the tolerance of the patient. Daily
dilatation may be practised either for the prevention or relief of
strictures following cicatrices due to caustic fluids and the like.
A small passage may in time be stretched up to nearly the normal
diameter, after which instruments may be passed at regular intervals,
as the tendency to recontraction is inevitable. These methods of
dilatation have taken the place of more complicated mechanical
procedures performed with instruments like those intended for use in
the urethra. The writer has, however, in one or two instances used with
advantage the Otis dilating urethrotome in cicatricial strictures of
the gullet.

2. _Internal esophagotomy_ is practised either with instruments
carrying concealed blades, like those used within the urethra, or by
a method suggested by Abbe, where the stomach is first opened, and a
retrograde divulsion effected, or at least a small bougie is pushed
upward from beneath. When its tip is felt in the mouth there is
firmly attached to it a strong silk thread which, as the instrument
is withdrawn, is brought down into the stomach and then out through
the stomach opening. With one hand in the stomach and the other in the
mouth this thread is then manipulated in such a way as to saw through
the strictured passage. It is well, should the surgeon use silk in
this way as he would use a Gigli saw, to pass it through a piece of
rubber tubing, both above and below, in order that its sawing effect
may be limited to the esophagus proper. This is a procedure which
should be done with great precaution. The operator should stop at
short intervals, and, by using a bougie, satisfy himself whether the
strictured passage has been enlarged. When the desired result has been
attained the thread is withdrawn, the stomach and abdominal wounds
closed, and dilatation resorted to every day or two in order that the
benefit gained may be maintained.

The use of the _esophagoscope_ may permit the exposure of a cicatricial
band or an annular stricture, so placed that it may be divided by a
fine knife directed through the tube. Whatever cutting is done in this
region should be done cautiously, so as to avoid injuring adjoining
structures.

3. _External esophagotomy_ is easily performed for the removal of
foreign bodies. When done from below it may be combined with a
gastrotomy, the cardiac end of the esophagus being thus exposed and
exploring instruments or those intended for either removal of foreign
material or division of stricture being thus introduced. After the
measure is complete the stomach is first closed and then the abdomen.

4. _Esophagectomy_ is an operation undertaken from without, and is
seldom performed for other purposes than for the removal of malignant
growths. A cancer of the esophagus should be seen early and be
favorably located in order to be amenable to such a radical measure,
yet cases of this kind have been successful. Too often, however, they
are done too late. The esophagus is exposed by the same incision as
that described for esophagotomy, namely, on the left side along the
anterior border of the sternomastoid, the vessels and nerves being
retracted to either side in such a way as to permit its clear exposure.
The portion to be removed is then isolated by blunt dissection and
resected. This leaves two ends of the canal, which can usually be
brought together by sutures, after the fashion of an end-to-end
intestinal anastomosis. The principal difficulty met with will be
adhesions and infiltration caused by extension of disease, and these
of themselves in well-marked cases would be contra-indications to
operation.


=Transthoracic Resection of the Esophagus.=--Bryant and others have
shown how the esophagus may be exposed from the posterior aspect of
the thorax by a _posterior thoracotomy_, made in the third and fifth
intercostal spaces, where, by resection of the ribs and dissection,
the esophagus may be exposed behind the hilum of the lung. The azygos
vein which crosses it at about this level should be either retracted or
divided after a double ligation. Experimentation has shown that it is
possible at this point to stretch the tube in such a way as to permit
of restoration of its caliber, if but a small amount have been removed,
but great care should be exercised, otherwise tension would be extreme.
Because of the doubt regarding the success of such a resection Mikulicz
has suggested the following procedure of _externalization of the
esophagus_: After exposure the distal end of the esophagus is closed
and dropped back. An opening is next made along the anterior border
of the sternomastoid, where the esophagus is exposed, pulled up and
out of its situation--_i. e._, dislocated--and brought out through the
upper opening, which can be done because of its loose connective-tissue
surroundings. A third incision is then made over the second intercostal
space in front, where a bridge of skin is lifted up, the esophagus
drawn down beneath it and fastened, the intent being to connect this
opening with the stomach through a gastric fistula by means of some
special apparatus, thus making it possible to again feed the patient
through the mouth. The incisions in the back are closed by layer
sutures. The principal objection to this method is that the passage of
fluid through the _externalized_ portion of the esophagus would have to
be accomplished by massaging the part and forcing it down through the
tube. Sauerbruch and others have shown that in animals at least it is
possible to make a transdiaphragmatic anastomosis of the stomach and
esophagus. By much the same method as that last above described, _i.
e._, through a posterior opening, the esophagus can be exposed near its
lower end, resected, and then turned into an opening in the stomach,
the latter having been brought up through an opening in the diaphragm.
It is hardly necessary to go into details of this operation here,
since the occasions which would justify it are almost as rare as the
individuals who could be entrusted with its performance.


OPERATIONS UPON THE THORAX.

_Exploratory puncture_, either of the pericardial sac or of a pleural
cavity, is an exceedingly simple matter, the ordinary hypodermic needle
sufficing for many instances, while in some cases the contained fluid
will be too thick to flow through a finer needle and will necessitate
the use of a larger one. Such needles are furnished, with so-called
exploring syringes, and their use is a convenient preliminary to the
use of the aspirator--_i. e._, _thoracentesis_--or open division--_i.
e._, _thoracotomy_. It is essential that both the patient’s integument,
the instrument, and the operator’s hands be absolutely clean. When
several points are explored at one time and fluid is found at but one
it is well to indicate this with a little nitrate of silver or tincture
of iodine, which will make a temporary mark. Thoracentesis implies a
withdrawal of fluid through a hollow needle, which will make a small
puncture that will promptly close, a vacuum apparatus of some kind
being attached to it. The needle may be introduced at various points
to enter either the pericardium or the pleura. Ordinarily no harm
pertains to exploratory puncture and but little to withdrawal of fluid,
providing certain precautions are used, though fatal syncope has been
known to immediately follow it. Beyond absolute sterilization the most
important feature is to withdraw fluid slowly rather than rapidly,
and to desist so soon as symptoms of a serious nature appear, such as
faintness or collapse. When a collection of fluid has existed for some
time in one of the pleural cavities it may have gradually so displaced
the heart that its too sudden withdrawal may permit a too sudden
restoration to its normal position--so sudden, in fact, as to place
extra stress upon it and perhaps to seriously embarrass or completely
check its action. This is always a matter requiring attention. The
position of the patient also should be regarded, and a patient who
is seated in a chair, in order that fluid may gravitate to the lower
part of the chest cavity, should be promptly placed in the recumbent
position so soon as alteration in pulse or coughing or serious
embarrassment of respiration are noted.

The skin over the point selected for puncture may be anesthetized with
the freezing spray or with a sterile cocaine solution. The needle
point should be driven in sufficiently to secure fluid and not such
a distance as to puncture the heart or the lung within. The better
aspirating needles are provided with rounded points rather than with
sharp ones, in order that scratching with a sharp end may be thus
avoided. When using a more blunt needle of this type it is well to
make a trifling puncture in the skin with a small knife-blade. While
the more elaborate instrument outfits sold by the dealers are pleasing
to use, fluid may be siphoned through a needle and tube with a fountain
syringe just as in lavage of the stomach. Consequently it is not
necessary in emergency cases to have anything more than a satisfactory
needle. Care should always be given that no air is introduced. Thus in
managing the last-named expedient the tube and the needle itself should
be filled with fluid before the latter is introduced. Then the bag
may be lowered in order that no fluid escape into the chest. It is an
advantage to have a piece of glass tubing connected with the apparatus,
in order that the character of the fluid first withdrawn may be easily
ascertained. If the patient begin to cough or to have a feeling of
oppression the operator should temporarily cease, and if symptoms are
not ameliorated he should withdraw the needle, renewing the procedure
a day or two later. A lung too suddenly forced to expand by removal
of fluid may not only give distress to the patient, but there is a
possibility of hemorrhage.


=Thoracotomy.=--The term thoracotomy implies an incision made through
the chest wall, usually for withdrawal of fluid, with or without
removal of some portion of its bony structure. Thoracotomy performed
for pericardial collections of fluid has been described. That for
removal of ordinary empyemic collections is usually a simple measure.
It may be practised under local anesthesia. In a general way the extent
of the fluid collection is made out by percussion, and its character
by exploratory puncture. The endeavor should be to make the opening
laterally and posteriorly near the lower aspect of the cavity to be
emptied in order that it may drain by ordinary force of gravity with
the patient in the dorsal position. Unless it be intended to remove a
portion of rib the incision need not be more than one inch in length.

Ordinarily the skin is pushed a little one way or the other so that a
rib can be seen underlying it, in order to steady it for the external
incision. Then it is allowed to glide back to its normal position
and the knife-blade is so directed as to at once enter the thoracic
cavity. Only rarely is it necessary to make a careful dissection. It
is not often that vessels of importance will be divided, and one may
usually proceed boldly with the incision. It will be promptly followed
by appearance and usually by forcible expulsion of fluid, perhaps even
in a jet, for which a basin should be provided. In fresh cases this
fluid will be thin; in old empyemic cases there will be so much caseous
material mixed therewith that it may obstruct the opening and check
escape of fluid. In these cases it may be pushed aside with forceps
or by the introduction of a finger. When such material is present,
however, there is need also for its evacuation, and in such cases the
incision should be extended and an inch or more of rib may be removed
in order to afford sufficient exit.

The objection above mentioned regarding speedy evacuation applies
theoretically rather than practically to this procedure, for when it is
necessary to open the chest cavity widely it is because the walls of
the cavity thus opened have already become so thickened or stiffened by
the disease process that there is not the danger of sudden change of
position of the thoracic viscera which obtains in the less serious and
more acute cases.

The fluid having been removed the next question is one of _irrigation_.
This is only rarely necessary or even justifiable. Even in cases
where the evacuated pus has a more or less offensive odor it is found
sufficient to remove it, while experience shows the inadvisability,
sometimes the practical danger of prolonging the procedure and trying
at this time to wash out the chest cavity. If irrigation be practised
it should be with a bland fluid, for antiseptics are here peculiarly
irritating.

The third question is one of _drainage_. In recent cases it will
often be sufficient to insert some flexible material, like a piece of
oiled silk folded upon itself, secured externally by a safety-pin, or
stitched to the skin in such a way that it shall not be lost within
the cavity. In the older and more serious cases more complete drainage
should be provided. This is usually effected with a short piece of
rubber tubing, which needs to be amply secured against loss, either
with a large safety-pin or by being stitched to the skin with silk
rather than with gut, lest the latter soften too soon. This tube
should ordinarily be quite short, in order that it may not irritate
the pleural surface of the expanding lung. It is rarely necessary to
make valve-like protection of the opening, nor is it usually advisable
to insert any sutures in the external wound. These openings in most
instances close too soon rather than too slowly.

The surgeon should avoid making the opening too low, lest the
diaphragm, having been pushed downward by the accumulation above it,
rise and cover the end of the tube. Well-marked cases of empyema will
often improve more quickly if a counteropening be made. It is an easy
matter to introduce the end of a long forceps and determine the best
point at which to make this opening. The forceps being then held at
this point, one may easily cut down upon its end, force it through,
and utilize it for drawing backward, completely through the chest, a
long piece of perforated drainage tube, which perhaps may be eventually
replaced by a few strands of silkworm gut. A very large and copious
external dressing should be applied, and changed as often as need be,
in order to receive and provide for such discharge as may take place.
Sometimes this will be quite considerable, and necessitate, for the
first two or three days, a change every few hours.

Some surgeons have endeavored to make drainage more complete by a
vacuum irrigating apparatus, on the Bunsen pump principle. Should it be
necessary to resort to this the more complicated older methods may be
supplanted by the simple procedure, illustrated later in this work, for
continuous drainage or siphonage of the bladder.

One should never attack a case of this kind without being prepared to
_remove a section of one or more ribs_. Indications for this will be
found in the character of the contained fluid, or in the thickness
of the wall of the abscess, _i. e._, the old pleural cavity. The
difficulty usually is that these openings tend to close too promptly,
and that, especially in children, the proximity of the ribs to each
other affords too small space for the maintenance of drainage. When
it becomes necessary to remove a piece of one or more ribs there is
little object in trying to preserve the periosteum, and the operation
may be made within a few seconds by simply retracting the skin wound
and the musculature, introducing the bone-cutting forceps, with which
the rib or ribs are divided at points one inch or more apart, the
intervening portion being promptly lifted out with forceps and cut away
with strong scissors. The operation of dividing the rib will often so
compress the intercostal arteries that there will be little hemorrhage
from this source. Should they bleed too much strong forceps should be
used to compress the lower edge of the rib, and, by crushing it produce
hemostasis, as though the artery were itself seized with forceps, or
the vessel itself may be seized and secured. A special form of forceps
for dividing ribs, known as the _costotome_, has been devised and has
proved serviceable, since it is so made as to prevent easy slipping of
the rib from the grasp of the blade.

The larger opening thus made is treated in practically the same way as
the smaller. Through it the fingers or a blunt spoon may be inserted
and any cheesy material lifted out, or a sponge or gauze swab held in
the grasp of a long forceps may be introduced, and with it the cavity
thus opened may be wiped out or swabbed. In this way a considerable
amount of caseous material or shreds of membrane may be removed. The
more that can be removed the better, since there is so much less to
come away later. Such manipulation is, however, sometimes attended by
embarrassment of respiration, and one should use discretion in the
extent to which he practises it. Hemostasis having been secured, it
will depend on the case and its extent whether any effort is made to
partially close the wound or whether it should be left open. Even large
defects thus made usually heal kindly and fine or careful suturing is
rarely needed.

The subsequent management of such a case is usually simple. After the
first few days it may be advisable to practise irrigation. According to
the age of the case will be found the expansile capacity of the lung.
The lung itself expands by relief of pressure and by its own inherent
tendencies and returning function. Again by a process of granulation
it is gradually made to attach itself to the chest wall and is thus
withdrawn toward its surface. The combination of these agencies will
usually in time produce satisfactory results. The functionating power
of the lung may be determined by filling the cavity with fluid, the
patient lying upon the other side, and then noticing the difference
between the amount of fluid held in extreme inspiration and extreme
expiration.


=Thoracoplastic Operations.=--In old and neglected cases of empyema,
especially of tuberculous type, the pleura itself becomes more or
less thickened and stiffened, and affords such an obstacle to lung
expansion as to justify more radical measures. These have sometimes
to be undertaken as secondary operations, while in other instances,
where there has been spontaneous perforation and escape of purulent
overflow, perhaps for months or years, the necessity for such measures
may be foreseen. This necessity was first appreciated by Warren Stone,
an American surgeon, but the procedure was first formally placed before
the profession by Estlander, of Helsingfors. The principle upon which
it and all similar operations has been based may be likened to the
various efforts which it is necessary to make when a person tries to
collapse an ordinary barrel whose heads have been knocked out. So long
as the hoops of the barrel are intact the staves cause it to retain its
cylindrical form. If, however, the hoops be divided it easily falls
apart. In the case of a human chest, the lung, having been so long
bound down, is incapable of expansion, and the chest walls are rigidly
maintained by virtue of the hoop-like arrangement of the ribs. It is
necessary then to divide and remove a section from several of these
ribs, in order that the wall, falling in, may meet, at least half-way,
the lung, which may be expected to partially expand to meet it.

[Illustration: FIG. 519

Incision for resection of thorax. (Bergmann.)]

[Illustration: FIG. 520

Trap-door thoracotomy. (Lejars.)]

The original _Estlander operation_ has been modified by Schede, and as
now practised is made by a long incision passing obliquely across the
lateral aspect of the chest, from the origin of the pectoralis major,
at the level of the axilla, to the tenth rib in the posterior axillary
line, and then ascending to a point between the spine and the scapula.
The large flap thus outlined is made to envelop all the tissues outside
the ribs. The ribs thus exposed are resected from the tubercles forward
to their insertion into the costal cartilages. The large area of the
chest wall thus exposed is then removed with the underlying pleura,
and all hemorrhage checked. This flap includes the periosteum, the
intercostal muscles, the ribs, and the pleura, and thoroughly uncovers
the entire abscess cavity. It makes a formidable procedure, but is more
often life-saving than the reverse. Over the opening the skin flap may
be later drawn down and tacked in place at points sufficiently near to
each other to properly hold it in place (Figs. 519 and 520).

This procedure may be modified to suit the indications of any given
case, and simply includes what may be done in extreme cases. The
surgeon who thus for the first time uncovers such a cavity will be
surprised at its interior appearance, and at the shreds of tissue and
debris which hang from its walls. The measure thus described provides
for collapse of the chest wall. Fowler and others have shown, however,
that even now the principal obstacle to expansion of the lung is
not removed, and have suggested what Fowler has aptly described as
_decortication of the lung_--namely, a removal of its thickened pleura
by a process of dissection and stripping, which may be made partial
or complete, as circumstances permit. In some respects this adds to
the gravity of the case and will perhaps better be done at a second
operation. Should it, however, be justified by the condition of the
patient it is best done in connection with the resection of the chest
wall.

When decortication cannot be practised Fowler has advised that a series
of incisions be made, and that by thus gridironing the thickened
membrane it may be weakened or caused to lose its inelasticity and thus
a mild degree of similar effect secured. Fig. 521 illustrates the end
result of such an extensive thoracoplasty.

[Illustration: FIG. 521

End result of an extensive thoracoplasty. (Park.)]


=Pneumotomy.=--This is a term applied to an attack upon the lung
itself, it having been exposed by a thoracotomy. It is necessary in
cases of gangrene, abscess, hydatid cyst, and occasionally in large
bronchiectatic cavities. It is not ordinarily a difficult procedure
when the lung has attached itself to the chest wall in the course of
the disease process. Here the lesion having been located a part of
one or more ribs is removed, as may be needed, thus exposing the lung
surface, the cavity is then opened either with a knife or by dilatation
with the blades of a forceps, or preferably with the thermocautery
blade, by which hemorrhage is better controlled and possibilities of
absorption reduced. If such a cavity can be located it may be opened
with a large trocar and cannula, which should be introduced with great
care, lest it be thrust too far, the method by incision being therefore
preferable. If after opening the chest the lung be found non-adherent,
it depends on the character of the lesion whether adhesion should be
provoked or the cavity itself attacked. In the former case adhesions
may be produced by stitching the exposed lung surface to the margins
of the wound, and waiting for sufficient exudate to be poured out to
ensure that the pleural cavity has been hermetically sealed. The same
result may be obtained more crudely by packing gauze around the opening.

In case of urgency it would probably be best to attach the lung to the
chest wall with sutures and secure it there. This is a comparatively
safe method in dealing with hydatid cysts, and will give a fair measure
of success in many other instances. The suppurating or gangrenous
cavity being opened its contents should be removed, dead or sloughing
tissue excised, and the cavity then packed for drainage purposes, the
external wound being kept open until it can be safely allowed to close.

_Pneumonectomy_, that is, removal of a portion of the lung substance,
may be done with comparative safety upon animals, but rarely upon
human patients. It is occasionally required in connection with the
removal of malignant tumors of the chest wall, to which the lung has
affixed itself. In exceedingly rare instances it may be justified for
localized tumors of the lung itself. It would be equally valuable for
circumscribed, primary tuberculosis of the lung, were it possible to
recognize this in time. This an Italian surgeon once thought that he
had done, in the case of his fiancée, and proceeded to resect the upper
lobe of one of her lungs. His lack of success quickly led to his own
suicide a few days later.

The lung is exceedingly vascular and at the same time bears sutures
well. The suturing, however, should be accurate in order to prevent
secondary hemorrhage and favor the process of repair.

Other operations may be practised upon the chest wall for relief of
such conditions as _acute osteomyelitis of the ribs or sternum_,
_caries_ of the ribs, _necrosis_, and the like. It should be scarcely
necessary to give explicit directions, save that the pleural cavity
should never be opened unless the pleura itself be involved in the
disease. Every case demanding such operative relief should be measured
by its own needs, and the operative procedure adapted to them. Necrosed
portions of bone may be completely removed. The suppurative and carious
conditions necessitate rather a sufficiently wide exposure from without
and then a judicious use of the bone curette. One need never hesitate
to remove so much bone as is diseased, this being true even of the
sternum.


THE THYMUS.

The possibility of suffocative and other disturbances proceeding
from enlargement of the thymus has been discussed, as well as
the use of long trachea tubes in cases of this character which
call for tracheotomy, as they usually do if they permit of any
surgical intervention. The thymus is seldom the site of primary
malignant disease. Certain acute lesions are due to a peculiar
form of _hypertrophy_ in the young, which takes place instead of
that spontaneous disappearance which should have occurred during
the earliest months of infancy. Its connection with the _status
lymphaticus_, with thymic asthma, and laryngismus stridulus has
already been mentioned. While it can hardly be considered absolutely
exempt from ordinary infections and the like it nevertheless is rarely
involved.

The thymus has been removed by operation, usually with success. Should
it become necessary to resort to such a measure it should be preceded
by the removal of the sternum, for only in this way can sufficient
exposure be obtained, and sufficient opportunity for checking such
hemorrhage as might result from its enucleation.


THE AXILLA.

The axilla as a surgical region belongs as much to the thorax as to any
part of the body, although none of its diseases are peculiar to this
area.

It is frequently the site of furuncles of local origin, which
occasionally assume carbuncular type, and which are expressions of
local infection along the hair follicles or mammary ducts. It is full
of lymph nodes, through which are filtered the lymph streams coming
from the upper extremities. In this way there are entangled therein
septic germs, which frequently give rise to small or large _phlegmons_
proportionate in size to the magnitude of the lesion beyond them. It
takes but a trifling infection of the finger, for instance, to produce
such involvement of axillary lymph nodes as to make them palpable
under the finger. Such lymph nodes once genuinely inflamed frequently
coalesce, and the resulting abscess cavity may be large, especially if
neglected. The sooner these phlegmons are incised and cleaned out the
better for the patient. In order to do thorough work an anesthetic is
usually required.

In the axilla also are frequently seen _tuberculous_ manifestations,
the result of propagated infection from some part of the arm or hand.
These may be involved in a mixed infection and quickly break down, or
may assume the type of the chronically enlarged nodes, which undergo
caseation and more or less encapsulation, with such infiltration of the
surrounding tissues that when extirpated considerable difficulty is met
in the dissection.

In _syphilis_, also, the lymph nodes become involved, frequently
enlarging to a degree making them palpable, and sometimes participating
in a mixed infection in such a way as to break down into abscesses.

Again, in the axilla are occasionally seen conspicuous evidences of
_Hodgkin’s disease_. Any disease of constitutional character which
precipitates trouble in one axilla will cause nearly duplicate
alterations in the other, whereas disease of local origin is usually
confined to one side.

Any phlegmonous cavity or tuberculous lesion which has been incised
through the axilla should be carefully cleaned out and then drained,
lest the external incision close before the deeper parts are ready for
it. Incisions made in the axilla should be parallel with the great
vessels and nerve trunks, by which they are better exposed and avoided.
A wound made in the axillary vein may be sutured or the vein be doubly
ligated. The former is much the better course, very fine silk sutures
being employed. In some lesions where it has not been possible to
discover the bleeding point the writer has not hesitated to secure it
with the ends of pressure forceps and to leave these forceps included
in the dressings for forty-eight hours. He has never seen harm result
from this procedure.

[Illustration: FIG. 522

Congenital diaphragmatic hernia, with other congenital defects. Wood
Museum. (Dennis.)]

Finally the axilla is almost always involved in cases of _malignant
disease of the breast_, of the arm itself, and sometimes of the regions
adjoining. Primary malignant disease in this region is rare, while
secondary cancer is not unusual. According to the modern plan of
treatment of cancer there is reason for scrupulous extirpation of every
particle of infected tissue and all involved lymphatics, and in dealing
with such cases the surgeon need not hesitate to divide or extirpate
the pectoral muscles, in order to permit of thorough work. The disease
being present nothing can be so serious for the patient as to allow any
particle of it to remain.


THE DIAPHRAGM.

The diaphragm may show certain _congenital defects_, consisting mainly
of fissures or openings which permit displacement of viscera, usually
from the abdomen below into the thorax above. This is often fatal,
constituting a form of _diaphragmatic hernia_, which is particularly
liable to strangulation. Fig. 522 indicates a case of this kind,
showing the hopelessness of the condition.

Anatomically it is worth while to recall that the diaphragm may rise to
a level with the third cartilage during forced expiration, and descend
to the level of the fifth intercostal space on the right side, and a
little lower on the left, during forced inspiration. When forced upward
by pressure from below it may rise even higher than stated above. These
facts are of surgical interest in considering the possibility of injury
or perforation of the diaphragm in connection with gunshot and other
perforating injuries to the thorax or abdomen.

_Diaphragmatic paralysis_ is the necessary result of injury to the
phrenic nerve. It may occur as the result of injury to the thoracic
viscera, especially those of the posterior mediastinum, or injuries
to the cervical or upper dorsal vertebræ, usually fractures or
dislocations, followed by ascending degeneration and involvement of
the phrenic nerve roots. Double phrenic paralysis is in these cases
obviously fatal. Paralysis of a single side will cause at least serious
embarrassment of respiration. An hysterical form of diaphragmatic
paralysis has also been described.

_Primary tumors_ are exceedingly rare in this muscular partition.
Advancing growths, however, attach themselves to it or perforate it, as
may also aneurysms.

Aside from the ordinary injuries which the diaphragm may suffer from
without, and already mentioned, there are peculiar forms of _rupture_,
the result of force applied from below, usually at right angles to
the surface of the body, this being permitted on account of the
dome-like shape of the muscle. When thus ruptured abdominal viscera
may be forced into the chest and even out through openings between
the ribs. A gunshot wound of the diaphragm will be serious mainly in
proportion to other injuries involving the viscera above or below it.
These injuries produce no typical symptoms, but are nearly always
accompanied by severe pain radiating toward the shoulders, with dyspnea
and a substitution of abdominal for diaphragmatic respiration. When the
viscera have been forced upward they will displace the heart, and this
may produce cardiac symptoms. It is said that the so-called “sardonic
grin” is still observed on the faces of corpses who came to sudden
death from some injury to the diaphragm.

Thus diaphragmatic wounds are not of themselves of serious import. When
inferentially present they may, therefore, be disregarded so long as no
serious symptoms are produced. On the other hand, exploratory celiotomy
should be performed at any time, should conditions seem to justify it.


SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS.

While this is a condition pertaining, strictly speaking, to the
abdominal cavity, it nevertheless arises so frequently from
intrathoracic causes as to justify its consideration here, as well as
because of its close relations to the diaphragm. It was Volkmann who,
in 1879, first showed how these abscesses could be successfully and
surgically treated. The term is applied to collections of pus beneath
the diaphragm, usually between it and the liver, which, however, may
extend to and later involve surrounding viscera.

The _causes_ may be divided into those met with above the diaphragm
and those below. The former may include empyema, pus having escaped
beyond the normal pleural limits, advancing tuberculous disease from
any of the structures above the diaphragm, echinococcus in the lung,
or suppurative mediastinitis. From below the diaphragm the infectious
process may travel from the direction of a gastric or a duodenal ulcer,
hydatid disease in the liver, phlegmon around the liver or kidney.
The contained pus may, on culture, show the presence of colon bacilli
or pneumococci, as well as the ordinary pyogenic cocci and tubercle
bacilli. If connected with hydatid disease hooklets may be seen in pus
which is not too old.

Subphrenic abscess may result in large collections of pus, which may
travel a considerable distance, separating the peritoneum from the
diaphragm and from the lateral abdominal walls, appearing even low
down in the pelvis. The same is true of escaping pus from a case of
empyema. The primary trouble gives rise to a localized peritonitis
or perihepatitis, by which are produced certain barriers that serve
to retain pus within bounds, and to keep it from spreading save as
above mentioned. Should it be due to extension of abscess or disease
within the liver it may be confined by adhesions about it. Fig. 523
illustrates the relations which such a collection may sustain to the
liver and the diaphragm, as well as how the opening by which it may
be best evacuated should be made through the thoracic walls. Even
with this condition produced by disease below the diaphragm it is not
infrequent to find some collection of fluid or evidence of exudate
above it.

A study of this condition will nearly always lead one back to a history
of some illness which may furnish the explanation for the commencement
of the trouble. Thus, there may be obtained a history of pulmonary
tuberculosis, of empyema, of gastric ulcer, of gallstone trouble, or
of abscess in the liver or in or about the kidney. When the result of
perforation from above, the chest wall may furnish signs which will be
sufficiently indicative.

The _symptoms_ will include swelling, pain, tenderness, with fixation
of the liver, and apparent enlargement of its boundaries, because it is
pushed away from the diaphragm. The abdominal wall will frequently be
edematous. The ordinary signs of the presence of pus are rarely absent,
including the evidences furnished by a differential blood count.
Diagnosis is proved by the use of the exploring needle. The disease
is nearly always situated upon the right side. The more distended the
abscess cavity the less respiratory murmur will be heard over the
lower part of the chest, while the line of the hepatic dulness may be
considerably above the normal. Sometimes a succussion sound may be
obtained.

Should pus be withdrawn from the lower part of the chest by the
exploring needle there might still be doubt as to its actual location,
whether above or below the diaphragm. The absence of cough and of
indications of pleural involvement would prove much in favor of the
latter.

Subphrenic abscesses tend in time to evacuate themselves. Thus they
sometimes perforate the diaphragm and escape into the pleural cavity,
or through a lung which has attached itself at its base, and thus
afforded an outlet for pus through the bronchi and the mouth. On the
other hand, pus may burrow downward and appear in the flank or beneath
the skin near the liver and in front of it. The nearer it comes to the
surface the more easily it is recognized.

[Illustration: FIG. 523

Transthoracic opening for subphrenic abscess. (Beck.)]


=Treatment.=--The treatment of subdiaphragmatic abscess, like that
of all other abscesses, consists in evacuation of the contained pus,
with provision for drainage. In some instances this may be done with
an ordinary trocar and cannula, but serious cases are best treated by
incision, with resection, if necessary, of a portion of a rib. When
the chest wall is entered the best place is between the ninth and
tenth ribs in the axillary line. Nevertheless pus which is presenting
at any other point may be best reached by taking advantage of the
indication thus afforded. An opening having been made the question of
counteropening may be raised. This should be decided in each instance
upon its merits. While an opening made in front does not drain so
well as one placed posteriorly it may be made to drain by keeping the
patient upon the side or face for a portion of the ensuing few days.
When it seems desirable to go through the chest wall it should be
incised carefully, and if the pleura has been opened before reaching
the abscess, the pleural surfaces may be either stitched together or
packed; after waiting a day or two for protective adhesions to form
the abscess may then be opened. The less extensive operations may be
performed with local anesthesia. Rib resection and extensive incision
will usually require general anesthesia.




CHAPTER XLIV.

THE BREAST.


ANOMALIES OF THE BREAST.

_Amastia_, or complete absence of one or both breasts, is a rare
defect. _Polymastia_, or the occurrence of _supernumerary breasts_,
is more frequent.[51] These may be found on any portion of the thorax
or abdomen, and may constitute masses of trifling size or may bear
considerable resemblance to the normal breast. A supernumerary breast
has even been found upon the thigh. The condition is to be regarded as
atavistic, and a return to the polymastia of animals, which produce
a litter at one birth. Similarly absence of the nipple, _amazia_, is
occasionally seen, or more frequently _polymazia_, the occurrence of
more than one nipple, either upon the normal breast or in some abnormal
position. Some of these lesions are so small as to escape observation,
or to be considered moles unless carefully noted and recognized when
found.

  [51] History records interesting examples of the importance attached
  to these conditions. Thus the beautiful Anne Boleyn fell under the
  displeasure of King Henry because of a supernumerary breast, and it
  is said that the mother of the Roman Emperor Alexander Severus was
  given the name of Julia Mammæ because of a similar abnormality.

Ordinarily supernumerary breasts are met near the middle line and
below the normal mammary gland. A more common condition is one of
defect of the nipple, which fails to assume its normal prominence and
remains ill-developed, so as not to be seized by the infant in the act
of attempting to nurse. Nevertheless with the physiological activity
which occurs in the breast at the time of pregnancy these ill-developed
nipples usually expand sufficiently to fulfil their function, even
though imperfectly.

_Hemorrhages_ from the breast sometimes take place idiopathically,
at others as vicarious efforts at menstruation. There is a peculiar
sympathy between the pelvic organs of women and the mammary glands,
and the latter evince this in more than one way, becoming sometimes
extremely tender or swollen at the menstrual period, or at other times
peculiarly sensitive or even neuralgic, while at times congestion
will proceed to the point of hemorrhage. These conditions do not
require particular attention, but are not to be confused with a bloody
discharge that may occur later in life, in connection with certain
forms of malignant disease occurring in the interior of the breast.

[Illustration: FIG. 524

Idiopathic hypertrophy of breasts in a girl of sixteen. (Bebee.)]

There exist the widest differences in development of the breasts in
different individuals. The term “breast” is used intentionally, since
the difference is not so much in the actual glandular development as
in the surrounding connective tissue and fat. Thus a plump breast
may contain very little more secreting structure than one apparently
ill-developed. Nowhere outside the uterus save in the breast do such
compensatory changes take place under the stimulus of pregnancy. In
fact, a mammary gland in preparation for lactation is a physiological
adenoma. At conclusion of lactation there is absorption and atrophy
from disuse, usually not to the original degree, although in some
instances the fatty tissue disappears irregularly and leaves the
breasts in quite different shape from their originals. In this way the
breasts may become exceedingly pendulous, so much so as to lead to pain
and soreness from traction, and to call for their support.

_Idiopathic hypertrophy_ of one or both breasts is a rare deformity,
occurring usually in the young, sometimes in girls, involving them to
an indefinite degree, but in some producing enormous overgrowth, with
corresponding deformity. For such hypertrophy no known cause has been
assigned. Fig. 524 illustrates an instance of this character in a young
girl, occurring under the observation of my colleague, Dr. Bebee.


INJURIES TO THE BREAST.

These consist largely of _contusions_ to which, from their positions,
the breasts are peculiarly exposed, and these may be followed by
hemorrhage, by extensive ecchymosis, or by any of the consequences
of infection. They may also be followed by more or less permanent
_induration_. The fact that in the course of time certain contusions
of the breast are followed by development of cancer is incontestable,
although the relation which may exist between the accident and the
neoplasm has not yet been made clear. The breasts are also subject to
the same possibilities of injury as other parts of the thorax, which
has been considered in the previous chapter. The _nipples_ are more
often injured by efforts of the nursing infant, or by the friction
of ill-fitting stays or rough clothing, than in any other way. These
injuries, at first of a minor character, are not infrequently followed
by serious results, erysipelas, septic infection, or tuberculosis being
conveyed through trifling abrasions thus inflicted.

The nipple of a nursing woman once excoriated, or its surface broken,
is kept constantly liable to maceration and surface infection. In this
way a trifling lesion may result in a linear ulcer known as a _fissure_
(“cracked nipple”), or in a more extensive involvement. These fissured
nipples are very erethistic, and great pain is caused by each attempt
at nursing. On this, account the mother postpones the act as long as
possible, and until her breast has become overdistended, the result
being injury to the breast itself, with a greater possibility of
infection and of subsequent abscess formation.

The slightest _excoriation of the nipple_, under any circumstances,
should lead to the adoption of every precaution for its cleansing
and protection. Both before and after nursing it should be carefully
washed, while, after removal of the child from the breast, it should be
carefully dried and dusted with dry boric acid or a similar antiseptic.
Any abrasion which fails to heal should be treated with silver nitrate.
More pronounced abrasions and ulcers should be cocainized, then
cauterized, and afterward treated as above. Finally in extreme cases it
may be necessary to discontinue nursing and allow the breast to dry.
If this policy be adopted it should be applied to both breasts, for
such is the sympathy between them that the use of one gland seems to
stimulate the other. The local use of such preparations as belladonna
ointment, etc., is to be avoided. Pressure, rest, and the care above
described afford more relief.

_Paget’s disease of the nipple_ implies an eczematous condition, first
described by Paget as a precursor of many cancers. It is a more or
less chronic affection, involves the nipple and the areola, is quite
intractable to treatment, gives more or less discomfort, and is to be
dreaded when noted. It seems to sustain about the same relation to
later cancerous involvement as does leukoplakia in the mouth and on the
tongue.

There is no reason why any person may not have an attack of eczema
about the nipple, but cases in which the condition is persistent and
obstinate, and especially in which the underlying tissues gradually
become infiltrated or indurated, should be viewed with suspicion, and
should be treated by eradication of the area involved, even though this
may require extirpation of the nipple or of the entire breast. When the
condition is developed no ordinary treatment will suffice, although a
fair trial might be given to the cathode rays.


MASTITIS.

A true inflammation of the mammary gland may occur at one of three
periods: (1) At _birth_, when the tiny breasts of the newborn infant
secrete a milk-like fluid, become more or less congested and tender,
and when they are unintelligently treated by massage or interference of
any kind; (2) at _puberty_, when a perfectly natural turgescence and
congestion occur, which, however, rarely proceed to suppuration unless
infected or unless violence or some indiscreet treatment have been
received; (3) during _pregnancy and lactation_, this being the time
when mastitis is most common.

Considering that the nipple affords a number of open paths, from an
area which it is difficult to keep clean, extending into the depths of
inflammable tissue, it is strange that infection through the milk ducts
does not occur in most cases. Such a path of infection affords the
explanation for at least a large proportion of mammary abscesses. Again
the presence of excoriations, abrasions of any kind, and especially of
deep fissures which are not easily cleansed, will account for infection
through the lymphatics. In these two ways nearly all cases of mastitis
and of mammary abscess are to be explained, and both these accidents
are likely to occur during pregnancy and lactation.

The consequence of such infection is _mastitis_, which begins with
painful induration and local indications of inflammation, but which
may under suitable treatment undergo resolution. This failing, the
infectious process proceeds to suppuration, and the consequence is a
superficial, deep, or retromammary _abscess_, all but the last named
often in multiple form. The lobular construction of the breast permits
the independent occurrence of distinctive suppuration, occurring
synchronously at several different points, and hence it may be that a
breast is riddled with abscesses, which form successively or almost
simultaneously.

There is a _superficial form_, which occurs usually near the nipple,
and in which the deeper structure of the breast is scarcely involved.
This comes usually through infection of some surface lesion. Simple
incision is usually sufficient, and the local lesion is thus quickly
terminated. _Deep or intramammary abscess_, single or multiple, is
always painful, sometimes distressing and occasionally an extremely
serious condition. Occurring in a breast already well developed and
fatty, abscesses may form at such depth as to be recognized with
difficulty. The surgeon infers their existence rather than discovers
it. This is unfortunate, for the longer the delay the greater the
local disturbance, with a tendency to burrowing, and the worse are the
consequences for the patient. It is, therefore, far safer to early note
the minor signs of deep suppuration and to freely incise, than it is to
wait for pus to come toward the surface and give its ordinary surface
indications. The amount of induration, sometimes dense and brawny,
which such conditions will produce within the breast, the size which
the latter may assume, and the consequent suffering to the patient
from neglected conditions of this kind, need to be seen to be fully
appreciated.

_Retromammary abscess_ may be the result of conditions not primary to
the breast itself. Thus the writer has seen spontaneous perforation
of the thoracic wall in a case of empyema, with escape of pus into
the loose cellular tissue behind the breast, and the consequent
protrusion forward of the latter until it presented as an enormous
tumor. Treatment in such cases would mean not alone evacuation of
the retromammary collection, but emptying the pleural cavity of its
accumulated fluid.

An infected breast will produce not only the ordinary local
indications, but will be characterized by extreme tenderness, with
enlargement of the lymph nodes in the axilla and later abscess
formation in this location. In proportion to the amount of pus
thus imprisoned, and the virulence of the infecting organisms,
constitutional symptoms may be mild or extreme.

Nowhere is there greater need for release of an imprisoned amount of
pus than under these circumstances, although the incisions necessary
for the purpose may be sometimes multiple and deep. Every incision made
for evacuation of a mammary abscess should be placed _radially_--_i.
e._, in a line radiating from the nipple--in order that lobules may
be incised along their course, and that neither they nor vessels be
cut across transversely. There is also need for complete drainage, and
several tubes may be used for this purpose, being passed completely
across or beneath the breast.


=Chronic Mastitis.=--Chronic mastitis may be the termination of a
partially resolved acute process, or of injury, or of apparently
unknown causes, being in these instances of apparently spontaneous
origin. Pathologically it comprises induration, with more or less
infiltration of the interacinous and interlobular tissue, and with some
infiltration of the other structures of the breast, by which fixation,
retraction of the nipple, or condensation of the surrounding structures
and adhesion of the overlying skin are produced. The result may be to
produce either an enlargement or diminution in size of the breast. One
or both glands may be involved. It is a disease usually of late adult
life.

Breasts thus affected are often tender and painful, especially during
menstruation, and upon palpation are found to be irregular in shape,
more or less nodulated, extremely firm in some cases and places, and
perhaps so infiltrated as to strongly simulate cancer. The changes
which are thus produced are slow, and it is important to note that
the lymphatics are usually not enlarged, and that after attaining a
certain degree the diseased condition becomes stationary. The general
health usually does not suffer beyond a certain point; at least even in
the more chronic cases there is no characteristic cachexia. While the
condition is more frequent in women who have nursed it may be met in
those who have never borne children nor have been married.

_Suitable examination_ of all these cases can only be made with the
upper portion of the patient stripped, the body in the horizontal
position, and both breasts compared and examined, first with the flat
hand in order that differences of shape, size, mobility, and fixation
may be determined. Subsequently the patient should be raised to the
sitting position, the surgeon standing behind to examine each breast
with one hand and simultaneously, in order that differences may be more
accurately noted. Any tumor present will be more easily discovered
with the flat hand than with the finger-tip, while chronic induration
will not give the sensation given by neoplasms. The axillæ should also
be carefully examined, as well as the supraclavicular regions, for
evidences of lymphatic involvement. When the entire breast is involved
diagnosis is less difficult than when one or more lobules alone are
concerned. These constitute the painful nodular conditions to which so
many names have been given by different writers.

Significant features in their differentiation from cancer are the
disproportionate pain and tenderness, their diffuse leathery hardness,
and the fact that both breasts are usually similarly involved,
though perhaps not to the same extent. Cancer is, on the other hand,
somewhat dense and confined to one breast, and affords a sensation
of infiltration of the surrounding tissues, with the peculiar
“saddle-skin” retraction or adhesion of the overhang skin and nipple.
Moreover, the growth is more rapid and localized, and the lymphatics
are involved in nearly every instance. Some of these cases are so
obscure that diagnosis previous to operation is impossible, while
innocent lesions may gradually merge into malignant, and no one can say
when the transition begins or has begun.


=Treatment.=--The milder forms of chronic mastitis gradually
improve under the influence of local applications such as the
ichthyol-mercurial ointment, to which menthol may be added for its
soothing effect. Pendulous or painful breasts should be supported
as much as possible. Otherwise these cases are best let alone--_i.
e._, they should not be rubbed or massaged. There is usually a
constitutional condition which is closely related, and in nearly every
instance there is more or less failure of elimination. These features
should be studied and treated as they are identified. Finally there
are some intractable forms of innocently indurated breast which give
so much trouble that it is best to remove them as though they were
cancerous.


NEURALGIA OF THE BREAST; MASTODYNIA.

Many women suffer from annoying and painful affections of the breast
for which no sufficient excuse is found, while others who have small
fibrous nodules or innocent lobular tumors will suffer an amount of
pain which is disproportionate, and in instances of either type we
are prone to point to the neurotic or hysterical features of the case
and to say that it must be, at least to a certain extent, neurotic.
Inasmuch as these cases usually occur in young and otherwise neurotic
women, often of the more impressionable type, it is generally proper to
consider them as to some extent hysterical, while in others there are
pelvic accompaniments which may perhaps account for neuralgic breasts,
because of the well-known intimate relations between the pelvic organs
and these glands. In some cases, again, are found actual small tumors,
single or multiple, but of innocent character. In other cases there are
hypersensitive areas of entire breasts, to a degree where the patient
cannot stand the slightest handling. These cases are hyperesthetic,
even if not hysterical, and some are unsatisfactory to treat. The pains
are more or less periodical, and often radiate down the arm or the side
of the thorax; this may be explained through the intercostohumeral and
other nerve connections.


=Treatment.=--The treatment of mastodynia should include
constitutional, local, and moral measures, but of these the local
are the least important. The excision of painful nodules is often
disappointing, the remaining scars becoming even more sensitive
than the original lesions. Women who under these circumstances have
insisted upon the removal of an entire breast have still suffered
from intercostal neuralgia or other remaining painful conditions, so
that their ultimate condition has not been much improved. Each case
should be studied upon its merits, and while one may be benefited by
some pelvic operation, or another by Turkish baths and improvement of
elimination, others are best let alone, or given a minimum of drugs
with a maximum of general and sexual hygiene.


TUBERCULOSIS OF THE BREAST.

I cannot agree with writers like Fowler, who claim that tuberculosis
of the mammary gland is extremely rare. I think it not infrequent. In
the breast may be noted the presence of lesions, either separate or
coalescing, and gummas as such, or breaking down into caseous masses or
into cold abscesses. In connection with the local lesions there may be
more or less involvement, even to ulceration, of the overlying skin,
with the formation of lupoid ulcers, while the axillary lymphatics
will be nearly always involved. In some instances the disease may have
gone on to suppuration and burrowing of pus, with its discharge, and
the existence of tuberculous sinuses; or in others may be seen results
of a secondary infection of the remains of multiple mammary abscess.
The condition is most often met with in the young and fair, but may be
seen in elderly women. Around the distinctly tuberculous lesions there
may be considerable tissue sclerosis. The actual proportion of cases
is about one of this condition to fifty of cancer. Lesions are more
frequent in the outer quadrant of the breast than the inner, and they
occasionally produce retraction of the nipple or adhesion of the skin,
above described, before its distinct involvement.

In any of these circumstances secondary purulent infection may occur,
and an acute phlegmonous process may seriously complicate the previous
chronic condition.


=Treatment.=--There is but one satisfactory method of dealing with
tuberculous disease of the breast--_i. e._, its extirpation. The
entire breast, or so much of it as may be distinctly involved, should
be extirpated as though it were cancerous, while the axilla should be
opened and its contents cleared out, if it appear in the slightest
degree involved. Moreover, every other tuberculous lesion in the
neighborhood should be eradicated, either with the knife, the scissors,
or the sharp spoon. After such radical treatment results are usually
satisfactory.


ACTINOMYCOSIS; SYPHILIS OF THE BREAST.

_Actinomycosis_ is not common in this location; nevertheless tissue
conditions are such that it would furnish accessible and diagnosticable
features which would be distinctive, at least until some secondary
infection had occurred.

_Syphilis appears_ in this location in many of its protean
manifestations. _Chancres about the nipples_ and on the surface of
the breast are not uncommon, the disease being often conveyed from
syphilitic infants through cracked nipples, while many other methods
of contamination have been reported. Near the nipple the chancre may
not have those characteristics which usually distinguish it upon the
genitals, but may appear rather as an indurated, intractable ulcer,
with firm base, accompanied by distinct involvement of the axillary and
supraclavicular nodes, and unless early recognized and promptly treated
as such will so endure until the occurrence of the first significant
secondary eruption, whose appearance should dispel doubt and lead to
radical treatment.

There is difficulty, sometimes, in distinguishing between tuberculous
and syphilitic skin lesions upon the breast, especially near the
nipple. When other methods fail the therapeutic test will nearly always
clear up the difficulty. All truly syphilitic lesions here, as well as
elsewhere, yield promptly to well-directed treatment.


TUMORS OF THE BREAST.

The mammary gland is a frequent site for tumors, although neoplasms of
embryonic origin are not as frequent here as might perhaps be expected.
Nearly one-fifth of all tumors occurring in the body will be found
in this location, while the larger proportion of breast tumors are
malignant.

_Cysts_ abound in this locality, occurring in one or both breasts,
and singly or in exceedingly multiple form, the latter being small
and containing but a few drops of fluid. Their cystic contents are
colorless and of a serous consistency, sometimes thick and mucous,
occasionally discolored, and in rare instances almost like unchanged
milk. In the latter case the condition is known as _galactocele_.

In an organ so thoroughly provided with ducts it is easy to understand
how _retention cysts_ may readily occur from plugging of some duct and
the accumulation of secretion behind it. Should it occur at a time when
milk is forming galactocele may be readily explained. At other times
it is in every respect an abnormal development. This occlusion of the
ducts may be the result of disease or of injury, and is not always
complete, for it often happens that from a distended duct more or less
accumulated material may be expressed by gentle pressure. In this case
it will be found thick and loaded with the epithelial cells which line
the passages. These retention cysts are spoken of as serous, mucous,
or sanguinolent (blood cysts), according to their contents, while
the lacteal contain material more or less resembling butter. _True
galactocele_ seems to be rare. While the original contents are milky
it is claimed that through changes taking place in the neighborhood
induration and proliferation in the surrounding membrane may result, or
that mammary tissue may soften and break down into pulpy detritus.

_Cystic tumors_ in the breast may be of innocent character, or may
assume all degrees of malignancy. A cyst whose lining membrane is
smooth, without reduplications or irregularities, may be regarded as
innocent, while the complete extirpation of its walls will be all that
is required. This may be made more complete after injecting it and
staining it with methyl blue, or filling it with melted paraffin in
order to occupy the place of the fluid, which should have been drawn
off. On the other hand, every cyst whose interior is roughened, _or
presents the slightest papillomatous appearance_, or which is unduly
_adherent_, or has about it any mark of _infiltration_, calls not only
for its own eradication, but for practically the complete removal of
the breast.

The _signs of cystic tumor_ in the breast are essentially those of any
other neoplasm, except that it is frequently possible to recognize
its cystic character by fluctuation. A cyst ordinarily presents as a
distinct tumor, and when innocent is circumscribed and non-adherent,
lacking the clinical evidences of malignancy. Pain is an uncertain
feature. Most cysts develop slowly, but a cyst developing suddenly
after parturition or during lactation, without previous local
inflammatory changes, is probably a galactocele. The small multiple
form of cyst, with which one or both breasts may be studded, is
frequently confused with chronic mastitis, from which it is difficult
to separate it. The escape of sebaceous material or of milky fluid
from the nipple, or the possibility of making it appear by gentle
pressure, will probably afford the best indication. If along with this
possibility the nipple be found ulcerated, or if the extruded fluid be
bloody, complete extirpation of the breast would be the only suitable
measure.


=Treatment.=--The general treatment of cyst has been indicated. It is
a question simply of how extensively the eradication should be made.
The advice of the older text-books is misleading, and it is the studies
of very recent years which have shown how early the lining membrane of
apparently innocent cysts may undergo malignant changes, by which the
breast is soon compromised and which necessitate its entire removal.[52]

  [52] It will be a safe rule to follow if it be assumed that every
  cyst whose contents are bloody, unless this can be traced to recent
  accident, and especially every cyst whose interior is papillomatous,
  is on the border-land of malignancy, if not malignant in character.
  All such tumors then should be extirpated. If they occur in the
  breast a complete operation, as for cancer, should be done.

Of the _benign_ tumors _lipomas_ in the substance of the gland are
rare, while they may frequently develop in its fatty surroundings.
_Adenoma_ and _fibroma_, with their various combinations, are the
most common of the innocent tumors, and they constitute single or
multiple nodules, located in the substance of the gland, or in evident
communication with it, constituting masses of well-marked density, slow
growth, nearly always mobile and non-adherent to the skin, causing
neither retraction of the nipple nor lymphatic involvement, and being
frequently accompanied by a very disproportionate amount of pain and
tenderness, some of them being, in fact, exquisitely sensitive. While
these growths are rare previous to puberty they are frequently met
in girls and young women, and, occurring in these neurotic subjects,
they cause considerable mental as well as physical trouble. In these
patients there may be found coincident pelvic disorder. The removal
of these sensitive masses, which seems to be plainly indicated, is
often disappointing, as the remaining scar may retain the original
hypersensitiveness, and patients often suffer as much as before the
operation.

The enlargement of the breast, which normally prepares it for
lactation, is to be regarded as the development of a normal or
_physiological adenoma_. Anything which simulates this under other
conditions is abnormal, and any overdevelopment of true mammary gland
tissue, when localized and circumscribed, should be referred to as
_adenoma_. In such tumors cystic changes often occur, as well a later
transformation into _adenocarcinoma_, something always to be dreaded.
These changes are more likely to take place during lactation, at which
time the blood supply to the breast is more free. The development,
then, of _an adenoma in the breast of a nursing woman_ should be
regarded with suspicion, and unless benign it should be regarded
as demanding removal of the entire organ. These tumors also are
non-adherent and lack the ordinary signs of malignancy.


=Cancer of the Breast.=--Cancer occurs in the breast more often than
anywhere else, and _carcinoma_ constitutes about 85 per cent. of these
malignant tumors, the balance being mostly sarcomas, the remaining
small number being made up of endotheliomas and the other rare forms.
The most common type of carcinoma is the so-called _scirrhus_, in which
there is a large amount of dense stroma, and which forms a strong
contrast with the rare forms of rapidly growing, true soft cancer--_i.
e._, the _encephaloid_ or _medullary_ as they used to be called--in
which the cancer cells proliferate with greater rapidity and in which
there is a small amount of stroma, so that in consequence the tumor
itself is soft or almost gelatinous.

_Sarcoma_ of the breast may assume either of its well-known types, and
is a tumor seen in the earlier rather than in the later years of life.
It sometimes grows rapidly and attains large size, seeming to approach
the surface more rapidly and readily than ordinary forms of carcinoma.
In consequence it may be mistaken for abscess. As a rule, however, the
skin is not so likely to be adherent to the tumor as in carcinoma, and
the lymph nodes are not so early involved, while in a cut section of
the tumor the fat is not so disposed as in carcinoma, where it may be
seen in layers, while in the former case it has been transformed into
malignant tissue.

The two principal forms of _carcinoma_ are the _acinous_ and the
_tubular_, in the former the cells being packed into the alveoli and
surrounded with a firm and adventitious stroma, while in the latter
the primary development seems to be within the milk ducts, which
being first involved cause a more multiple minute invasion and a less
distended tumor formation.

The _general indications of cancer in the breast_ are as follows:

The presence of _tumor_, sometimes of regular and definite outline,
sometimes diffuse and not easily outlined.

_Fixation of this tumor_ in the surrounding tissues in such a way that
it cannot be moved without disturbing them.

_Fixation of the general area_, either to the skin above or to the
pectoral fascia below, or both. This gives to the part an immobility in
contrast with normal conditions.

_Retraction of the nipple_, when the growth is large or located near
it. This is a feature perhaps not noticeable in the primary stages when
it is so important to recognize the disease if present.

_Retraction of the overlying skin_, at points if not over a
considerable area, giving it a peculiar “saddle-skin” or “pig-skin”
appearance. This indication of itself is always suspicious and one
which should be noted if present.

In addition to the local evidences in the breast the _involvement of
the nodes in the axilla_ and of the lymph vessels leading up toward it.
These should be carefully studied, the patient’s arm being held loosely
away from the body, and somewhat to the front, in order to relax the
pectoral muscle. In fleshy subjects it may not be possible to discover
them even if present. The supraclavicular region should also be
examined, and enlargements may be felt here or along the cervical chain.

In addition to the above features others which are more indicative,
because they point to advanced disease, are the appearance in the
skin or just beneath it of shot-like nodules, more or less red, or of
any mass which causes the skin to protrude and to have an unnatural
appearance, usually one of lividity or threatening ulceration. _Pain
is an uncertain and variable feature_, upon which little stress should
be laid. The laity have incorrect notions about the constancy and
significance of pain, and many a woman has deluded herself into the
notion that she had no cancer because her tumor was not painful. _Pain
is sometimes pronounced_ and severe, even radiating down the arm; _at
other times it is absent_ until almost the terminal stage.

_Any tumor in the breast which presents any one of the above
characteristics is to be regarded as at least suspicious, while the
occurrence of two or more of the above features should stamp it as
malignant, and consequently condemn it. This is equally true of the
cancers which rarely appear in the male breast._

Cancer is supposed to be a disease of _middle and usually of advanced
life_. _This, again, is an error._ To be sure, carcinoma is rare below
the age of thirty, and yet one sees it not infrequently in women much
younger than that. One of the saddest cases I have ever known was one
of carcinoma of both breasts in a young mother of twenty-two, advanced
to hopeless condition because her physician had held that it could not
be cancer at her age, and because she had coincided with his belief,
since she had not suffered pain.

The _course of a cancer in the breast_ depends on several factors.
There is a rapidly growing type which tends to kill within a few
months, this occurring usually in younger patients. On the other hand
there is a slowly growing type which may last over a period of years.
This is the so-called _atrophic cancer_, and its slow growth is due
to the perfection of the protection afforded around the cancerous
masses by the density of the stroma. Occurring in a fatty breast it
leads to a diminution of its total mass, even though the cancerous
features themselves be advancing, and this makes it sometimes hard to
convince patients that a breast which is actually diminishing in size
is becoming more and more seriously involved. _Cancer tends ever to
advance, and sometimes_, as it were, _by leaps_, the method of invasion
being usually one of steady progress and infection of the adjoining
tissues; while metastases are to be expected as the case goes on, and
occur sometimes in unexpected forms. Thus in cancer of the breast
there is a well-known metastatic invasion of the bones, even of the
extremities, with the consequent liability to so-called _spontaneous
fracture_. In cases of the latter the former condition should always
be suspected. There is a possibility always of invasion of the sternum
and the ribs by continuity. It has been shown that invasion of the
pectoral muscle, and even of the firm pectoral fascia, was a common
result, and this demonstration has led to the adoption of the more
recent radical methods of removing both of these structures along with
the involved breast. In rare instances both sarcoma and carcinoma
assume the _miliary type_, and evince it by a miliary invasion of the
skin of the thorax which becomes gradually infiltrated, softened, and
perhaps finally ulcerated, the involved skin thus having the aspect of
a corset of diseased tissue, and being spoken of as “jacket cancer” or
“_cancer en cuirasse_.” Such a condition may before the patient’s death
involve the entire circumference of the thorax. Any of these miliary
expressions of malignancy stamp a case with a hopeless aspect. General
miliary carcinosis is also known to occur.

Nearly all cancers grow faster in the young. Other things being equal,
there is a somewhat better prognosis for the condition in elderly
people, and this applies equally to prospect of recurrence after
removal.

In regard to the curability of cancer the reader is again referred to
an earlier chapter on the general subject, but doubtless _there is a
time when if the growth were recognized and thoroughly removed it would
not recur_ and the patient might be cured. This time is, unfortunately,
too often past when the case comes under the observation of one
competent to deal with it. This is due partly to fear and ignorance on
the part of the patient, and unfortunately too often to failure on the
part of some practitioner to appreciate the significance of the early
manifestations, _i. e._, to a failure in early diagnosis.

_Cancer also occasionally occurs in the male breast_, and I have record
of a number of fatal instances of this kind. It is, however, quite
rare. It is usually of the scirrhus type, but may be the result of
epithelioma commencing about the nipple and spreading. It cannot assume
marked size without becoming thoroughly distinctive, and probably
ulcerating, and there should be no difficulty in diagnosis. It demands
the same radical operation as cancer in the female (Fig. 525).


=Treatment.=--In regard to the method of treatment there is but one
which needs to be seriously considered, _all others being fallacious
and irrational. It is by operative removal alone that every hopeful
case should be treated at the earliest possible date._ Patients may
dread the knife and some men may fear to use it. Nevertheless the
above statement holds true. Even then cure is not obtained unless
the knife be used thoroughly. Treatment by plasters is barbarous
and unscientific, as well as uncertain and absolutely unsurgical.
None of the popular remedies is of the slightest value. Treatment
by the Röntgen rays should be reserved for the hopeless cases or
for _postoperative protection_. Eradication is, therefore, the only
scientific surgical relief.

_Any growing tumor in the breast of a woman which cannot be clearly
recognized as perfectly innocent demands operative removal_, and the
operation itself should be made thorough if success is to be attained.
In the presence, then, of lymphatic involvement, of any adhesion or
infiltration of the overlying skin, or of the surrounding textures, or
of retraction of a nipple, or of fixation of the breast upon its base,
operation should be advised without any reference to the question of
pain. Equally important is it to decide _when not to operate_. When the
condition is disseminated, when the presence of cancer in any other
part of the body can be demonstrated, when the lymphatics of the neck
are notably involved, when the arm is already swollen from obstruction
to the return circulation, when the skin presents numerous miliary
nodules, or when from disturbance of the heart or of respiration--_i.
e._, chronic cough--it might appear that there is involvement of the
bronchial nodes, with consequent pneumogastric irritation, then it may
be held that the case is so far advanced that it is useless to subject
the patient to the risk entailed by operation. There are exceptions,
however, even to this statement; such as an evidently hopeless case
that has reached the stage of ulceration, in which discharge is
offensive or hemorrhage recurring, when operation may be done for
temporary and with humane purposes.

[Illustration: FIG. 525

Cancer of male breast. (Buffalo Clinic.)]

[Illustration: FIG. 526

Recurrent carcinoma eight months after incomplete operation in a woman
seventy-five years of age, showing the extensive nodular, ulcerating
surface surrounded by cancerous masses under the skin. The edema of the
right arm from the circulatory obstruction occasioned by metastatic
growths about the axillary vessels is well shown. (Parker.)]

_Recurrence_ is to a large extent inseparably connected with the matter
of both _early and thorough removal_. Only when this can be practised
should any hope of radical cure be offered. While the results attained
by modern methods are very encouraging, they nowise contradict this
statement. The discreet operator will, therefore, be guarded in giving
a favorable prognosis or making promises. Fig. 526 illustrates many of
the sad features pertaining to recurrence.


OPERATIONS UPON THE BREAST.

Every precaution having been taken the operator should decide whether
the operation is to be enucleation of the tumor or complete excision
of the breast, with dissection of the axilla. An evidently innocent
tumor of small size may be removed, either through a straight incision,
which should be placed radially, or by raising a flap with an ovoid
incision, by which more perfect dissection is permitted. Small nodules
and superficial growths may be removed under cocaine anesthesia. The
first essential is to leave behind nothing of the mass which it is
desired to remove; the second is exact hemostasis, and the third is
the closure of the wound. It is possible to remove portions of the
gland itself, as well as to enucleate tumors from within its substance.
V-shaped incisions may be coapted with sutures, by which the size of
the gland is reduced, but its general proportions maintained. Tumors
situated posteriorly may be removed by making an incision beneath the
breast, around its border, raising it from the thorax, and returning
it to place after the necessary excision. It is advisable to provide a
small drain for these cases, as in the more or less loose tissues of
the breast blood is likely to accumulate, and by distending the wound
to interfere with its repair.

_Operations for cancer of the breast_ are performed more radically
than a few years ago. This is due to a more thorough knowledge of the
pathology of the disease, and to the better appreciation of the value
of thorough extirpation of all affected tissues, especially if this
can be done _early rather than late_. Therefore the modern operation
includes not only the removal of the breast and of the axillary
nodes, but of the pectoral fascia and muscle, the fatty tissue in the
neighborhood, and everything in which the disease may lurk.

The essential feature, then, of every case is the _removal of all
tissue which may be involved_. It is therefore necessary to remove the
skin covering the mamma, as well as the structures above mentioned.
This is done by elliptical or ovoid incisions, the amount thus included
being sufficient to take in every particle of skin which shows the
slightest possibility of infection--_i. e._, every nodule or dimple
which may be in any way connected with the primary disease. Inasmuch as
only in cases seen early is it at all safe to be less radical than just
mentioned the pectoral fascia and muscle should be removed. For these
purposes large and long incisions are necessary, extending from the
anterior border of the axilla down toward the costochondral junction,
while the lower part of the opening is divided and the incision made
elliptical, in order that the breast, with its coverings, may be
completely removed. The upper end should follow the lower border of the
pectoral tendon, or at least be placed near it, extending as far as the
insertion of this tendon, since that portion belonging to the muscle
excised should be divided at its insertion and removed with the rest of
the mass. The incisions then are usually carried down first to the deep
fascia, and then through this, in such a way that the underlying muscle
may be lifted from the thorax and detached therefrom. The result is
that there is dissected from the chest wall a total mass of gland, fat,
fascia, and muscle, which is continuous upward and outward toward the
axilla, from which the final dissection is made. Then, commencing on
the outer side of the axilla, so much of the pectoral tendon is divided
as may be necessary; close beneath it will be found the axillary vein,
and this is next to be freed from its cellular and fatty surroundings.
The dissection is now carried toward the deeper part of the axilla,
vessels being secured before division, and the entire contents of the
axilla being carefully removed in one continuous mass. This requires
careful and sometimes tedious dissection, which is made much easier by
exact hemostasis. If the greater part of the great pectoral muscle be
removed, complete exposure of the axilla is easier. When this is not
sufficient, because in the uppermost portion of the axillary cone may
be felt enlarged lymph nodes, at the level of or beneath the clavicle,
then the lesser pectoral should be divided at its middle, and its ends
held apart, this affording a still better exposure of the axillary
depths. By this measure the vessels and plexuses may be easily followed
up to the level of the emergence of the former from the thorax,
especially if the arm be held upward and forward, much depending upon
the position in which the assistant thus holds it.

Everything which is actually involved should be sacrificed. This
might even apply to the axillary vein, which may be doubly ligated
and exsected. It will occasionally happen that it is cut or torn in
some deep dissection. In this event, before resorting to final double
ligation, an effort should be made to suture the opening with fine silk
sutures passed with a round needle, which may be successfully done,
or to secure a small tear within the jaws of a curved hemostat, may
then be left within the dressings for forty-eight hours or longer; by
this time a clot will have formed which will permit its detachment.
While much work may thus be done upon the axillary vein the writer
nevertheless has the feeling that when a case is advanced to such a
degree as to demand this it is scarcely worth while, because recurrence
is practically sure to follow. Nevertheless in the interest of general
thoroughness, if the work has been begun, it is usually well to finish
it as completely as possible.

[Illustration: FIG. 527

Diagram showing skin-incisions: triangular flap of skin, _a_ _b_ _c_,
and triangular flap of fat. (Halsted.)]

[Illustration: FIG. 528

Breast and pectoral muscle completely separated from thorax; axilla
exposed. (Halsted.)]

The operation as thus described has been extended by Halsted to a
degree which requires often much more work, and which has furnished
even better results, since he includes in it, if necessary, the
removal of both pectoral muscles, and even the division of the clavicle
for better exposure of the axillary and lower cervical regions,
and the more thorough extirpation of involved lymphatics. In other
cases he makes a vertical incision along the posterior margin of the
sternomastoid, exposing the junction of the internal jugular and
subclavian veins, and removes the supraclavicular fat by a downward
dissection and the infraclavicular fat by a dissection from below. This
is facilitated by elevating the shoulder, by which the clavicle can be
removed one inch or more from the first rib.

Figs. 527 and 528 illustrate the incision recommended by Halsted and
the general method of attack.

Throughout these operations the primary question is removal of disease,
the matter of subsequent closure of the wound being a secondary
consideration. Nevertheless the extirpation being completed, there
arises the question of how best to close the extensive defect thus
created. This will depend on its size and upon the amount of loose
skin in the vicinity furnished by the patient’s general physique. With
emaciated patients, whose skin is tightly drawn, it is not easy to
furnish flaps, whereas in those who are fatty, with flabby flesh and
skin, it is easy to rearrange the latter. Beck has suggested to make
quadrilateral instead of elliptical incisions, leaving a square defect,
which can then be closed by sliding flaps from two directions. The
names of Warren and Meyer are also connected with elaborately described
plastic operations. Years before any of these were published the writer
was doing similar sliding of flaps, but never endeavoring to make them
conform to a single pattern, raising semilunar flaps, or those of any
other shape, as might best fill the demand, and taking them from that
portion of the thorax, side, or even the abdomen, which would seem best
to furnish them. There is, therefore, no one method to be especially
recommended, for every operator of good judgment will be able to secure
sufficient integument from some surrounding location, so that it is
rarely necessary to leave such a wound uncovered. In those cases which
require an amount of dissection not permitting this it is a question
if operation be advisable. Nevertheless should it happen that for
some reason a sufficient skin covering is not thus easily available,
Thiersch skin grafts may be applied to any uncovered area at the time
of terminating the operation or later, and may be nearly always relied
upon for their destined purpose.

At least one opening should be made in the lateral flap in such a
location as to drain the axillary cavity when the patient is lying upon
her back, and through this a drainage tube of sufficient size should
be inserted. This should rarely be left more than forty-eight hours.
Inasmuch as there will sometimes be considerable tension upon flaps
a certain number of strong and reliable sutures (silkworm or thread)
should be used, to prevent parting of the wound margins, while long
retention sutures may be inserted if required. The balance of the
suturing may easily be done with catgut. The intent should be to leave
no dead spaces. Any isolated mass of fat which stands out by itself
after the dissection is complete should be pared down to the common
level, in order that it may not perish from ill-nutrition, nor disturb
the general level of the adjoining surfaces. It is rarely necessary to
keep patients in bed more than two or three days after even extensive
operations of this kind, but it is necessary to ensure that equable
pressure be made with the dressings, and that the entire arm be bound
to the side and immobilized in such a way that the patient cannot move
it nor disturb the dressing.




CHAPTER XLV.

THE ABDOMEN AND ABDOMINAL VISCERA.


GENERAL CONSIDERATIONS AND CONDITIONS.

That large portion of the human body which with its contents we term
the abdomen was for a long time _terra incognita_ to the surgeon.
Despite the sporadic success of such men as McDowell and others there
was felt, until the latter part of the last century, a universal and
well-merited fear of intrusion upon the peritoneal cavity, because
of the tremendous probabilities of infection and fatal peritonitis.
Until the memorable researches of Lister and the introduction of an
antiseptic, later of an aseptic technique, there was, therefore, the
best of reason for regarding the abdominal cavity as a sanctum to be
entered only when dire necessity required. In spite of the complexity
of its anatomical arrangements, as well as the peculiar and widespread
ramifications and connections of its vessels and its sympathetic
and spinal nerves, with the almost innumerable complications thus
permitted and favored, and the resulting uncertainty of symptoms
and distant disturbances of function, the abdominal cavity became,
first, a favorite seat for laboratory study and experiment, and then
a fascinating field for surgical endeavor. Today this region is
invaded by the surgeon in a manner and with a freedom which would have
been criminal and unjustifiable when the writer of these pages was
a student; and yet, while we have in the main lost our fear of the
peritoneum and our dread of peritonitis, we nevertheless see the latter
occur now and again, as it were as a punishment for forgetfulness or
inattention, the patient unfortunately paying the penalty for the
errors of which he is not guilty. Abdominal surgery has now become a
specialty which has attracted too many of those not thoroughly fitted
by training and by experience. One hears today of many, the older
practitioners especially, insisting that the abdomen is too often
opened; perhaps it would be more just to say that it is opened by too
many. By this expression is meant simply that enthusiasm has not always
been tempered by discretion, and that this is a department of surgery
which has been too enthusiastically cultivated by men who have not
waited to ripen their judgment or perfect their methods. My own feeling
is that not merely large observation should be regarded as an essential
preliminary for such work, but extensive experimentation in a surgical
laboratory; while even here the tyro has to learn, perhaps by severe
experience, that not all human beings can recover after manipulations
which some of the lower animals bear with apparent impunity. Previous
experience as assistant to a skilled operator is of the greatest value.

While uttering this caution we must, at the same time, candidly
acknowledge that accurate diagnosis of deeply seated lesions is by no
means always possible, and that the tendency, especially among the
practitioners of internal medicine, has been, and often is, to waste
valuable time in the application of methods of physical diagnosis, all
of which are valuable, many extremely ingenious, and yet which prove
insufficient or misleading. To give but one illustration--cancer of
the stomach, for instance, is a disease absolutely without a special
symptomatology. If we are to wait for the development of a recognizable
tumor or other features which are unmistakably significant, we wait
until the period for successful surgical attack has nearly or quite
elapsed. Thus rather than permit months of valuable time to be wasted,
it seems to the modern surgeon far more humane to make an early
exploration, in order that he may attack the disease while it has
involved but a minimum of tissue.

The general practitioner has seen himself robbed, as it were, of one
part of the body after another, by the application of this general
principle, until there has developed a feeling of irritation or one
even more pronounced, in certain cases, of rebellion, as it were,
against the cession of this territory to the surgeon; but this is
wrong, and such feeling should not exist. Rather should there take
place the heartiest coöperation between physician and surgeon, while
the operative procedures directed toward the early recognition of
these more or less vague conditions should be regarded more kindly and
the procedures themselves regarded rather in the light of operative
therapeutics. A recognition, then, of the limitations of physical
diagnosis, combined with an earnest desire to do the greatest good to
the patient at the earliest possible time, when cheerfully combined,
and practised by those of ripened experience and cultivated skill, will
redound to the greatest credit of all concerned and afford the greatest
prolongation of human life. It is to be hoped that the day when the
physician shall charge the surgeon with killing his patient, and the
surgeon shall have it in his power to retort that the patient did not
reach him until he was almost dead for lack of surgery, may soon pass
away.

_Diagnosis of abdominal diseases_ requires, first of all, a
comprehensive knowledge of anatomy and physiology, as well as
familiarity with all the methods of biochemical and mechanical
research, on which large volumes have been written, along with a
peculiar tact which in some individuals amounts to a gift, and includes
the cultivation alike of the senses of touch and sight, and the power
of analytical reasoning.

While some of the intra-abdominal lesions may be recognized within a
minute or two, others defy a study prolonged over hours or days. The
general methods to be applied do not differ here from those available
elsewhere, save that they find perhaps an even wider application.

_Transposition of the viscera_ is one of the rare anatomical anomalies
with which we may at any time meet most unexpectedly. This applies
equally well to the thorax and to the abdomen, but the condition is
met with oftener in the latter. It may be met as a surprise or it may
be diagnosticated before operation. In one case upon which the writer
operated for appendicitis he found the thoracic viscera transposed and
the heart upon the right side. The occurrence is so rare as to figure
but seldom in the consideration of a given case, but its possibility
should not be forgotten. Thus acute pain upon the left side, with other
indications of appendicitis, has been known to have an anatomical basis
of this character. It will usually be easy to determine whether the
liver and the spleen have changed places, and if so it may be expected
to find relative rearrangement of all the other abdominal contents.

_Inspection_ should be made with the patient well exposed, in
the dorsal position, divested of clothing, and with fear and
hypersensitiveness allayed as much as possible by tact, and perhaps
even by the administration of some soothing remedy. Inspection should
concern not alone the abdomen but the attitude of every portion of
the body, the character of the breathing, the motility of the chest,
the expression of the face, the degree of muscle spasm, and the fact
whether pain impels the patient to move and toss or to lie quietly. Any
irregularity of abdominal contour, with or without the legs flexed,
should not fail of observation. The cause of any great increase in
normal proportions should be promptly sought and assigned, either to
collection of fat outside of the peritoneal cavity, of fluid within
it, to gaseous distention of the bowels, or to the presence of some
intra-abdominal growth. Any bulging in either side or loin should
also be noted, as the latter may be due to some renal condition. The
existence of a distended bladder should be recognized, while the
appearance of the umbilicus sometimes affords valuable information,
it being flattened in tumor cases or bulging and perhaps containing
fluid in dropsical conditions or tuberculous peritonitis. When the
superficial veins are enlarged it may be felt that there is deep
obstruction to return circulation, which may be often located in the
liver. When the veins of the limbs show the same result it may be
believed that the obstruction is rather of the general circulation
than of the hepatic, and when involving one side alone a unilateral
lesion may be expected. The coexistence of hemorrhoids will indicate
obstruction to the hepatic return, while varicosities of the external
genitals would probably indicate it in the general circulation. Much
importance may sometimes attach to the presence or absence of the
lineæ albicantes, or of those pigmented areas which almost invariably
indicate a previous pregnancy. Fixation of superficial tissues or of
viscera implies either an infectious or a malignant process, while
recognizable local edema may point to a suppurative condition if the
disease be recent and acute, or to venous obstruction if it be old.

_Palpation_ will afford information in proportion to the tactile
sensibility and ability of the observer, and the relaxed, rigid,
collapsed, or distended condition of the patient’s abdomen. It may
afford aid in one case and little or none in another. The value
of what it may reveal is also greatly influenced by the pain and
tenderness which its practise may cause. Its value may also be limited
by hypersensitiveness or reflex contractions, from which some patients
can never voluntarily free themselves. So completely may the value
of palpation be limited or destroyed that every means of producing
relaxation or of abolishing spasm may have to be employed. When these
are present in lesser degree nothing is more efficacious than to
examine the patient just after removal from a hot bath or even while
submerged in hot water. In extreme cases the aid of complete anesthesia
may have to be sought.

_Bimanual palpation_ is of special service in examining the region of
the kidneys or the loins, and may often be advantageously combined with
the finger of one hand in the vagina or rectum. Special rigidity, like
special tenderness, is always a sign of great significance. When the
neurotic or hysterical feature can be eliminated one may almost hold to
the view that it points unerringly to something wrong within. Palpation
should include the recognition of abnormal pulsation in the aorta, and
determination whether this is due to the presence of an overlying tumor
or is one of those cases in which the aorta pulsates more prominently
than it ordinarily should. Any abnormal pulsation should be estimated
as to its expansile or non-expansile character. The recognition of
a _bruit_ may be supplemented by its further identification with a
stethoscope. An intra-abdominal growth once discovered, the surgeon
should obviously learn about it all that he can, regarding its real
location, its origin, its movability, its density, its fluctuation,
etc.; also whether there is free fluid in the abdominal cavity. It is
not infrequently necessary to differentiate tumors in the lower abdomen
and pelvis from pregnancy, either normal or abnormal, and one should
be familiar with the ordinary evidences of this condition, as well as
alert to the possibilities of such a case. The value of palpation is
often enhanced by changing the position of the patient from that upon
the back to the lateral or the genupectoral position.

The value of added vaginal and rectal examinations is sometimes
inestimable, even in conditions which apparently do not involve the
pelvic organs proper. In cases of obstruction of the bowel, for
instance, the finger in the rectum may discover an intussusceptum,
while in the female every tumor of the lower portion of the abdomen can
be better examined and estimated by this combined bimanual palpation.

The value of palpation is increased by the addition of _percussion_ as
part of the procedure, although conditions made evident by the latter
are usually detectable by the former. The surgeon will, however, rely
but little upon percussion alone, although it may be possible in a
large hernia to decide as to the probable nature of its contents by
this test. Auscultation is of especial value in recognizing fetal
heart sounds and placental or aneurysmal bruit. Friction sounds with
splashing in stomach dilatation, and gurgling sounds in certain
subdiaphragmatic abscesses which contain gas, are also discernible
through the stethoscope.

_Measurement_ affords ordinarily small help, save as one may in this
way record the progress of a chronic or inoperable case.

_Inflation_ by means of carbon dioxide or hydrogen was first suggested,
as an aid in abdominal diagnosis, by Ziemssen in 1883, and was applied
especially to recognition of perforating wounds of the intestine by
Senn. Nevertheless it is but little employed, except in estimation
of the degree of dilatation of the stomach or of the lower bowel, as
when, by distending the colon, the kidney may be pushed backward toward
the loin and the gall-bladder up beneath the ribs, the bulging thus
produced settling the question of diagnosis as between enlargement of
one or the other. Even this is not, however, always accurate.

The _aspirating needle_ is now but rarely used, especially by those
most experienced. In those instances where such grave doubt exists as
might indicate its use it generally appears that the welfare of the
patient is better observed by an exploratory incision rather than by
puncture with a needle.

_Pulse and respiration_ nearly always, and _temperature_ frequently,
give information of great value in abdominal conditions. A rising pulse
or a rate over 112 to 120, occurring during any serious intra-abdominal
condition, will stamp it as one of considerable severity, the gravity
being proportionate to the increase above the figures just given. This
is particularly true in acute appendicitis, with or without prominent
local symptoms. A rising pulse rate, then, should always be considered
as a warning. A very rapid, feeble, thready pulse will usually indicate
a condition seen too late to justify surgery, the patient being then
in a condition of practical collapse. Nevertheless if it appear that
this be due to hemorrhage, either from injury or by rupture of an
extra-uterine pregnancy, it may be felt that so long as the pulse is
perceptible the indication is present.

_Respiration_ is markedly affected in many intra-abdominal diseases.
The more thoracic it becomes--_i. e._, the more the abdominal muscles
are disused--the more it bespeaks a serious condition below the
diaphragm. A rigid abdominal wall accompanying frequent thoracic
respirations bespeaks a condition of grave danger. It should never be
forgotten that some of the acute diseases, especially of the lungs
above the diaphragm, cause symptoms and pain referred to the viscera
below. Thus in the early stages of pneumonia and of diaphragmatic
pleurisy there may be thoracic respiration, abdominal spasm, and pain
referred even below the waist line, with strong simulation of acute
appendicitis or of localized or general peritonitis.

_Temperature_ is an uncertain feature. Rapid elevation is usually of
serious import, but one is constantly surprised at the revelations of
an operation, or an autopsy, where temperature is not significantly
elevated or is even subnormal. Small matters may suddenly send it up--a
stitch abscess, for instance--and it is often difficult to distinguish
between the pyrexia of intestinal toxemia and that of actual septic
infection. When elevated temperature is intermittent and accompanied
by chills the surgeon is justified in suspecting the presence of pus,
although the reverse of this is not true, and _pus may form within the
abdomen without causing chills or even fever_. Intermittent fever,
with tenderness in the upper abdomen, points as often to infection of
the biliary tract, usually with gallstones, as to all other conditions
combined. Pyrexia with chills and enlargement of the liver may indicate
hepatic abscess.

When pulse, temperature, and respiration rate seem to keep pace with
each other, no matter what the rate may be, they together afford a fair
indication as to what is going on. A careful blood count, especially
a differential count, will often be of service, though it will
occasionally mislead.

The significance and importance of _pain_ in abdominal diseases are
very great, since nearly all of them are characterized, at least at
some stage, by more or less suffering. Much value attaches to the
history, when it can be accurately obtained, as to the suddenness
of onset, the location and character of the pain; as, for instance,
whether it could be accurately localized or was diffuse. Unusual
intensity of pain may afford an index to the acuteness of the trouble,
but in its location or reference it may be exceedingly misleading. A
large proportion of patients are unable to describe their pains with
sufficient accuracy, and a neurotic patient suffering severely will
evince a widespread hyperesthesia which will be deceptive. It should be
ascertained whether previous and like pains have ever been experienced,
and, if so, where. The pains of acute appendicitis, for instance, are
widely referred, and will sometimes be complained of as intense in the
left side or high up in the abdomen. I have known patients to refuse
operation because they could not be convinced that, with pain on the
left side, it was possible to have acute appendicitis, while even an
experienced practitioner may be tempted to wait too long for similar
reasons. Pain, accompanied or followed by jaundice, or a history of
pain so associated in time past, will point significantly to the
biliary passages. A history of previous pains constantly associated
with taking of food will indicate gastric or duodenal ulcer. Still pain
is probably more often associated with mechanical rather than chemical
conditions. Pain arising from the gall-bladder radiates usually toward
the right infrascapular region, and with adhesions between the stomach
and the gall-bladder pain is frequently referred to the right shoulder,
while when these adhesions are between the stomach and the colon it
is more commonly referred to the left shoulder. Pains due to kidney
lesions usually are referred along the corresponding genitocrural
nerves, although, by association of the renal nerves with the semilunar
ganglia (and thus indirectly with the phrenic and pneumogastric nerves)
we may hear of shoulder pains even in these cases. In most cases of
acute appendicitis the first complaint of actual pain will be in the
umbilical region, since the appendix receives its blood supply from the
superior mesenteric artery and its nerve supply from branches which
accompany this vessel, which are given off from the spine at a higher
level than those which supply the colon and sigmoid. Thus the reflected
pain involves the tenth and eleventh dorsal nerves.

The pain of colicky affections is usually relieved by pressure, while
that of true inflammation is made worse and is continuous. When pain is
accompanied by tenesmus it is generally supposed that the disease will
be found in the lower third of the intestinal tract.

In this connection we may perhaps be a little more specific, and,
following Hemmeter, make out a catalogue somewhat after the following
fashion:

Gastritis will cause sudden abdominal pain, with sensitiveness, made
worse by ingestion of fluids, by which, in all probability, vomiting
will be promptly produced.

Duodenitis will cause constant pain and increased sensitiveness,
especially in the right hypochondriac region, with mucus and perhaps
blood in the stools.

Enteritis causes rather a colicky pain, more widely referred, with a
general unpleasant sensation of pressure, accompanied by distention,
diarrhea, anorexia, and thirst.

Colitis will produce more diarrheic symptoms, with more accurate
limitation of pain and tenderness on pressure, while sigmoiditis
and proctitis will cause characteristic stools, in addition to the
localized pain which they produce. A chronic colitis may cause
backache, sometimes quite sharp, while the same may be produced by a
well-marked condition of enteroptosis.

The more chronic forms of enteric disorders cause irregularly
recurring pains, having definite relation to errors in diet, exercise,
excitement, and environment. The membranous form of colitis nearly
always produces abdominal pain, referred along the course of the
transverse and descending colon. The complaint of pain and the
condition of the stools will be found to have a close relationship.
Fecal impaction rarely produces sharp pain until it proceeds to the
degree of actual obstruction, but does cause feelings of discomfort and
distention, especially in the right iliac region, with more or less
tenesmus.

Lead poisoning produces severe abdominal pain, distention, and
tenderness, with vomiting and alternating constipation and diarrhea,
which may lead to confusion, especially as a subject of lead poisoning
may be a sufferer from one or the other acute abdominal conditions. Of
course, in its chronic forms the characteristic line upon the gums and
the nature of the occupation would aid in diagnosis.

Tuberculosis of the intestines and peritoneum produces more or less
colicky pain, especially in children, with enlarged mesenteric
nodes; while in consumptive patients recurring abdominal pains,
with alternating constipation and diarrhea, would suggest secondary
intraperitoneal involvement.

The possibility of abdominal pain being caused by parasites, especially
by tapeworms, should not be overlooked.

The intestinal ulcerations produce nearly always continual pain,
associated with localized tenderness on pressure. The higher in the
intestinal canal the ulcer be located the more regularly will it
produce pain from one to two hours after eating, while the lower the
location of the ulcer the more likely are we to find recognizable blood
in the evacuations. During typhoid any sudden onset of abdominal pain
associated with bladder irritability, and often with pain in the penis,
may be regarded as indicating perforation.

In appendicitis the pain is usually first referred to the more central
portion of the abdomen, later becoming localized in the right iliac
fossa. Frequently the overlying muscles will be already in a condition
of spasm before this pain is localized beneath them. In this disease,
no matter where pain may be referred, the tenderness will usually be
felt and the resulting tumor detected in significant position. Constant
mild pain and tenderness in McBurney’s region are usually indicative of
a chronic catarrhal and more or less obstructive appendicitis. In the
chronic and relapsing forms the pain is intermittent, but tenderness is
nearly always significantly located.

Strangulated hernias, when external, will usually attract attention
by their presence without reference to pain, even though the latter
be referred to some relatively distant part. Whatever might be
characteristic of strangulation will more or less quickly merge into
symptoms of intestinal obstruction, but no case presenting local
indications should escape detection. Internal strangulations nearly
always defy accurate detection before operation.

Intestinal obstruction from any cause, when acute, produces early sharp
and severe abdominal pain, sometimes localized vaguely, but nearly
always becoming general, and so quickly followed by muscle spasm with
distention and the soreness of vomiting, that, with the accompanying
general disturbances, it lends little aid in accurate diagnosis.

Acute pancreatitis of either clinical type produces a pain which is
central and agonizing and is quickly followed by collapse, with
abdominal rigidity. The resulting pain and tenderness are usually
confined to the upper abdomen and may be expected at least to attract
attention to this part of the belly.

Mesenteric embolism and thrombosis also produce intense pain, with
pronounced depression and speedy collapse, the complaint usually so
widespread as to be suggestive.

Pain made suddenly worse by extra exertion or straining, as perhaps
in defecation, may be due to pressure or to rupture of some part
previously involved. When this is complained of in the lower bowel it
is usually due to some ulcerative condition in the rectum.

Aside from conditions briefly specified as above, there may be numerous
other causes of acute abdominal pain, as, for instance, in connection
with various tumors, either those which involve the bowel, where
there is suddenly precipitated a condition of acute obstruction, or
ovarian cysts and pelvic or other tumors which have undergone a sudden
deprivation of blood supply, as by twisting of a pedicle. In nearly
all of these instances the previous existence of such a tumor has been
learned, or else may be made out by such physical examination as may be
permitted with or without anesthesia. Again rupture of an extra-uterine
gestation may produce intense pain, followed by speedy collapse and a
condition widely referred. I have been repeatedly called to operate for
acute appendicitis when the actual lesion was of this character.

_In general, of abdominal pain_, it may be said that, excluding
hysterical cases, when severe it is usually an indication of a more
acute condition, while mild, chronic and intermittent pain, accompanied
by more or less tenderness, indicates a chronic condition which may not
amount at any given time to an emergency, but which may precipitate one
that may call for immediate intervention. The nearer, anatomically,
the morbid condition to the stomach and the great ganglia the more
likelihood there is of nausea and vomiting of purely reflex character.
When these occur with conditions low in the abdomen or pelvis, vomiting
may be an expression of obstruction rather than a neurosis, pregnancy,
of course, forming a well-marked exception to this statement.

In the presence of severe pain the general practitioner and the surgeon
alike feel inclined, from humane motives, to do everything in their
power to relieve it. While, on one side, it is kind and rational
to give sufficient anodyne, usually morphine, to relieve intense
suffering, it may be felt sometimes that the practise is not to be too
widely extended or commended, since by relief of pain the significant
feature of the disease is masked, and there may be temptation to wait
longer than would be advisable. While wavering, then, as between
advice in either direction, my own view is that most of these cases,
when symptoms are so severe, can be classified by themselves as those
justifying or demanding surgery.

One last caution in this respect is needed, lest the inexperienced
regard the sudden subsidence of pain as necessarily a good sign. When
a patient who has been suffering from acute obstruction or acute
peritonitis becomes suddenly relieved the fear is rather that the
disease has gone beyond all possibility of help, and that such relief
will soon be followed by coma and death. Such cessation of pain, then,
is not necessarily a favorable indication.

_Localized tenderness_ is the next most important sign of value in
determining the location and nature of abdominal diseases. The more
accurately it can be localized the better, since it permits us to
select, in all probability, one organ or one location as the site of
the disease. When it is accompanied by radiating and diffuse tenderness
it may be suggestive rather than indicative.

_Muscle rigidity or spasm_ is the third of the trio of symptoms
which give the surgeon his most imperative indications. Excluding
the hysterical and purely neurotic cases there is no occasion for
pronounced muscular rigidity save some disease concealed beneath it,
which produces these reflex phenomena. This, too, may be localized
or generalized. In the latter case it may indicate, for instance, a
general peritonitis or a local process tending to become generalized.
Of the trio of signs and symptoms it is perhaps the most significant
and reliable.

_Pain_, _tenderness_, and _muscle spasm_ constitute the tripod upon
which the surgeon has most to rely, and which are never absent in
serious disease, while conversely it may be said that serious disease
is rarely ever present without producing them. These with such other
phenomena as special conditions may produce--_e. g._, vomiting,
intestinal hemorrhage, etc.--are our principal aids to diagnosis. When
present and progressive they nearly always indicate necessity for
surgical intervention, the most pronounced being in those instances
where abdominal distention and collapse with other grave features have
already taken the case beyond the help even of the surgeon.

In more deliberate cases aid is also to be obtained from examination
of the discharges from the various viscera, and by examination, for
instance, of stomach contents, as well as by differential blood count.
All of these, however, take time, and the experienced surgeon may see
clearly his indication to operate at once rather than to wait the time
which they require. The whole intent of this paragraph, as, in fact, of
this section, is _not to make light of the ordinary means of diagnosis,
but to insist upon the necessity for early appreciation of important
signs and symptoms in order that one may know when it is not safe to
wait, since too many lives are even now sacrificed to this kind of
delay_.


GENERAL TECHNIQUE OF ABDOMINAL OPERATIONS.

_Abdominal section_, generally called _laparotomy_, though more
properly termed _celiotomy_, is often begun as an exploratory measure,
and then called _exploratory laparotomy_, whose wisdom and safety may
be properly explained to even an ignorant patient, the underlying
intent being a relatively small and safely made opening for the purpose
of orientation and decision. It is with me a rather favorite expression
that the danger of such an operation is insignificant, and that the
danger of whatever may be required, as revealed through the opening, is
proportionate to the gravity of the condition thus indicated.

Abdominal section having once been decided upon, careful general and
local preparation should be made, as indicated elsewhere in this book,
if time be afforded. There are, however, emergency cases in which
moments are valuable and when there must be omitted almost everything
but the considerations of cleanliness. More and more I am impressed
with the value of sterilization of the entire trunk, both front and
rear, since should necessity for posterior drainage be revealed we need
not halt in order to disturb everything else and sterilize the skin of
the back. It is presupposed, then, in this place that all the ordinary
measures have been carried out and that the ordinary equipment is at
hand. There should always be a supply of warm, sterile water (112°) in
order that the intestines may be protected, should it be necessary to
temporarily remove them from the abdominal cavity, and saline solution
at proper temperature should be ready for irrigation purposes, if
needed.

_The abdomen may be opened at any point_, and by incision in almost
any direction. Nevertheless there are provisions which should be
observed. When there is no special reason for a lateral incision
it is to be opened in the middle line; any incision, including the
umbilical region, should be made to pass to the left of the navel
rather than to the right. There is no reason why the entire navel may
not be excised. It is a difficult point at which to insert sutures and
in most individuals is at best an infected region. Therefore there
need be no hesitancy to include it in an oval incision and completely
remove it. It is, furthermore, a wise precaution to drop into the
umbilical region a few drops of tincture of iodine just before the
operation, in order the better to sterilize it. It is my custom to
use one knife for the skin and then lay it aside and employ another
for the deeper work, in order that no germs may be transplanted from
the skin. The surgeon has to cut deeply in fleshy individuals before
reaching the deep aponeurosis, and sometimes it is necessary to pass
through two or three inches or even more of fat. This necessitates a
long, superficial incision. The deep aponeurosis being reached we have
to either go through or between muscle fibers, at least in most places.
It is desirable rather to separate muscle fibers longitudinally. When
opening in the middle, or parallel to the middle line, this may be done
with the fibers of the rectus, the transverse tendinous intersections,
however, always requiring division. Operating in either iliac fossa,
and coming down upon the broad and flat abdominal muscles, there may
be adopted the so-called “gridiron method,” and, after exposing those
fibers which run at a right angle to the line of incision, one may
endeavor to spread rather than divide them. This is done when making
the small openings required in removing the appendix, or in making an
artificial anus. For removal of considerable tumors, or for temporary
disembowelling, large incisions, however, are required.

By suitable disposition of the patient’s body much assistance and
comfort are afforded the operator. When the upper abdomen, especially
the region of the gall-bladder, is to be attacked, the upper part
of the body should be raised with dorsal flexion above the pelvis,
thus permitting gravitation away from the liver and facilitating the
retraction which may be required. Again, in operations upon the pelvic
viscera the reverse position was suggested by Trendelenburg, and it is
of the greatest help, the pelvis and the limbs being elevated until the
body assumes a position at an angle of some 45 degrees. The intestines
then gravitate toward the diaphragm, and the pelvis is more easily
emptied and kept empty. When, however, there is no particular need for
either of these positions the ordinary dorsal position is the best.
With an operation begun in the latter there should be no reason why
position may not be changed, when the exploration reveals necessity for
the same, and all good modern operating tables are so constructed as to
permit of this being rapidly done.

Of late the _transverse incision_ has been received with growing
favor. In 1896, Küstner reported a number of cases where he had used
a transverse suprapubic incision down to the aponeurosis solely for
a cosmetic effect, the method being adopted by Rapin about the same
time. Others went farther and made use of an incision above the pubis
and parallel to it, carried down through the aponeurosis, over the
recti, with vertical separation of the muscles, in order to diminish
the chances of hernia. The incision is made just below the margin of
the pubic hair or in the natural fold of the abdomen. The fascia being
divided in one direction and the muscle in another, there is less
tendency to hernial protrusion, the disadvantages being that there is
limited space through which to work and that more time is required in
its performance. All vessels should be secured so soon as divided. The
incision through the fascia may be somewhat curved, if necessary, at
the outer edges of the recti, by which a sort of horseshoe flap may be
lifted up if desired. The fat should not be dissected from the surface
beneath. Scissors will be required to separate the aponeurosis from the
muscles in the middle line, this separation being made high in the same
line. The peritoneum is opened in the middle with the usual vertical
cut. When more room is required the aponeurosis should be incised
farther on each side, outside of the recti. The method finds its
greatest serviceability in those cases where not more than four inches
in a thin woman and two inches in a fat woman of vertical separation of
the recti muscles will be required.

Ordinarily when the peritoneum is reached there will be no difficulty
in recognizing it. It is a membrane easily shifted, both upon its
attached surfaces, beneath the fat, and over the bowel or whatever may
cause it to protrude into the wound. Unless one is very sure of his
work he will, however, pick it up very carefully, nick it slightly,
and convince himself that he has the desired membrane, and then
will dissect it with care, since the bowel beneath will lie closely
in contact with it, and might easily be wounded were the operator
careless. The peritoneum in the presence of such disease as tuberculous
peritonitis becomes very much thickened, and is then not easy of
recognition. Again, it is sometimes slightly adherent in the presence
of recent exudate, or firmly adherent in the presence of old disease,
to the tumor or viscera beneath. When the tissues are edematous and
become more so as the peritoneum is approached, pus may be found
beneath, and extreme caution should be exercised, making at first a
small opening through which pus may escape, and endeavoring not to
tear adhesions apart nor thus permit escape of pus into the peritoneal
cavity.

The true abdominal cavity once opened, the first endeavor should be
to ascertain the conditions within. Through a small opening this is
done with the finger. This measure, trifling as it seems, requires
a knowledge both of normal and pathological anatomy which cannot be
too great. Unless the normal arrangement, size, density, and location
of all its contents is known and the way which they should feel when
healthy it will be somewhat difficult to distinguish between health
and disease. Again, unless the surgeon is familiar with pathological
conditions he will not know how to interpret what he may thus discover.
Through a small opening it can usually be discovered whether or not
there is a serious condition within. According to knowledge thus gained
there may be justification for enlarging a small opening or closing
it. One caution here is of the greatest importance--an exploratory
operation should never be begun unless the operator is provided with
means for meeting any indication which should thereby be disclosed,
else the patient would be subjected to two ordeals when one should
suffice.

The “diagnostic finger,” having once entered the abdominal cavity,
should be used with extreme gentleness, especially in the presence of
adhesions, which yield easily, and which may point to the existence
of a purulent focus in the neighborhood, as scarcely any disaster
could be more fatal than to rupture such a focus and permit escape of
its contents in every direction before surgical protection has been
afforded. Much will depend upon whether there is reason to suspect
the presence of pus, and it is always best to proceed as though such
a contingency might happen. Again, adhesions which seem firm may be
met with in the presence of malignant or ulcerative disease. In some
instances they will be so firm that surrounding normal structures will
yield before they part, or are closely associated with a dense adhesion
which will be found a weakened area that will tear easily. The process
of separating adhesions, then, should always be conducted with extreme
caution.

When the presence of pus is suspected the adjoining parts should be
protected by “walling off” with gauze. Gauze pads, either of sufficient
length to be secured with forceps or provided with tapes for the same
purpose, by which their loss in the abdominal cavity may be prevented,
are now used almost to the exclusion of the flat sponges formerly
employed, for they are more reliable when properly sterilized. With a
sufficient number of these spread out as carefully as may be, a neat
padding or protective wall of gauze is made and formed around the focus
of disease, into which any discharge of blood or pus may take place,
and by means of which contact of surfaces is prevented. Sometimes a
large amount of gauze is needed for this purpose, and when the abdomen
is widely open sterile towels may be used. The greatest care should
be given that nothing be left within the abdomen at the completion of
the operation, and every loose piece of gauze should be secured with
forceps and every towel accounted for. By this protective “walling
off,” spreading of an infectious process may be prevented, as also the
distribution of infectious material. The gauze should be changed as
often as needed and there is often no apparent limit to the amount that
may have to be employed. Advantageous as the process may be, it has its
disadvantages, in that material so employed is a source of irritation
and is practically a foreign body, intruded within the abdomen in
such a way as to have always a depressing influence. This depression,
however, is but temporary, and is the lesser of two evils, and in the
presence of pus can scarcely be avoided. Instruments, especially the
smaller ones, should also be counted before and after operation, or be
so accounted for that none may remain or be lost.

The general indication having been met, the next question is one
of local cleanliness and resort to irrigation. If the protection
above described has been sufficient there will be a minimum of local
cleansing required. This may be effected with hydrogen dioxide, or with
or without other antiseptics, according to the choice of the operator.
Obviously every focus of disease should be as thoroughly cleansed both
of clotted blood and debris or pus. When this can be accomplished
by gentle wiping or swabbing it may be sufficient. When this is not
possible irrigation and drainage should be provided.

_Irrigation of the abdominal cavity_ has been widely practised, and
has advantages as well as disadvantages which have caused it to be
differently regarded by different operators. While little hesitation
need be felt about washing out a well-localized cavity, it is felt by
many that to use a quantity of water within the complicated peritoneal
cavity is to more widely distribute that which would best be not
disturbed. On the other hand, it is maintained by some that infectious
material so diluted and scattered is more easily capable of disposition
by natural processes. The general trend of opinion is that a localized
condition is best treated by local measures, and that general abdominal
irrigation should be limited to cases of generalized infection. The
temptation to use antiseptic solutions is very strong. Yet one must
remember that any solution, of which a portion must remain, used in
such a cavity and having sufficient strength to kill bacteria, will
prove at least profoundly and perhaps fatally toxic to the individuals,
because the peritoneum is a membrane of tremendous potential
capabilities in the matter of absorption, and those chemicals which are
toxic to germs are also harmful to the human tissues. Strong, then, as
the temptation may be to use antiseptics under these circumstances,
solutions used for the purpose should be made extremely weak if we
are to do more good than harm. Warm sterile water or saline solution
is then the generally accepted irrigating fluid, while a few use such
antiseptics as acetozone in the strength of 1 to 10,000, or others of
the more harmless drugs. In cases of tuberculous peritonitis exception
may be taken to this and a solution used which is sufficiently strong
to have some perceptible immediate effect.

When general abdominal irrigation is practised quarts and even gallons
of fluid should be used, sufficient to accomplish the desired purpose.
Various tubes have been devised for the purpose of conducting the
fluid into the deeper recesses, and yet these, while convenient, are
not essential. Practice varies somewhat as to whether to leave a
considerable amount of saline solution within the abdominal cavity
or try to free it of all fluid. The former practice is desirable, in
theory at least, for if readily absorbed it will help in relieving
shock and keeping the kidneys active. In general it may, however,
be said that unless an isotonic saline solution is employed it is
advisable to remove all that can conveniently be withdrawn before
closing the belly.

The next important question is one of _drainage_, and here, again,
men differ widely in their opinions. A distinctly purulent focus is
doubtless always best drained. The question is argued rather with
regard to the matter of possible spread of infection or in cases of
general doubt. Drainage is always a confession either of fear or of
impossibility of ideal removal of the primary difficulty. It certainly
is less practised than in years gone by, but will always find a certain
field of usefulness. Thus after some deep, extensive pelvic operations,
where the separation of adhesions almost ensures a certain amount of
leakage of blood, one should insert a glass or metal drain for a few
hours, or a day or two, and through it aspirate at intervals such
amounts as may accumulate in the cavity thus emptied. Nearly all cases
of abdominal traumatism require drainage, best applied posteriorly,
and practically all instances of acute pancreatitis, whether purulent
or otherwise, will also require it, posteriorly as well as anteriorly.
All old abscess cavities also demand drainage, no matter where located.
No case of septic peritonitis, general or local, can be safely closed
without similar provision. Drainage through the cul-de-sac is the best
method of all, when available.

_Drainage methods_ include the use of hard tubes made of glass,
aluminum, or celluloid, perforated with numerous openings through
which fluid may escape into their interior. These are used mainly for
drainage of the pelvis through an abdominal wound. Soft-rubber tubes of
varying sizes may be used in many ways, either by themselves or when
split longitudinally, and made loosely to enfold a strip of gauze,
or when lightly wrapped with gauze and covered with perforated oiled
silk. Except when it is desired to drain a gall-bladder or some similar
circumscribed cavity, which can be closed around the tube, such tube
should have numerous large openings cut in it. Cigarette drains consist
of small rolls of gauze wrapped with oiled silk, then fenestrated and
secured with a piece of catgut tied around it to prevent it unwrapping.

Ordinary absorbent gauze or prepared gauze may be used by itself to
any desired extent, but when so used it is usually well to make the
amount sufficient to effect the purpose. Thus a drain at least one inch
in diameter or even exceeding that size will be much more effective
than two or three small strips. In using this it is well to protect
the wound margins with strips of oiled silk, between which the gauze
is deeply passed, as in this way its adhesion to the wound edges is
prevented, such adhesion being undesirable both because it helps to
prevent the escape of fluid and causes pain when the gauze is removed.
In this way it is well to combine the double purpose of drainage, and
pressure to check oozing, by packing in sufficient gauze to accomplish
both. These gauze drains, when well soaked with discharge, are easily
removed. Otherwise they frequently adhere and cause much discomfort
during the act of removal. In such a case it is an advantage to wet
them from the outside, perhaps three or four hours before withdrawing
them. Even with such a gauze drain there is always the danger of
causing fecal fistula if it be left too long _in situ_. It is,
therefore, always undesirable to leave a drain, even of this apparently
innocent character, longer than absolutely necessary.

In not a few cases through-and-through drainage--_i. e._, by a
counteropening--will be of great value, this especially in many cases
of peri-appendicular abscess, where pus has collected behind the
cecum. So-called posterior drainage of the abdomen is also advisable
in cases of acute pancreatitis or deep retroperitoneal phlegmon. Here
the opening is made from the back, by an incision two or three inches
in length, just outside the upper part of the quadratics lumborum and
near the costovertebral angle. In stout individuals a distance of
two or three inches, or even more, must be traversed. After the more
superficial incisions this opening may be effected by blunt dissection,
and is best done with conjoined manipulation, one hand working on
the exterior and the other in the interior of the abdominal cavity.
Occasional necessity for such posterior drainage shows the wisdom of
the practice of sterilizing the back as well as the front of the body
as part of the preparation for operation.

Drainage having been effected by one of the above methods, the best of
good judgment will be called for in determining how long it should be
continued. First of all, no drain which fails to effect the purposes
intended should be allowed to remain, and any drain around rather than
through which material is discharged may be regarded as useless and
a mere deleterious foreign body. Gauze which is supposed to drain by
osmosis often fails, and in some of these drains it may be well to
insert a few strands of silkworm-gut in order that material which is
to become moistened may not collapse and adhere, thus destroying its
own capillarity. A pelvic drain in a non-septic or but slightly septic
case, inserted for removing escaping blood or collecting serum, may
be removed in from twelve to sixty hours, according to the amount of
discharge, which when collected with a syringe should be carefully
estimated. Any cavity which is not filled at a rate faster than 2 or
3 Cm. in an hour may be regarded as capable of disposing of all the
fluid which may collect within it, and every tube which is no longer
needed is an irritating foreign body, whose lower end may press upon
intestine, and even produce ulceration if allowed to make pressure
too long. Appendicular abscesses usually require to drain from two to
three or four days; gall-bladders and hepatic abscesses for a much
longer time. In nearly all instances it may be expected that within
from forty-eight to sixty hours after the establishment of drainage a
natural passage will be formed, by exudate appearing first around the
drain, and remaining after its removal, which should serve drainage
purposes as would a canal. Sometimes the outer end of such a canal
tends to close too quickly, and then with accumulation in the deeper
part there may come retention, with later spontaneous escape, or
possibly rupture into the abdominal depths, which may be serious. In
nearly every instance, however, a large drain may be substituted within
a short time by a smaller one and final removal be thus accomplished.
Any localized cavity whose discharges are offensive or putrefactive
should be cleansed each day, either with hydrogen peroxide or by gentle
irrigation, or with a reasonably strong antiseptic solution--iodine,
silver nitrate, etc. While no such cavity will close until all such
material has escaped, it nevertheless is well to keep the external
opening wide open, in order to hasten the whole process. This may be
accomplished by gauze packing or the insertion of a short tube.

Cavities which persist, with apparently permanent fistulas, require
more radical treatment, which will consist at least of a thorough
curetting and considerable enlargement of the fistulous opening, in
order to permit of this. Such a cavity, then, may be comfortably packed
with gauze for a few days.

The use of massive tampons and the introduction of large-sized pieces
of gauze into the abdominal cavity have been generally discontinued,
largely through the writings of Morris, who stigmatized such practice
as “committing taxidermy upon patients.”

_Abdominal drainage_ may be favored by one other expedient--_i. e._,
_position_. The peritoneum possesses unusual powers of absorption
and is capable of taking care of morbid material up to a certain
point. It has been shown that the peritoneum of the upper abdomen
especially, even that lining the diaphragm, is particularly potent in
this direction--next to it perhaps that of the pelvic cavity. Septic
processes in the upper abdomen are then sometimes advantageously dealt
with by placing the patient in bed in a position with the pelvis
considerably elevated and the head dependent. This is the more valuable
after irrigation has been practised, where there may be considerable
fluid which may thus gravitate. On the contrary, in serious septic
pelvic infections it is often good practice to keep the patient in
the semisitting posture, so soon as sufficiently recovered from the
anesthetic. (Fowler.) These expedients are perhaps the more valuable
when provision is made in either one of the dependent portions for
drainage, gravity thus favoring the accumulation of fluid where it can
be best cared for.


CLOSURE OF ABDOMINAL INCISIONS.

In what may be termed a clean abdominal operation it is seldom that
drainage is provided. Such cases are expected to heal promptly and
the wound to close immediately and without pus formation. It is
only in cases where drainage has been necessitated that there is a
really legitimate excuse for subsequent yielding of the scar, and
the production of _postoperative ventral hernia_. These at least are
the ideal and theoretically correct notions, although it should be
acknowledged that in the practice of even the most competent such
undesirable sequels as ventral hernia do sometimes occur. Foreseeing
the possibility of their occurrence and realizing the conditions
which permit the same, every known precaution should be taken. The
question then of the method of closure of even a small abdominal wound
is one of great importance, which has long engaged the attention of
the most experienced operators, who have not yet united upon what all
consider the ideal or perfect method. In general it may be said that
_suture of each separate tissue layer comes nearest to this ideal_,
along with the employment of a suture material which should serve its
purpose sufficiently long, and yet not remain as a possible future
irritant. When time is afforded, and there are no contra-indications,
the following may be given as the best directions in this regard: A
_suture of the peritoneal edges_, with or without the deep fascia. In
or near the middle line the posterior sheath of the rectus may also be
included in this row. These sutures should be inserted with extreme
care so as not to include any peritoneum of the bowel surfaces. Then
the _muscle edges_ are brought together by a second row, over which
the _deep aponeurosis_ is covered and brought together with a third
row. Rather than fail in accurate approximation of this third row it
would be better to overlap the edges and fasten them together in this
position. These sutures should be made with hardened catgut, of whose
sterility and durability there is no question. It should have been
so treated that reliance may be placed on its remaining for at least
twenty days. The method with the balance of the wound may depend to
some degree upon its thickness. In individuals with fat abdominal walls
it is better, in order to avoid dead spaces, to insert _one or two
rows of buried sutures_, by which the fatty surfaces are brought into
contact. Finally the _skin margins_ may be approximated, either with a
subcutaneous chromic or silkworm suture, or by the ordinary continuous
or interrupted suture, which may be made, according to choice, of
celluloid thread (Pagenstecher’s linen thread soaked in a celluloid
solution and thus made non-absorbent), sterile silk, or fine wire.

The nature and the location of the incision and the thickness of the
tissues, along with the degree of tension which may be made upon
them, will to some extent determine how the more superficial stitches
may be placed. The depressing effect of postoperative vomiting may
be forestalled by placing another set of three or four mattress or
quilted sutures, which may be brought out at a distance of two or three
inches from the incision and guarded with shot, plates, or rolls of
gauze. These sutures have a tendency to take off tension from those
immediately closing the wound and are a valuable means of securing
primary union.

Ordinarily, as stated above, one never drains the abdominal wound
proper. Nevertheless if it has been infected by contact with gangrenous
or infectious material it is better to leave some opening for escape,
or else, as a final precaution, to trim the surfaces which have been
exposed and bring into contact only those which are absolutely fresh
and uncontaminated. _In gunshot wounds_, for example, unless the track
of the missile has been cleanly excised some provision should be made
for drainage thereof.

A further protection should be, however, afforded in the dressings,
by strips of plaster placed over the deeper dressings, by which
again tension is taken off the wound, and still further by such snug
bandaging and arrangement of compresses and dressings as shall complete
this protection.

There are occasions when this procedure, which necessarily consumes
a little time, cannot be completely carried out, and when there
must be haste in order to get the patient off the table in suitable
condition. In such cases the operator usually contents himself with the
application of silkworm-gut sutures, which include the whole thickness
of the abdominal wall, or the use of secondary sutures, which can
be tightened and utilized later. As Binnie has said: “Inexperienced
surgeons, after completing a prolonged operation on an exhausted
individual, sometimes forget that it is better to have a postoperative
hernia in a living patient than a perfectly closed wound in a corpse.”


AFTER-TREATMENT OF ABDOMINAL OPERATIONS.

While in the general principles regarding the after-treatment of
abdominal cases practitioners are well agreed, the world over, they
differ so in regard to minor points that it is difficult to give
explicit directions which shall be acceptable to all. Much will depend
upon whether the patient has had suitable preliminary preparation. If,
for instance, the bowels have been thoroughly emptied there need be no
haste to administer laxatives, as though this had not been the case.
In many instances where this precaution has been neglected catharsis
is, after operation, the most important consideration, and yet this
may be difficult to secure, the difficulty being enhanced by the fact
that an individual just operated on and extremely tender finds it
difficult to give natural assistance to the process of defecation.
The matter is particularly complicated by the difficulty of selecting
an active cathartic which may be retained by a sensitive stomach. One
of the greatest needs of the surgeon, as well as of the physician,
is a suitable medicament of active cathartic properties which can be
satisfactorily administered with a hypodermic syringe. Nothing of this
kind is as yet known.

It is good practice in many cases to throw into the intestine, through
a fine needle connected with a large syringe, a considerable quantity
of saturated solution of Epsom salt before closing the abdomen. This
places it where it will not be rejected by an irritable stomach, and
where it must have the desired effect. The needle so used should be
carefully introduced, in a very oblique direction; while should the
minute puncture bleed or seem to leak it may be included in a suture
or ligature loop, which should take up the peritoneal coat only.
In addition to this, an occasional expedient, the writer usually
administers, before the patient leaves the table, a subcutaneous
injection of ¹⁄₅₀ Gr. of eserine sulphate, the active principle of
Calabar bean, this being a powerful stimulant to the muscular coat of
the intestine. The bowels should be thoroughly emptied in the easiest
manner after every operation.

The next question is one of _pain_. Patients should not be allowed
to suffer when morphine is at hand, and this would always be true
were it not that morphine has, at times, undesirable effects, both
in checking intestinal activity and in “locking up the secretions.”
Moreover, it frequently nauseates. On the other hand, patients who have
undergone serious operations need to be kept absolutely quiet, and to
be prevented from tossing and moving themselves in bed. Some expedient
then is called for in many cases, and one may, if he choose, begin with
the milder of these--such, for example, as the administration of 2 Gm.
each of chloral and sodium bromide, with or without chloretone, in a
little saline solution or sterile water, thrown high in the rectum.
When pain is not severe this is frequently sufficient to soothe and
allay, and often to produce sleep. It reduces or prevents the nausea
with which many patients suffer. This, too, may be given before the
patient leaves the table. Such an enema, with or without asafetida or
other soothing drugs, may be repeated as often as indicated, and does
much to quiet a rebellious stomach.

It is assumed here that the reader is already familiar with the
precautions advised before the administration of anesthetics and that
it is now simply a question of after-treatment. (See Chapter XX.) My
own advice is not to withhold morphine in those cases which seem to
require it, remembering, at the same time, that suitable management
of the stomach is required. It is inadvisable to permit the patient
to take any fluid in the stomach for several hours, for even plain
water will upset a stomach which has seemed to be perfectly calm and
controllable. According to the degree of nausea and discomfort should
the stomach be used, the patient’s need for fluids being supplied by
more or less copious saline enemas. So soon as the stomach becomes
quiet ice pellets or small quantities of water, as hot as can be borne,
may be used, the latter frequently proving the more acceptable.

Until the bowels are freely moved whatever food may be administered
should be fluid, and, under most circumstances, not more than
forty-eight hours should elapse after any operation before the
intestinal canal is emptied. Milder degrees of _nausea_ may be treated
by the use of milk of magnesia, of small doses of orthoform, or by a
mixture which the writer is fond of using, in each dose of which the
patient receives 0.02 of cocaine, one minim of carbolic acid, and one
or two minims of dilute hydrocyanic acid, in a small amount of water. I
have found this in many instances very soothing.

The _after-management_ of many of these cases includes also the
treatment of _shock and collapse_, which have been considered in a
previous chapter. It should include, also, suitable attention to
the bladder, and a catheter should be used within the first ten
or twelve hours if no urine be passed, and as often thereafter as
may be necessary. Catheterization should be conducted with the
same precautions as indicated at any other time. Other details of
after-treatment, such as the removal of drainage materials, change in
position of the patient, etc., have been discussed. Stitches of chromic
catgut need no further attention, while those of silk or thread will
need removal. It is to be emphasized that the great danger of the
so-called _stitch-hole abscesses_ comes not so much from the material
first employed as from failure to protect it and guard it against the
possibility of subsequent infection. Non-absorbable sutures in the
abdominal wall are usually allowed to remain from ten to twelve days,
but any stitch which is seen to fail in accomplishment of its purposes
should be immediately removed, as should also stitches around which a
drop of pus is seen to be escaping.

Certain abdominal wounds, especially in fleshy individuals, seem to
heal perfectly, then part a little and give vent to material which is
hardly pus, but appears more like liquefied or altered fat. Such, in
effect, it often is, and the condition implies a necrosis of a certain
amount of fatty tissue, with its liquefaction and escape instead of
absorption. In this way a small cavity will be left which should heal
by granulation, and this may be hastened by the use of mild nitrate of
silver solution.

A patient having been removed from the operating table in a
satisfactory condition the principal danger is that of _internal
hemorrhage_, which, though fortunately rare, is disturbing when it does
occur. In fact, severe abdominal hemorrhage is one of the most serious
of surgical accidents, either primary or secondary. It may occur from
wounds of all descriptions, as the result of erosion, perhaps of a
foreign body, even of a drainage tube, from the slipping of a ligature,
from reaction after shock, the heart recovering its vigor and pumping
blood out from the vessels which had not previously oozed. In other
instances, of course, it may be the result of rupture of an abdominal
aneurysm or the twisting of the pedicle of an abdominal tumor.
Constitutional causes which contribute toward it are jaundice, both
with or without accompanying cholemia (mentioned more particularly in
the section on the Biliary Passages), hemophilia, scurvy, and that form
of myelogenous leukemia for which splenectomy has been occasionally
performed. In all these cases the patients are abnormally prone to
bleed freely. When this condition is suspected it is well to determine
the coagulation time of the blood. If this be over six minutes the
calcium salts, with iron and fruit acids, should be administered some
time previous to operation.

The most important _symptoms of postoperative or internal abdominal
hemorrhages_ are rising pulse, with fall in temperature, pallor,
and that marked reduction of blood pressure which gives rise to the
ordinary symptoms of shock or collapse, along with extreme restlessness
and disturbance of vision or almost complete blindness. When there
has been any notable collection of blood within the abdomen there may
be found dulness on percussion over the flanks. Richardson has spoken
of the nurse’s duty and the surgeon’s duty under these conditions,
the former being to recognize the indications of increasing shock and
alteration in pulse rate, the latter being to adopt every expedient for
the checking of hemorrhage, including, in many cases, prompt re-opening
of the abdomen. The more promptly this measure is instituted when
demanded the greater the probability of saving the patient.

The principal danger after all abdominal operations, next to
the possibility of hemorrhage, which rarely occurs, is that of
_peritonitis_, a danger so imminent in the pre-antiseptic era as to
have made the abdomen an almost sacred cavity, but one which is now
almost abolished by perfection of aseptic technique, yet calling for
never-ending care and attention to detail, and occurring occasionally
in spite of all the precautions which the most experienced and
conscientious operator can take. This condition is to be feared
when vomiting continues or comes on afresh, and in the presence of
tympanites, with a steadily rising pulse. The first appearance of these
threatening signs will be always a warning, although not invariably
an indication of danger, since the condition producing them may be
averted by catharsis or by meeting some special indication. _Septic
peritonitis_, the great dread of the abdominal surgeon, and practically
the only form with which he as such has to deal, will be considered
by itself a little later. Yet it is always a question whether it is
advisable, even in these cases, to administer powerful cathartics
which provoke undue intestinal motion and favor the distribution of
infection. While it is true that opium masks symptoms and leads to
erroneous conclusions the same is frequently true of cathartics. From
them a really obstructed or really paralyzed bowel suffers harm rather
than good. They are too sparingly absorbed, and if absorbed their
effect is bad. It is much better in these cases to wash out the stomach
with a weak soda solution, and then keep it empty, emptying the lower
bowel by the same means, and thus placing as much as possible of the
intestinal tube at rest. With from 1000 to 2000 Cc. saline solution
introduced beneath the skin each twenty-four hours patients can be
kept from starving for a sufficient length of time to permit of other
treatment for the condition.


INJURIES OF THE ABDOMINAL WALL.


=Contusions.=--Contusions of the abdominal wall may be followed
by serious consequences, even though they have the appearance of
being trifling. The injury that may be done implicates not alone
the abdominal wall proper, but the viscera beneath. A blow upon the
abdomen, followed by immediate collapse of temporary character (as the
history of many a prize fight has shown), indicates a sudden reduction
of blood pressure, the nausea and other features being due to the
mechanism of the semilunar ganglia and the sympathetic nerves.

Contusions of the abdominal walls alone are serious largely in
proportion as they are followed by _extravasation_ or _hematoma_,
since from failure of absorption of the latter there may result a
cyst, or possibly an abscess should local infection occur. In either
event evacuation and suitable local treatment are demanded. But any
blow, even without penetration, may give rise to serious disturbances
within the abdomen. Thus, as Richardson has said, the hollow viscera
are liable to rupture, with extravasation, the solid to fracture
with hemorrhage, while lacerations of the omentum or mesentery may
produce immediate hemorrhage and subsequent possibility of intestinal
obstruction. When extravasation has occurred distention and the
ordinary evidences of peritonitis supervene. When the spleen or liver
has been torn or crushed there will be obtained evidences of extensive
internal hemorrhage.

Of the _hollow viscera_ much will depend upon the degree of their
fulness--especially with fluid. In a small tear there may be eversion
of the mucosa, which may hinder or even prevent extravasation.
Escape of infectious material into the cavity of the lesser omentum
may produce local peritonitis, with subsequent development of what
is practically a _subphrenic abscess_. When the patient vomits
blood it shows that there has been rupture of the gastric mucosa.
Intestinal rupture will be made known by rapid distention and the
ordinary evidences of acute peritonitis. These injuries rarely lead
to vomiting of blood, but when occurring low in the bowel may lead to
the occurrence of bloody stools. Rupture of the spleen or pancreas
is rarely diagnosticated previous to exploration, save as a severe
abdominal injury. It is not so likely to lead to rapid peritonitis.
Rupture of the liver permits of more or less escape of bile, as well as
of blood, and rupture of the gall-bladder permits the free emptying of
bile into the upper abdomen. As this is usually harmless, in otherwise
healthy individuals, the injury is not necessarily so serious as might
appear. In such a case the resulting peritonitis will probably be local
rather than general.

In this connection may be considered _ruptures of the kidney_, which
are produced by similar injuries to those under consideration, and
which may permit escape of urine or blood into the abdominal cavity,
as well as the appearance of blood in the urine. While these will be
considered in another place the possibility of their complicating
abdominal injuries cannot be overlooked.

_Considerable laceration will predispose to subsequent hernias_,
either direct or indirect, in the latter case by absorption following
injury. The more serious consequences of abdominal contusions--_i.
e._, the deep hemorrhages and lacerations of viscera--may then include
all degrees of such injury, from trifling subperitoneal ecchymosis to
extensive ruptures of such organs as the kidney or liver, or perhaps
multiple perforations of stomach and bowel. These deep injuries will
be considered by themselves when dealing with special organs. It is
sufficient here to indicate their possibility and to warn that every
severe contusion of the abdomen which is followed by local symptoms,
or those which are grave and progressive, may at any time _demand
exploratory section_, which should be made early rather than late. It
is advisable to pass a catheter to make sure that there is no blood
mixed with the urine, and to make a rectal examination in order to
discover blood should it have escaped.

_Penetrating wounds of all descriptions_, punctured, incised, and
gunshot, are again of importance largely in proportion to the damage
done to intestines and great vessels. Some of these injuries are so
evidently superficial that exploration may be abstained from, but
_every penetrating wound which has truly penetrated_ is to be treated
either as they are treated on the battle-field, by mere inspection and
occlusion, or by careful exploration under all aseptic precautions.
_What the operator would do deliberately may not be what he can do
in an emergency, but if he cannot reach one extreme he would best be
content with the other._

Abdominal contusion has been found by Makin to be the cause of about 70
per cent. of the cases of intestinal rupture which have followed sudden
or sharp blows, while the other 30 per cent. have been due to the
passage over the abdomen of heavy objects. Le Conte has well summed it
up in the following words: “If the force be circumscribed, and of high
velocity and of small inertia, such as a kick or blow from some rapidly
moving object, crushing of the intestine is more likely to occur; while
if the force be diffuse, as from a slowly moving, ponderous object of
considerable inertia (_e. g._, a wagon wheel), the belly is more apt
to be torn at one of its fixed points or the mesentery injured. Thus
out of 61 cases of horse-kicks of the abdomen in 59 intestinal rupture
occurred. When the abdominal muscles have been braced in expectation of
a blow less harm results than when it has been suddenly inflicted upon
a relaxed musculature.” Crile has shown that the more specialized and
abundant the nerve supply to a given viscus the more will it contribute
to the production of shock when injured.

Pain is not always an immediate symptom. It may be delayed for hours,
or possibly even for days. When intestinal rupture has occurred pain is
most often referred to the central portion of the abdomen. In rupture
of the spleen it is complained of in the left side, while when the
kidneys have been ruptured pain follows the course of the ureters to
the genitals and there is usually retraction of the testicle.

Muscle rigidity is a sign of equal diagnostic value with pain, and
immobilization of the abdominal wall nearly always indicates intestinal
rupture. The facial expression is also of importance, it being in the
more severe cases almost distinctive. A steadily rising pulse is always
a bad sign, usually indicating a developing peritonitis. Vomiting, if
long continued, after a patient has rallied from the immediate shock,
is considered of itself to justify operation. The same is true of
paralysis of peristalsis.

Such injuries to the abdominal walls proper may divide important
vessels, such as the epigastric, and give rise to hemorrhage which
may be internal rather than external. The first and most important
danger of hemorrhage having been passed or being avoided, the next and
always urgent risk is of infection. This may come from non-penetrating
injuries, as well as those which open a wide path into the interior,
and it is sometimes the small punctures which prove most disastrous.

From any wounded abdomen there may protrude omentum, intestine, or
portions of some other abdominal viscus, while extensive abdominal
incisions permit more or less evisceration. There are cases on record
of pregnant women being injured by the horn of an infuriated animal
and having the entire abdomen, as well as the pregnant uterus, ripped
open, everything thus escaping. The omentum is the most likely to
escape through small openings of all the abdominal contents, and this
is fortunate for the patient for reasons to be mentioned in connection
with the omentum and the peritoneum.

When the nature or the appearance of the wound make a complete
perforation of the abdominal wall probable it will always be safer
to be satisfied regarding deeper conditions. The parts having been
thoroughly sterilized the ordinary probe is rarely sufficient, the best
method of orientation being the sterile finger. Its use may require
enlargement of the incision, and this should always be made. Such an
opening being made and proving insufficient should be enlarged to any
desired extent. Possibly a deep condition will be thereby revealed,
which will make it expedient to open the abdomen freely in the middle
line, and to deliberately practise one of the many expedients called
for in such an emergency, such as ligation of vessels, intestinal
suture, removal of a foreign body, and the like. The indication once
met the incisions are closed, an infected wound being suitably drained.

In general it may be said that laparotomy is the wiser course in
nearly every instance, and that it should be done when the surgeon
is in actual doubt as to its necessity, it being better to give the
patient the benefit of the doubt and operate. In all cases with serious
symptoms it is certainly safer than to wait for further symptoms. This
will appear advisable in view of Curtis’ collection of 116 cases of
intestinal rupture which were left unoperated, all of which died.


=Gunshot Wounds.=--In regard to gunshot wounds the principles of
treatment in civil life are different from those obtained in an active
military campaign. In the former the patient is usually given the best
chance by an early exploratory section, with thorough examination of
the abdominal contents, done with every aseptic precaution and every
means for correct work. This is not possible upon the battle-field.


=Foreign Bodies.=--Foreign bodies are occasionally met with in the
abdominal wall. These may be introduced from without by accident or
design, such as needles or splinters, or may result from the escape by
slow process of some foreign body from within, such as a fish-bone, a
needle, and the like. Thus in an abscess of the abdominal wall I once
found a stick-pin over five inches long with a large glass head. This
had been swallowed by an insane patient, who, subsequently recovering
from her mania, went home and developed this disturbance a year or so
after her release from the asylum.


PHLEGMONS AND OTHER SEPTIC INVASIONS OF THE ABDOMINAL WALL.

_Abscesses_ may develop within the abdominal wall, without reference
to deeper phlegmonous processes within. Thus they are occasionally
seen after typhoid and the exanthemas, appearing perhaps as often in
the rectus as anywhere. They may at any time result from superficial
abrasions and travelling infections. They may occur sometimes as the
extension of suppurating bubo, especially after phagedenic chancroid.
They are recognized by signs which are usually unequivocal, and when
once detected should promptly be evacuated.

_Gummas_, both tuberculous and syphilitic, frequently break down and
form abscesses of mixed type. These may burrow deeply behind fascial
planes, and require one or more counteropenings. As the result
of a particularly virulent infection with the specific organisms
that produce it one sees, rarely, about the abdomen expressions of
_gangrenous cellulitis_ or malignant edema, which may spread here from
some adjoining part and involve wide areas. Abscesses also result
from infection of hematomatous or other cysts, while collections of
pus arising in the chest, travelling far, may spread downward along
the subperitoneal connective tissue and appear even low within the
abdomen or externally upon it. Acute _osteomyelitis_ of the bones of
the pelvis, or acute _suppurative spondylitis_, may produce abscesses
which will also involve the abdominal wall, while it frequently
suffers in the effort of pus to burrow toward the surface, as in large
_perinephritic_ collections and the like.

_Erysipelas_ not infrequently involves the abdominal surface, and,
spreading deeply, may produce suppuration or a virulent type of
peritonitis. The latter is more likely to occur in connection with
wounds and other injuries.

Aside from _burns_ of the minor type, which may involve large areas,
there may be seen, especially upon the abdomen, extensive and
distressing expressions of _x_-ray dermatitis, so called, followed by
ulcerations, perhaps with the later development of epithelioma. These
results of injudicious exposure to the cathode rays are always of the
most painful and erethistic type, and most difficult to heal. Resistant
cases are probably best treated by complete destruction of the surface
with knife or spoon and skin grafting.

Upon the abdominal surface are seen some of the characteristic
expressions of the _ulcerative syphilide_ and of _tuberculosis_ of
the skin. The former will require active antispecific medication and
the latter call for the curette or complete excision. In either case
radical treatment is usually promptly successful.

_Actinomycotic_ lesions are also seen, perhaps as often about the
abdomen as anywhere. They are likely to be mistaken at first for
tuberculous or syphilitic disease, but may be differentiated by
appearances elsewhere noted. They require active eradication, combined
with the local and general use of iodine and copper sulphate.


TUMORS OF THE ABDOMINAL WALL.

The abdominal walls are not exempt from _tumors_ which involve similar
textures in other parts of the body. About the ordinary hernial outlets
it is advisable to proceed cautiously with any tumor, lest it may prove
to contain or to be combined with a true _hernia in disguise_. This is
especially true at the umbilicus. _Congenital cysts_ in the walls are
usually met with along the middle line, and will prove to be remnants
of _embryonic cysts_, vitello-intestinal, urachal, echinococcus, or
dermoid. Cysts should be distinguished from fatty tumors and sometimes
from hernias or from cold abscesses.

_Fatty tumors_ are common in all shapes, locations, and sizes. Among
the benign tumors frequently observed are the _fibromas_, especially
those of the type spoken of in Chapter XXVI as _desmoids_--_i. e._,
those arising from the dense, fibrous, aponeurotic tissues, growing
slowly, being exceedingly firm and hard in character, intimately
connected with the fascia or aponeurosis, but not with the overlying
skin nor with the viscera beneath. They are practically painless, may
attain great size, and should always be removed while yet small, in
order that the abdominal wall may not be weakened more than necessary
by taking away the fibrous structures which especially give it strength.

The _vascular tumors_ which call for surgery are uncommon. Pigmented
nevi, however, are occasionally met, and these should always be
promptly removed lest they degenerate into melanosarcomas. Varices
and venous angiomas, sometimes of extensive dimensions, are also not
infrequently found here. Extensive varicosities may have a congenital
cause, the deep venous channels being insufficient, or they may be
due to thrombotic occlusion of the abdominal veins following typhoid,
puerperal fever, or injury.

_Primary carcinoma_ originating within or upon the skin, _epithelioma_
of similar origin, and _sarcoma_ arising from the deeper mesoblastic
tissues, may occur as primary tumors of the abdominal wall. We may
also have _endothelioma_ springing from the peritoneum, with possible
origin elsewhere. Occurring secondarily we may see any of the ordinary
metastatic expressions of any of these forms of growth, as well as
those spreading by continuity, the most frequent example of the latter
being so-called _cancer en cuirasse_ following cancer of the breast.

Finally, for those enormous overdevelopments of fat and connective
tissue which accompany exceedingly pendulous abdomens, such as
most commonly follow pregnancy or elephantiasis, the surgeon has
occasionally to excise large areas, closing the defects thus made by
numerous tiers of buried with strong superficial and retention sutures.


THROMBOSIS AND EMBOLISM FOLLOWING ABDOMINAL OPERATIONS.

It is well known that these conditions occasionally follow parturition
and then lead to sudden death. A similar condition is now generally
appreciated as occasionally following abdominal operation, and
sometimes leading to the same fatal result. It has been said that
thrombophlebitis follows about 3 per cent. of abdominal sections. It
occurs oftener in the left than in the right leg, and its etiology
is obscure. It begins with pain in the calf and groin, the leg
rapidly swelling and then becoming edematous. Various writers have
called attention to the occurrence of pleurisy and pneumonia during
convalescence from appendectomy, and ascribe them to the presence of
small emboli detached from the thrombi formed around the immediate site
of the operation.

Two rather opposite theories prevail at present regarding the
condition--one that it starts as a phlebitis due to infection at
the time of the operation, the other that thrombosis is the primary
lesion and therefore responsible for the phlebitis. Clark and others
have contended that injury to the epigastric veins, by retracting and
holding open abdominal incisions during protracted operations, is the
cause of the trouble.

It would seem rational to hold that mechanical violence to the vessel
walls, at or about the site of the operation, is the actual exciting
cause in non-septic cases. On the other hand, the cases of infectious
type should be accounted for either by local infection or as an
expression of toxemia such as we see when similar thrombophlebitis
occurs during the course of typhoid fevers and the like.

Years ago, Agnew, for instance, stated that after operations in which
much blood has been lost there is always more or less tendency to the
formation of coagula, but certainly the majority of these operations
today are accompanied by very little loss of blood. Embolic pleurisy
and pneumonia may appear without preliminary symptoms, while abdominal
thrombophlebitis rarely shows itself until at least the end of the
first week and sometimes not until the fourth week after operation, and
then more often in the left than in the right leg.

In the treatment of these cases palpation and massage are to be
strongly avoided, lest thrombi be dislodged and thereby produce
pulmonary infarcts. Rest and sorbefacient ointments constitute the best
treatment.




CHAPTER XLVI.

THE PERITONEUM AND ITS DISEASES.


Were the peritoneum spread upon a flat surface it would be found
to equal in area that of the skin which covers the body. In man it
is a closed sac; in woman it is exposed to exterior contamination
through the Fallopian tubes by way of the uterus and vagina. Hence
the frequency with which infections of the latter are transmitted to
the membrane itself. Thickened in some places, or duplicated, for the
purpose of forming ligaments and membranous visceral supports, it is
usually thin, connected with the structures which it lines or covers
by a more or less delicate, cobweb-like connective tissue. In some of
its duplications relatively large amounts of fat may be collected.
While freely supplied with bloodvessels it may be regarded as an
enormous lymph sac, its capabilities of absorption being relatively
immense. It is because of this that human beings escape many of the
possibly fatal consequences of infection. Along it infectious processes
travel, sometimes with wonderful rapidity, while again it throw’s out
exudates and rapidly walls off a serious disturbance, imprisoning it,
as it were, and often effectually. Fluid may escape from it (fluid
exudate) with great rapidity, or it may exude a fluid rich in fibrin
which rapidly accumulates and forms a dense, firm exudate that serves
to bind surfaces together and is often the surgeon’s best friend. In
fact, the surgeon looks for a minimum and desirable amount of this
exudate to ensure the result of whatever sutures he may pass through
the peritoneum and the tissues which it covers. Thus after an ordinary
intestinal suture it is expected that within some six hours the exudate
thus formed will be of itself almost sufficient for the purpose of
safety.

Peritoneum is said to possess the power of absorbing from 4 to 8 per
cent. of the weight of the individual within an hour, but this only
under normal circumstances, since inflammation or previous lesions
delay or interfere with the process. Increased peristalsis hastens
it, the reverse being also true. On the other hand, conditions may
be easily reversed, and the presence of sugar or glycerin within the
peritoneal cavity causes a diluting fluid to be thrown into it at
about the same rate. It is by virtue of a firm, fibrinous exudate
that foreign materials, _e. g._, ligatures, sutures, and even larger
substances, are encapsulated, those which are capable of disintegration
finally disappearing from within this investment. Occasional instances
are on record of instruments, sponges, or pieces of gauze being left
within the peritoneal cavity, in consequence of inadvertence during or
when concluding an operation. Such bodies as these often encapsulate
in this way and have been found years after at postmortem examination,
or have been slowly extruded during life by natural processes. Such
unfortunate occurrences as the latter afford the greatest reason for
care during all such operations.


PERITONITIS.

The term peritonitis has been made to cover so many conditions, of
widely differing pathological character, that it is intended here to
consider only those which have a practical interest for the surgeon.
It is unfair both to terminology and pathology to include under the
same name conditions that may be brought about slowly, or without any
participation of bacteria, with those which are due solely to bacterial
invasion. No attempt will be made here to go into a minute or complete
classification of the various conditions included by different writers
under this name. For instance, they have spoken of an idiopathic form
of peritonitis, thus confessing by use of this adjective ignorance of
the etiology of the condition. The surgeon has neither use for such
an expression nor belief in such a possibility. The thickening of the
peritoneum which may result from the proximity of an old hemorrhage, or
the irritation produced by the circulating fluids in cases of Bright’s
disease, is for him an entirely different entity, and is neither an
idiopathic form nor peritonitis itself.

For surgical purposes we mention especially the following forms:

  A. Consecutive;

  B. Traumatic;

  C. Perforative;

  D. Tuberculous;

  E. Malignant;

  F. Intra-uterine and infantile.

Forms A, B, and C may merge into one another or be confused from the
beginning, or they may themselves be consecutive to D, while E, the
malignant form, is hardly a distinct type, but rather a peritoneal
expression of a more widespread general condition.

Again writers have endeavored to make distinctions by the use of such
terms as “virulent,” “septic,” “putrid,” between which, however, no
lines can be clearly drawn nor sharp distinctions made. They depend to
some extent on the nature of the bacterial invasion, and again upon
the actual virulence of the bacteria involved. The most distinctive
type of surgical peritonitis is the _tuberculous_, which is usually
relatively slow and recognizable as such, but as between the cases
produced by spreading erysipelas, gonorrhea, intestinal perforation or
postoperative infection one can make few, if any, distinctions which
are serviceable or useful.

Anatomically considered there are two types of great importance--the
_circumscribed_ or _local_ and the _general or diffuse_--prognosis
depending in no small degree upon the extent of limitation of the
active process, while at any time the former may merge into the
latter. _Consecutive peritonitis_ may include that which is the
result of direct extension, as from erysipelas, appendicitis, acute
cholecystitis, pyosalpinx, or other acute infections which have
spread to and involve this membrane. Under this head also may be
included those cases due to thrombosis or embolism, of mesenteric or
other vessels, which lead to speedy gangrene of a part or all of the
intestine.

_Traumatic peritonitis_ refers rather to those cases where infection
has been carried directly inward from the exterior. Traumatic
peritonitis may be the result of extension of the same conditions which
produce the first, the consecutive form, or only occur more directly,
as, for instance, those cases produced by rupture of the stomach or
duodenum after ulcerations of the same, or perforation of typhoidal
ulcers, actual rupture and escape of the contents of a suppurating
gall-bladder, appendix, tube, or any other collection of pus, or
perforation due to the gradual extension of tuberculous, syphilitic, or
malignant disease, with final rupture of a viscus.

The nature of the bacterial invasion is of more interest to the
pathologist than to the surgeon as such. In general, however, it may be
said that, in addition to the ordinary pyogenic organisms, the colon
bacilli are perhaps the most frequently to blame, while the more putrid
types are the result of actual escape of bacteria from the intestine,
as through a perforated appendix, and the addition of a mixed type
to one which began perhaps as a simple one. Thus in the so-called
_putrid_ forms multiple bacterial contamination is usually discovered
upon making cultures. The pneumococcus, the capsule bacillus, and the
gonococcus are also not infrequently found, in cases of peritonitis
whose nature and origin will be suggested by the discovery of the
particular germ involved in each case.


=Symptoms.=--While varying much in time and intensity, and even
completely changing their type during the successive stages of the
disease, there are, nevertheless, certain cardinal symptoms which are
universally recognized in cases of surgical peritonitis. These include
_vomiting_, _pain_, _tenderness_, with more or less shock, followed
sooner or later by abdominal _spasm_ and _distention_, while to these
symptoms there is sure to be added _bowel obstruction_ of some type
which becomes, toward the end, perhaps the most profound feature, and
which may even mask the significance of other symptoms. According
as the lesion is localized or generalized _pain_ may be referred to
a particular area or may be general and intense. _Local pain_, with
tenderness, usually implies, at least at first, a localized lesion,
and is not so likely to be accompanied by vomiting as the more diffuse
form. Depression is found to correspond largely to the type and degree
of sepsis, while collapse is a prominent feature in the more severe
cases. The pain, which is sometimes intense, subsides, and it should
be emphasized that a speedy subsidence is not necessarily a favorable
symptom. It too often marks the transition of an ordinarily acute case
into one of intensely septic or even putrid type. _Tenderness_ may
be acute and localized, or diffuse and only evoked on deep pressure.
One of the most significant symptoms is _abdominal rigidity_, which
persists throughout the active state of the disease, and which, when
followed or accompanied by meteorism, may to some extent mask and
obscure all conditions within. If the patient be not seen until this
stage is reached diagnosis can be made only by history and conjecture,
for it is almost impossible to determine anything by palpation.

_Temperature_ is an uncertain factor. It sometimes rises high at first,
and then falls, while if it fall too low the prognosis is serious. The
_pulse_ also shows very irregular variations, usually rising, however,
as the disease becomes more severe, and being often almost uncountable
at the end. A combination of rising pulse and falling temperature is of
serious import.

In addition to the _vomiting_, which is a pronounced early feature of
the disease, we have, as bowel obstruction comes on, an added _fecal
character_ to the vomitus, which sometimes is most characteristic
of complete obstruction. This obstruction is due in part to toxic
paralysis of the muscular coat of the bowels, and in part to the
result of adhesions or fixations by which bowel motility is completely
prevented. Thus in many instances of peritonitis following acute
appendicitis there are loops of intestine glued together by exudate in
such a way as to practically occlude or disable them.

The depression, shock, and final collapse of the disease are
characteristic, as is also the _facial appearance_, the cheeks
becoming discolored and the orbits hollowed out, so that the eyes
early sink back. Other expressions of diminished blood pressure are
not lacking--coldness of the extremities; cold, clammy perspiration;
lividity of the skin, and the like.

While this is a picture of the most common expressions of acute septic
or surgical peritonitis, it is occasionally found that conditions
equally serious arise without such marked symptoms, and that the
patients become rapidly worse, finally dying, who neither vomit
continuously nor show extreme meteorism nor abdominal rigidity.
Such cases are thereby stamped as those of more extreme toxicity,
where systemic reaction is paralyzed almost from the outset, and are
accordingly the more hopeless on that account.

Ordinarily it is not difficult to recognize the onset and the course
of peritonitis in surgical cases. The condition may be confounded with
one of septic intoxication from some focus which has not involved
the peritoneum; otherwise differentiation is rarely difficult. The
occurrence of such a condition does not necessarily indicate faulty
technique on the part of an operator, as the condition is too often
present when the surgeon begins his work. On the other hand, it too
often follows faulty technique and constitutes the strongest argument
for vigilance both in preparation, performance, and after-treatment.


=Treatment.=--But little will be said here about non-operative
treatment, although first it should be emphasized that treatment in the
past was too often of the non-operative type. Many cases of peritonitis
could be saved by operation were it performed while the infection is
still localized, but this is at a period when they too rarely reach
the surgeon’s hands, he being called in as such when the inefficacy
of drug treatment has been already demonstrated. Without denying that
the surgeon is not blameless in all these respects, blame should,
nevertheless, be placed where it properly belongs, at the door of the
man who fails to recognize and carry out plain surgical principles.

The opium treatment for peritonitis, with which the name of Clark will
always be associated, was introduced at a time when many things were
considered as peritonitis which were not necessarily such. It was
furthermore an advance on previous methods and gave better results.
That, however, is no excuse for adhering to it when better means are
at hand. On the other hand it must not be denied that much can be
done medicinally to give comfort and meet certain indications. In
spite of the many disadvantages attaching to the use of opiates it
seems unnatural to let patients suffer as they would without them. It
is justifiable, then, to use them in cases which are hopeless, or in
those which refuse operation; but given indiscriminately and early
they often mask symptoms which, if properly appreciated, would lead
to early diagnosis, and, it is to be hoped, early operative relief.
Views also differ regarding catharsis. It is a great disadvantage
to permit the intestines to retain fecal matter for days and add a
consequent copremia to the other features of the disease. On the other
hand, intestinal activity tends to disseminate infection, and is,
consequently, most undesirable. If at the outset the intestinal canal
could be emptied and then left at rest it would best meet the somewhat
contrary indications.

Ordinarily, however, it is of small advantage to keep bombarding the
stomach with repeated doses of laxatives which are more often rejected
than retained, and which have little effect.

One of the most distressing features is _vomiting_, and here it is well
to follow Berg’s suggestion and test the vomitus with litmus paper.
If it be found alkaline small doses of morphine should be given, each
with a drop or two of aromatic sulphuric acid, in a little chopped
ice. If it be found acid small doses of milk of magnesia are advised
or some such preparation, with minute doses of morphine, frequently
repeated. The greatest relief in these cases, where the upper bowel
is emptying itself into the stomach, will be obtained from _lavage_.
In the same way tympanites and meteorism are best treated by passing
a rectal tube high, leaving it in place, and utilizing it for lavage
of the bowel, using warm water with a little sodium salicylate. Not
the least distressing feature of such a case is the reflex hiccough
which is produced by diaphragmatic spasm, since the phrenic nerve
distributes sensitive fibers as well to the peritoneum. For this there
is no really effective remedy. Small doses of Siberian musk, with or
without morphine, beneath the skin will sometimes quickly relieve it.
Depression and lowered blood pressure are best treated by adrenalin and
digitalis, rather than by strychnine, which stimulates peristalsis.
Fever, when high, should be treated by cold sponging rather than by
antipyretics. The kidneys should be kept active, if necessary by
hypodermoclysis, and the skin equally so by hot-air baths, as through
both of these emunctories much elimination may be effected. The
question of catharsis comes up again in considering what can be done to
improve elimination of ptomains by watery stools, but these are hard to
secure; it is, after all, questionable whether their effectiveness in
this regard has not been greatly over-rated. Richardson, for instance,
is inclined to believe that cases reported as cured by free catharsis
would, in all probability, have recovered without it, it being doubtful
whether the really infectious element be present.

_Surgical treatment of peritonitis_ includes a recognition of the
cause, and, if possible, its removal. Richardson has grouped in the
following suggestive manner the indications for operative intervention
in the early stages, when cases are not without hope:

  General pain, becoming local; or local, becoming general, according
  to cause;

  Tenderness, showing the same indications;

  Abdominal rigidity;

  Green vomitus;

  Rising pulse and temperature;

  Diminished peristalsis without too much shock.

On the other hand, in cases of fully developed peritonitis, where the
surgeon may still consider the possibility of intervention, but where
prognosis is far less favorable, the conditions include:

  Lessening or vanishing pain;

  More general tenderness;

  Great distention, replacing rigidity;

  Excessive dark or fecal vomitus;

  Obstipation;

  Rapid and feeble pulse;

  Pain extremely severe;

  Low temperature and the ordinary evidences of reduced blood pressure.

In such cases the decision rests largely upon the degree of collapse.
To operate upon a moribund patient is hopeless and brings discredit
upon surgery. Before operating upon any serious case of this kind the
circumstances should be fully explained to those concerned, and they
should be impressed with the fact that should the patient die he dies
_not in consequence of the operation but in spite of it_.

The _operation_ itself will in a large measure depend upon what can
be learned of the etiology of the disease and the diffuseness of the
resulting infection. To reach a localized focus the incision may be
made at any point which will best afford access; but in dealing with a
generalized process the middle line, and an extensive incision, will
ordinarily afford the best opportunity for doing whatever is necessary.

The _preliminary incision_ may be made short, as for exploratory
purposes. Unless a loop of distended bowel be at once blown into
the opening there will be prompt escape of fluid, whose character
will reveal much of what has gone wrong within. If reasonably clear
the operator is fortunate. If it be purulent he has to combat a
most serious condition; if it be offensive, it is probably due to
contamination from a septic abscess or from intestinal gases, while if
the fluid be nondescript and contain floating particles of fecal matter
there is an intestinal or gastric perforation. So soon as one comes
upon fixation or adhesion of viscera he will find lymph, in condition
of greater or less organization. Inside the masses thus bound together
he will probably find the greatest centre of pernicious activity.

The more one sees of these intra-abdominal conditions the more respect
he, as a surgeon, feels for the _omentum_. Only recently have surgeons
learned to appreciate the kindly activities of this duplicature of
the peritoneum, with its slight or heavy load of contained fat. It
manifests a tendency which may be almost regarded as a sagacity or
instinct for shifting itself toward a local focus of infection, and
there throwing out lymph by which it becomes attached and helps to
form a protective barrier that often is most effective. Were it not
for this tendency many cases of acute appendicitis, for instance,
which now recover would be lost during the early days of the attack,
in consequence of a quickly disseminated infection. Thus a gangrenous
appendix, or hernia, or gall-bladder, is frequently so wrapped up in
a protective layer of omentum that the operator has first to detach
this, or go through it, before he comes upon the actual site of the
trouble. Some such disposition of the omentum, then, may be easily
discovered during the earliest moments of his exploration, and if later
he conclude to remove a portion of it, because of actual or impending
gangrene, he nevertheless sacrifices it with a feeling of regret
because of the good it has already done.

The further treatment of these cases is essentially a matter of what
can be done to remove the exciting cause. Questions of gravest import,
and often difficult of immediate decision, will present in nearly every
case; as, for instance, whether to resect a portion of intestine,
to remove a gall-bladder, to hunt for an appendix when embarrassed
with the difficulty of the effort and necessity for widely separating
intestinal coils, or of the treatment of distended bowel, which it may
perhaps be impossible to restore to place, of extensive and complete
flushing of the abdominal cavity, or of mere local cleanliness. And
after these questions have been decided, and action taken, there comes
still the question of _drainage_, with the wisdom of or necessity for
counteropening, as in the loin or in the cul-de-sac, and the character
of drain to be used. As to what should be attempted _in general_ there
will rarely be much room for doubt. As to how best to accomplish it
should be decided according to the training, the experience, and the
opportunities of the operator, and the nature of the environment. When
the entire peritoneal cavity is invaded, and flooded with more or
less infectious material the more thoroughly it can be washed out the
better. At the same time to do this with any degree of even apparent
thoroughness requires practical evisceration of the patient, and an
amount of time spent and shock produced by handling the viscera, which
are exceedingly depressing and may of themselves be more than can be
borne. The meteorism, which is so conspicuous a feature of most of
these cases, means the distention of the bowel to such a degree that
when once the intestines lie upon the surface of the body they can
usually be restored with the greatest difficulty; and this would raise
the question of the desirability of either one or more punctures,
through which gas should be allowed to escape, or a sufficiently
wide opening, with the introduction of a Monk tube, and the complete
emptying both of gas and putrefying fecal matter. The latter is
certainly in theory the much more desirable measure, if the patient’s
condition will only justify it. Probably after pelvic drainage the
Fowler semi-sitting posture in bed would be desirable, while after high
drainage the Trendelenburg position, with the pelvis higher than the
thorax, would be preferable.

If free abdominal _irrigation_ is to be practised a large quantity of
warm sterile saline solution should be used, to which may be added
perhaps a small proportion of acetozone or of mercury bichloride. The
silver salts also make equally effective and less irritating fluid, the
nitrate being used in the proportion of 1 to 10,000, or the citrate or
lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts
will coagulate the albuminoid fluids and give to the peritoneum an
opaque appearance, which, however, need cause no alarm.

Another question of importance is that of _enterostomy_. In some of
these cases the acute bowel obstruction is the most predominating and
distressing late feature, and an enterostomy may be attempted, even
though it be known it will serve but a temporary purpose, in order to
relieve distress. There never can be more than sentimental objection to
it, in such cases, with the possibility of something more than mere
temporary relief. It can be effected under local cocaine anesthesia, by
attaching to the parietal peritoneum the first loop of distended small
intestine that presents, and, after firmly fixing it in place, making a
small opening, and then preferably inserting a glass or other tube for
better drainage purposes.

These constitute the precautions to be followed and the advice to be
given in cases of septic or surgical peritonitis. How successful they
may be, or how satisfactory the termination of the case, cannot be
foretold by statistics nor by reports of cases in the hands of others.
Success will depend in large measure upon the early or late period
at which the case is thus treated, and upon the general surgical
discretion and experience of the operator. It is probable that
disappointment will result more often than success. Nevertheless every
life thus saved is one snatched from a certainly fatal termination
without it, and if successful but once in ten times one life has
thereby been saved that may be worth saving, without saving the other
nine. While I would advise to make the attempt in any case which offers
a reasonable prospect of success, caution should be used against doing
it without a full understanding with those concerned that it is an
effort in the right direction, concerning which no promise can be made;
death results not from the operation so much as in spite of it.

Summarizing, briefly, the best methods of treating a diffuse septic
peritonitis we may agree with Le Conte,[53] that they consist of the
following measures: The least possible handling of peritoneal contents,
the elimination of time-consuming procedures, most perfect drainage of
the pelvis by a special suprapubic opening, as well as free drainage
through the operative incision, the semi-sitting posture of the
patient after its conclusion, the prevention of peristaltic movements
by withholding all fluids by the mouth, and perhaps by small amounts
of opium, and the absorption of large quantities of water through the
rectum, by which there may be produced a reversal of the current in
the lymphatics of the peritoneum, making it a secreting rather than an
absorbing surface and increasing urinary secretion. It is inexpedient
to waste time sponging peritoneal surfaces or wiping away lymph, for
danger of septic absorption is increased rather than diminished.
Patients with diffuse septic peritonitis bear brief operations fairly
well, but prolonged ones badly; therefore a minimum amount of work
should be done.

  [53] Annals of Surgery, February, 1906.

One of the most valuable procedures in carrying out the above advice
is Murphy’s method of _slowly introducing large quantities of water
into the rectum_. The rectal tube used for the purpose ends with a
sort of nozzle containing three or four openings, and the reservoir
containing the solution is elevated but a few inches above the level of
the bed, the intent being that it shall simply trickle into the bowel
no faster than absorption can occur. In this way from a pint to a quart
may be absorbed each hour, the pressure being continuous, and the flow
so regulated that no accumulation of fluid takes place in the bowel.
Murphy claims that by this method the lymph current in the peritoneal
lymphatics is so reversed that the peritoneum is bathed with free
discharge and that this should be afforded escape by suitable drainage
methods, coupled with Fowler’s (the sitting) posture.


TUBERCULOUS PERITONITIS.

_Acute or chronic tuberculosis of the peritoneum_ assumes usually,
first, the _miliary_ form, after which, in the slow cases, infiltration
and great thickening occur to such an extent as to alter the
appearance, texture, and behavior of the peritoneum itself. It is
rarely a primary condition, but is usually secondary to some other
tuberculous focus, which may be one or more of the mesenteric nodes,
these being involved in consequence of infection from the alimentary
canal; or the peritoneum may be easily infected either from the
genito-urinary tract or directly from the intestine. In children, the
most common path of infection is through the mesenteric nodes; in
females, through the Fallopian tubes, and in males, either through
the intestine or the kidneys or ureters. The peritoneum, under these
circumstances, behaves very much as does the pleura, in the presence of
acute or chronic tuberculous lesions which extend to and involve it.
Thus it may become so thickened, and even “leathery,” as to have lost
all its original characteristics, and to appear more like a dense, firm
membrane than in its original semblance.

_Peritoneal tuberculosis_ appears in three different types: A
_fibrinoplastic_ type, characterized especially by adhesions; an
_ulcerative and sometimes absolutely suppurative_ form, marked always
by the presence of pus and pyoid; and an _ascitic_ type, characterized
by leakage of increasing amounts of serum and the development of
well-marked ascites.

The first, or _fibrinoplastic_, is a localized lesion, and leads to the
formation of dense adhesions, as, for instance, between a Fallopian
tube and the pelvic walls or the other viscera. As the disease spreads
all the tissues become matted together in a mass which renders them
almost indistinguishable, frequently much resembling malignant disease.
In some instances it may be possible to remove the entire affected
area. At other times it is best to let it alone.

The _ulcerative form_ is characterized by more general symptoms of
conspicuous febrile type. It produces rapid loss of strength and
weight, frequently attended with evidences of intestinal ulceration and
with abdominal tenderness and pain. A certain proportion of these cases
justify exploration, though but few of them will be found favorably
disposed for radical surgical measures.

The _ascitic type_ is characterized by rapid accumulation of fluid,
with accompanying malaise and debility. As the abdomen distends and
the diaphragm is pushed upward respiration becomes more difficult and
rapid. A certain _protrusion of the umbilicus_ also characterizes
many of these cases. Their course is not so febrile, but it may be
possible, especially in the early stages, to make out some enlargement
of mesenteric nodes, or involvement of the viscera, which will aid in
diagnosis. It is most common in children, but it may be met with at any
age. In general such a collection of fluid, which cannot be accounted
for by recognizable disease of the heart, liver, or kidneys may be
suspected to be tuberculous.


=Treatment.=--Treatment of tuberculous peritonitis should be _surgical_
when possible. This statement is based partly upon the fact that it
is so commonly a secondary condition. Such treatment will depend, in
large measure, upon the extent to which it may be possible to remove
any exciting foci of the disease; but experience shows that even this
is not always necessary to bring about a cure, as in those cases of
the ascitic type where it is desirable only to wash out the abdominal
cavity and close it again, this simple procedure seeming to suffice.

It is the cases of the _ascitic type_ which seem most benefited by
_incision and irrigation_, usually without drainage, and it is these
which are perhaps as hopeless as any under non-operative treatment.
It was Van de Warker, of Syracuse, who, in 1883, first recognized
the value of simple irrigation in these cases, and while at present
we find it impossible to explain the benefit which so often and so
rapidly accrues, the measure is universally recognized as that offering
the most hope. This, like every other surgical procedure, should be
practised early rather than late, preferably so soon as diagnosis
is made, or, when this is difficult, it should be made a part of an
exploratory operation intended partly for diagnostic purposes. The
measure itself is simple. A small opening in the middle line, between
the pubis and the umbilicus, permits free escape of all contained
fluid, which should be facilitated by changing the position of the
patient, thus preventing plugging of the opening by presenting bowel.
Every drop which can escape having been removed, the abdomen is then
flushed repeatedly with either warm saline solution or a plain watery
solution of acetozone, 1 to 1000, or silver lactate or citrate, in the
same proportion or a little stronger. My own preference has always
been for the latter, and with a silver solution I have obtained a
large degree of success. There is no objection to leaving a small
amount of either of these fluids in the abdominal cavity--_i. e._, no
more than an ordinary effort to empty it before closing the wound.
An incision one inch long, made for this purpose, will serve nearly
every indication. Through it the parietal peritoneum, as well as that
covering numerous loops of intestine, can be inspected, and through
it also a finger may be inserted for exploratory purposes, for the
detection of mesenteric nodular disease or of any other focus. Should
any serious local condition be revealed which might be benefited by
radical measures, this would be the time to practise them.

Before closing the wound margins it would be well to thoroughly
disinfect them, for over them has flowed infected fluid, and we
sometimes see tuberculous foci develop at this point. This fact
explains also the disadvantage obtaining in these cases of making
drainage openings. They serve their purpose admirably for a short time,
but, becoming thus infected, lead to the establishment of tuberculous
fistulas and sinuses, which may call for subsequent operation. Fecal
fistula may even be a more remote consequence. As the peritoneum is
approached it will be found more or less altered, and there may even be
observed bowel or omentum adherent behind it; therefore caution must be
observed.

A final caution should also be given in order that we may avoid
mistaking that form of ascites which is frequently seen in connection
with cancer of the abdominal viscera extended to the peritoneum, and
particularly that form spoken of as _miliary carcinosis_ or _miliary
sarcomatosis_, for a tuberculous collection. While surgeons are
occasionally deceived, one will usually find much in the history of the
case, and in the results of local examination, which may save making
this error, if it be so regarded; but, in effect, the opening and the
evacuation will give relief, even though this character of the disease
makes it less amenable to help from any such source.




CHAPTER XLVII.

INJURIES AND SURGICAL DISEASES OF THE STOMACH.


CONGENITAL MALFORMATIONS OF THE STOMACH.

These malformations are quite rare, at least those raising the question
of possible surgical remedy. _Transposition_ does not require relief,
nor does a stomach abnormally small allow it. More or less _stenosis
of the pylorus_ as a congenital defect has been observed, but it is
extremely rare. Along with it is often associated a certain hypertrophy
of the stomach muscle. _Hour-glass deformity_ may be of congenital or
acquired origin. The latter two conditions permit of easy surgical
remedy. Pyloric stenosis may be atoned for by gastro-enterostomy or
treated directly by a plastic operation, while the hour-glass stomach
permits of an anastomotic rearrangement, either of its dilated portions
with each other or with the bowel below.

The _acquired malformations_ are connected with the consequences
of ulceration and stricture. They include more or less complete
_stenosis_, either cicatricial or malignant, various forms and types of
_gastroptosis_ and _gastric dilatation_, in which sometimes enormous
degrees of distention are produced, with disturbed or practically
destroyed stomach digestion. These cases will be considered by
themselves a little later, along with their surgical relief.

The _anatomical relations of the nerves_ supplying the stomach are
worthy of the surgeon’s especial consideration. Its sympathetic nerve
supply is in particular and intimate relation with the seventh, eighth,
and ninth spinal roots, by which we account for the tenderness of the
overlying surface in ulcer of the stomach, and the pain which is often
referred to the region of the left shoulder-blade. When the stomach is
adherent to the gall-bladder, in cases of biliary calculi, the pain
is often referred to the right shoulder, but so soon as the pylorus
becomes entangled and bound down pain is referred also to the left side
as well.


HOUR-GLASS STOMACH.

Hour-glass stomach is now more common, and is to be attributed more to
results of pathological conditions than to any congenital anomaly, it
being now well established that it is usually the result of perigastric
adhesions of chronic ulceration, with cicatricial constriction,
as well perhaps of subsequent malignant implantation. Cancerous
infiltration may produce the so-called _“leather-bottle” stomach_.
Moynihan suggests, among other methods of _diagnosis_, the passage of
a stomach tube and lavage with a quantity of fluid. If there be loss
of a certain amount of this, when it is returned, it will indicate
that a portion has escaped into the distal sac of the stomach. Again
if the stomach be washed until the fluid returns clear, and then if
there suddenly comes an amount of offensive fluid, or if the stomach be
washed clean, the tube withdrawn and passed again a few moments later,
and if then offensive fluid escape, the facts can be best explained on
the hypothesis of an hour-glass constriction. “Paradoxical dilatation”
may also be noted, _i. e._, the fact that palpation will still elicit
a splashing sound after a stomach tube has been passed and while the
organ is apparently empty.

Moynihan has suggested still another method of recognition. The area of
stomach resonance being outlined, a Seidlitz powder in two halves is
then administered. After about twenty or thirty seconds great increase
in resonance of the upper part of the stomach will be found, while
the lower part remains unaltered. If now a bulky pouch can be felt or
outlined the diagnosis is determined, as the increase in resonance
occurs in the distended cardiac segment.

The method of treating an hour-glass stomach will consist either, in
selected cases, of a plastic operation by which an incision made in
one direction is closed in the opposite, _i. e._, a measure like that
practised at the pylorus for benign stricture, or else the separate
sacs of the stomach must be united by an anastomotic opening and a
_gastrogastrostomy_ thus performed.


FOREIGN BODIES IN THE STOMACH.

These are most commonly those which have been swallowed, either
by design or through inadvertence, and may consist of almost all
imaginable substances. In those animals that have the constant habit
of licking their own fur or that of others, and thus scraping off a
quantity of hair, _hair-balls_ in the stomach are frequently formed,
and, as may be seen in museums, these sometimes obtain relatively
enormous size--a foot or more in diameter. Hair-balls in the human
being are of rare occurrence, and are the result of the habit of
chewing the hair, observed in some hysterical or insane patients.
There are several instances now on record of successful removal of
such hair-balls from human stomachs. _Artificial dentures_, partial
or complete, are not infrequently passed into the stomach, sometimes
during sleep. In dealing with a case of this character extreme caution
should be exercised, because many individuals have deceived themselves,
or have been deceived, and the missing teeth supposed to have been
swallowed have been found in some place where they have been mislaid
and forgotten. Children have a habit of swallowing almost anything
left loose in the mouth, and all sorts of toys and small playthings
have disappeared into their stomachs, sometimes causing death,
and occasionally passing through the alimentary canal. The insane
sometimes show a maniacal tendency to swallow foreign bodies, such as
nails or anything else which they can get into the mouth. Hysterical
patients and museum freaks evince the same habit, and it is wonderful
how tolerant the stomach becomes in some of these individuals, and
what objects seem to pass the pylorus and escape externally without
doing serious harm. Still, sooner or later nearly every one of these
individuals comes to grief. Thus from one patient at the Erie County
Hospital, in Buffalo, Gaylord removed an astonishing amount of junk,
including nails, screws, pieces of glass, knife-blades, and the like.
As a general rule, any reasonably smooth object which can pass through
the esophagus may also pass through the pylorus.


=Symptoms.=--The symptoms produced by these foreign bodies will vary
according to their size, number, and character. A hair-ball may lie
for a long time within the stomach, producing few symptoms, and none
by which it may be recognized. So long as no perforation of the
entire thickness of the stomach walls occur, nor any infection which
may produce a local peritonitis, the disturbances they set up may
be limited to those included under the name “dyspepsia.” So soon,
however, as pain, tenderness, or septic indications, or those of local
peritonitis supervene, the abdomen should be promptly opened. Today we
have the cathode rays as an aid in diagnosis, which will clear up doubt
in most instances, and afford a definite indication for operation.
Nevertheless a negative result does not necessarily imply that no
foreign body is present.


=Treatment.=--The operation indicated is _gastrotomy_, _i. e._,
opening of the stomach at a suitable or convenient point, removal of
the foreign body or bodies, and the complete closure of the wound
as well as of the abdominal incision, without drainage. If due care
be maintained throughout, and the element of previous infection be
excluded, prognosis is good. When perforation with local peritonitis,
and perhaps abscess, has already occurred, there is a local indication
as to exactly where to open; one should then complete the operation
with the establishment of suitable drainage.


WOUNDS OF THE STOMACH, INCLUDING RUPTURE.

As already indicated, the stomach maybe ruptured, especially if
weakened by previous disease, by severe abdominal contusion. It is
subject to all possible wounds by perforation, either gunshot or by
puncture. As it is more protected than the bowel below it is less
liable to perforating injuries. Much will depend upon the nature and
the extent of the injury. A small perforation may be protected by
prolapse of the mucosa in such a way that little escape of contents
takes place. On the other hand it may be extensive, and nearly the
entire gastric contents may be poured out into the upper abdomen. The
location of the stomach lesion by no means necessarily corresponds to
that of the abdominal wall, this being particularly true in gunshot
cases. Extravasation depends in amount and rapidity upon the stomach
contents and their fluidity. If the posterior wall alone be injured
it will empty rather into the cavity of the lesser omentum. Stomach
injury may always be diagnosticated if, after abdominal injury, the
vomited matter contains blood. The pain is usually severe and involves
generally the entire upper abdomen. In proportion as the lesion lies
near the diaphragm the breathing may be affected. Collapse is usually
prompt and may be due to hemorrhage from a vessel of considerable
size. _Pain_, _collapse_, and _hematemesis_ constitute indications for
the promptest possible opening of the abdomen and investigation, with
suitable suture of the stomach wound, toilet of the peritoneal cavity,
and drainage, which should be posterior as well as anterior. Every
ragged or compromised margin of a stomach wound, especially gunshot,
should be neatly excised, and sutures applied in such a way as to
only bring clean and fresh surfaces together. An external opening of
sufficient length should be made to permit easy and complete withdrawal
of the entire stomach, and a complete search over both its surfaces in
order that no lesion may escape detection. If the opening made into the
stomach be sufficiently large to permit, it would be best to thoroughly
empty its contents and gently wipe it out, in order that it may be left
not only empty but clean. Should the puncture be very small it would
be well to pass a stomach tube from above and wash out the stomach,
protecting the opening by pads and pressure, and thus preventing
contamination of the peritoneum.

While _apparently spontaneous rupture_, _i. e._, without previous
ulcer or disease, is most rare, there are a few cases on record where
patients have been seized with intense paroxysmal pain and have died
more or less quickly, and where the condition has been found with
little or nothing to explain it. Immediate operation might possibly
have saved some of these had the possibility of its occurrence been
recognized. _Perforation from within_ may also occur, as it is known to
have happened in the cases of sword or knife swallowers.

_Suture of the stomach_ is practised in exactly the same way in these
cases as for other purposes and the method will be described later,
along with the other operations upon this viscus.


TUBERCULOSIS AND SYPHILIS OF THE STOMACH.

The gastric mucosa presents a remarkable contrast to that of the
intestinal tract, the latter being exceedingly likely to succumb to
_tuberculous infection_, which is exceedingly rare in the former.
_Primary tuberculous ulceration_ of the stomach, then, is most unusual.
When tuberculous ulcers are found there they are usually the result of
a secondary or perforating process. Such ulcers may attain great size,
as in one case reported by Simmonds where the ulcerated area measured
four by eight inches, yet produced no symptoms during life. This
would correspond almost to a lupus of the gastric mucosa. Tuberculous
_gummas_ are even more rare, and, occurring in the stomach, are
pathological curiosities rather than surgical possibilities.

_Syphilis of the stomach_ is met with either as gumma or ulcer, the
latter leading almost inevitably to more or less stricture as recovery
follows suitable treatment. Although it is claimed that 10 per cent. of
cases of chronic ulcer of the stomach have suffered from syphilis at
some time, it by no means follows that such ulcers are to be considered
as of genuinely syphilitic origin, as a syphilitic patient is not
exempt from other stomach conditions. However, symptoms of gastric
ulcer, associated with actual manifestations of syphilis, might well
indicate associated syphilitic lesions and would probably yield, with
the others, to suitable treatment.

Lesions of either character, which do not subside under proper medical
treatment, and which require a surgical operation, would be equally
benefited by it whether of one of these types or of the other.


DILATATION OF THE STOMACH.

The _acute form of gastric dilatation_ was described by Fagge in 1872,
the chief symptoms being excessive vomiting and anuria, and the disease
proving fatal within three days, the dilatation being enormous. For a
condition occurring as rapidly and progressively as this does there is
as yet no satisfactory explanation, careful autopsy failing to disclose
a sufficient reason. It has been known in at least twelve instances to
follow surgical operation, four only of which were upon the abdomen,
and none of them upon the stomach proper, in all instances the patients
apparently progressing favorably. The stomach becomes rapidly and
enormously distended, and bent upon itself with a sharp kink in the
lesser curvature. Thus it seems to occupy the entire upper abdomen.
Two factors at least seem to assist in the condition: A paresis of
the gastric musculature, and the fact that as it becomes distended it
itself produces obstruction of the duodenum, and thus aggravates the
primary condition.

It has been suggested that these acute cases of _postoperative
dilatation_ are closely connected with certain cases of ileus and
obstruction after abdominal operations, the dilatation once initiated
tending to more and more obstruct the duodenum, as well as cause upward
pressure on the diaphragm and embarrassment of the heart’s action.
Hence the value of the stomach tube in treatment of such conditions.


=Symptoms.=--The symptoms are usually sudden and fulminating, beginning
with intense pain, which finally involves the entire abdomen. Vomiting
comes early and persists, the vomited fluid being greenish in color
and large in amount, changing later to a brownish color and having an
offensive odor. The act of vomiting is passive rather than active or
violent. In spite of it the stomach never seems to empty itself. The
outline of the dilated stomach may be seen through the abdominal wall,
bulging being often extreme. With the passage of the stomach tube there
may be escape of a large amount of gas as well as of fluid. Thirst is
intolerable and never satisfied. The amount of urine is almost always
reduced and sometimes anuria is practically complete.


=Treatment.=--The treatment is too often ineffectual, since the
condition itself is lethal almost from the beginning. Early and
frequent lavage, or perhaps leaving the stomach tube in place, would
be indicated. It might be practicable to pass a small tube through the
nostril and leave it, as is done with the insane. Gastrostomy would be
theoretically indicated, could it be done sufficiently early. The same
is perhaps true of gastro-enterostomy, although it has never had a fair
trial, these cases coming to the surgeon too late to permit of much
help.


=Chronic Dilatation of the Stomach.=--Chronic dilatation of the
stomach, often spoken of as _gastrectasis_, is a frequent complication
of various other conditions, being essentially a consequence rather
than a primary condition. It may be due to:

1. Pyloric stenosis or its equivalent in the first part of the duodenum:

  (_a_) From cicatricial processes following ulcers of the pyloric
  region;

  (_b_) From perigastritis with cancer of the stomach;

  (_c_) From pylorospasm and hypertrophy continuing after recovery from
  ulcer, and including more or less thickening of the biliary region;

  (_d_) From neoplasms outside the pylorus proper;

  (_e_) From cancer of the pyloric end of the stomach;

  (_f_) From pressure upon the duodenum by pancreatic lesions;

  (_g_) From the results of gallstones ulcerating and causing great
  local disturbances;

  (_h_) From displacement of the pylorus, due either to falling of the
  stomach or dragging of an attached but movable right kidney.

2. A dilatation due to old lesions which have subsided, the atonic
stretching not having been repaired.

It will be seen, then, that the condition may be met as a sequel to
many different pathological processes. As such, therefore, it has no
constant etiology nor necessarily distinctive features. In general it
is recognized by tardiness in escape of gastric contents, associated
with vomiting, the vomitus being distinctive, consisting often of old
and undigested food, or perhaps of food which has rested in the stomach
until putrefaction has occurred. The vomitus also contains evidences
of fermentation, with sarcinæ and yeast cells and much mucus. In cases
of ulcer it is usually very sour, owing to excess of free hydrochloric
acid. When due to cancer the acid is usually due to excess of lactic
acid, while hydrochloric acid may be nearly or totally absent. Even
if vomiting does not occur after ingestion of food, heaviness and
discomfort, with much eructation of gas, are produced. Constipation and
diminished urine secretion are almost invariable accompaniments. When
the obstruction is of the mechanical type a visible peristaltic wave
can often be seen and felt, and this is a sign which should be regarded
as always indicating operation.

Patients gradually lose flesh and become anemic and run down, suffering
from what has been often vaguely called indigestion, their lives
sometimes being terminated by starvation, occasionally by gastric
tetany. The question of diagnosis can usually be settled by having the
patient swallow the dissolved separate parts of a Seidlitz powder, one
after the other, when the carbon dioxide released within the stomach
will cause it to balloon up and assume that shape and position which
the amount of its dilatation permits.

_Gastric dilatation which does not quickly yield to lavage and suitable
medication is of itself always an indication for operation._ When
accompanied by a tumor, especially if this move and change position
with the stomach, a cancerous condition may be assumed, which,
while not permitting a cure, may nevertheless be ameliorated by a
gastro-enterostomy. In the absence of actual cancerous conditions the
surgical treatment of chronic dilatation is exceedingly satisfactory.

This surgical treatment consists in the application of one at least of
the following expedients:

  1. Local relief of mechanical pyloric obstruction, as by any one of
  the pyloroplastic methods;

  2. Gastroplication, by which the capacity of the stomach is
  materially reduced;

  3. Gastro-enterostomy, by which mechanical obstruction is atoned
  for by a free outlet, provided at a point where gravity as well as
  peristalsis shall assist in completely emptying the viscus.

The methods in vogue a few years ago for opening the stomach and merely
stretching the pyloric outlet have been supplanted by other plastic
operations which have proved more satisfactory because of the greater
permanency of their results.


GASTROPTOSIS.

The downward displacement of the stomach, to which the term
_gastroptosis_ has been given, implies not only more or less actual
dilatation, but also a stretching or lengthening of the upper
attachments and peritoneal folds which should hold the stomach up
in place. When these yield and the stomach is thus permitted to
drop, more or less obstruction of the pylorus and kinking of the
duodenum are apt to occur. The condition regarded surgically is not
essentially different from that of chronic dilatation. When the stomach
is distended with carbon dioxide its normal position may be easily
recognized, while, at the same time, it is determined that it is
perhaps but little dilated.

The causes which lead to this condition, aside from those which affect
the stomach proper, include tight lacing, by which the supporting
viscera are forced downward and the stomach permitted to fall with
them. In addition to such a cause any previous disease by which the
abdominal viscera have been affected or ligaments weakened would be
of more or less effect. The condition leads sooner or later to one
of dilatation, and always merges into it. Its symptoms are those of
dilatation, only in milder degree. On account of the dragging upon the
upper supports patients frequently complain of intense lumbago, and
they nearly always become neurasthenic.


=Treatment.=--The ordinary routine treatment failing to give relief,
one may, in mild cases, adopt an external mechanical treatment,
consisting of a suitable abdominal bandage which should press the
viscera up from beneath, and thus relieve splanchnic congestion and
weight.

Mechanical support failing and symptoms persisting, the surgeon is
able to afford relief by _gastropexy_, first suggested by Duret, and
consisting of an exposure of the stomach through the middle line and
its fixation to the anterior abdominal wall. This, however, has its
theoretical disadvantages, since it might be followed by symptoms
similar to those resulting from pathological adhesions. The method
has been more or less modified, sutures being passed through the
gastrohepatic omentum and gastrophrenic ligament in such a way as to
bring them into close contact and looking to their complete union.
Thus, Beyer, of Philadelphia, has reported four cases apparently
successfully operated upon in this fashion. Bier has added four others,
all of which seem to afford much encouragement to operative treatment
of gastroptosis. Furthermore, Coffey has modified the technique in such
a way as to include a sort of suspension of the stomach by making a
hammock out of the great omentum. He did this by stitching the omentum
to the abdominal peritoneum, about one inch above the umbilicus, with a
transverse row of sutures about one inch apart.


GASTRIC TETANY.

Gastric tetany has but relatively small interest for the surgeon,
save as it may complicate some of his results or prevent his endeavor
to secure them. The condition is usually characterized by peculiar,
disturbed sensation in the extremities, with a feeling of coldness or
numbness in the limbs, and drowsiness, vertigo, and disproportionate
weakness after exercise. Somewhat severe attacks are sometimes
precipitated by lavage, and are then begun with a complaint of
formication, followed by tetanic contraction of the muscles of the
extremities. Instead of tonic spasm the muscles may be in more or less
constant motion. The muscles of the face, neck, and abdomen are also
involved. The facial expression changes, and patients may complain of
loss of vision. During these paroxysms they may even mutter or speak
unintelligibly. Chvostek some time ago showed how to produce these
spasms, when the condition is present, by tapping over the facial
nerve just at its exit from the cranium, and Trousseau demonstrated
that during the attack the paroxysms may be produced at will by
compressing the affected parts in such a way as to impede venous or
arterial circulation through them. Some of these spasmodic attacks are
accompanied by severe pain, while spasm is usually made less painful
by gently yet forcibly overcoming it by pressure. The condition is
essentially toxic, usually autotoxic, and yet, inasmuch as it may
complicate the best efforts of the surgeon or complicate the case
upon which he would wish to operate, it is deserving of this brief
description here, largely in order that it may not be mistaken for true
tetanus or be misinterpreted in any other way.


CARDIOSPASM.

This is a term recently suggested by Mikulicz for a peculiar
contraction of the lower end of the esophagus and the cardiac orifice
of the stomach, which is occasionally met with, and until fully
described by him was somewhat misunderstood. In consequence of the
spasmodic stricture thus produced there occurs dilatation of the
esophagus above and formation of a sac, which may be discovered by the
bougie or tube, or by a good radiogram, after having been filled with
a weak bismuth emulsion. Such sacculation had always been previously
regarded as due to esophageal diverticulum, which it greatly simulates
at first and in time practically becomes. It is due either to primary
and unexplained spasm of the muscular coat at this level, or to a
primary atony for the esophageal muscle above the stricture. It has
been ascribed also to paralysis of the circular fibers and spasm of the
cardia, due to vagus involvement and to primary esophagitis. The view
that it is of congenital origin can scarcely be sustained.


=Symptoms.=--The symptoms and signs produced are not widely different
from those of a capacious diverticulum. It is difficult, often
impossible, to pass a stomach tube into the stomach, it being diverted
into the upper cavity. The patient moreover, vomits material which
is undigested and more or less putrefactive, and, at the same time,
without evidences of actual stomach disease. Such a sac may hold even
two pints, and thus it will be seen how much material may be vomited
or washed out by lavage which, at the same time, never entered the
stomach. Should it be possible to enter the stomach the two sets of
contents will be found quite different.


=Treatment.=--While more or less benefit and relief may be obtained
from frequent washing of the abdominal sac thus produced the real cure
will only come, as shown by Mikulicz, from opening of the stomach and
dilatation of its constricted upper orifice.


PYLORIC STENOSIS.

Reduction in caliber of the pyloric opening, amounting in extreme cases
to absolute closure, may be met with at various ages and following
various conditions.

A congenital stenosis has been observed, although very infrequently.[54]

  [54] Fiske (Annals of Surgery, July, 1906) states that there are at
  present on record 121 cases of hypertrophic stenosis of the pylorus
  in infants. The three theories advanced to account for the condition
  as occurring before birth presuppose either a true malformation
  with muscular hypertrophy, a secondary hypertrophy due to prenatal
  pyloric spasm, or a spastic condition of the pyloric region without
  definite gross anatomical lesion. None of these theories satisfies
  the condition in any but a small proportion of cases, although
  either of them doubtless is or may be correct in certain instances;
  71 of these cases have now been operated upon, of which 33 died,
  gastro-enterostomy giving 57 per cent. of recoveries and pyloroplasty
  54 percent.

_Pyloric constriction following cicatricial contraction of healed
ulcers_ is perhaps the most common non-malignant form. This rarely
proceeds to absolute closure, but is frequently sufficient to lead to
dilatation.

Conversely any condition of the stomach which drags it out of shape and
leads to kink or abrupt angulation near the pylorus may lead to early
postural and later to actual structural contraction.

The pressure or alteration of shape produced by neoplasms, either
within the substance of the stomach or more frequently without, will
cause more or less irregular contraction of the pyloric end amounting
to pyloric stricture.

By _old adhesions_ similar conditions are produced, while a definite
form of _spastic contraction_, corresponding much to cardiospasm just
described, will cause more or less pyloric obstruction.

Finally _malignant tumors_ involving the pyloric region invariably
spread to the pyloric ring, and not only infiltrate it but cause it to
become inflexible and diminished in size, to a degree finally amounting
to almost complete or to absolute obstruction.


=Symptoms.=--No matter what the cause the symptoms are essentially
the same, in that they produce dilatation of the stomach and frequent
vomiting. According to the cause there will also be a history of
pain and hemorrhage, suggesting ulcer, or of biliary colic, denoting
perigastric adhesions, or of pancreatic disease, accounting for
adhesion of the duodenum and displacement of the pylorus. The discovery
of tumor or the results of examination of stomach contents may also
suggest or corroborate the diagnosis of cancer.

The essential feature being the failure of the gastric contents to
pass onward into the bowel, and their accumulation in the stomach or
rejection by vomiting, the condition will be seen to have a purely
mechanical as well as a pathological aspect. The case, therefore,
must be extreme in which a mechanical remedy will not afford at least
temporary relief.


=Surgical Treatment.=--This remedy obviously is either to overcome
the stricture by dilatation, or plastic operation upon the region
involved, or to form a new opening by which the stomach shall connect
with the upper intestine--_i. e._, _gastro-enterostomy_. The latter
has gradually supplanted the former in the choice and in the hands of
most surgeons, although occasionally a case may be met which invites
the performance of a pyloroplasty, by either the Heinecke-Mikulicz or
the Finney operations, which will be described later. In the absence of
malignant disease few serious operations give more satisfactory results
than do these.


GASTRIC ULCER.

During the past few years the studies of internists, of pathologists,
and of surgeons have all served to show that _gastric ulcer_ in any
form is a more common lesion than was suspected by the previous
generation. At first it nearly always comes under the care of the
internist, but too often, becoming chronic, it is too long continued
under his care until a serious, perhaps almost fatal, hemorrhage makes
operative relief more dangerous, if not impossible, or until a chronic
ulcer has degenerated into a cancer, and this is permitted to go on
until the patient pays with his life the penalty for such inattention.

_Ulcers in the gastric mucosa_ vary from a simple _fissure_ (such as
may be seen in the mucosa of the lip or the anus) to extensive and
deep ulcerations, which weaken the stomach structure in spite of
protective infiltration and even adhesions, until a final perforation
may terminate the case, either by hemorrhage or septic peritonitis.
While surgical teaching has of late pointed more and more definitely to
the importance of ulcers resulting from simple erosions, or apparently
mere abrasions which have not been appreciated, most pathologists and
surgeons fail to realize that even from so trifling a surface alarming
hemorrhages may occur. Such lesions appear upon the postmortem table
to be minute and unimportant, but, occurring during life, they have an
importance of their own.

Gastric ulcers, then, should be referred to as _erosions_, as _simple
or complicated ulcers_, and as _ulcerating cancers_, in addition to
which there may be mentioned the rare lesions produced by tuberculosis
and syphilis. These ulcers are always to be regarded seriously,
because in their milder expressions they cause pain and various forms
of dyspepsia and indigestion, while their more serious consequences
include hemorrhage, which may be fatal, and perforation, which is
essentially so unless surgical intervention be prompt and complete.


=Symptoms.=--The symptoms and discomforts which they produce include
_pain_, which is nearly always most pronounced within a short time
after the ingestion of food, and which may be accompanied by local
tenderness more or less constant. As the case progresses, with the pain
usually comes vomiting, by which the former is relieved, the vomitus
nearly always containing excess of hydrochloric acid and sometimes
fresh or old blood. The pain of gastric ulcer is usually referred
to the back. The indigestion and the frequent vomiting together are
sufficient to produce a well-marked anemia, which is more pronounced
when much blood is lost. Blood may not be vomited but escape into
the duodenum, and will then give to the stools a tarry character,
which should always be looked for and identified when discovered. The
greater the loss of blood in either direction the more pronounced will
be the anemia. _Pain_, _vomiting_, and evidence of _loss of blood_
constitute the most distinctive features of gastric ulcer. When these
are accompanied by tenderness in the epigastrium, and by pain in the
back, the diagnosis is almost complete. In the more chronic cases there
may have already occurred contraction of the pylorus and consequent
dilatation of the stomach. Thus symptoms of the latter may be added to
those of the previous condition.[55]

  [55] In doubtful cases accompanied by pain it will sometimes be of
  value to try the effect of orthoform in ¹⁄₂ Gm. doses, to see if it
  will relieve it. This remedy will not anesthetize nerve endings which
  are protected by skin or mucous membrane. The fact, then, that it
  affords relief implies an ulcerated or exposed area.

The two ever-present and alarming _dangers_ are those of _hemorrhage_
and _perforation_. Serious hemorrhage permits the escape by the mouth
of large quantities of bright, fresh blood, with a corresponding
degree of shock or collapse, and depression. Perforation is indicated
by sudden onset of intense pain, with collapse, rapidly spreading
tenderness, with abdominal rigidity and increasing distention. In other
words the _symptoms of perforation are those of acute local peritonitis
of abrupt origin_.

In either of these events the paramount indication is for prompt
intervention, unless the patient is already too weak to withstand
the shock of any operation. In one case this will consist of
gastro-enterostomy, with or without a gastrotomy for the purpose
of discovering the bleeding vessel and making local hemostasis. In
the other it will consist of free incision, complete toilet of the
peritoneum, with removal of all escaped material, and local attention
to the site of the perforation, doing there whatever may be needed.


=Treatment.=--Should the surgeon see a case of gastric hemorrhage due
to ulcer after the apparent cessation of the active loss of blood he
may easily decide to wait for a few days until the patient has in
some degree recovered strength and atoned for such loss. On the other
hand if he see the case during its active stage he need not hesitate
to open the abdomen, withdraw the stomach, open it sufficiently for
exploration, and then attack the source of hemorrhage, be it large
or small, in such manner as he may see fit--either with the actual
cautery, with a sharp spoon, with complete excision of the ulcerated
area and union of its borders by suture, or by merely including a
bleeding vessel in a loop of suture, addressing himself at once to
the formation of an anastomosis, preferably posterior, between the
stomach and the uppermost loop of the small intestine. This procedure,
which is wise in all instances, would be imperative in nearly all save
those perhaps where an ulcerated area could be cleanly excised and its
margins neatly sutured. Should it prove that suture of the stomach
wall were impracticable its edges might be fastened to those of the
abdominal wound, a gastrostomy thus resulting, which could be later
closed by another operation.

_For perforation_ the surgeon might have to rely, in emergency, on a
gastro-enterostomy as a relief opening, accompanied by local gauze
tamponage; the point of perforation could not be made accessible
for suture, but one should prefer suture for all cases that permit
of it. In these cases a considerable margin should be enfolded and
included within the grasp of the suture, or else the margins should be
completely excised until healthy tissue is reached. In rare instances
it has been feasible to fit into a perforation a drainage tube, or
to pack about it a gauze strip which should conduct from the stomach
cavity directly to the abdominal wound. The question of _excision of
the entire ulcerated area_ should rest entirely upon the possibility of
repairing the defect by sutures, and this will depend in large degree
upon the location of the ulcer and the freedom with which the stomach
can be manipulated, especially with which it can be withdrawn into the
wound.

Practically every case of perforation thus operated will demand
posterior as well as anterior drainage. Aside from the treatment
of the stomach itself the general peritoneal cavity needs the same
thoroughness of cleansing and the same care in every manipulation that
would be given in a case of well-marked peritonitis already established.


GASTRIC FISTULAS.

This term has reference especially to _external fistulous openings_,
which are an exceeding rarity save as relics of injury or of operation.
They have been known to occur spontaneously by perforation of an
ulcerated and adherent stomach, such perforations occurring either
in direct line or irregularly in the direction of least resistance.
_Traumatic fistulas_ result usually from gunshot or stab wounds, or are
due to incomplete union of an opening deliberately made. In any event
they permit of the escape of more or less of the stomach contents.
Their tendency is usually toward spontaneous repair, but this is often
so slow or so incomplete that it needs to be hastened by stimulation of
the fistulous tract with silver nitrate, the actual cautery, curetting,
or by a complete resection of the entire tissue involved, and a neat
reunion with suture.

_Intra-abdominal gastric fistulas_ result usually from perforation of
gallstones or the escape of foreign bodies. Produced in this way they
empty usually, though not always, into some neighboring portion of the
intestinal canal.


TUMORS OF THE STOMACH.

_Benign tumors_ are occasionally found in the stomach, and are most
often of the adenomatous type. Papillomatous growths into the stomach
have also been observed. Beneath the peritoneum, or in the submucous
tissue near the pylorus, fatty tumors have also been seen. Myomas of
mixed type have been described, and cysts have been met in the walls
of the stomach. These have rarely attained a size larger than a hen’s
egg. All of these non-malignant tumors are of pathological rather than
surgical interest. Every one of them, however, will admit of successful
surgical remedy when once recognized, operation consisting of excision,
with suitable suturing.


CANCER OF THE STOMACH.

_Carcinoma_ is perhaps as frequently seen in the stomach as in any part
of the body, the breast possibly excepted. In about three-fifths of the
cases it involves the pyloric region, in one-tenth of them the cardiac
end, the balance occurring in the intermediate part. It is usually of
the round-cell or scirrhous variety, and is generally supposed to be a
disease of adult or advanced life. While this is generally true there
have been exceptions. It is occasionally met in the young, and has
been reported even in early childhood. True sarcoma of the stomach is
exceedingly rare. It spreads especially in the submucous tissue and
evinces a tendency to involve especially the lesser curvature.

The duodenum evinces an extraordinary immunity from malignant disease,
even that involving the pyloric region. When the pyloric end is
involved the lesion is frequently complicated by adhesions, which are
present in considerably more than half of the cases. The lymph nodes
of the adjoining mesentery are nearly always involved, practically
always in cases which come to the surgeon for operation. As the disease
advances it spreads in several directions, and adjoining viscera may
be involved, or even those at considerable distance, while metastases
to other parts of the body are common. It is somewhat more common in
males than females. In proportion as the pyloric ring itself becomes
infiltrated and involved pyloric obstruction is an early feature, with
the inevitable gastric dilatation and greater frequency of vomiting.
Pathologists and surgeons are learning that the _most frequent cause
of gastric cancer is gastric ulcer_, and recent investigations are
to the effect that in at least 80 per cent. of cases there has been
ulceration which has been followed by this malignant change. This
affords additional reason, then, for regarding gastric ulcer as a
surgical disease and operating upon it early and before such transition
has occurred.


=Symptoms.=--As repeatedly emphasized throughout this work _cancer is
a disease without a pathognomonic symptomatology_. For this reason it
is rarely diagnosticated in its early stage, the symptoms which it
produces being those of indigestion or dyspepsia.

The most _distinctive features_ met with in gastric cancer are _pain_,
_vomiting_, more or less _dilatation_, and presence of _tumor_. _Pain_
is an early and constant symptom, the complaint at first being of
heaviness and oppression, made worse after the ingestion of food, and
later referred to as actual pain, which may be limited or may radiate
to either side or to the back. Much will depend upon whether the cancer
develop from the site of a previous gastric ulcer or independently.

Individual complaints are variant regarding the intensity and reference
of this pain. In large measure it is due to the formation of adhesions,
and its reference will depend much upon their location.

_Vomiting_ is an equally constant and perhaps even more important
symptom, being met in nine-tenths of the cases. When the growth
involves the pyloric end the vomitus is copious in amount, while the
intervals between attacks of vomiting are relatively long. When the
more central areas of the stomach are affected and its capacity is
thus reduced vomiting is more frequent, usually following soon after
taking of food, and the amount of vomitus is consequently less. In
general the character of the vomited material depends upon the length
of time it has been retained, upon the possible presence of bile or
blood, the presence of small amounts of blood giving to it a somewhat
characteristic appearance, indicated by the term “coffee-grounds.” As
the ulceration proceeds the amount of blood may be increased, and it
may even come up fresh and red. The degree of actual ulceration will be
indicated by the odor and the more or less putrefactive character of
the materials ejected.

Too much reliance has been placed upon examination of the stomach
contents. The amount of hydrochloric acid present therein depends in
large measure upon the area involved. The same is true of pepsin. The
glands which produce these digestive materials are found especially
in the more central area, and when this is involved their amounts
will be much reduced, whereas as long as these are free they are not
necessarily so affected. The presence or absence, then, of hydrochloric
acid may prove most misleading. The Oppler-Boas bacilli are perhaps
of more significance, but even here the surgeon is often deceived. I
regret thus to appear to belittle the significance of features upon
which internists place so much reliance, but I have so frequently seen
their unreliability that I think it is a sad error to wait for weeks
in order to make a diagnosis by means of material secured through a
stomach tube.

McCosh believes that for diagnostic purposes the stagnation test
is of greater value than any examination of stomach contents. This
consists simply in the discovery by lavage of food within the stomach
when it should have left it. Thus an ordinary meal should pass out
of the stomach within five hours, but if after six hours undigested
food still remains there it denotes sluggishness of digestion. Food
remaining ten hours makes positive the fact of stagnation. This being
once established it should be determined whether it is from atony,
spasm, pyloric stenosis, peritoneal adhesions which kink the opening,
or cancer. In all of these except the first, surgical intervention is
necessary.

_Tumor in the stomach region_, in connection with symptoms already
mentioned, is corroborative. In nearly every case it can be felt sooner
or later. Too many have waited, however, for this corroborative symptom
before considering the case a surgical one, or even one of unmistakable
cancer. Anyone can make a diagnosis when he can discover the tumor.
What is needed is recognition of the condition before it has advanced
to that stage. When it escapes detection it is usually because it is
situated in the posterior stomach wall, high up, or else because the
abdomen is enormously fat. The tumor when felt will be found firm and
usually tender, sometimes regular in outline, sometimes quite the
reverse, usually movable, but occasionally firmly attached either
to the abdominal wall or to the viscera, usually the liver. Such a
tumor, changing its position with the change in shape of the stomach
produced by its inflation with carbonic dioxide, may be regarded as
almost certainly a cancer of this organ. One rarely detects lymphatic
involvement through the abdominal wall, but in many instances it may be
noted at the root of the neck. The tumor usually rises or falls with
respiration. Occasionally it will not be discovered until the stomach
has been washed out and completely emptied.

However, further aids to diagnosis may be furnished, for instance,
by the discovery of cancer cells in the vomitus or washings, by the
presence of adventitious materials, such as lactic acid, whose especial
significance is rather that of stagnation and motor paresis.

It is of great importance, when possible, to decide as between ulcer
and actual cancer. In general the following aids to diagnosis may be
considered: Ulcer is a disease of the earlier years of life, cancer
rather of the later; in ulcer the pain is direct and boring (extending
to the back), in cancer it may be widely referred to the shoulders;
in ulcer the vomited blood is usually fresh, in cancer it furnishes
the so-called “coffee-grounds;” in ulcer there is ordinarily no tumor
present, in cancer this is a late but sure sign; the history of a case
of ulcer will often be a long one, that of a case of cancer is rarely
long, but steadily progressive; in ulcer there may be distinct anemia,
whereas in cancer it assumes rather the type of a peculiar cachexia;
and the free hydrochloric acid which is increased in ulcer is usually
diminished or absent in cancer.[56]

  [56] Sahli has suggested what he calls a _desmoid test_ for free
  hydrochloric acid. A small amount of methylene blue is enclosed
  in a small gutta-percha bag, and this is tied by means of a small
  strand of raw catgut. This catgut will not be affected by pancreatic
  juices, and will only dissolve in the stomach in case there be
  free hydrochloric acid present. The fact of its solution and the
  liberation of the methylene blue is made evident by the peculiar
  color given to the urine in a short time. If, therefore, this appears
  within an hour or so after the material has been swallowed one maybe
  sure there is free hydrochloric acid present in the stomach. The test
  is not absolutely accurate, but will often serve as a fairly reliable
  one and a substitute for the more disagreeable and ponderous method
  of a test meal and lavage. In some respects it is perhaps even more
  reliable.

_The question in cases of gastric ulcers is whether they have yet
advanced to actual malignancy._ Probably no surgeon has ever attacked
a case of gastric cancer which has not been under treatment for a time
for so-called “dyspepsia or indigestion,” perhaps with a more definite
diagnosis. Too many internists have waited for the discovery of a tumor
before thinking of surgery. It is the business and the duty of every
surgeon to impress upon the profession that _the only way to treat
cancer successfully is to treat it radically, and the only way to do
this is to operate early_. This applies equally well to the viscera or
to the external portions of the body. _Gastric cancer is essentially
a surgical disease_, and could it be recognized early and treated
radically it could often be cured.

What are we to do then in the absence of early and indicative symptoms?
The following rule may be laid down as one to which there is no
exception: _A well-founded suspicion of cancer of the stomach (or of
any part of the alimentary canal) justifies an exploratory operation
for its detection and recognition, which then should be extended into
an operation for its complete removal should circumstances justify
it_. If this rule were followed we would not hear of cases of this
description remaining for months or years under drug treatment, and
then perhaps being finally turned over to the surgeon for relief of
pyloric obstruction at a period when strength is so reduced that no
operation should be seriously considered.

_Gastric cancer is, then, at least in its earlier stages, a surgical
disease._ How is it to be recognized? By exploratory incision when
there is serious doubt as to the nature of dyspepsia or indigestion
which fails to promptly improve under suitable treatment. In
an early stage even this might not be easy, especially for the
inexperienced. Nevertheless any cancer of the stomach which produces
distinct disturbances of digestion will have advanced to a degree of
infiltration and thickening which will permit of its recognition by
the touch of a practised operator. The discovery, then, of thickening
in the stomach wall will imply the presence therein of either an
ulcerated or cancerous area, which will in either event demand relief.
In such a case the stomach may be opened and the mucosa exposed to
sight and touch. Should the lesion prove to be malignant the same
rule will apply with greater force, with the sole difference that the
area should be much larger and that the surgeon should keep clear of
suspicious tissue. This may necessitate a more or less complete removal
of a considerable portion of the stomach. The greatest care should be
exercised in the discovery and removal of all infected _lymph nodes_,
which will be found especially along the curvatures and within the
peritoneal fold. When retroperitoneal lymph involvement is discovered
a hopeless aspect is put upon the case. Life may be prolonged for two
or three years, even under such circumstances, and the patient is
certainly entitled to whatever can be afforded him. If the cancerous
process has advanced to a point or a degree making radical removal
impossible, one may at once select the other alternative and perform
a gastro-enterostomy at a point of election, by which relief may be
afforded for at least a number of months.

Only by exploration, then, can it be decided whether to attempt a
radical measure or a palliative procedure. It is scarcely fair to
quote statistics in this regard, especially any but the most recent,
as only lately have these cases been referred for early operation.
Obviously the less wide the removal the less reduced the patient, the
more favorable is his condition to withstand operation, and the more
favorable the aspect of his case. Thus pylorectomy before gastric
dilatation has occurred is more promising than pylorectomy when half
the stomach is involved. In proportion, then, as these cases are
submitted to early operation, statistics will improve and better
results be attained, while if physicians and surgeons can be made to
_coöperate early_ an ever-growing number of cases will be seen and
operated at a favorable time.

The various operations practised, including gastrectomy, pylorectomy,
etc., will be discussed with the other operations upon the stomach.


PERIGASTRITIS.

To this term attaches about the same force and significance as to
perihepatitis or perisplenitis. The expression implies the consequences
of a _local peritonitis_, usually of low grade, by which adhesions
are produced that may anchor the stomach in whole or in part, in any
possible direction and to any of the surrounding viscera or part of
the abdominal wall. Such adhesions are more common at the pyloric end
than elsewhere. Their causes may be intrinsic or extrinsic, among the
former ulceration and cancer being by far the more common; among the
latter gallstones, tuberculous processes, and occasionally the remote
consequences of typhoid ulceration. In the majority of cases the
adhesions thus produced are protective and purposive, although they
often constitute a serious obstacle to surgical work. While they may be
suspected in almost any of the conditions above named, they are rarely
discovered or identified until the abdomen is opened. Nevertheless,
distention of the stomach with gas and the discovery of its irregular
movements or shape because of fixation will afford good ground for
suspicion as to the condition itself. When it can be shown that
these adhesions are producing pain or discomfort, as they often do,
operation, _gastrolysis_, affords the only legitimate and reasonably
certain relief. Time sometimes permits a stretching of adhesions or the
possible absorption and amelioration of symptoms, but only by surgical
intervention can anything radical or prompt be offered.


PHLEGMONOUS GASTRITIS.

Under this term is included a _suppurative or necrotic inflammation of
the stomach wall_, beginning probably in the submucosa, but extending
in both directions. It appears in two forms--the circumscribed and
diffuse.


=Symptoms.=--The symptoms of the latter are those of an intensely acute
gastritis with rapid, almost inevitably fatal course, beginning with
severe pain, quickly followed by faintness and collapse, with early
vomiting, vomited matter being first bile-stained, then containing
blood. The sensation of nausea is extreme and a complaint of thirst
constant. Frequently there are hiccough and peculiar and uncontrollable
general restlessness. Pain is, however, a variable feature, and some
cases are too rapidly necrotic to afford much pain or tenderness. The
pulse is rapid, weak, and poor, and the temperature usually runs high.
After a short time the abdomen may be much distended, while symptoms of
paralytic ileus (_i. e._, obstruction), supervene, though occasionally
there is offensive diarrhea. A well-marked case of this type comes on
with fulminating suddenness, patients later becoming apathetic and
dying in stupor.

About all this there is nothing peculiarly characteristic, and similar
symptoms might be caused by mesenteric thrombus, by acute pancreatitis,
or acute gangrenous cholecystitis.

_Symptoms of the more circumscribed form_ are similar to those just
described, but of less severity. The pain and vomiting appear suddenly,
but are less intense. If time be afforded for formation of abscess a
distinct tumor may be felt. Appetite is lost and food regurgitated.
A localized lesion favorably placed might lead to adhesions and
circumscribed collection of pus, assuming the subphrenic or some less
typical form. The pyloric end of the stomach is more commonly involved
in such a process and affords evidence to the effect that it begins as
an infection, the port of entry being usually a gastric ulcer.


=Treatment.=--Treatment would be surgical if any were available,
but has never yet been applied sufficiently early to save an acute,
generalized case. On the other hand, when the lesion has been local and
has led to subsequent phlegmon, cases have been successfully opened and
drained.


OPERATIONS UPON THE STOMACH.

In every instance, when time is afforded, certain preparations should
have been made by which the stomach has been put in an aseptic
condition. Not only should it be emptied of food in the ordinary
sense, but it should have been washed out at least once, and in most
instances repeatedly, first with cleansing lavage and then with a
fluid containing a small proportion of borax, with the intent that by
a mildly alkaline solution its contained mucus may be more thoroughly
washed away. This alone, however, is not sufficient, for quantities
of septic material may be introduced by the patient from his nose
and throat. Frequent use of the toothbrush, with a strong antiseptic
powder or solution, and frequent rinsing of the mouth with a suitable
antiseptic mouth-wash, should be practised at frequent intervals for
two or three days before such an operation. If offensive mucus be
dropping from the nasopharynx this also should be cleansed and sprayed.
In other words the possibility of contamination from the nose and mouth
should be prevented as completely as possible.[57]

  [57] The first deliberate operation upon the stomach seems to have
  been that by Crolius, in 1602, for removal of a knife, and a similar
  operation was made eleven years later by Günther. Up to 1887,
  however, only thirteen such gastrotomies had been reported. The first
  unsuccessful gastrotomy was done by Sédillot in 1839; the first
  successful one by Jones, thirty-five years later. While pylorectomy
  was suggested by Merrien in 1810, it was not actually performed until
  1879 by Péan. Gastro-enterostomy was first done by Wölfler in 1881.
  The first operation for hemorrhage from gastric ulcer was performed
  by Mikulicz in 1889. It will thus be seen how recent is the whole
  matter of modern surgical attack upon the stomach.


=Operation for Penetrating Wounds.=--When the stomach has been opened
by gunshot, stab, or other wounds it should be closed at the earliest
possible moment. The operation intended for this purpose may be simple
or difficult, and may be complicated by the fact of injuries to other
organs. A simple opening is easily closed, when exposed, by sutures,
of which there should be at least a double row, the internal devoted
entirely to the mucosa, whose edges should be brought together and
held by a continuous chromicized catgut suture, with stitches at
intervals sufficiently short to prevent the possibility of hemorrhage,
and interrupted occasionally to prevent puckering. A second row of
sutures, of fine silk or thread, is then applied, by which the serous
and muscular coats are firmly approximated, care being taken that
the needle is not allowed to perforate a vessel and thus produce
hemorrhage. The stomach walls are so thick that two layers of sutures
thus applied usually suffice. If thought advisable a third suture may
be applied after the manner of the second. A round needle is usually
preferable to a flat one with cutting edges.

Great care should be maintained to _prevent escape of stomach contents
or infection of the peritoneal cavity_, if this has not already
occurred. In some cases after exposing the stomach wound it may be
advisable to pass a stomach tube and wash out the stomach, holding the
wound with a compress in order that no leakage at this point can occur.
Unless there is some good reason for not doing this it should be the
method of choice. Two dangers particularly characterize cases requiring
_gastrorrhaphy_: the first that of assuming that there is but one wound
and failing to discover others which may co-exist; the second that of
infection by the stomach contents which have already escaped. The first
is to be avoided by careful observation and examination; the second by
a careful toilet of the peritoneum, both before and after suturing.
Drainage may be provided according to the necessities of the case.

A _gunshot wound_ produces more or less contusion of the tissues in
its immediate vicinity. Liberal allowances should then be made in
suturing that gangrene and subsequent perforation may not occur; or,
better still, when it can be properly done, the margins of gunshot
wounds should be smoothly excised and fresh clean surfaces thus brought
together.


=Gastrotomy.=--The stomach is opened for purposes of _exploration_ or
_for removal of foreign bodies_, as may be needed, and then promptly
and completely closed when the opening has permitted such diagnosis or
removal, or after a diseased area in its interior has been exposed by
incision. Such may be the procedure in certain cases of gastric ulcer,
where the stomach is opened, its entire lining examined and the sharp
spoon or cautery applied, with or without linear suture. The stomach is
also opened for dilatation of its orifices as in cases of cardiospasm
or pyloric stenosis, although the latter procedure has given way to
anastomotic methods, which are more permanent in their results.

The stomach having been exposed, usually by a sufficiently long median
incision, it is brought out and divided at a point of election, the
incision being made of sufficient length to permit introduction of
forceps or finger, or even of more or less eversion of its interior
surface in order that it may be carefully inspected. The purposes of
the opening having been achieved, it is closed as indicated above, with
at least two layers of sutures. A perfectly clean wound will scarcely
call for drainage. One which has been infected should be protected in
this way.

Gastrotomy has also been done in order to permit of the retrograde
division of strictures of the esophagus, when it has been impossible
to pass even the smallest bougie from above. In these cases it has
been occasionally possible after exposing the stomach to introduce a
whalebone bougie which, passing upward, may follow the tortuous passage
and be made to appear in the pharynx. To its upper end may then be
attached, by strong silk, the small end of another bougie, and thus
guide it downward as the first one is withdrawn. This procedure has
been improved on by Abbe, who has thus been able to pull down from
the mouth a stout piece of coarse silk, bringing it out through the
stomach opening, and then, by a species of sawing manipulation, divide
the tightest and densest part of an esophageal stricture sufficiently
to permit of the passage of some other instrument. This having been
accomplished the stomach wound is immediately closed.


=Gastrostomy.=--This term implies making an opening into the stomach
by which its cavity may be directly connected with the exterior
abdominal surface, and the communication thus established maintained
indefinitely. The procedure itself is necessary in cases of dense
stricture or malignant disease of the esophagus, or the growth of
such a tumor in its vicinity as shall occlude it, and thus cause slow
starvation unless atoned for in some manner. In one instance recently,
where I expected to do a gastrostomy, because the stomach itself had
been so destroyed by powerful caustic that not only was the esophagus
ruined as such, but the stomach decreased in size and motility, I found
the stomach too immovable to permit of this procedure, and accordingly
utilized the duodenum just beyond the pylorus, thus making essentially
a _duodenostomy_; the indications, however, being the same as for
gastrostomy. We have, in other words, to effect a _permanent gastric
fistula_, the older method being to make the most direct possible
communication between the stomach and the surface of the body, and then
to introduce a tube, or resort to some similar expedient for preventing
cicatricial contraction, and perhaps even subsequent closure. Silver
tubes were formerly used, whose openings were corked and kept closed
when the tube was not in use. In consequence of this foreign body
with the irritation it produced there was always more or less leakage
and discomfort. The more recent methods have been devised with an
intent of making a tunnel rather than a direct opening, through which,
as needed, a soft rubber tube may be introduced, whose walls shall
collapse at other times and close themselves, if necessary, with a
little assistance, by pressure, thus preventing leakage. Sometimes it
is possible to attain this ideal. At other times a rubber tube is worn
a greater part at least of the twenty-four hours.

[Illustration: FIG. 529

Gastrostomy: Witzel’s method. Tube in position; sutures ready to tie.
(Richardson.)]

[Illustration: FIG. 530

Gastrostomy: Witzel’s method. Tube in position; sutures ready to close
abdominal wall. (Richardson.)]

[Illustration: FIG. 531

Gastrostomy by Frank’s method: cone of stomach stitched into the
peritoneal wound. (Richardson.)]

All operative methods include fixation and consequent adhesion of
the anterior stomach wall to the parietal peritoneum, just below the
border of the ribs. Of the many methods employed the following will be
described, most of which can be easily appreciated in diagram:

Figs. 529 and 530 illustrate, for instance, Witzel’s method, where a
sterile, soft rubber catheter is infolded in the stomach wall, and
finally passed into its cavity through the smallest opening that may
suffice for the purpose, after which the outer layer of the stomach
is completely closed over it. The stomach itself is stitched to the
deep margins of the external wound, and these are then closed without
drainage. If everything has been neatly done feeding may be begun
within a few hours. Care should be exercised about passing into a
stomach which has long been without much food a quantity which may
disturb it, or of a quality which may distress it. A procedure very
much like Witzel’s is that described by Marwedel, who first sews the
stomach to the abdominal wound after drawing it partly into the wound,
in order to afford sufficient working material, and then infolds the
tube and inserts its lower end through a small opening. This is perhaps
preferable, since the stomach being so fastened up at once there is no
possibility of leakage into the abdomen.

Figs. 531, 532 and 533 illustrate Frank’s method, where the stomach is
pulled up through a sufficiently long incision and drawn out into a
cone, whose apex is then brought out through a second small incision,
parallel to the first and at a distance of an inch or so from it. Here
an actual opening is made into the stomach, while the cone is fastened
to the skin here and to the peritoneum through the other opening,
which is then completely closed. This method cannot be applied to a
contracted stomach.

[Illustration: FIG. 532

Gastrostomy by Frank’s method: cone of stomach pushed through the
second skin incision. (Richardson.)]

[Illustration: FIG. 533

Gastrostomy by Frank’s method: suture of abdominal wound; stomach
stitched in the skin incision. (Richardson.)]


=Cardiospasm.=--Operation for this condition consists essentially in
a gastrotomy as above, the opening being made sufficiently near to
the cardia in order that either with finger or with suitable dilating
instrument passed upward from below, the contracted cardiac orifice
may be stretched, or, if necessary, nicked at several points, and then
forcibly dilated, in this latter procedure great care should be given
that stress be distributed as much as possible. If it be practicable to
introduce any dilating instrument a four-bladed uterine dilator would
probably be ideal for the purpose.


=Operations for Pyloric Stenosis.=--Among the earliest suggestions
of a method of _pylorodiosis_ was that of Loreta, who opened the
stomach near the pyloric end and deliberately introduced through the
constricted pyloric ring a dilating instrument, fashioned much after
the shape of the ordinary glove stretcher, which, in fact, might be
used for such a purpose should emergency require. The operation is
simple and but slightly dangerous, but it was found that strictures
here as elsewhere tend to contract, even after forcible dilatation,
and that the method, while temporarily successful, was but seldom
permanently so. It was applicable only to the cicatricial, _i. e._, the
non-malignant cases.

A _plastic_ method was then suggested independently by Heinecke and
Mikulicz, with which their names are often connected and which is
referred to as _pyloroplasty_. It consists essentially in making
a buttonhole incision in one direction and then closing it in the
opposite, as illustrated in Figs. 534, 535 and 536.

[Illustration: FIG. 534

Linear pyloroplasty. Seat and length of cut. (Richardson.)]

[Illustration: FIG. 535

Linear pyloroplasty. Appearance of cut sutured transversely. Two more
sutures to be applied. (Richardson.)]

[Illustration: FIG. 536

Pyloroplasty. Shape of cut when more than a linear incision is
desirable. (Richardson.)]

When cicatricial tissue is not too dense, and the parts not
infiltrated, it has given satisfactory results. Even here it has been
found to be frequently reduced in size by subsequent contraction, and
the method suggested by Finney is more serviceable.

[Illustration: FIG. 537

Finney’s pyloroplasty: posterior suture. (Bergmann.)]

[Illustration: FIG. 538

Finney’s pyloroplasty: anterior sutures drawn aside; incision made.
(Bergmann.)]

[Illustration: FIG. 539

Finney’s pyloroplasty: posterior suture of mucous membrane. (Bergmann.)]

[Illustration: FIG. 540

Finney’s pyloroplasty: anterior stitches inserted but not tied.
(Bergmann.)]

_Finney’s pyloroplasty_ consists in making an anastomotic opening
between the pyloric end of the stomach and the first part of the
duodenum, and will be best appreciated from the accompanying
illustrations (Figs. 537, 538, 539, 540 and 541).

[Illustration: FIG. 541

Finney’s pyloroplasty: anterior suture completed. (Bergmann.)]

The opening can be made as extensively as desired, and it is not easy
to see how it can be subsequently reduced to a degree disadvantageous
to the patient.

_Gastro-enterostomy_ may be needed in non-malignant cases, because
of fixation and the impossibility of bringing the pyloric end of
the stomach out sufficiently to make operation feasible. It will be
required in cases of cancer when pylorectomy is not indicated. The
method of making gastro-enterostomy will be described later.


=Operations for Dilatation of the Stomach.=--_Gastroplication_ consists
of taking a number of “tucks” in the stomach wall and thus reducing
its capacity. The purpose and the method of the operation will be
appreciated by the accompanying illustrations. These operations are
mainly indicated, however, in the absence of pyloric stenosis, for if a
free opening be afforded from the dilated stomach into the upper bowel
the gastric enlargement will usually be spontaneously reduced (Figs.
542 and 547).

_Gastropexy_ is a term applied to fixation of the stomach to the
anterior abdominal wall. It has been thus stitched up in a few cases
when greatly dilated or depressed into the lower abdomen. Fig.
548 illustrates the method. The stomach has also been suspended
by shortening the gastrohepatic and gastrophrenic ligaments, as
illustrated in Fig. 549.

[Illustration: FIG. 542

Gastroplication. When the threads _a_ _a´_, _b_ _b´_ are drawn up a
fold is formed. (Bircher.)]

[Illustration: FIG. 543

Sectional view to show result of operation.]


=Operations for Gastric Ulcer.=--In dealing surgically with an ulcer of
the stomach the selection has to be made between anastomosis and direct
exposure of the stomach wall with the performance of a gastrotomy
(_i. e._, opening the stomach) and then discovering the site of the
ulcer, either treating it with the actual cautery, the curette, or,
preferably, when this general method is adopted, completely excising
the involved area and bringing the margins of the wound thus made
together with sutures, which over the mucosa only may be of chromic
gut. Should it seem advisable to excise the entire thickness of the
stomach wall it would be better to suture in two layers, making the
external one of thread or silk, while the inner one may be made of
reliable chromic catgut. If this operation be attempted the incision
into the stomach should be made sufficiently large to permit of
thorough exploration. Nothing being found in the anterior wall, the
gastrocolic omentum should be opened and the entire stomach palpated
between the operator’s hands. Any suspiciously indurated spot on
the posterior wall may then be so manipulated as to be brought into
view through the anterior opening. Other surgeons besides myself have
noted the occurrence of serious hemorrhage, which, upon exposure, must
have come from small fissures or cracks in the mucous membrane. In
fact the lesion which may furnish a considerable amount of blood may
thus be so small and concealed as to be really difficult of exposure.
However, exploration should be made as thoroughly as possible. The
stomach having been opened and the ulcer found, it should be treated
by one of the above methods. If, on the other hand, nothing be found
the surgeon still has the measure of gastro-enterostomy. Any ulcer,
however, which is threatening perforation can usually be recognized by
the sense of touch alone, corroboration being afforded by inspection.
An ulcer which is recognized and found to be favorably situated may be
completely excised. It has been found, however, that this ideal measure
of local attack gives but little better results than does the general
procedure of gastro-enterostomy, while, on the other hand, it is less
satisfactory in some respects and seems to be an equally if not more
dangerous procedure.

[Illustration: FIG. 544

Surface view of the result.]

[Illustration: FIG. 545

Sectional view of the result when two folds are turned in.]

[Illustration: FIG. 546

Gastroplication. (Brandt.)]

[Illustration: FIG. 547

Sectional view of the result.]

The _rationale_ of making an anastomotic opening between the stomach
and the upper end of the bowel is simply this: that thereby the stomach
is given a degree of physiological rest to which it has long been a
stranger, and that food may pass easily from the stomach into the
upper bowel without irritating or aggravating the ulcerated portion,
which is usually at the pyloric end. It should be understood, then,
that gastro-enterostomy, done for this purpose, is simply a means of
carrying out the universally applicable canon of physiological rest for
diseased organs or surfaces. The operation of making this anastomosis
will be described below.


=Pylorectomy and Gastrectomy.=--A complete removal of the pyloric end
of the stomach is usually referred to as _pylorectomy_, while still
more extensive extirpation of portions of the stomach proper are spoken
of as _gastrectomies_. In a few instances it has been possible to
practically remove the entire stomach, this having first been done by
Schlatter. Such an operation would be spoken of as _total gastrectomy_.
These operations are done almost exclusively for removal of areas
involved in cancerous growth. Obviously the more extensive the growth
the greater the amount of stomach which should be removed. For some
reason as yet unknown cancer of the stomach rarely transgresses the
pyloric ring, and thus the first part of the duodenum usually escapes
involvement, even though the stomach be extensively diseased. All these
operations, therefore, include simply the removal of a part terminating
with the pyloric ring proper. It is seldom necessary to take away any
of the duodenum. Removal of the pylorus may be also applicable in
certain cases of benign strictures, where the mere plastic operations
would seem insufficient, as well as in the cases of ulcers encroaching
upon the pyloric ring itself.

For all of these operations the stomach is exposed through a median
incision, or, if a tumor presents distinctly upon the right side, the
incision may be made even far to the right and near the semilunar
line. Through an opening sufficiently liberal the stomach and the
movable part of the duodenum are withdrawn and carefully examined.
When the pylorus is so fastened by dense adhesions within the abdomen
that it cannot be withdrawn it is best to abstain from this particular
procedure, as the mechanical difficulties too greatly enhance its
dangers. Suitable clamps, whose blades are protected with soft rubber,
are essential in order that the duodenum may be clamped beyond the line
of its division, and that the stomach as well may be fixed between
their blades, for the double purpose of controlling hemorrhage and
preventing escape of contents. The omentum along the involved part of
the stomach should then be carefully tied off, in a series of loops,
before its vessels are cut, and one should take great pains to hunt out
enlarged lymph nodes and include them in the area to be removed, or
else make a separate incision for those that cannot be thus extirpated.
To leave lymph nodes which are perceptibly involved in the cancerous
process is to invite the speediest possible return of the disease,
even though the operation should be successful. The upper and lower
borders of the stomach being thus freed, the surgeon is then at liberty
to cut away all the diseased portion, going at least an inch beyond
the apparent limit of the disease. There will result from any such
operation two divided ends of the alimentary canal, _i. e._, one, that
of the divided stomach, much larger than the other, which is the upper
end of the duodenum.

[Illustration: FIG. 548

Rovsing’s operation for gastroptosis: _V_, stomach; _V_₁, position of
the stomach before operation; _U_, urinary bladder; _N_, right kidney;
_A_, _B_, _C_, silk sutures; _x_, _x_, scarifications. (Bergmann.)]

Two procedures are now open to the surgeon: He may entirely close
each of these openings with sutures and then make a posterior
gastro-enterostomy, making new openings for this purpose, and by the
common method described below, or he may reduce the size of the stomach
opening and endeavor to fit it to that of the duodenum in such a way
as to bring the two openings opposite each other, where they are then
approximated as in ordinary end-to-end resection of the intestine. The
earlier operation of Billroth and his followers was made according to
the latter plan. It has been found usually easier and more successful
to adopt the former method, as it is easier thus to prevent leakage and
consequent infection; that is, the majority of operators would today
probably completely close the stomach and the duodenum, and proceed at
once to make a posterior gastrojejunostomy.

[Illustration: FIG. 549

Suspension of stomach by three rows of interrupted stitches through the
gastrohepatic and gastrophrenic ligaments: 1, 2, 3, single stitches of
the three rows. (Beyea.)]

[Illustration: FIG. 550

Resection of the pylorus. Suture completed. (Richardson.)]

Figs. 550, 551 and 552 give a fair idea of the procedure of end-to-end
reunion. The edges of the mucosa should be united with chromic gut, the
stitches being close to each other, to prevent leakage and to control
hemorrhage from small vessels. The external sutures of silk or thread
should be placed sufficiently deep to afford a strong bond of union,
and, at the same time, to escape the mucosa. Some difficulty is met
here, for the thin wall of the duodenum should be attached to the thick
wall of the stomach, but with care it can be done. When the divided
stomach end has been reduced or trimmed off in such a way as to leave
only a portion to be matched with the duodenal opening, there is need
for extreme care at the corners and angles of the suture margins, as
here tearing of stitches or separation by tension, perhaps during the
act of vomiting, are most likely to occur. Fig. 553 indicates the first
of the procedures above mentioned.

[Illustration: FIG. 551

Resection of the pylorus. This figure illustrates the method of fitting
the duodenum to the stomach when the gap in the stomach is too large to
fit the duodenum. (Richardson.)]

[Illustration: FIG. 552

Resection of the pylorus. (The same as Fig. 551). Suture of the stomach
to the duodenum completed. (Richardson.)]

[Illustration: FIG. 553

Resection of the pylorus according to Billroth’s second method.
(Bergmann.)]

In performing _complete gastrectomy_ the cardiac end of the stomach is
brought down and fitted to the upper end of the divided duodenum, after
removal of the stomach, which will usually be possible under favorable
circumstances, but which exposes the patient to great risks of tearing
apart reunited surfaces by undue tension.


=Gastric Anastomosis.=--This consists in making an anastomotic opening
between the stomach and the uppermost part of the jejunum, the duodenum
proper being too bound down in its course to permit of its utilization
for this purpose. Gastro-enterostomy, then, should be referred to
as _gastrojejunostomy_. In brief, it consists in making an opening
by which the stomach shall empty directly into the upper bowel, and
while, for this purpose, one of the uppermost loops would theoretically
suffice, it has been found that the shorter the loop, _i. e._, the
portion between the duodenum proper and the upper part of the bowel
used for this purpose, the better for the patient.

Gastrojejunostomy is, first of all, referred to as _anterior_ or
_posterior_, according to whether a loop of bowel be brought up in
front of the omentum and around it, and attached to the anterior and
exposed wall of the stomach, or whether the lesser peritoneal cavity
be opened by perforating the omentum behind the colon and below the
stomach, so that the posterior wall of the latter is found, drawn
into the wound, and made accessible and utilized for the purpose. The
anterior operation is the easier of performance, but the posterior is
far preferable in most instances. Should it be found that the posterior
wall of the stomach is far more involved in cancerous infiltration than
the anterior, the anterior operation should be performed.

Simple as is the procedure in theory there are about it one or two
complications which were not at first foreseen. Perhaps the most
important of these is that bile emptied into the duodenum passes
downward until it has an opportunity to escape through the opening
directly into the stomach, usually in the direction of least
resistance. This may then carry it where it is a most undesirable
fluid, and prevent its passage onward into the intestine, where it is
physiologically needed. This circulation of bile has been spoken of
as the “_vicious circle_” and it is the formation of a vicious circle
which has complicated not a few of the anastomotic stomach cases, and
which has engaged the attention of not a few clinicians and operating
surgeons.

The second objection is that the contact of stomach contents with the
mucous membrane at a point below where the bowel is normally prepared
for it, and before intestinal contents have been prepared by bile or
materials alkalinized by this fluid, sometimes leads to the formation
of _ulcer_ just opposite the opening, and this has been referred to
as _peptic ulcer of the jejunum_. This is a possible though not a
frequent complication, but has added weight to the other considerations
regarding the best way of performing anastomosis. Again, it has been
feared that this anastomotic opening would contract in time, or
sometimes completely close. This objection obtains especially with
anastomosis, made with a Murphy button, or its equivalent, and can
rarely be made against the ordinary suture methods. Again, if the
opening in the intestine be made too long the intestine itself may
be narrowed, for too much of the circumference of the bowel may be
taken up in the formation of the anastomosis, and thus there will be
mechanical obstruction with vicious circle.

“Vicious circle” produces symptoms which do not appear until the
lapse of at least three days after the operation. If vomiting should
persist and retain a bilious character it is to be feared that some
complication of this kind has occurred. Under these circumstances when
lavage is practised a large amount of fluid mixed with bile, perhaps
blood, may be returned.

Much depends also on the exact location of the attachment of the
intestinal loop to the stomach. Other difficulties arise from possible
twisting of the loop of small intestine, or its strangulation by being
entangled beneath the bridge of the jejunum, which is always made in
every anastomosis. Again the small intestine may become incarcerated
in an imperfectly closed opening made in the mesocolon. It will thus
be seen that the posterior method has disadvantages which need to be
fully appreciated. On the other hand it has this great advantage, that
it permits of drainage or emptying of the stomach into the jejunum by
gravity, in almost any position which the patient would ordinarily
assume, either sitting or lying. Many operators have devised methods of
preventing formation of the vicious circle.

Fig. 554 illustrates how valves may form which there is no sure
method of preventing. Fig. 555 represents the suggestion of Braun,
to make a second anastomotic opening between the small intestine
above the stomach opening and below it, hoping that in this way bile,
for instance, may pass directly through this opening, which it will
first meet, into the intestine below, and thus not pass on and into
the stomach. Others have divided the loop of jejunum after making
the second anastomosis, in this way planting the efferent portion of
the bowel in the stomach and then planting the afferent portion of
the bowel into the side of the efferent part. This is the so-called
_Y-gastrojejunostomy_. Roux does much the same thing, save that his
method is all carried out behind the colon instead of in front of
it. The principal argument in favor of the use of the Murphy button,
in this procedure, is that vicious circle is less frequent after its
use than after most of the suture methods, all of which would simply
indicate that vicious circle is largely a matter of valve formation,
and that by the time the button is loosened and passed on the danger
period seems to have elapsed, and the current in the new direction to
be well established. Nevertheless the button is now discarded by almost
everyone in favor of the suture.

[Illustration: FIG. 554

Formation of valves in gastro-enterostomy: 1, intestinal valve; 2,
right-sided gastro-intestinal valve. (Bergmann.)]

[Illustration: FIG. 555

Gastro-enterostomy with entero-anastomosis according to Braun.
(Bergmann.)]


=Gastro-enterostomy.=--Artificial anastomotic opening between the
cavity of the stomach and some part of the intestine below is indicated
in a number of conditions, which have been discussed. It is done
mainly, however, for two good reasons: first, to atone for pyloric
stenosis, and, secondly, to give the stomach a more physiological rest
in cases of gastric ulcer, permitting food to pass readily from it into
the jejunum, with a minimum of gastric activity or disturbance. This
particular form of anastomosis is but the application to these viscera
of a general principle, which in various ways, in different parts of
the body, has constituted one of the greatest features in the advance
of modern surgery.

The operation is practised in two ways. In the _anterior_ operation
the highest accessible loop of small intestine is brought up in front
of the omentum, or else the omentum is fenestrated in such a way that
the bowel shall be brought through its window, and then attached to the
anterior wall of the stomach, where the latter is much more accessible.
In this operation there is less handling of the stomach and bowel,
and, in general, it is easier of performance. Nevertheless the bowel
loop itself may become adherent to the abdominal wound and give rise
to pain, or even obstruction simulating the vicious circle. Volvulus
of the jejunum has also followed it. Another objection is that as the
patient gains flesh the weight of the transverse colon and omentum
sometimes causes dragging upon the loop, which may cause serious
trouble. The opening thus made is not where gravity will afford the
best drainage of the stomach, and it is now considered undesirable in
almost all cases save those where one is compelled to its performance,
either by necessity for haste, or because the posterior wall of the
stomach is so involved in cancerous infiltration as to afford no
suitable area for fixation and opening. This method is of use mainly in
dealing with malignant disease.

The _posterior operation_ calls for all the resources of a perfected
technique, and takes longer in performance. Nevertheless when once the
anastomosis is safely effected it is more satisfactory.

The posterior operation alone, therefore, will be described at length
in this place, and only that form of it which discards the anastomotic
loop, the writer quite agreeing with the Mayos, who have had larger
experience with this operation than any other surgeons, and who advise
the direct attachment of the jejunum, as near as possible to the
termination of the duodenum, without further complication by operative
procedure. The direction of active propulsion from the stomach comes
from its pyloric end, the larger end of the stomach being mainly for
storage purposes and having thus a forceful action; consequently
the preferable site for the stomach opening is on a line with the
longitudinal part of the lesser curvature, with its lower end at the
bottom of the stomach. The Mayos have abandoned reversing the jejunum
and now apply it directly to the posterior wall of the stomach from
right to left exactly as it lies under normal conditions, having had
better results with this method than with any other.

In brief the operation is as follows: Incision is made a little to the
right of the median line, the transverse colon is withdrawn by steady
traction to the right and upward, and the mesocolon made to follow
it until the jejunum comes into view. The latter is then grasped at
a distance of three or four inches from its origin. When, now, it is
drawn tight the fold of peritoneum which covers the so-called ligament
of Treitz is demonstrated; this is a small band containing muscle
fibers, having its origin on the transverse mesocolon and extending
down to the beginning of the jejunum, thus acting as a suspensory
ligament. It leads to the base of the vascular arch of the middle
colic artery, and indicates the place where the mesocolon should be
torn through in order to expose the posterior wall of the stomach. At
this point, in the least vascular area which can be discovered, the
mesocolon is first incised and then torn, until a good liberal opening
is made, through which the posterior wall of the stomach is easily
exposed, and, later, drained. It should be forced through this opening
by combined manipulation with one hand introduced above it and gently
urging it through the opening where it presents. It may be easily
identified by its resemblance to its anterior surface in its thickness,
the arrangement of its vessel and the like. The posterior wall alone
is then secured and drawn through the mesocolic window, in such a way
that after the jejunum is attached to it the anastomotic opening can
be made at a point one inch above the greater curvature and ending at
the bottom of the stomach two and a half inches to the left of the
pylorus. This area having been exposed and prepared, a considerable
portion of it is drawn into a pair of specially constructed clamps
(Doyen’s or Moynihan’s), whose blades are usually protected with
rubber. The Mayos prefer to have the handles lying to the right and to
direct the forceps transversely to the body axis. Moynihan prefers to
reverse this direction and make them point to the right shoulder. The
stomach being thus protected, and prevented from slipping by suitable
tightening of the clamps, the jejunum is similarly secured with forceps
lying in a direction parallel to the first, having within their grasp
a portion of the gut extending between points one and a half and three
and a half inches from its origin. If this be properly effected the
left low point of the stomach lies in the grasp of one pair of clamps
and the first part of the jejunum in that of the other, and these
two portions should be easily brought into close contact with each
other. A gauze pad having been placed behind the damps in order to
avoid soiling, should there be any leakage of intestinal contents, the
clamps should now be carefully and attentively held by an assistant,
and their distal ends may even be bound together in such a way that,
after the suturing process has once begun, nothing shall disturb the
perfect contact between the surfaces thus mutually applied. The first
row of sutures, usually of the ordinary continuous type, is made of
silk or thread, the serous and muscular coats being seized and united
over a line some two inches in length, the suture being carefully
secured at either end of this line. Next, with a scalpel, an incision
is made through the serous and muscular coats, parallel to the line
of sutures, at a distance of about one-quarter of an inch, and over a
length a trifle less than that of the line which they occupy. Here the
vessels will bleed freely and forceps may be momentarily used for their
securement. Through the opening thus made the mucous membrane will
prolapse. Moynihan especially has shown that it is not enough to merely
incise this membrane in the same direction as the other coats, but that
a narrow elliptical portion of it should be excised, since it tends
to prolapse. Therefore with knife or scissors a strip of the mucosa,
perhaps a half-inch in width, should be cut away from either surface,
thus widely opening into and exposing the interior respectively of the
stomach and of the gut. Extreme pains should now be given to prevent
both leakage and soiling, and instruments used upon the mucosa should
be discarded after it has been divided and sutured. Now with reliable
chromicized catgut a row of continuous sutures is applied by which all
three coats of both cavities are bound snugly together, the needle
passing through six distinct layers as each stitch is made. These
sutures should be drawn sufficiently and secured at frequent intervals
so as not only to ensure perfect application but sufficient pressure to
prevent hemorrhage when the clamps are released. The lower side having
been first closed the same character of sutures is continued until
the upper margin of the buttonhole-like opening is thus completely
closed. The fourth line of sutures, this time of the same material as
those used in the first, is applied in a similar fashion, and with it
the serous and muscular coats are accurately affixed to each other in
such a way that there can be no leakage. Two or three extra sutures at
either end of the line may be inserted for greater security. The clamps
are now withdrawn, the gauze behind the anastomotic opening is removed,
and it should be found that the smaller bowel is neatly and perfectly
fastened to the posterior stomach wall and that no possibility either
of hemorrhage or of leakage remains. This being accomplished there
remains only to tack the margins of the mesenteric opening to the
posterior wall of the stomach, at a distance sufficient to prevent all
possibility of subsequent constriction or strangulation, after which
the parts are carefully cleansed, restored to the abdomen, the colon
and omentum dropped back and made to cover them, and the abdominal
wound closed as usual. (See Figs. 556, 557 and 558.)

[Illustration: FIG. 556

Anterior wall of stomach grasped by forceps passed through from behind.
(Case of saddle-ulcer of lesser curvature near pylorus.) (Mayo.)]

[Illustration: FIG. 557

Mesocolon lifted and posterior wall of stomach drawn through the
opening made in it. Dotted lines show site of proposed anastomotic
openings. (Mayo.)]

[Illustration: FIG. 558

Stomach and jejunum in the grasp of the large clamps, made ready for
suturing. Small forceps still marking low point of stomach. (Mayo.)]

Such is the operation with suture, which may occupy from thirty to
forty minutes in performance, it takes a little longer than the methods
either with the button or with the elastic ligature, but seems to be
the method generally used. In this method, as stated at the outset, no
special provision is made as against “vicious circle,” because it has
been found that it is seldom that this unpleasant complication ensues.
If, however, the anastomosis with the jejunum has been made at a point
twelve inches or more beyond its beginning, there is a likelihood of
finding that vicious circle will cause later complications, and perhaps
necessitate the performance of a second anastomotic opening in the
small intestine above and below the stomach opening.

Of course all the precautions mentioned previously for prevention of
infection, such as washing out the stomach previous to the operation,
and ensuring both its emptiness and that of the upper bowel, are a part
of these procedures and cannot be safely neglected in any of them.

Many an ingenious device for effecting the same kind of communication
between the stomach and the bowel, or between various parts of the
alimentary canal, has been placed before the profession, though but a
few will be considered more in detail when dealing with the operations
upon the intestines proper. The most prominent of them, and the one
which has found the most lasting favor in the eyes of the profession,
is the _Murphy button_, or some similar expedient, by the use of which
time is economized and the operations in some respects simplified. All
devices of this character, however, depend upon a necrotic process for
their eventual success, as the intent is that parts compressed between
the halves of the button shall first adhere and then slough, the button
falling through the opening thus made and passing on. But to rely
upon a necrotic process is much like relying upon a criminal for the
performance of a serious duty. The button, therefore, has gone out of
general favor for purposes of gastro-enterostomy, although for other
intestinal work it is still frequently used.

McGraw, of Detroit, has devised a different and equally ingenious
method of keeping surfaces in contact with each other until adhesion
shall have occurred, and then effecting a further necrotic process
by which opening shall be finally accomplished. This is the so-called
method with the _elastic ligature_. In many respects it is simplicity
itself, and permits of ready and rapid employment. One needs especially
a round rubber cord, about 2 Mm. in diameter, of the purest gum
obtainable and sufficiently fresh to be reliable. The surfaces to be
united are first approximated by a posterior row of silk or thread
sutures which shall include their outer surfaces. Then a long straight
needle armed with this rubber cord is passed into the intestine and out
again at a distance of from 5 to 10 Cm. An assistant now holding the
intestine, the operator stretches the rubber suture until it is very
thin and then draws it rapidly through the bowel. This same step is
repeated in the opposite direction within the stomach. A strong silk
ligature is next passed across and underneath the rubber between the
latter and the point where the stomach and the intestine are to come
together and a single knot is then made in the rubber after it has been
tightly drawn. Another silk ligature is passed around beyond the ends
of the rubber ligature where they cross and is here securely tied. The
rubber ends thus released are then cut off. The original silk suture
is next continued around in front until the point of its beginning
is reached. In this way the rubber ligature and the parts which it
includes are surrounded with an elongated ring of silk sutures, and
with this the operation is complete. Here it is the continuous pressure
of the elastic suture which first shuts off the circulation and finally
cuts its way through both coats, and permits the communication between
the bowel and the stomach. This method is as applicable to other
portions of the alimentary canal as to the stomach.




CHAPTER XLVIII.

THE SMALL INTESTINES.


CONGENITAL ANOMALIES OF THE SMALL INTESTINES.

The entire intestinal canal is sometimes too short and sometimes fails
to develop sufficiently in caliber, or sections of it may remain
undeveloped. None of these changes have interest or importance for the
surgeon as such, save those which produce acute or chronic obstruction
or conduce to acute inflammatory affections.

_Intestinal diverticula_ are usually of that type described by Meckel
and everywhere known by his name. Aside from these the others usually
met are irregular sacculations or hernial protrusions which may be due
to previous disease or to some congenital anomaly of structure. These
are sometimes seen in multiple form, and in one case recently under my
observation over one hundred of them were found scattered along the
intestinal canal, but, inasmuch as the patient died practically of old
age without a history of serious previous disease, it could not be
ascertained whether the pouches were of congenital or acquired origin.

The genuine Meckel diverticulum is a relic of the tubular structure
which leads from the primitive intestine to the vitelline or yolk sac,
and which should persist until about the end of the second month of
embryonic life. After this time it should be completely obliterated
and disappear. When this does not happen there may result a fecal
fistula at the navel, which is then usually referred to as _persistent
omphalomesenteric duct_, and which implies a continuous passage-way
between the skin and the interior of the bowel.

When the umbilical portion alone persists there results a small cyst on
the posterior side of the navel.

When the intestinal end alone persists a protrusion or sacculation will
remain to mark its site.

The duct may become obliterated and yet fail to disappear, thus
leaving a fibrous cord which represents the original omphalomesenteric
structures and vessels, which will be probably mistaken for an
inflammatory band and may serve as a later cause of acute obstruction.
If such bands lead to the umbilical region their identity may be easily
established.

The presence of Meckel’s diverticulum may cause serious abdominal
mischief. It may become involved in a localized process exactly
as the appendix often does, which may then be referred to as a
_diverticulitis_, where ulceration and perforation may occur. It may
constitute the whole or a portion of the contents of a hernial sac. I
have twice found it in inguinal hernia, once in umbilical hernia, and
by others it has been reported in all the ordinary hernial locations.
Porter has collected from literature 184 cases in which its presence
caused serious abdominal crises. The condition itself is probably
present in at least 1 per cent. of mankind, and is stated by Halsted
to be the cause of intestinal obstruction in 6 per cent. of cases.
In the 184 collected cases above mentioned it caused obstruction in
101. Out of 21 cases of the above collection it was not only found in
the hernial sac, but in all but 1 was shown to be the actual cause
of the trouble. In 5 of these cases the diverticulum was open at the
umbilicus. In such a case if the opening be large the gut wall might
prolapse and thus form a hernia.

Diverticulitis has been repeatedly mistaken for appendicitis, its
symptomatology not being distinctive. Exact diagnosis is seldom
possible before operation.

On general principles, considering their possible dangers, it would
be well to remove all diverticula which are found in the course of
ordinary abdominal operations, whether they appear to be causing
trouble at the time or not.

While the average length of Meckel’s diverticulum is three inches
it may exist as a mere nipple-like projection, or it may be a free
tube attaining a length of several inches. Its attached end is
usually larger than its distal portion and its diameter usually less
than that of the gut from which it arises. It may be provided with
a scanty mesentery or may hang independently. While ordinarily its
distal end is free it may nevertheless be continued as a solid cord
attached, as above mentioned, to the umbilicus. This cord frequently
contracts secondary adhesions, and it is under these conditions that
it most often constricts the bowel by forming a loop within which the
intestine becomes entangled. Free diverticula of sufficient length are
sometimes found tied in a genuine knot in a manner which is absolutely
inexplicable. There are numerous ways by which such a diverticulum may
produce strangulation of the normal bowel; thus, by formation of a ring
in which its own free end projects, in which is later entangled a bowel
loop, or by surrounding the pedicle of an intestinal loop as might a
noose. Again bowel is sometimes tightly drawn over such a diverticular
band, just as a shawl may be thrown over the arm, obstruction following
in the displaced bowel. When much contraction is brought to bear the
gut may be so acutely bent as to become occluded. Finally the bowel at
the point of origin of the diverticulum may undergo gross structural
changes, the result of long-continued traction, which may lead to
cicatricial narrowing. More indirectly diverticula seem in some unknown
way to predispose to intussusception at their point of origin, or
they have been found inflated and hanging from the intestine after
obstructing it (Fig. 559).

[Illustration: FIG. 559

Meckel’s diverticulum still attached at the umbilicus and producing
obstruction. (Lejars.)]


ACQUIRED MALFORMATIONS OF THE SMALL INTESTINE.

Of acquired malformations of the small intestine we have mainly to
deal with those which are produced by injury or disease. Among the
former would be the results of violent contusions or of any of the
lacerated, incised, or gunshot wounds to which the bowel is so often
exposed. Should recovery ensue cicatricial contraction is likely
to result. On the other hand, such previous disease conditions as
ulcerations--tuberculous or typhoidal--or the so-called chronic
catarrhal or malignant, may in one way or another occlude and thus
finally obstruct the lumen of the bowel. Distention diverticula may
also result, which correspond to the traction diverticula of the
esophagus already described.


WOUNDS OF THE SMALL INTESTINE.

The small bowel, like the larger or the stomach, may be ruptured in
consequence of abdominal contusions, the condition depending on the
nature of the injury, the degree of fulness of the bowel itself,
and other obvious causes. This character of injury has been already
sufficiently considered in dealing with rupture of the stomach. Their
symptoms are not essentially different, neither are the principles of
ordinary surgical treatment. Of all gunshot wounds those of the abdomen
constitute about 6 per cent., being more frequent than stab wounds.


=Gunshot Wounds.=--Gunshot wounds of the intestine would by themselves
fill an interesting chapter in a work on surgery. In such an epitome
as this they can be given but short consideration. The condition was
for centuries hopeless, until the American surgeons Parkes, Bull, and
Senn took up the subject and taught the profession how to more quickly
recognize the injury as well as to treat it. The special dangers of
all punctured wounds of the bowel, like those of the stomach, are
hemorrhage and escape of fecal contents. The great length of the
intestinal tube, and its coiled arrangement within the abdominal
cavity, subject it to the possibility of multiple punctures, from a
dozen to twenty having been inflicted by the passage of one bullet.
The multiplicity of these injuries, therefore, gives a still more
formidable character to their presence. Much will depend upon the size
and velocity of the bullet and the distance from which it is fired. The
perforated gunshot wounds of the abdomen which occur in civil life are
usually inflicted by a smaller bullet than those occurring in actual
warfare, while, at the same time, the distance is usually short.

Gunshot wounds are followed by an apparently disproportionate amount
of collapse. There is no accurate method of recognizing from the
exterior the amount of harm done by the passage of a bullet into or
through the abdominal cavity. This constitutes one of the greatest
arguments in favor of immediate exploration, an argument which is
strengthened by the fact that almost every penetrating wound of the
abdomen is complicated by injury of some abdominal organ. The greatest
danger attaches to perforation of the transverse colon or of the small
intestine, because these are the most movable parts of the intestinal
canal. The dangerous wounds are those which lie in the frontal plane.
Bullets which pass through the abdomen obliquely are perhaps less
likely to produce fatal result. Astonishing differences prevail between
the severity of those accidents received upon the field of battle and
in civil life. In battle men are shot through the abdomen and not
conspicuously disabled, recovering sometimes with no other treatment
than antiseptic occlusion. It is impossible to assume that the bowels
have not been injured, and yet they recover. The fact thus stated best
indicates the reason for abstention from intervention on or near the
firing-line in battle, and its most prompt and early performance when
the patient is in a well-managed civil hospital.


=Symptoms.=--The symptoms of _intestinal perforation_ in these cases
are not so prompt as when the stomach is wounded. Blood may occur in
the vomitus or in the stools, but only ordinarily after the expiration
of a few hours. Should fecal matter be found within the external wound
evidence would be complete, but this is rarely the case. The probe may
show whether the abdominal wall has been completely perforated or not;
beyond this it will give little information. By far the best probe
is the sterile finger, introduced through the opening enlarged for
the purpose. With this more distinct information may be gained. Some
years ago Senn proposed the method of inflating the colon and small
intestine with hydrogen gas, on the expectation that it will escape
through any intestinal perforation into the abdominal cavity, which it
would distend, and that then by inserting a small glass tube in the
abdominal wound it could be lighted and made to thus identify itself
at the distal orifice of this tube; but this method requires special
conveniences which are rarely at hand in emergency cases, and has been
practically abandoned.

A study of the direction of the abdominal wound which may be sometimes
made from an accurate account of the accident, and at other times by
noting the location of the wounds of entrance and exit, will do much to
determine whether intestines were probably in or out of harm’s way. If
it can be established that the bullet has probably avoided them then
some would wait for the inception of the first serious sign of mischief
before exploring. On the other hand, if it should seem inevitable that
such injury must have occurred, or, without such reasoning, if the
patient present a serious condition, he should be promptly operated
unless practically moribund.

The general principles of recognition and treatment of gunshot wounds
have been considered in an earlier chapter and the subject will not be
further considered here except as regards treatment.


=Treatment.=--The principles of surgical treatment for gunshot wound
of the intestines include a free abdominal incision, an inspection of
the entire length of the intestinal canal, which can only be made by
passing it through the examining fingers while exposed to sight upon
the abdominal surface, the accurate securement of all bleeding vessels,
and the closure of all punctures. Any portion whose blood supply has
been so completely cut off as to threaten or produce gangrene should
be removed by resection, with end-to-end or a lateral anastomosis.
The patient having been thus eviscerated and the intestinal viscera
examined, the abdominal cavity should be further explored, not so much
to find the missing bullet as to discover what further harm may have
been done; while if such be found the indication should be met. Then
after an exceedingly careful toilet of the peritoneum the intestines
may be restored, it being of course assumed that every puncture has
been fully recognized and properly sutured and secured. Nearly all of
these cases will call for some abdominal drainage, which may or may not
be posterior, as shall seem best.

_The location of the bullet is a matter of minor importance._ Should
it lie where it can be easily identified and removed this should be
done. Otherwise one should not waste valuable time in hunting for it,
remembering that he is performing not an autopsy but an operation.


ULCERS OF THE SMALL INTESTINES.

There is no point of the intestinal tube between the pylorus and the
anus which may not be involved in an ulcerative process, either acute,
chronic, or malignant. Acute ulcers of the upper bowel are usually of
typhoidal origin, while those of the lower bowel may be due to either
typhoid, tuberculosis, or syphilis. At certain points ulcers assume
somewhat distinctive character. Thus the acute catarrhal ulcer, so
called, seems to have a more definite entity than a declared pathology,
it being somewhat difficult to account for its existence. The peculiar
duodenal ulcers which have been met with after operations or burns
have been elsewhere discussed, and are to be regarded as of an acutely
toxic origin. A special type of ulcer of the duodenum has also been
noted opposite the anastomotic opening which is made in the ordinary
gastro-enterostomy, for whatever purpose performed. This appears to be
due to the outpour of the gastric juice upon a surface not normally
prepared for it, upon which it acts as an irritant, in time producing
more or less acute ulceration. This is the so-called _peptic ulcer of
the duodenum_, an occasional complication of gastro-enterostomy.


=Duodenal Ulcer.=--Duodenal ulcer of a type corresponding to gastric
ulcer has been recently determined to be a more frequent lesion
than has been supposed. A series of over fifty operations for this
condition, reported by Moynihan, in 1905, thus occurring in the
practice of one surgeon, will dispose of the question as to its
great rarity. Its symptoms are often so characteristic as to admit
of reasonably easy diagnosis, and it has, therefore, become more and
more a matter of greatest interest to the surgeon, since duodenal like
gastric ulcer is essentially a surgical condition.

These ulcers are usually located in the first portion of the duodenum,
_i. e._, in at least 90 per cent. of cases. They may be solitary or
multiple, and may be associated with gastric ulcers. In the ordinary
postoperative peptic ulcer the sequence of events is usually gastric
ulcer, hyperchlorhydria, and duodenal lesion. It may occur at any age,
and is the frequent cause of melena of the newborn or of the young.


=Symptoms.=--Symptoms of duodenal ulcer include pain, hematemesis, and
melena. Pain may be a vague uneasiness or may be severe. It is usually
described as of a burning character, felt mainly in the middle line or
along the right costal margin. It becomes gradually more severe and may
finally disable. It is sometimes described as cramp-like. When severe
it is referred to the right of the middle line. In cases where there
are adhesions to the liver or gall-bladder, pain radiates upward to
the right breast, or even around the chest to the back. The pain is
associated, by more or less marked time limit, with the ingestion of
food, coming on from two to four hours after a meal, whereas that of
gastric ulcer comes soon after eating. Sometimes it is even regarded
as a “hunger pain,” and patients find that the taking of a little
food will give relief. So soon, however, as this is digested pain
returns, when they again call for more food. Hematemesis and melena
may be present together or either may appear without the other. Small
quantities of blood in the vomitus is more likely to attract attention
than considerable quantities in the stools. It has been estimated that
in from 25 to 30 per cent. of acute cases hemorrhage is frequent,
and occurs in 40 per cent. of chronic cases. In the stools blood is
found in perhaps one-half of the instances. The amount of blood may
be considerable, even sufficient to produce faintness. In fact, the
intestine has been found full of blood when the abdomen was opened, and
Moynihan has seen even the colon distended with blood.

The more serious _complications of duodenal ulcer_, aside from
hemorrhage, are those of _perforation_, cicatricial contractions or
_stricture_ formation (obstructing the bowel or the common duct, or
both), _local peritonitis_, cancer, and indirectly gall-bladder or
pancreatic disease. Next to hemorrhage perforation is more likely to
occur in a duodenal than in a gastric ulcer and with more disastrous
consequences. Such perforation affords a peculiar mimicry of acute,
gangrenous appendicitis which, as Moynihan has shown, is due to the
direction taken by the extravasated fluid down along the right of the
transverse mesocolon toward the iliac fossa. In fact, the condition
is more likely to be mistaken for one of acute appendicitis than for
anything else.

With a primary ulcerative lesion in the duodenum it is easy to realize
that infection may readily travel up the common duct, involving
both the pancreas and the biliary passages, while the resulting
cholecystitis will intensify and spread the local peritonitis
previously produced, and all combined will cement the viscera in
this region into one common mass in which anatomical identity is
easily lost. A good history, when obtainable, will help very much in
diagnosis, especially when the absence of previous gastric symptoms can
be established. This, with the symptoms already given above, and the
tenderness over the duodenum, which is rarely absent, will afford good
basis for diagnosis in the more chronic cases. Duodenal perforation may
even be mistaken for rupture of an extra-uterine pregnancy, as well as
for perforation of the stomach or of the gall-bladder, or, as mentioned
above, of an appendix.

Quite recently attention has been called to a condition of the duodenum
resembling that known as hour-glass stomach, and produced in much the
same way. It seems to be the result of cicatricial contraction of
an old ulcerated area, and may cause almost complete constriction.
_Hour-glass duodenum_ is amenable to surgery only, and should be
treated either by gastrojejunostomy or possibly by a resection with
end-to-end suture.


=Treatment.=--For duodenal ulcer when recognized before perforation,
there is but one treatment, _i. e._, _gastro-enterostomy_, preferably
posterior, performed exactly as for gastric ulcer, for the same
reason, and with the same prospect of relief, inasmuch as it affords
physiological rest for the diseased area. In rare instances it may be
possible to so expose the duodenum as to make it justifiable to attack
the ulcer directly, but the simplest and, in general terms, the best
procedure is that just mentioned.

_For perforated ulcer of the duodenum_ the indication is not alone for
a gastro-anastomosis, but for exposure of the site of perforation,
removal of all extravasated material, a most careful toilet of
the peritoneum, and suture of the perforated area, this being the
indication when possible. Provision should be made for drainage, while
at the same time affording a direct outlet from the stomach into
the first portion of the jejunum beyond. Should the surgeon operate
apparently for appendicitis and discover that he has to deal with a
perforated duodenum he should extend far upward the incision made for
the former purpose, and, having thus widely opened the abdomen, should
thus find himself perhaps better provided with space in which to work
than had he opened at first directly over the duodenum.


=Typhoidal Ulcers.=--Typhoidal ulcers of the intestines have a
tremendous surgical interest in that they not infrequently lead to
perforation, and that this almost always is fatal if let alone. It may
be possible, however, by prompt recognition of the occurrence of the
perforation and by immediate intervention to cleanse the peritoneal
cavity of extravasated feces and close the opening thus made.


=Symptoms.=--The symptoms of perforation are at first not unlike those
of hemorrhage, in that shock is immediate and profound, and pain,
usually intense, is produced. These are quickly followed by abdominal
rigidity, while a blood count will show a rapidly increasing and high
leukocytosis. To the expressions of local peritonitis are quickly added
those of one which is generalized, with well-marked rigidity and great
meteorism.

The condition having occurred admits of but one remedy--namely,
operation. One of the latest collections of statistics includes 63
operations for typhoid perforation, with 11 recoveries, although
probably today the percentage is somewhat better than in 1903.
_Operations to be effective should be immediate._ Patients are
usually too profoundly collapsed to justify general anesthesia,
unless perhaps this may be secured with ethyl chloride or somnoform.
Many of them have been operated under local anesthesia. This has
its disadvantages, however, in that it is so difficult to make free
opening and exploration or free toilet. Opening having been effected,
the loops of intestine must be successively examined until the site
of the perforation is discovered. Here sutures must be applied, if
possible. Should the condition of the bowel render it absolutely
unreliable, _i. e._, should it be too extensively gangrenous to retain
sutures, it should be brought out and an artificial anus made, at
least for temporary purposes. In addition to these measures the most
careful toilet of the peritoneum is needed, perhaps including extensive
irrigation, unless it can be shown that the area contaminated by
extravasation is localized and shut off.

_Perforation of tuberculous, dysenteric, cancerous, or other ulcers_
will cause symptoms very much like those of typhoidal perforation, and
the case will differ essentially only in this respect, that in most of
the latter the general condition of the patient will not be so extreme,
and the danger of administering an anesthetic or of operating not so
great. Otherwise the indication, the necessity, and the method do not
differ.


=Tuberculous Ulcers.=--Tuberculous lesions of the small intestines
produce less destructive features than when situated in the colon.
Tuberculous infection of the intestinal tract occurs more often through
the swallowing of infected sputum, and, consequently, is a frequent
condition among consumptives. Such lesions in the small intestines will
lead to infection of the mesenteric nodes which, in time, may become
serious or even fatal, or it may lead to tuberculous peritonitis with
its finally disastrous consequences. As a rule, however, tuberculous
ulcers are not so likely to perforate, this being in large measure due
to the frequency with which they contract adhesions or affix diseased
surfaces to others, thus rather guarding against such an accident.


=Symptoms.=--Tuberculosis may also appear throughout the intestinal
tract in miliary form, or we may find _tuberculous gummas_, either
in the folds of the peritoneum or subperitoneally in the wall of the
bowel. Any of these lesions may lead to any of the others, and by
the time the case has been diagnosticated or has come to operation
or autopsy it is sometimes difficult to say what was the primary
lesion. Diagnosis is made partly with the thermometer and partly by
inspection and palpation, where one may be able to discover mesenteric
enlargements or the presence of fluid, as it usually collects in
tuberculous peritonitis; and perhaps partly by the general appearance
of the stools, in which a careful search may possibly, although by no
means with certainty, reveal the tubercle bacilli.


=Treatment.=--The treatment of such tuberculous lesions is largely
constitutional. When the case assumes the aspect of tuberculous
peritonitis much more can be accomplished by abdominal section
and irrigation, at which time it may be possible to remove some
localized focus without thereby doing more harm than good. The usual
constitutional measures, including oxygen, are indicated; but there
maybe difficulty in forcing hypernutrition because of the actual state
of ulceration. In this case foods which are cared for by the stomach
should be given in preference. Such intestinal antiseptics as creosote
or other remedies of its class may also be pushed to the point of
toleration.

The other _granulomas_ produced by either _syphilis_ or _actinomycosis_
may give rise to ulceration and its consequences and sequels, in a
way resembling those of tuberculosis. While the lesions they produce
may give rise to uncertain symptoms, a diagnosis can hardly be made
without accurate history and without the co-existence of other
lesions in more accessible parts of the body, by whose character
they may be determined. Primary actinomycosis of the intestinal
tract is more common than is generally realized. As it develops it
tends to spread to adjoining viscera and form tumors which later may
break down. The debris thus resulting will be indicative, especially
when the characteristic calcareous particles are felt in it, or
the characteristic ray fungus discovered with the microscope. (See
Actinomycosis.)


STRICTURE OF THE INTESTINES.

Save in rare instances where stricture may be due to congenital defect
the condition is never primary, but is secondary to some previous
and active disease. Stricture proper should be distinguished from
obstruction produced by compression from without and should usually
be made to include those cases due to intrinsic disease of the
intestinal wall. Here it is in the vast majority of cases either due to
cicatricial contraction, following the healing of some previous lesion,
or else to the infiltration and progress of malignant disease. In the
former instances a great deal may be accomplished by operation. In the
latter much will depend upon the relative period at which the case is
seen by the surgeon.


=Symptoms.=--The symptoms of stricture are those of bowel obstruction.
The tumor which produces it may be identified by palpation, or by
the fecal impaction, at least accumulation, which is likely to occur
above it, which may appear as a tumor and be mistaken for it until
cleared away by suitable cathartic measures. Ordinarily the surgeon
never recognizes stricture of the small intestines, then, save by its
obstructive features.


=Treatment.=--The treatment consists in what can be done by radical
surgical measures, and this can only be determined after exploratory
abdominal section.


TUMORS OF THE SMALL INTESTINES.

Benign tumors of the small bowel are relatively infrequent, perhaps
the most common being the lipomas which develop along the mesenteric
border, usually as excessive epiploic appendages. But circumscribed
and even pedunculated lipomas are seen occasionally in this location
and are of surgical interest largely because, at points where they are
located, intussusception is peculiarly liable to occur. In fact, the
condition figures as one of the predisposing causes of invagination.
Fibromas develop occasionally in the intestinal walls and adenomas grow
from the glandular structures which abound therein. Other benign tumors
are exceedingly rare.

Besides predisposing to intussusception these tumors are innocent, save
that in time they constrict or obstruct the lumen and produce one form
of stricture with obstruction, which will first be chronic and then
terminate acutely and fatally unless promptly relieved.

All benign tumors of the bowel should be removed with the least harm
possible to the bowel itself, but when a neat extirpation without
reduction of intestinal caliber is not possible no hesitation should be
felt about resecting a sufficient portion of the gut; or should this be
impracticable in making an anastomosis, thus excluding that part of the
bowel involved.


=Cancer of the Bowel.=--In the small intestines by far the most common
type of malignant tumor is the round-cell carcinoma, epithelioma rarely
appearing except in the lower part of the rectum, where flat epithelium
is met. Adenocarcinoma, then, is common, and sarcoma relatively rare,
the latter arising, of course, from mesoblastic elements. A diagnosis
is made by first noting symptoms of intestinal obstruction plus
certain added features of cachexia, lymph involvement and possibly of
metastasis, for which a benign stricture would not account. Sometimes
a tumor is easily felt within the abdominal wall; at other times
one simply makes the general diagnosis of intestinal obstruction,
presumably cancerous, because of age and cachexia, and leaves the rest
to be determined by operation. Cancer of the bowel will naturally
spread in the direction of the lymphatics at the root of the mesentery,
and these will nearly always be found involved. It is fortunate if a
case may come to operation before this invasion has occurred.


=Treatment.=--Cancer of the bowel permits of but two methods of
treatment, one _excision_ of the entire infected area, both of
bowel and of mesentery, in cases not too excessive, the other an
_anastomosis_, by which temporary relief at least may be afforded. In
all cases I am strongly inclined to advise the use of the _x_-rays,
for a long time after operation; in favorable cases because it exerts
a prophylactic influence, in the unfavorable cases because it nearly
always relieves pain and retards growth, seeming sometimes even to
disperse it. Such treatment should always be tempered by the best of
judgment, lest _x_-ray dermatitis complicate or prevent it.


ACUTE INTESTINAL OBSTRUCTION; ILEUS.

The somewhat badly derived and indefinite term “_ileus_,” in common use
abroad, is coming into more fashionable use in the English-speaking
profession, which is rather unfortunate, for it has not always meant
exactly the same thing in the writings of different authors. It will
be used, however, in this chapter as practically synonymous with acute
obstruction or strangulation.

Acute obstruction may be classified in two ways, as to types and as to
causes. For the first purpose the best classification is perhaps the
simplest, and, as recently rehearsed by Murphy, is as follows:

  1. Adynamic, including those conditions which are due to absence of
  power of propulsion.

  2. Dynamic, where obstruction is due to excessive power or excessive
  contraction of the muscular wall.

  3. Mechanical, including all of those conditions of strangulation
  or obturation which, in a mechanical way, impede the advance of
  intestinal contents.

Conditions which permit the adynamic type may include those of _spinal
origin_, those interfering with mesenteric _nerve supply_ or that of
the walls of the intestines (for instance, in cases of fracture of
the spine), or, again, where extensive operations have been performed
on the mesentery, or where there have been extensive wounds. Thus in
removal of mesenteric tumors, unless care is exercised in separating
the mesentery from the tumor and in ligating bloodvessels without
including nerves, a paralytic ileus may promptly result. Gunshot wounds
of the chest or of the spine may also include _injuries to nerves_, by
which paralysis of the bowel ensues. So, too, adynamic ileus sometimes
results through the _paralyzing reflexes_ which follow strangulation of
the omentum--as, for instance, in a hernial sac--or it may be due to
biliary calculus acting in the same way.

The dynamic forms, as well as the mechanical, are much more likely
to be characterized by pain and violent symptoms than are the
paralytic. _Gastric tetany_ is a condition to be differentiated
from reflex ileus. _Enormous distention of the stomach immediately
after operation_ leads perhaps to a belief that a patient has acute
obstruction of the intestine, when the fact is that such a case
may be relieved by vomiting or passage of a stomach tube. _Local
peritonitis_ of septic type, as well as peritoneal traumatism, tends
to weaken if not to paralyze peristalsis. In general peritonitis the
entire intestinal tract is involved, partly from reflex paralysis,
partly from inflammation of the intestinal wall. The _embolic type of
paralytic ileus_ may be due either to interference with nerve supply or
with blood supply. In thrombophlebitis symptoms develop more slowly,
especially when this follows abscess of the liver or spleen. Here there
is not so much meteorism, and the bowel may be even nearly empty, while
we have the other symptoms of pain, nausea, and vomiting. Borborygmus
is one of the most pronounced manifestations of mechanical ileus and
the stethoscope will then give much assistance. In fact auscultation
of the abdomen, with a recognition either of active motion within or
of absence of peristalsis, should not be neglected; when one can hear
intestinal waves the condition is much more likely to be one of purely
mechanical obstruction.

Classified by causes, we may make out the following well-marked groups:

  1. Strangulated hernia of all varieties, including diverticula.

  2. Intussusception.

  3. Volvulus.

  4. Ileus from fecal impaction.

  5. Stricture.

  6. Intrinsic neoplasms.

  7. Extrinsic neoplasms.

  8. Gallstones and foreign bodies, enteroliths, etc.

  9. Peritonitis, with paralytic ileus or kinking of bowel by
  adhesions, or both. This condition is seen in severe cases of
  appendicitis.

  10. Bands, congenital and acquired, recent and old.

  11. Slits and apertures in the mesentery or omentum.

  12. Effects of contraction and intestinal looping.

  13. Congenital causes, including diverticula, unobliterated
  omphalomesenteric and hypogastric remains, etc.


1. =Strangulated Hernias.=--By far the most common of all the causes of
acute obstruction are strangulated hernias. These are, however, treated
by themselves in a distinct chapter.


2. =Intussusception or Invagination.=--These terms imply a protrusion
or prolapse of one part of the intestine into the lumen of an
immediately adjoining portion. This is found to be the cause of perhaps
one-third of the total number of cases. Enteric invaginations occur
along any portion of the small intestine, being more common in the
lower portion and rare in the uppermost. They seldom attain great
length and are often very short. The ileocecal is the most common
variety, since obviously it is the easiest of occurrence, the ileum
protruding into the cecum or the ileum and cecum together passing into
the ascending colon. Colic invagination may occur anywhere along the
large bowel, being again more common near its distal termination. The
colon may descend into the colon or the sigmoid into the rectum, even
to such an extent as to present at the anus or possibly protrude.
Statistics show that the ileocecal occurs in 44 per cent., the enteric
in 30 per cent., the colic in 18 per cent., and the ileocolic in 8 per
cent. of cases.

While the surgeon is concerned only with the obstructive form of
intussusception it is of interest to know that the condition occurs
occasionally shortly before death and is then spoken of as the
_intussusception of the dying_, being usually due in these cases to
irregularity and uncertainty of peristalsis during the concluding hours
of life; paralysis occurring at one portion of the intestinal tube and
abnormal activity just above it. These conditions are discovered at
autopsy, and can be recognized as such by the absence of exudate or of
any attempt either at repair or inflammation. They occur most commonly
in the young and may also be multiple. In direction intussusception is
practically always descending, although there may be a secondary and
associated ascending movement, the latter being unimportant.

_Double_ intussusceptions are somewhat common, and triple or multiple
have been described.

Cross-section of an invaginated bowel will show that on each side one
must pass through three distinct layers of bowel wall. That portion
which is intruded is spoken of as the _intussusceptum_, while that
portion which receives the latter is known as the _intussuscipiens_
(Fig. 560). Obviously when invagination occurs the mesentery should
be drawn in with the intussusceptum, while traction upon it should
increase with advance of the included bowel. This is particularly often
seen in ileocolic varieties where the ileum, with its mesentery, may
travel the whole length of the colon and even present at the anus.
Moreover, this may occur within a relatively astonishing short time,
and the fact that the intussusceptum may be felt in the rectum within
a few hours after the occurrence of the first symptoms is a fact not
easily to be explained.

[Illustration: FIG. 560

Diagrammatic section of an intussusception: _A_, reflected tube; _B_,
receiving tube or sheath; _C_, entering tube.]


=Causes.=--The causes of intussusception are obscure, postmortem
findings or even the revelations of a laparotomy demonstrating
conditions, but not often affording explanations. The presence of
tumors, especially lipomas, which may even be pedunculated along the
small intestine, has been demonstrated in a number of instances, and
they have been supposed to be active factors in the first disturbance.
Everything points to the association of disordered intestinal movements
with the mechanical condition of obstruction, and the former are more
frequently seen in the intestinal complaints of the young, along with
the presence of masses of undigested food or impacted feces within the
bowel, or the occurrence of intestinal polypi. The most complicated
case of ileocecal invagination which ever came under my notice was
associated with the presence of a polyp in the ileum. All of these
conditions, save the presence of tumors, pertain more frequently to
the young than to the aged. The influence of the ileocecal valve is
also undeniable, and that at this region parts are more predisposed to
invagination than elsewhere is quite obvious. In at least half of the
cases that have been recorded no satisfactory cause could be shown.
Any condition which causes severe intestinal colic may give rise to
intussusception; the next most common causes are paralysis or weakening
of some part of the bowel, such as may follow injury or disease, or the
presence of tumors, while even the role which they play is not entirely
explained (Fig. 561).

That invagination will produce mechanical obstruction is obvious,
while the fact that such obstruction is not always nor necessarily
complete incites surprise. The orifice of the intussusceptum is
distorted, while the included portion may be greatly bent or curved
upon itself, in addition to which the obstruction to the circulation
leads to congestion, exudation, and swelling, and predisposes to
active inflammation, all of which tend to still further narrow the
passage-way. If, in addition to this, some tumor or hardened fecal
mass be included in the grasp of the bowel involved it may be seen
how complete shutting off of the intestinal tube may occur within
a few hours. Invagination having occurred tends quickly to become
irreducible; most commonly by the formation of adhesions, as lymph
quickly exudes and bowel surfaces are by it thus glued together. Such
adhesions may persist throughout the whole involved length of bowel
or may occur at various scattered spots. As pressure becomes greater
circulation of the invaginated portion is impeded and finally shut
off, gangrene of the intussusceptum thus resulting. Cases occasionally
terminate favorably through this actual condition, the included portion
being finally cast off as a slough and passing onward and outward. It
is on record, for instance, that six feet of invaginated bowel have
thus been obtruded from the rectum after having sloughed, the patient
eventually recovering. While this possibility, then, is present it is
never safe to wait for it, and it is to be regarded simply as a happy
accident when it occurs. Unless, then, a case of intussusception be
very early and promptly operated, the included portion of the bowel may
be regarded as dangerous and unsafe, unless upon disengagement it prove
to have been but very slightly affected. Even then there is danger of
immediate recurrence of the previous condition because of distention
of the bowel above, paralysis of the part disengaged, and stretching
of the part below. In proportion as obstruction becomes more complete
distention of the bowel above the lesion, from accumulation and gas
formation, will cause more and more distress, until finally complete
paralysis of the muscular coat and possibly eventual rupture may
terminate the case.

[Illustration: FIG. 561

Invagination of ileum, cecum, and ascending colon into transverse
colon. One probe is passed into the appendix, the other into the
invaginated portion of the ileum. (Rafinesque.)]

In addition to the conditions above described, all of which are acute,
there is known also a _chronic form of intussusception_, whose whole
course is much slower and less severe, where symptoms of obstruction
never become more than partial, but may involve any portion of the
bowel, and with about the same relative frequency as the acute forms.
Such a condition in the rectum, for instance, has been mistaken for
cancer.


=Symptoms.=--The special symptoms by which intussusception may be
recognized, or at least by which suspicion is aroused, are, in addition
to those common to all forms of acute obstruction, the _abrupt onset_,
which may even occur during sleep, the _late_ rather than the early
occurrence of _vomiting_, complaint of _tenesmus_, the _wave-like
or colicky character of the pain_, and the fact that along with the
violent peristalsis of which this colicky pain is an indication
_diarrhea_ is a common accompaniment, the actual local coprostasis
being masked by this fact. As the lumen of the bowel becomes occluded
and fecal matter fails to pass, the _evacuations become more bloody
and contain little but mucus_. Finally, almost pure blood may be
passed. _In no other form of obstruction is the passage of blood so
distinctive as in this._ Urine elimination is but slightly influenced,
and strangury is an exceedingly rare feature. Meteorism is also less
pronounced. The discovery of a _tumor_ formed by the invagination
will lend further aid in diagnosis. It may be felt either through
the abdominal wall or by the rectum, and may be noted in about half
of the cases. It is most frequently found in the ileocecal and colic
varieties, and felt in the rectum with the lower colic forms. In
children it is more distinct than in adults. The tumor may even take
the outline of the involved bowel, is usually movable, but may be
fixed. When such a tumor is felt within the rectum it may have to be
distinguished from some intrinsic neoplasm of the lower bowel; but the
history of the case should prove satisfying if the physical examination
leaves one in doubt.


=Treatment.=--_Spontaneous cure of an intussusception_ by a sloughing
process has been mentioned above. Cure may also occur by spontaneous
reduction. It would seem possible also only in recent cases and in the
enteric forms. Cure may also occur by formation of a fecal fistula,
although this is most rare.


3. =Volvulus.=--The term “volvulus” implies some form of twisting or
of revolution of a part of the bowel upon itself or its mesenteric
axis, the result being knotting or intertwining of intestinal coils to
an extent causing their partial and finally complete obstruction. A
common site for volvulus is the sigmoid flexure. Still no part of the
intestine which hangs loosely is exempt.

The most common causes of volvulus are chronic constipation and fecal
impaction, with distention and ptosis. Intestine thus displaced and
overloaded becomes more or less paralyzed, its circulation more or
less impeded, and any twist which has once occurred is not likely to
right itself. The twisted loop having been engorged becomes distended
with gases, and thus tends to increase the difficulty. In these cases
the bowel loop is closed at both ends. Unless relief be afforded by
operation it is a question merely of how soon the loop will become
gangrenous from aggravation of every one of the features above
recounted. Bowel thus involved permits easy passage of bacteria, and
thus to the other features are rapidly added a septic peritonitis. The
resulting abdominal distention may appear early and will become more
prominent.


4. =Ileus from Fecal Impaction.=--A condition of extreme coprostasis,
or fecal impaction, to a degree producing actual obstruction, may
occur without necessary volvulus or twisting of any portion of the
bowel. As fecal impaction increases the overloaded bowel becomes more
and more paralyzed until there may occur final and complete arrest of
peristalsis, with gradual development of symptoms of obstruction. The
longer the condition persists the less the prospect of restoration of
peristaltic movement. Moreover the condition may be complicated by the
development of ulcers above the obstructed segment, known as _stercoral
ulcers_, due partly to gangrene from pressure and partly to the
chemical effects of long-retained decomposing material. They may appear
as sloughs of the mucous membrane and finally lead to perforation.

This form of ileus is more common in the large than in the small
intestine, and especially so in the cecum. Here there is little chance
of retrograde movement, while fecal matter coming down from above will
continue to pack the colon, and thus the cecum may have to bear the
brunt of great pressure. The amount of fecal matter which may be thus
collected is sometimes astonishing, for the bowel may dilate to the
diameter of six or even ten inches, and contain many pounds of impacted
feces. Such masses of collected feces can usually be palpated through
the abdominal wall, and will at least indicate the location of the
principal disturbance, if not its actual character.


5. =Strictures.=--The most common causes of cicatricial stenosis in
large or small intestine are the results of cicatricial contraction
following recovery from local ulceration or repair of injury, as,
for instance, after reduction of a strangulated hernia. The exact
character of the ulcer does not matter. Any lesion which may granulate
and heal will also contract, and the extent of the stricture will be
proportionate to the area first involved. Should this extend well
around the mucous membrane there may be a distinct annular stricture.
Stricture may also result from infiltration and thickening in
connection with a more active diseased process, and such a condition
may be multiple. This is particularly true in cancerous involvement of
the bowel.

Previous history of the case will shed much light on the probable
existence of intestinal stricture. Thus a history of typhoid, of
dysentery, of tuberculosis, or of syphilis will be most suggestive,
for in any of these diseases there may be numerous intestinal ulcers.
A history of hernia, reduced or operated, or of injury, is also of
importance, as also is one of operation upon other viscera, especially
within the pelvis, the lower bowel being often involved in a disease
process within this cavity which may have left its marks.

[Illustration: PLATE L

Enterolith with Gallstone for a Nucleus; Removed by Enterotomy.
(Richardson.)

This patient was a man of sixty-nine, with symptoms of complete
intestinal obstruction. There was no previous history whatever of
gallstone. The impaction was high up in the small intestine. The
gallstone was removed by a small linear cut which was satisfactorily
sutured. The patient died in the course of twenty-four hours.]

Stricture may be recognized by the gradual course of the case and by
a history of increasing difficulty or of increasing constipation. A
stricture as such is not formed within an hour, and in this sense is
the result of a previous more or less active disease. This is true,
also, of cancerous stricture.


6. =Intrinsic Neoplasms.=--The possibility of both innocent and
malignant tumors occurring within the intestinal structures has already
been considered. It is obvious that any such growth will cause gradual
obstruction by the usual process, or may precipitate by its presence
the occurrence of intussusception, of volvulus, or of some kinking by
which obstruction is suddenly produced.


7. =Extrinsic Neoplasms.=--What has been said above applies equally
well to growths not primarily involving the intestine, but encroaching
upon it. Thus obstruction may gradually result from retroperitoneal
growths, or from the impaction of a growing uterine myoma pressing upon
the rectum and finally occluding it. Also cancers growing in various
locations encroach upon and finally involve the bowel in conditions
which nevertheless were originally quite external to it.


8. =Gallstones.=--In the section devoted to the biliary passages
the accidents which may occur during gallstone disease have been
summarized, and it has there been related how large ones may ulcerate
through and drop into the small or even into the large intestine.
Enteroliths may be thus produced, which were originally small
gallstones that have lodged and grown by accretion until they have
reached considerable size, or by gallstones which have suddenly entered
the intestine by ulceration above, or by other material which may have
collected in some sacculation or diverticulum, where it has received
more or less calcareous deposit and has grown by accretion until it
produces obstruction, either by occlusion or by causing the intestine
to kink. Other foreign bodies may also produce obstruction. Although it
has been generally held that whatever may escape through the pylorus
may be evacuated from the rectum, nevertheless peculiarly shaped
objects become entangled in such a way as to be checked in progress and
serve as impacted bodies upon which an accumulation may take place.
(See Plate L.)


9. =Peritonitis.=--While coprostasis is a feature of almost every case
of acute peritonitis the obstruction referred to in this paragraph
comes rather from the adhesion and fixation of bowel from outpour of
lymph than from paralysis and ileus in consequence. It may be doubted
whether acute peritonitis is ever idiopathic. As seen by the surgeon,
at least, it has some point of origin which furnishes ample excuse
for its existence. The most common cause in the male is the appendix,
and in the female the appendix or the tube. At least one-half of the
cases occurring in general practice originate in one or the other of
these ways. Infection may also easily spread from the mesenteric nodes,
beginning locally and resulting in adhesions, the disease spreading
by a natural process until perhaps the whole abdomen is finally
involved. While healthy bowel is ordinarily impervious to germs, when
it becomes diseased germs may easily travel from its interior to its
exterior and thus set up peritonitis. In this way a purely mechanical
original condition may bring about a fatal septic peritonitis. It is
known also that intestinal diverticula are subject to exactly the same
lesions as is that one in particular which is called the appendix, and
the symptoms and sequences of the diverticulitis may simulate those
of an acute appendicitis. In acute appendicitis coprostasis and even
apparently fatal obstruction are frequently met with. Their occurrence
is to be explained not alone by toxemic paralysis (_i. e._, toxemic
ileus), but by the actual mechanical impediments offered by loops
of bowel strongly bound together around the appendix in the actual
protective effort.

10. =Bands.=--Bands of tissue which may cause obstruction of the
bowel are neither necessarily long nor large, and one will frequently
be astonished to see how trifling a tissue cord may produce intense
disturbance. The bands which may be found within the abdominal cavity
under these circumstances include those produced by peritoneal
adhesions, where the cohering lymph has organized and at the same
time stretched, such bands being found to arise from and connect
with the bowels alone, to arise from the omentum from any other
causes, particularly traumatic, or to occur at any point within the
peritoneal cavity. They may be single or multiple. When speaking of
Meckel’s diverticulum it was stated how it might be mistaken for a band
extending to the region of the umbilicus, and acting as one cause
of obstruction. (See Fig. 559.) An adherent appendix or tube tightly
attached at its free extremity may also act as a band, and the former
is known to very frequently produce at least a mild form of intestinal
obstruction, which may at any time assume acute proportions. The
pedicle of an ovarian or other tumor may also, if long, by becoming
twisted, include an intestinal loop and thus produce obstruction.

11. =Slits and Apertures.=--The mesentery is the occasional site
of fenestra which apparently are of congenital origin. Through
such openings or slits a loop of bowel may easily pass and become
strangulated. The same is true of the omentum. Openings in either of
these structures are perhaps more frequently the result of traumatisms.
Similar conditions result where omental or mesenteric surfaces have
united over small areas, leaving pockets or openings in which bowel
might be caught. Quite a similar condition results in so-called hernia
of bowel into and through the foramen of Winslow.

12. =Intestinal Loops and their Traction Effects.=--These causes
are not perhaps independent of some of those above mentioned, yet
presuppose a certain looping or abnormal festooning of intestine, with
the further stretching that occurs as the result of greater loading
and the final entanglement of such loops, or their adhesion, in such
a way as to become completely occluded. To this result some local
inflammatory process may contribute. The condition is often met in
connection with pelvic disease of females. Much that may happen to
a loop of bowel which has become attached to a growing tumor during
its migration, as it gradually changes its shape and position, may be
imagined.

[Illustration: FIG. 562

Strangulation of bowel by a long diverticulum. (Lejars.)]

13. =Congenital Defects.=--Certain congenital defects predispose to
acute obstruction. Among these are diverticula, as already mentioned,
which may produce trouble, either by incomplete obliteration and
separation from the umbilicus, in which event they act as bands or
cords, or by becoming acutely inflamed, then attaching themselves and
indirectly producing the same effects (Figs. 559 and 562). Even the
smaller diverticula or sacculations which extend between the folds
of the mesentery may, when infected and inflamed, thicken and cause
angular bending of the intestine, with consequent partial obstruction,
which later is made complete by the consequences of local peritonitis,
with its dense inevitable adhesions. Statistics show that acquired
diverticula occur twice as often as Meckel’s, and nearly as frequently
in the small as in the large intestine. They are mostly of the traction
variety and occur at the mesenteric border, where they have close
relation to the bloodvessels, thus increasing the dangers of operative
measures because of possible gangrene from shutting off circulation.
Porter has recently collected 188 cases of violent and even fatal
trouble thus produced within the abdominal cavity, returning an
exceedingly high death-rate after operation, which unfortunately was
almost always done late. In nearly all of these cases the diverticula
were found within the lower four feet of the ileum. In one case of my
own an unobliterated hypogastric artery caused acute obstruction.

14. =Postoperative Obstruction.=--Finally cases of postoperative
obstruction are met with in a way to bring disappointment and disaster
when everything else has seemed favorable, and constitute a clinical
type without any distinct pathological foundation. Most of them are due
either to some form of paralytic ileus, or else to local or general
peritonitis with its combined sequels of paralysis and adhesion by
the gluing of portions covered with exudate. Some of these cases
will justify reopening the abdomen, while in others the condition is
absolutely helpless because of the septic element present.


=General Symptoms of Acute Intestinal Obstruction.=--Certain symptoms
and signs characterize all cases of acute intestinal obstruction and
may be, therefore, included as common to each; consequently they may
be considered collectively. The cardinal indications are _pain_,
_vomiting_, _constipation_, _distention_, and _collapse_.

_Pain_ may be the first indication, and usually is so in invagination,
volvulus, and mechanical obstructions generally. It is usually of
violent paroxysmal character, continuing at least during the earlier
stages, rapidly wearing away the patient’s strength, diminishing as
distention increases and nerve endings become paralyzed.

_Vomiting_ is an early or late feature, according to the portion of the
alimentary canal obstructed. The more prompt its occurrence presumably
the higher in the small bowel the defect. In consequence of the
remedies usually administered it will be found that when nothing but
stomach contents are ejected it is easier to produce fecal evacuation
from below, while the greater the difficulty in securing a return from
the lower bowel the lower the obstruction and the more likely the
vomited material to become fecal in character. Vomiting once begun is
usually continuous until relief is afforded or the patient utterly
exhausted.

_Constipation_ or obstipation sooner or later characterize these cases.
The tenesmus of intussusception, with the passage of bloody mucus,
which may occur in this form, or in volvulus, for instance, does not
imply that the bowel itself is not obstructed, nor does the emptying
of the larger bowel of an accumulated load necessarily imply that
the fecal stream is in motion. Even the passage of flatus usually is
promptly shut off, and it is the gas which forms and cannot escape that
produces the distention.

_Distention_ gradually becomes excessive, the abdomen becoming
ballooned and extremely tympanitic on percussion, while its surface
becomes shiny because so stretched. This _meteorism_ is in large degree
due to the formation of gas within the bowel proper, but is permitted
by the additional features of paralysis of intestinal muscle and
weakening of that of the abdominal wall. As it increases the diaphragm
is pressed upward and respiration is much impeded, while even the
bladder may be compressed below. It affords another reason why fluid
which is taken into the stomach is quickly ejected.

Characteristic _collapse_ comes on more or less promptly, according to
the nature of the exciting cause, and the date of its occurrence is in
some degree an index of its violence.

In dealing with obstructive cases any history that may bear upon the
conditions, as of previous peritonitis, appendicitis, of so-called
dyspepsia which might indicate gallstone disease or gastric ulcer,
or of pelvic conditions which might indicate pyosalpinx or the like,
should be obtained. The manner of onset should be learned, whether
acute or gradual, with the relative date of the occurrence of pain,
vomiting, and stools, along with their character, if there be anything
distinctive therein. Past and present history being secured, the most
methodical examination of the body should be made, including the
physiognomy and general conditions, the attitude (_e. g._, whether the
knees are drawn up, whether the patient is able easily to turn), the
type of respiration, and the amount of restlessness. The character
of the abdominal movements during respiration should also be noted,
as well as the presence of any prominence or the indications of
violent peristalsis. By palpation the degree and location of greatest
tenderness, the presence of muscle spasm or of tumor may be learned.
_Careful examination of all the ordinary hernial outlets_ should be
made and the rectum and vagina explored. Revelations thus obtained may
also prompt a careful physical examination of the chest. Percussion
will show the presence of free or localized fluid or gas, while
localized dulness may denote a loop of intestine distended with fluid
or impacted feces. Auscultation will enable the surgeon to hear the
sounds produced by violent peristalsis or to note the absence of
movement within the bowel. A study of the temperature and the pulse
may reveal much in certain cases, especially the inflammatory, and
particularly in appendicitis, while the urine may be examined for
indican, and a differential blood count made.

_Meteorism, constipation, and fecal vomiting of themselves indicate
acute obstruction_, but furnish no aid as to the nature of the exciting
cause. They are, however, sufficient to indicate the wisdom of
immediate intervention.

Pathologically every case of intestinal obstruction has an interest of
its own. _Surgically, however_, they are readily grouped _as a class of
cases in which operation should always be performed early_, inasmuch
as it offers the better prospect of relief and in which death is the
inevitable spontaneous termination. It can scarcely be imagined how a
more distressing case than an acute strangulation can be allowed to
go to its fatal termination without being offered the prospect of a
judicious operation, if only performed early. The disfavor with which
operation is received by the general physician, as well as by laymen,
is due to the fact that too much time is wasted with futile drug
treatment, and that the golden hours when surgical intervention might
save are allowed to pass unutilized. Of most of these cases it may be
said that dying after operation they have died _in spite of it rather
than in consequence of it_.

This is particularly true with intussusception and volvulus in young
children or infants. Within six hours, in such cases, the harm which
may be done is necessarily fatal, and to keep them for a day or more,
dosing them with cathartics or making strenuous efforts to relax
invagination, is to deprive them of the only measure which offers them
any chance. The disrepute into which operative treatment of these cases
has fallen in certain quarters is due, then, solely to the fact that
the physician does not call the surgeon early, because there is a time
in the history of nearly every one of them when it could be saved were
mechanical relief afforded.


=Treatment.=--There are certain cases of obstruction by fecal impaction
or lodgement of enteroliths which may be successfully treated by
internal or non-operative means. Could these always be diagnosticated
it would be known when not to operate. But to wait until paralysis of
the bowel has occurred, or gangrene due to stasis, or perforation have
taken place, or septic peritonitis has set in, is to wait far longer
than circumstances justify and reflects on those responsible for the
delay rather than on the operator or the operation. In general terms,
_acute intestinal obstruction is always a surgical disease_.

It is not necessary to wait for accurate diagnosis--_recognition of the
existence of obstruction alone is all that is required_. Conditions
rapidly aggravate themselves, and strength is rapidly lost, if we wait
for more than distinctive symptoms. _There is no palliative treatment
save operation, and the drugs and other harsh measures which are often
prescribed serve to intensify and aggravate rather than to relieve._
Anodynes given, though administered with the most humane intent, serve
only to mask conditions and lead to delay.

Exploration once resolved upon, careful judgment must decide as to
where to place the incision. If local indications be present they may
be followed. If there be good reason to believe that the original cause
was an acute appendicitis, then the incision may be placed upon the
right side. In the absence of all indications the surgeon operates most
safely in the middle line by an incision below, above, or around the
umbilicus, as circumstances may indicate. Edema of the subserous tissue
or of the abdominal muscles indicates the presence of pus beneath.
Peritoneum should be sought and opened with care, as in the presence of
much distended bowel injury to the same may easily occur. The opening
once made the operator will be embarrassed from that time until the
conclusion of the operation by the distention of the bowels--at least
those above the obstruction, and by their being constantly in the
way. If a mechanical cause for obstruction be found it will be noted
that the intestine above is more distended than that below, which
latter may be collapsed and apparently smaller than natural. Thus if a
constricting band be found, or an internal hernia, the removal of the
obstructing cause will permit of prompt restoration of equal gaseous
pressure between the parts above and below.

Scarcely any surgical emergency requires wiser discretion than do
cases of this kind. Bands may be double ligated and divided, kinks
straightened out, twists untwisted, invaginations withdrawn, if this
be possible by reasonable effort. On the other hand the surgeon should
be prepared to find bowel which has apparently lost its vitality or is
actually necrotic, either for a few inches or for several feet, and
he will soon realize that to leave such gangrenous masses within the
abdomen is to accomplish naught, while to remove them is to subject
the patient to a procedure longer and more severe than he can bear. He
must, then, decide whether to close the abdomen for form’s sake and let
the patient die a natural death, or whether to undertake the risk of
resection, or perhaps to leave a considerable portion of the intestinal
canal upon the outside of the body, opening it and establishing an
artificial anus in the hope that the sloughing portion may be cast
off, and that the artificial anus, having served its purpose, may be
subsequently closed by another operation. Such cases live, though not
very often. Here, perhaps as often as anywhere, can be seen the most
desperate expedient succeed and the most trifling measure fail.

Another question is what to do with distended and paralyzed intestine,
especially when it appears impossible to restore it to the abdominal
cavity. Paralyzed as it is, it is almost too much to hope that it
may recover its tone, and distended as it is, it is practically
unmanageable. To open it at one point would be to empty several loops,
at least of gas and probably of fluid fecal matter, all of which
will help. One cannot but reflect on the toxic nature of all fecal
matter so retained and feel that could it all be evacuated the patient
would, other things being equal, be in vastly better condition. And so
operators have often made openings, taking all possible precautions
to prevent contamination, and have not only evacuated a considerable
length of the intestinal canal, but, as suggested by Mixter and others,
have washed it out.

A more perfect method, however, of accomplishing this purpose has
been suggested by Monks, of Boston, in the use of a large glass tube,
from twenty to twenty-four inches in length, strong and with smooth
ends. He has shown how, an opening having been made, say just above
the obstruction, it is possible by manipulating the bowel with gauze
pads to draw it over the tube (as shown in Fig. 563), to an extent
of several feet, and to thus more completely evacuate it than could
be accomplished in any other way. Monks is undoubtedly entitled to
priority for this suggestion over Moynihan, who has elaborately figured
and described it. All in all this permits better management and more
complete effect than any other method. The bowel having been emptied,
the opening is closed by the usual double row of sutures and is then
easily dropped back into the abdominal cavity. Cases occur where this
procedure might be carried out at two different points, say above and
below the obstruction.

[Illustration: FIG. 563

Method of inserting a tube (through an enterostomy opening) a
considerable distance into the intestine by drawing the intestine
around it with the help of a piece of dry gauze. The tube used in this
case has a curved extremity, the opening being on the concavity of the
curve. It is shown entire at the lower left corner of the illustration.
The longer the abdominal incision and the longer the tube the greater
the length of intestine which may be drawn upon it and emptied of its
contents. (Monks.)]

What may be done with the obstruction produced by local and
septic peritonitis, such as is especially seen in acute cases of
cholecystitis, appendicitis, and pyosalpinx? Here the surgeon deals
not only with twisted, kinked, and obstructed bowel, tensely distended,
but with much infected lymph and perhaps a collection of pus and a
gangrenous appendix. Such a condition becomes appalling and every
such case should be dealt with upon its merits. Any collection of pus
should be evacuated and drained, and it must then be decided whether
to endeavor to withdraw entangled loops, disengage and straighten them
out, or to be content with an artificial anus for temporary purposes,
the latter often being the safer course, even though it may lead to
a tedious convalescence and the necessity for subsequent operation.
It might even be advisable to evacuate pus and remove a sloughing
appendix, if it were easily found, and then make an enterostomy,
opening at some other point, in order to keep the two procedures and
fields of activity quite distinct.

A case may occasionally be seen where the question of affording some
relief is paramount to every other consideration, and where, at
the same time, the patient’s condition is such as to make anything
extra-hazardous. I have saved life under conditions of this kind by
making a simple enterostomy under cocaine, the intent being only to
attach a loop of distended bowel to the parietal peritoneum and to open
it then or a little later, thus establishing an artificial anus. This
may be done with local cocaine anesthesia. I have even seen the fecal
fistula thus produced close spontaneously in the course of time, and,
while the exact character of the lesion was never known, have had the
satisfaction of thus saving a life which I believe would otherwise have
been lost.

One of the most unfortunate accidents that can occur during operation
for acute obstruction is to have the patient practically drown in
his own fecal vomit. This may occur either on the operating table or
soon after leaving it. The term implies simply this--that there is
regurgitation of fecal matter into the stomach, and that as this is
ejected by a patient in his unconscious condition he is not able to
prevent its aspiration into the trachea, with the occurrence of all
that essentially constitutes drowning. Even a few ounces of fluid
material drawn into the lungs, under these circumstances, would be
sufficient to cause asphyxia and death.

The accident is to be prevented not alone by _lavage_, both before
and at the conclusion of the operation, but by placing the patient
upon his side in such a way that any gush of fluid into the mouth may
escape from it and not be sucked into the lung. The amount of fluid
that may arise is sometimes astonishing. The introduction of harmless
fluid, under these circumstances, would be sufficient, but the entrance
into the lungs of a viscid, offensive, and septic fluid, even in small
quantity, would quickly serve to induce a septic pneumonia if nothing
else. The accident once having occurred, resuscitation is almost
impossible. Under the relaxation of anesthesia it may occur without
outcry and almost unsuspected, and with the patient on his back, death
may be determined even before the attendant has noticed anything
particularly wrong. To prevent this accident tubes have been devised
having balloons around them which can be inflated with air, to the
desired degree, and the esophagus thus be plugged.

Hence it will be seen that the surgeon should temper his measures
to the condition of the case, its exigencies and its surroundings.
Operation, therefore, may be exceedingly mild or exceedingly severe,
taxing the resources of the best-equipped clinic.

Strangulations recognized from surface indications are usually dealt
with according to standard indications. Those discovered only after
abdominal section are to be dealt with each on its merits.


CHRONIC OBSTRUCTION OF THE BOWEL.

The expressions of chronic obstruction are essentially those of acute,
in which they usually terminate, occurring meantime in milder degree.
Their causes are nowise different from those tabulated above.


=Symptoms.=--The symptoms of chronic obstruction are those of
intermittent colic, constipation, perhaps with local tenderness,
with change in shape of the abdomen due to the primary cause or to
intestinal distention, and in many instances with some characteristic
appearance or shape of the feces. Thus the stools are often loose, or
scybalous masses when removed by cathartics, and these are followed by
diarrheal stools containing many gaseous bubbles. Obstruction of the
lower bowel will frequently cause the hardened fecal masses to assume
a tape-like shape. With increasing obstruction there is increasing
severity of symptoms, until finally they become acute.


=Treatment.=--The treatment of chronic obstruction is also operative,
either radical or palliative. When the exciting cause can not only be
detected on exploration but removed, it should be radical. If, however,
this be not possible then enterostomy or entero-anastomosis only can be
practised. Thus in cancer of the rectum or sigmoid, colostomy is the
last resort. In cancer of the bowel above the sigmoid anastomosis may
relieve the obstruction and permit the patient to linger until he dies
of the natural progress of the disease.

Here, as elsewhere, operation should not be too long delayed. To wait
for a chronic obstruction to merge into one of the acute forms, and
then to wait until the patient is moribund, is to have deliberately
deprived him of that which otherwise might have prolonged his life.

For chronic obstruction whose cause is not easily revealed the
hypothesis of cancer affords the most common explanation. This may be
intrinsic or extrinsic, so far as the bowel itself is concerned, the
results however not differing. It matters but little whether cancer is
producing an annular stricture or involving a considerable extent of
bowel, something should be done. When health has gradually failed, and
obstructive symptoms have come on slowly, and when distinct cachexia
is present the presence of cancer within the abdomen may be suspected.
When a distinct tumor is palpable or when the abdomen gradually
fills with fluid there is little doubt. When to these signs is added
_pigmentation of the abdominal wall_ the diagnosis may be considered
certain. Even now exploratory section is justified, in the hope that
some operative measure may offer comfort and at least temporary relief.

On the other hand, when obstructive symptoms appear and increase
without the accompaniment of other serious indications, it may be
hoped that the condition is benign rather than malignant. Obstruction
with ascites may possibly be due to _tuberculous_ lesions, which are
not uncommon, especially in children. The recognition of enlarged
mesenteric nodes would corroborate this diagnosis. A history of typhoid
fever or of injuries or foreign bodies might confirm the theory of
cicatricial stenosis. The possibility of enteroptosis of the colon and
impaction of hardened fecal matters should not be disregarded and that
of enteroliths, especially gallstones, not forgotten.


FECAL FISTULA; ARTIFICIAL ANUS.

A fecal fistula implies any communication between the intestinal tract
and the exterior of the body or one of its other cavities. Thus it is
possible to have a _rectovaginal_ fistula as well as a vesicovaginal.
In rare instances we may meet also with intestinal communication with
the bladder, the other viscera, or even the pleura or lungs.

Fecal fistulas are always abnormal productions, and result either from
congenital causes, previous injury, or disease. Among the traumatic
causes may be mentioned penetrations or ruptures of the intestines,
injuries to the bowel occurring in the course of abdominal operations
(for instance, the inclusion of some part of the bowel wall within
a ligature or suture), while the pathological causes include the
possibilities of perforation of any form of ulcerative lesion,
cancer, actinomycosis, or the secondary sloughing which may follow
appendicitis, or even the pressure of a drainage tube. Fistulas
result also from escape of foreign bodes (for instance enteroliths or
bone fragments), which may work their way into some other viscus, or
out through the abdominal wall to the body surface. Old pelvic and
abdominal abscesses also occasionally cause perforation and fecal
fistulas. These fistulous tracts may be long or short, and direct or
indirect. They may also permit the escape of a large amount of fecal
matter or the smallest appreciable amount. The majority of them tend to
close spontaneously in the course of time, but this time is sometimes
so prolonged that a surgical operation is preferable to waiting for
natural processes. The communications may be high in the intestinal
canal. In such a case matter that escapes will be but partially
digested and will have the character of chyme rather than of feces;
and patients suffer in consequence, as products of digestion are not
complete and opportunities for absorption have been too limited, and
they are deprived of all that should normally happen further along in
the bowel. In such a case there is temptation to operate much earlier
than is advisable. Another form of fistula results from certain cases
of strangulated hernia, in consequence of necrosis of the strangulated
loop of bowel. In fact this is true of any of the mechanical causes
of acute obstruction, where this expedient may be resorted to under
compulsion and we produce a fistula as an emergency measure.

The difference between intestinal or fecal fistula and artificial anus
is that the former is an undesirable and untoward event, whereas the
latter is deliberately produced by operation practised for the purpose.
_Artificial anus_ is in the main limited to cases of cancerous or other
hopeless or inoperable obstruction of the lower bowel, and in such case
is purely a palliative measure. It is made occasionally at the upper
end of the colon in order to give a diseased colon physiological rest
and permit of more perfect irrigation of that tube, the intent being
to later close the opening. It is an inevitable emergency measure
in certain cases of acute obstruction, where the patient is in no
condition to bear anything more extensive or prolonged.

The operation for making an artificial anus, usually referred to as
_enterostomy_ or _colostomy_, will be described below.

Fecal fistulas should be treated largely according to their causes;
when they are the product of actinomycotic or cancerous disease little
can be done, and perhaps nothing should be. On the other hand, when
resulting from traumatism, from sloughing of some portion of the bowel,
or from strangulation, much can be accomplished.

A small, fistulous tract should be kept clean and stimulated
occasionally with silver nitrate or something of the kind, and perhaps
by introducing into it every day a small piece of gauze, which
provokes the granulation process as well as fills the opening. It
is bad practice, however, to simply close the outer end and let the
lower portion distend with feces. Much will depend upon whether it now
connects with the bowel. This may be determined by injecting into the
fistula some methyl blue and then noting the subsequent stools. When
communication with the bowel is evidently free the surgeon may feel
like making a deeper operation, perhaps with intestinal suture or even
intestinal resection, whereas if there be little or no actual fecal
leakage it may be sufficient to enlarge the outer end of the fistula,
to thoroughly scrape it with the sharp spoon, and then, lightly packing
it, see it close with granulations. A passage-way which is exceedingly
short may be treated by simple superficial plastic operation, including
freshening of the entire margin of the opening and the passage around
it, and a purse-string suture, with or without a circular incision of
the skin. By drawing this suture tight the external opening may be
closed. This is a neat way in which to dispose of a small fistulous
opening resulting from a previous enterostomy or appendicitis operation.

A _rectovaginal fistula_ may be closed by formal operation, similar to
that for closure of a _vesicovaginal fistula_, based upon the simple
principle of freshening the edges of the opening and then holding them
together with suitably placed sutures. A rectovesical fistula would, in
most instances at least, require a laparotomy, with careful separation
of the rectum from the bladder, and then a separate suture of each
opening. Such an operation might be quite difficult, made so not by
its plan of performance but by the conditions which necessitated it.
Any bladder thus attacked should be kept perfectly empty for several
days by the use of a self-retaining catheter. Every case of fecal
communication with any large abscess cavity, or through the diaphragm,
directly or indirectly, as with a bronchus, should be treated on its
individual merits, it being a grave question whether operation would be
indicated or not.

Certain fecal fistulas will justify more formidable operation, in
which, after opening the abdomen and carefully protecting its contents
against contamination, the adhesions should be separated entirely and
that portion of the bowel which is involved removed, making either
an end-to-end suture or a lateral approximation. If this be done it
will be best also to completely excise the old fistulous tract through
the abdominal wall, and to remove everything that was involved in the
previous condition.

It is possible to atone for almost every opening of this character,
save those produced by some seriously malignant disease. If such a
condition be the result of cancerous extension then it is practically
hopeless.


OPERATIONS UPON THE INTESTINE.


=Intestinal Suture.=--Intestinal suture is by no means a new or modern
operation. It was spoken of by the ancient writers and was evidently
practised in the middle ages by the “Four Masters” of the School of
Salernum and their followers. But until it was reduced to a science
by the French surgeons, Jobert and Lembert, during the first quarter
of the past century, it was always a hazardous measure. Success with
intestinal suture depends upon exact hemostasis of the edges to be
united and their accurate approximation in layers (_i. e._, mucosa
to mucosa and serous and muscular coat to its like). Save when haste
compels, this accurate application is effected by two distinct suture
rows, the first or deeper (of hardened gut) made to include the mucosa
alone, the suture being usually continuous, but knotted at intervals,
with stitches close together and drawn tightly to amply secure against
leakage from the relatively large vessels of this membrane. It is
better to apply this row by itself, as any suture drawn through the
mucosa and out again through the serous coat is liable to contaminate
the latter, it being much better to keep the contaminated row of
sutures distinct. The first row having been applied and the surface
carefully cleansed the operator may then coapt the balance of the
annular wound by a continuous row of fine silk sutures, made to include
the serous and muscular coats and to avoid the mucosa. The stomach and
the colon are sufficiently thick to take a row of rather coarse sutures
for this purpose, but most of the small intestine is so thin-walled
that these need to be applied with caution as well as with dexterity.

Every row of sutures should be so applied and directed that the lumen
of the bowel be not reduced by its presence, it being a serious matter
to greatly encroach upon the diameter of the bowel, since obstruction
will thereby be favored and extra tension made upon the sutures (Figs.
564 and 565).

[Illustration: FIG. 564

Application of the interrupted Lembert suture. (Richardson.)]

[Illustration: FIG. 565

The continuous Lembert stitch. (Richardson.)]

So many different forms of intestinal suture have been devised that it
is useless to attempt here to describe them all.

Any minute puncture of the bowel may be closed by purse-string suture.
Any perforating wound should be not only first carefully cleansed, but
also slightly enlarged, cutting away its more or less contused margins
in order that fresh, viable tissue may be exposed. This is particularly
true of gunshot wounds. Many of the operations now practised include
inversion of the end of the bowel, a method illustrated in Fig. 566,
showing a method equally applicable to burying the stump after removing
the appendix, closing the end of a portion of the small or even the
large bowel.

Most operators now use for the mucosa a carefully prepared and
reliable chromicized catgut, the smaller size being preferable, with
the ends cut short after the knots are tied. It is well also to use
for intestinal suture needles which are round rather than made with
cutting edges, as by the latter openings are made larger and vessels
sometimes cut, this requiring the insertion of extra sutures for their
securement. Whether the operator shall use curved or straight needles,
and shall do the work with his fingers or depend upon various forms of
needle holders, is purely a matter of choice and training. _Success or
failure depend not so much upon the needle holder as upon the holder
of the needle_, and his care and attention to detail. In the presence
of multiple lesions the procedure may have to be repeated to meet each
indication.


=Anastomotic Operations.=--For the general application of the principle
of anastomosis to intestinal work the profession is largely indebted to
Senn. The principle having been once recognized will never be rejected,
but methods have already varied much from those first introduced, and
will be improved by the substitution of simpler procedures for the more
complex.

In general an anastomotic opening may be made between any distinct
portions of the alimentary canal, and almost any one part may be thus,
as it were, connected up with any other. Gastrojejunostomy has already
been described. Only under compulsion does one thus connect the stomach
with any other part of the alimentary canal. From the jejunum down to
the rectum one may, however, effect attachments of this kind at any
desired point. These operations are in the main done for one of the
following purposes:

  (_a_) In cases of obstruction of the bowel;

  (_b_) For the purpose of exclusion of a certain length; or

  (_c_) As a substitute for end-to-end reunion, after resection of a
  portion of the bowel.

The method of performance will depend not so much upon the nature of
the difficulty requiring the operation as upon the condition of the
patient, the equipment, and the operative skill of the surgeon. With a
patient in extremely serious condition that method which may be most
quickly performed is obviously the best. When time and method are under
control, then that is best which can be most perfectly performed by
the operator, or that which he is compelled to adopt, as when, for
instance, he resorts to a suture method because he has no button at
hand.

In order to simplify the subject as much as possible the following
methods alone will be mentioned here:

The _method by suture_ is essentially similar to that described as
gastro-anastomosis, the surfaces which are to be brought together being
properly placed, and approximated, first, by a row of silk suture, the
openings being then made with excision of a strip of mucosa, and the
mucosa being next sutured with chromic gut, first on the further side,
then on the near side of the opening, after which the serous membranes
are accurately sutured around the opening by continuation of the first
row of silk sutures. The actual opening made for the purpose should
be at least an inch in length, preferably an inch and a half or more,
while when the lower bowel is attached to the colon such an opening
may well have a length of at least 2¹⁄₂ inches, for if successful it
will be followed by a certain degree of cicatricial contraction and
will never remain of its original size (Figs. 566, 567, 568 and 569).
The suture may be combined with the _elastic ligature_, the method
again being similar to that for uniting the jejunum with the stomach,
already described. The rubber ligature used for the purpose is of the
same size, and there is no difference to be made in the directions
already given. The elastic ligature, however, can not be relied upon
in emergency cases where it is necessary to effect a communication at
once. It is serviceable only in instances where there is a leeway of
at least three or four days. This method has for one of its advantages
the fact that in its performance it is not necessary to clamp or secure
the bowel by any instrument, simply to empty it for the moment with
the fingers, it not being opened during the operation by anything save
the needle puncture, which is promptly filled with the rubber. It
does require, however, that the rubber used for the purpose shall be
reliable and new, it being unfortunately the case that pure rubber
which will last for a long time is seldom found in the market.

[Illustration: FIG. 566

Entero-anastomosis of intestinal loops which have been resected and the
bowel ends closed; the first row of sutures has been applied and the
line of opening indicated. (Lejars.)]

[Illustration: FIG. 567

Suture of the distal edges of the mucosa.]

[Illustration: FIG. 568

Insertion of the last (fourth) row of sutures. (Lejars.)]

[Illustration: FIG. 569

Resection of intestine with lateral anastomosis. Posterior suture
inserted. The free ends of the bowel inverted and sutured.
(Richardson.)]

The button method depends for its success upon a mechanical device of
Murphy, known everywhere as the “_Murphy button_,” or upon one of its
modifications. Fig. 570 illustrates the component parts of this device,
which is made in various sizes and, in fact, in various shapes for
different purposes, though the circular forms suffice for practically
all cases. In Fig. 572 it is seen in actual use, while Figs. 573 and
574 illustrate the method of its insertion and securement.

[Illustration: FIG. 570

The Murphy button.]

[Illustration: FIG. 571

End-to-end union of intestine by means of the Murphy button: the
two portions of the Murphy button, held in position by purse-string
sutures, are ready to be pressed together. (Richardson.)]

[Illustration: FIG. 572

Union--end to end--with the Murphy button.]

The underlying principle of the Murphy button is that each half can be
inserted separately and that then, by pressing these halves together,
an opening is at once afforded from one part of the bowel to the other.
If the halves be pressed together with the proper degree of firmness
they produce, first, adhesion between considerable areas around their
circumference, followed in the course of a few days by a necrosis of
the central portion, which sloughs because deprived of its circulation
by the pressure. So soon as this separation or sloughing is complete
the button drops into the intestinal canal, being completely loosened,
and is now carried along by peristalsis and by the fecal current from
above, its position shifting as would that of a scybalous mass or a
fecal concretion, until it finally emerges from the intestinal tube,
being passed from the anus. How soon it will thus appear will depend in
large measure upon the point of the intestinal canal into which it is
thus intruded. If this be high up it will be slower in appearing. If
low down it may be expected sooner. While it usually appears within ten
days or two weeks it may, however, be longer retained, and in one case
of my own was not passed for three months, although the anastomosis
was made with the ascending colon, into which it must have dropped.

Fig. 573 shows one of the halves held in the grasp of a forceps, being
inserted into a small buttonhole opening just large enough to receive
it, around which there has been passed a buttonhole or purse-string
suture of silk. This portion once thus inserted should not be lost
within the bowel, it being necessary to retain control of it by the
forceps until its application to the other half. Both halves being
inserted and brought opposite to each other, as in Fig. 574, the
smaller is introduced into the larger, and they are then pressed
together until the included serous surfaces are brought into contact,
with sufficient pressure inflicted to bleach them, in order that their
subsequent necrosis may be ensured. A circular row of sutures should
now be placed around the surfaces thus applied, in order to more widely
secure them in contact. The procedure being completed in this way, the
parts are dropped back into the abdomen and the abdominal wound closed.

[Illustration: FIG. 573

Introduction of one-half of a Murphy button. (Bergmann.)]

[Illustration: FIG. 574

Intestinal anastomosis with a Murphy button, showing the halves in
position ready to be pushed together. (Bergmann.)]

_End-to-end reunion_ can be accomplished by the same method, or the end
of the small intestine may be applied to the side of the large, after a
method which will be best understood by reference to Fig. 571, it being
necessary here to draw the squarely cut end of the intestine around the
button with a circular suture, and, at the same time, to so grasp the
button that it shall not recede into and be lost in the bowel.

Small buttons have been made for the purpose of uniting the
gall-bladder to the upper bowel and extra large ones are made for the
large intestine.

The particular advantage of the button method is the shortness of the
time required for its performance, as it can be conducted in a few
moments by one who might take four times as many minutes in using
sutures. The disadvantages attaching to it are these: (1) That it
depends for its success upon necrosis, _i. e._, of the part of the
bowel included within its grasp; (2) that it might itself serve as a
foreign body and produce acute obstruction, a not unknown event; (3)
that it is not always at hand, especially in emergency cases, and that
to rely upon it is to be limited in one’s abilities.

There is but little question that, when properly performed, the simple
suture methods are the best of all, and the operator who has never seen
a button used should abstain from its use. Still it has given many good
results. My belief is that the better the surgeon’s judgment, and the
more developed his skill, the less he will rely upon any mechanical
expedient of this character, and the more upon what he can accomplish
with the needle in his own fingers.

_End-to-side anastomosis_ is in no essential respect different from
resection, only it may be done for the purpose of exclusion when
nothing is absolutely removed. Thus in case of cancer of the cecum a
lateral implantation can be made of a lower loop of the ileum upon
the side of the ascending colon, using for this purpose a button,
having divided the ileum on the proximal side of the ileocecal valve,
and turned in both ends and invaginated the stumps. Here one resects
nothing, but makes a direct communication between the bowel above
and below the cancer, short-circuiting the intestinal canal, as
electricians would say, and all for the purpose of giving temporary
relief. Thus end-to-side or end-to-end anastomosis may be made,
according as circumstances dictate, and, if one chooses, with the
Murphy button.

_Resection of some portion of the large or small intestine_ is
required under a variety of different circumstances. Thus after
certain injuries, contusion and rupture, or numerous punctures or
gunshot perforations, it may be decided to remove a considerable
length of bowel rather than be compelled to give special attention to
a number of distinct lesions, believing it a time-saving measure, and,
therefore, for the welfare of the individual. The same measure will be
indicated when, either by injury or disease, the blood supply of any
portion of the bowel is apparently compromised or certainly shut off.
Here necrosis is so certainly to be expected, or perhaps has already
occurred, in such a way as to necessitate removal of whatever length of
bowel may thus be involved. Several of those cases, already mentioned,
which produce obstruction of the bowel will demand resection, as,
for instance, when reduction of an invagination is impossible,
with gangrene threatening. In a few instances extensive gangrene,
precipitated by embolism or thrombosis of the mesenteric vessels, has
been successfully treated by resection of considerable lengths of
bowel. Again, the bowel is resected for closure of fecal fistula or
artificial anus, as well as for relief of stricture due to various
causes. Finally, nearly all of the tumors of the intestine itself,
and especially all of the malignant forms, will require removal of at
least a few inches of gut, save in those cases where this is shown to
be impracticable because of the presence of cancer elsewhere, in which
case it may be sufficient to make an anastomosis.

When intestinal resection is not an emergency measure there should be
as much preparation as the case will permit, including lavage of the
stomach, the ingestion of sterilized food, the use of antiseptics and
the most thorough emptying of the bowel which can be accomplished.[58]

  [58] Sanderson has suggested a new method of sterilization of the
  interior of the bowel at the time of operation. He injects a solution
  of acetozone through a hypodermic needle, or, after opening the
  bowel, freely irrigates with the same.

One of the greatest difficulties attendant upon the operation is the
avoidance of all contamination by contact of peritoneum with intestinal
contents. Against this the most minute precautions should be taken.
This is never an easy matter, and in the presence of distended bowels
and the emergency of acute obstruction it sometimes taxes every
resource at hand. A variety of clamps have been devised by different
operators, the intent being to so clasp the bowel beneath their blades
as to completely occlude it. These blades are covered with sterilized
rubber tubing to keep them from acting too harshly, and it is necessary
to use pressure upon the handles with great discretion, lest permanent
injury be done to the bloodvessels. The bloodvessels of the bowel are
essentially terminal, and the blood supply should be kept sufficient
for every part which is not removed. These vessels are, moreover,
numerous and relatively large, and hemorrhage is not always easy of
control, especially when clamps are not at hand. As a substitute for
clamps tapes of sterilized gauze may be used, being tied around the
bowel, or the fingers of a reliable assistant may be substituted. Such
use of the fingers is not easy nor simple, not only because they become
tired and relax their grasp, but since they slip so easily, and because
the escape of one drop of fecal matter may cause a fatal contamination.

Resection of the bowel may imply in one case a removal of but two or
three inches of its length, while the other extreme is not reached
until several feet of bowel have been removed. I have been able to
successfully remove eight feet and nine inches of intestine, the lower
part including the cecum and a portion of the ascending colon, and
there are now on record nearly twenty cases where over 200 Cm. of
bowel have been resected, nearly all of them recovering. Success in
this procedure depends partly upon the condition necessitating the
operation, as well as the general condition of the patient, but in no
small measure hangs upon the perfection of the operator’s technique.

[Illustration: FIG. 575

End-to-end or circular anastomosis by enterorrhaphy. First row of
distal sutures in serosa. (Type of needle differs from that used in
this country). (Lejars.)]

[Illustration: FIG. 576

Completion of last row of sutures, begun as shown in Fig. 575.
(Lejars.)]

Whatever be the condition which requires such resection it should be
made sufficiently extensive to completely include and permit the total
removal of the diseased or injured portion. The abdominal incision
should be large enough to permit the delivery upon the surface of
the body of all that portion to be removed. Unless this be done the
difficulties are greatly enhanced. Save where there is some distinct
indication for opening elsewhere, this incision is made in the middle
line. The compromised bowel having been sought and thus delivered and
one having decided exactly where to divide it, clamps are so placed
both above and below each line of division as to prevent leakage.
Underneath the bowel to be thus divided gauze is placed in such a way
as to receive the small amount of discharge which will escape from the
portion between the clamps. The exposed bowel surfaces should then
be thoroughly cleaned, the contaminated gauze removed, fresh pieces
substituted for it, and the other division of bowel made in the same
way. While in some cases it may be well to tie off the mesenteric
border and secure all its vessels before dividing the bowel, this may
at other times be delayed until after the division. At all events it
is the next step. Whether the mesentery shall be simply separated
along the intestinal border and tied off in small portions, one
after another, or whether a triangular resection of a portion of the
mesentery itself should be made, securing the larger vessels nearer to
its root, will depend on the nature of the case and upon whether the
mesentery itself be involved in the disease. In dealing with cancer
it is often necessary to remove, at the same time, every enlarged
lymphatic. It may be inferred that no incision or tear, no matter
how short, can be made in these tissues without danger of subsequent
hemorrhage unless the parts be secured against it. A series of
ligatures and sutures is therefore called for here which may consume
no small proportion of the entire time of the operation. (See Figs. 575
and 576.)

All that portion of bowel which has been condemned having been removed
and a careful toilet of the parts having been made the surgeon next
proceeds to restore the bowel lumen. A V-shaped defect in the mesentery
should be united with sutures. The line of former mesenteric border
left after removal of bowel should be not only carefully protected with
ligatures, but the whole margin should be overcast and so folded in
or drawn together in tucks as to make it easy to bring the bowel ends
together without undue stress.

[Illustration: FIG. 577

FIG. 578

Circular anastomosis of portions of the bowel having different lumina.
(Bergmann.)]

The sutures by which the divided bowel is restored should begin at the
mesenteric border, and every care should be taken to make the joint at
this point absolutely water-tight. Suture methods have been described.
To unite bowel ends of the same diameter it is an easy matter to suture
together first the mucosa and then the outer layer, so long as the
intestine is on the outside of the body and equally accessible on all
sides (Fig. 578). The surgeon is sometimes compelled to do this work
within the body cavity, as in resection of the rectum for cancer. It
may be advisable to first place a row of sutures between the serosa
and muscularis on the further side of the margins to be united, then
to close the mucosa completely around, and then to finish the outer
layer of sutures. So long as differences of size are not conspicuous,
end-to-end approximation can be made almost anywhere. When, however,
it is necessary to attach small bowel to large, the size of the larger
opening should be reduced to fit the smaller, or one or both ends
may be closed, turning in the stump, as already described, and then
making lateral or end-to-side anastomosis. Any such anastomotic opening
should be so placed, and bowel so directed, that there shall be no
interference in the direction of the natural bowel stream, failure to
observe this precaution producing not only added immediate danger but
more or less permanent obstruction (Figs. 579 and 580).

[Illustration: FIG. 579

Isoperistaltic lateral apposition.]

[Illustration: FIG. 580

Antiperistaltic lateral apposition (bad).]

All that has been said above with regard to the Murphy button and its
use in anastomotic operations holds equally good here with regard to
its usefulness after resection.

Numerous devices, either instruments for the purpose of holding the
bowel together while it is sutured, or of affording substitutes for the
Murphy button, have been planned by operators all over the world. There
are few of them, however, which give any better results than the simple
methods above described, to which I prefer to limit description here
because of their very simplicity.

Intestinal suture or any other method of completing the resection
having been finished, a careful toilet of all exposed parts should be
made, by which bowel may be dropped back into the abdominal cavity and
the latter closed without drainage.

The _subsequent management_ of these cases will consist in two or
three days’ starvation, in order that peristalsis may be reduced to a
minimum, the patient being meanwhile fed by the rectum. Then will come
a time when both fluid food, and cathartics a little later, should be
gently and discriminately administered. Any satisfactory suture method
will rarely give way after forty-eight hours. Buttons, on the contrary,
may break loose after many days or even weeks, and this fact affords
another argument against their use.

[Illustration: FIG. 581

Enterostomy; preliminary fixation of a loop of bowel to the peritoneum.
(Lejars.)]

[Illustration: FIG. 582

Enterostomy; fixation of margins of opened gut to skin. (Lejars.)]


=Enterostomy.=--Enterostomy for establishment of fecal fistula, or
_artificial anus_, is performed for relief purposes and sometimes as
an emergency measure. It consists in attaching some portion of the
bowel, naturally that above the constriction or disease which compels
the operation, to the parietal peritoneum through a small wound in the
abdominal wall. When the large intestine is opened for this purpose the
operation is usually referred to as a _colostomy_, and this preferably
is done in the left iliac region. When enterostomy of the smaller bowel
is preferable it may be done at any point on the abdominal surface.
Thus if through a median incision a condition be found necessitating it
the bowel should be attached at the lower end of the abdominal opening,
for here drainage will be better and contamination less likely. When
enterostomy is done for acute obstruction, it is preferable to place
the opening in one iliac fossa or the other.

Enterostomy consists essentially of the following steps: opening
through the abdomen, recognition of the parietal peritoneum, which
is seized with forceps on either side, opened and secured with these
forceps, after which the first tensely distended loop of bowel which
presents is taken, and, with a series of fine sutures in a round
needle, the serous surface of the gut is attached to the margins of the
parietal peritoneum (Figs. 581 and 582). In the more desperate cases
a portion of the bowel may be brought out through the wound and fixed
there in such a way that it cannot recede. If the emergency is great
the bowel may be immediately punctured, the patient so placed and so
protected that fecal contents shall escape away from the body rather
than over it. If one can take a little time he may wait a few hours
for the adhesion which is sure to take place between the peritoneal
surfaces and the consequent shutting off of the abdominal cavity from
the outer wound. Thus after twelve hours the surface of bowel exposed
through the wound may be punctured either with a knife, scissors, or
the actual cautery, and this may be done without causing pain to the
patient. Escape of bowel contents will instantly ensue after puncture.
After permitting all to escape that will, abundant protection should be
provided for the reception of the discharges, which will continue at
reduced rate. The best way to do this is to pass into the bowel in the
proper direction a rubber tube, as large as it can accommodate, or a
glass tube, bent at an angle, which shall connect with a flexible tube,
and thus conduct away all discharge.

Another method of performing the operation is to bring out the loop of
bowel, open and empty it, then to introduce a glass or rubber tube,
around which is snugly fastened the bowel margin. The intestine is
then stitched in place and the tube so arranged as to conduct away all
discharge.

Just how much may be expected of such a relief opening will depend upon
the case. These operations, especially for cancer of the rectum or the
lower bowel, may prolong life for two or three years. An emergency
opening into the small bowel for relief of acute obstruction may need
to be kept open for but a few days, after which the tube may be removed
and the fecal fistula be allowed gradually to contract. According to
the case an intestinal resection may be made or the opening may be
closed by one of the plastic methods.


=Appendicostomy.=--Appendicostomy is the more complete form of carrying
out a suggestion first made by Hale White, of opening the colon on
the right side in cases of intractable colitis. Gibson suggested to
accomplish this by a method similar to Kader’s for gastrostomy, making
a valvular colostomy through which the colon might be irrigated,
without escape of feces. In 1902, Weir, intending to do this operation,
found the appendix rising so invitingly into the wound that the
inspiration occurred to him, and was promptly acted upon, to utilize it
for the purpose.

In performing the operation the smallest possible incision should be
made through which the appendix may be delivered, its mesenteric artery
is tied, and its mesentery stripped down to its origin. At the latter
the cecum is fastened to the parietal peritoneum by a suture on either
side, avoiding the appendicular artery itself. The balance of the wound
is then closed as usual, the appendix being fastened to the lower angle
by suture, the protruding part then wrapped with gutta-percha tissue
and included in the dressing. At the end of two days the external
portion may be divided about 1 to 4 inches from the skin, after which
a catheter is passed along its lumen and the stump tied around it.
This serves the double purpose of preventing leakage and severing the
appendix flush with the skin. The catheter is introduced from 2 to 4
inches, and its external portion left open to allow escape of gas, or
doubled and fastened to prevent leakage, as circumstances may require.
Irrigation may be begun on the third or fourth day.

When the appendix is used for the purpose of forming an artificial anus
it will be probably in instances where there is more of the emergency
element present, and it may be sufficient then to simply utilize it for
the purpose of anchoring the cecum to the abdominal wall, or with the
purpose of dilating it after the expiration of a few hours. In other
words, the method may be modified to meet the indication.

It is scarcely necessary to devote space to any other operative
procedures upon the small intestine. Consequently it will simply
be mentioned here that the upper part of the jejunum can be used
for artificial feeding and _jejunostomy_ made to take the place of
gastrostomy under those rare circumstances which may demand it.

Upon the large intestine _colopexy_ may be practised, attaching it
to the anterior abdominal wall or to the border of the liver or the
gastrohepatic omentum. Andrews’ suggestion to attach the colon to
the lower border of the liver, after certain operations upon the
biliary passages, will be described in connection with the latter.
In cases of extreme dilatation, with loss of muscular tone, etc.,
involving especially the colon, an _enteroplication_ may be practised
corresponding to gastroplication, and having the same purpose, with a
technique practically identical with the other. Thus when the sigmoid
flexure is so dilated as to largely fill the abdominal cavity, with an
enormous S-shape, much can be done by thus reducing its dimensions,
the only objection being the fear that the causes which produced the
condition will conspire to reproduce it even after enteroplication.




CHAPTER XLIX.

THE APPENDIX AND ITS DISEASES.[59]

  [59] The laity, as well as part of the profession, having not
  yet ceased to wonder at the great importance attaching today to
  appendicitis, when twenty years ago it was practically unknown, it is
  worth while to insert here the following brief historical account:
  The term “appendicitis” was coined by Fitz for a condition which
  had not been hitherto unknown, but to which he gave a classical
  description. That the appendix might be primarily diseased had
  been known for one hundred and fifty years; that peri-appendicular
  abscesses were frequent may be seen by reference to works of the
  middle and latter part of the past century on perityphlitis and
  perityphlitic abscess, Willard Parker, of New York, being the most
  prominent writer of his day upon this subject. In the _Transactions
  of the Medical Society of the State of New York_ for 1875, Gouley
  reports a case of so-called perityphlitic abscess due to perforation
  of the appendix, with remarks upon its surgical treatment. The
  curious feature attaching to this case was that two years previous
  to its occurrence the patient had swallowed one of his teeth.
  Although this tooth was not found at the time Gouley alluded to the
  possibility of it or any other small body lodging in the appendix and
  finally causing ulceration. He referred also to the case published
  in 1856 by Dr. Lewis, of New York, who reported an individual dying
  at the age of eighty-eight, whose appendix was found to contain
  one hundred and twenty-two deer shot, it appearing that he had
  been exceedingly fond of game; he supposed that the shot found in
  the appendix were contained in meat which he had eaten. Lewis also
  referred to forty-seven cases of foreign bodies which he tabulated,
  all but one of which died.

  Fitz’s article appeared in 1886. In it he claimed that operation
  should be done much earlier than was then the custom, and he showed
  that 34 per cent. of these cases died during the first five days
  of illness. But the first real operation for appendicitis as such
  was done by Krönlein, of Zurich, according to a suggestion made by
  Mikulicz in 1884. The second was done by Symonds, in England, in
  1885, this being an interval operation. The first operation in the
  United States was done by Hall, of New York, in May, 1886, although
  to Morton, of Philadelphia, the credit must be given of the first
  operation in this country on a case deliberately diagnosticated. This
  was in April, 1887, Sands doing the next one in December of the same
  year.

  McBurney had assisted Sands in a large number of cases, and in 1889
  published his classical paper with an account of “The First Recorded
  Case where an Acutely Inflamed Appendix had been Removed while Full
  of Pus.” In the same year Weir also published an elaborate paper,
  making similar recommendations. It is not necessary to follow the
  subject later than the year 1889, since to it every surgeon of note
  has probably contributed.


=Anatomy.=--The vermiform appendix is an embryonic relic, and, like all
such remains, is not merely superfluous, but often troublesome. That
at some time it may have had an ordinary function is not to be denied;
that now, in quadrupeds at least, it has one cannot be successfully
maintained. Its past importance may, however, be perhaps indicated by
the fact that in the ostrich, for instance, it is said to assume a
length of six feet. Because of its relatively wide variations in size,
length, and emplacement, as well as because of its mesenteric and
other anatomical arrangements, its affections are often complicated
and variable in the symptoms they produce. The appendix is, in fact,
a miniature intestinal tube, having the same structure as the small
intestine, though but greatly reduced. Its average length should be 8
to 9 Cm., the shortest on record being 1 Cm., and the longest perhaps
24 Cm. Its average gross diameter should be that of a No. 16 French
catheter, but it may be found 1.5 Cm. in size. The average diameter of
its lumen should be 1 to 3 Mm. The appendicular artery is given off
from the right colic branch of the ileocolic artery, and it ordinarily
divides into four or five branches, according to the length of the
appendix and the extent of its mesentery. It derives its nerve supply
from the superior mesenteric plexus of the sympathetic ganglia, which
itself is connected with the right pneumogastric, this fact explaining
many of the reflexes accompanying its diseases. In it lymph abounds and
lymph follicles are numerous. Around its neck, as around the origin of
every other embryonic canal (as Sutton has shown), is found a _collar
of lymphoid tissue_ corresponding in structure to that seen in the
pharynx. This tissue is inflammable, and succumbs easily to infection.
Hence probably the apparent ease with which infection and gangrene
occur in this locality. The position of the appendix is variable, and
depends in effect on the development of the cecum and the degree of
its rotation during this process. Its most frequent location (40 per
cent.) is behind the cecum. In 30 per cent. of cases it occurs on
its anterior surface or just at its lower end. It may lie as a free
pouch with a loose mesentery, movable in the abdominal cavity, or it
may be essentially a retroperitoneal affair not only not free, but
even difficult to find. In direction it may vary correspondingly.
Thus it may lie behind the colon, perhaps pointing straight upward
toward the liver; it may hang in the pelvis, it may point toward the
sacrum, or it may coil up anteriorly; and, according to the extent and
freedom of its mesentery, in any of these locations, it may either be
unattached and movable or quite bound down. Again, it may lie nearly
straight or it may be kinked, bent, or coiled. It is necessary that
the surgeon appreciate these possible variations, for they account
for vagaries in symptomatology. In brief it should lie in the iliac
fossa, at least, and to the outer side of the iliac vessels, but it
may hang over into the pelvis in 20 to 25 per cent. of cases, or its
tip may rest in a pocket or even in a subcecal fossa. In other words,
it may be found in almost any attitude or position, these variations
being explainable by peculiarities of fetal development. Furthermore
it may even have its own _diverticula_, as has been recently shown.
Normally it should be practically empty, save perhaps for a little
muddy mucus. Very frequently, however, it contains fecal matter, and
upon this fact depends much of its importance. If from retained fecal
matter fecal concretions gradually result, then these become irritants
and may produce either appendicular colic or may predispose to acute
infection. Upon the retention of fecal contents should depend also a
miniature peristalsis, and imitation of what goes on in the intestine
above, in the production of a genuine appendicular colic. How annoying,
painful, or even disabling this may be may be learned from the history
of many a patient. On the other hand the appendix may become gradually
occluded or obliterated, in whole or in part. If this process begin
at its distal end and involve the entire tube it might be considered
a fortunate occurrence for the patient. If, however, it be due to
previous inflammation, or to subinvolution of the previous process,
and if fecal concretions be thus imprisoned, it is hardly desirable
and will frequently lead to trouble. More or less occlusion occurs in
probably at least one-fourth of mankind.

Like the bowel above, the appendix may suffer in various as well
as in similar ways. Thus in it may be seen pathological conditions
which involve the bowel proper. Tuberculosis and actinomycosis may
even occur here as apparently primary lesions, while cysts have been
discovered within its walls, and such tumors as fibromyomas or primary
adenocarcinomas are also met here. I have seen three or four instances
of primary cancer of the appendix, and have now living one patient from
whom six years ago I removed an appendix and adjoining portion of the
cecum involved in most distinct cancer.

Again, the appendix participates in certain hernias and has been found
in instances of strangulated or non-strangulated inguinal and femoral
hernia, and has been seen also in cases of umbilical hernia. Twice I
have found it in the inguinal canal and once in the femoral.

Furthermore when diseased the appendix, like the bowel, may contract
adhesions to certain viscera, while it is now well known that it may
attach itself to the kidney, the bladder, the right ovary, the tubes,
or the uterus. This is of more than mere passing interest, for by such
adhesions cases are not only surgically complicated, but diagnosis is
made difficult, because of associated symptoms pointing to the organ
thus involved.


=Foreign Bodies in the Appendix.=--Foreign bodies are occasionally
found. This expression refers not merely to the fecal concretions
above mentioned, which are practically small enteroliths. Thus, Kelly
has mentioned cases in which ordinary pins have been found in this
location, two of these cases being my own. In one instance I found the
appendix to contain a round-worm at least three inches in length, and
other intestinal parasites have been found by other observers. The
laity have been greatly impressed by the reputed frequency with which
grape and other seeds are found in the appendix, these figuring in
their eyes as exciting causes of disease. In truth seeds are seldom
found, that which has been mistaken for them being fecal concretions of
various sizes and degrees of density. I have found actual seeds two or
three times, but probably not oftener.


=Bacteriology of Appendicitis.=--Acute appendicitis being essentially
an acute infection one inquires naturally which are the organisms most
commonly involved. Answer to this question should be sought rather
in the text-books on pathology, and should be summarized here by
simply saying that the colon bacillus is perhaps more often found in
connection with these cases than any other one organism. Streptococci
and staphylococci rank perhaps next in frequency, while the
pneumococcus, the capsule coccus, and all of the other pyogenic forms
may be present, either as contaminations or in almost pure cultures.
The fauna and flora of the intestinal tract afford ample opportunities
for contaminations with many forms of microbes. If pus found here be a
pure culture of any one organism it is most often of the colon variety,
which is known to vary much in virulence, even when occurring alone.
Mixed infections, however, are more predominant and more serious,
especially in proportion as the more active pyogenic organisms appear
in greater numbers. The bacteriology of appendicitis is then of great
pathological interest, but concerns the surgeon very slightly, unless
he have to do with some peculiar form, such as pyocyaneus, or a
particularly virulent streptococcus.

[Illustration: PLATE LI

Illustrating Various Degrees of Involvement of Appendix Vermiformis.
(Richardson.)

_A._ Chronic, recurring.

_B._ Chronic, much thickened.

_C._ Acute, with necrosis and rupture.

_D._ Showing necrosis of mucous membrane.

_E._ Gangrene and perforation, permitting fecal extravasation.

_F._ Total gangrene without perforation.]


=Appendicular Colic.=--Sufficient has been said above regarding the
appendix as a miniature intestine, its outlet guarded by the little
valve of Gerlach, to afford an anatomical reason why conditions even
in the larger bowel should be imitated here. Some writers have not
placed as much stress upon appendicular colic as I would here. One
sees many instances of it if he will only recognize it, the frequency
of its occurrence not only disturbing the comfort of patients, but
keeping ever before their minds the necessity for operation. An
absolutely empty appendix will be free from all abnormal activity
of this kind, but when a little fecal matter has become imprisoned,
and when by its long retention fecal concretions have formed, they
may give rise to considerable disturbance without actually producing
inflammation, the former being due to the spontaneous effort of the
appendix to expel them. This effort may be excited by other conditions
in the bowel adjoining, but by itself it may be the essentially
relatively violent muscular effort which produces pain and is followed
by soreness. That not a few cases of acute appendicitis commence with
an appendicular colic is extremely probable, and that it may occur
at frequent intervals and never pass the colicky stage is equally
true. _Appendicular colic, then, may be a precursor of an infectious
appendicitis, acting as a predisposing cause, or either may occur
independently of the other._

Indications of this form of colic are frequent, viz., nagging pains in
the region of the cecum, which may last a few moments or a few hours
and then subside, leaving a tenderness which persists for a day or
two, after which the patient seems to be free for a longer or shorter
interval, to suffer again and again in the same way. These attacks may
be accompanied by some nausea, will be found frequently associated with
whatever may have disturbed ordinary intestinal activity, and may even
produce a mild degree of fever, which latter is partly due to mental
perturbation and partly to a mild degree of toxemia, the latter being
possible in connection with abnormal appendicular activity, as the
_appendix itself is a closed sac_ and the very materials which it is
trying to expel may furnish the toxins.

It is difficult to distinguish between appendicular colic and mild
attacks of catarrhal appendicitis. The transitory nature of the former
is its particular diagnostic feature, coupled with absence of all
lasting indications.

The following would seem the simplest working classification of lesions
of the appendix.

                 {Catarrhal. Endo-appendicitis.
                 {
                 {Diffuse.   Parietal or   {Hyperplastic.
                 {           interstitial. {Obliterative.
                 {
  _A._ Acute.    {          {Intertubular.
                 {Purulent. {Intramural.
                 {          {Peri-appendicular.
                 {           Any of these may lead to
                 {Gangrenous or
                 {Perforative lesions.

  _B._ Subacute.  Recurrent or relapsing.

  _C._ Adhesive or obliterative.

Almost any of the above forms may be associated with diseases of
other abdominal viscera, as, for example, with typhoid. Thus out of
119 autopsies on typhoid patients 19 showed changes in the appendix
corresponding to those produced by the typhoid organisms in other
portions of the intestines. (Kelly.) Of 3770 autopsies on tuberculous
patients tuberculous lesions were noted in the appendix in 44
instances. The appendix may also become involved with any form of
ileocolitis, either in the young or in the adult. Again an infection of
the right tube and ovary may easily extend to and involve the appendix,
just as infection may travel in the opposite direction. (See Plate LI.)

Before discussing the causes of this condition it is advisable to
take a comprehensive view of the entire subject in its pathological
relations. As Dieulafoy has shown, appendicitis is the consequence
of the transformation of the hollow conduit into a closed cavity,
whose length and narrowness make it liable to such changes, for
which various causes are to be assigned: for example, the formation
of calculi or concretions which are quite comparable to renal or
biliary and which lead to a true appendicular lithiasis. There is even
reason to believe that a calculous appendicitis may be hereditary and
belong to the patrimony of gout. At other times it is the consequence
of local infection, followed by tumefaction, and corresponding to
obstruction of the Eustachian or the Fallopian tubes. Again it results
from slow, progressive fibrous alterations or from the strangulations
due to twisting or formation of adhesions. In any event the closed
cavity varies in size and shape, and does not necessarily lead to
self-destruction unless the bacteria thus pent up are sufficiently
virulent. At all events the attack declares itself only when the cavity
is actually closed, and it is then that imprisoned bacteria, previously
harmless, multiply and intensify their virulence, as they do in a
blocked loop of bowel. At times an acute intoxication from toxins is
produced, and may be so pronounced that patients succumb to it almost
before the characteristic lesions, or any local peritonitis, has become
fairly outlined. On the other hand if retained bacteria be but slightly
virulent, or have been successfully conquered by phagocytes, or if the
canal has become pervious again, the attack may spontaneously subside,
although there is great probability of recurrence. In many instances
the infection ends in ulceration, abscess, gangrene or perforation,
all of which may give rise to peritonitis of varying extent and
severity. Germs may traverse the walls of an affected appendix without
perforation. It may then become the direct cause of peritonitis,
septicemia, or hepatic abscess.


=Recurrent Appendicitis.=--_Every attack of appendicitis, no matter
how mild, predisposes to a repetition of the trouble, in mild or in
fulminating form._ Every appendix once inflamed has had its blood
supply compromised and may break down easily upon a second attack.
While not every patient who has once suffered in this way should
necessarily suffer again, the majority who have had one attack may
have another. No one can be prophetic in this regard and no one may
truly assert that several mild attacks may not be followed by another
most severe. That an appendix has been once inflamed is sufficient
to justify its subsequent removal. That it has been several times
involved makes operation next to imperative. Even repeated attacks
of appendicular colic predispose to trouble in this region. In any
appendix which has in this way frequently excited suspicion, or which
gives rise to frequently recurring though mild colicky pain and local
tenderness, especially when coupled with mild stercoremia, indications
are for removal. It may be safely laid down, then, as a rule, to
which there should be few exceptions, that _any appendix which causes
frequently recurring or almost continuous trouble should be removed_.


=Causes.=--It is impossible in any brief summary to include all the
possible causes of appendicitis. Those mentioned below are perhaps
those most commonly recognized or pronounced, yet the list is far from
complete. First of all it should be remembered that the disease occurs
in a vestigial organ, containing relatively considerable lymphoid
tissue, especially around its neck, that it is comparatively poorly
supplied with blood, and that such tissue under such circumstances
inflames easily and breaks down quickly. Doubtless the trouble in some
instances commences within the tiny intestinal tube. At other times its
originating cause lies without, as, for instance, when its blood supply
is interfered with by pressure of an overloaded cecum, by tumors,
or by violent intestinal activity; this especially in connection
with an appendix firmly anchored and not freely movable, it being
so fixed in many instances that it cannot readjust itself easily to
varying conditions. Thus an overloaded cecum may first press upon the
appendix and then by violence of activity so displace it that it may
easily succumb. Again in those appendices which hang downward into the
pelvis there is little or no drainage by gravity, and they may easily
become overloaded. A movable kidney may also disturb the integrity of
an appendix in certain locations. Foreign bodies frequently excite
pernicious activity, especially fecal concretions, and actual calculi
or miniature enteroliths. Traumatism sustains a certain relation to
some cases of violent activity of the psoas muscles in athletes, which
may upset the circulation of appendices which lie directly upon the
muscles involved.

Many of the causes mentioned above are predisposing rather than actual.
The actual exciting causes of acute infection have mainly to do with
_germ activity_ and with _vascular supply_. It is well known that the
more virulent the organisms the more acute the resulting inflammation,
and it is also well known that colon bacilli and the ordinary pyogenic
organisms vary in virulence within wide limits, and that mixed are
often more acute than simple infections. Typhoid bacilli, tuberculous
bacilli and the like vary in the same way, and, in company with other
germs, may easily light up serious disturbance.


=Complications.=--Of the complications which may accompany or ensue
upon appendicitis the most common are those which involve the
peritoneum, either local or general. Acute peritonitis is to be
feared not only because of its autotoxic expressions, but because
of the acute obstruction which it may produce by gluing intestinal
loops together and paralyzing their motility. When to more or less
widespread peritonitis are added general sepsis, with all its possible
complications, and such further local expressions as cellulitis, which
may be pericolic, subphrenic, perineal, or pelvic, or phlebitis which,
involving the portal system, would soon lead to formation of hepatic
abscess, it will be seen how easily the case may become serious.
Furthermore not only may the ovary and tube suffer, but cystitis
and nephritis may occur as toxic complications, while finally, by
violence of the ulcerative process, a fecal fistula may form. This is
by no means a complete list, but includes some of the more frequent
complications.


=Symptoms of Acute Appendicitis.=--_Pain with nausea, tenderness_, and
_rigidity_ constitute the triad of the most indicative early signs and
symptoms, each of which needs to be considered by itself.


=Pain.=--Pain is at the same time an important yet variable feature. In
few other acute lesions does it vary as much in degree and location.
Generally it is referred at first to the more central portion of the
abdomen, as around the navel or between it and the right side of the
pelvis. Later it may be localized at some widely distant point, as,
for instance, far over upon the left side. Such vagaries may be held
to be due to peculiarities of emplacement of the appendix, and would
indicate that the organ will probably not be found in its most common
location, but rather extending to the left or hanging over into the
pelvis. When the appendix is attached to or lies near the bladder there
may be considerable pain in the pelvis and in the bladder. It should be
remembered that the parietal peritoneum is much more sensitive than the
visceral, and in proportion as the lesion approaches the surface more
exact information may be gathered from location of pain. Occasionally
it may be referred to the region of the gall-bladder, or even to the
chest above the diaphragm. In some instances it is agonizing, almost
from the outset; in others it is never very severe. The rapidity
of the process may be measured to some extent by the intensity and
character of the pain. When the disease resolves slowly and kindly pain
_gradually_ subsides, but the _sudden_ subsidence of pain, especially
without equal improvement in other respects, is a _bad_ rather than a
good sign, indicating probably that perforation has occurred.


=Tenderness.=--Tenderness is a more constant and persistent and,
therefore, a more reliable indication than pain, and, as well, less
misleading. No matter where the patient may seem to feel pain the
actual tenderness will indicate the location of the appendix itself.
Thus even if pain on the left side be severe, tenderness will not
accompany it, but will be found centred at the location of the
appendix. This is a fact of great importance. In his first paper on
appendicitis McBurney showed that the appendix is most commonly located
at a point beneath a line drawn from the umbilicus to the anterior
superior spine and one and a half or two inches away from the latter.
This has since been known as McBurney’s point. To it, however, too much
importance should not be attached, since the appendix is often not
found under this area, and tenderness may be found at a distance two
or three inches away from it. Over the actually tender area the skin
will also be hypersensitive, and this intense hyperesthesia is also an
indication of considerable value.


=Rigidity and Muscle Spasm.=--Rigidity and muscle spasm are to be
carefully studied, and upon them much reliance may be placed. With
the first onset of pain they may be general, but they usually become
more and more localized, unilateral, and finally limited, save in
those instances where general peritonitis has begun and is spreading.
For instance, Richardson regards it in this light: “Rigidity with
distinctly localized pain strongly suggests appendicitis; with fever
it almost proves it; with tumor it fully establishes diagnosis.” When
to ordinary abdominal rigidity is added actual muscle spasm, provoked
by even light palpation, and occurring in the rectus or one of the flat
muscles lying in close relation to the appendix, then a still more
important indication has been obtained. When true muscle spasm involves
all the abdominal musculature general peritonitis has probably begun.


=Tumor.=--The presence of tumor in the suspected area will nearly
always be a corroborative sign, but diagnosis should not depend upon
its presence. It is hardly to be looked for during the early hours or
perhaps days of an ordinary attack. It may be due to fecal impaction
in the cecum, to outpour of exudate, to binding together of omentum
and intestine, or to the presence of pus. If a considerable mass can
be detected within the cecum during the early hours of an attack
this should be regarded rather as an expression of coprostasis and
impaction, to which the attack itself may be due. Tumor, therefore, is
significant when present, while in some instances its absence is still
more so.


=Vomiting.=--Vomiting is an irregular and uncertain feature. Probably
the majority of cases begin with nausea (after the initial pain) or
with vomiting, either one without the other, or with both combined.
Likely through the course of the disease vomiting may be an occasional
disturbing element, though patients may have no nausea whatever.


=Bowels.=--The condition of the bowels and their behavior will depend
very much upon their actual state at the moment of attack. Some attacks
seem precipitated by violent intestinal activity; here diarrhea or
dysentery will be an early feature. Others are precipitated rather
by overloading of the cecum; in these cases constipation would be a
well-marked feature. Bowel inactivity is to some extent an expression
of bowel paralysis due to toxemia, which in some instances is profound,
in others slight.


=Temperature.=--The temperature is also a variable and uncertain
feature. It may be normal at first or very high. At any time it may
rise gradually or suddenly, and may subside in the same atypical way.
Taken by itself it is an unreliable feature. When, however, temperature
steadily rises the surgeon may take alarm, and if the pulse rate goes
up correspondingly the case takes on a serious aspect. A sudden fall of
temperature is almost as serious a feature as a sudden rise. A normal
or subnormal temperature may be seen when a large amount of pus is
present, or but a minimum of disturbance may be found when operating
upon a patient whose temperature is 104°.


=The Pulse.=--The pulse is a more reliable guide than any obtained with
the thermometer, its rapidity being proportionate to the gravity of
the disturbance. _A constantly rising pulse is a serious indication_,
especially if accompanied by vagaries of temperature. Some operators
regard the pulse as a sufficient indication for operation, holding
that when it rises above 112 operation should be made. I hold this to
be a good rule, but would not have it interpreted as indicating that
operation should not be done unless the pulse attains this figure, and
believe that, no matter what the other conditions, the final indication
has arrived when the pulse goes above 112.


=Abdominal Distention.=--Abdominal distention may be due to gas
formation, to constipation, or may indicate the paralysis of
peristalsis. When it becomes well marked it is a serious indication,
and when toxemia is profound no sound whatever will be heard within
the bowels thus distended. It usually indicates the onset of general
peritonitis. It is unfortunate in more than one respect, since
intra-abdominal conditions are masked by it and operation complicated,
it being sometimes impossible to restore the bowel to the abdomen
without at least partially emptying it.


=Jaundice.=--Jaundice, when occurring, is a toxic expression, possibly
due to temporary obstruction of distended or paralyzed bowels.

Finally the _general appearance_ of the patient will be suggestive,
patients with serious conditions having always an anxious or haggard
facial expression, rarely moving themselves easily or freely in
bed, or smiling at anyone or anything, their faces being perhaps
somewhat flushed, their expression and action being apathetic, while
perhaps later there will be delirium with restlessness. When the face
is pinched, the eyes sunken, the nose sharp, the skin dusky, and
respirations rapid and unsatisfying, as well as of thoracic type, any
intra-abdominal infection may be regarded as serious and unpromising.

What shall be said about the _value of the blood count_? It is
possible in nearly every instance to make a diagnosis of appendicitis
without the aid of the microscope, as well as even to judge of the
advisability of immediate or postponed operation. Nevertheless an
indicative differential blood count, an affirmative result of the
iodine test, or the discovery of indican in the urine, may afford
positive corroboration in cases where doubt may have existed. In
reality, however, any case which will furnish satisfactory and distinct
responses to these tests should be recognized without them. A leukocyte
count above 12,000, in connection with other indications, is usually
sufficient to justify operation. A very high leukocytosis--_e. g._,
above 24,000--is a matter of great importance. In the more chronic
cases the leukocytosis is but slight.


=Diagnosis.=--Obvious and indicative as many cases of acute
appendicitis are from the outset, there are still others when one may
be in serious doubt, even for some days, either because patients do
not clearly state their own symptoms, because of peculiar reference of
pain, or because of the co-existence of complications, each of which
may mask the other.

_Colitis_ of adults and _enterocolitis_ of children will produce
sometimes severe attacks of pain, with cramps and local tenderness,
that may at first mislead. There is a form of _mucous colitis_ which is
now more generally recognized than in time past, in which diagnosis is
sometimes quite difficult. The onset is often sharp, while the right
iliac fossa may be occupied by an elongated, resistant, tender mass,
showing fecal impaction within the cecum. On the other hand the same
condition may be met in the left iliac fossa, and will thus indicate
that the sigmoid is especially at fault. In these conditions there is
often actual exudate around the inflamed bowel, and this may even break
down; it is proper then to speak of a _circumscribed colitis_, and
there is reason to think that in certain cases it arises from infection
of a diverticulum from the large bowel. The pain is not infrequently
complained of at the so-called McBurney point. In not a few instances
the appendix has been removed when under perfectly natural suspicion,
and found so slightly involved as to show that the actual trouble was
in the cecum rather than in the appendix itself. Dieulafoy believes,
in fact, that formerly the cecum was made too much of and the appendix
disregarded, while today these conditions are sometimes reversed.

From _gallstone disease and cholecystitis_ its symptoms are sometimes
quite difficult to distinguish. Especially is this true when pain is
not accurately localized, and when, on the other hand, muscle spasm and
tenderness are widespread. The previous history of the case will give
much aid in this matter, while the pain in gallstone trouble radiates
rather toward the right shoulder, in appendicular disease toward the
umbilicus or downward. When dulness on percussion shades directly into
liver dulness the gall-bladder is naturally the more to be suspected.
When patients themselves cannot make minute distinctions in description
of pain and tenderness the condition may be difficult of recognition.


=Peritonitis.=--_The majority of all attacks of so-called idiopathic
peritonitis spring from appendicular disease_, at first and perhaps
throughout unrecognized. A condition of peritonitis, then, for
which other explanation is not found may be considered as, in all
probability, due to appendicitis whose peculiar features may have
been masked. It is not difficult to recognize a condition of general
peritonitis. The great difficulty is to ascribe its proper cause. As
already and elsewhere indicated these conditions merge into expressions
of acute obstruction which still further complicate the case, and
it is by no means infrequent to have this order of events: an acute
gangrenous appendicitis followed by local peritonitis, with adhesions,
which, becoming dense, rapidly produce obstructive symptoms, the
condition going even farther and gangrene spreading from the appendix
proper to any or all of those intestinal loops which come in contact
with the primary focus, so that when the condition is thoroughly
revealed it is found to be one of multiple gangrene of the bowel as
well as of fierce and septic peritonitis.

_Gastric and intestinal ulcers with perforation_ are easily mistaken
for appendicitis, especially when the duodenum is involved. In at least
half of the recorded cases of perforating duodenal ulcer the condition
has been at least at one time supposed to be one of acute appendicitis,
while after perforation has occurred and the matter which has escaped
has worked its way down toward the right iliac fossa the similarity of
conditions will be all the more striking. If an accurate history can be
obtained there will probably be learned from it that which will tend to
avoid mistakes. The exceedingly abrupt and acute onset of symptoms will
also be more pronounced than in most cases of commencing appendicitis.
This is true also of the perforations of typhoid ulcer, especially
of “walking typhoid.” While acute appendicitis during the course of
typhoid is by no means unknown, the abrupt onset of pain, rigidity, and
tenderness during the third week or later would suggest perforation
very much more than the possibility of an appendical lesion.

_Acute obstruction of the bowel_ due to other causes than
appendicitis--_e. g._, volvulus or intussusception--might give rise to
symptoms which would be regarded as indicating appendicitis. This is
true also of _strangulated hernias_, especially the internal forms,
since there will be no excuse for failing to discover an external
strangulation of this kind. _Lead colic_ may simulate some of the
milder and more chronic forms of appendicitis, from which it should
not be difficult to exclude it by its history, the occupation of the
patient, and the appearance of the gums.

The _kidneys and ureters_ are sometimes so involved as to occasion
doubt. A _floating kidney_, with its possible crises, displaced into
the right iliac fossa, where it might be mistaken for an inflammatory
mass, might thus cause some hesitation. So also might the acutely
suppurative forms, the formation of a sudden phlegmon about the kidney,
or the entanglement of a calculus, either at the hilum or along the
ureter, produce severe pain, tenderness, and fever, which would at
first easily perplex. The pain of renal colic, however, is usually more
agonizing, beginning in the flanks and referred down along the ureters
to the genitals and the inner side of the thigh. It may also be intense
in the back, and may be accompanied by nausea and vomiting. Renal colic
is also nearly always accompanied by frequent urination and sometimes
by the appearance of blood in the urine. With an impacted calculus at
the lower end of the ureter at the level of the appendix diagnosis may
be very difficult. Here the _x_-rays may afford some assistance.

_Acute pancreatitis_ begins with intense abdominal pain that may at
first suggest appendicitis. The pain, however, is usually epigastric;
abdominal distention comes on early; vomiting may be profuse, and
the tenderness is most marked along the left costal border. There
is, moreover, a more profound prostration, sometimes accompanied by
cyanosis. An acute suppurative pancreatitis may soon be followed by
peritonitis, which when seen will so completely mask all symptoms that
diagnosis as between the two is quite impossible, but symptoms which
can be accurately localized will usually point to the upper rather than
to the lower abdomen.

_Mesenteric thrombosis and embolism_ are rare conditions which
commence usually with fulminating symptoms and produce intense agony,
with tenderness and rigidity all over the abdomen. Their onset is so
profound that patients fall into a condition of extreme collapse within
the first few hours, and their tendency is so rapidly to the bad that
they are not likely to be mistaken for acute appendicitis.

The _pelvic viscera of women_ also furnish acute inflammations, such
as _pyosalpinx_, with or without rupture, that sometimes precipitate
very acute symptoms which may point to the abdomen rather than to
the pelvis. In many of these instances the appendix is more or less
adherent to the adnexa on the right side, and infection in either
one may easily travel to the other, so that both become ultimately
involved. Local examination will reveal the existence of pelvic
conditions, in whose absence there may be justification for inferring
that the trouble has not originated in that cavity.

_Ruptured extra-uterine pregnancy_ has been in numerous cases mistaken
for acute appendicitis. It usually begins with violent pain and
pronounced muscle spasm, with more or less shock. I have repeatedly
been called to operate for appendicitis and found the other condition
present. The operator may be prepared to find it if he elicit a
suggestive history or if a vaginal examination reveals a pelvis more
or less filled with semisolid material. Amenorrhea does not always
signify ectopic gestation, yet when doubt arises it would be advisable
to inquire carefully into the menstrual habit of the patient. On the
other hand it is known that acute appendicitis may bring on uterine
hemorrhage. When, however, the possibility of pregnancy exists, along
with a history of menstrual irregularity, or of hemorrhages unaccounted
for, and one finds within the pelvis the uterus pushed forward or
displaced, or perhaps an irregular tumor, he may suspect the condition
if not actually diagnosticate it.

A peculiarly unfortunate combination is that of acute appendicitis
occurring _during pregnancy_, or still worse, as I have seen it, _e.
g._, in a woman with a large uterine myoma, gone to about the seventh
month of pregnancy, and then suffering from an acute peri-appendicular
abscess, the whole proving more than she could withstand.

With an appendix placed behind the cecum it will usually rest upon the
psoas muscle, where it may be disturbed by violent exercise, or where
it may lead to mistaken diagnosis either in case of acute inflammation
of the muscle itself or of acute appendicitis. When the right limb is
drawn up, and especially when all motions of the limb give pain, we may
believe at least in the participation of the muscle in the inflammatory
activity. On the other hand, an insidious _psoas abscess_ may give
rise to a certain degree of tenderness in the right iliac fossa, with
flexion of the thigh, and gradual development of tumor, which may be
mistaken for chronic appendicitis.

The possibility of _appendicitis occurring during typhoid_ has been
mentioned. Differential diagnosis between the two conditions will
ordinarily not be difficult when one can obtain an accurate history.
In classical appendicitis pain is always the first symptom, and
temperature rarely rises until a number of hours at least after the
first attack of pain. Even the milder typhoid cases may show tenderness
in the right iliac fossa, but one should look for the characteristic
eruption and make a Widal test. The presence of splenic enlargement
would point to typhoid, as would also the occurrence of bronchitis,
epistaxis, or headache, with perhaps albuminuria. The most perplexing
cases will be those of _perforation_, perhaps even of typhoid ulcer
of the appendix. In these cases acute pain will usually indicate
perforation.

_Intrathoracic affections_ sometimes begin with or are accompanied by
severe pains which are referred to various parts of the abdomen and
cause great confusion. Thus I have repeatedly seen pneumonia, even
on the left side, regarded at least at first as acute appendicitis,
because patients referred most of their pain to the abdomen rather
than to the chest, while the abdominal muscles participated to such
an extent as to produce pronounced rigidity. Here a blood count
would scarcely help, but careful physical examination of the chest
would reveal the difficulty. _Such examinations should be made when
respirations become irregular, or when the breathing is evidently in
any way embarrassed._ Acute pneumonia and acute pleurisy, especially
diaphragmatic, may have then to be differentiated from acute
appendicitis.

Finally, _hysteria_ is an element not to be disregarded in some of
these cases; not that it is likely often, if ever, to lead to serious
doubt, but that patients with the hysterical or neurotic temperament
are constantly tempted to so seriously exaggerate their complaints
as to lead to at least a more serious view regarding themselves than
circumstances justify. Thus a mild appendicular colic in a neurotic
patient may produce a disproportionate complaint, and one must be ready
to assign to hyperesthesia or exaggerated complaints their proper value.

The _symptomatology of appendicitis_ may then be summarized briefly
as follows: When pain comes on suddenly and is referred to the lower
part of the abdomen, or even its central region, becoming perhaps
more localized as the hours go by, is shortly followed by nausea
or vomiting, and this by general abdominal sensitiveness, with an
increasing degree of rigidity; and when temperature, which at first
is not elevated, begins to rise in from twelve to twenty hours, then
it may be held that this is a classical picture of an attack of acute
appendicitis. So strongly does Murphy, for instance, hold to this order
of events that he even questions diagnosis when symptoms are not thus
timed, and especially if vomiting precede pain.

When pain which has been severe subsides, and comes on afresh after an
interval of perhaps thirty-six hours, it is to be regarded as due to
fresh peri-appendicular involvement, and is an unfavorable feature. _In
fact the subsidence of pain and apparent improvement often noted do not
always mean actual improvement, but may be the forerunners of a still
more dangerous condition._ Thus the “perilous calm” of appendicitis
should hasten operation, or at least increase watchfulness, rather than
beget confidence. Should one rely too much upon them and procrastinate
he will find that his mortality rate will rise accordingly. The
statement elsewhere quoted in this work that “the resources of surgery
are rarely successful when practised upon the dying,” will apply here.

There is scarcely any equally limited area of the body in which as many
varied and widely different pathological conditions may be exemplified
as in the appendix and the space immediately around it. The mildest
degree of hyperemia or vascular engorgement, the most destructive form
of inflammation, with fulminating necrosis, may here be observed.
Moreover, conditions commencing under one type may quickly change and
the whole type of an attack may within a short time be merged from the
mildest into the most severe.

In _catarrhal or endo-appendicitis_ it is mainly the mucosa which
suffers. This may undergo merely a congestion, with increase of
discharge, and, so long as the outlet be not completely obstructed,
may be a purely temporary matter of but a few hours’ duration, or it
may extend over a few days. The purulent or more destructive forms may
commence in either of the coats of the appendix. It is no uncommon
thing to find a necrotic mucosa with a still unbroken serosa, or a
perforation of the outer coats and a hernial protrusion of the inner,
perhaps just ready to give way. In location and extent the _suppurative
and destructive process may also vary_. Whereas ordinarily the distal
portion, being less supplied with blood, will suffer first, it is not
uncommon to find perforation at the junction of the appendix with the
cecum, or even gangrene of a limited area of the cecal wall itself.
Again, at times, the trouble seems limited to accumulation of pus
within the appendix, _i. e._, an _empyema of the appendix_, without
great tendency to involve the structures adjoining, and an appendix
may be found containing a few drops of pus or distended almost to its
bursting point still free or but slightly attached by exudate. In the
milder cases there may be found strictures indicating the site of
previous lesions. Again, aside from pus, there may be more or less
fluid or semisolid fecal matter or dense concretions, in addition
to the possible foreign bodies whose presence has been elsewhere
considered. In the more subacute or chronic forms there will be found
relics of previous rather than active expressions of present trouble,
such as strictures, thickenings, contortions, old adhesions, sometimes
quite dense, and contained concretions, or other foreign bodies, or
one may find appendices shrivelled up or more or less obliterated
(appendicitis obliterans).

The role of the omentum has elsewhere been mentioned, but must be
alluded to again at this point, since it participates more or less in
almost every case of acute appendicitis. The moment the appendix is
acutely inflamed the omentum tends to shift itself over toward it and
finally around it, and it is not uncommon to find a gangrenous appendix
wrapped in a roll of this kindly disposed fatty apron. In fact this may
constitute the tumor which may have been already discovered and found
to be fixed or movable. The inner surface at least of the omentum thus
applied will nearly always have sacrificed itself and one has need
usually to remove a considerable area of gangrenous omentum, as well
as the appendix itself, feeling as he does it that he is necessarily
sacrificing the best friend that the incriminated appendix has had.

Aside from what may concern the appendix itself the two most serious
complicating local conditions are _abscess_ and _gangrene with
perforation_. Abscess is not necessarily the result of perforation, at
least at first, but may be due to infection by continuity, the sequence
of events being acute appendicitis, with exudation, fixation, and
adhesion of surrounding tissues, followed by pus formation, perhaps
first within the appendix and then perforating, or perhaps having
its origin in the infected exudate exterior to it. So long as this
process is localized by a protective barrier of surrounding lymph, with
intestinal adhesions and the assistance of the omentum, there is to be
dealt with a more or less complicated _peri-appendicular abscess_, such
as in the past was frequently seen and spoken of as _perityphlitic_.
Concerning the frequency of perityphlitic abscess in days gone by the
literature of the previous century will afford ample illustration,
but in spite of the surgical acumen and advice of Willard Parker, who
taught the profession how to deal with it, its proper explanation did
not come until the researches of Fitz, alluded to at the beginning of
this chapter. Even now it is perhaps not quite correct to say that
every typhlitic abscess, _i. e._, every collection of pus around the
typhlon or head of the large intestine, is of appendicular origin,
for the tendency has been to forget the possibility of phlegmonous
cellulitis about any part of the bowel without reference to the
appendix.

Such a peri-appendicular abscess may be small, containing but a few
drops of pus, or extensive, even to the degree of holding a pint or
more. The pus is usually offensive and sometimes one will find floating
in it shreds of tissue, or even a completely separated and sloughed-off
gangrenous appendix. According to the original location of the
appendix, and the disposition of the adjoining parts, such a collection
of pus may form a tumor in the iliac fossa, which may also fill the
pelvis, or may present in the loin, closely simulating a perinephritic
abscess.

It is unfortunate when the natural walling off process has failed and
we have to deal with a _spreading, generalized, septic peritonitis_.
A partial compromise between these conditions sometimes appears as a
widespread yet practically localized peritonitis, in which several
loops of bowel have become affixed, and, what is worse, infected to
such an extent that they are themselves breaking down, so that there
may be impending or actual gangrene of the intestine. Such a condition
bespeaks the intensity of the infection and the destructiveness of
the infectious process, and produces a condition which may appall
the operator. The result is not only acute obstruction of the bowel
but such a local condition that one scarcely knows where to begin
or terminate his operative efforts. It was in such a case as this
that I removed eight feet and nine inches of bowel, the last nine
inches including the colon, turning in both ends and making a lateral
anastomosis, because of multiple gangrenous patches, each of which
taken alone would have required a distinct and laborious intestinal
resection, it seeming better to remove the entire amount involved.
This patient recovered and was well years after the operation. Still
other complications may disturb the surgeon’s calculations. Thus _fecal
fistula_ may have already occurred, or _suppurative thrombophlebitis_
may have already produced the beginnings or an _hepatic abscess_, while
septic expressions within the lungs, the heart, or elsewhere may have
also occurred. In addition to this general peritonitis, with all of its
terrors, may put a hopeless aspect upon the case.


=Treatment.=--Viewed in the above light it will be seen that
_appendicitis is essentially a surgical disease_, and that while mild
attacks may at times be successfully conducted to resolution, or tend
in that direction without treatment, the danger of spreading infection
with all its possible disasters is ever present, and even a mild case
is at no moment free from the danger of becoming acute. Considering
its widest relations, and believing in the greatest good to the
greatest number, the surgeon may easily maintain that, _save when it
is too late, it is never a mistake to operate_, providing operation be
properly performed. This, however, is sometimes out of the question,
and the laity occasionally assume responsibility for a decision against
the better judgment of the profession. We have to accept, then, the
fact that, no matter what the theory may be, we are not always allowed
to operate when we desire. Nevertheless if a universal rule could be
established it could be laid down in terms such as these, that more
lives would be saved by operating upon every case of appendicitis as
soon as the diagnosis has been made or even in the presence of good
reason for suspicion.

With conditions such as they are, and the fact that these cases are
usually first seen by general practitioners whose surgical judgment has
not been cultivated, and whose prejudices often actuate them, it may
be said that every case should be seen early by a surgeon, no layman
and no ordinary practitioner of small experience being in position to
assume responsibility for delay. It then remains for the judicious and
competent operator who may see such a case early, as thus advised, to
study it carefully in order to convince himself whether there be about
it good and sufficient reasons for not operating. The most honest
operator does not gainsay the possibility of mild cases recovering
without operation. He does, however, question by which course they run
greater risk.

The following may serve as a brief summary of conditions which justify
waiting:

  1. When symptoms are mild and not increasing in severity;

  2. When pain and tenderness are not pronounced and gradually subside;

  3. When the pulse rate does not exceed 100;

  4. When temperature is not rising nor showing abrupt changes,
  especially if during the first thirty-six hours there have been no
  rise. (Murphy states that if there has been no temperature during the
  first thirty-six hours he begins to doubt the diagnosis.)

  5. When the belly is not distending;

  6. When rigidity is not increasing and there is no evidence of
  peritonitis;

  7. When nausea is not increasing;

  8. When neither in facial expression nor elsewhere are there
  evidences of septic infection;

  9. When there is no perceptible tumor in the right iliac fossa.

Under the above conditions the conservative surgeon will be justified
in waiting; being prompt, however, to intervene, should there be change
for the worse in any one of the features specified. Even here it may
be said that with conditions all as favorable as above represented pus
may be present (in small quantity) and the whole picture may suddenly
change into one of local disaster.

Finally it may be summed up in these words: _When there is no doubt
as to the advisability of waiting, then wait; but in case of doubt
operate_, i. e., _give the patient the benefit of the doubt_, which he
in this way the more certainly obtains.


=Non-operative Treatment.=--While thus waiting in cases which justify
it, what should be done? Absolute rest in bed, even to the extent of
using bedpan instead of commode, is the first essential. The second
comprises abstention from all food, and practically the temporary
starvation of the patient, who may be allowed water in abundance and
nothing else. Altogether too much stress has been placed upon the
so-called starvation treatment as “saving patients from operation.”
Active therapeutic treatment is limited mainly to the use of cathartics
and of anodynes, according to reason therefor. On one hand it is
not advisable to rudely stir up the large intestine, one part of
whose structure is already involved in a serious and questionable
inflammatory process; on the other hand it is not for the general
welfare of the patient to permit him to continue with a condition of
coprostasis and the ever-increasing stercoremia which it encourages.
On the whole it would seem better to clean out the lower bowel at
the earliest possible moment, after which if the patient be properly
starved there will be less necessity for subsequent active catharsis.
The question of anodynes is one of equal importance. Those who bear
pain badly, or those who suffer intensely, will demand anodynes, which
every physician knows both help to mask the symptoms and interfere
with elimination; but such cases seem to be of themselves so violent
that the extreme expression of pain should of itself be regarded as
an indication for operation. It should be held, then, that cases
which demand opiates for relief of pain demand operation even more
strongly. In the mild cases, expectantly treated, the local application
of ice may be of some value. In effect these cases are to be treated
expectantly, and, while expectant treatment is a confession of weakness
or of ignorance, it may be unavoidable because early operation is
flatly refused.


=Indications for Operation.=--Sufficient reasons for not operating
being absent or having passed, the following may be considered among
the more urgent indications for immediate surgical attack:

  1. Continued and especially increasing pain and tenderness;

  2. A rapid pulse (110 or over) tending to increase in rapidity;

  3. Any rapid change in the temperature, either a sudden rise or a
  drop to the normal or subnormal, without corresponding improvement in
  every other particular;

  4. Increasing or widespread abdominal rigidity; when the right side
  of the abdomen of a sensible and non-neurotic subject is rigid this
  of itself should be sufficient to justify operation;

  5. The appearance of tumor in the right iliac fossa;

  6. Recurring and especially constant vomiting;

  7. Any indication of septic infection, local or general.

Such are the indications by which the surgeon may say upon the instant
of their recognition that a given case requires immediate operation.
Fortunate are both he and the patient if the case be seen early, when
these conditions have but lately shown themselves, and before it be too
late. It has been said that almost _every death from appendicitis means
the loss of a life that might have been saved_ and for which someone is
responsible, this responsibility being divisible among the patient, the
parents or family, and the general practitioner who first saw the case
and was tardy in recognizing its essential features. While patients die
after late operations the surgeon himself is rarely censurable, it not
being his fault that he was called in too late, and the patient dying
of the progress of the disease in spite of an operation and not because
of it.

_Operation for appendicitis_ may be one of the simplest and easiest
of the abdominal operations, especially when the acutely infectious
element be not present, or it may be one of the most trying and
difficult of all possible surgical procedures, taxing alike the
judgment of the experienced operator and the resources of the clinic.
Much will depend upon the time at which it is performed. If within the
first forty-eight hours the surgeon may expect to find but a small
amount of pus; if from the second to the fifth day, he may find a
well-marked collection, while later he may have not only localized
abscess but extensive complications. Again, he who operates between
attacks, during the interval or interim stage, will find conditions of
adhesion and results of old disease rather than its active products.

These operations should then be considered under these different
headings:

  1. Early operations in acute cases, where there is little or no tumor;

  2. Operations in cases where abscess is present;

  3. Operations in cases of more or less peritoneal involvement, with
  obstruction;

  4. Interval operations.

Under the above headings conditions vary so widely that they can
scarcely be spoken of or described under the same name. The seat of the
disease should first be approached. Here there is wide range for choice
of location of incision and even the method of its performance. Some
prefer the outer border of the rectus, others go through the rectus
muscle proper by an incision parallel to its fibers, which when exposed
are separated, its sheath both anteriorly and posteriorly being divided
separately. Others go through the abdominal wall by incisions more or
less oblique, and made near the anterior superior spine, where are
found the different layers of the abdominal muscles arranged in proper
order, their fibers being disposed at right angles to each other. That
incision is best in each case which affords the shortest and easiest
route to the site of the lesion when it can be located. If tumor
be present it is ordinarily best to go in directly over it. In the
absence of tumor the point of greatest tenderness is the best guide.
The possibility of subsequent hernia at the site which is weakened by
operation should be taken into account. If it be possible to avoid
drainage hernia may usually be avoided. When drainage is necessary
hernia is sometimes unavoidable. The advantage of operation through
the rectus is that the muscle fibers can be separated without dividing
them. Incision here may, however, carry the operator so far from the
site of the appendix that he must necessarily disturb the interior
arrangement more than is advisable, and thus increase the danger of
infection. The oblique exterior incisions near the ilium always permit
of separation of the fibers of the external oblique. The deeper muscle
fibers which cross at nearly a right angle may sometimes be nicked
and widely separated by firm traction, as in the so-called “gridiron
method,” or they may require division. A short external incision is
desirable when it suffices for the purpose. Considerations of safety
(_i. e._, the better exposure and easier removal of the appendix) may
call in some instances for long incisions, and they should be made
sufficiently long for his purpose.

It will often happen that as the surgeon passes more deeply toward
the peritoneum he will find the tissues more or less edematous. This
is a reliable indication of the presence of pus beneath, and should
make him open the peritoneum with care and then use extreme caution
in his further manipulation, lest by separating recent adhesions he
permit pus to escape. The peritoneum being opened sufficiently the
finger is gently insinuated, and thus the first orientation concerning
internal conditions is obtained. With the exploring finger there should
be ascertained, first, the existence of any adhesions; second, their
location and relative firmness, and, third, in a general way, the
amount of surrounding disturbance. With an appendix placed anteriorly
we may thus come directly upon it, while when placed deeply and
posteriorly we may have much to do before reaching it. After the first
general exploration the next procedure should be to protect and wall
off the region involved from the rest of the abdominal cavity by strips
of gauze. These should be long and so secured that none may be lost
by being left within the abdomen. The introduction of gauze for this
purpose will sometimes increase depression and decrease blood pressure,
but it is a necessary procedure in nearly every instance. Moreover,
several strips may be needed, and the incision may have to be extended
to a limit of two or three inches, according as further exploration
reveals a more complicated situation. The fluid pus which may escape
should be gently removed with dry gauze, or, if present in considerable
amount, be carefully conducted toward the surface. Loops of bowel or
tissue bound together by lymph should be gently separated, as they
may easily tear, or since imprisoned between them there may be found
small collections of pus. If found gangrenous the situation is thereby
seriously complicated, and it is advisable not to restore such a loop
to the abdominal cavity.

The omentum, as already indicated, may serve as a valuable guide to
the location of the appendix, which may be found wrapped within it.
It should be handled with great caution, while, at the same time,
it is made to reveal the desired information. When the omentum is
infiltrated, contorted, and adherent we may be sure of finding pus
concealed within the cavity which it helps to wall off. That which is
already gangrenous should be removed, with use of sutures in such a way
that there shall be no subsequent bleeding. It may be found easily,
or not until many other details have been mastered. The involved
appendix, when found, may be in one of the conditions described above,
all of which demand its removal save those where this has been already
accomplished by violence of the disease, in which case the opening in
the cecum may have to be closed, or one may employ it for the purpose
of an artificial anus. The appendix is often so hard to find that any
reliable guide will be welcomed. Such a guide may be found, first, in
the location and relation of the omentum, and, secondly, in the cecum
if this can be exposed, or in either one of its firm, longitudinal,
white tissue bands, which, leading down on either side of the colon,
meet and blend at the point of origin of the appendix. Either of these
followed in the right direction leads to this spot. Conditions may
be such, however, as to obscure both of these guides, and then the
colon should be followed downward toward the ileocecal valve, or the
small intestine up toward it, in the belief that in this vicinity, and
probably in the centre of the tumor, the appendix will be found. What
the surgeon shall next do depends on the details of each case. He has
not only to remove the diseased appendix, but to ligate and separate
from it its mesentery; furthermore to separate either or both of these
from surrounding tissues or organs, _e. g._, the wall of the pelvis,
the ovary, the bladder, the retroperitoneal tissue above the sacrum,
or from the lateral or anterior abdominal wall. This separation may
be easy, or in its performance the tube may rupture and both pus and
fecal matter escape; or perforation may have already occurred and the
operator will be conducted into a cavity containing matter, pus and
fecal mixed, in which perhaps fecal concretions of considerable size
will be found loose. He is fortunate who, finding a condition of this
kind, finds at the same time that he is still within a circumscribed
cavity. This he should respect, and, while endeavoring to clean it
thoroughly and drain it, he will avoid doing further harm by breaking
down its walls.

Another condition which may arise after the peritoneum is opened is
that of escape of a quantity of seropurulent fluid or of almost clear
pus which is free within the abdominal cavity. There may be little or
much of this. When present it should be removed by gentle sponging
before the gauze packing is introduced. Some operators are inclined
to irrigate freely and endeavor to wash out all this contained fluid.
Others are opposed to this method and believe that gentle dry sponging
is preferable. When the appendix is found free and movable, and when
the tissues in previous contact with it are free from evidences of
destructive infection (as, for instance, when peritoneal surfaces have
not lost all their glimmer or sheen), one should carefully remove it,
cauterizing its stump, burying it beneath the surrounding peritoneum,
and close the abdomen without drainage. In spite, however, of the
assertions and actions of some operators, I believe it to be the wisest
rule to lay down for general application that it is safer to drain in
every case where free pus or breaking down exudate is discovered.

The _question of drainage_ thus raised is as important as any connected
with this subject. When and how shall one drain is a question upon
which hundreds of pages have been written by various operators, and one
which, while settled for individuals, can hardly be settled for the
profession at large by any brief statement. Inefficient drainage is
almost as bad as none. Efficient drainage may call for the insertion
of a tube into the depths of the pelvis, even for counteropening in
the cul-de-sac, or for additional opening in the loin, or for the
employment of two or three tubes and drains of various kinds. A large
tube loosely packed with gauze, perhaps split through its length and
abundantly provided with openings, is probably the most effectual drain
for most purposes. The cigarette drain, of gauze wrapped in oiled silk,
or a few folds of oiled silk loosely tied together, along which fluid
may percolate, may be sufficient for cases of lesser extent. Large foul
cavities are better left more widely open, and abundantly drained with
gauze packing, in spite of the humorous stigma which has been cast
upon some of these methods by Morris with his expression “committing
taxidermy upon patients.” The depressing reflex influence of such
packing being readily conceded it may be regarded as the lesser of two
evils.

Another almost equally important question is that of _treatment of the
peritoneal cavity_ when involved. Here methods and opinions have varied
widely. A peritoneal cavity once inflamed cannot be made absolutely
clean in any way, and much reliance should be placed on the properties
of the membrane itself, which, to a large extent, should act as its own
scavenger. When, however, by removing the parts evidently diseased we
have taken away the main source of infection we may feel like relying
upon the natural protective forces of the human body; still even here
opinions differ. Thus some would flush the abdomen with hot saline
solution and even leave some portion of it there, closing the external
wound, while others would carefully avoid the introduction of anything
by which infectious material may be spread; and while each method has
much to justify it one is scarcely found preferable to the other. I
believe, however, in thoroughly cleaning out any distinct abscess
cavity, and if the pelvis be such then I would irrigate it. I would
also thoroughly drain it.

The attention of the reader is here directed to the general
considerations found earlier in this work concerning the general
technique of abdominal operations, and the matters of drainage and
after-care, it being scarcely necessary to reiterate what has been
there said regarding the general use of saline solution locally and by
the rectum, the advantage of the Fowler position, or of Murphy’s method
of slow and gentle introduction of saline solution into the rectum,
providing for its continuous absorption, etc.

The possibility of appendicitis leading to general peritonitis, this
to acute obstruction of the bowel, and this possibly even to multiple
gangrene, has been mentioned. What should best be done under these
circumstances must depend upon the patient and upon the surroundings.
With a patient too much reduced to justify any prolonged operation the
surgeon would probably content himself with evacuation of pus which may
be readily reached, and then perhaps by the formation of an artificial
anus. Cases which will justify such extensive operation as that above
reported by myself in this connection, where it was possible to
successfully remove nearly nine feet of intestine, will be exceedingly
rare, as well as impracticable in the ordinary private house.

A condition perhaps a little less serious but always perplexing is that
of _gangrene of a limited area of cecum_ around a gangrenous appendix.
To remove the appendix alone in this condition is to accomplish
nothing, while to meet the indication may require the exsection of
a small area of cecal wall or the resection of the entire cecum, or
perhaps in cases of limited extent the enfolding of the gangrenous area
and the suture of its edges in such a manner that when it sloughs it
may slough into the bowel cavity.

When the surgeon sees a case of peri-appendicular (the old
perityphlitic) abscess late, and after it is easily recognized, he
should operate according to the local indication, making incision
perhaps short and placing it at a point where pus will apparently be
most easily reached and best drained. Most of these instances present
rather on the side or even in the loin behind the colon, and here a
posterior incision might be sufficient. This may here be more liberal,
since there is little danger of postoperative hernia, while through
it one may possibly expose the cecum freely and often reach even the
appendix itself. In making this opening it is well, if possible, to
separate the fibers of the transversalis by blunt dissection. Here, as
in all of the other incisions made toward the outer side of the body,
the opening should be made, if possible, obliquely and parallel to the
branches of the iliohypogastric nerves, which are thereby avoided and
loss of sensation thus prevented. In fact this posterior method is
sometimes even more rapid, and preferable in exceedingly fat patients,
while it will always cause less shock and abdominal distress than
does an anterior section; moreover, drainage takes place in the most
desirable direction.

_Fecal fistula_ is sometimes the immediate and unavoidable, sometimes a
more or less delayed and apparently inevitable, result or complication
of some of these operations. In the former instance it will be
because of more or less gangrene or the necessity for an immediate
enterostomy. In the latter case it results from conditions which are
concealed, but may be imagined, comprising the giving way of tissues
already compromised or else being a continuation of the ulcerative
or gangrenous process. These complications are always unpleasant and
untoward, though they rarely reflect upon the method or judgment of
the operator, being essentially inevitable. If only the fecal outflow
escape externally the condition may be regarded as inconvenient and
temporary. Only in those instances in which the peritoneal cavity is
contaminated does septic peritonitis ensue. The majority of these
fecal fistulas close spontaneously by granulation tissue. Sometimes
closure is rapid, sometimes delayed, in which latter case it may be
stimulated by the use of silver nitrate, as already indicated above.
In a few instances the condition is so extensive or so permanent as
to justify or require further operation, which may be in the nature
of a curettement of the fistulous tract, a slight plastic procedure,
including a buttonhole suture about the opening, or possibly a complete
intestinal resection. I have seen small, fistulous tracts discharge
occasionally, even for years, and then finally close spontaneously, and
have far oftener seen some form of spontaneous closure than necessity
for operative intervention. The danger of infection around any such
fistulous tract is ever present, and when it has occurred the fact will
be made known by increase of edematous granulations, with swelling and
tendency to breaking down. In every such case active cauterization,
or, better still, the use of the curette, will be required.

A _tuberculous form of chronic appendicitis_, as well as tuberculous
infection of a subacute exudate, is possible, the case being converted
into one of greater chronicity, with more or less mild but constant
septic features (hectic). In any event, so soon as the tuberculous
element can be recognized radical measures should be instituted.

[Illustration: FIG. 583

Omentum being gently lifted in order to uncover the appendix enclosed
with its fold. (Lejars.)]

[Illustration: FIG. 584

Appendix delivered from the abdominal cavity and brought to view.
(Lejars.)]

[Illustration: FIG. 585

Separation of the meso-appendix. (Gosset.)]


=Operation for Chronic or Recurring Appendicitis; Internal
Operations.=--Other things being equal the most favorable time at which
to remove the appendix is that when pathological processes are least
active. If, therefore, there be a choice the interval of quiescence
rather than the stage of active infection would be chosen. Interval
operations, so called, are usually comparatively simple, both in
principle and technique. There are times, however, when it is difficult
to find a partially obliterated appendix which has been covered up in
thickened peritoneum or partially organized exudate. In such a case
considerable blunt dissection or separation may have to be done before
it can be removed. In those instances is this particularly true where
it had originally a retroperitoneal location, and at no time a free or
movable position. When difficult of recognition we may be unerringly
led to it if we but follow the bands of white fibrous tissue on either
side of the cecum to their junction.

The opening by which the appendix should, under these circumstances,
be reached may again be made at the point of election, and should best
be located over the area of greatest tenderness. Whatever incision is
selected we should endeavor to separate muscle bundles as much and
incise as little as possible. The appendix being delivered through
the wound, either before or after ligation of its mesentery, and being
thus completely isolated, is removed close to the large intestine,
its base being tied and its structure being seized within the blades
of a forceps in such a way that none of its contents may escape. The
scissors with which it is divided are contaminated by its contents and
should not be used again until cleansed. The stump on the proximal side
may be touched with the actual cautery, or scraped and then cauterized
with pure carbolic acid or formalin solution in order to thoroughly
disinfect it. Subsequent treatment of this stump differs with different
operators. Some are satisfied to leave it thus cauterized, while others
cover it with the adjoining peritoneum, which is brought together over
the stump end by either a purse-string or a continuous suture. Yet
others have been satisfied to invert the ends of the stump into the
cecum and thus leave it with or without further protection. It seems to
make really very little difference how the stump is treated, providing
only it be disinfected and prevented from leaking. Nevertheless it
would appear preferable to give it at least a peritoneal covering to
prevent adhesions (Figs. 583 to 588).

[Illustration: FIG. 586

The base of the appendix is tied with silk. The meso-appendix is being
tied in sections with the Cleveland needle. (Richardson.)]

[Illustration: FIG. 587

Appendix surrounded with ligature at its base, after its isolation from
its mesentery. Purse-string suture in place. (Gosset.)]

[Illustration: FIG. 588

Complete detachment of appendix. (Gosset.)]

In the subsequent closure of the external wound drainage is not made,
there having been no pus to call for it; while the more perfectly the
wound layers be closed, each with a row of chromicized catgut sutures,
the peritoneal incision being first carefully approximated and over
it the muscle and aponeurotic layers, each by itself, the less the
tendency to subsequent postoperative hernia. On general principles,
also, the shorter the incision the less the danger of this undesirable
event. Nevertheless other considerations should not be sacrificed to
shortness and beauty of the cutaneous scar.

The essentials of after-treatment of these cases have been already
summarized in the previous section, and to these little exception may
be taken in cases such as those above described. Every precaution
should be taken to prevent vomiting, as every muscular effort involved
in the act tends to disturb a freshly sutured wound. While violent
muscular efforts of defecation are also to be deprecated, there is
perhaps as much or more to be dreaded from the abdominal distention
which may result from inattention to free intestinal elimination.
Until the bowels have been moved it is best to restrain the diet to
the simplest fluid nourishment. So soon as elimination becomes free
more liberality in diet may be allowed. There is the same liability to
and danger from other possible complications, such as postanesthetic
pneumonia, anuria, or lack of expulsive power of the bladder, which
requires the use of the catheter, in these as in other abdominal cases.
Principles of treatment, however, do not vary, and the reader is
referred to the previous section already indicated.

_Paratyphlitic abscesses_ are to be distinguished from perityphlitic
or peri-appendicular abscesses in that they arise from a phlegmonous
process in the cellular tissue around the colon not due to
intra-appendicular infection. In consequence of such a cellulitis
more or less considerable collections of pus may form, which are most
likely to present either in the loin or just in front of the cecum,
which may burrow either upward or downward, or appear elsewhere. They
are mentioned here, not because they are to be differently treated or
surgically regarded, but because it is worth while to remember that
here about the cecum and ascending colon, as on the left side, such
pericolic abscesses may form without reference to the appendix.




CHAPTER L.

THE LARGE INTESTINES AND THE RECTUM.


ANOMALIES OF THE LARGE INTESTINE.

The more common _congenital anomalies_ of the various divisions of
the colon have to do mainly with the presence of _diverticula_ and
_atresiæ_, or possibly total _absence_, due to defects in development.
Diverticula are much the more common. Some degree of constriction is
not particularly infrequent, but complete absence of even a section of
the colon is an extremely rare anomaly.

The _acquired anomalies_ have to do with disease processes or results
of injury. _Displacements_ may be the result of old adhesions and
distortions; of _chronic constipation_, _i. e._, fecal impaction and
resulting overloading, with sagging, stretching, and complete change
in shape and position; with displacement due to enlargement of other
organs, _e. g._, the liver, stomach, spleen, uterus, or, in milder
degree, with the gradual but inevitable and chronic results of tight
lacing. The causes which produce a gradual _enteroptosis of the
transverse colon_ are not supposed to concern the surgeon, yet the
condition may precipitate acute obstruction which will necessitate his
urgent participation in its final treatment.

There are no diseases peculiar to the large which do not also concern
the small intestine, and no surgical diseases peculiar to it which
have not been considered in the foregoing pages. It is not, therefore,
necessary to make even a brief summary of the surgical diseases
peculiar to the large intestine. Of well-known lesions, however,
in this location there is perhaps a little worth emphasis in this
place. The most serious surgical conditions of the large bowel, aside
from the acutely obstructive, are those pertaining to expressions of
tuberculosis, syphilis, actinomycosis, dysentery in one or other of
its tropical forms, and cancer. There is a condition also of either
acute or chronic _colitis_ or mucocolitis which may assume such extreme
degree as to necessitate a colostomy made at the cecum (appendicostomy)
for the purpose of more perfect irrigation and physiological rest.
The amount of suffering, as well as of toxemia, which may proceed
from a seriously inflamed colonic mucosa, must be at least once seen
in order to be fully appreciated. Such a condition is characterized
by local and general suffering, with septic and copremic symptoms, as
well as by tenesmus and the passage of numerous small or larger and
more infrequent amounts of blood-stained mucus, sometimes of almost
pure blood. As an illustration if one recall what may be seen in case
of a violently inflamed conjunctiva or pharyngeal mucous membrane,
and realize that this condition is duplicated through a large portion
of the colon, a more vivid picture of what it actually represents
can be afforded. When exposed to inspection, as it may be when the
rectum and the sigmoid are involved, it will be found to bleed at the
slightest touch and to freely discharge large quantities of thick
mucus. While such a colitis is usually treated by non-operative methods
an anesthetic is sometimes required for its more perfect diagnosis and
recognition, as well as for such local applications as can scarcely be
made without it.


TUBERCULOUS AND SYPHILITIC ULCERATIONS OF THE COLON.

Tuberculous and syphilitic ulcerations of the colon may be localized
and relatively insignificant, or numerous, disseminated, extensive,
and serious. In extreme cases of this kind the entire colonic mucosa
will be involved and the amount of distress thus occasioned be scarcely
controllable. These are the cases which, failing to yield to ordinary
therapeutic measures, justify colostomy at the cecum, for the purpose
of temporary exclusion of the large intestine and its physiological
rest, as well as its more perfect local treatment by the irrigation and
suitable local applications thus permitted.


STRICTURES OF THE LARGE INTESTINE.

Strictures of the large bowel have the same etiology as those of the
small bowel, and are to be recognized by the same general indications,
of which increasing obstipation, perhaps with alternating attacks of
diarrhea and increasing difficulty in evacuation, are unmistakable
features. The nature of a stricture is not always to be foretold before
the exploration which it will necessitate. No stricture of the large
intestine which is above easy reach from the anus can be successfully
treated by any save operative methods, _i. e._, by abdominal section
and proper attention to whatever may be thereby revealed. Thus at one
time bands may be divided or some external mass removed by pressing
upon the bowel (_e. g._, a uterine myoma), or there may be found an
associated tumor, malignant or benign, whose complete removal is both
possible and permissible, or at other times a malignant stricture so
complicated that only an entero-anastomosis, for temporary relief, can
be effected.


CANCER OF THE LARGE INTESTINE.

Cancer of the large intestine spares no part of its length or lumen.
Primary _cancer of the cecum_ may commence in the region of the
appendix, and has frequently been mistaken for a chronic appendicitis.
If the transverse bowel be involved there may be more or less sagging
or fixation, while at the flexures obstruction is more easily produced.
Such growths in time become sufficiently prominent to be easily
recognized from without, but then they have usually gone beyond the
time when radical operation can hold out much promise. In the large,
as in the small, intestine radical operations are, however, often
successful, and always in proportion as they are made early and
thoroughly. When extirpation is impossible anastomosis will offer a
temporary substitute (Fig. 589).

[Illustration: FIG. 589

Cancer of cecum, showing ulcerating growth protruding interiorly and
obstructing. (Dr. E. A. Smith.)]


OBSTRUCTION OF THE LARGE INTESTINE.

Chronic obstruction of the large bowel is usually due to one of the
causes above considered. Acute obstruction of the colon is the result
either of precipitation of an acute condition upon the base of an old
chronic trouble, of invagination, of volvulus, or possibly of one
of the other mechanical contortions not included in either of these
expressions.

_Intussusception_ is most likely to occur either at the ileocecal
valve or in the region of the sigmoid. _Volvulus_ is more common in
the latter region. It is here due to relaxation of natural ligamentous
supports, to overloading and stretching, or is possibly permitted
by some congenital condition. Volvulus in this section having once
occurred the patient is liable to its subsequent recurrence. So well
known now is this fact that surgeons have endeavored to take special
precautions against it, which unfortunately have not been brilliantly
successful. It has been suggested, for example, to anchor the sigmoid
to the anterior abdominal wall, or to resect a portion of it, to
anastomose it with the cecum, as well as to reef the mesosigmoid.
Desirable as such operative relief may be, all of these methods present
inherent objections, while those which include absolute fixation of
the sigmoid perhaps predispose it to subsequent obstruction from other
causes. At present it would appear that a _sigmoidopexy_ is probably
the best procedure, in order to prevent local recurrence, in a sigmoid
volvulus which has once been exposed by operation, care being taken to
fasten it well up to its outer side, as well as posteriorly, in order
that there may be no vacant spaces in these directions.


THE RECTUM.


GENERAL CONSIDERATIONS.

The rectum was for too long a time relegated to the care and almost
sole interest of the itinerant charlatan, or the somewhat ambitious,
though scarcely more honest, specialist, who preyed alike upon the
suffering and ignorance of patients, until the practice of rectal
surgery was almost a mark of disgrace. From this unfortunate condition
it was rescued by the organized effort of honest men, until now, in the
light of their researches, the rectum has been shown to be both the
site of numerous, easily discernible, and serious, alike mysterious
and reflex lesions, all deserving careful study. The connection
between the sensory nerves with which its terminal inch and a half are
freely endowed and the vasomotor nerves throughout the body is easily
shown by their influence, for instance, upon the respiration and the
circulation, and in these respects some important lessons have been
learned from the charlatans. We have learned, for example, that general
vasomotor spasm, with its evidence in coldness of the extremities and
pallor of the surface, may often be overcome by so simple a measure as
stretching the sphincter; while to cure lesions which produce more or
less sphincteric spasm is to frequently restore general circulatory
tone. Again, what may be accomplished in stimulating respiration by
dilatation of the sphincter has been shown to be of the greatest value
in patients breathing badly under an anesthetic.

The “orificialists,” then, while making absurd and impossible claims,
have nevertheless taught us considerable concerning the value of
recognizing the importance of sphincteric spasm. Their claims
concerning so-called “pockets” and “papillæ” are untenable and absurd,
and the expression which they have taught many of the laity that they
are sufferers from “rectal pathology” indicates alike their ignorance
of good English and good surgery. That papillæ do become, under certain
circumstances, exquisitely sensitive and are occasionally in need of
the cautery or the scissors, as well as of the general relief afforded
by stretching the sphincter, is undoubtedly sometimes true.

The itinerant “pile-drivers” and charlatans of their class have done
more harm than good, and yet even from them the honest practitioner
has learned that “it pays” often to give attention to the rectum. As
a source of various disturbing and particularly distressing reflexes
there is scarcely any portion of the body of equivalent area which
can furnish so many. The relief to mental conditions, amounting often
to pronounced melancholia, which follows cure of rectal lesions, is
often astonishing, all of which shows that the rectum is well worth the
attention of the scientist, and especially of investigation in every
case where the slightest complaint is made.

All of which properly leads up to the subject of _rectal examination
and how to make it complete_. Much can be learned here by use of the
educated finger, as well as in the vagina, and the surgeon should
cultivate that tactile sense which will orient him so soon as the
finger-tip comes in contact with a morbid or diseased surface. In this
way it is possible to detect ulcers which are within reach by the
finger alone, without having to use the speculum, at least to make a
diagnosis sufficient to indicate what further procedure is required.
The rectum and lower bowel should be thoroughly emptied. It is safe to
assume that exquisite sensibility and pronounced sphincteric spasm are
the result of morbid conditions. The use of a local anesthetic will
in many instances be sufficient to permit at least of a preliminary
digital examination, the suggestive characteristics especially sought
being the general size of the rectal tube, infiltration or fixation of
its walls, and the presence of stricture, tumor, or other impediment
to insertion of the finger, including pronounced spasm at the anus.
The presence of bloody mucus or pus should also be noted. In addition
the rectal surroundings should be examined and the presence of any
phlegmon, fistula, sinus or other evidence of present or past disease,
including old scar, either of ulcer or incision, should be noted. The
degree of pain as well as of hypersensitiveness produced should also be
noted. With tact and gentleness satisfactory knowledge of the condition
of the parts within reach may be obtained.

A rectal bougie may be used should suggestions of the presence of
stricture be present. Rectal bougies are usually made of soft rubber of
various sizes, with tips variously shaped, of which the tapering and
conical are the most useful. One of these may be anointed and gently
introduced, the endeavor being to guide it first in the middle line
along the course of the rectum and then gently toward the left as the
rectum swerves in this direction as it comes down from above. With
such a bougie the presence of a stricture beyond reach of the finger
may be detected. When recognized its nature is, however, still left
in doubt, to be decided by the history or other features of the case.
There is never excuse for roughness in handling a rectal bougie, since
perforation or serious injury might result.

The next method of more complete examination of the rectum is through
one of the various forms of specula, from the so-called rectal
speculum, with its blades only a couple of inches long, to the more
formidable proctoscope or sigmoidoscope, with their possibilities or
artificial illumination, etc. According to the nature of the lesion
and the sensibility of the surface exposed various specula may be
used, with or without an anesthetic. For the majority of purposes
local anesthesia is sufficient. One will furthermore often need the
aid of position. The ordinary digital examination may be made with
the patient upon the side or back. When an ordinary speculum is used
a position corresponding to Sims’ for gynecological work is far
preferable. For more thorough work when the long, tubular instruments
are used, the knee-chest position is necessary. The specialists have
devised certain elaborate chairs, instruments, and methods by which
exceedingly complete and satisfactory exposures of twelve or fifteen
inches of rectal and colonic mucosa can be made. What is written
here, however, is not for their purposes, but rather for those of the
general practitioner, who must work with ordinary means and methods.
The knee-chest position, for instance, can be assumed upon the ordinary
table or it may be facilitated by certain additions made to a regular
operating table. With all these facilities and the peculiar skill which
specialization produces it is possible to make striking demonstrations
of the valvular arrangement of the rectal mucosa, and of the varying
degrees of obstruction which mucous folds or cicatrices may produce,
as well as to successfully dilate or divide them. In the hands of a
limited number of skilled surgeons local treatment of obstipation, as
well as of various other conditions of the sigmoid or upper rectum,
has become extremely satisfactory. These are, however, in the writer’s
estimation, methods and procedures which are scarcely within the domain
of the general practitioner or even the general surgeon, as they
require a degree of peculiar facility and an amount of time which can
scarcely be expected of him. Therefore the conditions and methods of
treatment here considered will be limited to those intended for general
use.


CONGENITAL DEFECTS AND MALFORMATIONS OF THE RECTUM AND ANUS.

The lowermost portions of the intestinal tube are by far the most
common sites of congenital anomalies and defects. These rarely occur in
the direction of excess, rather of atresia or entire deficiency. The
lower end of the alimentary tube is differentiated from the balance
of the original neurenteric canal, and connected with the exterior,
in ways similar to those followed at its upper extremity. The canal
itself should early become obliterated at a point whose site is marked
by that small collection of lymphoid tissue known as the _coccygeal_
or _Luschka’s body_, corresponding in this respect and location to
the pituitary body at its other extremity. The rudimentary rectum is
then connected with the surface by the formation of a depression and
disappearance of tissue in just the same way that the mouth is formed,
and as about the mouth we find atresia or incomplete communication,
so we may find the same condition in various expressions about the
termination of the rectum. Moreover, there may occur also more or
less arrest or abnormal development of the tissues which eventually
shut off the rectum from the genito-urinary tract. In consequence,
we have various degrees of rectal _atresia_, and, finally, actual
_imperforation_. Beyond this we may more rarely meet with complete
absence of the rectum, and even of some portion or of nearly all of the
entire large intestine. In one case under my observation this entire
tract was represented by little more than a mere cord.

[Illustration: PLATE LII

Cancerous Stricture of Rectum. Bowel Laid Open for Inspection.]

The mildest degree of such malformation refers to partial occlusion
of some portion of the rectum, or extreme smallness of its natural
opening, either of which constitutes essentially a stricture of
congenital origin, which may be sufficiently tight to barely allow
passage of meconium. Such strictures may escape notice for a
considerable length of time and will always tend to produce dilatation
and consequent displacement of bowel above.

Ordinary _imperforate anus_ is produced by its closure by a more or
less thick, membranous diaphragm, which may act, in some cases, like
a thin but imperforate hymen, or, in others, be so dense and massive
as to act more like a plug than a partition. The thinner the diaphragm
and the more perfect its structure as such the simpler the case, for
it simply needs perforation, with sufficiently frequent subsequent
dilatation to maintain the proper size of the aperture.

Complete _absence of the anus and the lower end of the rectal pouch_
may be so marked that scarcely a dimple indicates the point where the
anus should be found. In these cases the external sphincter may or
may not be present, while the rectal pouch may present loosely in the
pelvis, or be defective, or attached to some portion of the abdominal
wall, the intervening space being filled with indifferent tissue.
The fact that there appears to be a slight anal depression is to be
taken for nothing more than an indication of what should be found, and
signifies nothing regarding the deeper condition.

A somewhat mitigated expression of this last defect is seen when the
anus is normal, with a more or less complete sphincter, but where a
distinct partition separates this pouch from the rectum above. This,
again, may vary considerably in thickness. If, then, fluctuation be
detected the condition may prove less unfavorable for the little
patient, since at this point communication may be easily established.
Too often, however, this diaphragm is dense and tough. When
successfully perforated, like the hymen, it may allow a slow dribbling
of material, and will require constant attention and dilatation. Figs.
590 and 591 portray these conditions in some of their expressions.

[Illustration: FIG. 590

Rectum ending in a blind pouch. (Kelsey.)]

[Illustration: FIG. 591

Rectum ending in pouch; anus normal. (Kelsey.)]

The _anus_ itself is by no means a fixed anatomical opening, and its
position may vary considerably. It may be found anywhere along the
middle line of the perineum or even in the sacral region.

Another variety of complication is, with the conditions represented
as above, a practically imperforate anus or rectum which nevertheless
opens into one of the _other pelvic cavities_--the vagina, the bladder,
or the urethra. In female infants an opening into the vagina may
be of a size sufficient to serve its purpose, even throughout life.
This condition has occurred in ignorant women who became wives and
mothers, and were never conscious of anything abnormal. When the rectum
communicates with the urinary passages meconium will escape with the
urine. When the opening is in the urethra it is not so serious, and
patients live to adult life, whereas when the bladder is thus involved
the ureters will become infected and the patient eventually dies of a
terminal infection of the kidney.

There is a somewhat reversed condition similar to this where the
urinary passages connect with the rectum or with the colon.

Most of the anomalies above catalogued produce conditions of acute
intestinal obstruction within the first two or three days of the
newborn infant’s life. The condition is perhaps first made known by the
nurse’s failing to note the presence of meconium upon the diapers. A
suspicion of such a condition should prompt immediate investigation,
which should be made with the little finger or with a soft catheter
properly anointed; the finger making the best probe for purposes of
orientation. The first thing is to determine the patulency of the anus.
This established, the next procedure is a determination of the rectal
condition and of possible communication with other passages. In this
the presence of a small sound or metal catheter in the urethra and
bladder may be of assistance. If a fluctuating sac presenting downward
can be discovered in the location of the rectum its character may be
assumed, and, after exploring with an ordinary aspirating needle, one
may, if meconium be discovered, leave the needle _in situ_ for a guide
and with sharp scissors or pointed knife passed along it carefully cut
into the sac, and then gradually enlarge the opening until it be given
a sufficient size. The surgeon is fortunate in this respect who has a
case of imperforate rectum so simple as to permit of doing this and
finding it sufficient.

Every completely obstructed case becomes instantly a surgical one,
whose outcome depends not on the operator alone, but on the actual
anatomical condition. There is justification, therefore, in going to
almost any extreme in the endeavor to open up a passage-way, for no
danger can be greater than that of failing to establish it. After
a careful search of the pelvis, aided by anesthesia and a metal
instrument in the bladder, if no trace of large bowel can be found or
if tissues be so dense as to completely mask the anatomical details,
then as a last resort an artificial anus may be made in the left
inguinal region, if there be no reason for not violating the usual
rule and opening the large bowel in the right groin. _Colostomy in
an infant_, under these circumstances, is always a hazardous and
serious matter, but it offers the only resource. It is made in exactly
the same way as enterostomy described previously, and the operation
requires no special description here. Very young infants thus affected
make bad subjects, and operation should be performed as expeditiously
as possible. Considering the danger of leakage it would be well if
practicable to wait a few hours after attaching the intestine to the
abdominal surface before opening it, in order that the peritoneal
cavity may be more perfectly protected.

Even those cases where the rectum communicates with the urethra
or bladder should have a natural anal opening. In cases where
communication is into the vagina it may be proper to wait until youth
or adult age is reached, when more may be accomplished.


INJURIES AND FOREIGN BODIES IN THE RECTUM.

The rectum may be the site of injuries of various kinds from both
extrinsic and intrinsic causes. When weakened by disease it may
be burst by accumulation and straining, or it may be the site of
perforation of ulcer, just as may any other part of the intestine.
Although well protected from most directions it may suffer from
penetrating wounds, such as stab or gunshot. It is occasionally injured
in fractures of the pelvis, and possibilities of such injuries should
be excluded in such cases. It may also be lacerated during parturition.
The sphincter and even the muscular tube itself sometimes suffer. It
has been indifferently wounded or punctured in operations, especially
for stone in the bladder and in prostatectomy.

In the absence of disease a laceration occurring in any of these ways
may be repaired by prompt suture, although to make a suitable exposure
may require an extensive removal of sacrum, or the performance of a
laparotomy with the patient in the Trendelenburg position. The rectum
is also frequently injured by accidental or intentional introduction
of _foreign bodies from without_. Museums, especially the foreign, are
full of collections of foreign bodies which have been removed from the
rectum, most of which have been placed there with intent, malicious or
otherwise. They include objects of all imaginable character, shape, and
size, some which are easily introduced and are also easily removed;
others which have been passed inward under no small difficulties are
removed only with a more or less formidable operation, or have even
determined the death of the individual. The ignorant have peculiar
superstitions, and the criminal most vicious tendencies, toward the
insertion of such foreign bodies, and the complications that may be
brought about are too numerous to be rehearsed here.

On the other hand, by actual accident serious injuries may be produced;
as in one case under my observation where a boy of twelve fell, in the
squatting position, over an iron picket nearly one inch in diameter in
such a way as to permit it to pass into the anus, scarcely bruising
the mucous membrane, yet entering the pelvis for nearly six inches,
penetrating the anterior wall of the rectum, the posterior wall of the
bladder, and bruising its anterior wall without perforating it. One
feature of the accident was the carrying into the bladder of a piece
of his trousers. In this case I opened the abdomen in order to be sure
that there was no abdominal complication, closed the major part of the
wound, and drew a good-sized drainage tube through from just above the
pubes out through the anus, after removing the piece of cloth above
mentioned. The boy made a perfect recovery.

The danger in all these cases is of infection, either of the bladder
or of the pelvic cellular tissue. In the female similar perforating
injuries may involve the vagina or the other female organs.

Some of these accidents or conditions above recounted take place during
intoxication. The recurrence of tenesmus, pronounced rectal pain, the
appearance of blood either at the anus or in the urine, should in every
instance prompt a thorough investigation of the rectum, if necessary
under an anesthetic.


PROCTITIS.

Under the term proctitis are comprised acute inflammations of the
rectal mucosa, which are characterized by discharge of mucus, mucopus,
and perhaps blood, and accompanied by more or less tenesmus, pain, and
sphincteric spasm. The conditions which produce proctitis are those
which lead to ulceration. It may be the result of a downward extension
of trouble from above, as in mucocolitis, dysenteric, tuberculous or
other forms of colitis, or it may be the result of infection from below
(_e. g._, gonorrheal). An inflamed rectum may be more or less easily
exposed for study through some form of speculum (see above), and a more
perfect picture of the actual condition thus presented to the eye than
can be seen elsewhere, save in the mouth and pharynx, of the effects
which serious and even ulcerative inflammation may produce in the way
of congestion, swelling, bleeding, and actual breaking down.

_Gonorrheal proctitis_ is not common, yet it may occur either by
extension or by direct infection, and will be of an acute type. The
other forms may vary in severity according to their cause and duration.


=Symptoms.=--The symptoms differ only in degree, and include the
features already mentioned. There are soreness, tenderness, and often
pain, especially when the lower part of the rectum, with its numerous
sensory nerves, is involved, while reflex pains are referred to the
sacrum and the lower part of the back. Sensation of local heat and of
soreness is generally noted, while the patient is more or less tortured
by frequent desire to evacuate the bowel, but passes perhaps a little
bloody mucus with the accompaniment of tenesmus and straining. In acute
cases the condition is an exceedingly painful one.


=Treatment.=--Treatment should be begun by a search for and removal
of the cause. Relief is afforded by local anodynes, of which the hot
sitz bath is one of the most comforting, and by hot rectal lavements
of soothing antiseptic fluid, such as linseed tea, to which a little
thiol or ichthyol has been added. These should be retained as long
as possible, then ejected. Local anodynes may be furnished through
the medium of suppositories containing opium, or preferably some of
the milder local anesthetics, such as orthoform. Cases which do not
quickly yield to this form of treatment should be anesthetized in order
that complete exposure of ulcerated areas and vigorous local treatment
may be accomplished. A brushing of the entire surface with a 2 or 3
per cent. solution of silver nitrate will frequently be followed by
relief, which will be further furnished by sufficient stretching of
the sphincter to overcome its painful spasm. The diet should be so
regulated as to leave a minimum of undigested residue that may irritate
the lower bowel, and laxatives should be so administered that there
shall be no coprostasis in the colon, but that whatever enters it
shall be speedily extruded. The specific forms of proctitis require
specific treatment, for which there is perhaps nothing better than the
silver preparations, either the mild, like argyrol, or the active, like
solutions of silver nitrate.


ULCERATION OF THE RECTUM.

The causes of the formation of ulcer in the rectum nowise differ
from those of ulcer elsewhere about the body. They may be summarized
as _catarrhal_, _i. e._, more pronounced and local extensions of
non-specific inflammation of the mucosa, which, in certain areas,
assume more intense and later infective and degenerative form (in this
way are formed the so-called catarrhal ulcers); _specific_, including
primary chancre, which is rarely met with high up in the rectum, or
the later expressions, varying from mere mucous patches which may
abound both within the rectum and around the anus, to the deeper, more
destructive, and usually tertiary ulcerations, with destruction of
tissue, extensive involvement of surface and most pronounced tendency
to subsequent cicatricial contraction when they begin to repair.

What has been said regarding syphilitic ulcer is true also of
_chancroid_, which when found in this region involves most frequently
the anus, but which may extend or even be seen as a primary lesion
higher up.

_Tuberculous ulcers_ are not infrequently primary, usually the
accompaniment of advancing and ulcerative infection of the intestine
above, or secondary, as frequently occurs when the more innocent forms
suffer a secondary tuberculous infection, becoming thus converted into
lesions of pronounced type.

_Typhoid ulcers_ in the rectum are rare, but those connected with
_dysentery_ are common, especially in localities where tropical or
other forms of the disease prevail. The innocent tumors within the
rectum, such as polypi and adenomas, etc., tend to break down because
they are kept continually macerated and exposed to contamination. Even
innocent hemorrhoidal tumors are extremely prone to suffer in this way
because their epithelial covering is thin and they are exposed to both
external and internal contamination. Finally every malignant tumor
which grows into the rectum tends to break down, and sooner or later to
present an ulcerating surface. The causes of rectal ulceration are then
seen to be various. Nearly everyone of them may be an exaggeration of a
condition first producing an acute proctitis.

_Ulcers occupying the anal region_ are usually compressed into a
linear form and present rather as cracks or linear abrasions. These
are known as _fissures_ and are spoken of as _fissures in ano_ or
_rectal fissures_, according to their situation. These fissures occupy
the most sensitive portion, _i. e._, the lower inch and a half of
the rectum, and become in time irritable, erethistic lesions, whose
sensibility is constantly enhanced by the reflex spasm of the sphincter
which they produce. An essential part of the treatment of every such
case is dilatation of the sphincter, as well as the destruction of the
irritable surface, even the former alone often sufficing for the milder
cases. Anal fissures, like corneal ulcers, give rise to exquisite pain
and annoyance, and produce irritability and general distress. Their
treatment is so simple that there is no excuse for allowing patients
thus to suffer.

To a peculiar form of combined infiltration and ulceration involving
the lower part of the rectum, the anus, and, in females, more or less
of the vulva, the French have given the name _esthiomene_. It has been
considered due to more or less mixed forms of infection, including
those of chancroid, syphilis, tuberculosis, and other undescribed
types. It is a mixed infection, and not necessarily of the same type
in all cases. It is usually seen in old syphilitic subjects or in
prostitutes. It produces more or less deforming lesions, and sometimes
such active and protuberant granulations as to cause it to be mistaken
for epithelioma or condyloma. It is essentially chronic, and its
most striking characteristic is the combination of ulcerative and
hyperplastic processes which it presents. Clinically it is a chronic
ulcer, with thickened and deformed base and with all the possible
consequences or complications of ulcer in this region.

The other forms of ulcer above mentioned appear singly or multiply
in any and every possible location, pronounced types presenting
extreme pictures of an ulcerated, inflamed, partially destroyed tube,
which needs only to be seen before recognizing the advisability of a
colostomy for the purpose of rest of the inflamed surfaces.


=Symptoms.=--The symptoms of rectal ulceration are essentially those
of proctitis, mild or severe as the case may be, with local pain, and
escape of pus and blood. Much depends upon their location, _i. e._,
whether within the sensitive area or not. Ulcer low down in the rectum,
no matter how produced, will always cause a disproportionate amount of
suffering, because of the reflex sphincteric spasm which it produces.
On the contrary, ulcers high up give rise to little or no suffering,
and may be discovered only after a history of discharge of blood or
pus prompts a thorough local examination. Therefore, without reference
to the feature of _pain_, every statement that mucus, pus, or blood is
discharged from the rectum should lead to an examination, sufficiently
thorough to detect and expose the cause and permit of proper treatment.
Should local anesthesia prove unavailing for this purpose a general
anesthetic must be administered. Thus the non-specific, the syphilitic,
and the tuberculous ulcers may be scraped and cauterized, care being
taken not to perforate. If ulcerating tumor is found it should be
operated upon at once. Sometimes, however, by these examinations
unsuspected conditions are revealed such as to give the case a serious
aspect. In this event a second anesthetic, with operation, will be
necessary. For all ordinary purposes, however, sufficient specula,
curettes, the actual cautery, and applicator, by which suitable local
treatment can be made to the affected surfaces, should be provided.


=Treatment.=--As indicated above in the treatment of proctitis there
is need also for various local anodynes and soothing applications.
Physiological rest for the inflamed bowel is imperative. Finally, in
extreme cases, it has been shown that it is best to open the colon
above the seat of the principal disturbance, doing this even on the
right side should the whole large intestine be involved, and by thus
relieving it of its duties enable more complete physiological rest and
local treatment.


STRICTURE OF THE RECTUM.

The inevitable consequences of any of the serious forms of ulceration
above described are, if recovery ensues, and usually even if it does
not, the formation of cicatricial constrictions by which varying
degrees of rectal stricture are produced. Rectal strictures, then, are
to be grouped as:

  1. Those due to previous and more or less active, morbid intrinsic
  processes;

  2. Those due to the presence of organized exudate, tumors, or other
  compressing causes from without;

  3. Those due to traumatism.

The _symptoms and signs of rectal stricture_ include those of
ulceration and obstruction, or difficulty in defecation. A history of
alternating constipation and diarrhea, with perhaps tenesmus, and with
discharge of pus or blood, will prove the presence of some obstruction.
One characteristic feature met with in some strictures is the passage
of stools which when solid or semisolid have a characteristic tape- or
cord-like shape, as though extruded through a constricted passage-way.
This is not a feature necessarily present, and may be produced even in
non-malignant cases, as when the rectum is obstructed by uterine myomas.

With respect to any suspected rectal or colonic stricture it is
necessary to determine: (1) Its existence; (2) its location; (3) its
character; (4) any other circumstances bearing upon the case which
might affect the question of treatment. The latter is particularly
important when the question of syphilis is raised.

The above features are determined by careful physical examination
for which the finger alone may be sufficient, or which may require
instruments and postures already described.


=Treatment.=--Treatment of rectal strictures is necessarily mechanical,
but will depend in large measure upon their cause and extent. Thus
a stricture produced by conditions extrinsic to the rectum proper
might require abdominal section and removal of a pelvic tumor or other
similar operation. Many a patient with retroflexed uterus will complain
of a rectal condition which is essentially one of stricture, the
overturned uterine fundus being forced against the rectum and pressing
upon it, demanding not a rectal operation but one for suspension of the
uterus. The obstipation which is produced by ptosis of the sigmoid, or
by hypertrophy and abnormal arrangement of the folds and rectal valves,
may necessitate operation upon the colon (coloplication or colopexy) or
a careful division of hypertrophied mucosa through the proctoscope, as
used by one skilled in its manipulation.

[Illustration: FIG. 592

Stricture of rectum. (Bryant.)]

Strictures of recent origin may yield to a forcible dilatation, which
should, however, be systematically repeated in order to maintain the
desired effect. Old, dense, and chronic strictures will require more
radical procedures, according to their location and extent. Strictures
practically impassable may indicate conditions so extreme as to
necessitate colostomy, while in a small proportion of cases conditions
will be found so favorable as to justify a resection of the rectum,
either from below and from without, or through abdominal section with
the patient in the Trendelenburg position. Nearly every stricture is
accompanied by more or less ulceration, sometimes in extreme degree.

Dilatation or expansion by some mechanical method is the necessity in
every case. Simple in theory its performance is often difficult because
of density of the structures, and its danger often pronounced because
of the serious surrounding conditions and the possibility of rupture
or perforation of the bowel at some weakened part, or of infection and
phlegmon following division of the stricture and exposure of fresh,
raw surfaces. Various instruments have been devised for dilating
rectal strictures, some of which are ingeniously arranged to be used
at a considerable height above the anus. Danger attaches to their use
in proportion to the amount of force employed and its distance from
sight and touch, _i. e._, from intelligent means of control. The best
method is that which permits of exposure through the speculum and more
accurate division with knife, scissors, or actual cautery, the latter
often being preferable, as hemorrhage is less after its use.

It should be remembered that “once a stricture always a stricture,”
and that the tendency of cicatricial tissue to contract is continuous
and never ceasing, and that wherever there has been a stricture (and
this is true of any tubular portion of the body) there is necessity for
constant and more or less frequent later attention. If possible, then,
milder methods and those more capable of repetition should be adopted.
The best of these is the use of the finger for cases within reach of
it, and of the soft-rubber, conical bougies for those placed higher,
and for the patient’s individual use. Dilatations should be gradual and
increased as rapidly as circumstances permit, and with tight strictures
the endeavor should be with each sitting to make some gain until a
sufficient size has been attained. Local anesthesia may be required,
and is justifiable when needed.


PRURITUS ANI.

This condition, usually accompanied with irritative or ulcerative
conditions of the lower end of the rectum, the verge of the anus,
and the surrounding skin, is one of intense itching, leading to an
uncontrollable desire to rub or scratch, by which temporary relief may
be afforded, but which tends to produce excoriation and ulceration. The
condition is not primary, but secondary to something else, although
the conditions which produce it are widely variant, ranging from the
neuroses due to anemia or other causes, to the toxemias of uric acid
origin, the local irritations produced by lesser degrees of internal
disturbance, or eczema or other itching eruptions on the outside. In
corpulent persons eczema and intertrigo from friction are common, and
these, combined with irregular tags of skin or remains of old piles,
permit of irritation and maceration which still further complicate.
Annoyance is usually greatest at night, when the attention is less
distracted by other things.


=Treatment.=--The treatment should consist in removal of the cause
and local relief. The former may be difficult and require prolonged
effort. Local relief may be afforded by frequent applications of water
as hot as can be borne, with local application, after the parts are
thoroughly dried, of a powder containing menthol, a solution containing
camphophenique, with the addition of a little chloroform, or by
soothing ointments containing carbolic acid, menthol, and orthoform.
When there is abrasion of the skin applications of silver nitrate, in 5
per cent. solution, may be made; but when there is multiple ulceration,
stretching the sphincter and thoroughly cauterizing or excising the
ulcerated surfaces will be more radical and effective.


PHLEGMONOUS AFFECTIONS OF THE RECTUM.

On either side of the rectum, between the dividing folds of the deep
pelvic fascia, is situated the _ischiorectal fossa_, a pyramidal-shaped
cavity filled with fat and cellular tissue. This is not only in close
relation with the outer rectal surfaces, but is peculiarly liable to
infection and acute inflammatory disturbance. Thus it happens that
_ischiorectal_ or _perirectal abscesses_ are of frequent occurrence,
often of marked violence, and not without their peculiar dangers.
Infection may travel from the rectum, or the first excitement may
occur in one of the mucous or skin follicles at or near the anus. The
consequence is what the patient ordinarily calls a _boil_, which to the
surgeon is a phlegmon, first limited by the walls of the cavity within
which it rises. So long as the phlegmonous process be confined within
these walls it is acutely painful.

The _local signs_ of such an abscess are redness and infiltration of
the exterior surface, swelling, which becomes quite distinct, and pain
and tenderness, of which the patient may complain bitterly. The local
soreness is so extreme that defecation becomes difficult or almost
impossible. Any attempt at digital examination of the rectum will give
rise to extreme pain.


=Treatment.=--Could every perirectal abscess be distinctly recognized
and properly treated in its comparatively early and localized stage
there would be few cases of residual trouble. This treatment consists
of early and extensive incision, made externally and directed to the
centre of the phlegmonous mass, sufficiently _deeply_ also to reach
it. The evacuation of even a small amount of pus, followed by more or
less blood, will give prompt and immediate relief, and bleeding may
be encouraged rather than checked for purposes of local depletion.
Such incision may be in most instances made with freezing spray or
local anesthesia. In children and exceedingly nervous patients it
would be better done under general anesthesia, in order that it be
done thoroughly. It is in patients who decline such early relief,
or who, from ignorance or inattention have not received it, that
ischiorectal abscesses sometimes assume serious proportions and become
extensive phlegmons, breaking down anatomical partitions in the
pelvis, burrowing extensively in various directions, since there is
considerable fatty and cellular tissue both inside and outside of the
pelvis in this region. Thus the surgeon may not see such a case until
the entire buttock is involved, or until the process has gone perhaps
even farther. Relief now must come from radical application of the
same principles, by the aid of general anesthesia, multiple incisions
with counteropenings, use of drainage tubes, etc. The patient now is
fortunate if perforation into the rectum has not already occurred so
that no pus is discharged from the bowel. If this has not yet happened
it will probably be prevented by the above measures; but when it has,
and a fistulous communication has already been established, it may be
sufficient to thoroughly cleanse the infected cavity to see both it and
the fistula close by granulation in the course of time. Wide external
incisions are necessary in these cases, for complete access to the deep
fossæ must be made. In more pronounced cases the pus evacuated will be
extremely offensive, and there will be found masses of necrotic tissue,
sloughs of fascia, and evidence of extensive local gangrene. Such
putrid cavities must be thoroughly cleaned out, and will then be found
to quickly resume a healthy aspect when treated by packing with gauze
saturated in brewers’ yeast.

The more chronic and slower expressions of this condition are usually
connected with local _tuberculous_ disease. In fact every _phlegmon
which has passed the acute stage is favorably situated for tuberculous
infection_, and becomes in time a tuberculous lesion, which is to be
treated on the general principles elsewhere enunciated. These fistulas
are often seen in consumptive patients, and apprehension has widely
prevailed that the pulmonary disease might be aggravated by radical
attention to the fistula. This was only when such attention was made
incomplete. To divide the fistulous passage and leave its raw surfaces
unprotected and in contact with tuberculous tissue is to invite the
spread of infection. To do the proper thing, on the other hand, _i.
e._, to radically dispose of all tuberculous tissue and so treat both
fresh and old surfaces that a new infection is not invited, is not to
make a patient worse in any respect, but to relieve him of at least one
focus of disease. There is, therefore, no reason why rectal fistulas
should not be radically treated even when they occur in consumptive
patients.


RECTAL FISTULAS.

Rectal fistulas are always the consequence of ischiorectal abscesses
left to open spontaneously in either or both directions. They may
occur also without the preëxistence of a distinct phlegmon, as, for
instance, when a small ulcer in the rectum gives way and permits the
gradual extension into the perirectal tissues of a mildly ulcerative or
suppurative process.

Rectal or anal fistulas are classified as _blind external_, _blind
internal_, or _complete_, according as they open and discharge
themselves or show a complete passage-way from the rectum to the
exterior. They may be small and single, or numerous and extensive.
Old and especially chronic tuberculous cases are seen when the whole
gluteal region is honeycombed and perforated by numerous fistulas, some
of which probably connect with the interior of the bowel. I have seen
such openings as low as the knee and as high as the dorsal spines, as
the result of extremely insidious advance of tuberculous granulation
and its subsequent breaking down. In such cases a history of an acute
phlegmon occurring years previously may be obtained.

A _blind external fistula_, simple or complicated, naturally discharges
its pus upon the exterior. It may be accompanied by little or no
local tenderness or pain. A _blind internal fistula_ makes itself
known by a certain amount of rectal tenderness and by the discharge
of pus with the stool, or at other times of pus which may possibly
be blood-stained. Here there may be a history of old trouble, with
external evidences of it, which suggests that exterior communication
has been shut off while that with the bowel remains. In _complete
fistulas_ there is discharge not only of purulent material, but of
more or less of that which is distinctly fecal, while gas sometimes
escapes through them. Such a statement made by a patient is of itself
significant. A fistulous passage may be surrounded by more or less
infiltrated and inflamed tissue, or it may appear much like a duct.
While always causing more or less annoyance, it may produce symptoms
which seriously disturb. (See Plate LIII.)


=Treatment.=--The treatment of rectal fistula in any of its forms is
distinctly surgical and should always be radical. A blind internal
fistula can be discovered only with the speculum.

Every such fistulous passage should be split up and its tubular
portion thoroughly excised or destroyed with a sharp spoon or caustic.
Furthermore it should be followed to its ultimate ramifications.
For this purpose it is of great assistance to first inject it with
methyl-blue solution, or something else which shall stain it and
make it recognizable wherever it may extend. To incise a superficial
and external fistula is a simple matter, for which local anesthesia
alone may suffice; but to deal radically with an extensive fistulous
tract requires dilatation of the anal sphincter and such thorough
investigation, with complete relaxation of the patient, that general
anesthesia is needed. Now with a probe identifying the tract, and the
knife and spoon made to follow it, or by identification of the stained
tissues colored as above mentioned, the surgeon should proceed to the
extreme of every morbid passage-way, dilating, cutting, trimming,
scraping, as may be needed; while after the work is done every particle
of disturbed raw surface should be cauterized with some reliable
caustic (such as pure carbolic followed by alcohol) so as to sear the
surface and prevent the possibility of reinfection.

To do this operation thoroughly necessitates sometimes multiple and
extensive incisions, with a fierceness of action which may cause
surprise. It is, however, the only effective way in which to proceed.

[Illustration: PLATE LIII

Illustrating Various Forms of Rectal and Anal Fistulas, and the
Conventional Methods of Dealing with Them. (Bernard and Huette.)]

One source of doubt and disappointment is met occasionally in the
radical treatment which requires division of the sphincter, for to
completely divide this muscle is to practically paralyze it and leave
the patient thereafter with fecal incontinence more or less marked.
Such accidents leave more or less disabling consequences. Usually they
are avoidable, for it is rarely necessary to cut completely through a
sphincter muscle, it being possible to avoid the necessity by partial
division, with perhaps more complete exposure above and below. Even
in those instances where it seems unavoidable if the muscle be first
vigorously stretched, and thus temporarily paralyzed, it may then be
safely divided, provided it be neatly and completely sutured _at once_,
and the parts kept at rest for a few days, the intent in stretching
the muscle being partly to so weaken it that it shall be temporarily
disabled. It was suggested years ago by Jenks, of Detroit, and later by
Kelly and others, to make a complete excision of the entire fistulous
tract and then to treat this as any other fresh wound, closing it
completely with sutures. The method is good in theory and occasionally
applicable, and should not be neglected when circumstances favor its
practice.

Every fistulous tract, simple or complicated, not promptly and neatly
closed, should be dressed with gauze, with or without yeast, balsam, or
some one of the other local applications recommended elsewhere in this
work.


PROLAPSE, PROCIDENTIA, AND INVAGINATION OF THE RECTUM.

Prolapse of the rectum is observed in two degrees, either as a mere
_eversion of its mucosa_, which, however, may be profuse and extreme,
or as an actual _escape by process of invagination_ through the anus
of some portion of the rectal tube, with all its coats, including in
well-marked cases even its peritoneal covering. The former is more
common in children as the result of diarrhea, colitis, the presence
of pin-worms, or other parasites, or any other cause which produces
tenesmus and frequent straining, with consequent relaxation of the anal
sphincter. It is amenable to treatment and is usually of insignificant
proportion. It is also frequently seen in adults in connection with
internal hemorrhoids, which are extruded with every stool, carrying
with them more or less mucosa, and which are usually returned within
the rectum by the patient at the conclusion of the act of defecation.

The more complete form of prolapse by true _invagination_ is rarely
seen, save in adults, and in consequence of some serious preëxistent
condition, such perhaps as complete laceration of the perineum in
the female, paralysis of the sphincter from previous accident, or
from the existence of spinal-cord disease. Here and in extreme cases
several inches of bowel may be extruded from the anus, and to an extent
scarcely permitting spontaneous or even individual restoration. So
complete a form is permitted only by some previous lesion of the pelvic
floor, while the mesorectum and even the mesosigmoid become gradually
stretched and useless. The lower portion of the rectum is by far the
more muscular, and such a condition requires that its intrinsic muscles
yield also with those around them.

_Prolapse_ is a condition of general and usually slow development
rather than of abrupt onset. It is made known by the presentation at
the anus of the bright-red mucosa of the rectum, where it pouts and
protrudes, forming a tumor of varying size, with more or less tender
surface, which, with gentle coaxing pressure, is easily made to return
within the rectum. It can usually be made to appear by straining
effort on the part of the patient. Boys with phimosis, who are in
consequence made to strain every time they urinate, will frequently
present minor degrees of the condition, perhaps oftener than when the
rectum itself is at fault, as the act is so frequently repeated. The
oftener such protrusion occurs the more relaxed becomes the anus and
the more irritated the presenting surface, until ulceration and even
keratosis may result. Chronic constipation of children or adults will
also produce the same effect. The presence of hemorrhoidal tumors or of
polypi, or even of parasites, causes the same result.

The most pronounced and complete types of invagination produce a
condition in which reduction is perhaps not possible and procidentia
is constant. There may form here a pouch around the rectum, containing
loops of bowel, bladder, or ovary, or there may even occur a perirectal
hernia.

While patients nearly always become more or less accustomed to the
condition it nevertheless is distressing in proportion to its size and
the individual’s temperament.


=Treatment.=--Treatment depends entirely upon the nature and extent of
the condition. Mild forms occurring in young children may be easily
obviated by attention to their stools, by circumcision if needed, or by
the use of a five-grain capsule of ergotin inserted as a suppository,
it having the effect of invigorating the involuntary muscle and
stimulating the sphincter. Cases not amenable to the milder methods
become surgical and the treatment is then apportioned to the extent of
the lesion. If connected with hemorrhoids or other tumors it becomes
a part of their treatment and is to be dealt with at the same time.
Occurring apparently independently the milder forms will often yield
to the proper use of caustics. The actual cautery being preferable, it
is applied in streaks up and around the rectum, in such a way that,
when the ulcers thus formed cicatrize, the rectum shall be shortened
by cicatricial contraction as by a series of loops drawn up to shorten
it. When permitted by rupture of the perineum and more or less combined
perhaps with cystocele, repair of the perineum, rather than attention
to the rectal condition itself, will be demanded, while the latter
may be combined with an operation for rectocele by excision of an
elliptical portion of the vaginal mucosa and the approximation of its
edges into a line of sutures. This will reduce the capacity of both
the vagina and the rectum and a double indication be thus met. Acute
inflammation sometimes follows exposure of a prolapsed rectum and it
may slough, thus leading to spontaneous recovery, the process not being
without its dangers of thrombosis and septic infection. This procedure
may be imitated by a surgical excision of the entire prolapsed
portion, always with great caution so that if peritoneal surfaces be
exposed they be protected from infection. It has been possible in
many instances to completely excise the protruding portion, and then
to apply a double row of sutures similar to those used in intestinal
resection, only with attention first to the peritoneal rather than
the mucous surface, in such a way as to excise several inches of the
prolapsed bowel and thus meet the indication. Nevertheless cases where
this can be done are exceptional.

Pratt has suggested a _temporary_ purse-string suture of the anus,
effected by a curved needle, completely circumscribing the anal
opening, but kept between the skin and the mucous membrane, to be
brought out through the same puncture at which it was inserted.
The finger of an assistant being passed into the anus, the suture
is now tied around it. This may be used as supplementary to linear
cauterization above mentioned.

Numerous methods of _proctopexy_, or elevation and fixation, have been
devised. Fowler, for instance, made an incision half-way between the
anus and the point of the coccyx, and after separating the rectum from
the latter and the sacrum inserted two fingers in the rectum, holding
it up while its posterior wall was forced into the external wound and
there held by heavy sutures of kangaroo tendon. By further incision he
brought out the ends of these sutures on each side of the coccyx and
tied them across the bone, thus by traction bringing the rectum up into
position.

_Colopexy_ has been practised as a more radical measure for the same
purpose. As advised by Bryant the abdomen is opened by an incision
parallel to Poupart’s ligament on the left side and one inch above it,
and the prolapse is reduced by firmly pulling the rectum upward. It
is then secured to the peritoneum about it, and is held by quilting
sutures, which include the entire muscular coat of the bowel. Save in
exceptionally favorable cases one or the other of these methods may be
considered preferable to the complete amputation above described.


HEMORRHOIDS; PILES.

Hemorrhoids constitute perhaps the most common and, in some respects,
uncomfortable or distressing disease of the rectum. The term implies
a varicose condition of the lower veins, sometimes those of one set
of hemorrhoidal veins being involved, at other times nearly all of
them participating. They are spoken of as _external_ or _internal_. In
the former case it is the external hemorrhoidal veins alone which are
involved, and usually only two or three of them, although occasionally
one sees outside the anus, as within, a general involvement of the
entire venous distribution. A _pile_, then, is essentially a venous
angioma, or a single varicosity, and its peculiar features are due
solely to its location.

Any vein thus involved is liable to the same dangers and accidents
as veins in other parts of the body. Thus it may undergo dilatation,
thrombosis, and suppuration, while the ordinary consequences of the
latter condition may follow here, as elsewhere, with this difference
alone, that when the middle and upper hemorrhoidal plexuses are
involved the thromboseptic process, should it occur, follows the
_portal vein_, and the first metastatic abscess that forms occurs
_within the liver_. Thence it may spread to other parts of the body in
classic form.

The hemorrhoidal veins, save those at the verge of the anus, are
more or less entangled among the fibers of the levator ani and the
sphincter. These muscles are thrown into a condition of more or less
spasmodic contraction when the veins are so involved. In consequence
more pressure is made upon the veins themselves, and the conditions
of spasm and venous engorgement react upon each other in a vicious
circle, each tending to make the other worse. Hence the great advantage
of _stretching the sphincter_ in any operation save that for a small
external pile.

Hemorrhoidal angiomas may appear as single tumors or in multiple
form surrounding the lower part of the rectum. The most common cause
for their occurrence is chronic constipation. Occasionally the first
exciting agent is some violent strain in defecation, or possibly the
actual rupture of a small vessel, but such constant overloading of the
rectum as obstructs its return circulation conduces to engorgement and
the other conditions may easily follow. A small pile may be brought
into existence in brief time, but a general hemorrhoidal condition
is one of slow development. Chronic cases are always accompanied by
further changes involving the surrounding connective tissue and the
overlying mucosa, both of which become thickened and infiltrated, while
ulcers form frequently upon the latter, and the occurrence of those
linear ulcers which are ordinarily called _fissures_ is very frequent.
This gives an additionally distressing feature to these cases. As
the condition goes on and the angiomas increase in size there is an
increasing tendency to prolapse. This may be temporary or constant, _i.
e._, it may occur with the straining effort at stool or it may result
in a condition of permanent protrusion at the anus of the engorged
mucosa; or, if the sphincter has finally become prolapsed a true
prolapse of the rectum may result. A mucous surface thus constantly
exposed to irritation will nearly always be more or less ulcerated and
tender, while hemorrhages in either variety are common. It is not an
infrequent event, then, for a patient to lose a number of ounces of
blood with or just after stool, and sometimes the blood loss is even
excessive. There is then added to the local condition a secondary
feature of anemia and its attendant consequences which are sometimes
extreme, and may even make operation somewhat hazardous. The lower
inch and a half of the rectum is the portion particularly supplied
with sensory nerves, and, under these circumstances, the irritated
area becomes erethistic and painful and the patient’s suffering may be
extreme. This is the so-called “_pile-bearing area_,” as it is within
it that the hemorrhoidal condition is practically confined. Even a
small individual pile connected with one of the little external veins
may give rise to a disproportionate amount of discomfort.

There has been so much quack literature upon this general subject
that ignorant patients are very likely to say that they have piles,
no matter what may be the local condition. A statement to this effect
should, first of all, provoke a physical examination with the finger,
then with the speculum. The educated finger will easily detect the
presence of the rugosities or tumors produced by internal piles, the
external being always self-evident. The coexistence of ulceration
will be indicated by an extreme degree of sphincteric spasm and of
tenderness. It should be remembered that, along with hemorrhoids,
there may coexist fissure, ulcer, painful spasm, prolapse, and, in
long-existent cases, even cancer. The average patient with cancer of
the rectum will go to his physician saying that he thinks he has piles.


=Treatment.=--Treatment needs to be something more than merely local
in aggravated cases, as it should also be more comprehensive. Patients
who have thus long suffered have almost inevitably contracted the
constipated habit, postponing defecation whenever possible because of
pain and tenderness, and perhaps the hemorrhage accompanying it. The
large bowel has, therefore, become weakened, and attention should be
given to it as well as to the general digestive process.

_Locally_ very mild degrees of purely temporary disturbance may
be sometimes acceptably and temporarily treated by the use of
suppositories containing some soothing and anodyne drug, as well as
ergotin, the latter being valuable because of its constringent effect
upon the bloodvessels. A five-grain gelatin-coated pill of ergotin
makes a satisfactory suppository for the young, under these conditions.

A freshly formed, external hemorrhoid, which may attain a size no
larger than that of a pea, but which will seem to the patient as large
as a bird’s egg, is best treated by _open division_, turning out the
blood or clot contained within the dilated vein, which will quickly
obliterate, so that recovery will be complete within two or three days.
This may be done under local anesthesia and with prompt relief. There
have been methods in vogue, especially among the charlatans and some of
the specialists, of treating external and the more localized internal
conditions by _injection of carbolic acid_, either pure or reduced
with a little glycerin. A few drops are thrown into the tumor with a
hypodermic needle, the effect being to promptly coagulate the contained
blood, the intent being to produce a final cure by absorption of the
clot and obliteration of the veins. This, in fact, is the secret method
long employed by the travelling charlatans and often connected with the
name of Brinkerhof. It is uncertain in action, and the production of
a clot under these conditions is by no means always free from danger,
nor is the relief prompt. What is desired is to empty the vein and
turn out the clot rather than to provoke its production. The method is
rarely practised by judicious surgeons, who have too often seen serious
sloughing and even general septic disturbance follow it.

For the _radical relief_ of distinctly hemorrhoidal conditions there
is no satisfactory method save the operative. So many measures have
been devised in time past that it is necessary here to be selective
and only mention one or two. On general principles every pile is a
venous tumor, and there is no reason why it should not be treated like
any other tumor, _i. e._, by _enucleation or excision_. The same is
true of the area which contains a number of such tumors, _i. e._, the
so-called pile-bearing area. Hence, surgeons of the largest experience
have practically discarded the more bungling methods and have applied
to these conditions the same radical measures which they recommend
elsewhere.

One important feature which should always be practised is thorough
_dilatation of the sphincter_, not only for reasons above described,
but because of the facility with which the surgeon then exposes
the diseased tissues. Any distinct tumor or series of them may,
for instance, be seized, isolated, and dissected out, either by an
elliptical incision of the mucosa or by a more blunt dissection with
scissors. The base, or pedicle, if sufficiently large to justify
it, may be ligated before the incision is completed, after which
catgut sutures may be used to close the opening in the mucosa. When
the tumor is small the suture may be made to include the bleeding
points so that even a ligature is not required. A more radical method
of extending this same principle to the entire pile-bearing area,
especially when prolapsed, or to so much of it as is affected, is
the so-called _Whitehead’s operation of excision_, which practically
consists in trimming off a ring of exposed mucosa, with its clusters of
enlarged and more or less pendulous veins. This ring extends from the
mucocutaneous border, at the verge of the anus, to a point perhaps 1¹⁄₂
inches above, the intent being to separate the mucosa and the tumors
from the fibers of the sphincter, which can be practically effected
in such a way that sphincter control is not lost. Hemorrhage will be
free for a few moments, but is always within control. Larger vessels
which spurt may be twisted or tied, while oozing surfaces are included
within the row of catgut sutures, which is later placed in such a way
as to unite the divided mucous tube with the skin border at the anus.
The operation is, in effect, an annular excision of the lining of
the rectum, and as such proves satisfactory. There is about it this
temporary disadvantage that the pile-bearing area thus removed is also
the sensitive area, and that for a few weeks, at least until nerve
communications have been reëstablished, there is a lack of peculiar or
normal sensibility about the parts which is annoying, and may perhaps
lead to some incontinence, but this soon passes away. The measure is
the most satisfactory of all for well-marked cases of hemorrhoids
associated with more or less ulceration and prolapse.

An occasional dilatation, scattered here and there around the lower end
of the rectum, perhaps with a mild degree of ulceration, is usually
very satisfactorily treated by a method which it must be confessed
would be rarely used on the exterior of the body, and yet which proves
quite serviceable here, namely, the _actual cautery_. The consequences
of its application are obliteration of the vein, cicatricial
contraction of the overstretched tissues and eventual relief.

[Illustration: FIG. 593

Multiple polypi of rectum. (Potherat.)]

Other methods of operation include the use of the _clamp and
cautery_ for removal of considerable masses, a method ordinarily
less satisfactory than excision, and the use of the ligature, with
or without incision of the mucosa at the base of the tumor, it being
thus cauterized and expected to separate by sloughing, an uncertain
procedure. None of these methods, nor others not worth mentioning,
compare with the newer methods of excision.

Much has been recently written concerning the advantage of local
anesthesia in doing these operations. This seems to have been
advocated largely for effect, although external tumors can be treated
by cocaine applications or by the ordinary injections of cocaine or
one of its substitutes. It is claimed that the infiltration of the
surrounding tissues with normal salt solution affords an effective
local anesthetic. Mere local anesthesia is not sufficient for thorough
work upon parts not easily visible, and the actual stretching of
the sphincter is half the battle in dealing with these conditions.
This cannot be thoroughly accomplished without general anesthesia.
Consequently for any well-marked hemorrhoidal condition chloroform
offers decidedly the preferable method, not alone from considerations
of comfort, but from the standpoint of permitting more thorough and
effective work to be done.

After these operations it is advisable to place within the grasp
of the anus a stiff rubber tube wrapped with gauze. It permits the
escape of flatus without distress to the patient, and it effects a
better coaptation of surfaces recently united by suture than would
otherwise be secured. Such a tube may be left _in situ_ for from six to
thirty-six hours.


TUMORS OF THE RECTUM.

The rectum is the frequent site, more especially in children, of
_polypoid degenerations_ similar to those seen in the nose. In
consequence there are formed the so-called _rectal polypi_, which, in
origin, consistence, and course correspond to the common nasal polypi.
Such a pedunculated tumor may attain considerable size, especially when
solitary, while, on the other hand, the mucosa may be studded with
small pedunculated growths, giving the appearance represented in Fig.
593.

Pathologically these polypi are originally of myxomatous or adenomatous
type. They may bleed easily and may be passed with stool. In their
multiple and smaller expressions they give rise rather to rectal
uneasiness and tenesmus than to more distinct symptoms. On the other
hand an isolated tumor, so pedunculated as to become gradually
stretched out, may attain considerable size and give rise to all the
sensations of a foreign body in the rectum, with constant tenesmus and
desire to expel it, while it may even present at the anus or bleed
freely.

Only exceptionally will these tumors be recognized previous
to examination, which, however, should easily disclose their
characteristics. Isolated polypi should be removed, either by being
twisted off or by excision and ligature of their bases. General
polypoid degeneration may be treated with the curette or with the
actual cautery. In all these instances surgical intervention in some
form will be required.

Other _benign tumors_ in the rectum are mainly of the _adenomatous_
type. Owing to their location it is rare that they are seen early by
one competent to judge of them. In consequence the surgeon sees them
usually as more or less ulcerated, sometimes extensive growths, perhaps
bleeding freely, and much changed by maceration and by compression from
their original condition.

In such cases it becomes a question of importance to distinguish
between the benign and the cancerous growths. This is not always easily
done, especially when they are high up and ulcerated. The matter is
usually decided by the presence or absence of actual infiltration
around the base of the growth, and perhaps the involvement of lymph
nodes. A movable tumor with an infiltrated base is usually clinically
benign, nevertheless it should be radically removed. It is in many
of these instances that one may see expressions of transformation of
adenoma into carcinoma.


=Cancer of the Rectum.=--This will be considered here rather from
its clinical side; hence what is said refers alike to sarcoma and
carcinoma, the latter being far more common. _Carcinoma of the rectum_
may assume the type either of epithelioma, as when it begins low and
spreads upward, or of adenocarcinoma, when it arises from that portion
of the tube not lined with squamous epithelium.

It usually begins _insidiously_, and for a considerable length of time
furnishes scarcely any recognizable symptom. The first indications
noticed by the patient are usually more or less frequency of stool,
with tenesmus, and the passage of mucus, perhaps stained with blood,
rather than of fecal matter. By the time those conditions are noticed
there will usually be more or less mechanical difficulty of defecation,
due to the presence of the tumor and obstruction of the rectal tube.
Pain may be a long-deferred feature, and local soreness may be absent
until late in the case or until its terminal stage, when the growth
is above the peculiarly sensitive part of the rectum, _i. e._, when
it does not approach to within 1¹⁄₂ inches of the sphincter. As time
goes on there is more and more suffering in the rectum, with backache,
referred pain, while the tenesmus and other local conditions cause
increasing distress. It often happens that it is not until this period
is reached that the patient consults a physician, and then he usually
goes with the statement that he is suffering from piles.

[Illustration: FIG. 594

Epithelioma of anus and rectum. (Grant.)]

So frequently is this the case, and so prone are many practitioners
to accept such a statement, that the proper examination which should
permit the recognition of the condition is perhaps not made until the
patient is really in a pitiable condition. _I do not recall ever having
seen a case of cancer of the rectum which had not been regarded, by
some physician as piles, and in most cases locally treated by him,
usually without any adequate local examination_, and usually also until
the time had passed when a radical operation could be practised with
any degree of hope. The first examination at least will be digital,
and if the malignant growth be within reach of the finger it should be
possible to appreciate it, to estimate its size, degree of attachment,
and the amount of infiltration, as well as the extent to which it is
breaking down. A soft, rapidly growing cancer will give a fungous
sensation to the finger, while the more dense, scirrhous forms produce
hard masses, growing in irregular shapes, sometimes involving one side
of the bowel, sometimes appearing in annular form, and tending sooner
or later to produce malignant destruction. The only difficulty would
be in cases seen exceptionally early or in those beyond reach. The
circumstances above detailed should lead to a careful _proctoscopic
examination_ with suitable instruments, perhaps in the knee-chest
position, when the growth is not easily appreciated from below. _Any
complaint of tenesmus, with discharge of blood and mucus, with more or
less pain and tenderness, local or referred, demands an examination
sufficiently careful to reveal the nature and extent of the lesion and
indicate the treatment._ If such an examination call for an anesthetic,
it should be administered. Practically every rectal cancer is a
malignant ulcer by the time it is recognized, ulceration being favored
by warmth and moisture.


=Treatment.=--There are few malignant lesions anywhere about the body
which require more good judgment in treatment than cases of cancer of
the rectum. So much depends upon their location, their extent, the
degree of infiltration, the age and general condition of the patient,
that it is almost impossible to lay down succinct rules. The question
of treatment hinges, first, upon the location and extent of the lesion;
is it operable or is it not? When the lymph nodes of the pelvis or the
groin are noticeably involved it is practically too late, under any
circumstances, to hold out prospect of radical cure. When the disease
has extended far above reach of the finger it is again late to expect
much even from radical measures. When the prostate, the floor of the
bladder, the vagina, or any of the pelvic viscera are involved it is
again too late to justify them. There are wide differences of opinion
between surgeons as to the propriety of extensive operations in serious
cases. Mild cases are certainly much benefited and even actually cured
by early and thorough removal, but this occurs too infrequently,
because such cases are rarely seen sufficiently early.

The class of cases universally acknowledged to be inoperable, so far
as radical measures are concerned, are nevertheless much benefited and
their lives prolonged by a _colostomy_, the effect being to provide
an easy and manageable outlet for fecal discharge, and to avoid the
irritation and attendant difficulties associated with an obstructed and
malignantly ulcerated rectal outlet. The surgeon has to select between
some method of excision and colostomy. My own opinion is growing in
favor of the latter, save when the prospect of complete excision is
good. The opening is more manageable, the progress of the disease
seems much checked, patients have better fecal control and live in
far greater comfort, while their lives are placed in less jeopardy,
and, in general, are actually prolonged. Thus a colostomy performed
in a well-marked case of inoperable cancer of the rectum may permit
of prolongation of life for two or three years, something not often
attained by any other method of treatment.

Of the various _radical operations_ some are made from below, _i. e._,
by the perineal route, some by the so-called sacral route, and some
from above. Of the latter it may be said that occasionally an annular
cancer of the rectum is seen so favorably located that by opening the
abdomen with the patient in the Trendelenburg position it is possible
to make a complete excision of the growth, to remove enlarged lymph
nodes, and to make an end-to-end reunion with success. In a case in my
own practice nearly six years have elapsed since this operation was
done, and the patient, a young woman, is still absolutely free from the
disease.

Through the _perineum_ the lower portion of the rectum may be attacked
either by splitting the sphincter and dividing it posteriorly,
completely dissecting out the gut from its surroundings, removing all
infiltrated tissue, and then, by dividing the bowel above the growth,
amputating the lower part. It may be possible to bring down the upper
end and attach it to the mucocutaneous border of the anus, reuniting
the divided sphincter, and aiming for a restoration to something like
the original condition, which under quite favorable conditions is
attainable. At other times it will be impracticable to thus attach the
lower end of the tube because it has been too much shortened, and in
these cases it should be brought out through a posterior incision just
below the tip of the coccyx, or higher up if the bone has been removed.
Here the rectal outlet is placed posteriorly, but is devoid of a
sphincter. Something like sphincteric action can be provided by giving
it a third or half of a revolution on its axis before fastening it to
the external wound. After this expedient more or less control of solid
fecal matter is afforded.

The more complete and radical operations, associated with the names
of Kraske and other operators, include removal of the coccyx, and of
the lower portion of the sacrum, which are usually completely excised,
although certain “trap-door” operations have been devised. If the
sacrum be not cut away above the third sacral foramen there is not
much damage done to the nerves, while sufficient room is afforded for
any removal that is justifiable. Some operators open the peritoneum,
others attempt to avoid it. If the growth be attached to that membrane
it becomes necessary. If peritoneal invasion can be avoided it is
desirable. It is possible to completely expose the contents of the
pelvis through such an opening, while from this direction, the gut
being withdrawn after the peritoneum is divided, the pouch of Douglas
may be opened and further removal of diseased tissue be effected. In
all these operations the endeavor should be to disturb the mesosigmoid
and the mesorectum as little as possible, in order to not interfere
with blood supply, for reasons already mentioned when discussing the
mesentery.

In all these operations contamination of the wound should be avoided,
especially of the peritoneum, by clamping or ligating the bowel, or by
amply packing and by every possible additional precaution. Bowel should
be divided between two clamps and the divided edges at once thoroughly
cleansed with compresses and with hydrogen peroxide.

One may read in the works on operative surgery descriptions of most
extensive and elaborate operations of this general character, and of
extensive and even daring feats of removal, where portions of the
bladder, of the tubes, of the ovaries, even the uterus, have been
removed. It has seemed to me that the surgeon should avoid operative
gymnastics, especially in this region, so far as possible, and confine
himself to measures which if successful would improve conditions rather
than complicate them. My own judgment then is that in any case where so
formidable an operation would be attempted by some, the best interests
of the patient will be served rather by simple colostomy.

_Early_ operations upon cancer of the rectum afford comforting
prospects. It is not so much to the discredit of surgery as to the
discredit of the patient’s judgment, and of the carelessness of the
practitioners who first see these cases, that cancer of the rectum has
become such a _bête noir_ and is justly regarded as so serious and
unpromising a measure.[60]

  [60] It becomes a question of importance just when and where we
  should cease to attempt operation on the colon from above or on the
  sigmoid from below; in other words, the exact location of the tumor
  should decide the measure when it can be accurately determined.
  Moreover, a wide margin of bowel on either side of any new-growth
  which is about to be resected should be excised. The question of
  blood supply to the margins of the wound thus made is also of
  importance, as the most ideal operation in appearance may be marred
  by gangrene due to lack of sufficient blood supply. When there is
  sufficient uninvolved gut below the tumor to permit of complete
  operation within the abdomen it is not advisable to do anything from
  below; but there are some cases in which anything like complete
  removal can only be effected by a combination of abdominal and sacral
  routes. A thorough extirpation should be made above the growth as
  well as of the involved tissue below. Those vessels which require
  ligation should be tied accurately at the level of their division,
  and no ligation of trunks or larger vessels should be attempted at
  any distance from the line of division. If this be carefully carried
  out and the divided mesentery, with its ends, and all the fat between
  the rectum and the sacrum be carefully dissected out, there will
  rarely be difficulty in making an end-to-end reunion of the divided
  bowel.

  It is rarely necessary to include a colostomy with this procedure; in
  fact, when a permanent opening has become necessary there is little
  possibility of removing the main growth. Colostomy is a procedure
  for the hopeless cases; resection is rarely to be thought of as an
  alternative. It should be an early not a late measure, the reverse
  being true of colostomy, though even this should not be _too_ late.


=Colostomy.=--Colostomy for relief of rectal cancer is not a radical
operation, but in many cases is far more humane and satisfactory than
are those alluded to above. The intent is to make an opening in the
left side of the groin at a point where it is easily made. There are
two methods of performing colostomy here. One is to make an opening
through the abdominal wall, attach to it the presenting surface of
the sigmoid or colon, and either open it at once or some hours later,
when adhesions have cemented the desired union. Such an opening may
be made for emergency purposes under local anesthesia, but when the
colon is movable, and when the disease has not yet involved the area
thus exposed, or any portion above it, a more desirable method is a
deliberate one. An opening is made such as is usually made on the
right side when operating upon the appendix. The bowel thus being
accessible is divided between two clamps, while the end of the lower
segment is inverted and closed with chromic or silk sutures, after
which it is dropped back. This leaves the upper portion with its open
end corresponding to the abdominal opening, into which it is fastened
by a series of sutures, being attached to the peritoneum and to the
deep musculature rather than to the skin, for if it be brought out too
freely and attached externally there is greater tendency to prolapse
and subsequent discomfort. Into the opening thus afforded a large-sized
rubber or bent glass tube is inserted for a few inches, around which
gauze is packed, and every effort is made to conduct fecal matter to
the exterior, as well to protect, at least for a few hours, the wound
itself from fecal contamination. Improvements in this technique have
been suggested, such as tying into the bowel a curved glass tube, thus
conducting its contents into a rubber bag or receptacle placed outside
the dressing. Another method which has been suggested by Stewart is to
connect the interior of the colon by a Murphy button with a rubber bag
or rubber dam upon the outside of the abdomen, by which protection for
this purpose can be afforded.

This operation makes a complete and final division of the colon, and
permanently excludes the rectum with its cancerous involvement. It
is not, therefore, in this respect, a radical measure. The result,
however, is that if the rectum be washed from below each day it is kept
far cleaner and freer from contact with irritative foreign material
than it otherwise would be. Furthermore, being disused it tends to
undergo to some degree a species of physiological atrophy, and, in
consequence, the cancer grows more slowly, if there do not occur an
apparent temporary cessation of malignant activity.

By suitable management of the artificial anus, including the deliberate
emptying of the bowel every morning and the use of protective pads
for receptacles, it can be made far less disagreeable than patients
ordinarily fear (Figs. 595 and 596).

[Illustration: FIG. 595

Gleason’s pouch and supporter.]

[Illustration: FIG. 596

Colostomy pad and bag, worn as is a truss. (Kelsey.)]

The colostomy opening in the abdominal wall should be made as small
as practicable lest there occur not only more or less ventral hernia
through the weakened outlet, but even, as I have seen in one case, a
most extensive prolapse of the colon, in which two or three years after
performance of the operation the colon could be made to prolapse to an
extent of twelve or fifteen inches.




CHAPTER LI.

HERNIA.


The term hernia of itself implies protrusion or escape of a contained
organ or part through its containing walls, yet covered by some of
them. Thus we may have hernia of the iris, of the brain, and the like;
but when no particular part of the body is specified, by common consent
the term is understood as implying hernia either of the _intestine or
the omentum, or of both_. Such hernia may be either of _congenital
or acquired character_, the former condition being permitted by some
defect or abnormality in the abdominal parietes, the latter being the
immediate or remote result of accident or of operation; and in the
latter case they are referred to as _traumatic_ or as _postoperative_.
Of these the former is usually of rapid and the latter of slow
development. Increased abdominal pressure doubtless has much to do with
the occurrence even of a truly congenital hernia, as this would hardly
develop were it not for the former. Such pressure may be the result of
occupation, of pregnancy, or of certain morbid conditions--for example,
those which cause constant coughing or straining at stool, or straining
during urination--as from prostatic hypertrophy or phimosis, or such
intra-abdominal conditions as tumors, which distort the abdominal
walls, or accumulations of fluid which weaken them. Accident produces
hernia mainly by causing the effects of pressure to be manifested in
a brief space of time. Thus pressure or strain on abdominal muscles
may part them in such a way as to permit the immediate appearance of
a hernia, or its more slow development. The postoperative hernias are
usually of the so-called _ventral_ type, and occur most often after
wounds which could not be immediately closed because of necessity for
drainage, or in those which were closed in such a way as to permit of
gradual warping or stretching of the resulting scar.

The surgical anatomy of hernia is described in works on anatomy. It
is necessary, therefore, here only to remind the reader that the
conditions existent in an old hernia may be different from those so
described, for the original anatomical outlines may perhaps have long
been lost and the original coverings more or less blended together so
as to become indistinguishable. Particularly is it true of strangulated
hernia that the more minute details are lost, and that in such
cases there is great difficulty in the effort to recognize distinct
anatomical layers and coverings. In old cases the _sac_--namely, the
original peritoneum--may be greatly thickened, while in strangulated
cases it will be discolored, perhaps even gangrenous, and will bear but
slight resemblance to the original condition. The same is true of its
contents, which may be _adherent_, _strangulated_, or _gangrenous_,
according to circumstances.

The opening through which the hernia appears is usually referred to as
the _ring_, to which, however, it may bear very little resemblance.
Thus it may be an elongated buttonhole-like, or a warped, irregularly
rounded sac opening, whose margins are thick or thin and easily
distinguished or otherwise.

By all writers hernias are classified according to their anatomical
characteristics as follows: _Inguinal_, indirect and direct; _femoral_,
_umbilical_, _ventral_, _diaphragmatic_, _gluteal_ or _ischiatic_,
_obturator_, _perineal_, _lumbar_, _sacrorectal_, _retroperitoneal_
(including the recently described _paraduodenal_ or Treitz variety),
and _properitoneal_.

Of these the most common are the inguinal and the femoral, the
umbilical ranking next, while the other forms are rare.


=Causes.=--Regarding the _cause_ and _nature_ of the common
forms--namely, the inguinal and femoral--I propose here to introduce
the views enunciated by Russell, of Melbourne, which seem to me
to furnish the actual explanation for nearly all instances. This
explanation refers to the _congenital origin of the condition, even
though it do not appear until the middle years of life_. In the case of
inguinal hernia it refers also to the persistence of the canal of Nuck,
or of at least incomplete obliteration of the original vaginal process
or prolongation of the peritoneum, which comes down with the migrating
testicle and whose lower portion furnishes the cavity of the tunica
vaginalis. It is more rational to explain the occurrence of hernia in
connection with this preformed sac than by the view that there are so
many instances of congenital weakness of the abdominal wall. That such
weakness exists in many cases of hernia is undeniable, but this is to
be regarded as the effect rather than the actual condition. From this
last statement it follows also that there is great advantage in early
operation, and in complete removal of the sac, which when performed
early will not only cure the hernia but prevent the weakening of the
abdominal wall itself. It follows, further, that the use of a truss,
save possibly in the case of young infants, is an improper method of
treatment. In other words, upon it is based the crux of the whole
matter of successful treatment, _i. e._, operative removal of the sac.

It will be seen, then, that the cause of inguinal hernia is closely
related with the cause of so-called congenital hydrocele of the cord
(_q. v._), the latter condition being one of sacculation of the canal,
with accumulation of fluid; and it is interesting to recall that
such sacculations are occasionally found in the ordinary so-called
congenital hernias, when they are seen early, and before all anatomical
surroundings have been merged together. _The existence of a hernia
implies the presence of a sac, and a congenital defect furnishes this
latter, while the variations in the type of hernia are due mainly to
the variations in the sac itself_, i. e., _in its location_.

[Illustration: FIG. 597

Congenital hernia.]

[Illustration: FIG. 598

Infantile hernia.]

Russell has traced out the relations between the peritoneal pouches of
the lower abdomen and the principal bloodvessels, and has shown how the
former arrange themselves about the latter and are carried with them
as they develop, assuming in consequence the type either of inguinal
or femoral hernia, according as they are placed to the inner or outer
and lower side of the same. He has insisted, and I think properly, that
the variations observed in the clinical manifestations of a hernia are
mainly determined by the size and the position of the sac, and that
these depend upon its relations to the femoral and epigastric vessels,
the associated sac and vessel being subject to the same vicissitudes in
development. In this way the occurrence at one time of a _congenital_
and at another of a so-called _infantile_ type of inguinal hernia may
be easily explained, as well as the differences between the so-called
_funicular_ and the partial form, and also the occurrence of the
_retroperitoneal_ or _properitoneal_ forms, which, as variations are
rare, and as clinical manifestations perplexing, but which nevertheless
are easily explained when viewed in this light (Figs. 597 and 598).

[Illustration: FIG. 599

Adhesions in hernial sac. Scarpa. (Lejars.)]

Thus viewed, then, what are the _relations of traumatism to congenital
defects_? When thus explained they seem to be as follows: By no means
every individual who sustains an injury to the abdomen suffers from
hernia, but when the parts are already weakened or prepared by the
preëxistence of these congenital defects, then a small amount of
strain or injury may serve to open them up and to produce a condition
apparently due to accident which otherwise could not have occurred.
The more I have studied the entire question the more I have come to
the conclusion that hernias of the ordinary type, save in case of
extreme violence, would not occur were it not for such a congenital
prearrangement and tissue permission, as it were; so that we are
justified in assuming that inguinal and femoral like umbilical hernias
are really of congenital origin.


=The Signs of Hernia.=--The signs of hernia include the existence of a
_tumor_, usually at one of the common outlets, which may be variable
in size, and fixed, changeable, or otherwise, according to whether it
consist of intestine or omentum. To a hernial protrusion consisting
of intestine alone may still be given the old term _enterocele_. One
consisting of omentum is known as _epiplocele_. Hernial protrusions
may attain tremendous dimensions, especially those appearing at the
umbilicus, and some of these sacs contain perhaps the larger proportion
of the intestine or even of the entire abdominal contents. Scrotal
tumors, again, may attain large size, _e. g._, that of the individual’s
head or even much larger. According to the nature of the contents such
a tumor will be more or less resonant on percussion, and more or less
compressible as well as reducible. _Reducibility_--namely, the ability
to be returned to the abdominal cavity--is the most characteristic
feature of a hernia and one possessed by nearly every such tumor, at
least at its inception. It may, however, be lost.

Loss of reducibility, when occurring gradually, is replaced by what
is known as _incarceration_, _i. e._, more or less complete fixation,
at the same time without such pressure on bloodvessels as to produce
necrosis. Incarceration may be the result of reduction in caliber
of the hernial outlet, or of the formation of adhesions between the
walls of the sac and its contents, such adhesions being common alike
to omentum and large or small bowel. (See Fig. 599.) _Strangulation_
is an acute process which may terminate either a reducible or
an incarcerated hernia. It implies some sudden change, such as
overcrowding of the bowel within the sac, or some peculiar kinking, by
which intestinal caliber is shut off, as well as blood supply affected
because of pressure, by which the vitality of the gut and of the sac
is compromised or perhaps quickly lost. Strangulation, then, includes
at least the possibilities and usually the simultaneous occurrence of
acute obstruction of the bowel with more or less gangrene of the sac
itself, as well as of the compromised gut.

_Reducibility_ as an ordinary feature of hernia is one with which the
patient himself is quite familiar, most patients with reducible hernias
being able to effect reduction in the horizontal position, accompanied
by some manipulation or maneuver. When in such cases reduction cannot
be accomplished incarceration or perhaps strangulation has begun and
the case immediately assumes serious proportions. Reduction is usually
accompanied by a peculiar gurgle, as well as disappearance of the
tumor itself, while the opening through which it has disappeared can
usually be identified with the finger, by invagination of the scrotum,
or by pressure over the femoral region. Such a tumor usually reappears
when the patient stands, or particularly when he coughs or makes any
straining effort, and the occurrence and recurrence of these phenomena
clearly establish the diagnosis of hernia.

Irreducible or incarcerated hernias usually give some _impulse upon
the patient’s coughing_, as do the reducible forms, yet in some cases
they lead to more difficulty of diagnosis. Ordinarily in the male
the question is mainly as between inguinal (or scrotal) hernia and
_hydrocele_. In the latter there is a pear-shaped tumor whose apex
should be found below the level of the inguinal outlet; a tumor which
will fluctuate, whose shape does not change, which gives no impulse
when the patient coughs, which is not influenced by pressure, even with
the patient in the horizontal position. It is only in incarcerated or
in peculiar types of congenital hernias, or in those combined, as they
may be, with hydrocele, in which doubt should not be easily dissipated.
While incarceration predisposes to acute obstruction it is not always
followed by it, but may produce a more chronic type of constipation,
with tendency to fecal impaction, because of the mechanical impediment
to freedom of bowel motility. This condition is more frequently met in
the aged.

_Inflammation of the hernial sac_, as well as of its coverings, leads
to a condition described as _inflamed hernia_. It is essentially one of
circumscribed cellulitis. It may be due to the irritation of a badly
fitting truss or to other external causes. The inflammation may extend
so as to involve the sac wall itself, and thus produce adhesions and
later incarceration, or it may set up actual peritonitis, which may
extend to the general abdominal cavity and terminate fatally. The more
superficial and less acute forms are scarcely distinguishable from a
local erysipelas which may terminate by abscess. Such a condition might
be mistaken for one of suppurating bubo. Nevertheless the existence
of the hernia itself should guard one against this error and make him
extremely cautious in using the knife, even though it be necessary for
the evacuation of pus.

[Illustration: FIG. 600

Gangrenous strangulated hernia; artificial anus; prolapse of bowel
requiring intestinal resection; eventual recovery. (Preindlsberger.)]

_Strangulated hernia_ has already been considered as the most common
cause of _acute obstruction of the bowel_. Its possibility should
be excluded in every case of this serious condition. While such are
its general features, locally there is added to the general bowel
obstructive condition that of more or less local destruction, which may
vary from the presence of exudate, fluid or solid, with infiltration of
adjoining tissues, to the most prompt and disastrous consequences of
venous stasis, namely, extensive _gangrene_, which, involving first the
bowel itself or the omentum, will later spread to the sac wall and its
surroundings. In this instance around the loop or loops of gut involved
will be seen a tight constriction or sulcus, above which the bowel
will be more or less discolored and distended, while below it will
be completely necrotic and perhaps actually sloughing. Minor degrees
of strangulation may produce conditions which would lead up to this,
but have not yet actually reached the stage of gangrene. Around such
bowel will be found more or less fluid, the result of transudation,
which will be swarming with bacteria and often offensive. The sac wall
closely corresponds in appearance to that of the bowel, and everything
about the sac and its contents will be infected and contaminated with
bacteria, often of most virulent activity. The gangrene may involve an
area of exceedingly small size, or the entire contents of the hernial
sac. In the former instance the condition is comparatively simple as
compared with the latter, which may require resection of several feet
of necrotic bowel. The proper treatment of these conditions will be
more fully dealt with below (Fig. 600).


=Symptoms.=--The symptoms of strangulation are those of acute
obstruction, plus the local evidences of a hernia, usually with added
pain and tenderness, sometimes acute. These symptoms may come on as
the result of strain or accident or without any known cause. Their
intensity will depend in some measure upon the completeness of the
blood stasis and the rapidity of the consequent gangrenous process. The
latter may vary in degree. Thus the death of the compromised bowel may
be practically determined within a few hours or within two or three
days. The hernial tumor, within which strangulation has occurred,
becomes more tense and incompressible, and, at the same time, more
tender. Sometimes there is marked augmentation in volume; at other
times this changes but little. So soon as a loop of bowel has lost
its blood supply and become actually necrotic it will have also lost,
when exposed, all of its luster or “sheen,” and will appear not only
black and lusterless, but will be more or less offensive in odor, and
of extremely septic character. The surrounding fluid will be found
swarming with bacteria, and will seriously and perhaps fatally infect
anyone inoculated with it.

Concerning the color of the exposed bowel and its appearance, it is
a fairly safe rule to follow that gut which has not lost its luster,
even though darkly discolored, is still viable, and may with safety be
returned to the abdomen, which is probably the safest place for it;
but when its sheen is actually lost the case becomes one either for
resection or for artificial anus. It is possible that such a case may
be seen only after absolute necrosis and fecal escape have occurred.
When actual sloughing is thus met it is a question for resection or
some other expedient.


=Varieties of Hernia. Inguinal Hernia.=--The inguinal form of hernia
comprises nearly four-fifths of cases in males, a much smaller
proportion in females. The hernial protrusion is always through the
external abdominal ring, either by way of the inguinal canal, which it
enters through the internal ring, or directly through the abdominal
wall. The former is called _indirect_, the latter _direct_. Such
a hernia is considered _complete_ or _incomplete_ according as it
descends below the lower margin of the inguinal canal. An incomplete
and direct hernia is often referred to as _bubonocele_. (Fig. 601.)

Holding the views above enunciated, regarding the congenital origin
of practically every inguinal hernia, it is necessary to pay less
attention to the distinctions insisted upon by the earlier authors
concerning the congenital, the infantile, or the encysted forms of
hernia, which depend upon the extent and degree of closure of the
vaginal process or the canal of Nuck, which is carried down with the
testis during its migration from the lower margin of the Wolffian
body, and which is normally obliterated at birth. Nevertheless these
conditions, however explained, are actually met during life and are
represented by the diagrams seen in Figs. 602, 603 and 604.

[Illustration: FIG. 601

Indirect inguinal hernia (bubonocele.) (Richardson.)]

[Illustration: FIG. 602

Congenital inguinal hernia.]

[Illustration: FIG. 603

Infantile or encysted hernia.]

[Illustration: FIG. 604

Hernia of the funicular process.]

In the female the canal of Nuck is a matter of minor importance,
containing only the round ligament. Nevertheless along it may proceed
an indirect inguinal hernia corresponding to that in the male.

The so-called _acquired indirect hernia_, according to the above
views, _would not occur were it not for the opportunity--as it were,
the temptation--already afforded by some deviation of the peritoneal
arrangement in this locality_. In these cases, however, the sac
appears to be new and is pushed along the inguinal canal anteriorly
to its normal contents. This may be the result of violent strain, or
of one which is apparently disproportionately small, but frequently
repeated.

_Direct inguinal hernia_ is generally an occurrence of adult life,
takes place commonly as the result of accident, is a direct protrusion
through the abdominal wall at the triangular weak spot, whose outer
limit is the deep epigastric artery, with the obliterated hypogastric
artery to the inner side and Poupart’s ligament below, _i. e._, the
so-called triangle of Hesselbach. This hernia appears always at the
external ring, from which it may descend and become scrotal.

[Illustration: FIG. 605

Scrotal hernia. (Richardson.)]

With complete or scrotal hernia there is usually little difficulty of
diagnosis (Fig. 605). An incomplete hernia, protruding at the external
ring, covered with considerable fat, and perhaps shifted a little in
position, is sometimes hard to distinguish from a hernia through the
femoral opening. The inguinal form escapes above Poupart’s ligament,
the femoral always below it, and Poupart’s ligament is to be located
by a line drawn from the anterior superior spine to the spine of the
pubis. The inguinal forms are usually nearer the middle line. If the
epigastric artery can be identified, either before or during operation,
the character of the hernia will be promptly demonstrated by its
relations to the neck of the sac.

Hernial protrusions give a familiar _impulse on coughing_ unless the
incarceration of an epiplocele may mask this feature. By it they are
to be distinguished from hydrocele, varicocele, aneurysm, undescended
testicle, and the like.

[Illustration: FIG. 606

Hernia of liver through congenital opening in the umbilicus.
(Richardson.)]


=Femoral Hernia.=--Femoral hernia is much more common in women than in
men, and constitutes about one-tenth of all cases. This form is also
nearly always congenital in the above sense, and is particularly liable
to strangulation. It escapes through the femoral ring into the femoral
canal, to the inner side of the femoral vein, and then, passing forward
through the femoral opening, finds its direction of least resistance
upward. In consequence a loop of bowel thus escaping from the abdomen
may first pass downward, then forward, and then upward, which will
illustrate the futility of the ordinary methods of taxis in the effort
to reduce it by manipulation. These hernias are usually small, hence
their greater danger. These cases have especially to be differentiated
from psoas abscess, from inguinal lymphatic enlargements, and tumors.
If the sac be entirely filled with omentum diagnosis is often difficult.


=Umbilical Hernia.=--Umbilical hernia is primarily permitted by failure
in obliteration of the opening at the navel for the omphalomesenteric
duct and for the urachus. Originally small, it may yet assume enormous
dimensions. Though actually of congenital origin, as just stated, it
may not be discovered until the later years of life. It occurs much
more commonly in females than males, and usually in connection with a
large deposit of fat in the abdomen, by which its existence, or, at
least, its limits and dimensions are masked. Through the umbilical
opening, which in the majority of cases is small, may escape other of
the abdominal viscera, as is shown in Fig. 606, illustrating hernia of
the liver. Fig. 607 illustrates the pendulous form which many of these
cases assume.

[Illustration: FIG. 607

Umbilical hernia of pendulous form. (Park.)]

An _infantile form_ (umbilical) is known, in which the actual
protrusion does not occur until the infant is several months old, and
which appears to be due to frequent strain, on a weak or incompletely
closed fenestrum, by coughing, crying, efforts to expel urine through a
strictured prepuce, and the like. These tumors at first are small and
always intestinal. It is often possible to so adjust a small pad over
these openings as to secure subsequent closure by natural processes.
On the other hand, the forms which come on in later life, acquired
during pregnancy, ascites, or in connection with excessive obesity,
assume sometimes relatively enormous size. Here the hernial contents
may be solely omental, but are usually at least partially intestinal.
Strangulation occurs in a large proportion of these instances and
incarceration is nearly always observed. Naturally, in consequence,
the patient complains of gastric disturbances, as well as of chronic
constipation, with frequent colicky attacks.[61]

  [61] A rare form of hernia into the umbilical cord has been described
  by Moran. It has been known as _hernia funiculi umbilicalis_, and has
  been held to be due to abnormal persistence of the vitelline duct,
  which holds the loop of intestine to which it was attached inside the
  abdominal wall, the intestine continuing to grow, the umbilical ring
  remaining open and the hernia thus enlarging. Occurring in this way
  it happens about the tenth week of fetal life. Such a hernia has no
  covering except the peritoneum and the amnion--_i. e._, is without
  muscle or skin covering. It would be probably first noted when the
  cord is about to be tied, when at its loop, as a translucent tumor,
  varying in size from that of a small cherry to a lemon, the cord
  being distended and assuming its own natural size only after it has
  left the hernial tumor. The bloodvessels will run on one side of the
  amniotic sac. Such sacs rupture easily, perhaps during crying efforts
  or even during parturition. The condition is serious, and when
  present no traction should be made on the cord. If easily reduced by
  taxis an antiseptic compress should be fastened over the opening.
  Should anything like strangulation occur operation is imperative and
  should be done immediately.


=Ventral Hernia.=--Ventral hernia is of two types--the _spontaneous_,
usually _epigastric_, which is an omental escape in the middle line
above the umbilicus, occurring most often in fat women, in whom it
is likely to be mistaken for a hernia of ordinary umbilical type. By
fixation of its contained intestine and omentum there is more or less
dragging upon the upper abdominal viscera, with consequent disturbance
of function.


=Postoperative Hernia.=--Postoperative hernia often also spoken
of as ventral, occurs through the cicatrix of the wound which has
permitted it, whether this be in the middle line or elsewhere. It is an
unfortunately frequent sequel of laparotomy wounds which have required
drainage, but occasionally occurs in perfectly clean wounds which have
closed satisfactorily in the first place, but which have subsequently
parted because of unsatisfactory methods of bringing together their
deeper portions. (See p. 778.) Consequently it should be sufficient
here to remind the reader that the more accurate the method of
approximating the margins, layer by layer, and effecting a complete and
perfect union between them individually the less the tendency to this
unpleasant sequel.

Postoperative hernia may be so small as to be kept under subjection
with some form of abdominal support, or it may call for operations for
radical cure, as do other cases. They are subject to the same dangers
of strangulation of their contents.


=Diaphragmatic Hernia.=--Diaphragmatic hernia may be _congenital_, as
when occurring through a defect in this partition, or _acquired_, as
when under stress or strain some of the abdominal contents are forced
into the thorax, either through natural openings or through a rent
or tear. Such escape may include but a small portion of bowel; in
congenital cases one-half the abdominal contents have been found within
the thorax. The left side seems more often involved than the right.
Serious wounds of the diaphragm may be followed by this condition.
Under these circumstances the thoracic viscera are more or less
displaced, and the heart may be pushed considerably out of place. In
cases with a history of violent accident the surgeon may more readily
suspect and recognize the condition than in congenital cases, where
anatomical relations have long been disturbed, but apparently more or
less adjusted or compensated.


=Pelvic Hernia.=--In the lower part of the pelvis, under rare
circumstances, hernial protrusions occur either through the
sacrosciatic foramina, in which case they are known as _gluteal_ or
_ischiatic_ (Fig. 608), or through the obturator foramen, when they
are known as _obturator_ hernias, the latter occurring more often in
stout women. Unless these constitute some form of recognizable tumor,
or produce acute obstruction by strangulation, they will pass quite
unrecognized. A _perineal_ form of hernia is also known, which occurs
in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani
muscle being more or less disturbed, and the protrusion occurring
somewhere between the labium and the anus. In such hernial sacs the
ovary has been found, as well as intestinal loops, and the so-called
_ovarian_ hernia includes some anatomical anomaly of this kind.

[Illustration: FIG. 608

Ischiatic hernia. (Richardson.)]

[Illustration: FIG. 609

Hernia into foramen of Winslow.]


=Lumbar Hernia.=--In so-called lumbar hernia, which is very rare, the
hernia escapes along the outer border of the quadratus lumborum muscle
into the triangle of Petit. Such a tumor, usually small, may be easily
mistaken for lipoma or for cold abscesses.

Other anomalous types of hernia may occur in connection with congenital
defects of the bones or the less dense structures of the pelvis proper.


=Retroperitoneal and Properitoneal Hernia.=--Retroperitoneal and
properitoneal hernia are types which seem to corroborate the views
already enunciated concerning the essentially congenital origin of
the ordinary forms. The former implies a protrusion into an internal
peritoneal pouch, and is usually found in the upper abdominal cavity
in the duodenojejunal fossa, although it may also occur lower down on
either side. It will not be recognized save by its effects, which will
usually be those of acute intestinal obstruction, and even then will
only be diagnosticated after the operation which the condition will
necessitate. Hernia through the foramen of Winslow has already been
mentioned in the chapter on the Small Intestines. (See Fig. 609.)

_Properitoneal hernia_ implies usually the existence of a double sac,
with a common opening, its inner portion lying between the peritoneum
and the abdominal musculature, while its outer portion takes the
usual position of the hernial sac, either the inguinal, the femoral,
or the umbilical form. It may be suspected when reduction which has
been apparently successful has later evidently failed. It occurs most
often in the inguinal region, where it is usually referred to as
_inguinoproperitoneal_ hernia, and where it was first recognized by
Parise, and later fully described by Krönlein. It may be with equal
propriety called _interstitial hernia_, and is often associated with
imperfect descent of the testicle, which perhaps has served to deflect
the descending hernia in an unusual direction. The properitoneal sac
is most often found between the internal ring and the anterior spine,
although it may be directed downward and inward toward the bladder,
or backward toward the iliac fossa. In size it is usually small as
compared with the external portions. Its existence may be suspected
when a patient with a hernia previously easily reducible suddenly
develops strangulation, which is apparently relieved by taxis, only to
recur a little later. So far as its radical treatment is concerned all
that is necessary is the extirpation of the extra sac, with perhaps
separate treatment of its neck, when dealing with the greater and more
completely filled pouch in front (Fig. 610).

[Illustration: FIG. 610

Properitoneal hernia. This illustrates also incomplete reduction of
hernia. (Richardson.)]


=Littre’s or Richter’s Hernia.=--These terms have reference to
strangulation of intestine in which, nevertheless, the entire lumen
of the bowel is not completely involved, rather only a small area,
which soon becomes sacculated, or perhaps by a diverticulum becoming
involved in the occlusive and later gangrenous process. These forms
are most frequently seen in women and at the femoral ring. They are
peculiarly dangerous in that they produce symptoms which do not include
those of total and acute bowel obstruction, and hence are often allowed
to go unoperated until gangrene has already occurred. These forms,
then, will produce signs and symptoms of partial strangulation, with
incarceration, followed after hours or perhaps days by those of local
cellulitis, with perhaps necrosis; conditions which when opened may
expose gangrenous bowel and promptly become fecal fistulas.


=Treatment of Hernia.=--Hernia is treated for three different purposes:
for the _relief of strangulation_, _i. e._, as an emergency, for
_palliation_, or for _radical cure_, according to the nature of the
case and the wishes of the patient.

_The relief of strangulated hernia_ becomes a measure of instant
importance so soon as the condition is recognized, mortality being due
to delay, practically every case being curable could it be recognized
and operated promptly. The symptoms of strangulation, as repeatedly
indicated, are those of acute obstruction of the bowel, including
fecal vomiting with meteorism, and the local indications which may be
trifling, as in very small hernial protrusions, or unmistakable, as in
large hernial masses. The indication in every instance is to restore
the occluded bowel to the abdominal cavity. Occasionally this may be
effected by the method of _manipulation_ or by _taxis_, which should
never be thought of save at the very outset, and which may be aided by
the local use of cold, or especially by the Trendelenburg position,
which may be exaggerated. Under these circumstances, as Richardson has
said, minutes are precious and delay adds materially to the danger, so
that usually all non-operative methods are to be condemned.

[Illustration: PLATE LIV

Strangulated Right Inguinal Hernia. (Richardson.)

The sac has been opened and its edges are drawn apart by means of
forceps. The inguinal canal and spermatic cord have been dissected.]


=Taxis.=--The principal danger in connection with taxis is that of
doing harm to the occluded bowel by rough manipulation. The method
includes a coaxing pressure in the proper direction, with more or less
compression of the external mass, the effort being to gently persuade
it back into the abdominal cavity. In this effort the temptation,
especially among the inexperienced, is to use too much force, by which
extravasation is produced, exudate increased, and the local condition
in every way made worse. That which is possible during the first hour
after strangulation has occurred may be impossible a little later, when
edema and exudate have distorted the parts or cemented them together.
The effort should not be prolonged, but rather very brief, and if after
a very few moments no gain be made it should be discontinued.

_Reduction “en bloc”_ is an unusual but ever-present danger. It implies
forcing back the peritoneal sac as well as its contained intestine
unreduced, so that while the external tumor is dissipated the actual
condition of strangulation is not influenced. Its effect would be in
no way to diminish the danger of the condition, but rather to more
seriously menace the patient, under the supposition that reduction had
been accomplished satisfactorily.

Two or three axioms in the treatment of strangulated hernia are
imperative:

_Very little time, if any, should be wasted in manipulation or taxis._

_Taxis failing or there remaining any suspicion of reduction en bloc,
open operation is imperative._

_The time to operate is just after the diagnosis has been made and
the condition recognized. Every hour of delay increases danger of
obstruction and of gangrene._

_Operations for strangulated hernia_ should thus always be done early
and before much exudate or local disturbance has occurred, as when thus
performed they may be combined with measures for radical cure, which
are hardly to be thought of when infection has occurred. (See Plate
LIV.)

Strangulated hernia, then, being always a dire emergency, is in
nearly every instance best treated by _herniotomy_, whose principles
are the same, no matter whether applied to inguinal, femoral, or
umbilical hernia. By a suitably planned incision the sac is exposed.
In the inguinal region this follows the general direction of the
cord and inguinal canal. In the femoral region it is best to raise
a flap, while in umbilical hernia, although the first incision may
be in the middle line, it will usually be found necessary to make an
elliptical excision of the overlying skin, in order that both it and
the sac may be removed. Under conditions of long existent hernia, plus
strangulation, the original anatomical conditions are much altered,
and it is not necessary to waste time in the endeavor to recognize
the various coverings of the sac. One cuts directly down upon it
with such care that he may recognize it as he comes upon it, usually
by its color and by the sensation of proximity to its strangulated
contents. This is ordinarily not a difficult matter; all bleeding
vessels should be secured before the sac is finally opened. Final and
complete identification may be made by finding that the sac itself may
be pinched up between the fingers or forceps, while the underlying
contents slip away. Only when parts are bound together in exudate will
there be difficulty in this regard. The surgeon should still proceed
with caution, although the sac will usually contain sufficient fluid
of transudation to protect against injury to the enclosed bowel.
Nevertheless the greatest care should be observed not to wound the
intestine, which sometimes lies very closely under the skin, especially
in the middle line of an umbilical hernia, although there may be
masses of fat on either side of it. Sometimes the sac distended with
discolored fluid is itself mistaken for the bowel. Error can usually be
avoided by following it upward and identifying its continuity with the
surrounding tissues.

When opened its contained fluid may be found quite clear,
blood-stained, purulent, extremely offensive, or even fecal, according
to the relative age of the condition and the degree and results of
strangulation. Under all circumstances it is advisable to disinfect the
sac and its contents before endeavoring to release them. This may be
done with dilute peroxide of hydrogen or with any ordinary irrigating
fluid.

Within the sac, when thus identified and opened, may be imprisoned
omentum or bowel, or both, in any degree of preservation from that
which is almost normal, and with circulation but slightly disturbed,
to that which is absolutely gangrenous. Congested bowel will nearly
always be more or less discolored. So long as it is dusky or even
almost black, _but has not lost its luster_, it may probably be safely
returned to the abdominal cavity; but if green or if luster be gone,
or if the contained fluid be distinctly putrefactive, then serious
doubt as to its viability will arise. In case of actual perforation,
gangrene, or fecal abscess there will be no doubt as to the danger of
returning such bowel, and other measures should be adopted.

The _viability_ of the bowel having been determined and the sac
disinfected the location and degree of tightness of the constricting
ring should now be determined. In inguinal hernia the constriction may
occur either at the external or internal ring; in femoral hernia it
is usually at the femoral ring; in umbilical hernia, at some portion
of the umbilical opening; while in all three forms constriction may
occur within the sac itself and with little reference to the ordinary
hernial outlets; all of which needs to be clearly kept in mind. This
identification is usually done with the tip of the little finger,
gently insinuated and used as a probe. The operator who is sure of his
methods does not necessarily need to expose the constricting ring in
order to nick it or divide it, but he who is not as proficient should
extend and deepen his incision until the parts are clearly exposed, so
that he may be sure of not doing more harm than good.

Ordinarily it is necessary only to nick at one or two points the margin
of the ring, which will feel much like a wire loop, and then to use
the finger as a dilator, stretching and perhaps tearing, _i. e._,
making the knife do as little and the finger as much work as possible,
in order to so loosen up the constricted canal that by gentle taxis
or manipulation reduction can now be accomplished. The text-books on
anatomy give minute descriptions of the relations of these hernial
outlets to important bloodvessels, with which even the student should
be perfectly familiar. Nevertheless by following the subjoined rule,
and never departing from the principle thereby indicated, the operator
may safely proceed in practically every instance. _This is to cut in
the direction of the patient’s nose._ The knife used for this purpose
is ordinarily the _herniotome_, _i. e._, a blunt, slightly curved
bistoury, with but a small exposed cutting blade, whose dull point is
passed along the finger until the constriction is reached, and then, by
the sense of touch, beneath and beyond it, until the wire edge of the
ring rests upon the cutting part. The handle is then turned until this
edge points upward and is moved with a gentle sawing action always in
the above-specified direction, until the peculiar resistance is felt
to have yielded. It may then be turned a little and another nick be
similarly made. These nicks should not be more than one-quarter of an
inch deep, after which the knife is withdrawn and the finger now made
to dilate and tear. With these precautions there is very little danger
of dividing an anomalously placed vessel.

Dilatation of the ring being now sufficient it is well to pull the
hernial mass a little downward, in order that the condition of the
bowel at the point of constriction may be exactly noted. It should
therefore be gently coaxed into the wound, once more subjected to
inspection, and then to disinfection. The surgeon should now determine
what to do both with the bowel and the omentum. Omentum which is
covered with exudate or darkly discolored, or surrounded by offensive
material, should be first liberated, then ligated, above the original
point of constriction, and the undesirable part removed, the stump
being returned to the abdominal cavity. The bowel, if decided by above
indications to be viable, may then be gently coaxed back if handled
with care.

But gut which has perforated, or is so compromised as to be threatening
gangrene, should _not be returned_ into the abdominal cavity, but
treated by resection, or by fixation and the formation of an artificial
anus, decision depending both upon the condition of the patient and of
the bowel. Some of these cases are too nearly moribund when operated to
justify such procedures as resection, and are suffering too profoundly
from the consequences of obstruction to make it advisable to do more
than open the bowel for its immediate relief. Artificial anus is,
therefore, the inevitable necessity in some forms of strangulation.
When the bowel is gangrenous it is not necessary even to endeavor to
draw it farther down into the sac, but it may be simply opened _in
situ_.

_Intestinal resection and suture_ instituted under these circumstances
are essentially the same as those already described in the chapter on
the Small Intestines. With the formation of an artificial anus there
results the inevitable fecal fistula which will require subsequent
operation, probably secondary resection.

In non-septic and favorable cases, the reduction having been
accomplished, the operator then may proceed to extirpation of the sac
and the closure of the hernial outlet, _i. e._, operate for radical
cure, this being a modern extension and addition to the old operation
for relief.

If obstructive symptoms should persist after operation the possibility
of twisting of the intestine, or a possible reduction _en bloc_,
may be feared, which is not likely to occur if the open part of the
operating have been done thoroughly.

Clean cases of strangulation may be closed without drainage. In case of
doubt, however, it is advisable to provide at least a capillary drain,
while every case known to have been contaminated should be perfectly
drained.

[Illustration: FIG. 611

Bassini’s operation. Ligation of the sac by means of a purse-string
suture passed through the internal surface of its neck. The cord is
drawn to one side. The aponeurosis of the external oblique is drawn
apart with forceps. (Richardson.)]

[Illustration: FIG. 612

Bassini’s operation. Suture of the conjoined tendon to the internal
surface of Poupart’s ligament. Fortification of the posterior surface
of the canal. (Richardson.)]


=Radical Cure of Hernia.=--From the earliest times rude and crude
methods of endeavoring to effect a radical cure of hernia have been in
vogue. While sometimes effective they have always been dangerous and
always clumsy. Not until the antiseptic method was introduced could
they be regarded as in any way safe or reliable. With the introduction
of Listerism it became practicable to do this work, upon principles
simple in character and ordinarily easy of performance, which may be
summed up in the formula: _Isolation and obliteration of the hernial
sac, with permanent closure of the hernial outlet._ Easy as such
description may sound it has been found more or less difficult in
practice, and numerous methods, apparently both simple and ingenious,
have proved defective and have called for the most pronounced
modification. Considerable space could be devoted to operations for
radical cure, but the intent here shall be to simplify the subject
as well as the method, and consequently but two or three will be
described. Suffice it to say that while all are based on the same
principle they vary somewhat in detail, and that some of these details
have to be adapted to the special requirements of individual cases.

With increase in experience has come enlarged confidence in the
operation, and it is now regarded as justifiable in nearly every
instance among individuals otherwise in good condition. It has a double
purpose--namely, the avoidance of the danger of sudden strangulation
and the riddance of necessity for wearing trusses, or suffering the
discomforts of hernia without any mechanical control. Some modern
methods include the utilization of some portion or all of the sac,
while in others it is entirely cut away. Consequently some operators
have endeavored to utilize such portion of the sac as could be made
available for either purpose, either as plug or suture material.

The _method of Bassini_ for relief of inguinal hernia, more or less
modified to meet individual demands, seems to have become of late years
the most popular and widely adopted. The incision is made over the most
prominent part of the tumor, extending as far downward upon the scrotum
as necessary, and upward to near the anterior superior spine. Through
it the external ring, with its pillars, is exposed, and then the sac,
by a dissection long and sufficiently wide to fully reveal it. The
exposure is made more complete by dissection of the aponeurosis of the
external oblique from the level of the external ring upward and outward
for an inch or so above the external ring. By seizing the edges of
the aponeurosis on each side with forceps and retracting there is now
afforded an excellent view of the hernia proper. (See Fig. 611.)

[Illustration: FIG. 613

Park’s method of utilization of sac, showing its isolation and one way
of employment in making the suture further represented in Fig. 614.]

By careful dissection the sac and cord are identified and isolated,
while the sac is opened and its edges held apart by forceps, after
which it is carefully separated from the other structures of the cord.
After thus isolating the sac, and with the least possible disturbance
of the cord and of the testicle, it is ligated as high as the internal
ring, or, if possible, higher yet. This leaves the cord uninjured; its
size should next be reduced by cutting away all superfluous tissue.
Some operators remove all the veins, but this seems unpromising and
dangerous.

[Illustration: FIG. 614

Park’s operation. Continuous suture made with a long thin sac.]

By all this dissection and reduction the inguinal canal has been
temporarily, cleared, and the sac having been elevated, ligated, and
cut away it becomes now a question of what to do with the cord. The
lower surfaces of the external oblique and of Poupart’s ligament are
next freed, the edge of the internal oblique, of the transversalis with
its fascia, the outer border of the rectus and the conjoined tendon
being all exposed to view by whatever dissection may be required, all
fat and areolar tissue being removed. The cord is finally disposed
of by holding it out of the way, usually by a loop of gauze, while
the deep layer of the external oblique and the external portion of
Poupart’s ligament are sewed to the muscle edges of the internal
oblique and transversalis, as appears in Fig. 612, by a line of sutures
which include the conjoined tendon, at the lower angle of the wound,
which should be affixed to the outer border of the rectus. In the
deeper portion of every such wound there is danger of injury to the
external iliac vessels as well as to the epigastric. For the escape of
the cord, and to avoid its undue constriction, an opening should be
left for it, _i. e._, a new _internal_ ring, adapted for the purpose
and not too small. This is made by not suturing the upper part of the
wound. The cord being afforded this exit is now dropped, and the edges
of the external oblique are brought together over it, the sutures
extending well downward, but being omitted at the lower portion, where
a new _external_ ring is thus left, only not of its original size, but
sufficiently large to accommodate the cord.

Such are the essentials of the Bassini method, which has been modified
by Halsted in such a way that the cord, reduced as much as possible,
usually by removal of most of its veins, is now not left within the
inguinal canal, but transplanted entirely outside of the external
oblique, escaping at the upper part of the incision and requiring no
further accommodation in its course toward the testicle. In children,
or even in adults with very small veins, he does not so reduce the
cord. After isolation, opening and transfixion of the upper end of the
sac, and its secure ligation, he drops the stump back into the abdomen.
The muscular and tendinous layers of the ring and abdomen are united
also, by layers, with quilted sutures.

[Illustration: FIG. 615

Park’s method. Shoelace suture made with a sac split into two strips.]

In these as in many other methods, much, practically everything,
depends upon the certainty and durability of the sutures used for
disposal of the inguinal canal. For some years surgeons used silver
wire, which has now been abandoned. The choice now seems to depend on
_silk_, thoroughly and freshly boiled, or _animal sutures_, such as
kangaroo or reindeer tendon. McArthur suggested to dissect off a strip
from the margin of the opening in the external oblique, or from the
aponeurosis, and to use this strip of the patient’s own tissue for
suture material. I have modified this method, as will be described
later. Kocher devised a method of isolation of the sac, without such
complete emptying of the inguinal canal, the sac being drawn up through
the canal, then through the internal ring, and finally through an
opening in the external oblique, over the internal ring, where it was
twisted and fastened, after which the external portion was removed.

My own preference in operations for radical cure has been, until
recently, an exposure similar to that of Bassini’s, with complete
isolation of the sac, which is separated up to the level of the
internal ring or even higher. At this point it is drawn out through an
incision made in the external aponeurosis, twisted and fastened. The
inguinal canal is then closed, its deeper layers by a shoelace suture
of tendon, threaded into two stout curved needles, by which the deeper
margins of the canal are brought accurately together. Sometimes I have
transplanted the cord and again have dropped it back, the layer of
shoelace sutures closing the external aponeurosis over it. It has not
seemed to me to make any difference which method was adopted, and I
have practically never seen any atrophy or permanent disturbance of the
testicle.

More recently it has occurred to me to utilize the sac itself for
suture material, and this is the method which I now adopt in those
cases that permit of it.

Figs. 613 to 616 show the method of thus utilizing the sac. A long thin
sac may be twisted into a cord and used as an over-and-over suture, by
which the margins of the canal are brought together. If found thick
and unwieldy it may be trimmed down into a single suture, or it may be
_split_, with more or less trimming, into two portions, by which the
canal is then braided together or closed with a shoelace suture, the
ends being tied or fastened at the lower portion. Fig. 616 shows how a
short sac not otherwise available can be lengthened and made sufficient
for the purpose.

[Illustration: FIG. 616

Park’s method. A short sac is so divided as to be elongated
sufficiently for use as a suture.]

This again is utilization of the patient’s own tissue, he himself
furnishing his own animal ligature, which, being fresh and sterile, may
be regarded as reliable. The method, furthermore, has this advantage,
that there is reason to believe that tissue so utilized becomes
organized, in time, and that the union becomes more reliable rather
than otherwise. At all events in a considerable number of cases it
has yielded satisfactory results, and in no case has it caused any
disappointment.

[Illustration: FIG. 617

Radical cure of femoral hernia. Dissection of the saphenous opening.
The sac of the hernia has been tied. (Richardson.)]

[Illustration: FIG. 618

Radical cure of femoral hernia, showing method of application of
purse-string ligature to close saphenous opening. (Richardson.)]

[Illustration: FIG. 619

Radical cure of femoral hernia. Sutures applied to pectineal fascia,
fascia lata, and Poupart’s ligament. (Richardson.)]

[Illustration: FIG. 620

Obliteration of the femoral opening by purse-string suture. (Coley.)]

_Recurrence_ after these operations occurs less and less frequently
as operators gain in experience and technique is improved. At all
events the procedure has now become standard and disappointments are
relatively rare. It is useless to quote statistics of individuals, for
they necessarily differ. In general, however, it is probable that from
90 to 96 per cent. of cases properly operated suffer no recurrence.

_In the female_ inguinal hernia is treated in practically the same way,
conditions being simplified by the absence of necessity for making any
provision for the blood supply of the testicle or cord. The canal and
rings may, therefore, in the female be absolutely closed.

_Femoral hernia_ is radically treated on the same general principles,
but with greater difficulty, as anatomical conditions are less
favorable. A flap is raised below Poupart’s ligament, with its centre
over the tumor, and the sac exposed and completely dissected, then
opened, as in inguinal hernia. Its contents being reduced obliteration
of the sac and its utilization, if possible, are in order. It is rarely
difficult to separate it from its surroundings well up in the femoral
canal. It may be twisted and its neck ligated, or it may be possible
in some cases to either infold or reduce a sufficient portion of it
to thus form a plug, which, being pushed upward, serves as a means
of closing the femoral opening from above. Whatever use may be made
of it it should be obliterated as a pouch, and its descent prevented
by closure of the canal around it. This is difficult because of the
proximity of the femoral vein and the somewhat unyielding character of
the falciform and crural fasciæ. By some form of purse-string suture,
or by a little dissection and sliding of aponeurotic flaps, it is
usually possible to bring the surrounding structures snugly together.
Even here I have been able to apply my principle enunciated above,
and, by cutting away a strip of the sac, utilize it for the purpose of
closing the femoral canal; but it is not often that a femoral pouch
will be sufficiently large to afford tissues for this purpose. Figs.
617, 618, 619 and 620 will save the necessity for further description.

[Illustration: FIG. 621

FIG. 622

Graser’s method of dealing with umbilical hernia.]

In many inguinal and umbilical and in a few femoral hernias the
operator will be hampered by _adhesions_ between the omentum or between
the bowel and the sac wall. These may be infrequent and slight or
extensive and dense. They are relatively unimportant so long as they
involve only the omentum, which may at any time be cut away, the stump
being dropped back into the abdomen, after being suitably secured; but
when bowel, especially large intestine, is thus adherent, great care
should be exercised, avoiding all possibility of shutting off the blood
supply while securing every divided vessel.

Particularly is this true in treatment of umbilical hernias, either
radical or under conditions of strangulation. In stout individuals,
usually women, umbilical sacs sometimes contain several feet of bowel,
and adhesions may be met at many points, difficulties arising not only
in their separation, but in the final disposition and accommodation
of all this bowel within the abdominal cavity, from which it has been
so long absent. Radical cure will in these cases leave intra-abdominal
viscera in a rather overcrowded condition.

The essential details of _radical treatment of umbilical hernia_ are
the same, modified by the extent of sac which has to be removed,
and by the wisdom in many instances of a large elliptical excision
of the overlying skin and removal of much superfluous tissue. After
freeing the contents and reducing them, the sac wall being completely
separated, there is the choice of two or three methods of closing
the umbilical opening, either by overlapping of flaps, which may be
cut from the thickest portion of the sac, which will be close to the
outlet, or by dissecting them from the aponeurosis, as suggested by
Mayo, and turning the upper down over the lower, or by any other
expedient which individual peculiarities may suggest (Figs. 621 to
624). I have been able to employ, to apparent advantage, my method
of securing suture material for this deep closure from the sac wall
itself, this not preventing the employment of any other method or
improvement.

[Illustration: FIG. 623

FIG. 624

Method by transverse closure of both deep and external incisions.]

_Ventral and postoperative hernias_ are operated on in essentially
the same manner as the forms above described. Adhesions may be found
in these cases, and plastic methods should be devised for bringing
together irregularly shaped openings and holding them in the firmest
possible manner. In any extensive abdominal hernia, umbilical or
ventral, it is advisable to use buried sutures, closing the abdominal
walls, layer by layer, and finally to insert at some distance a
sufficient number of through-and-through retention sutures, guarded by
plates or small rolls of gauze, these taking off tension from the wound
and affording protection against any special strain, such as vomiting.




CHAPTER LII.

THE LIVER.


CONGENITAL DISPLACEMENTS OF THE LIVER.

The congenital defects and displacements of the liver which interest
the surgeon are few. More or less transposition, sometimes complete
_situs transversus_, is encountered. The same is true of more or
less _hernial protrusion into the chest_, through a defect in the
diaphragm, or such displacement as may be permitted by some defect
of the abdominal walls or other viscera. Hammond has recently shown
that the _left lobe of the liver is sometimes congenitally enlarged_
to an extent sufficient to cause symptoms, a condition alluded to by
very few writers. In this way the liver may cover the stomach and even
extend over the spleen. Similarly the _right lobe_ may be affected, but
giving a different train of symptoms. Under these conditions mistakes
may arise. Thus the left lobe might be mistaken for a large spleen,
from which, nevertheless, it should be separated and differentiated by
its free movement during respiration. Hammond even reports one case
of this kind where, instead of removing the elongated portion of the
liver, it was held up against the abdominal wall by sutures. For a
similar condition Langenbuch has successfully resected a portion of
this viscus. What is said here pertains to a true congenital variety,
and not to acquired displacements or enlargements. In Fig. 625 is
represented the case of xiphopagous twins united by a band of liver
tissue and operated (by division of the band) by Baudouin.

[Illustration: FIG. 625

Xiphopagous twins, separated by division of a band of common liver
tissue. Case of M. Baudouin. (Pantaloni.)]


WANDERING OR FLOATING LIVER.

The relations between congenital laxity of the natural supports of
the liver and certain morbid conditions, especially those produced
by marked enlargement followed by great reduction in size, to the
so-called wandering or floating liver are very indefinite. The term
“wandering” implies a mobility far beyond the normal, with more or
less yielding of ligaments, especially the suspensory, which permits
undue displacement. We often fail to realize that the liver, which is
the heaviest of the viscera, is nevertheless, in man, placed at their
top, and hence that it has, in at least some respects, very meagre
support. This is one of the disadvantages of the upright position, and
it does not prevail in animals. In addition to this may be mentioned
the peculiar enlargement of the right lobe, very rarely of the left,
so often seen in connection with biliary obstruction, and often spoken
of as _Riedel’s lobe_. Floating liver is more common in women than in
men by four to one, and is often ascribable to the ill effects of tight
lacing. Repeated pregnancies, with the consequent relaxed and pendulous
abdominal walls which often follow them, also conduce to the condition
by weakening, in fact almost removing, its lower supports.


=Symptoms.=--The symptoms produced are those of indigestion, dyspnea,
perhaps with cyanosis, nausea, vomiting, and occasionally biliary
obstruction and jaundice. In addition to these the patient will show
the ordinary physical signs of a displaced or displaceable liver,
noticeable in the upright or in the knee-elbow position.


=Treatment.=--The treatment of milder cases will consist of support
from below by suitably adapted and well-fitting abdominal binders or
supports. Serious cases may necessitate surgical relief. This consists
of _hepatopexy_, _i. e._, fixation of the liver to some of its upper
surroundings. The operation is performed through an incision such
as that used for exposure of the gall-bladder. The lower surface
of the diaphragm and the upper surface of the liver are scarified
until they ooze perceptibly. The anterior edge of the liver is then
fastened to the abdominal walls, as also the gall-bladder, if it can
be utilized for the purpose. The patient is then placed in bed with as
much compression of the abdomen below the liver as can be tolerated,
in order that the scarified surfaces may be kept in contact until
adhesions result.


INJURIES OF THE LIVER.

By its size and construction the liver is made peculiarly liable to
certain injuries, while from others it is made more or less exempt by
its protected situation, especially by the ribs, which nearly enclose
it. From contusions it may undergo different degrees of laceration,
sometimes even to the degree of fragmentation and pulpifaction. Again
it is frequently involved in punctured wounds (stab, gunshot, etc.),
which may be inflicted from any possible direction, perforation
sometimes taking place from above and through the chest, and involving
the tissues beneath.

General indications of injury to the liver will be furnished
by its nature and location, the degree of collapse, and the
consequent abdominal rigidity, with the common signs of internal or
intra-abdominal hemorrhage. There is no doubt but that minor injuries
of the liver are nearly always repaired, and that they occur much
oftener than is generally appreciated; but a severe tear of the liver
is a source of great danger because of hemorrhage. In general, of these
injuries it may be said that any traumatism which produces profound
or increasing symptoms should be regarded as indicating a careful
exploration, done with every precaution at hand for carrying out any
possible indication. What the liver may safely bear in the way of
ligatures, sutures, and operative disturbance will be indicated later.
Many fatal cases show a period of a few hours of temporary amelioration
of symptoms which may have lulled to a sense of false security, and
during which internal mischief is still increasing. Moreover, any
blow sufficiently severe to rupture the liver may do other harm. In
such instances, then, it becomes a simple question of whether there
can still be sufficiently early intervention to save life. To what
extent this intervention may be required in stab and gunshot wounds
it is difficult to state. If hemorrhage and puncture of any hollow
viscus can be excluded and if no other serious symptoms be present, it
may be advisable to wait; otherwise the possible harm of a judicious
early exploration is so small, while the prospective benefits are so
great, that it is far the wiser course. Here, again, the general rule
may be applied. _When in doubt operate._ Further details of operative
procedures will be given below.


ABSCESS OF THE LIVER; HEPATIC ABSCESS.

While _abscess of the liver_ is, like all other abscesses, due to germ
activity, it may yet definitely follow injury or be the result of a
primary disease, or an extension from some one of the adjacent tissues
or organs; as from _above_ (empyema, pyopericardium, subdiaphragmatic,
spinal), from _below_ (gall-bladder and ducts, pancreas, stomach),
from the _portal circulation_ (superficial or ulcerating piles,
typhoid and other intestinal ulcers, peculiar or tropical parasites
like amebas), from the _appendix_, from the _general circulation_
(pyemic, metastatic), through the _lymphatics_ (mesenteric nodes), from
the _intestinal tube_ (ordinary round-worms and various parasites),
from _cancer_ breaking down, as well as from _degenerating gumma_ or
granuloma and from _hydatid cyst_.

Hepatic abscess may be acute or chronic, small or large, solitary or
multiple. The tendency is to enlarge and finally to kill. This they
do usually by _rupture_, _e. g._, either into the pleural cavity or
the lungs, after adhesions have been contracted, the pericardium, the
mediastinum, the peritoneum, any part of the upper alimentary canal, or
the biliary passages. Finally they may open externally and perhaps be
followed by spontaneous recovery.

A certain convenience of description is afforded by dividing these
cases into the so-called _solitary_ abscesses and the _multiple_ forms,
the latter being more commonly associated with tropical diseases of
the amebic type or with pyemic processes. In most _solitary_ cases the
abscess is located in the right lobe, its extent varying within wide
limits, especially when the subphrenic space has been involved. Its
contents may be of almost any color and the pus is often thick and foul
in odor. (See Subphrenic Abscess.)


=Symptoms.=--Symptoms of the solitary type may be at the onset acute,
with or without history of previous sickness, the patient being
suddenly seized with severe epigastric or hypochondriac pain, which
is followed by prostration, with fever, chills, and sometimes cough.
Characteristic rigidity and tenderness follow and the liver increases
in size, the whole type of illness being one of acute abdominal
infection. The slower forms appear to come on without early liver
symptoms, patients complaining of cough and discomfort in the chest,
with loss of flesh and appetite. Gradually the indications point to the
hepatic region, while chills or intermittent fever occur, the liver
gradually increasing in size and becoming tender. Again, in some cases,
the trouble begins with irregular fever, patients running down rapidly,
yet showing few local signs until the abscess invades the subphrenic
region. In such instances examination of the chest gives negative
evidence, save that there may be found elevation of the diaphragm
due to accumulation below it. In nearly all instances there arise,
sooner or later, severe chest pains, with enlargement of the liver,
tenderness, and often indications of fluid in the right pleural cavity,
which on aspiration may be found clear or purulent. Tenderness along
the liver border will be most marked among characteristic features.
Sometimes there is intercostal tenderness. Any indication of local
peritonitis should be taken as evidence of approach of pus toward the
surface. Jaundice is an occasional accompaniment. Previous malaria
should be excluded if possible and a careful case history is a great
help.

Diagnosis is usually to be made between hepatic and subphrenic
abscess and between the single and multiple forms of the former. The
possibility of empyema or of one or two subphrenic abscesses should
be carefully determined. In fact, first of all, the surgeon has to
determine whether the lesion is above or below the diaphragm. Some
of the subphrenic abscesses contain gas, and, should indications of
its presence be found below the level of dulness due to the presence
of fluid, interpretation of the facts is easy. Localized edema of
the chest wall, or of the region of the liver, is of importance when
present. It is necessary, also, to exclude phlegmons of the abdominal
wall. These are cases where it is justifiable to use an exploring
needle repeatedly, if necessary, in order to determine the presence
and location of pus. After anesthesia the needle may be used even
more freely, its use being not only of assistance in diagnosis, but
it appearing to be an agent of great value in the relief of pain. I
have known painful affections of the liver to be much relieved by such
exploration.

The accompaniment of dysentery of amebic type, and the discovery of
amebas in the stools, would quite settle the question of the origin
and nature of such abscess. Hydatids are of slow growth and are almost
symptomless until they produce pressure disturbances or those due to
the presence of pus. The fluid withdrawn from them is clear and may
contain hooklets. Cancer eventually produces jaundice and the resulting
enlargements are nodular, while the lower border is irregular, and the
liver itself less tender and more movable, and there is usually more
or less ascitic fluid present. Syphilitic gumma may cause enormous
enlargement of the liver, with difficulty in diagnosis, especially
in the absence of a significant history. Under vigorous mercurial
treatment it will steadily improve; without it such gummatous tumors
may suppurate. It will often be advisable, in case of doubt, to make
this therapeutic test. Actinomycosis produces granulomas which tend
to increase, infiltrate, produce adhesions, and gradually work toward
the surface, as well as eventually to break down, the débris thus
produced containing not only pus, but the peculiar calcareous particles
characteristic of this disease.


=Treatment.=--Multiple foci in the liver scarcely admit of successful
operative treatment and are nearly inevitably fatal. The solitary
liver abscess, even though large, is, on the other hand, usually
satisfactorily treated by the general method of free incision and
drainage, although, in exceptional cases, aspiration alone has seemed
to suffice. Any collection of pus, no matter what the internal
condition, so long as it be not distinctly cancerous, which tends to
present externally, no matter at what point, should be thus treated.
Incision may be made over any protruding or edematous area where pus
seems to be nearing the surface. With a considerable collection of
this fluid in the right lobe, especially nearer its diaphragm-covered
portion, it is usually safe to assume that the upper surface of the
liver has become adherent to the diaphragmatic dome above it, and
that there one may follow the costal border or may enter between the
lowermost ribs, or may even resect one or more ribs if necessary, and
drain posteriorly or by counteropening, as may be indicated. When
approached from beneath, the lower surface of liver thus affected
will usually be found more or less matted to the colon, omentum, or
pyloric region, as the case may be, so that by carefully opening the
abdominal cavity, and walling it off with gauze, pus may be evacuated
from below and cavities satisfactorily drained. In this work it is of
advantage to use an exploring needle, the operator guiding his further
procedures largely by what it may reveal. Vessels which may be divided
and spurt should be ligated or secured _en masse_, while oozing is
overcome by gauze pressure. Drainage of a cavity already protected is
simple; otherwise it may require a very careful combination of large
fenestrated tube, if possible sewed in place, with the margins of
the opening carefully puckered and secured around it and protected
with gauze. Counteropening may be made, as well as drainage of any
neighboring purulent focus.

[Illustration: FIG. 626

Abscess of liver, opened by transperitoneal hepatostomy. (Pantaloni.)]


HYDATIDS OF THE LIVER.

Echinococcus disease is almost a surgical curiosity in the central
portions of the North American continent, whereas in some parts of
the world it is extremely common. Thus while very rare in the United
States, in Winnipeg it is an exceedingly common disease, being
brought there by immigrants from a locality where it is still more
prevalent, namely, Iceland, where it is said that nearly half the
inhabitants die of some form of hydatid disease. In New Zealand, also,
as elsewhere, this form of parasitic invasion is very common. With
most American practitioners, however, it is so seldom seen that its
mere possibility may be overlooked. In the liver it produces cystic
disease whose symptoms are rarely significant until the cysts have
attained considerable size and have begun to suppurate. That the liver
is so frequently affected is easily understood, as the parasites make
their first invasion along the duct from the intestinal tract. The
history of these cases is always slow, as four years is a short time
and twenty-five years not an exceedingly long one in which hydatid
cysts run their course. Small cysts may even undergo spontaneous
retrogression and calcify. These cysts when large may rupture, just
as do hepatic abscesses, and in various directions. (See above.)
Ordinarily it is only when suppuration occurs that the general health
suffers, and not until that time are they, at least intentionally, seen
by the surgeon.

Hydatid cyst of the liver appears as a tumor, evidently cystic or
fluctuating, growing painlessly and attaining considerable size. It
may usually be excluded from abscess, cancer, dilated gall-bladder,
aneurysm, gumma, hydronephrosis, renal cysts, or tumors of unknown
origin. A tumor peculiar to the liver will move with that organ. The
aspirating needle will probably need to be used before diagnosis is
complete, the fluid withdrawn being clear unless suppuration has begun.


=Treatment.=--Hydatid cysts require radical treatment. Aspiration does
not remove the mother-cyst nor any of its semisolid contents. Even
the injection of iodine and resort to electrolysis hitherto in vogue
have been abandoned. Open incision, first, of the abdomen, and then,
after careful protection of the abdominal cavity, of the cyst itself,
with scrupulous attention to prevention of escape of its contents
save externally, is the only radical and promising procedure. These
precautions should be taken because of the possibility of implantation
of some living fragment of the parent organism, or its offspring,
elsewhere in the abdomen and the growth of the same in this new
location. After free evacuation of such a cyst it should be explored
and thoroughly cleaned out, after which its edges are to be affixed
to those of the parietal peritoneum if practicable, a large tube
inserted and suitably connected up for drainage, while the opening
around it is closed with sutures or packed with gauze. This connection
of an interior cavity with the exterior of the body is called
_marsupialization_.


SYPHILIS OF THE LIVER.

The operating surgeon as such is only concerned with gummatous tumors,
not with diffuse expressions of syphilis which produce interstitial
hepatitis or cirrhosis. The latter are often met in cases of general
syphilis, and yield to suitably directed treatment. Either the
_diffuse_ or the _gummatous form_ may produce enormous enlargement of
the liver, with suspicion at least of an abscess. In one case of this
kind, known to the writer, the lower border of the liver extended below
the crest of the ilium, and yet within a short time, under vigorous
treatment, the liver resumed its normal size. Gummas have, then, an
interest for the surgeon, as no other similar enlargement ever reduces
its volume so speedily under any other circumstances. Moreover gummas
may occasionally break down and produce abscesses requiring incision
and drainage. If syphilis can be recognized as the etiological factor
prognosis is satisfactory in nearly every instance.


ACTINOMYCOSIS OF THE LIVER.

The specific fungi of this disease may be easily carried from the
alimentary canal to the liver through the portal circulation, and its
peculiar granulomas, appearing first here, may spread to the diaphragm,
to the abdominal wall, or in any other direction. Unless aided by the
presence of other distinctive lesions diagnosis is rarely made until
the presence of a granulating tumor and its ulceration, with the
escape of the distinctive calcareous particles, makes it recognizable
to touch as well as to sight. This often might be secured by an
exploratory operation, which circumstances might justify. (See chapter
on Actinomycosis.)


TUMORS OF THE LIVER.

Benign tumors in the liver are rare. So-called _adenomas_ of somewhat
indistinct type, and _fibromas_, have been described as occurring
here. The former are of uncertain origin and probably do not deserve
the name given here. Nevertheless they have a structure more or less
simulating true gland tissue. Fibromas may spring from any of the
fibrous structures. Other benign tumors occur here so rarely as to
scarcely warrant mention. _Aneurysms_ and large _venous dilatations_
also occur occasionally in the liver. Any of these lesions may justify
exploration, and those favorably situated may be enucleated or excised,
with subsequent suture of the liver and drainage of any remaining
cavity.

Of the _malignant_ tumors the _sarcomas_ and _endotheliomas_ may
arise in almost any part of the organ. _Primary carcinomas_ have
their origin only about the gall-bladder and its ducts, from whose
epithelial lining they may spring; otherwise they are products of
extension or metastasis. By far the larger proportion of cancers arise
from the gall-bladder, within which they begin to grow, either as the
expressions of irritation or of parasitism. The presence of _gallstones
in the gall-bladder is now known to be an extremely common provocation
of cancer_, and the relation obtaining between the two is certainly
more than accidental or casual. (See Cancer of the Gall-bladder.)

That an associated and solitary cancerous growth of this kind may be
successfully removed has been proved in my own experience, by the good
health persisting at least six years after operation upon a woman from
whom I removed a large cancerous gall-bladder containing two large
calculi, and with it a considerable amount of the adjoining liver
tissue. It is, therefore, possible to successfully remove some benign
tumors, as well as occasionally a malignant one, from the liver when
other conditions are favorable; but this should always be done before
it be too late, as a comparison of cases will demonstrate. If the lymph
nodes or any other viscus be involved in malignant disease, then it is
too late. The tumor is to be attacked from its most accessible aspect.
A pedunculated growth, like a distinct benign hypertrophy, may be tied
off, sutures being also used if needed. The actual cautery furnishes
the best means of division of liver tissue, while with a sessile
growth elastic constriction may be of assistance. The principal danger
in these operations is from hemorrhage. Methods of meeting it are
discussed below, as well as other general procedures. A tumor stump may
be fastened to the abdominal wound, or it is better treated by being
packed around with gauze, the latter being allowed to remain for three
or four days.[62]

  [62] As a means of preventing the ligature cutting in liver sutures
  Gillette has suggested the use of a piece of rubber tube drawn over a
  No. 10 catheter and placed along the proposed line of sutures, which
  are passed around this, and through the abdominal wall, making exit
  between the ribs, after the manner of a staple.

Von Bruns, in 1870, was probably the first to resect liver tissue,
after injury, with good results. Modern surgery has done much to
improve the prognosis in these injuries and to show that it can be
attacked much more freely than previously supposed. Within the past
fifteen years Ponfick and many other experimenters have shown the
regenerative capacity of the liver by removing as much as three-fourths
of it. The fear of cholemia, due to escape of bile, has also passed,
and it has been found that peritoneal complications do not result
from its presence, for bile, unless actually mixed with pus, is not
septic, although its antiseptic properties have been much overrated.
Most of the expedients which have been suggested by various operators
for controlling hemorrhage have been abandoned for the more simple
methods of the tampon and the suture, although the actual cautery is
still generally used for the operative attack. For suture catgut is
preferable to silk. Even large wounds may be successfully fastened
in this way. Arterial bleeding is easily distinguished from venous
oozing. Spurting arteries may be ligated _en masse_, while continuous
oozing usually subsides under pressure. In contusions of the liver,
when it is not practicable to bring hepatic surfaces together, loops of
catgut may be passed with a large needle through the liver structure
in such a way as to bind its edges whenever they are bleeding. The
sutures or loops may be drawn tightly to check hemorrhage before they
cut through the liver structure. When the attempt is made to actually
suture liver tissue it is necessary here as elsewhere to avoid dead
spaces. If liver surfaces can be brought into actual contact they will
heal kindly. In fact when there is access, and the emergency is not too
pressing, the portion to be removed may be excised with ordinary knife
or scissors, and this is better when suture methods are to be employed.
There are times, however, when the Paquelin cautery knife will perhaps
be preferable. It is a mistake in these cases to try to work through
too small an incision. For wounds located posteriorly Lannelongue has
suggested resection of the thoracic wall along the anterior portion of
the eighth to the eleventh costal cartilages, since the pleura does
not extend down to that level. He makes an incision parallel with the
costal border, 2 Cm. above the same, beginning 3 Cm. from the border of
the sternum, and terminating at the tenth costochondral junction. After
retracting the muscles the costal cartilages are to be resected. If,
now, the rib ends be firmly retracted and pressed apart a large portion
of the convexity of the liver can be made accessible.

In order to make better access to the upper margin of the liver it may
be well to adopt Marwedel’s suggestion of retracting the rib arches
by a curved incision, parallel with the costal margin, with complete
division of the rectus and the external oblique, which latter is to
be separated from the internal and transverse. The cartilage of the
seventh rib is divided at its sternal junction and the cartilages of
the eighth and ninth are also exposed and divided by blunt dissection.
After thus loosening the lower ribs the lower part of the chest wall
can be retracted, and much better access made to the region below the
diaphragm. When necessary the left side of the abdomen may be treated
in the same manner.

From the liver we pass to the consideration of the surgical aspects of
cholelithiasis and other affections of the biliary passages.


THE GALL-BLADDER.

The gall-bladder is a convenient but more or less superfluous
receptacle or reservoir for bile, whose normal capacity is from 50 to
60 Cc., but which, when distended, may, by virtue of its elasticity,
contain at least 200 Cc. of fluid. Its normal position is beneath the
ninth costal cartilage, at a point where it crosses the outer edge of
the rectus. Only its lower surface is covered by peritoneum, in average
cases, but when it is distended or hangs well down in the abdomen the
peritoneum may enclose the larger amount of the sac. Its neck is bent
into an S-shape, and contains two folds of mucous membrane, which serve
as valves. When this neck is mechanically obstructed the sac itself
may be distended with glairy, bile-stained mucus, amounting even to
500 Cc., but in patients who have had repeated attacks of gallstone
colic and have suffered for a long period of time, the gall-bladder is
usually contracted, shrivelled, and sometimes almost obliterated. Under
these conditions there is a strong resemblance between it and so-called
appendicitis obliterans, and when so contracted and buried in adhesions
it may not be easily found. In certain cases of cirrhosis of the liver
the gall-bladder is carried up well beneath the ribs and then descends
with whatever motion depresses the liver. On the other hand when
distended it may hang down into the abdominal cavity as a pear-shaped
mass, which may even cause doubt and uncertainty in diagnosis, for it
may be then found in the cecal region or in the pelvis.

The common duct is from 6 to 8 Cm. long. Its size is about that of a
No. 15 French sound. It is both extensile and distensible, and may be
dilated even to the size of the small intestine. About one-third of it
is in intimate relation with the pancreas, whether wrapped within its
head or lying in a groove upon it. This is of surgical import, for in
enlargement of the pancreas the duct may be first pushed away and then
obstructed; this explains why biliary drainage is indicated in so many
pancreatic cases. The part which passes obliquely through the duodenum
is expanded into a reservoir beneath the mucosa, into which opens
also the pancreatic duct, the latter lying lower and being separated
by a fold of mucous membrane. This dilatation, the ampulla of Vater,
is 6 or 7 Mm. long, and is surrounded by an unstriped muscle fiber--a
miniature sphincter. Its opening constitutes the narrowest portion of
the entire biliary canal. Seen from within it forms a little caruncle
or papilla, distant 8 Cm. from the pylorus. The duct of Santorini
opens normally about 2 Cm. above this papilla, and is patent in about
one-half of these cases, while in about 80 per cent. of cases it
communicates with the duct of Wirsung. Many variations from the normal,
as above epitomized, occur--especially in and about the ampulla. They
are both congenital and acquired. Thus an _hour-glass gall-bladder_ is
occasionally seen, or one so divided by a partition that one part may
contain mucus and the other calculi. It is worth remembering in this
connection that along the free border of the lesser omentum there are
three or four lymph nodes which, when enlarged, may be easily mistaken
for calculi. The gall-bladder lies in a peritoneal pouch, having the
colon below it, the spine and the pancreas to its inner and posterior
aspects, the liver above and the abdominal wall on its outer side. When
this pouch is seriously affected it may be drained not only from in
front but often to great advantage from behind, _i. e._, by posterior
drainage. This pouch may hold a pint before it overflows into the
pelvis, or through the foramen of Winslow into the greater peritoneal
cavity. The right lobe of the liver is sometimes enlarged so as to form
a tongue-shaped projection which may extend some distance below the
costal margin. This is frequently called _Riedel’s lobe_. (See Plate
LV.)

The gall-bladder is essentially a biliary reservoir, convenient but
not essential, storing bile between meals and expelling it during
digestion. It is absent in the horse and in many animals, and
individuals from whom it has been removed seem to suffer thereby no
inconvenience. Consequently there need be no hesitation in removing
it when necessary. Bouchard claims that bile is nine times more toxic
than urine, and that the liver of man may produce sufficient in
eight hours to kill him if it cannot escape. _Consequently biliary
obstruction may become a very serious matter._ Besides containing bile
the gall-bladder has numerous minute glands of its own, which secrete
the ropy mucus with which it is so often found distended. A mixture of
bile and pancreatic juice seems ideal for perfect emulsification and
digestion of fat. Hence the disadvantage of anything which interferes
with the escape of bile into the duodenum. Bile possesses by itself
slight antiseptic properties, _yet when uncontaminated is not septic_.
It may be regarded as mainly excrementitious, and its function as an
intestinal stimulant has been much overrated. The average quantity
secreted in twenty-four hours is about thirty ounces. Its excretion
is constantly going on, but is more abundant by day, is not much
influenced by diet, nor nearly so much by the so-called cholagogues
as has been generally supposed. All these points have a practical
interest for the surgeon who has to do with the consequences of biliary
obstruction, or who has to watch its progress for lack of a biliary
fistula.

[Illustration: PLATE LV

Surgical Anatomy of the Gall-bladder and of the Omental Foramen and
Cavity. (Sobotta.)

The probe enters the omental (epiploic) foramen. By retraction and
removal of its anterior covering the cavity of the lesser omentum
(omental bursa) is exposed, revealing especially the pancreas in
situ.]


BILIARY FISTULAS.

These may be due to accidental injury during operation or to disease
processes. They may be direct or indirect, and internal or external.
An example of direct, external traumatic fistula is afforded by a
cholecystostomy or a cholangiostomy; of indirect internal when the
gall-bladder has burst into an abscess and this into a hollow viscus. A
fistula might arise from a local abscess outside the biliary passages,
later communicating in both directions, or it may be connected with
the thoracic organs, with evacuation into the bronchi or esophagus,
and cases are on record where gallstones have been passed from the
mouth. The external or cutaneous fistulas tend in most instances to
spontaneous healing, but the time required is often long. They may
discharge thin, biliary mucus or true bile.

Mucous fistulas result from cholecystostomy where the obstruction
in the cystic duct has not been overcome, as when it is the seat of
stricture or extrinsic pressure. They cause but little inconvenience.
Nevertheless if allowed to close the mucus accumulates and pain results
from distention. In these cases either a small tube or drain should
be worn, or a cholecystenterostomy may be made. Sometimes after the
discharge of some foreign body, such as a silk ligature or small
stone, such a fistula will close of itself, or it may be possible to
frequently cauterize its interior with a bead of nitrate of silver
melted upon the end of a probe, or perhaps by using a long curette to
so destroy its mucus lining as to do away with the condition and its
consequent discharge. Ordinarily cholecystostomy will not be followed
by permanent or even long-continued fistula if the common duct have
been thoroughly cleared, and if the gall-bladder be fastened to the
aponeurosis and not to the skin. _Postoperative biliary fistulas_, with
discharge of large amounts of bile (one to two pints per day) and their
consequent inconvenience, will ordinarily not be long tolerated by
the patient, who will insist on some further procedure for relief. If
possible, in every such case, the real cause of the difficulty should
be removed. If the ducts be cleared and stimulation with caustic be
not sufficient, then the abdomen should be opened, the gall-bladder
detached, and its fistulous opening freshened and sutured. If the
patency of the common duct can be established this will be sufficient.
Otherwise, after closing the gall-bladder, it should be anastomosed
with the small intestine as near the duodenum as possible.

_Spontaneous or pathological fistulas_ often open at the umbilicus,
the disease process having followed the track of the umbilical vein up
to that point. Here, too, calculi are thus spontaneously extruded, one
case on record including the discharge in this way of a stone three
inches in diameter. In any such case as this the fistula cannot be
expected to close until the calculi are all extruded. In the treatment
of any such lesion the margin of the wound and the entire track of the
fistula should be carefully curetted and disinfected, as at least a
part of the procedure.

_Biliary intestinal fistulas_, due to escape of calculi into adherent
intestine, are also occasionally seen. These often form without marked
disturbance until perhaps at the last, when there may be destructive
symptoms, both biliary and intestinal, symptoms which will suddenly
subside when perforation or passage of a calculus occurs. After their
occurrence patients may enjoy some relief for a considerable time,
or until the contraction of the fistula may necessitate a subsequent
operation. At other times their formation by ulceration is often
accompanied by severe pain and fever, and possibly even by hemorrhage.
Impaction of a gallstone in the intra-intestinal portion of the common
duct is perhaps the most frequent cause of this kind of trouble.
Fistulas into the colon are less common than into the small intestine.
Such fistulas should never be intentionally made if it be possible to
utilize any part of the small intestine. Although the pylorus and the
gall-bladder often become firmly united to each other gastric biliary
fistulas are rare. If, however, there be vomiting of gallstones, such
a sign would make it quite certain. Mayo Robson has reported one such
case where he separated adhesions, pared the stomach opening, closed
it with sutures, and utilized the opening in the gall-bladder for the
removal of calculi and subsequent drainage, the patient recovering.


INJURIES TO THE BILIARY PASSAGES.

These are less common than injuries to the liver proper. They may be
caused by penetration or by severe blows and concussion. In those
already suffering from local disease accidents are more likely to be
followed by rupture. Injuries have also been attributed to traction and
later adhesions. The fundus of the gall-bladder is the most exposed
portion; therefore, that part is most often injured; while neighboring
organs may suffer simultaneously--for example, the liver, stomach, and
colon.

Injury will either produce such damage as to lead to acute local
peritonitis, with extensive exudation for protective purposes, and
with all the possibilities of subsequent infection, or there will be
actual rupture, with extravasation of bile, and perhaps of blood, and
the development of well-marked local as well as general symptoms.
Fluid thus escaping will first fill the abdominal pouch, already
described above, where it will then be confined by the mesentery
until it begins to overflow. A small opening may be sealed by lymph,
and a small collection of fluid may even be encapsulated, so that
it may be subsequently opened and drained. The symptoms of such
injury will include shock, pain, fever, fulness in the right side and
hypochondrium, abdominal rigidity and the development in certain cases,
after a few days, of jaundice, indicating absorption of bile. Should
this bile have been aseptic, no great harm may ensue, but if infected a
general and probably fatal peritonitis will result.

In any case where the condition may be recognized or where it is
strongly suspected, abdominal section should be promptly made.
According to the conditions thus disclosed the opening may be sutured,
if possible or the gall-bladder or other cavity containing bile may be
drained. It has been possible in some such cases to successfully suture
a tear or wound in the duct, while in a few cases the duct has been
doubly ligated and the bile flow been turned into the intestine by an
anastomosis.


ACUTE CATARRH OF THE BILIARY PASSAGES.

The formation of bile takes place under low pressure and therefore is
easily hindered by slight back pressure. In this way jaundice may be
easily produced with no greater degree of chemosis of the duodenal
mucosa than that produced by a relatively small amount of activity in
the duodenum. Inasmuch as the common duct traverses the intestinal
wall obliquely its small outlet would be the first to suffer. In minor
catarrhal duodenitis it is of small surgical importance, but when the
condition becomes chronic the obstruction then becomes a matter to be
dealt with by the surgeon. Such conditions may occur in connection
with typhoid fever, pneumonia, influenza, ptomain poisoning, and other
diseases, and are often accompanied by vomiting and diarrhea, with
referred tenderness and possibly enlargement, while even the spleen is
sometimes enlarged.


=Treatment.=--In the early stage of such a condition the treatment is
medicinal, but when the condition has become chronic biliary drainage
may be required.


CHRONIC CHOLANGITIS.

This is frequently a sequel to the above acute condition, and generally
accompanies jaundice, no matter how produced. It is a frequent
concomitant of cancer and often the actual cause of its accompanying
jaundice. It has been known to lead up to suppurative lymphangitis,
the lymph nodes along the border of the lesser omentum, already
described, being nearly always involved and occasionally suppurating.
_Pylephlebitis_ may also have this origin. Gallstones nearly always
provoke a certain degree of cholangitis and cause the formation of
thick, ropy mucus which causes pain when passing, this pain being often
mistaken for that produced by calculi. Riedel believes that two-fifths
of the cases of jaundice occurring in connection with gallstone disease
are really produced by accumulations of mucus and thickening of the
mucosa, rather than by the stones themselves. Moreover, there is a form
of membranous catarrh, both of the ducts and gall-bladder, where actual
casts are shed, this condition corresponding to fibrinous bronchitis
or enteritis. Thudichum believes that these casts often form nuclei
for gallstones. The condition has been spoken of as _desquamating
angiocholitis_, and casts of the duct or even of the gall-bladder have
been found in the stools.

The surgical interest attaching to these conditions lies in the fact
that the symptoms produced are often identical with those caused by
gallstones, and the desired relief is to be sought in the same way--_i.
e._, by operation. The operator should not feel chagrined if on opening
the abdomen he finds the gall-bladder containing such material rather
than calculi.


CHRONIC CATARRHAL CHOLECYSTITIS.

This is often mistaken for cholelithiasis, although when the
gall-bladder is opened only thick, ropy mucus will be found. This,
as just remarked, may give rise to very painful spasm. The trouble
when present is usually connected with similar trouble in the ducts.
Moreover, around such a gall-bladder numerous adhesions are formed
which give rise to much pain, tenderness, and local distress. Under
these conditions the gall-bladder is enlarged and thickened.

Here, too, the curative treatment is essentially surgical, although
pain may sometimes be temporarily relieved by aspirin in doses of from
0.5 to 1 Gm.

_Cholecystitis obliterans_ corresponds closely to appendicitis
obliterans, and is a condition characterized by a reduction in the size
of the gall-bladder or its almost complete obliteration. In order to
account for this it is seldom necessary to assume a congenital defect.
The morbid process which produces it begins early, perhaps even during
fetal life. The bile ducts are extremely small at birth and further
stenosis is easily produced. The accompanying enlargement of the spleen
will illustrate the toxicity of the condition which led up to it, and
which may have occurred in infancy or early childhood. In a small
proportion of cases early constriction of the ducts produced by local
peritonitis and infection along the track of the umbilical vessels may
account for the condition.


ACUTE CHOLECYSTITIS AND CHOLANGITIS SUPPURATIVA.

A suppurative condition within the gall-bladder is necessarily an
expression of an infection, in nearly all instances proceeding from the
intestine. The colon bacilli and those of typhoid are the organisms
usually at fault. As has already been shown in the earlier part of this
work they are facultative pyogenic organisms. Mixed infection with the
ordinary pus-producing germs may also occur here. Such infections may
spread through the walls of the gall-bladder and cause at least local
and sometimes fatal general peritonitis. The condition is an especially
frequent complication of typhoid fever, occurring sometimes relatively
early, at other times after apparent recovery from the disease. In
most of these instances it is supposed that the bacteria reach the
gall-bladder by migration along the ducts, although direct penetration
or infection through the blood is not to be denied. Impacted gallstones
especially predispose to such infections. The result of all such
cases is the formation and retention of pus--_i. e._, _empyema of the
gall-bladder_--save in those rapid virulent or fulminating infections
when it quickly becomes gangrenous, as does the appendix when similarly
infected.


=Symptoms.=--In acute infections of the bile passages patients suffer
severe pain, made worse by movement, with general malaise, rapid loss
of appetite and flesh, extreme tenderness over the gall-bladder and
often around it, because of the accompanying local peritonitis. It is
frequently possible to make out enlargement of the gall-bladder, which
will move with the liver during respiration--this at least until it has
become fixed by local inflammation--after which the patient will have
thoracic rather than abdominal respiration. As such a case progresses
local indications of disease will be added, with finally visible
tumefaction and redness of the overlying skin. Jaundice is an uncertain
feature, depending on the patulency of the common duct.

_Pus when formed may escape and burrow in various directions_; thus
it may follow the suspensory ligament of the liver and appear at the
umbilicus, or it may pass along other reflections of the peritoneum
and appear about the cecum or above the pubes, or it may pass into the
liver and appear as an hepatic abscess, or around it and thus give
rise to a perihepatic or subphrenic abscess. It may even perforate
the diaphragm and produce such collections of pus or such phenomena
as have been described in the previous chapter, including empyema,
pericarditis, abscess of the lung, etc. Again it may burst into the
hollow viscera, stomach or intestines, or into the general peritoneal
cavity, where it will cause speedily fatal peritonitis. Pulmonary
abscess, with discharge of pus and bile, has been cured by Mayo Robson
by removing a stone from the common duct. Gallstones have also been
found in the pleural cavity and have even been passed by the mouth.
Finally pus collecting in the right abdominal pouch may also be
mistaken for perirenal abscess.

_Acute phlegmonous cholecystitis, with gangrene_, corresponds to
the fulminating form of gangrenous appendicitis, and only received
its first description in 1890 by Courvoisier. This is not common,
but when met with becomes a disastrous lesion. It is essentially a
still more virulent expression of infection and consequent necrosis
than the condition described above. It may be so rapid as to destroy
the gall-bladder before it has had time to fill with pus. It may
occur with or without a history of previous trouble, in the absence
of which a diagnosis will be made more perplexing. As the condition
declares itself and progresses there will usually form about its site
a protective barrier of lymph and omentum, which may prove, when
present, the salvation of the patient, especially if the surgeon who
makes the operation, _and this should be early_, recognizes the value
of these protections and does not break them down. The condition occurs
in connection with gallstone disease, but may follow typhoid fever,
cholera, puerperal fever, or other intense infection.

_Symptoms_ of gangrenous cholecystitis are essentially those of the
less severe types of infection, only more pronounced. They include
severe pain of sudden onset, rapidly growing worse, spreading over
a larger area, extreme tenderness and muscle spasm, rapid thoracic
respiration, quick pulse, intense depression and collapse, vomiting,
rapidly increasing tympanites, anxious facies, with every expression
of intense sapremia. Jaundice is an inconstant symptom, while fever is
usually present, but is of little importance. The disease may be so
rapid as to quickly kill. At all events local destruction occurs early,
either with abscess or gangrene, or both.


=Diagnosis.=--The diagnosis consists virtually in a recognition of
the cause of the intense local peritonitis, after which a history of
previous disease, if obtainable, may help. The condition is to be
differentiated especially from perforated ulcer of the stomach or
duodenum, from acute pancreatitis, and from acute mesenteric embolism
or thrombus with gangrene of the intestine. It is also occasionally to
be distinguished from an acute appendicitis, and this may be difficult,
since the appendix is sometimes found high up and the pain widely
referred or not accurately localized. In acute cholecystitis the pain
is more likely to be subcostal, and the tenderness and muscle spasm
are more marked in the upper part of the abdomen, to which the various
local expressions of the disease are referred rather than to the
lower. In any or all of these troubles symptoms of acute peritonitis
are likely to be present and paralytic ileus or bowel obstruction may
complicate the case.

Ransohoff has called attention to a hitherto unnoted sign of gangrene
of the gall-bladder--namely, a localized _jaundice about the
umbilicus_, apparently brought about by staining of the fat beneath the
peritoneum, and noted after incision, if not previously. He considers
it the result of imbibition, and that it appears at the navel first
because here the abdominal wall is thinnest, it being also possible
because of the anatomical relations of the round ligament of the liver
to the transverse fissure, where there may be a retrograde flow of bile
through the lymphatics and toward the navel.

_Fortunately all of these acute conditions as between which doubt may
arise are to be dealt with in only one way--namely, by prompt operative
intervention_--and minute diagnosis is of less importance than ability
to appreciate necessity for immediate operation as it may arise.

_Gangrene_ is the extreme degree of disaster in these cases, and its
occurrence may be marked by sudden cessation of the pain, a most
important symptom, which may be deceptive to the uninitiated. Gangrene
may be due to thrombosis of the vessels of the gall-bladder, to
bacterial invasion, to extreme tension because of obstruction of the
duct, or to all three.

_Acute cholangitis_ was first described by Charcot, who called it
intermittent hepatic fever. It is usually due to the presence of one or
more gallstones in the common duct, but any obstruction of the hepatic
or common ducts may favor infection of retained bile and involvement
of the duct. Thus it has followed chronic pancreatitis, cancer, hydatid
disease, pancreatic calculus, typhoid fever, and the presence of the
parasites. Mertens has collected forty-eight cases in which _ascarides_
have been found in the bile-duct, their entrance having probably been
facilitated by the previous escape of gallstones and enlargement of
the duct end. Round or lumbricoid _worms_ have also been found in the
duct, as they are occasionally met with in the duodenum, and I once saw
a long one in the appendix. Cancer in this neighborhood is also a not
infrequent exciting cause in producing acute cholangitis.

_Symptoms._--There is usually a history of spasmodic pain covering
a considerable period, and then of such an attack followed by chill
and fever, with more or less jaundice, which may persist for some
time. Such attacks as these become more severe and more frequent; the
gall-bladder enlarges if it contain no stone, or contracts if calculi
be present. This association was especially noted by Courvoisier, who
formulated a statement to this effect, often absurdly known as his
“law.” Later the entire liver or its right lobe may enlarge, while
patients complain of tenderness over the gall-bladder, as well as of
loss of appetite and flesh, and those vague symptoms included in the
term “dyspepsia.”

Such a condition may possibly subside in time, but is more likely to be
followed by acute trouble of one of the types already described. In the
matter of diagnosis it may be distinguished from malaria, especially
in districts where malaria prevails by absence of relief from quinine,
and the results of a carefully completed examination, combined with
the fact that in the former it is usually the gall-bladder which
is enlarged, and in the latter the spleen. When the condition has
proceeded to its suppurative form the occurrence of still more
significant symptoms and signs should lead to prompt operation.


=Treatment.=--In the acute infections and affections, both of the
gall-bladder and of the duct, _operative intervention_ is imperative.
The more acute the case the more urgent the indication. _Free
evacuation and drainage are the indications to be met, and as early
and completely as possible._ These cases call for cholecystostomy,
often for choledochotomy, with drainage of both gall-bladder and duct,
and perhaps of the peritoneal cavity, while possibly even posterior
drainage may be indicated. So true is this that the back should be
as carefully prepared for operation as the abdomen, in order that no
time be lost during the operation, should one decide on the wisdom
of a posterior counteropening. Of course much will depend upon the
patient’s condition at the moment and what it may appear he can endure.
By free opening of the gall-bladder evacuation of its septic contents
and removal of calculi are secured, if present, while the ducts are
permitted to empty themselves and free flow outward of all septic
material is invited and permitted, pressure is relieved, the tumor is
disposed of, respiration allowed to become normal, and no small load
removed from the kidneys; and the chronic pancreatitis which so often
accompanies many of these cases is allowed to subside by virtue of the
other relief thus afforded.


ULCERATIONS AND PERFORATIONS OF THE BILIARY PASSAGES.

These may occur anywhere along the biliary tract, and vary as between
the superficial and the perforating, the former being sometimes
multiple, the latter solitary. Of these lesions cholelithiasis is the
most common cause, while typhoid and cancer should be ranked next. They
are all of pathological import, because of their possible sequels, _i.
e._, not merely perforations with fistulas, but possible strictures or
hemorrhages, or peritonitis with sepsis. When ulceration is extensive
a previous local difficulty may be supposed, with more or less
adhesions, but as the trouble becomes more serious the local excitement
will extend to the peritoneum, at least that of the area involved.
In fact most cases of gallstone disease are accompanied by more or
less peritonitis, and adhesions which are protective, although they
may cause other troubles as well, such as dilatation of the stomach
from displacement of the pylorus. Hemorrhage is not a frequent event,
for thrombosis usually precedes erosion. Some degree of sapremia or
septicemia will be present in nearly all cases.

_Stricture of the ducts_ is the most common result, especially of the
cystic duct. If this occur and the mucous membrane be still active
the gall-bladder will become distended with pus or mucus, or both.
These are the cases which perhaps give the best results after ideal
cholecystectomy.

Perforation is a constant possibility whose menace cannot be estimated,
but which is always actual, the great danger depending on the virulence
of the extruded material and the consequences of delay in operating.
Although healthy bile is but slightly toxic, these cases do not furnish
it, and one may always look for consequences of infection. Nevertheless
if diagnosis be made sufficiently early to bring about immediate
operation prognosis is good. Occasionally during such an operation
there will be found a gallstone endeavoring to extrude itself, but not
yet completely escaped. It might be, in rare instances, possible to
utilize the opening which it has partially made for subsequent drainage
purposes.

It is not advisable to permit patients with distended gall-bladders to
go unoperated, even in the absence of serious symptoms, because the
risk of operation is small and that of rupture is large.

_Acute intestinal obstruction due to gallstones_ will usually, but
not invariably, involve the upper intestinal tract. It may be due
to the actual occlusion of a large stone which has escaped from the
gall-bladder or duct, or it may be caused by volvulus due to intense
colic accompanying peristaltic effort, or it may depend upon adhesions
after a local peritonitis due to previous disease of the gall-bladder
or to stricture following ulceration; or again it may be purely
paralytic, and in this way result from a local peritonitis. Impaction
of a biliary concretion may happen at any point, but most often at the
ileocecal valve, where the intestinal tube is narrowest. The size of
the stone is not the only consideration. Obstruction depends perhaps
as much upon spasm above and below as upon any local disturbance that
its presence may have caused. Biliary concretions may enlarge as
they pass downward, growing by accretion of calcareous and of fecal
matter. The larger the calculus the more likely it is to obstruct the
upper intestine. The majority of these calculi have escaped from the
gall-bladder by a previous process of ulceration, and usually into the
duodenum, rarely into the colon.


=Symptoms.=--Symptoms of this condition, thus produced, will obviously
be those of acute obstruction from any cause, the most marked features
being severe pain and early frequent vomiting. Bile may be raised in
quantities because of the biliary fistula so near the stone, and from
which it is supposed to have escaped. The higher the exciting cause the
more violent the symptoms and the less the distention of the abdomen
by gas. A significant history may help in assigning the cause for the
evident obstruction.


=Treatment.=--Since more than half of these cases treated expectantly
die without relief early operation is to be urged. It should always be
preceded by lavage in order that the stomach may be thoroughly emptied.
When a stone has been exposed within the intestine it is advisable
to open the bowel a little below where it rests, so as to make the
division at a point where the chances of repair are not compromised
by previous excitement. In severe cases a temporary enterostomy may
be made, but this should of necessity be high. The volvulus may be
relieved by untwisting the kink or by an anastomosis. Obstruction due
to adhesions will require separation of these adhesions, with perhaps
an anastomosis.


CHOLELITHIASIS, GALLSTONE OR BILIARY COLIC, BILIARY CALCULI.

There is so much which may be said about the formation of gallstones
and the troubles which they may produce that it is necessary here to
epitomize as much as possible and to refer mainly to the surgical
features of this condition. _Gallstones_ are of all _sizes_, from the
most minute to that of a hen’s egg, are present in _numbers_ varying
from a single calculus to thousands of calculi, are found commonly
in the gall-bladder, in the cystic duct, or in the common duct, but
occasionally are met with just escaping into the duodenum, through the
duodenal ampulla, or in the smaller ducts of the liver or the main
hepatic duct (Fig. 627). In at least 99 per cent. of cases they will be
seen in one of the locations first mentioned.

[Illustration: FIG. 627

Gallstone presenting at the ampulla of Vater, _i. e._, endeavoring to
escape into duodenum. (Pantaloni.)]

Pages might be devoted to a discussion of the reasons for their
formation. That cholesterin, their principal component, should more
readily deposit in such a way as to produce these calculi, and more
often in some individuals than in others, is hard to explain, but
may be held to be largely due to its formation in excess in certain
individuals and to concentration of those fluids which hold it in
solution. Increase of cholesterin seems to be connected with catarrh
of the membrane which produces it, and thus stagnation of bile may
predispose. That bacteria have much to do with biliary calculi is now
conceded, and a history of typhoid is obtainable in many cases. It has
been shown experimentally that aseptic foreign bodies introduced into
the gall-bladder remain indefinitely without becoming covered with
precipitate, while virulent organisms set up disturbance, and only the
attenuated or moderately infectious organisms produce calculi, and
usually then only when some trifling foreign body is introduced at the
same time. It will thus be seen that a nidus may be afforded by a clump
of epithelial cells or débris.

It is not at present so much a question of what organisms are at
fault, although they are usually the colon and typhoid bacilli and
the ordinary pyogenic organism. It has been shown, moreover, that in
typhoid fever the gall-bladder is often invaded, and that the typhoid
bacilli may live there indefinitely, and that they tend to clump or
agglutinate themselves in a very suggestive way into trifling masses
which may serve as minute foreign bodies. Thus each predisposing factor
reacts upon the other, and by a vicious circle either an acute lesion
may be established or calculi may be formed in varying numbers.

Gallstones have been found in the _newborn_, but are relatively
infrequent below the age of twenty-five, and are most common in the
later years of life. The condition is by four to one more frequent in
women than in men. The only predisposing habit seems to be such lack of
exercise as gives no expulsive movement to the gall-bladder by action
of the abdominal muscles. They are more common in the gouty and in
those predisposed to uric-acid diathesis, while abundance of nitrogen
seems rather protective. Biliary calculi have never been found in the
wild carnivora.

McArthur has formulated the following conclusions of interest in this
connection:

  1. Not all gallstones originate within the gall-bladder.

  2. The origin of a cholesterin stone is probably the gall-bladder,
  with subsequent accretion, either in passing through, or in the duct,
  where it may have lodged.

  3. Bilirubin calcium is the principal constituent of the smaller
  intrahepatic duct stones.

  4. Calculi in immense numbers may exist for months in the ducts
  without producing serious symptoms.

  5. Under these circumstances the surgeon need not reproach himself if
  there be recurrence of symptoms after common duct drainage.

_Biliary calculi are serious menaces_ to a patient’s welfare, not
alone because of the obstructive symptoms which they may produce, but
because of the acute or chronic conditions to which they indirectly
give rise. These have been in some degree already mentioned. Thus
cholecystitis and cholangitis of all degrees of severity, from the
milder chronic forms to the phlegmonous and fulminating varieties, may
be at least associated with the presence of such calculi and seem to be
to a greater or less extent due to their presence. Around such foci of
excitement there will always occur local peritonitis, which will result
in adhesions, and the consequent tenderness with referred as well as
local pains to which it necessarily gives origin. The viscera suffer
not only in this direct way, but functional disturbances are produced,
and are usually covered under those vague terms “dyspepsia” and
“indigestion” with which patients crudely describe their discomforts,
and under which physicians too often conceal their failure to
appreciate the actual condition.

Furthermore there is always a possibility of cirrhosis resulting,
because of distention of the hepatic ducts and backing up of the
hepatic secretion. Thus the liver becomes larger and more dense, is
colored green, its edges become more rounded, this occurring especially
in the right lobe, or at least attracting more attention in that
location because more easily recognized from without. Again the more
acute inflammatory conditions sometimes cause paralytic ileus, or at
least paralysis of the lower bowel, and thus lead to conditions almost
identical with, and difficult to distinguish from acute intestinal
obstruction.

Of equally great and growing importance is the fact that, according to
Schroeder, some 14 per cent. of gallstone sufferers develop cancer, the
presence of these irritating foreign bodies in the biliary passages
having much the same relation to cancer of the liver as does the
existence of previous ulcer to cancer of the stomach.


=Symptoms.=--There is scarcely any morbid condition which is at one
time characterized by such significant symptoms and at another by
none at all as cholelithiasis. In rehearsing the list of the ordinary
symptoms produced by the conditions exceptions should be made, for no
matter how complete the list something may be omitted which has been
noted in some particular case.

Gallstones confined within the gall-bladder proper may produce few or
no symptoms, this being particularly true so long as the ducts are free
and there are no persistent consequences of previous acute trouble. A
stone may grow in the gall-bladder to a large size and cause little or
no distress until it begins to work its way by the ulcerative process.
Doubtless small concretions pass with little or no disturbance, or only
that which would be considered a “temporary dyspepsia.”

When, however, gallstones produce symptoms these usually include
more or less paroxysmal pain, occurring unprovoked and at irregular
intervals, referred not alone to the upper abdomen, but radiating
to the rest of the trunk, as well as in the direction of the right
shoulder-blade. (The shoulder pains of biliary and renal lesions are
due to the connection of the pneumogastric nerves with the ordinary
sensory nerves above, and below with the sympathetic ganglia.) Attacks
of pain are usually followed by nausea and vomiting, and if extremely
severe by more or less depression and collapse. At times there will
be a sensation as of distention in the region of the gall-bladder.
Tumor in this location may or may not be present, and _jaundice is
an uncertain_ symptom, not occurring unless the ducts are occluded.
The stomach so far sympathizes that digestion is at least temporarily
disordered. In proportion as angiocholitis is produced by the passage
of calculi we may meet with more or less septic features. The pain
produced is uncertain in severity and duration, and is often relieved
by the relaxation which may accompany or follow vomiting. After
subsidence of severe pain there remains a dull ache for several days,
lasting perhaps until another acute paroxysm. These pains are sometimes
referred to the left side and over the stomach, in which cases it will
usually be found that the gall-bladder is adherent to the stomach,
while when the pain is felt in the right side of the thorax it is
usually because there are numerous adhesions between the lower surface
of the liver and the viscera below it. Such pain may even simulate
angina pectoris or may involve the genitocrural distribution. In fact
it may be referred to almost any part of the body.

_Vomiting_ which is at first paroxysmal and colicky may become
persistent, continuous, and even dangerous. It is essentially an
expression of pneumogastric irritation. The vomited matter may contain
bile or even, by retrostalsis, fecal matter. The depression which at
first occurs may merge into complete collapse; it may even be fatal. It
will necessarily be more marked when the paroxysms are more frequent.

A significant feature in nearly every case is _muscle rigidity_,
especially of the upper abdominal muscles on the right side, but
not necessarily confined to these. This muscle spasm is a symptom
common to many serious conditions and is not of itself indicative. It
simply _implies a serious condition within_. Tumor or enlargement in
the region of the gall-bladder may be met with, but are by no means
constant. These may become more pronounced with each attack, being
reduced between times because of the escape of bile between paroxysms.
It is a valuable symptom when noted, but no importance should be
attached to its absence.

The presence of gallstones _in the stools_ is, of course, indicative,
but most valuable time is often wasted when waiting for their
discovery. Moreover, a number of hours, or even days, may elapse, the
time depending on the activity of peristalsis, between the escape
of calculi into the duodenum and their appearance in the stools. A
convenient way to search for them is to let the stool be stirred with
a 1 per cent. solution of formalin and then strained through a sieve
which has about sixteen meshes to the inch. The question of the wisdom
of operation can practically always be decided without reference to
the appearance of calculi. In this way the surgeon may feel that his
diagnosis is corroborated by it, but in no sense weakened without it.

_Jaundice_ is always a significant sign when present, but is absent in
at least four-fifths of cases which nevertheless should be subjected
to operation. Its occurrence is a matter of interest along with the
previous history of the case. It is, however, of great value if it
were noted in connection with the first pains or cramps. In chronic
obstruction by stone in the common duct it is important to determine
the _intensity_ of the jaundice, since this may indicate whether we
deal with calculous disease or obstruction from tumor. In _chronic
obstruction by stone_ the color changes are _less marked_, and often
clear up entirely, while when produced by tumor they become gradually
more intensified.

_Deep and persistent jaundice is suggestive of malignant disease._ The
degree of cholemia rather predisposes these patients to hemorrhage or
persistent oozing during operation. Jaundice gradually deepening with
each attack of pain is also very suggestive. Such attacks, coming on
with symptoms like those of malaria, chill, sweating, and pyrexia,
are extremely suggestive and _always call for surgical intervention_,
_i. e._, _drainage_. In brief it may be said that jaundice, with
enlargement of the gall-bladder, is at least suggestive of cancer,
while a history of gallstone colic, without much enlargement of the
gall-bladder, is indicative of stone in the common duct. Although
this statement is probably true for the majority of cases there
are occasionally marked exceptions to it, as, for instance, when a
gall-bladder is distended with hundreds or even thousands of small
calculi, or to such an extent that it may form even a pear-shaped tumor
hanging down within the abdomen.

In addition to these features thus rehearsed there might be made
a long list of possible “extras,” by which the original condition
is complicated and made to appear in unusual aspect or even life
endangering. Such a list would include nearly every imaginable lesion
of the upper abdomen. Suffice it to say that the liver, stomach, and
the pancreas especially may suffer, while other viscera and the larger
veins, with the surrounding tissue, may any or all of them become
involved.


=Diagnosis.=--Diagnosis has to be made mainly from _non-calculous
obstruction_; from the _acute gastric conditions_, ulcer, etc.; from
_renal colic_; from the acute or subacute _pancreatic_ affections,
_duodenal ulcers_, _renal lesions_, _localized peritonitis_ from
some other cause; from _cancer_, _lead colic_, _angina pectoris_,
_pneumonia_, _pleurisy_, and even _hysteria_. Not so rarely pneumonia
and pleurisy begin with pains which are referred to the upper abdomen
and are suggestive of gallstone disease, while they seriously perplex
the medical attendant. Much stress is to be laid on the first location
of the pain, especially if this be in the direction of the right
shoulder, and upon concomitant vomiting and jaundice, if present, as
well as on the location of the greatest tenderness and muscle rigidity.
_Recurrence_ of more or less similar attacks is also suggestive.
Diaphragmatic pleurisy may cause pain, referred especially along the
esophagus, and intensified during the act of swallowing or vomiting.
Affections of the _appendix and gall-bladder may co-exist_, as well
as be easily mistaken one for the other. The former is so true that
when operating for one condition it is always advisable to explore
in regard to the other. When the appendix is placed high, especially
behind the colon, confusion may confound. Biliary colic is usually
free from the associated ordinary symptoms which are so often met with
in renal colic, while in the latter the urine will contain no bile
pigment and the pain will usually be referred to the external genitals.
In lead colic the characteristic line upon the gums and the habitual
constipation which always accompany it will be suggestive. When the
stomach is at fault and the pylorus obstructed this viscus will usually
be dilated, and the vomit is of a different character, while, at the
same time, actual stomach movements may or may not be made visible.
With gastric or duodenal ulcer pain it is more regular and associated
with food taking after a definite interval, longer in the latter case.

_Chronic pancreatitis_ is so often associated with cholelithiasis that
it is impossible to disassociate their symptoms, but the referred pain
is rather midscapular or even on the left side. It will be particularly
suggested by rapid loss of flesh. In acute pancreatitis the symptoms
are usually more excessive, the distention earlier and greater. Cancer
of these various organs does not commence with pain, but has a more
gradual, distinctive downward course, with cachexia. These are some of
the considerations which may aid in differential diagnosis.

The detection of bile pigment in the urine and blood will have
corroborative value.[63]

  [63] Hanel has shown that a small capillary tube filled with blood,
  sealed at both ends, may afford a convenient corroborative test.
  After standing for a few hours in a vertical position its separated
  serum can be examined against the light. Normal serum is colorless,
  while even a trace of bile pigment will give it a distinctive yellow
  tint.

  Baudouin’s test for the urine will be the most satisfactory in the
  matter of precision and simplicity. If two or three drops of a ¹⁄₂
  per cent. solution of fuchsin be dropped into urine containing bile
  it immediately develops a fine orange tint, in marked contrast
  with its own red. No other coloring matter in the urine gives this
  reaction; which is very delicate. (Mayo Robson.) Methyl blue and
  methyl violet each give a reddish tint; Loeffler’s blue solution
  gives a green tint which vanishes on heating, to reappear on cooling.
  There are numerous other tests, but these are the simplest and most
  satisfactory.


=Treatment.=--The general subject of cholelithiasis and its associated
lesions constitutes an important topic in the so-called “border-land”
between medicine and surgery, where views and advice regarding
prognosis and treatment will depend on the experience and the training
of the medical attendant. Surgeons now recognize, and physicians are
being gradually converted to their view, that _gallstone disease
is essentially a surgical disease_, _i. e._, one to be combated by
surgical intervention. While it is not to be gainsaid that many
patients live and die with gallstones who are never conscious of
their presence, and while others who have had serious attacks live
to die of some other disease, nevertheless the general statement may
be boldly made and easily defended, that _when the disease is well
marked and when patients suffer more or less constantly from it the
only successful method of treatment is the surgical_, and that, in
other words, operation offers the only prospect of permanent relief.
Regarding its associated dangers it may be said that _danger comes
from delay rather than from operation_, and that here, as with many
other conditions, patients often wait too long, partly from lack of
proper advice, partly from timidity, and that a septic and moribund
patient, allowed to become so for lack of earlier application of the
resources of surgery, is a reflection on the one who waits rather than
on the surgeon, who, endeavoring to save, still unfortunately loses his
patient.

This is not the place to discuss non-operative measures--_i. e._,
medicinal and dietetic treatment--valuable as they may be in certain
cases. Most of the drugs which are supposed to be effective in their
power of solution of gallstones or of facilitating their escape are
disappointing, and at best are vague and uncertain in their action.
The hydrotherapeutic treatment, such as carried out, for instance, at
Carlsbad, will do good in many cases, especially for those who have
been indulgent in their appetites and careless in their habits. Cases
of any description not too far advanced would be benefited by a careful
regimen of this character, but that Carlsbad or any other waters
will certainly cure cholelithiasis is now absolutely disproved. As a
preparation for operation a sojourn at some such place may be advised;
as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.)
often temporarily relieve the pain of biliary colic.

In general, then, it may be said that cases which give a history of
recurring attacks of biliary colic, with or without recurrent jaundice,
and with those varied concomitant symptoms which are usually grouped
under the term “indigestion,” in which there is definite tenderness
over the region of the gall-bladder, with or without muscle spasm,
and with the other referred pains so often present in this condition,
should be regarded as legitimately surgical, where operation is more
than justifiable and usually decidedly advisable, even too often
imperative. The same is true of those cases of distended gall-bladder
with obstruction of the duct where perhaps no calculi are present, but
where the patient suffers in much the same way as though they were
present. _Biliary drainage is equally called for, and the presence or
absence of calculi is but a minor feature_ upon which too much stress
should not be laid nor too much disappointment expressed if they be not
found.

Many cases of chronic cholelithiasis have become more or less toxemic,
as well as cholemic. It is a well-recognized fact that cholemic
patients are more likely to cause inconvenience to the surgeon from
free hemorrhage or persistent oozing, because of the slowness with
which coagulation of their blood takes place. When time is afforded for
preparation it is of great value in these cases to administer calcium
chloride, of which several doses may be given each day, in considerable
water, the former varying in amount from 1 to 2 Gm. When time suffices,
too, it is always of value to prepare these patients for the operation
by measures already discussed, improving their elimination, reducing
the degree of their toxemia, and fortifying their circulatory systems
by well-known measures. The value of such preparation is perhaps more
apparent in such instances than in most others. On the other hand, many
cases calling for operation are almost as imperative as those of acute
appendicitis, where every hour’s delay is to the disadvantage of the
individual. The operations which are practised upon the biliary tract
will all be discussed together in a section by themselves.


TUMORS OF THE GALL-BLADDER.

This expression refers rather to actual neoplasms of the gall-bladder
itself than to distention of the sac by which an intra-abdominal tumor
may be formed. The latter subject may be dismissed with the mere
statement that the gall-bladder may become distended with bile, with
mucus, with pus, with concretions, or with the products of such disease
as echinococcus, actinomycosis, etc. In this way it may be so much
enlarged as to be easily felt through the abdominal walls or to be even
mistaken for other conditions. In the latter case it may have to be
differentiated between such a condition and a movable right kidney, a
tumor of the kidney itself or of its capsule, as well as from tumors of
the stomach, especially the pylorus, of the liver, or of the intestine
and from the enlargement of the right lobe which often accompanies
cholelithiasis, or from fecal impaction. It would be best to abstain
from the use of the aspirating needle in these cases, as more harm
might be done by the escape into the abdomen of deleterious fluid
than would be atoned for by the information which the procedure would
afford. Even when the abdomen is open the gall-bladder should rarely
be punctured in this manner, unless one is prepared at the same time
to open it and drain. In other words, there is less risk about a small
exploratory incision than in puncture.

Nearly all varieties of _malignant_ and many of _benign_ tumors have
been reported as occurring in this location. It will be sufficient in
this place, however, to say that _cancer_ of the gall-bladder, which,
of course, may extend in various directions, is by no means an uncommon
affection, and is _usually a complication of gallstones_. In fact, it
may be doubted whether primary cancer of the gall-bladder ever occurs
in the absence of such a source of irritation. These cancers vary in
type between the round-cell and the squamous, most of them, however,
being of the former character. Although Musser has put the percentage
at 65 and Zenker as high as 85 of instances where gallstones are found
within cancerous gall-bladders, it does not follow that the above
statement may not be true regarding their almost universal association
and causal relation, for any gall-bladder found empty at a given
time may at some other time have contained a calculus. This frequent
association is justly among the valid arguments which surgeons may now
use in making a plea for earlier operation, and for making it a more
standard procedure.

_Cancer_ may be suspected in cases of progressive and unintermittent
jaundice, especially when there can be felt in the region of the
gall-bladder a distinct tumor or an enlargement of the liver. Pain
is a frequent but by no means a constant or reliable symptom. As the
disease spreads the adjoining textures will become matted together, and
a low grade of local peritonitis may still further cement them into a
mass which will occupy a considerable portion of the upper part of the
abdomen.

But few cancers of the gall-bladder which are so apparent as to be
recognized without exploration can be considered as still amenable to
surgery, which for them can hold out but little prospect save perhaps a
temporary relief by biliary drainage. It is the cases in their earlier
stages, when the condition is made out by exploration, and by it alone,
which still afford prospects of more or less permanent relief. The
very impossibility of detecting the condition in these earlier stages
without exploration affords one of the strongest arguments for such a
procedure in every vague case of the kind. That cases of this character
are not necessarily hopeless is instanced by an experience of my own,
where on opening the abdomen of a large and fleshy woman I found a
distinctly cancerous gall-bladder containing two large calculi, and
removed the entire mass, with a considerable portion of the surrounding
hepatic tissue, the removal being effected with the actual cautery.
At present date of writing, nearly six years after the operation, the
patient is apparently perfectly well and doing her own housework.


OPERATIONS UPON THE GALL-BLADDER AND BILIARY PASSAGES.

The small area included under the above title has been made the field
for a variety of operations, dignified with formidable names, the
entire list of which might be made quite long. In order to simplify
their arrangement and illustrate their purposes they may be referred
to as (1) operations upon the _gall-bladder proper_; (2) those _upon
the ducts_; and (3) the more complicated operations upon one or
both of these in connection with some other part of the intestinal
tract; or, to catalogue them somewhat definitely, the operations upon
the gall-bladder include _cholecystotomy_, _cholecystostomy_, and
_cholecystectomy_, according as the surgeon opens the gall-bladder
and closes it, makes a more or less permanent opening, or completely
removes it. Again, upon the _ducts_ he may make _cholangiotomy_ or
_cholangiostomy_, or, using their practically equivalent synonyms,
_choledochotomy_ or _choledochostomy_, these terms referring to
operations upon the cystic and the common ducts; while when similar
procedures are applied to the hepatic duct they have been spoken of
as _hepaticotomy_ and _hepaticostomy_. _Cholecystenterostomy_ refers
to an anastomosis between the gall-bladder and the upper bowel, while
when this is effected between the common duct and the bowel it is
referred to as _choledochenterostomy_. When a stone lies partly in the
common duct and partly within the wall of the duodenum, and it becomes
necessary to incise the latter, it may be spoken of as _duodenotomy_.
The operation of merely crushing biliary calculi, hoping that the
fragments will be passed on with the flow of bile, and spoken of as
_cholelithotrity_, is now almost abandoned, and the term has historical
rather than present value.

To even attempt to epitomize directions for these various operations
into space available here would be impossible, for large volumes have
been devoted to this subject alone. The main thing for the student
and the junior practitioner is to appreciate the indications for
their performance, at which he should certainly have assisted before
attempting to perform them himself. General directions, however, may
be given as follows, the usual preparations having been made both
of the patient and the environment: A woman who has borne children
and who has, in consequence, relaxed abdominal walls, makes a more
favorable subject for operation than a muscular man whose abdominal
muscles cannot be relaxed until a profound degree of anesthesia has
been obtained. In many instances exposure is made better by placing
a sandbag behind the region of the liver, especially on the side to
be operated, by which the costal angle is more outlined and the parts
pushed forward.

A preliminary incision should be made of, say, three inches in
length, and is best placed a little to the inner side of the outer
border of the rectus, whose fibers are separated and its tendinous
intersection divided. This incision may be extended upward and curved
toward the middle line, as recommended by Bevan, or downward, as the
exigencies of the case may require. The beginner especially should
provide himself with sufficient space for manipulation. The posterior
sheath of the rectus and the peritoneum are best divided together.
Sufficient opening being thus made, a finger may be inserted for the
purpose of exploration. In the presence of adhesions, and especially
in acute cases in which pus is likely to be present, this should be
done with great caution. When no adhesions are present gauze pads may
be inserted and so disposed as to permit exposure to view of the lower
surfaces of the liver. The operator should be prepared for any and all
conditions--one of dense adhesions or their complete absence, as well
as for cobweb-like adhesions which surround foci of infected exudate
or of pus. The more reason he may have for suspecting the presence of
pus the more carefully should the region be walled off with protective
gauze. Adhesions are most likely to form between the omentum and
the colon, in front and below, and with the stomach, duodenum, and
colon below and behind. Those who have had experience with abdominal
operations will appreciate whether these adhesions are recent and
likely to cover purulent foci, or old, and will proceed accordingly.
Occasionally tissues will be so matted that even an experienced
operator will scarcely be able to differentiate them.

The endeavor should be, if possible, to expose the gall-bladder itself,
both to touch and sight, in order that after orientation concerning its
actual condition its duct may be followed into the common duct, and
this into the intestine. This is sometimes an exceedingly easy matter,
and again impossible. The presence or absence of pus will of itself
indicate what should be done. When, for instance, the gall-bladder is
found black or partly gangrenous the surgeon will content himself
with doing the least possible amount of separating, endeavoring rather
to provide the widest outlet for drainage. It might be better to make
simply a small opening and permit the escape of fetid débris, and to
postpone until a later day further attempt to remove the calculus,
which presumably has produced the difficulty. Local indications, then,
should be considered along with the general condition of the patient.

The lower surface of the liver will afford the guide to the location
of the gall-bladder, and when the latter is nearly obliterated its
discovery sometimes taxes the resources of the surgeon. When not
contracted it is usually easily exposed, and so far freed that it
may be even drawn up into the wound. After having thus isolated and
perhaps secured it, it must be decided by further exploration how it
shall be treated. It is of great importance to liberate the ducts from
surrounding adhesions.


=Cholecystotomy.=--Cholecystotomy, sometimes fallaciously spoken of
as ideal, consists in simply opening the gall-bladder, emptying it of
calculi or other contents through a small incision, and closing this by
sutures. The operation is ideal in but one way, but conditions which
permit it rarely justify it, for any gall-bladder so diseased as to
call for operation needs either removal or drainage.


=Cholecystostomy.=--Cholecystostomy includes provision for drainage
over a considerable length of time. A distended gall-bladder which
permits of easy manipulation and isolation may be sufficiently long and
large to justify uniting its surface to the peritoneum and deep margins
of the wound, in such a way as to permit discharge of its contents
through the latter. The old method was to unite it to the skin. This
should never be done, as fistulas thus resulting are more likely to
be permanent. If the gall-bladder be thus affixed to the parietal
peritoneum the better way is to insert a drain, its arrangement being
left somewhat to the choice of the operator. For my own part I prefer
a rubber tube, not too flexible, inserted two or three inches into
the gall-bladder, through a small opening closed around it, with
invaginated edges, by a purse-string suture of chromic gut, by which it
is intended to prevent leakage into the abdominal cavity. By another
suture of common gut the tube may be so fixed as to avoid danger of
being lost in either direction. If the gall-bladder be sufficiently
long to permit additional fixation to the depths of the abdominal wound
the operation is made still more ideal; but in the case of a short and
contracted cavity the tube may be left to follow it into the abdominal
recesses. Within forty-eight hours the exudate which has been thrown
out around it will have become sufficiently organized and well ordered
to form a canal in which the tube shall rest, and which shall serve
later as a conduit to conduct bile to the surface after removal of the
tube itself. Into such a tube, after the application of the dressings,
may be conducted another more flexible tube, whose upper end shall
connect with a receptacle of some kind, which may later be a bottle
held within the dressing, to receive the discharge, and thus avoid
soiling.

This operation has been done occasionally in two sittings, the
gall-bladder being brought into the upper part of the wound and
fastened to the peritoneum by sutures, which should not perforate its
walls, as that leakage would occur which the method is intended to
avoid. After waiting a day or two for adhesions to form the cavity is
then opened with a knife or scissors and drainage thus accomplished.
This method has been practically abandoned, for the reason that it
permits no digital exploration by combined manipulation.


=Cholecystectomy.=--Cholecystectomy includes the removal of the whole
or the greater part of the gall-bladder. It has already been stated
that this is a _reservoir_, convenient and advantageous, but not needed
in a way, and not essential to life. It figures as a superfluous
organ, then, similar to the appendix, and there is no reason why, when
diseased and troublesome, it should not be _extirpated_. Its removal
will sometimes be a matter of choice, and at other times a necessity.
The former is the case when the surrounding conditions lend themselves
to its dissection from the lower surface of the liver without too
much violence to other tissues; the latter when it is involved in
malignant processes or when its interior is seriously infected. An
incomplete method of treating the gall-bladder under the latter
circumstances might include the _scraping or removal of its thickened
mucosa_, without removing the entire thickness of its structure. In
this case, however, drainage would be required. That the gall-bladder
may be completely separated and thus isolated, with comfort and
speed, requires that its wall be sufficiently strong to stand the
ordinary manipulation. This may not be true of the perfectly normal
gall-bladder, but in such case no one would think of removing it,
whereas the cyst, which is diseased sufficiently to justify removal,
will usually permit of the necessary manipulation. Even if somewhat
torn in the process the procedure may be effected without much added
difficulty. This procedure consists essentially in separation of the
overlying peritoneum and enucleation of the gall-bladder from its bed
or the depression in the liver in which it lies, which, as already
indicated, may be narrow or wide and deep. Actual separation from liver
tissue will be followed by oozing and at least two or three vessels
in the surrounding structures and at the neck of the gall-bladder
will require to be secured. Removal should not be attempted in cases
which do not permit of it, but may be practised in those cases not
too infected, when after emptying the sac (full of calculi, for
instance) it can still be established with the probe that the common
duct is patulous. These are ideal cases for such complete work. The
gall-bladder having thus been isolated down to its cystic termination,
the surgeon proceeds much as though it were the appendix, by firmly
ligating the duct with chromic gut, guarding against escape of contents
while it is divided on the distal side of the ligature thus applied.
The stump of the duct is then cauterized with pure carbolic, after
which oozing is checked by tamponing for a few moments. It then is
often possible to bring together the peritoneum beneath the torn liver
surface and almost completely cover it anew. The liver tissue will bear
a ligature or suture not too tightly drawn. If the case have been one
otherwise surgically clean, and the operation properly conducted, the
abdominal wound may be closed without drainage. If, however, doubt be
felt a small cigarette or a tubular drain may be placed, to be left
not more than thirty-six hours. Every infected gall-bladder, if not
removed, should be thoroughly cleansed, its interior being mopped with
gauze, preferably with the addition of hydrogen dioxide. An important
step, next to attention to the gall-bladder proper, is to demonstrate
the patency of the ducts. This is done by gently passing a probe,
which should be bent to suit the case, along the duct and into the
intestine. This, of course, cannot be done if calculi are discovered
by manipulation, neither can it always be done when calculi are not
present. Gallstones in the duct can usually be distinguished by the
fingers with which the exploration is made, and failure to thus pass
a probe may be brought about by stricture rather than by calculous
obstruction. The importance of this determination will be seen in
removing the gall-bladder, as to remove it in an obstructed case is to
leave no outlet for bile except into the abdominal cavity, whereas to
fail to drain such a case is to plainly neglect to meet the indication.

[Illustration: FIG. 628

General scheme of cholecystectomy; detachment of gall-bladder and duct
from their investments; ligation of cystic duct and arteries. (After
Kehr.)]


=Cholecystendysis.=--The term cholecystendysis, now almost obsolete,
implies practically a cholecystotomy with drainage, the gall-bladder
having been opened for the purpose of removal of one stone or more and
then united to the abdominal wound.

Of the _operations upon the ducts_ there is something to be said
in addition to the directions already given. Inasmuch as they lie
more deeply they are more difficult of access, and variously shaped
retractors, with walling off the cavity with gauze, are more often
required, while in proportion as deep adhesions have enwrapped the
structures they are made more difficult of exposure. At present
surgeons have less hesitation in leaving duct incisions unclosed than
was formerly felt. It was formerly held that every incision into
a duct should be closed with sutures. It has been later found that
satisfactory results ensue when the end of the drainage tube is left
resting, or even fastened, within the duct opening, the operation being
thus made shorter and simpler and the difficulties of deep suture thus
obviated. As elsewhere noted the common duct may become enormously
_dilated_, and may be almost mistaken for the small intestine. The
passage-way between this duct and the gall-bladder may be so obstructed
that double drainage will be of advantage, or this may be a case where
partial removal of the gall-bladder may be effected, with drainage
of the common duct. Such cases should be judged upon their merits.
The more infectious the existing condition the more is free drainage
demanded. When a stone is impacted in the ampulla of Vater there should
be no hesitation in dividing the walls of the duodenum in order to
extract it. In such a case the duodenum is sutured, but the duct or the
gall-bladder must be drained (Fig. 629).

These deep operations require free incision, several inches in length,
and it will astonish the beginner to see how the liver may be delivered
from the abdominal cavity through such an opening. Much assistance
will here be gained by a large pillow or sandbag placed beneath the
back. Bleeding vessels need to be secured, at least temporarily, with
forceps, and usually with sutures or ligatures _en masse_. The exposed
or torn surfaces of the liver will ooze freely at first, but bleeding
usually ceases with the pressure of a gauze tampon. From the uninflamed
gall-bladder the peritoneum is usually easily separated, with but
trifling hemorrhage. For deep work traction on the middle portion of
the duodenum makes more prominent the junction of this part of the
bowel with the gastrohepatic omentum, at which point the peritoneum may
be incised and separated along the free border of the duodenum until
this portion is free from external peritoneal covering. There will be
exposed here the second portion of the common duct where it lies upon
the pancreas, it being more or less embedded in the latter further
along. When it is necessary to cut away more tissue it is better to
sacrifice a portion of pancreas rather than of duodenum itself. Blunt
dissection alone should be made here. When it is necessary to cut it
will be better to use the thermocautery.

[Illustration: FIG. 629

Removal of gallstone entangled at the papilla. Kocher’s method of
displacing the duodenum: _a_, incision in the paraduodenal peritoneum;
_b_, pancreas; _c_, location of the stone; _d_, duodenum; _e_, sutures
used either for retracting or closing opening in the common duct; _f_,
retroduodenal venous plexus. (Kehr.)]

These various cutting operations have superseded the previous methods
of endeavoring to crush stones within the duct and force the fragments
along by pressure. The Mayos have recommended the use of two fine
parallel sutures, introduced longitudinally into the duct, between
which the incision should be made, and which may be used as tractors,
or subsequently for purposes of closure.

Practically every gall-duct case should be drained with a tube
extending down to the deepest portion of the site of the operation.
This may be done with what has been called a “dressed tube,” made
by surrounding an ordinary rubber drain with a few layers of gauze
and covering this with oiled silk. The lower end of the tube is then
bevelled or trimmed in fish-tail fashion. This may be passed into the
depths, or it may be used for gall-bladder drainage as well.

Of the _anastomotic operations_ there is less heard now than a few
years ago. There are now considered to be but a few conditions which
are not better dealt with by biliary drainage as made above than by any
other method. Occasionally, as, for instance, when the common duct is
strictured or involved in pancreatitis or cancerous deposit, and bile
is backing up into the gall-bladder, it may be of great advantage to
effect an anastomosis between the latter and the bowel. At one time
the colon was used for the purpose, but this prevented the utilization
of the bile in the upper bowel, where it is most needed. Consequently
it should always be made into the upper portion of the bowel, the
duodenum, or one of the upper loops of the jejunum. For this purpose a
small Murphy button is probably still the speediest and best expedient.
This is true also when it seems necessary to drain the common duct
into the bowel, since the field of operation in most cases lies too
deeply to permit of accurate and satisfactory suturing. A further and
more difficult as well as later application of this principle has been
suggested for certain cases of permanent obstruction of the common
and main hepatic ducts. Under these circumstances the operation last
mentioned would be useless and a cholangiostomy would be objectionable,
as it would constitute a permanent fistula. As practised by Kehr and
others this _hepato-cholango-enterostomy_ is performed by removing from
the lower surface of the liver a strip of its tissue about 7 Cm. long
and 2.5 Cm. wide. The hemorrhage is checked with the thermocautery, and
with it an opening is made into the liver, of such a depth that several
of the bile ducts are thus divided and opened. The uppermost loop of
bowel which then can be utilized without tension is opened and sutured
to the margins of liver wound. The method is still on trial, and yet
in at least one successful case it was shown that the liver tissue
tolerated this unavoidable contact with the contents of the upper
abdomen (Fig. 630).

[Illustration: FIG. 630

Demonstrating the technique of anastomosis between the gall-bladder and
the jejunum. (Cordier.)]


=After-management.=--What to do with these cases of biliary drainage
after it has been effected is sometimes a serious problem. No
hard-and-fast rules can be laid down regarding the length of time
during which drainage should be maintained. In instances where the
gall-bladder has been removed the drain should be taken out within
thirty-six hours, but in those cases where a tube has been fastened
into the gall-bladder for so-called permanent drainage the term
“permanent” may be regarded as elastic, and covering a period of from
ten days to perhaps ten weeks. In the majority of instances three weeks
or so of such drainage suffice to meet the original indication. In
cases, however, of chronic pancreatitis a long period of easy outflow
will be demanded, while in rare cases of cancer drainage once thus made
cannot be abandoned.

When the gall-bladder has not been fastened nor allowed to adhere to
the skin, but only to the peritoneum, the fistulas thus made will
usually close and rarely need stimulation. Should, however, the
granulation process by which closure is effected be too sluggish it
may be stimulated by the application of nitrate of silver, either in
solution upon a swab, or in solid form, as when melted into a bead upon
the end of a suitable probe. Firm pressure will also assist in final
closure.

It is not reasonable to expect that after so much intervention, within
the rudely triangular potential cavity occupied by the gall-bladder and
the ducts, adhesions will not form as a part of the reparative process.
In fact it may rather be expected that as it becomes obliterated
adhesion must necessarily follow. In consequence there may result an
agglutination around the gall tract, and into a common mass, of the
liver, the colon, and the pyloric end of the stomach. In spite of these
adhesions bad symptoms rarely ensue, and when discomfort persists it
is usually in those cases in which no stone was found or those in
which stones have been overlooked. Andrews regards such postoperative
adhesions as unavoidable and even desirable, and, having no faith
in any measures to prevent their formation, differs from Morris in
regard to the technique of their subsequent removal. It appearing from
observation and experience that the stomach is the organ which suffers
most by extensive adhesion to the liver, he has proposed to substitute
the colon for the stomach in this necessary union of surfaces, and
would even practise it in old cases after separation of old adhesions.

The operation suggested by Andrews, and which he calls
_cholehepatopexy_, or _colon substitution_, is made with an incision
through the middle line of the right rectus, avoiding any old scar,
long enough to afford plenty of room. The stomach is then carefully
separated from the liver, tearing liver tissue rather than that of
the former, if something must be torn, and checking bleeding by hot
sponges. The pylorus having been exposed the stomach is invaginated
into it in order to demonstrate its patency. The freshly separated
viscera will now fall again into immediate contact unless the
transverse colon be pulled up and held in place between the liver and
the pylorus, this not being so much of a displacement as would appear,
as the bowel is not rotated and does not cross over the stomach.
The colon is held in its new relation by attaching its omentum to
the gastrohepatic ligament, to the liver surface, or to remnants of
old adhesions in the angle between the pylorus and the liver. The
looser the omentum and the more easily it can be interposed in this
way the better. Andrews’ conclusions are that gall-tract adhesions
are unavoidable, both in disease and after operation, that they are
harmless except in a very few cases, and often beneficial, and that in
the few cases where they do harm this comes from malposition rather
than from adhesions _per se_. He even believes that certain vague
gastric adhesions which might have been benefited by this operation
have been previously treated by gastro-enterostomy.




CHAPTER LIII.

THE OMENTUM, THE MESENTERY, THE SPLEEN, THE PANCREAS.


THE OMENTUM.

The omentum is something more than what it generally appears, _i. e._,
a more or less thick and extensive apron of fat, hanging down in front
of the small intestines, although in this respect alone it serves as
a sort of reservoir or storehouse for fat, which is always drawn upon
as the needs of the system may require. The omentum varies within
wide limits from being the flimsiest veil of peritoneum, whose four
original layers have become so blended as to be lost to recognition,
and which may even be perforated in places with openings through which
strangulation of the bowel is possible, to the thickest and grossest
mass of fat found in the human body, resembling a coarse mat rather
than any finer texture, and having a thickness, in obese individuals,
of two to four inches. Under these circumstances it makes a formidable
obstacle to nearly all abdominal operations. The thickness of the
omentum sustains usually a pretty constant proportion to the amount
of adipose between the skin and the abdominal muscles. In certain
enormously fat individuals one has then to go through from four to
six inches of tissue, mostly adipose, before reaching the rest of the
abdominal contents. This necessitates a longer incision and is always
a disadvantage and impediment. To the operating surgeon, then, the
omentum sometimes appears a nuisance.

It does not deserve, however, to be so regarded, and when properly
viewed the omentum will frequently appear in the role of the surgeon’s
as well as the patient’s best friend. This is due to its power of
shifting itself, and, as it were, enclosing actively dangerous foci
due to any variety of infection, the natural intent being, as it
were, to wrap itself around and thus completely imprison the source
of the trouble, a fact which is often actually accomplished, and by
which life-saving protection is frequently afforded. This is true of
the omentum whether thick or thin. By virtue of the adhesions which
often annoy the surgeon, and which necessitate separation and perhaps
considerable work before the actual trouble is exposed, a protective
barrier is formed and the greater portion of the abdominal cavity shut
off from danger of spreading infection. Moreover, that the omentum has
a really valuable purpose appears from the fact that its removal from
young animals seems to cause retardation of development, and from adult
animals a diminution of resistance to the action of poisons introduced
into the peritoneum. It is the omentum which, to a large extent,
absorbs foreign corpuscles, such as those from extravasated blood.
It helps, moreover, to dissolve blood clots and to facilitate their
disappearance, and after the removal of the spleen it would appear to
vicariously perform at least some of its duties. Thus when the complete
blood supply of the spleen is cut off the organ almost completely
disappears as the result of its absorption by the omentum. (This at
least in experimental animals.)

The omentum serves further useful purpose by plugging various openings
and wounds in the abdominal walls, and thus affording at least a
temporary protection, just as the mucosa sometimes acts in reference to
the stomach. Moreover, it is so vascular, so flexible, and so available
that it may be used for plastic purposes in covering weak spots, lines
of sutures, and the like, in the small intestine or even elsewhere.
These same physical qualities make it extremely prone to escape through
the natural outlets. Hence the frequency of epiplocele or omental
hernia (_q. v._). By a species of such hernial protrusion it has saved
many a life after bursting open or re-opening of recent abdominal
wounds. Sometimes it will escape after removal of a gauze drain which
has not been judiciously placed and protected, this accident then
constituting one variety of postoperative or traumatic hernia.

By virtue of its adhesions, which at first are short and flat, but
which later become stretched into bands, _obstruction of the bowels_
may be produced, or by atrophic or absorptive processes openings
or windows may occur in it with the same result. When participating
in septic processes it becomes infiltrated, is often covered to a
large extent with breaking-down lymph, and may become gangrenous.
All portions thus compromised are best tied off and removed when
exposed during operation. Nevertheless the omentum should be gently
handled, because its venous walls are thin and liable to rupture, and
its bleeding points should be carefully secured, especially after
separation of adhesions.


INJURIES TO THE OMENTUM.

By contusions, lacerations, and punctures various injuries to the
omentum may be inflicted, naturally more commonly when it is the
anterior abdominal wall which has sustained the traumatism. As result
of lacerations, hemorrhages or strangulations may occur. The immediate
danger is, then, from hemorrhage. Indications of such lesions of the
omentum are not specific, but grave symptoms after any abdominal injury
require exploration, and that minute punctures or lacerations should be
repaired, while other injuries should be treated according to obvious
indications.


TORSION OF THE GREAT OMENTUM.

Torsion of the great omentum was first described by Oberst, in 1882,
as a condition found in the sac of a large irreducible hernia. As a
distinct and serious condition it has been reported in about sixty
instances. The condition occurs within the abdomen as simple torsion,
also within hernial sacs, or in both, where the torsion is not limited
to the sac, but extends upward into the abdomen. It is more frequent in
males, and its onset is usually sudden. Of all its symptoms pain is the
most constant and the earliest. This is usually acute and persistent,
and in a large proportion of cases is referred to the right iliac
fossa. Vomiting is not constant; bowel conditions are not significant.
Absolute obstruction is usually rarely noted. In most of the recorded
cases some tumor can be felt on examination, which is hard, tender,
dull to light percussion, and irregular in shape. Meteorism is not
common. Death has occurred in about 15 per cent. of known cases.
Diagnosis previous to exploration can be inferential only, but such
symptoms as above noted should lead to exploratory laparotomy.


TUMORS OF THE OMENTUM.

The most common of the omental tumors are _cysts of inflammatory
origin_, such as may, for instance, be formed by inclusion between
surrounding adhesions or by previous hemorrhage; _lymph cysts_, often
large and multiple, and sometimes of congenital but often of lymphatic
origin, are also occasionally seen. The so-called _omental dermoids_
are usually ovarian products. _Hydatid cysts_ have been found in the
omentum, but only as secondary products. _Omental cysts_ are difficult
or almost impossible of diagnosis previous to operation, which latter
should always be performed, and without previous aspiration, as the
presence alone of any such tumor requires removal. If large they are
most likely to be confused with ovarian cysts. Those which may prove
not to be removable should be drained, after being fastened to the
abdominal wall--that is, marsupialized. _Angioma_ in the omentum is
rare, but has been recorded by Homans and others. _Fatty_ or other
benign tumors are also rare. Primary _sarcoma_ is rarely seen here,
but most of the sarcomas, and all of the carcinomas which never arise
here primarily, but are often seen, are either metastases or direct
extensions. In these forms cancer of the omentum is common.

With extensive involvement of the omentum radical operations in these
cases are seldom advisable. A circumscribed involvement may, however,
be removed, while such operations as anastomoses, enterostomies, and
the like are often necessitated.

Omental tumors are difficult of diagnosis, although they are usually
superficial and overlie the intestines. They are not affected by
respiration. They move laterally and upward, but not downward. If
confined to the omentum proper they cause no functional but only
mechanical disturbances. Obviously in the presence of extensive
adhesions every distinctive feature may be confused.


OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR MORRISON’S OPERATION.

The effect of stasis in the portal circulation is to produce outpour
of varying amounts of serous fluid into the pleural cavity. This
condition, long known as ascites (dropsy), is the most distressing
terminal feature of such diseases as cirrhosis of the liver, cancer,
and the like. The osmotic direction of fluid seems to be reversed, and
transudation tends to go on until intra-abdominal pressure equals that
within the vessels. Absorption is always impeded and finally prevented.
Reflecting on the biophysics of this condition Talma and Morrison,
independently, and at about the same time, suggested an expedient by
which a portion at least of this fluid might be brought back into the
general venous circulation. The plan was to attach the epiploön (the
omentum) to the peritoneum of the anterior abdominal wall in such a way
and over such an area that, by virtue of the adhesions thus produced
and the new vascular anastomosis thus established, a new line of
vascular connections should be formed, so that fluid not returnable to
the vena cava by the usual route should be given a new and artificial
direction. To this fundamental proposition much detail has been added.

Thus Schiassi has shown that, so far as the supply of toxins which
shall pass through the liver is concerned, there are really two portal
veins--the superior mesenteric and the splenic--or he would call what
we usually name the portal system the _splenoportal_. Consequently he
would include the spleen in the above mechanical procedure, especially
in those cases where it participates in the morbid process--_e. g._,
in the hepatosplenic or pre-ascitic form of Banti’s disease, and the
splenomegalic cirrhosis described by Gilbert. In 1904 this problem
was studied from its surgical aspects by Monprofit (French Congress
of Surgeons), who collected 224 operated cases. Of these 84 died, 129
recovered from the operation, and 11 could not be traced. In 25 cases
relapse occurred, in 26 there was improvement, while in 70 there was
claimed complete recovery.[64] In other words about one-third of the
cases thus reported have recovered. He insists, as would every other
surgeon, that with this showing the results would be far better were
cases seen and operated earlier. His statistics are not widely variant
from those of Zesas, who found that out of 254 cases which he collected
67 recovered and 82 died, while 42 were greatly improved.

  [64] It is but fair to add that, at the same time, Delagenière
  maintained that since, in his opinion, cirrhotic processes in
  the liver are due to intestinal infection, the treatment should
  consist of combating this and its possible consequences, to which
  end he would make a temporary cholecystostomy, having found it of
  benefit even in the atrophic, but mostly in the hypertrophic, forms
  of disease. Thus in two cases of this procedure, combined with
  hepatopexy, the patients survived eight and two years respectively.
  Nevertheless he acknowledged that the best results would probably
  be secured from combination of cholecystostomy, hepatopexy, and
  omentopexy.

In brief, we may hold, with Rolleston and Turner, that it is no longer
advisable to treat ascites by repeated tappings, when the patient is
otherwise in fairly good general condition, for numerous surgeons
have warned against repeated punctures. When liver cirrhosis can be
diagnosticated with fair certainty in the pre-ascitic stage, and when
there is evidence of splenic enlargement or hematemesis, operative
intervention would probably succeed far better than in the later
stages. So far as special indications for operation are concerned they
may perhaps be listed as follows:

  1. Thrombosis of the portal vein or its compression by inflammatory
  products or by tumor;

  2. Cirrhosis of cardiac origin, of the ordinary hypertrophic or even
  atrophic types, as well as that due to syphilis or malarial disease;

  3. Pseudoliver cirrhosis of pericardial origin;

  4. Diabetes of hepatic origin;

  5. Splenomegaly combined with hepatic cirrhosis.

_If these indications be met by reasonably early omental fixation
there would seem to be a well-marked place for the procedure_, while
they cannot give rise to any worse results than the repeated puncture
methods of old.

Among contra-indications to such operations may be mentioned the
presence of much biliary pigment in the urine, its absence from the
feces, jaundice, or marked pigmentation of the skin, while distinct
renal insufficiency would also make any surgical procedure hazardous.

The _operation_ itself, done according to the simpler and earlier
recommendations of Morrison and Talma, consists in median abdominal
section, withdrawal of all ascitic fluid, and the deliberate
provocation of adhesions between the diaphragm and the upper surfaces
of the liver and the spleen. This is produced by vigorous swabbing to a
degree sufficient to cause a little oozing from the surfaces attacked.
The margin of the liver may then be fastened to the costal border.
After this the anterior surface of the omentum is also scarified or
swabbed and affixed to the anterior abdominal wall, which has been
similarly treated over as large an area as possible, by means of catgut
sutures placed to the best possible advantage for the purpose. Some
operators have preferred to close the abdomen without drainage, some to
insert a tube in the lower margin of the wound for a day or two, and
others to drain the lower abdominal cavity through a small, distinct
opening above the pubes. Theoretically much advantage attaches to
permitting no immediate re-accumulation of fluid. Practically, however,
danger also attaches to it, _i. e._, from the difficulty of so managing
the dressings as to avoid infection.

Schiassi has modified the above procedure and has made an
_omentosplenopexy_ of it as follows: He makes a right-angled incision
across the median line and then another several inches downward along
the left semilunar. The tissues down to the peritoneum are reflected
toward the umbilicus, and a transverse deep opening is made just
below the horizontal skin incision. Through this the omentum is drawn
upward and spread over the right portion of the exposed peritoneum,
where it is sutured in place. Through another vertical opening in
the peritoneum, near the vertical skin incision, the spleen is then
exposed, a piece of gauze is placed under each pole of that organ, and,
while thus lifted, by means of a long curved needle three to six catgut
sutures are passed through it, including also the peritoneum and all
the superficial structures except the skin, this being closed later and
separately.

Finally, whatever operative method be selected it is important that it
be done _early rather than late_, bearing in mind that “the resources
of surgery are rarely successful when practised on the dying.”


THE MESENTERY.

No one has done more to forcibly place before the surgical profession
those anatomical features of the mesentery which most concern them
than Monks, who, for instance, has demonstrated the fact that the
mesentery is practically an enormous fan, composed of two layers of
peritoneum, between which are spread out the vascular structures and
more or less fat, and whose border contains the intestinal tube. This
fan at its base is but a few (six) inches in length, while along its
outer border, when completely unfolded, one may measure a distance of
twenty-one to twenty-three feet. Not one of the structures contained
between its layers can be regarded as a negligible quantity. The
arterial distribution in the mesentery is _terminal_ in the same sense
that it is in the brain. Consequently dependence can be placed only
on a sufficient blood supply for any given portion of the intestinal
tube when its mesentery is intact. If necessary to sacrifice a portion
of the mesentery it is requisite to resect that portion of the bowel
which is dependent upon it for blood. This will explain the reason why
thrombosis or embolism of the mesenteric vessels so quickly determines
the death of that portion of bowel supplied by the occluded branches,
this being equally true of the tiny fragment known as the appendix or
of the entire bowel.

The root of the mesentery is placed obliquely across the spinal
column, arising from the left side above and crossing obliquely to the
right side below. Monks has shown how easily we may make practical
application of this fact in determining approximately to what part of
the bowel tube a given loop may belong, since it is necessary only to
follow it down to the mesenteric insertion, and from this estimate what
proportion of the entire distance is represented.


INJURIES OF THE MESENTERY.

Obviously the mesentery may be injured in the same way as any other of
the abdominal viscera, either by contusions, lacerations, punctures, or
otherwise. Here the immediate danger is from hemorrhage, while a more
remote but quite possible danger is that of _thrombosis_ of some of the
vessels and its consequences in the direction of _necrosis_.

Erdmann has recently reported two cases of complete detachment, for
several inches, of the mesentery at the intestinal border, as well as
a case of multiple lacerations in the peritoneal coat of the mesentery
with hematoma. While the latter might not be so serious, the former
will almost invariably determine gangrene of bowel from lack of blood
supply; all of which shows the difficulty of diagnosis, and furnishes a
further argument for intervention when, after an abdominal contusion,
the patient has abdominal rigidity or pain, with or without evidences
of hemorrhage, either from the stomach, rectum, or bladder. These
features are sufficient without the addition of those by which a more
certain or minute diagnosis can be made.


THROMBOSIS AND EMBOLISM IN THE MESENTERIC VESSELS.

Mesenteric occlusion was first described by Virchow in 1859. Whether it
involves first the arterial or the venous circulation seems to matter
but little. Of course in one case it is to be regarded as embolic, in
the other as thrombotic. In this location either condition is harder
to explain than in many other places. The mesenteric veins have no
valves and collateral circulation is poor. Mitral stenosis and arterial
sclerosis will often account for the former. For thrombosis search
has to be made for some local infectious process, either in the veins
of the pelvis, the kidney, or the intestines. It seems to occur least
often when it might be most expected, _i. e._, after typhoid.

The blood supply may be simply shut off from portions supplied by one
of the mesenteric vascular branches, or, should the main branches be
involved, from the entire intestinal tract. I have myself reported two
cases of practically complete rapid gangrene of the entire alimentary
canal, due to lesion of this kind, explanation being forthcoming in
neither case.


=Symptoms and Signs.=--The more complete the occlusion and the more
extensive the area deprived of blood the more sudden and overwhelming
will be the onset. This is always sudden and characterized by intense
and often paroxysmal pain, so agonizing, in fact, as scarcely to be
quieted even by morphine. While this is common, instances have been
known in which the disease has run an almost painless course. Diarrhea
is frequently an early symptom, evacuations being profuse and bloody.
Symptoms of obstruction are not uncommon, perhaps followed later by
loose stools. Vomiting occurs usually early and becomes fatal in
a few hours. The general physical signs are intensely acute, with
rapid pulse, subnormal temperature, and meteorism, beginning early
and becoming more pronounced. Abdominal rigidity also constitutes
a distressing feature, which, while indicating the gravity of the
condition, masks its diagnostic features. If the patient live long
enough fluid will accumulate in the peritoneal cavity. The cases
terminate with complete collapse and delirium. When the inferior
mesenteric vessels are involved tenesmus is a more prominent
characteristic than when the lesion is confined to the upper, as the
colon and rectum are supplied from the former.

The surgeon may have to distinguish between the condition just
described and the following: Perforating ulcer of the stomach or
duodenum (which will have a previous history), possibly so-called
phlegmonous gastritis; acute obstruction of the bowel (whose onset is
rarely so acute); pancreatitis, which would, at least at first, produce
almost identical symptoms; acute splenic infarct (when the early
symptoms would probably be referred to the region of the spleen); acute
appendicitis; acute cholecystitis, and that acute peritonitis to which
either of these might lead; a ruptured ectopic pregnancy; and possibly
certain intrathoracic lesions, especially pneumonia in the lower lobes.
Mesenteric occlusion is essentially a fatal condition, at least when
extensive. There have been known cases where so limited an extent of
the bowel and mesentery were involved that an exsection, made early,
has proved successful, but when anything like the entire alimentary
canal or its major portion becomes necrotic there is no hope for the
patient.[65]

  [65] Annals of Surgery, April, 1904.


ABSCESS OF THE MESENTERY.

Abscess formation may take place within the mesenteric structures,
as an expression of acute septic infection or of a mixed infection
of old tuberculous foci in the nodes. A careful case history or some
peculiarity of local conditions may occasionally furnish a clue to
the conditions, otherwise it will not be distinctly revealed until
such operation as may be necessitated by unmistakable indications of
the presence of pus or by autopsy. Inasmuch as operation can scarcely
exaggerate the danger of the condition it would be best attempted when
such abscess is suspected. When the meso-appendix is involved, as is
often the case, the trouble may be so walled off that it is almost a
purely local affair.


TUBERCULOSIS OF THE MESENTERY.

Aside from the common miliary expressions of acute tuberculosis
which are seen so frequently dotted all over the bowel surfaces
and the expanse of the mesenteric folds, there is a peculiar form
of involvement of the mesenteric nodes, _i. e._, those which are
especially clustered along its root. These are always involved in
general tuberculous peritonitis, though but slowly in the absence of
such generalized features. To the slow forms of this condition the
early writers gave the name _tabes mesenterica_. The more limited
the involvement the greater interest the lesion has for the surgeon,
since it may be so limited to the nodes of a single coil as to justify
extirpation. In fact, if such a focus could be easily and thoroughly
removed without too much disturbance of circulation, tabes might be
remedied by surgery. Not very frequently, however, do the location
or the arrangement of a collection of tabetic nodes permit of their
enucleation. They are usually too numerous, too large, too degenerated,
too adherent, or the patient otherwise too extensively infected.

The acuter expressions of mesenteric tuberculosis may be considered
as already sufficiently discussed under the caption of Tuberculous
Peritonitis.

Occasionally a localized, slightly mobile tumor, especially in
the ileocecal region, may cause suspicion, or may be correctly
diagnosticated, by taking note of other symptoms, along with a good
case history. Especially is this the case in patients known to be
tuberculous. This is particularly true of the appendix and its
mesentery, where a tuberculous gumma may attain considerable size
before there is any active breakdown. The relation between this
condition and tuberculous ulceration within the bowel will also be
obvious. Moreover, it is of interest to recall that calcification of
mesenteric nodes is not impossible, and that occasionally chalky tumors
in this location may be thus explained.

There is also a possibility of involvement of the mesenteric nodes in
_constitutional syphilis_ and in _actinomycosis_.

The _treatment of mesenteric tuberculosis_ should consist of
exploration and orientation, followed by whatever procedure the
condition thus revealed may require--_e. g._, abdominal irrigation,
with or without antiseptics, extirpation, drainage, or even resection
of a portion of the bowel (appendix, cecum, etc.).


CANCER OF THE MESENTERY.

The other condition in which the mesenteric nodes are especially
involved is the cancerous. In this location, as in the omentum, sarcoma
may be primary and endothelioma may occur, but carcinoma is never
primary, although it invariably occurs as an extension from epithelioma
or adenocarcinoma of the bowel. Otherwise cancer will appear here as
an expression of metastasis. In all primary cancers of the intestine
early involvement of the mesenteric nodes may be looked for, while
involvement of everything in the vicinity, even the aorta or spine,
will occur in due time, often with more or less breaking down. There
would be little justification for attacking any cancerous portion of
the mesentery or any cancerous nodes unless the primary lesion could be
radically removed. Generally speaking, in bowel cancer invasion of the
deep-seated nodes imparts to the case such an unfavorable aspect as to
justify only palliative (anastomotic) rather than radical measures.


CYSTS OF THE MESENTERY.

Cysts of the mesentery are, in the main, similar to those met with
in the omentum (Fig. 631). A peculiar form of mesenteric cyst is
produced by obstruction and consequent dilatation of one or more of
the lacteals, and is known as _chyle cyst_. It may attain considerable
size and occur in multiple form. The contained fluid is naturally milky
and corresponds to that seen in chylous ascites and hydrocele. These
lesions are only recognized after exploration. When found they are to
be extirpated, on general principles, usually by enucleation, with
ligature of the connecting lacteals and avoidance of all unnecessary
disturbance of blood supply.

[Illustration: FIG. 631

Cyst of the mesentery, containing clear fluid. The hour-glass
constriction passes through the layers of the mesentery. (From a case
occurring in Richardson’s practice.)]


THE SPLEEN.

The spleen is often an object of surgical interest, not alone because
of the frequency with which it is enlarged in the course of the acute
surgical infections, but because it is something more than a reservoir
for blood. Thus it seems to enlarge to accommodate blood forced in from
the exterior under conditions of extreme exercise, etc., and in the
higher vertebrates it seems to be a place where blood corpuscles are
destroyed, especially those which are already disintegrating, rather
than one in which they are manufactured. It is claimed by Ehrlich that
the splenic enlargement of the infectious diseases is produced mainly
by the products of disintegrating leukocytes which are allowed to
accumulate.


ANOMALIES OF THE SPLEEN.

Of the _congenital anomalies_ or defects the surgeon is mainly
interested in the fact that _supernumerary spleens_ are common, being
found perhaps in one out of four bodies varying in number up to
thirty or forty, located near the hilus in the gastrosplenic omentum,
in the great omentum, or even in the pancreas. Doubtless after some
splenectomies no peculiar symptoms are produced, which is due to the
fact that some of the supernumerary organs have taken up the splenic
function. The spleen varies in shape to such an extent that the notch
upon which so much stress is often laid in diagnosis will not always
be found along the anterior border. In cases of transposition of the
viscera the spleen may be found on the right side. It has been found
in the sacs of large umbilical hernias and in the left thorax after
defects of the diaphragm.


INJURIES TO THE SPLEEN.

The spleen may be injured by itself or along with other viscera. The
most common injury is from contusion, which produces more or less
disintegration or rupture and hemorrhage. The organ is so friable
that it may literally burst under a comparatively slight force, other
conditions being favorable. Doubtless minor degrees of these injuries
pass unnoticed or are followed by some local peritonitis and adhesions.
On the other hand the spleen may be actually fragmented, with
necessarily fatal consequences unless promptly operated. _Rupture_ is
especially likely to occur after those infectious diseases which cause
its enlargement--_e. g._, typhoid.

In case of injury there is, in addition to the history, a prompt
location of pain in the region of the spleen, with signs of
intra-abdominal hemorrhage, but without blood in the urine; perhaps
with tumor or dulness on percussion, and always with abdominal
rigidity, all of which point to the serious nature of the injury and
_demand exploratory section_. Should this reveal a slight injury it
may be repaired with ligatures or sutures. More serious tears or
perforations are treated by gauze packing through a sufficiently open
wound, while the most serious cases of pulpifaction call for complete
_extirpation_. When the blood supply of the spleen is left in doubt its
total removal will be far the safer course to adopt. Obviously such an
operation should include examination of all the viscera and a careful
toilet of the peritoneum.


ABSCESS OF THE SPLEEN; SUPPURATIVE SPLENITIS.

Pus may form within the spleen in consequence of septic infarcts
or thrombosis, or it may be due to the extension of trouble from
adjoining foci, or to pyemic metastasis. Splenic abscesses are usually
localized, but the pyemic forms are always multiple, miliary at first,
but coalescing into larger collections, and practically destroying the
organ if the patient live long enough. The infectious fevers may be
followed by suppuration of the spleen, which is also known to occur
rarely in malaria.


=Symptoms.=--The symptoms of splenic abscess are indeterminate
until the capsule is involved and a perisplenitis--_i. e._, a
local peritonitis--results, after which pain becomes severe. These
collections occasionally discharge spontaneously into the colon or even
into the stomach.

On general principles any abscess which can be located, even somewhat
vaguely, should be attacked. After the abdomen is opened, preferably
through the left semilunar line, the exploring needle may be used,
especially if adhesions be present.


GANGRENE OF THE SPLEEN.

Gangrene of the spleen is the result of a still more rapid, otherwise
similarly septic or thrombotic process, or of severe injury, by which
circulation is practically cut off. It is a condition which rarely
permits of any surgical help, though if it could be foreseen it might
be prevented by an early splenectomy.


HYPERTROPHIES OF THE SPLEEN.

Enlargement of the spleen occurs during numerous acute and chronic
_infections_--_e. g._, typhoid, malaria--in connection with certain
affections of the _liver_; in consequence of interstitial or gummatous
forms of _syphilis_, with or without similar lesions in the liver;
in acute _peritoneal infections_; in general _septic_ and _pyemic_
disturbances; in _rickets_ and the _status lymphaticus_; in the various
forms of _leukemia_, _Hodgkin’s disease_, and _pseudoleukemia_,
and in that somewhat peculiar type known as Banti’s disease, or
_splenomegaly_. In fact the spleen enlarges under so many conditions
that its hypertrophy is an expression of a general infection rather
than of any pronounced or particular type of the same. Minor degrees of
enlargement have often passed unnoticed or given little or no trouble.
When seriously overgrown its principal features are its inconvenience,
weight, and size. The condition is recognized by its characteristic
shape and notch (See above.) By its extension upward it can be usually
distinguished from a tumor, of the kidney.

Every splenic enlargement, especially chronic, should lead to a
careful blood examination, by which, among other things, malaria may
be recognized or excluded, while the degree and form of leukemia, if
present, may be estimated. The lymph nodes throughout the body should
also be carefully examined. Splenomyelogenous leukemia, for example,
is progressive, severe, and marked by cachexia and anemia of peculiar
type. In many of these cases there is a tendency to hemorrhage, both
from surfaces and into the tissues. The hemoglobin is much reduced and
prognosis after any operation is unfavorable. (See chapters on the
Blood and the Lymphatic System.)

_Banti’s disease_, or _splenomegaly_, seems also a somewhat peculiar
type of lesion which is probably due to an infection proceeding from
the intestinal canal, and involving the liver in its later course. In
its last stage there is a tendency to hepatic cirrhosis, with ascites,
and hemorrhages in any part of the body are frequent.

_Removal of the spleen_ for any of these conditions is usually a
precarious procedure. It has been more successful when performed for
malarial hypertrophy than for other conditions, the patient’s chances
being then about three out of four; but here, too, the lesion is
usually amenable to other treatment. If done in the early stages of
Banti’s disease it would seem to be strongly indicated, but not in the
later stages, when the liver is involved and the abdomen full of fluid.
In the leukemias it has succeeded in a few instances. It is mostly
indicated in those cases where hemorrhages occur early.

The Röntgen rays have recently been shown to have an excellent effect
in many of these cases and are worthy of trial. Especially in the
leukemic forms, in connection with arsenic internally, they offer
probably the best prospects.


SPLENIC DISPLACEMENTS.

While, under ordinary circumstances, the supports of the spleen may
seem equal to ordinary needs they prove insufficient in many cases of
marked enlargement. Hence results _displacement_, or the so-called
“wandering spleen,” which may be due to the results of injury, to tight
lacing, possibly to congenital relaxation of ligaments, but mainly
to hypertrophy, with increase in size and weight. When the spleen
enlarges it descends toward the umbilicus, but it has even been found
in the pelvis. As it prolapses it brings down with it the stomach
and the pancreas, thus interfering with the circulation of all three
organs and producing a train of distressing secondary consequences.
A long-drawn-out splenic ligament may be much stretched and may even
become finally _twisted_, thus causing gangrene of the spleen from
torsion of its support. Moderate displacement and stretching produce
discomfort, pain, and disturbance of function. Such a displaced spleen
is to be recognized by its shape, size, and notch, and is occasionally
to be distinguished from a wandering kidney. When displaced its normal
location will not be dull upon percussion.


=Treatment.=--Palliative treatment, which may be tried first, calls for
whatever drugs may be needed to unload the bowels, but especially for
rest in bed and support by suitable abdominal binder, with or without
a pad. If the spleen itself be much enlarged it may also be subjected
with a judicious frequency to the _x_-rays.

_Operative help_, which is the only measure when other treatment fails,
should come either through a _splenopexy_ or _splenectomy_, preferably
the former, save in the presence of serious disease which may call for
its extirpation. Nevertheless splenopexy, which seems so simple and so
promising, is often unsatisfactory because of the friability of the
spleen itself and the weakness of its capsule. Here, as in hepatopexy,
the intent is to produce adhesions, by scarification of the external
peritoneal surroundings, which is made through a suitable incision,
directed usually along the left costal border; after thus intentionally
provoking adhesions, sutures may be used if there be any prospect of
their being serviceable.

[Illustration: PLATE LVI

Upper Abdominal Viscera, showing their Normal Relations. (Sobotta.)]


NEOPLASMS OF THE SPLEEN.

Splenic _cysts_ of the _serous_ or _blood type_ are seldom seen. Even
_hydatids_ here are uncommon. _Sarcoma_ of the spleen may be primary;
_carcinoma_ is due to extension or metastasis. In proportion as splenic
tumors develop they may be recognized as involving this particular
organ. While a careful blood examination may permit the exclusion of
certain conditions, exact early diagnosis will scarcely be made without
exploration, which is justifiable whenever the blood count would
indicate it. After exposing the lesion the surgeon is for the first
time in a position to judge whether to drain or extirpate a cyst, or
remove part or the whole of the spleen itself.


OPERATIONS UPON THE SPLEEN.

Besides those operations addressed toward fixation of a more or less
enlarged or wandering spleen a _splenotomy_ can be made--_i. e._,
incision and drainage at any suitable point, anterior or posterior,
which can be satisfactorily exposed; and evacuation of fluid may be
followed, with or without suture of the deep to the external wound, by
gauze packing or tubage, combined, if necessary, with counteropening or
posterior drainage.


=Splenectomy.=--Total removal of the spleen is performed through an
incision which should be made ample for the purpose, either along the
costal border or the left semilunar line or by combination of both. A
median incision may be also utilized if it will permit better access.
Splenectomy, under ordinary circumstances, would not be a difficult
operation, but with the organ enormously enlarged and the vessels
dilated, as they may be, it becomes usually a formidable procedure. The
most serious difficulty and danger arise from the numerous adventitious
vessels which may connect the spleen with the diaphragm or with some
of its other surroundings, and whose location is to be made out before
an attempt is made to remove it. Thus, in one instance, I have seen
an adventitious vein, the size of the little finger, between the
upper splenic surface and the diaphragm. Through such large vessels
torrents of blood will pour unless they be first secured. All such
connections then with the stomach and the diaphragm have to be ligated
and separated with great care, while gentleness of manipulation is
requisite throughout the operation. The spleen may be reached and
adhesions be located with great speed of manipulation, but in the
depths of such a wound valuable time may be consumed and much blood
lost, all at a time when the patient can least tolerate them. Oozing
from vessels which cannot be secured should be checked by gauze packing.


THE PANCREAS.

The anatomical features of the pancreas which have most interest
for the surgeon are the facts that its head is in contact with the
duodenum, and lies usually so closely against the second portion of
the former as to surround from one-fourth to one-third of its lumen.
Becoming adherent at this point it may then produce obstruction high
up in the intestine. In rare instances it may even completely surround
the duodenum, and thus may, when swollen, cause tight constriction of
the latter. Should this condition be met with a gastro-enterostomy
would be the proper measure for relief. These intimate relationships
account for the spread of disease from the pancreas to the intestine,
rarely in the reverse direction. The pancreas lies also in contact
with the stomach along its anterior peritoneum-covered surface, and
malignant disease travels easily from one to the other. Ulcers of the
stomach, favorably situated, may also be followed by adhesion and
inflammatory infiltration of the pancreas, by which the viscera are
cemented together, the same result following duodenal ulcer, as well
as serious disease about the biliary passages. Thus under a variety of
circumstances the operator may find these parts so cemented as to be
separated only with the greatest difficulty, or perhaps not at all,
without causing laceration or rupture of one or more of them, with
escape of contents which are often septic. Therefore when there is
reason to fear this accident it will usually be safer to simply make a
gastro-enterostomy. (See Plate LVI.)

The relations of the biliary ducts to the pancreas are most important,
the association of the common duct with that of Wirsung having the
greatest bearing upon a variety of conditions, which are nearly all
essentially surgical. The former, descending along the head of the
pancreas, comes in contact with the duct of the latter, and passes
alongside of it for a short distance before entering the intestinal
wall. In about two-thirds of individuals it is completely enclosed
by the pancreas. In the other third it lies in a deep groove upon
it. Resting here, as it were like Siamese twins, it will be easily
seen how disturbance in one duct or its source may be reflected to
the other. When the common duct lies in a groove it is less likely to
be seriously compressed by pancreatic engorgement than when actually
embedded in pancreatic tissue. The degree of resulting jaundice may
thus be dependent upon anatomical conditions not determinable before
exploration. Such pressure doubtless accounts for many cases of
so-called catarrhal jaundice. When the condition becomes constant, or
nearly so, a chronic interstitial pancreatitis may be assumed, which
really warrants an operation--_i. e._, cholecystostomy with drainage.
When a gallstone is passing through the common duct, especially when
lingering or impacted, it may have in turn reversed this condition,
and, by obstructing the pancreatic duct, set up as a consequence
pancreatic stagnation and consequent digestive disturbance, and such
other internal conditions as invite infection from the duodenal cavity,
with a more or less lively pancreatitis, perhaps even of fulminating
type, by which life may be jeopardized.

The pancreas, however, being usually provided with two ducts, the
second (that of Santorini) is often represented as an additional
safeguard, since it usually has a separate opening into the duodenum
below the ampulla. Opie carefully studied 100 cadavers and found that
in more than 50 of them the accessory duct could be of no use or
relief, and that in only 10 instances did two independent ducts enter
the intestine, while in the other 90 they were united, and in 21 of the
latter the accessory duct had become obliterated. Moreover, in only
6 of the 100 instances was it larger than the duct of Wirsung. This
will show, then, how little reliance may be placed upon the duct of
Santorini. Moreover, no matter which duct is opened, or whether both
are, so long as pancreatic fluid can escape there is an open channel
for infection, and when it cannot escape it may be seen that infection
has already occurred and is manifesting its pressure consequences.
Chemosis of mucous membrane may be the first mechanical result of such
infection, but this is sure to be followed by interstitial sclerosing
and compressing effects.

The normal duct opening in the duodenum is also a matter of surgical
interest. The ampulla of Vater, within the second portion of the
duodenum, is usually described as a conical protrusion or papilla,
having an average length of 4 Mm., with an opening 2.5 Mm. in diameter,
this being the narrowest portion of the common duct, but from this
arrangement there are many variations. The ducts may join at some
distance from the intestine, or they may open independently into a
depression or into a protrusion, and the ampulla be thus totally
wanting, all of which has the greatest possible bearing upon what may
happen during the passage of gallstones, for instance, or by infection
and according to its direction; and may account for the difficulty met
in certain cases, as when, for example, it becomes necessary to incise
the duodenum and open the ampulla for the removal of a pancreatic or
biliary calculus. It will emphasize, too, the necessity for always
exploring the common duct by opening the biliary passage and thus
making sure of its patency.


ANOMALIES OF THE PANCREAS.

Congenital anomalies include not only those of the ducts above
mentioned, but the presence of _accessory masses_, like the accessory
thyroids, which may occasionally lead to confusion and perplexity.
Furthermore, accessory nodules of pancreatic tissue may be found
alongside the ducts, or even in the walls of the stomach and intestine,
where they are probably present more often than is generally
appreciated, and are to be explained by the embryology of the parts,
since the pancreas is known to take origin from a cluster of cells in
the wall of the upper end of the developing intestinal canal. They have
been seen also along the line of a persistent vitelline duct. Such
small accessories, when present, usually empty by minute independent
ducts into the intestine. On the same embryonal grounds are to be
explained other anomalies occasionally met, such as separation into
detached portions. The existence of accessory pancreatic glands is also
held to account for the absence of glycosuria in certain cases where
the principal portion of the pancreas is itself extensively diseased.


GLYCOSURIA.

Glycosuria is so associated with the popular conception of pancreatic
disease that it seems imperative to state what importance should be
attached to it. It is now clearly established that the so-called
“islands of Langerhans” have to do with the elaboration of a certain
glycolytic ferment, and that the failure in its supply to the blood (it
being regarded as an internal secretion) is followed by the appearance
of sugar in the urine. These islands are not connected with the ducts,
at least not in the vertebrates, and usually escape pressure effects
in chronic interstitial pancreatitis of the interacinous as well as of
the interlobular form. This explains the accompaniment of diabetes in
some instances of pancreatic disease and its absence in others. Again,
if only part of the pancreas be affected, as in cancer, the remaining
healthy portion may still afford a sufficient amount of this ferment to
supply the body needs.

The uncertain symptomatology of the slower forms of pancreatic disease
is to be accounted for by the fact that, with the exception of its
glycogenic function just mentioned, all its other functions may be
vicariously assumed by other organs of the body. Thus as a compound
racemose gland it furnishes--

  1. Trypsin, a proteolytic ferment;

  2. Amylopsin, a starch-splitting ferment;

  3. Steapsin, a fat-digesting ferment; and

  4. A milk-curdling ferment.

The first of these functions may to some extent at least be assumed by
the stomach and the others by the bile and intestinal juices. (Mayo
Robson.)


INJURIES TO THE PANCREAS.

Injuries to the pancreas may occur with or without external
traumatisms. By any kind of injury which affects the gland it is
probable that its glandular structure may be so disrupted as to set
free an autodestructive secretion, which, by softening and weakening
vascular walls, may lead to hemorrhage and to the accumulation of a
collection of inflammable material, which is a good culture medium,
and which needs only the spark of infection to be easily aroused
into a conflagration. That possibility of infection is imminent is
apparent from the relations of the adjoining viscera and their ducts,
as already outlined. However, the same is true of even a first and
spontaneous hemorrhage, as of the clot, however produced. It has been
held that the manipulations to which the pancreas has been unavoidably
submitted during many operations may lead to its acute inflammation or
destruction. On the other hand, there seems no doubt but that it is
sometimes much relieved or benefited by a mild massage as a part of
the operative procedure. Mayo Robson has suggested that concretions
may thus be pushed along or adhesions removed, or, as it seems to me,
circulatory equilibrium restored and autonutrition improved.

Aside from the injuries which the pancreas may receive during
operations it is unquestionably the site of hemorrhages produced by
_contusions_ of the abdomen, although these are rare, and of injuries
produced by deeply penetrating _wounds_, especially those caused by
a stab or gunshot. The immediate result of a serious wound might be
hemorrhage, perhaps even a large escape of blood filling the lesser
cavity of the peritoneum. Such injuries are always to be treated
surgically, _as any external contusion followed by serious collapse and
evidences of internal hemorrhage should be promptly explored_, and,
even more so, _every case of penetrating wound_. Should blood be found
to be escaping from the pancreas the bleeding vessel may be sought and
secured, or, if necessary, a portion of the organ extirpated, since
no danger can be greater than that of uncontrolled bleeding. It is on
record that through an extensive gash in the abdomen the pancreas has
not only been exposed, but has partially escaped, and one case report,
apparently authentic, details its subsequent sloughing and spontaneous
separation.

Any wound of the pancreas which needs no further attention may at least
be sutured if it can be exposed. Nearly all surgical attacks upon this
viscus will require extensive incision and more or less emptying of
the upper abdominal cavity. It may now be of great assistance to place
the patient in the semi-upright position in order that the viscera may
gravitate toward the lower part of the abdomen--_i. e._, to reverse the
ordinary Trendelenburg position.


NON-TRAUMATIC SURGICAL DISEASES OF THE PANCREAS.

These diseases include especially the acute infections, the chronic
lesions, and the occurrence of neoplasms or calculi.

Certain local and general conditions predispose to pancreatic disease
of any type. Among them are to be reckoned--

  1. _Injury_, either by accident in the ordinary course of events,
  as by contusions or penetrating wounds, or bruising during the
  manipulations of operation;

  2. _Anatomical anomalies_;

  3. _Hemorrhages_ into the substance of the gland, whether from
  vascular changes or other causes;

  4. _Obstruction along either the biliary or pancreatic ducts_,
  whether due to catarrh, calculi, adhesions or stricture, parasites
  (worms) or cancer;

  5. General _toxemias_: typhoid syphilis, influenza, mumps, and the
  like.

The principal exciting causes are the various infections which
may proceed from the blood, as in pyemia or syphilis, or from the
alimentary canal, which is never free from bacteria, either by
adhesions and continuity, as from gastric ulcer and cancer, or by those
natural passage-ways, the ducts.

When summed up the most common of all the causes of pancreatic disease,
acute or chronic, will be found to be _cholelithiasis_, with some of
its variant consequences or complications. This will help to make clear
the reason for operating on the biliary passages in most cases of
pancreatic disease, especially the more chronic forms. A stone impacted
in any portion of the common duct, especially in its terminal portion,
after it has come into relation with the duct of Wirsung, may cause
an amount of disturbance disproportionate to its size. Moreover, a
stone impacted at the orifice of the duct will permit the entrance of
bile into the pancreatic canal, where it does not belong, and where of
itself it may cause trouble.


ACUTE AFFECTIONS OF THE PANCREAS.

These include--

  1. _Hemorrhagic pancreatitis._

  (_a_) Ultra-acute, where hemorrhage precedes infection, and bleeding
  occurs outside as well as inside the gland.

  (_b_) Acute, where inflammation precedes hemorrhage, the latter being
  less profuse and occurring in patches.

  2. _Gangrenous pancreatitis._

  3. _Suppurative pancreatitis._

  (_a_) Diffuse, destructive.

  (_b_) Subacute, localized, with abscess formation.


=Acute Pancreatitis.=--Acute pancreatitis is a distinct form of
disease, like appendicitis, with an etiology and symptomatology of its
own, which has been recognized only within the past twenty-five years.
This statement will account for the fact that so little reference to
it is made in any but the recent text-books. In fact it is to the
writings of Fitz, of some fifteen years ago, that the world owes its
first keen interest in the subject. By no means a frequent disease, it
nevertheless occurs with frequency sufficient to make it inexcusable
for the practitioner to fail to take it into consideration, although he
may waver in diagnosis.

The predisposition to infection which previous injuries, especially
minute hemorrhages or previous pathological conditions, seem to afford
has been already mentioned, and a history of previous injury or
digestive disturbances will aid in diagnosis. The exciting cause is,
however, in nearly every case when not distinctly traumatic, connected
with previous disease in the biliary tract, either cholelithiasis or
cholangitis. Reference to what has been said above, and a consideration
of the anatomical relations, will show how readily an infectious
process can travel upward from the duodenum into the pancreatic duct,
as well as into the common duct; or how, passing down the latter, it
may speedily find its way up the former. The previous condition of the
tissues, and the activity or virulence of the infective organisms, have
to do with the degree of acuteness of the resulting pancreatitis. This
is sometimes of such overwhelming toxicity that the entire gland dies
almost as does the appendix, within a few hours, the result being an
acute necrotic condition that of itself is necessarily fatal.


=Symptoms.=--Acute pancreatitis gives rise to symptoms which, in
general, assume the clinical form of an _acute peritonitis of the upper
abdomen_. It commences with sharp pain in the epigastrium, accompanied
by faintness, nausea, vomiting, and collapse, while tenderness over the
pancreas is an early symptom, and swelling or enlargement can sometimes
be detected. Constipation is so frequently a feature that the diagnosis
of acute bowel obstruction is sometimes made, but it will be found that
obstruction is not complete, for flatus may pass and enemas may be
successful. The pain becomes paroxysmal, is increased by movement and
pressure, while the tenderness becomes more localized. Meteorism may so
quickly succeed the other symptoms as to make physical signs uncertain,
while rigidity of the abdominal muscles makes them still more vague,
yet affording in itself a sign of value. Vomiting intensifies the
pain and the vomitus changes from food to bile, and then to blood,
which is dark and altered. Hence jaundice may be an early feature,
in which case it becomes more marked as the disease progresses, and
may become intense. This is likely to be the case if the exciting
cause prove to be a stone impacted at the ampulla. The face indicates
profound distress and disturbance. The temperature affords no certain
indication, save that in the most serious cases it may be subnormal.
On the other hand, as the case progresses, the pulse becomes small and
rapid. Every expression of overwhelming toxemia is added, and delirium
usually precedes death. In fact death may follow the first expression
of pain, in unrelieved cases, in from two to three days. Other less
acute expressions of the same general character are met with in the
so-called subacute forms of pancreatitis.

While the postmortem findings differ in various instances the symptoms
above noted do not vary conspicuously. They differ rather in intensity
only, in accordance with the gravity of the case.

The pathologists have described various forms of pancreatitis as
the _hemorrhagic_, the _gangrenous_, the _suppurative_, and those
distinguished by _fat necrosis_, as well of the omentum as of the
pancreas itself. These distinctions have the greatest interest for
those engaged in minute research and are not to be regarded lightly.
They have no small interest for the clinician, since prognosis is in
some measure dependent upon them. Nevertheless the symptoms of the
condition are but slightly modified, whether the destructive process
assume one or the other of these types, and the therapeutic indication
is the same for all--namely, the _earliest possible operation_.

If pathologists were better agreed on their pathology it might be
worth while to give more space here to this aspect of the subject. It
is, however, not yet certain, for instance, whether in a given case
inflammation precedes hemorrhage, or whether hemorrhage occurs first
and the outpour of blood is suddenly invaded by bacteria. In fact it
is probable that sometimes one thing occurs and sometimes the other.
Certain it is that the pancreas is not only loosely held together, and
consequently disrupts easily, but that it quickly succumbs both to its
own digestive juices and the disintegrating effect of bacteria, so that
putrefaction quickly occurs hours before life is extinct. The morbid
excitement quickly spreads to the adjoining peritoneum, and along it,
so that a more or less generalized peritonitis soon complicates the
case. Mayo Robson inclines to the view that in the most fulminating
cases the hemorrhage is the prior lesion.


=Diagnosis.=--The diagnosis should be made mainly from perforating
gastric or duodenal _ulcer_; phlegmonous or gangrenous _cholecystitis_
or _cholangitis_; rupture of the biliary tract, with escape of
contents; fulminating _appendicitis_; acute intestinal _obstruction_,
including internal hernias, and acute _mesenteric thrombosis_ or
_embolism_. Fortunately in every one of these conditions prompt
operative intervention is alike demanded, save possibly in the last
named; while even in the latter diagnosis cannot be made without
it, and it may still be possible to accomplish something if the
occlusion be not too widespread. A history of previous “dyspepsia”
or “indigestion” may point to the stomach or the biliary channels;
repeated hemorrhages to gastric ulcer, and repeated attacks of pain
to gallstone trouble. General tympanitis would indicate intestinal
obstruction, especially if no flatus were passed, while when limited to
the upper abdomen it would be more suggestive of pancreatic disease.
This would be corroborated by vomiting of blood, while fecal vomiting
would indicate obstruction. Tenderness and tumor located in the region
of the gall-bladder would point rather to it as the source of trouble,
while in pancreatitis something distinctive may be perhaps made out
by palpation and percussion, and the tenderness will be complained
of alike on each side of the middle line. Abdominal rigidity, while
general, is usually most pronounced near the site of the most important
lesion. Much importance is attached by Halsted to excessive pain, and
to cyanosis of both the face and the abdomen. The latter may be helpful
as a corroborative indication, but is certainly not always present,
and, on the other hand, is seen in many cases of general peritonitis.
Glycosuria is rarely a feature of the acute cases.


=Treatment.=--This is of necessity not only _surgical_, but, to be
effective, should be _prompt_, every added hour of delay causing
increased danger. While arranging for this it is possibly justifiable
to allay pain by giving morphine hypodermically. The colon should be
emptied by a copious enema. Collapse is to be combated by the usual
means, including hypodermoclysis or infusion, perhaps with the addition
of a little adrenalin to the saline solution. The preparation of the
patient, both before and during anesthesia, should include the same
scrubbing of and attention to the skin of the _back_ as that of the
abdomen, as there is much probability in any such case that posterior
drainage will be needed.

The _operation_ is begun as an exploration, through a median incision
above the umbilicus, some three inches in length, through which the
operator may inform himself as to the state of affairs within the
abdomen. Should fat necrosis be revealed, and first noticed in the
omentum, no doubt need be felt as to diagnosis. Any tumefaction by
which the stomach or colon is displaced, or the gastrocolic omentum
placed upon the stretch, calls for further and deeper exploration. The
upper abdomen should next be walled off with gauze and a small rent
made through the gastrocolic omentum; or it may in rare instances prove
wiser to push down an already depressed stomach, or more likely to lift
up the greater omentum and enter the lesser peritoneal cavity through
the mesocolon. In the majority of instances the condition can be best
appreciated and relieved by separating the stomach from the colon.

The condition may be one of extensive fat necrosis, disseminated,
but with its most abundant expressions in the neighborhood of the
pancreas, or there may be found evidence of extensive gangrene, the
pancreas itself sloughing and involved past any possibility of repair,
surrounded by disintegrating clot and debris; or there may be found a
more or less localized abscess, and perhaps evidences of putrefaction.
In at least two instances reported by Muspratt and Porter the pancreas
itself was not yet dead, but was so darkly discolored and swollen, as
well as so dense, that it was freely incised, the bleeding vessels
being tied and the clot removed. Both of these cases recovered. Such
incisions, if made in the gland, should always run parallel with the
duct and not across it. Whether pus be found or not will depend in
large degree upon the time that has elapsed since trouble began. It is
most desirable to expose the focus before pus has had time to form,
just as it is in acute appendicular disease.

The further operative treatment consists essentially in checking and
preventing hemorrhage, in removing all sloughing tissue which can be
safely taken away (and this may involve the greater part of the entire
gland), in disinfection of the cavity and general toilet of the upper
abdomen, with ample provision for drainage. This may be anterior
or posterior, and in bad cases should be both, unless procedure is
hastened by collapse. Posterior drainage is effected by having the
patient turned upon the right side, then making an incision 3 or 4 Cm.
long at the left costospinal angle, where, if the advice above given
have been followed, the skin will have already been prepared. Here the
outer border of the erector spinæ group of muscles is quickly exposed
and the blades of a pair of stout forceps entered and pushed toward
the inner cavity, within which the operator’s left hand is acting as a
guide. In this way it is possible to quickly insinuate the blades so
that the large vessels and the upper end of the kidney are preserved
from harm. A suitably prepared drain, preferably tubular, may then be
introduced deeply enough through the anterior wound to be seized by
the forceps and pulled through the tunnel made by their introduction.
It is thus drawn backward and outward to such an extent that its inner
end shall rest just where it is desired in the cavity of the lesser
peritoneum, the unnecessary external part of the drain being now cut
away. The whole procedure consumes but little time. Anterior drainage
will also be necessary, and the wound may then be closed.

It has been suggested to make the exploration as well as the drainage
from the loin, but this procedure cannot be here advised, since it
leaves too many features in doubt and affords insufficient means
whereby to appreciate and cope with many grave complications. Calculi,
either biliary or pancreatic, which are so often an exciting cause of
these troubles, should be carefully sought for and removed if present.
They could not be revealed nor removed through any small posterior
opening. Other good reasons are also advanced, since the intensity
of the symptoms is an expression of an intraperitoneal rather than
retroperitoneal lesion.

The reader will note that but little has been said as to the
distinction between the hemorrhagic, gangrenous, and other forms of
acute pancreatitis, as these are for the surgeon, as such, _side
issues_. _His paramount duty is to open the abdomen of every such case,
so soon as he can possibly effect arrangements._


=Subacute Pancreatitis; Abscess.=--Under this term are included disease
processes and lesions similar to or identical with those described
as causing acute and even fulminating expressions of pancreatic
obstruction, but less severe in their manifestations, less rapid in
their course, and more localized in their boundaries. They are often
so associated with a protective and natural walling off of the area
of excitement by barriers, which outpour of lymph and its consequent
condensation into adhesions afford, that they appear more often as
abscess of the pancreas or hematoma of the lesser cavity of the
peritoneum.

So far as concerns its etiology the causes are essentially the same as
in the acute cases, only the results are brought about more slowly,
weeks being in these cases as days in the others. Gallstones are by all
means the most common cause, and the pancreatic disease is itself an
expression of an infection travelling up its duct.


=Symptoms.=--The symptoms usually include pain, which, however, lacks
the agonizing intensity noted in the more acute cases. Vomiting is
usually associated with constipation, but the vomitus is rarely or
never bloody; jaundice of variable degree is a common feature, and
collapse is rare. Distention of the upper abdomen and tumor formation
come on more slowly. Tenderness is less extreme and muscle rigidity
less marked. While the pulse is less affected the temperature is
usually more so, often running high. Even early in the case we may
note general expressions of septic intoxication, such as mild chills
and a characteristic appearance of the tongue and face. Constipation
is followed by diarrhea; at least the stools which are fetid contain
blood, pus, fat cells, and undigested meat fibers. Pain is more or
less constant, but increased in paroxysms. Loss of appetite and rapid
emaciation are apparent from the outset. Albumin will be found in the
urine, but rarely sugar. The peculiar reaction described by Cammidge
will, according to Mayo Robson, give uniformly positive evidence. As
_abscess_ gradually or rapidly develops it will cause a swelling, which
has its origin behind the stomach and may displace this viscus, as
well as the colon, upward or downward, presenting usually toward the
abdominal wall. In rare instances the direction of least resistance
takes it toward one loin or the other, where it may appear as a
perirenal abscess, or around the crus of the diaphragm and above the
liver, where it would appear as a subphrenic abscess. It has been
known also to burrow along the psoas muscle and appear at the groin,
or even in the left broad ligament. Abscess of the pancreas may also
burst into the stomach, when pus will be vomited, or into the bowel,
whence it will be evacuated. A sudden relief, with disappearance of
tumor, followed by diarrhea and purulent stools, would indicate this
latter termination. Under these circumstances the abscess cavity may
repeatedly refill and reëmpty itself. Spontaneous recovery in this way
is possible, but septicemia and hectic usually persist until obviated
by operation.


=Diagnosis.=--The history, the evidently septic type of the case, and
the distinct signs above noted will make almost certain the presence
of pus, and Mayo Robson insists that the pancreatic reaction in the
urine (Cammidge) will make clear its location and origin; but, with or
without the latter, the important feature is that there must be a deep
collection of pus somewhere in the neighborhood of the pancreas.


=Treatment.=--This is necessarily operative, and in such cases as
those now considered there will be plenty of time afforded for all
the precautions known to careful surgeons. The aspirator should never
be used, at least not until the abdomen has been opened, then usually
with caution, lest pus escape along the needle track. The operation
is made as described above for the acute form of this disease. The
greatest care should be given to protecting the general peritoneal
cavity against infection. When adhesions to the anterior abdominal wall
are met they should be separated as little as possible, only to such
an extent as will permit direct approach to the collection below. Only
after the abscess cavity has been thoroughly emptied, disinfected, and
packed with gauze should the surgeon proceed to clear away or break
down adhesions so as to permit a suitable exploration of the lower
surface of the liver and the biliary passages.

And now perhaps comes the necessity for operative attention to these
latter, as one or many stones may be recognized in the gall-bladder or
the ducts. In this case there must be followed those general directions
elsewhere given in regard to the technique of operations upon the
gall-bladder and ducts. _Biliary drainage_ will in these cases be
nearly always indicated, for which a separate small opening in the
usual position may be made, if desirable, as it probably will be, for
one wishes usually to continue such drainage for several weeks, whereas
it is desirable to have a median incision heal as rapidly as possible.
The question of posterior drainage will also be raised. Ordinarily
it is of advantage, as the time required for anterior drainage can
be materially shortened, the abdominal wound be encouraged to close,
and because the natural effect of gravity is thus afforded. Moreover,
by it the whole period of confinement to bed may be materially
reduced. Therefore, unless the condition of the patient absolutely
contra-indicate, it will usually be a wise measure. In a few instances
it has been possible to drain a pancreatic abscess by a tube in the
common duct, after removal of the stone which has been obstructing
either it or the duct of Wirsung.


CHRONIC AFFECTIONS OF THE PANCREAS.

Chronic affections of the pancreas which interest the surgeon are:

  1. _Interstitial pancreatitis_:

  (_a_) Interlobular.

  (_b_) Interacinous, leading to--

  2. _Cirrhosis_ with accompanying diabetes.

  3. _Neoplasms_:

  (_a_) Cysts.

  (_b_) Solid tumors.

  4. _Calculi._


=Chronic Pancreatitis; Cirrhosis.=--The interlobular and interacinous
forms can both be considered under one heading so far as we are
concerned, their symptoms being similar, save that in the former the
compressed connective tissue by its presence causes atrophy of true
glandular elements, and thus by preventing their function interferes
with digestion; while in the interacinous type the proliferations of
this same sort of tissue invade the islands of Langerhans, impair
their glycolytic secretion or suppress it, and add a glycosuria to
those features common to both forms--moreover, their treatment is
essentially the same. In the advanced form of either type the pancreas
may be reduced in size and somewhat cirrhotic. This chronic affection
may be the result of an incomplete recovery from one of the more acute
conditions previously described; it may also have its origin in the
chronic irritation of the poisons of syphilis, typhoid, alcoholism,
and the like; but by far the most common causes are obstruction of the
pancreatic duct, either by biliary or pancreatic calculi, cicatricial
stenosis, the presence of tumors or the encroachment and erosion of
gastric ulcers and cancers. The morbid condition may involve the whole
gland or be localized, in the latter case particularly about its head.


=Symptoms.=--These should be studied with particular attention to the
case history, for a previous record of pain, cramps, chills, fever,
jaundice, very slight digestive disturbances, soreness, or local
tenderness will be suggestive and valuable if obtainable. As symptoms
gradually arrange themselves it will be found that tenderness over
the pancreas becomes constant, and is accompanied by at least a mild
degree of muscle spasm, that pain increases and is referred more
widely, often to the left side or even the scapula, while there may
be some fulness in the epigastrium. Dyspepsia and emaciation become
more marked. By the time the obstruction of Wirsung’s duct has become
complete, perhaps previous to it, fat and undigested muscle fibers will
be found in the stools, which are light-colored, bulky, and sometimes
contain blood. As pressure effects become more prominent evidences
of biliary obstruction, if previously lacking, present themselves;
the gall-bladder usually distends; the liver enlarges or may even
become cirrhotic from the irritation of pent-up toxic bile. Even the
spleen may become enlarged. In the urine sugar will be found in cases
of the interacinous type, though usually only at a late date; while
bile pigments are usually present and Cammidge’s test may reveal his
peculiar pancreatic reaction.


=Diagnosis.=--If the peculiar symptoms above rehearsed are present
diagnosis is not difficult. In many cases it is not easy to go beyond
the point of recognizing that both the pancreas and the biliary tract
are at fault, without deciding as to the exact degree of culpability
of each. The question of possible cancer arises in almost every one of
these instances. Should the ordinary pancreatic reaction in the urine
prove all that has been claimed for it, this grave problem can often be
settled previous to operation. If the operator satisfies himself by any
method short of actual operation that he has to do with cancer of the
pancreas, then operation may be considered inadvisable unless for some
special reason.


=Treatment.=--At least a reasonably long trial will usually be made,
in these cases, of medical, hydrotherapeutic, and other non-operative
treatment, with little or no benefit. When after appreciation of
the condition and intelligent treatment but slight relief accrues,
the case may be regarded (as it really is upon its commencement) as
surgical. Treatment, then, consists of _removal of the obstructing
cause by drainage of the biliary passages_. The operative procedure
will therefore take the form elsewhere described for this purpose.
Should deep exploration reveal no calculi it will be well to make sure
at least of the patulency of the ducts, by opening the gall-bladder or
common duct and exploring with the probe, or possibly even opening the
duodenum in order to do the same with the pancreatitic duct. Whether
calculi are discovered or otherwise a gentle stripping or massage of
the pancreas may be made to advantage. Biliary drainage should then be
established, and usually externally.

It has been difficult for the profession to appreciate why and how
these measures, which seem to be directed rather to the biliary
passages than to the pancreas, have given such brilliantly satisfactory
results as are everywhere reported. These are to be accounted for by
the facts that the primary cause most often lies in the former rather
than the latter, and is thus removed, and that one source of constant
irritation--namely, infected bile--is thus done away with, while
tension is removed and pancreatic juice again permitted to flow on as
it should; that a chronic toxemia (cholemia) is relieved, and that
physiological rest is afforded to the affected and disturbed organs.
When the operation is thus performed benefit may be expected; even when
done late it may be capable of great good.


NEOPLASMS OF THE PANCREAS.


=Cysts.=--In addition to _true cysts_ of the pancreas there have
been described so-called “_pseudocysts_” in the lesser peritoneal
cavity, and more or less surrounding the pancreas. They are rarely of
congenital origin, but are probably due rather to traumatism than to
any other cause. By many they have been likened to ranulas, or the
cysts which form in the salivary glands in consequence of obstruction
to ducts or their branches. Anything which obstructs any portion of the
pancreatic duct may lead to the formation of a retention cyst, the true
proliferation cyst--adenomas being practically unknown. That traumatism
figures so largely is due to the fact that injury is followed by
hemorrhagic extravasation, and this by more or less liquefaction or
degeneration, both of contents and of surrounding tissue, with the
secondary formation of a cyst whose walls are made of new connective
tissue.

A _true pancreatic cyst_ is a retroperitoneal tumor, while pseudocysts
are intraperitoneal. In front of the former lie four layers of
peritoneum, which may be completely merged together, but through which
a passage must be made when opening into it from the front. The
etiology of old pancreatic cysts may be completely concealed by the
changes which have slowly occurred since their origin. They may be
single or multiple, occur in any portion of the gland, and increase
even by coalescence. Within some of them, especially those of the duct
type, papillomatous excrescences may be found. The more distinctly
traumatic cysts occur perhaps oftener near the tail of the pancreas,
while into them repeated hemorrhages may take place, and the sac will
become quite thick, even exceptionally calcifying in places. These have
been described as _apoplectic cysts_.

Altogether, up to date, at least 150 of these cysts have been subjected
to operative intervention.

Pancreatic cysts contain a fluid which may be variously colored or
sometimes colorless, which is usually alkaline, and contains fat
globules, cholesterin crystals, blood crystals, albumin, and various
salts, most of these being evidences of their hemorrhagic origin. The
fluid may also contain the specific pancreatic ferments, of which the
diastatic is the more common, tryptic ferment being met occasionally,
while the fluid may also possess emulsifying properties. In size these
cysts vary from minute sacs to enormous collections of fluid.

As such a cyst attains marked size it will displace the adjoining
viscera, pushing the diaphragm upward and impeding heart and lung
action, obstructing the pylorus and duodenum and causing gastric
dilatation, pressing upon the intestines and perhaps even compressing
the ureters, thus producing hydronephrosis. Other peculiar pressure
effects may be met in particular instances. A sudden increase in size
indicates a fresh hemorrhage, which may lead to its rupture and to
death from peritonitis. These cysts rarely empty spontaneously into
the bowel. Their contents are liable to infection, and thus a cyst may
become converted into a large abscess.


=Symptoms.=--Symptoms include especially _pain_, which may have been
sudden, but becomes more or less constant, accompanied by a sense of
oppression, according to the size and the pressure effects produced
in each case. Digestion is always more or less disturbed; this may be
attributed to the stomach dilatation, which is itself a sequel of the
condition. The stools show little which is significant save that they
are occasionally bloody. Undigested muscle fiber would indicate loss of
pancreatic function. Other symptoms will vary so much with individual
cases that it is not necessary to consider them here.

The physical signs, coupled with a suggestive history, especially one
which includes an account of injury, are of the greatest importance
in diagnosis. These physical signs will include usually a yellowish
tinge of the skin, marked emaciation, dry skin, and the presence of a
tumor in the upper abdomen, which is usually centrally placed, but not
necessarily so. If the patient has carefully noted the development of
his own symptoms it will be found that the enlargement commenced above
and usually a little to the left, and developed in other directions
from that location. Palpation reveals a smooth, elastic, usually
fluctuating tumor, sometimes movable with respiration, rarely pulsating.

It must be remembered that a pancreatic cyst may rise above the
stomach, may rest entirely behind it, or may protrude either below
it and above the colon or else quite below the colon. Distention of
the stomach will afford accurate location, in these respects, upon
percussion, while percussion without distention may mislead. A tumor
which gives dulness below the stomach and above the colon is extremely
suggestive.


=Diagnosis.=--Diagnosis by aspiration is inadvisable, even dangerous,
for death has followed the introduction even of a needle into such a
cyst. Aspiration, then, should be reserved for tumors already exposed
through an abdominal incision.

For the purpose of _differentiation_ it will suffice here to remind
that tumors of the kidney, as well as hydronephrotic cysts, grow
downward and forward from the loin, and can be pushed backward to
their proper place unless too large, that they are not accompanied
by digestive disturbances, while the urine is usually more or less
indicative. A hydronephrotic cyst can scarcely be made to occupy a
position between the stomach and the colon and present in the middle
line in front. Ovarian cysts rise from the pelvis and will rarely
occur in the upper location, save those provided with extremely long
pedicles. Hydatid cysts of the liver show a continuity and fixation to
that viscus which are usually diagnostic.


=Treatment.=--The only treatment for pancreatic cysts is surgical,
it remaining with the surgeon to decide as between _drainage_ and
_extirpation_. While it is indisputable that extirpation is the ideal
method of dealing with all cysts and tumors, most of these cases are
of such long duration that the adhesions contracted between their
exteriors and the surrounding viscera are so dense and firm that
much greater danger attaches to a radical operation than to one for
simple incision and drainage. I have been able in at least one case to
completely extirpate such a cyst, but it was one exceedingly favorably
situated and surrounded.

_Incision and drainage_ may be effected in one operation or in two
sittings, and as between them it must be decided according to the
merits of the case. It is undesirable to permit the escape of the
contents of these cysts into the abdomen. In some instances, therefore,
it would be much better to make a small abdominal incision and through
it attach the surface of the cyst to the margins of the parietal
peritoneum, reserving the actual opening into the tumor until a day
or two later, when it may be expected that firm adhesions will have
attached the sutured surfaces. In this way any leakage within the
abdomen may be avoided. Care must be exercised, even in such cases,
as a large cyst too suddenly emptied may cause sudden displacement of
the heart or of other viscera, which would not be to the advantage
of the patient. In this case fluid could be withdrawn in portions as
desired, or, making a small opening, one could arrange for its gradual
escape. On the other hand, there are cases where it would be of great
advantage, if the cyst could not be emptied, to so open it as to permit
posterior drainage to be made, by which the period of recovery would be
much abbreviated.

No case of this kind can be treated without drainage, the explanation
being that the cyst being emptied will collapse, its walls coming
into more or less close contact with each other, that the presence
of drainage material will provoke exudate and the formation of
granulation tissue, and that a complete obliteration will thus in
time occur--but drainage in the natural direction of gravity as the
patient lies upon the back will permit of much more speedy fulfilment
of one’s hopes; hence its advantage. Better still, perhaps, would be
through-and-through drainage, with such irrigation as might be needed,
practised daily, or oftener if necessary.


=Tumors of the Pancreas.=--While _sarcoma_ and other forms of malignant
disease, as well as _adenoma_ of the pancreas, have been described,
they require no special consideration here, since the surgeon has so
rarely to do with anything of this character save _adenocarcinoma_ of
the pancreas. This is a disease of middle or advanced life, more common
in males than in females, usually of scirrhous type, and localized,
though it may appear in softer forms or be disseminated. It takes
its origin from the epithelial cells lining the acini and the ducts.
Metastasis is common and direct extension by continuity most easy and
frequent. It is made known by its pressure effects rather than by any
other important signs or constant features. It has been known to lead
to chylous ascites.

It is difficult in many exploratory operations to decide as between
a chronic induration or cirrhosis of the pancreas and that due to
cancer, and, in fact, in certain cases it may be impossible to clear
up the difficulty, leaving it to be solved either by recovery or death
in consequence of extension of malignant disease. Thus when operating
for biliary obstruction, where the parts are surrounded by adhesions
and the organs are only indistinctly palpable, it may be impossible
to decide as to the nature of a hard mass felt in the head end of the
pancreas, especially when other distinct expressions of cancer are
absent.

_Cancer of the pancreas_ is at present a primarily hopeless disease,
and is of interest to the surgeon only in that some of the most
distressing features which it causes may be temporarily relieved by
biliary drainage. The symptoms which will bring such a patient to him
will be essentially those of biliary obstruction, perhaps with the
accompaniment of glycosuria or the discovery of fat in the feces.
Neither of these, however, is an invariable symptom. Diarrhea is but an
occasional feature, and colorless stools may be discharged when there
is no jaundice. A perfectly painless progressive (bronzing) jaundice,
with distention of the gall-bladder, would perhaps more than any other
single feature indicate pancreatic cancer. When such a growth has
attained a size sufficient to make it discoverable on palpation it
might be mistaken for a biliary cancer, from which it would have to be
differentiated especially by the movability usually noted in the latter.

The only treatment for pancreatic cancer is operative, and consists in
_drainage of the gall-bladder_, and after a manner elsewhere described
in the section on Diseases of the Biliary Passages.


PANCREATIC CALCULI.

From the true pancreatic secretions precipitations of mineral salts,
combined with organic elements, may occur, just as from the saliva,
the latter thus furnishing the salivary calculi elsewhere described,
the two varieties having many points of resemblance. Again, calculi,
evidently of biliary origin, may be met with in the pancreatic duct.
The former consist largely of calcium oxalate, combined with calcium
carbonate and phosphate. They may be single or multiple, and vary
greatly in size up to that of a robin’s egg. Hypothetical calculi, with
consequent duct obstruction, have been held to be responsible for many
pancreatic cysts. Thus one may explain cyst formation, even though no
calculi be found at the time of operation.

Calculi reposing within the structure of the pancreas have much to
do with the acute and subacute, as well as the more chronic types
of pancreatitis, the latter when they act alone, the former when to
their essential disturbances are added the possibilities of bacterial
infection.

When pancreatic calculi produce symptoms they resemble those of
cholelithiasis, causing paroxysmal pain, with vomiting, and perhaps
transient jaundice. Glycosuria is an occasional feature.

The condition is rarely diagnosticated previous to operation. Should a
calculus be met in this location during the progress of any operation
it should be removed by an incision made parallel to the duct, with
such closure of the wound in the pancreas as can be subsequently
effected and with ample drainage of the deep wound, in order that
pancreatic fluid may not escape into the peritoneal cavity. If
encountered during operation for pancreatic cyst the same advice will
apply.




CHAPTER LIV.

THE KIDNEYS.


CONGENITAL ANOMALIES AND DEFECTS OF THE KIDNEYS.

Recent embryological studies have established the fact, in regard to
the kidneys, and given rise to the inference in regard to the other
viscera, that the primary cause of congenital variations has much to
do with the earliest development of the bloodvessels. The general
inclination has been to view the vessels as following the organs.
This should be reversed, as we are now learning that organs develop
_around the bloodvessels_, and that so-called congenital variations
arise from departures of vascular arrangement from the ordinary types.
Without pursuing this subject further it is sufficient to say that,
aside from defects of such character that the newborn infant can live
but for a few hours or days, those which have most surgical interest
mainly comprise variations in number and in size, including every
possible combination, from _absence of an entire kidney_ to _horseshoe_
forms, and various anomalies of the _ureters_ including _defects_ and
_redundancies_, _double ureters_, and the like. While _supernumerary
renal tissue or kidneys_ are extremely rare, the presence of
supernumerary _adrenal_ tissue in one or both kidneys (even in
adjoining organs) is not uncommon. Here it may lead to the development
of a distinct form of tumor, _hypernephroma_, which will be discussed
later. The complication of absence of an entire kidney is sufficient to
give it actual surgical importance, since it has repeatedly happened
that the remaining kidney has been removed for disease, the inference
being that its work could be carried on by its fellow, which proved to
be lacking. This accident might be prevented by a careful cystoscopic
examination. Nevertheless the rarity of this condition permits it to
be almost excluded from ordinary consideration. After removal of one
kidney the other undergoes compensatory physiological enlargement and
does double duty, if indeed this has not already occurred.

_Acquired defects_ may be due to intrinsic or extrinsic causes, _e.
g._, disease within the renal structures or ureters, or lesions
in adjoining organs and tissues, producing mechanical or other
disturbances. Thus the functionating capacity of one or even both
kidneys may be seriously compromised by either internal or external
conditions, and it behooves the surgeon to estimate the degree of renal
disability or inadequacy before operating upon either of these organs.
On the other hand if the disease be confined to one kidney he may feel
that it is doing so little good and so much harm that the patient will
be really relieved by its removal. Nearly everything, then, depends
upon a determination of the precise existing conditions. They should be
ascertained by means of the catheter, the cystoscope, the microscope,
and by the careful _chemical_ study of the urine. These methods have
been developed into a specialty of considerable complexity, but of
great practical importance. The surgeon should not fail to employ
them. If he is not familiar with the technique he should seek special
assistance.

[Illustration: FIG. 632

Laceration fragmentation of kidney. (Güterbock.)]


INJURIES TO THE KIDNEYS.

Although the kidneys lie in a protected position they are not
infrequently injured, both by contusions and by penetrating wounds.
From the latter blood will escape externally. In the former it can
only extravasate when the cortex and capsule are torn, or escape
through the ureter into the bladder, when it will be seen in the urine,
which, however, may have to be drawn by the catheter on account of
retention. _Blood in the urine after a local injury denotes serious
mischief inside the kidney or along the urinary tract._ If continuing
for several hours, but especially if accompanied by local indications,
swelling or other evidences of extravasation, by muscle rigidity or
by severe pain, with general symptoms, it should be assumed that
these fluids are escaping into the perirenal tissues, perhaps into
the peritoneal cavity, and that an immediate exploratory operation
should be urged. When once this indication is clearly recognized the
condition brooks no delay. The same is true of penetrating wounds. On
general principles, with a patient in such a condition and showing
no improvement, or especially if the reverse, _exploration offers
the safer course_ in by far the greater number of cases. The surgeon
need only convince himself that such blood as the urine contains does
not come from the lower tract, but rather from the kidney or ureter.
_Exploratory nephrotomy_ is by itself so harmless that one need never
hesitate to urge it. A kidney found slightly lacerated may be repaired
with sutures, while one found seriously disorganized should either
be sutured and drained or totally removed, as the case may require.
There is little room for doubt that it is better to institute such a
measure early rather than to permit the dangers and even ravages of
infiltration of blood and urine. In fact it may almost be laid down as
a precept that _every patient who has received an injury in the loin or
flank and who repeatedly passes blood in the urine should be explored_.


PAIN IN THE KIDNEY; NEPHRALGIA.

This is a vague term, implying pain or neuralgia in the kidney, and can
refer only to symptoms, not to any particular disease. Yet it must be
confessed that for certain cases of so-called nephralgia no physical
cause is easily discovered. Pain in the kidneys--or, as patients will
often say, in the back--may be associated with excess of oxalic and
uric acids and salts in the urine, and is then relieved by a steady
course of alkaline diuretic treatment, with plenty of fluid, the
severe pain being combated with aspirin. Nephralgia may be expected in
connection with many renal disorders, but the term should ordinarily be
confined to cases of pain without known cause.

When such pain is uncontrollable and intolerable the indication is to
make an exploratory operation, by which the kidney should be at least
exposed, perhaps delivered upon the external surface of the body, and
carefully examined. Its capsule should be split (capsulotomy), as
Harrison and others have suggested, and if on palpation or needling
(using a needle as a probe) there be any good reason for opening it
this may be done, so that with the finger its pelvic cavity may be
carefully explored, in order to find any previously unrecognized
calculus or other surgical lesion. The mere operation of _capsulotomy_
or capsule splitting has proved of such great value that I always
practise this measure upon any kidney which for any reason it may seem
wise to expose.


INFLAMMATIONS AND INFECTIONS OF THE KIDNEYS.

Under this head it is intended to consider (1) acute or subacute
specific infections of the upper urinary passages, due to bacteria,
with the effects of which we are familiar, _i. e._, septic, gonorrheal,
and tuberculous lesions, and (2) chronic nephrites of irregular or
uncertain type, for which operative treatment has been recently
proposed.


=Septic Nephritis; Pyelitis; Pyelonephritis; Surgical Kidney.=--Septic
infection of the kidney is usually the result of a process ascending
from the lower urinary passages, particularly when these are obstructed
by calculus, tumor, prostatic enlargement, or ureteral stricture. It
may follow catheterism either once or prolonged, especially when done
without strict precaution; or the infection may come from the other
direction _via_ the blood stream, as in typhoid and various other
fevers, the exanthems, and diphtheria. Gonorrhea is a frequent cause,
acting insidiously and by a creeping invasion, with the intervention of
a rather more abrupt cystitis. Nevertheless when gonorrhea is followed
by pyemia and metastatic abscess these form early in both kidneys, and
disaster quickly follows. These types of infection spreading upward
along the ureters do not spare the pelvis of the kidney, but expend
their first violence there. Beyond this they may extend to the renal
tissue proper, where they set up a true nephritis, which may prove
fatal.


=Symptoms.=--Clinical symptoms do not vary greatly except in detail.
They include fever, chills, and similar expressions of toxemia, with
more or less pain in the kidney, down the ureter, and even referred to
the ultimate distribution of the nerves sympathetically or anatomically
involved, _e. g._, to the testicle on the same side, often with
retraction of the scrotum, and down the thigh. There is a tendency to
_thamuria_ (frequency of urination) when the bladder is involved, as it
always is sooner or later. Pus and mucus are recognizable in the urine
by the naked eye, while a microscopic study of this fluid will reveal,
from the character of the cells, the extent and type of the invasion.
The tuberculous type will be considered separately. Suffice it to say
that in this form, however pure may have been its original type, it
becomes sooner or later converted into a mixed septic infection, with
which renal abscess is often connected. The gonorrheal type is nowise
clinically distinct, so far as the kidneys are concerned, but is to be
recognized either by the microscope or by other clinical evidence.


=Treatment.=--Such cases as the above may even perplex the surgeon,
since they complicate many other surgical conditions. Yet if they go no
farther than above described they are to be treated rather by internal
methods, _i. e._, diluents, with hot-air baths, and especially by
urotropin, the remedy of greatest value, while such drugs as aspirin,
benzosol, sodium benzoate and the like, in moderate doses and at rather
short intervals, may be administered to great advantage.


=Renal Abscess; Surgical Kidney.=--The conditions above described do
not necessarily nor often terminate with resolution. Not infrequently
suppuration follows, with resultant abscesses, which may be solitary
and possibly large, but are more likely to appear in multiple and
perhaps punctate form. Should this condition occur in one kidney alone,
it determines probably its ultimate destruction; if in both kidneys,
the prognosis is very grave, since later, if not immediately, such a
case will succumb to renal failure, due to the extra load put upon the
portion still capable of secreting. It is to kidneys thus crippled
by acute or subacute infections, with punctate abscess and similar
lesions, that in the past the term “_surgical kidney_” was applied,
because such kidneys were seen oftener in surgical than in so-called
medical cases.

Brewer has recently called attention to a type of _acute hematogenous
renal infection_, to which he has given an identity of its own.
The possibility of renal infection through the blood has been long
recognized, but it has been generally supposed to produce bilateral
lesions. Of late, however, it has been shown that these may be
unilateral, on account of the diminished resistance of one kidney
as the result of previous disease or injury, among the former being
calculus, renal retention, and floating kidney. While the colon bacilli
are most frequently at fault the infection is often of the pyogenic
or mixed type. It seems to be more frequent in women than in men.
The symptoms are those of an acute infection, often ushered in by a
chill, with sudden rise of temperature, sometimes followed by such
marked remission as possibly to suggest malaria. The pulse ranges
high. Abdominal pain is an almost constant symptom, although it is
usually vague and often shifting or referred. Sometimes it will cause
such a complaint as to lead to mistaken diagnosis in favor of an acute
appendicitis. Occasionally it radiates along the course of the ureter.
Tenderness in the costovertebral angle is nearly always present.
Muscle rigidity is frequent but inconstant. There is nearly always a
leukocytosis, with a percentage of about eighty polynuclears. Frequency
of urination may accompany these cases, but they will ordinarily be
diagnosticated by physical and urinary examination. The urine will
usually contain albumin, perhaps with pus, and occasionally a few
red blood cells. Urine obtained from the affected kidney by ureteral
catheterization will contain more of these evidences of abscess than
that from the other side. Brewer has had far better success in entirely
removing the affected kidney than in exposing and simply draining it.
He has thus done a great service in demonstrating the possibility of
unilateral acute and suppurative disease of the kidney, where diagnosis
is most obscure and the clinical picture one of acute general abscess
rather than of local affection, showing as well that the more acute
cases tend rapidly to terminate fatally unless promptly arrested by
complete removal of the affected organ.

As we consider the above infections, with others yet to be mentioned,
it becomes more necessary to appreciate those constituents and
characteristics of the urine which have for the surgeon the greatest
significance, and those methods of investigation which furnish him the
promptest and most satisfactory results.

The following include methods in present use for determining renal
_capacity and function_, _i. e._, the matters of greatest importance:

  1. Catheterization of the ureters;

  2. Cryoscopy of the blood and the urine;

  3. Phloridzin test;

  4. Chromocystoscopy;

  5. The toxin test;

  6. The test for electroconductivity (Kakells).

1. By _cystoscopy_, with _ureteral catheterization_, we determine
whether urine is secreted by both kidneys or but one, while the
secretion of each kidney may be separately collected and studied. Even
this method leaves much to be desired. Though one kidney be actively
diseased it may still contain sufficient tissue to make it partly
competent for its purpose, and undesirable to remove; or an organ with
very defective structure may, nevertheless, yield a certain amount of
nearly normal urine. These, then, are aids to determine the _character
of the morbid process_, and the information they furnish is valuable,
but not always sufficient.

2. _Cryoscopy_, based upon the physiochemical law that the freezing
point of the solution is proportionate to the number of molecules it
contains, _i. e._, to its molecular concentration, has revealed that
the blood of a person with severe kidney lesion freezes at a lower
temperature, while the freezing point of his urine would be much higher
than in a normal individual, because those materials which should have
been excreted in the urine are, on account of impaired renal function,
retained in the blood and do not get into the urine. The freezing point
of normal urine varies from -0.09° to -2.3° C.; the freezing point of
normal blood from -0.55° to -0.57° C. The reasoning employed in the
method is sound, but the method itself difficult, requiring special
apparatus and experience. Moreover, the limits of the possibility of
error are such that this method alone should never be relied on. It is
essentially a test of the _ability of the kidneys to act as filters,
but does not test their serviceability as secretory organs_.

3. The _phloridzin test_ is one of the most trustworthy for
estimating the secretory function of the kidneys, as it shows how
much active working epithelium remains in the organ. It consists in
the subcutaneous injection of 0.005 Cc. sterilized phloridzin with an
equal quantity of sodium benzoate, to hold the former in solution.
The bladder must be emptied just before the injection is given.
About an hour after its administration _sugar should appear in the
urine, if the kidneys are acting normally_. If they are to be studied
separately, catheterization of the ureters is necessary. The test is,
of course, worthless in diabetic subjects. It depends upon the amount
of sugar excreted, the time of its appearance, and the duration of its
elimination. If no sugar be present the kidneys are seriously affected;
if it be delayed, renal insufficiency is present. The average quantity
of sugar eliminated during the first half-hour, when the kidneys
are normal, is about 0.5 per cent. If the kidneys be diseased, this
quantity is reduced by a half, and there is very little more secreted
in the first than during the second half-hour. This valuable method is
unfortunately difficult of application and requires minutely careful
chemical tests.

4. _Chromocystoscopy_, introduced by Voelcker and Joseph, is perhaps
the simplest of all methods of estimating renal capacity. 20 Cc. of
a 0.4 per cent. solution of _indigo-carmine_ is injected into the
gluteal muscles. In fifteen or twenty minutes, if the kidneys be
normal, the cystoscope will reveal dark-blue urine flowing from the
ureteral orifices toward the median line, with a peculiar jet at
regular intervals of about twenty-five seconds, and lasting for perhaps
five seconds. There is both rhythm and force about this ejaculation.
If the color be pale, the jet weak, or the rhythm irregular, the
intervals prolonged or late, or if no flow whatever occur, there must
be hindrance in the secreting and filtering structure of the kidney, or
occlusion of the ureter. The results given by indigo-carmine in these
cases are superior to those furnished by methylene blue, since it is
not so much a solution as a mixture which is formed and ejaculated
as such. Moreover, in passing through the body the indigo-carmine
undergoes no reduction. By this method there is no necessity for
catheterization of the ureter. One needs only to use the cystoscope
with reasonable dexterity, and there is no necessity for chemical tests
of separate specimens. The method is generally useful in cases where
ureteral catheterization is made impossible by growths. It affords an
easy means of differentiation, for instance, between ovarian cyst and
hydronephrosis.

5. The _toxin test_ is one only to be carried out by the use of
animals, since it depends upon the amount of filtered urine required
to kill an animal after injection into its veins, the number of cubic
centimeters necessary to kill, divided by the weight of the animal,
being called the urotoxic co-efficient. It has greater laboratory than
clinical interest.

6. _Electroconductivity of urine_ is of value in determining the
capacity of the kidney for eliminating inorganic cells. It depends on
the resistance offered by the urine to the electric current. It is
complicated in method, requires special apparatus, and its results are
still of questionable value.

For _ordinary purposes_ the most trustworthy data for the surgeon who
is not provided with ample laboratory facilities are afforded by an
estimate of the _amount passed in twenty-four hours_, its _specific
gravity_, its _color and acidity_, and by the _presence or absence
of albumin_. The test-tube and the microscope then still afford
satisfactory means of deciding those matters which the surgeon needs to
know. If applied to urine collected separately from each kidney, they
may be regarded as trustworthy. If catheterization be impossible, then
it is advisable to inspect the ureteral orifices while elimination of
indigo-carmine is taking place.


=Hematuria.=--The significance of blood in the urine is rather that
of a _symptom_ than of a disease, although it should be admitted that
there are occasional patients who lose blood in this way, more or
less frequently, even periodically, without seeming to suffer in the
least. Hematuria may also be present as an expression of vicarious
menstruation. Again, blood may thus appear in scurvy and similar
conditions, especially in tropical climates; in certain of the
domestic animals its presence may be due to infection of the kidneys
by macroscopic parasites (the so-called “_black-water fever_” of men
and horses). Such cases as these are outside the pale of surgery.
Nevertheless general experience has shown that many cases of hematuria,
without perceptible changes in the kidney, have been benefited or
cured by exploratory nephrotomy. Among the causes ascribed for these
so-called “_essential hematurias_” have been incipient tuberculosis,
renal retention from prostatic enlargement, congestion from venous
obstruction (due to tight lacing or displacement from any cause), and
even the congestion of chronic nephritis.


=Treatment.=--When known or recognizable causes are absent, and the
ordinary therapeutic agents, the special styptics (cotarnin), and such
measures as hypodermoclysis with a 2 per cent. gelatin solution (see
Control of Hemorrhage) have failed, an exploration may be advised.
It is of the greatest advantage to be certain that but one kidney is
involved, or it may be necessary later to operate on the second kidney.


=Operative Treatment of Chronic Nephritis.=--The various changes
included under this head are usually bilateral. The term implies
a non-pyogenic infection of the renal bloodvessels, interstitial
tissues, and glomeruli or tubules, which produce changes, often spoken
of in this country as constituting _interstitial parenchymatous_ or
_diffuse_ forms of _nephritis_, and inducing gross changes which cause
the kidney to be spoken of as contracted, large, white, waxy, etc.
Discussion of the pathology of these conditions here is out of place.
They have all been grouped, most loosely, in common parlance as forms
of “_Bright’s disease_.” Apart from the significance of albuminuria and
the many terms implying peculiar features, the apparent hopelessness
of many of these conditions, and the disappointment following internal
treatment, finally led surgeons to attempt to ascertain what they could
accomplish. It was in 1886 that Péan operated on a case of chronic
nephritis with nephralgia and removed the kidney. Ten years later
Harrison made three nephrotomies, and, though under a wrong diagnosis
in each case, it was noticed that the symptoms all cleared up and that
albumin disappeared from the urine. About the same time Newman showed
that albumin and casts have often appeared in movable kidney, because
of torsion of the vessels, and that they disappeared after nephropexy.
Then Pousson, in 1899, reported some twenty-five cases of hematuria and
nephralgic nephritis, operated upon by nephrotomy and nephropexy, with
great benefit. In 1899, Israel was, perhaps, the first to formulate
rules for nephrotomy for these conditions. In 1899, also, Ferguson
claimed that chronic nephritis should be treated as are inflammations
elsewhere, by relief of tension and even drainage. Meantime, Edebohls
had been doing partial decapsulation and fixation in cases of so-called
unilateral nephritis (the possibility of which is disputed by the best
authorities, like Kümmel), and later extended his method to complete
decapsulation (_capsulectomy_), with replacement of the kidney in its
fatty bed, claiming that by and through the new adhesions thus produced
new and more complete as well as additional blood supply was furnished,
and that regeneration of the slightly altered parenchymatous tissue, as
well as absorption of exudates, was produced. (Guiteras.) The fact that
it seems now well established that these forms of chronic nephritis are
always bilateral does not of itself affect the cogency of Edebohls’
reasoning, if it be otherwise correct.

Accurate diagnosis has much to do with this problem. Israel has shown
that chronic nephritis is even more difficult of recognition in the
living than in the dead, not only after ordinary examination of the
capsule, but also after opening into the kidney. Age is not a serious
contra-indication, and enlargement of the heart is said frequently
to subside after these operations. If cardiac compensation be good
operation is permissible, if not otherwise contra-indicated. Edebohls’
method is to anchor the kidney to the muscles of the back, whether it
was previously movable or not. Primary healing is desirable, since
“nephritics” do not bear suppuration well.


=Indications for Operation.=--At present a satisfactory summary is
impossible. It is of the first importance that operation should be
undertaken _early_, since to wait until anasarca or other grave
conditions supervene is to invite disappointment as the result of a
procedure which is by many considered capital. The coincidence of
pronounced disease of any other type would be a contra-indication.
Bacteriuria, pyuria, etc., would perhaps make it more desirable
rather than otherwise. Cases of operative toxemia (postscarlatinal,
typhoid) and of cirrhotic type, without other contra-indications, are
the most favorable. When a careful examination of the patient and the
urine leads the surgeon to think that preparatory treatment may be of
advantage, he should find therein almost his only excuse for delay, if
operation is to be done. Low hemoglobin percentage should also lead to
postponement.

_Operation_ may consist of _nephrolysis_, or breaking down of
adhesions, by which pain is frequently relieved, of _decapsulation_, of
_nephrotomy_, and, finally, of _nephrectomy_, in case serious lesions
are disclosed. It is doubtful if benefit is due so much to formation
of new vessels as to a freer circulation of blood within the kidneys,
with their consequent improved opportunity for repair and elimination.
Guiteras, for instance, does not believe in total decapsulation, but in
partial exposure of a sufficient area on the posterior kidney surface
to assist in its fixation, if movable. Otherwise he considers that
simple division of the capsule over the convexity will be sufficient.
In cases of unilateral nephralgia and hematuria he advises nephrotomy,
not so much as an approved therapeutic measure as for exposure, perhaps
for revealing the possible existence of deep lesions.

[Illustration: FIG. 633

Acute pyelonephritis with multiple miliary abscess formation. (Israel.)]

The recent reports from various surgeons concerning the value of renal
decapsulation alone are by no means unanimously favorable, although a
majority of writers are in favor of exposure of the kidney, capsulotomy
and fixation, either by suture or tampon. Still, it does not seem at
present justifiable to maintain that decapsulation can be expected to
cure diffuse or deep-seated arteriosclerosis or degenerative processes
within the kidneys.

The question of the _suitable anesthetic_ is here one of importance.
For reasons set forth earlier in this work, ether should always be
avoided. If the operation be one that can be speedily performed,
nitrous oxide gas alone may suffice. Otherwise it should be done under
chloroform, preceded perhaps with ethyl chloride, or under somnoform.


=Pyonephrosis.=--As a condition this is to be distinguished from
ordinary abscess of the kidney, in that it implies the retention in
the renal cavity or pelvis of pus with eventual destruction of kidney
tissue. In other words it is an _empyema_ rather than an abscess. It
results from septic or tuberculous invasion, plus ureteral obstruction,
regardless of the obstructing cause, _e. g._, calculus, plugs of mucus,
stricture, kinking of ureter, or extrinsic tumor causing pressure.
Occlusion may be so complete that no urine escapes from the affected
kidney, while that from the other is clear, or the phenomenon may be
intermittent. There results more or less enlargement and often great
dilatation of the diseased kidney. Pus thus retained has been known to
be discharged into the intestine or even into the lung. Spontaneous
recovery is rare. Aspiration from the back in these cases is proper for
diagnostic purposes.


=Treatment.=--Pyonephrosis, like any other collection of pus, calls
for _incision_ (nephrotomy) and _drainage_, with removal of any
possible foreign body, such as calculus. If the entire kidney be found
destroyed, or so compromised as to jeopard its future, a _nephrectomy_
may be done at once, while it may be a secondary measure in cases of
permanent urinary fistula following drainage. So, too, if the kidney be
found tuberculous, it is better to remove it than to temporize.


=Perinephritis.=--To pus formed in a perirenal phlegmon is given the
term _perinephritic abscess_; this is sometimes due to external or
penetrating injuries; sometimes it appears as a primary condition
difficult of explanation; but it usually follows inflammation of
adjacent structures, such as the kidney itself (tuberculous pyelitis),
the liver, the colon, and the appendix. While perinephritis usually
terminates by suppuration, spontaneous recovery, with more or less
absorption of exudate, is known to occur. These perinephritic
collections sometimes attain enormous size, and are then sure to
migrate, always along lines of least resistance, which takes them
usually downward, either toward the loin or the groin. I once tapped
below Poupart’s ligament a collection which exceeded a gallon. These
abscesses may also, more rarely, burst into any of the adjoining
cavities, and discharge either by the mouth, bowel, or bladder, or even
externally.


=Symptoms.=--In addition to the usual systemic indications of the
presence of pus there may be _tumor in the lumbar region_, sometimes
with distinct fluctuation, usually with rigidity of the lumbar and
psoas muscles, perhaps even contractions of the thigh muscles which
may simulate hip disease. These abscesses have been mistaken for
peri-appendical phlegmons. If necessary to establish the presence of
pus the exploring syringe may be used, but this is rarely necessary.


=Treatment.=--While in the early stages the local application of
guaiacol may be of use, every collection of pus thus formed here, as
well as elsewhere, needs _evacuation and drainage_. This latter is to
be provided by opening through the loin, in order that gravitation in
the dorsal position may be of greatest assistance. A more or less free
incision, such as is made for exploring or removing the kidney, will
usually be sufficient, but may be combined with a counteropening at any
point where the latter would be of advantage. Thus should pus present
in the groin an opening should be made both posteriorly and at the
point where it appears to be coming toward the surface.


=Tuberculosis.=--At no age are the kidneys exempt from tuberculous
lesions, although these are more frequent in the earlier years of life.
Here as elsewhere they may assume the disseminated miliary type or
occur as a solitary focus. The infection may proceed upward from the
bladder, or it may be a local expression of a widely diffuse process.
In the latter case it has passed beyond the control of the surgeon
as such, and calls for general therapeutic measures, judiciously
selected and actively maintained. Not a few cases of renal abscess, of
pyelonephritis, and even of perinephritic abscess, are due to primary
tuberculous lesions.


=Symptoms.=--About the earliest symptoms that a patient may complain
of are _thamuria_ (frequency of urination), with blood or pus in the
urine. Even at this early stage the condition is essentially surgical,
so the diagnosis should be established. Cryoscopy alone is hardly
sufficient, although if the freezing point be studied it should be
regarded along with the amount of fluid ingested and the quantity
of carbohydrates taken with the food. Ureteral catheterization is
valuable, although until it came into vogue we were content to study
the cystoscopic appearance and to judge by the ureteral orifices,
assuming that if one appear healthy and the other not so operation is
indicated.

The question of removal of a totally diseased kidney when the other is
more or less affected is one demanding greatest judgment. Some of the
more recent operators endeavor to determine this by the cryoscopic test
of the urine from the less affected organ. If this stand the test they
do not hesitate to remove the one which is totally diseased. Thus it
would appear that the ideal method is one of careful study of the urine
from each kidney, although it is acknowledged that when the question is
still in doubt the associate kidney may be explored before deciding to
remove the one most diseased.


=Diagnosis of Renal Tuberculosis.=--The most frequent and significant
symptoms of renal tuberculosis are _pain_, local and referred;
_hematuria_, _polyuria_, and _pyuria_. In young adults suffering
from bladder irritability, _painless pyuria_ usually indicates
tuberculosis of the bladder, secondary to that of the kidney, this
being particularly true when the urine is hyperacid. This urine, if
noted, will be found at first faintly cloudy or smoky, while later the
admixture of pus becomes more evident. The frequency of micturition
(thamuria, pollakiuria), which is frequently noted early, may be due
mainly to polyuria; the final test is the discovery of bacilli in the
urine. There is another form of thamuria which is associated with
tenesmus, constituting the painful cystitis of Guyon, which depends
on complications in the bladder itself. A search for bacilli is often
disappointing, and tuberculin may be used in the endeavor to make a
diagnosis, as well as animal inoculation. Tuberculin might, however,
give rise to error were there tuberculous foci elsewhere about the body.

[Illustration: FIG. 634

Tuberculosis of kidney, nodular form. (Israel.)]

_Renal tuberculosis_ may run a painless course, or it may be
accompanied by a severe renal colic or renal crises, the latter
sometimes due to plugging of the ureter with cheesy debris. Pyuria may
be masked by hematuria, the latter trifling, apparently spontaneous,
and occurring even during repose.

More accurate diagnosis can be rarely made without resort to the
cystoscope and catheterization of the ureters. When in the cystoscopic
image the ureteral orifice is enlarged, congested, and even hemorrhagic
or ulcerated, it may be regarded as evidence of tuberculous disease in
the corresponding kidney. Meyer has claimed that in the descending
form of tuberculosis the mouth of the ureter is ulcerated, while in
the ascending form it is apparently healthy. When both outlets are
apparently healthy, and urinalysis indicates renal disease, the case
must be one of ascending lesion. Fenwick has described what he calls
a “golf-hole ureter,” the orifice being dilated and patulous, and the
appearance being to him pathognomonic.

Ureteral catheterization is perhaps less necessary on the suspected
side than it is to prove the healthfulness of the kidney on the
opposite side. The disease is more common in the female, and usually
occurs in early adult life. It is more often a descending than an
ascending affection.

[Illustration: FIG. 635

Renal tuberculosis as seen on section. Papillary granulomata seen at
_T_. (Israel.)]


=Treatment.=--Radical treatment of renal tuberculosis is possible only
when the lesion is limited to one organ. What shall be done with the
kidney involved, when exposed and the disease revealed, may depend
to some extent upon the actual degree of involvement. More and more
surgeons are agreeing that anything like partial nephrectomy is of
questionable value, and that an organ _distinctly tuberculous should
be removed_. In other words, partial nephrectomy is of doubtful merit.
Of course, the kidney should be opened before its removal, unless from
its exterior it is seen to be hopelessly involved. A further question
of great importance is that of _involvement of the ureter_. With a
few associated lesions in the kidney the ureter may easily escape,
but with a kidney thoroughly degenerated, and with infected urine or
tuberculous debris passing constantly down through the ureter it cannot
escape contamination. It is not a difficult procedure, nor does it add
to the gravity of the operation, to extend the incision sufficiently
to permit not only the delivery of the kidney but the exposure at
least of the upper portion of its ureter. In this way the renal pelvis
may be opened and the ureter itself examined. When thus involved, and
especially if it be determined to sacrifice the kidney, as much of the
ureter should be removed with it as can be reached. While theoretical
considerations would always require these measures to be combined,
many mild tuberculous lesions of the ureter undergo spontaneous
retrocession after removal of the diseased kidney from which it has
become contaminated.

The incision intended to expose the ureter should begin about a
half-inch forward and in front of the lower costal cartilage, parallel
with the last rib, and terminate on a level with the anterior superior
spine, about one inch toward its inner side. This incision will then
be about four inches in length. The use of a pillow is of assistance
in the easy performance of this operation. The body should be rolled
as far as possible without losing negative pressure upon the abdomen.
The more abdominal fat there is present the further over the patient
should be rolled; a stout patient should have the hips raised from
the table by a cushion, in order that the abdomen may be pendent,
while the foot of the table is somewhat elevated and the operator is
facing the abdomen. After exposing the fat which is adherent to the
peritoneum, and the knife is laid aside, the peritoneum is separated
from the abdominal wall until the kidney and the perinephritic fascia
are recognized. Then with a short retractor the posterior edge of the
wound below the ribs is elevated, after which, under the influence
of gravity, the cavity opens widely, the fascia may be torn through,
and the kidney exposed and freed. The retractor is then removed,
the anterior edge of the wound pressed backward, and the kidney is
easily delivered from the abdominal cavity; or if its delivery be
impracticable, it may be at least so drawn up that the renal vessels
are easily exposed, tied, and divided. After their division care should
be given that the weight of the kidney does not drag injuriously upon
the ureter. The latter is then cleared of peritoneum, especially
to its outer side, by blunt dissection, after which a medium-width
Sims speculum, with a long bill, may be passed downward between the
peritoneum and the abdominal wall and made to draw the latter upward.
Thus an extensive view of the ureter is afforded, while its lower
portion may be still further freed toward the base of the broad
ligament. By a continuation of this process of separation and exposure
it is possible to release the ureter almost to its junction with the
bladder, where it is tied, its stump being disinfected with pure
carbolic.


=Syphilis and Actinomycosis.=--These lesions may be briefly dismissed
so far as they pertain to the kidneys. _Gummas_ are rare, renal
syphilis being usually of a disseminated type, which should be treated
by internal therapy, except when abscess results or when there arises
some peculiar surgical complication. _Actinomycosis_ is rare in the
kidneys, and is not recognized until the peculiar fungi are found in
the urine, or until some granuloma, developing toward the surface,
breaks down and discharges its characteristic products.


RENAL COLIC.

Renal colic implies severe and often agonizing pain, which follows
spasmodic contraction of the renal pelvis and ureter, in the effort to
expel an obstructing object from one or the other. It may be produced
by _calculi_, by _clots_ of blood, _clumps of pus and debris_, by
particles of _sloughing tissue_ (as in breaking-down tuberculous or
cancerous foci), by _extrinsic pressure_ of various morbid products,
or finally by _kinking_ or alternating stricture and dilatation of
the ureter. _Pain_ is the constant and significant feature, marked by
spasmodic exacerbation. It is usually well localized, and referred
along the course of the ureter and the cord to the testicle in the
male, with retraction of the scrotum, to the labium in the female, and
down the thigh in both sexes. With it there usually occur more or less
sympathetic disturbances, such as _nausea_, with most pronounced local
tenderness and sometimes abdominal rigidity.


=Treatment.=--Treatment, while palliative during the intensity of the
attack, should be later made radical. For the former hot applications,
morphine, and chloroform inhalations may be used. It may happen that
an almost complete inversion of the patient will be followed by
relief. Large does of glycerin, and sometimes of aspirin, will also
occasionally prove beneficial. Meantime the case should be carefully
studied and a skiagram be taken, in order that one may intelligently
advise and carry out whatever indications may be revealed.


RENAL CALCULUS.

_Renal and vesical calculi_ are the result of the precipitation of
material previously held in solution by the urine as it escapes from
the tubules, their nuclei or nidi being usually a clump of cells,
particles of blood clot or of tissue. They are composed mainly of _uric
acid_, _urates_ or _oxalates_, less abundantly of _phosphates_, and
rarely of _cystin_ or _xanthin_. They vary in size from the smallest
visible particle to those weighing ounces, and in number from one to
hundreds. They occur more often in males, and usually late rather than
early in life. They may be found in one or both kidneys. When the
latter it may be assumed that some systemic defect underlies their
formation. In shape they vary greatly, the small, sharp particles
often causing as much pain as do large stones, or even more. Diathetic
conditions produce them in some _de novo_, while in others they result
from previous morbid processes.

Small calculi escaping into the bladder cause intense _renal colic_
(see above), and, within the latter, unless they escape through the
ureter, as they usually do when small or are not retained behind a
large prostate, they increase in size, and become then the common
_vesical calculi_, those with uric acid nuclei. Calculi long present
in the kidney usually set up what is known as _calculous nephritis_ or
_pyelonephritis_. It is quite possible, however, for such a concretion
to first form within the tubules or at the apex of one of the pyramids,
so that it does not fall free into the renal cavity. In such locations
it may produce great pain, with hematuria and tenderness, yet not for
a long time escape into the renal pelvis. Such a stone may be shown
by a good skiagram. Calculi long retained will cause other troubles,
whose characteristics will be revealed by careful study of the urine,
especially of that drawn from the affected kidney, albuminuria and
pyuria often figuring. The symptoms include _pain and tenderness_,
which may be referred; _colic_, _hematuria_, and _pyuria_. Symptoms
of less frequency include _thamuria_ (sometimes painful), nausea, and
vomiting. The accompanying features include pyonephrosis, tuberculous
or movable kidney, or possibly various neoplasms.


=Symptoms.=--_Stone in the ureter_ may cause symptoms likely to be
mistaken for appendicitis, especially when lodged on the brim of the
pelvis, or an inflamed appendix may hang over into the pelvis and cause
bladder and rectal symptoms, while on palpation through the vagina the
tenderness and thickening may be misleading. In such cases the urine
offers the surest guide. Acute pancreatitis should hardly be mistaken
for renal trouble, as there would be a history of former attacks of
indigestion, probably associated with typical gallstone colic, while
the location of pain and the presence of pancreatic enlargement would
be significant. In pancreatitis, moreover, the urine might show sugar.
Renal or ureteral colic is sometimes followed by such reflex paralysis
of the bowel, with meteorism and tenesmus, perhaps even with nausea and
vomiting, as to suggest intestinal obstruction. Again, the crises of
Henoch’s purpura, and of angioneurotic edema, sometimes accompanied by
hematuria, may mislead.

Inspection of the entire body will probably reveal purpuric spots or
areas of edema.

Finally, _x_-rays afford very convenient means of diagnosis under many
circumstances, although mistakes have occurred from misinterpretation
of shadows. Nevertheless, when a well-taken picture shows unmistakable
evidence it may be considered as quite reliable.


=Diagnosis.=--In the matter of diagnosis few diseases, as Hunner has
shown, present such protean symptoms. Between calculous nephritis
and tuberculosis the only positive indication is the discovery of
bacilli in the urine or the reproduction of the disease in animals by
inoculation. Blood occurs in both, but is more likely to be influenced
by exercise in cases of stone. Pus occurs also in both, while pain is
unreliable. Palpation shows nothing, unless it may reveal thickening
of the ureter in the female as felt through the vagina. In pyelitis
the presence of a stone may cause any of these conditions, or it may
develop because of them. If trouble have begun soon after an acute
infection, or during pregnancy, it is more likely to be a case of
infected kidney. When tumor is suspected, urinary examination is the
best guide. The sudden occurrence of hemorrhages, with their abrupt
cessation, rather favor diagnosis of tumor, as does also the absence
of pus. Still the latter may be absent when the ureter is obstructed.
Intermittent hydronephrosis is usually due to kinking of the ureter
connected with a movable kidney. During the attacks the kidney will
be enlarged and misplaced, while blood may appear. With return to
place comes subsidence of enlargement, while increase in the amount of
urine is characteristic. Idiopathic hematuria or “renal epistaxis” is
sometimes connected with the chronic interstitial forms of nephritis.
The urine shows blood, if dealing with renal calculus, and bile if with
biliary calculus. In the former pain is more likely to radiate down
the ureter, while in the latter it is upward and backward. In biliary
trouble the gall-bladder may be enlarged and movable or even pendulous.
Kelly has suggested a method of differential diagnosis by catheterizing
the ureter, and forcibly injecting into the pelvis of the kidney a
bland, sterile solution. If the pain which it produces be identified by
the patient as the same which is usually suffered it may be regarded
as diagnostic; if somewhat different, then the actual attacks are more
likely to be biliary. A normal renal pelvis should hold about 7 to 8
Cc. before the patient begins to complain.


=Treatment.=--In the milder cases, and those where small concretions
are repeatedly passed, medicinal treatment may be given a trial. While
the alkalies, especially the lithium preparations, have repute in
certain quarters, there is probably nothing superior to piperazin in
its power of dissolving small uric calculi. Its physical properties
and its expensiveness, however, make it disadvantageous to use. It is
so sparingly soluble that part of the benefit obtained from it may be
due to the volume of fluid ingested with it, and to the consequent
dissolving and washing down of small particles. Glycerin is also an
analgesic here, as in biliary calculi, and a half-ounce, administered
every two or three hours, will often give relief. Attention to the diet
is also necessary, especially in acute and uric acid patients.

When there is reason to believe that the kidney contains a calculus
which cannot be passed, and especially when an _x_-ray picture reveals
such a condition, then _surgical treatment_ alone offers prospect of
complete relief. This includes _nephrotomy_ and what has been named
_nephrolithotomy_, _i. e._, exposure and opening of the kidney and
removal of its contained concretions. When these are easily felt
the procedure is simple. However when only a small concretion has
been shown in the skiagram, and it is not easily palpable, even with
the kidney between the fingers, it is sometimes a difficult matter
to locate. One method of doing this is with a small needle, passed
repeatedly in the direction of the supposed calculus--used, in other
words, as a probe. When such a stone is thus recognized it should be
removed.

In cases of long-standing, renal pelves are dilated into relatively
large sacs, containing numerous concretions, or sometimes a large
stone in branching form, resembling coral. If a considerable degree of
pyonephrosis or of disintegration accompany such a stone a complete
nephrectomy should be made. It remains, then, for the surgeon’s
judgment to decide as between nephrolithotomy or nephrectomy, a
question which will be settled, in large measure, by what has been
ascertained regarding the condition of the other organ. If considered
fully competent little hesitation need be felt in removing the diseased
one; if its condition be distrusted, then it were best to not carry
out the surgical indication, but to substitute for it good general
treatment.


MOVABLE AND FLOATING KIDNEY.

In most of the serious and in many of the milder degrees of unnatural
mobility of the kidney to which the adjectives “movable” and
“wandering” are applied, the surgeon has to deal with a somewhat
anomalous condition, which, while it attains serious and alarming
symptoms during life, leaves little evidence after death. Thus, Ebstein
found it in only 5 out of 36,000, and yet it is said to occur in at
least 20 per cent. of all women examined. In women and children the
kidneys lie lower and deeper in the gutter on either side of the spine,
beneath the seventh to the tenth cartilage, the upper end of the left
kidney belonging at the level of the ensiform cartilage. The kidneys
are supported by perirenal fascia, by the renal vessels, by pressure
of the surrounding viscera, their anterior peritoneal covering playing
but small part. Abnormal mobility below the twenty-fifth year of age
is rare; its etiology is still obscure, it being found in women at
least six times as often as in men; more commonly in those who have
borne several children, or who have become suddenly emaciated after
long illness, while in men it is most common on the left side. The
kidney is afforded a small, distinct peritoneal covering, the so-called
mesonephron, which, with its other supports, may be more or less lax,
permitting differing degrees of abnormal mobility, the milder being
spoken of as _movable_ kidney, the more serious as _floating_ kidney.
As Belfield has shown, in every case of functional disturbance of the
urinary organs the possibility that a floating kidney may be the cause
of the trouble should be borne in mind.


=Symptoms.=--The symptoms vary from vague discomfort to agonizing
pain. Ordinarily they include dragging sensation in the abdomen, with
indefinable discomfort, a feeling of weakness, sometimes radiating down
the legs and across the back, these symptoms frequently accompanied
by dyspnea, flatulence, constipation, and frequency of urination, all
of which may be intensified by increased activity. In the more severe
forms we find abdominal tenderness, severe pain and vomiting, with
collapse and the occurrence of peculiar crises, sometimes of intense
agony, which may occur gradually or suddenly, ceasing in the same
fashion. Not one of these symptoms is pathognomonic of movable kidney,
nor can they be with certainty attributed to it until the suspicion
is confirmed by physical examination. The severe crises are described
as coming on with intense pain, nausea, vomiting, collapse, chills,
and sometimes considerable temperature, especially in hysterical
subjects. Osler and Atlee think that too much stress has been laid
upon the condition, especially after the patient’s realization of it,
the severer symptoms often dating from the first knowledge of the
facts. Obviously, temporary hydronephrosis may be caused by temporary
obstruction in the ureter, from displacement, while temporary venous
obstruction may cause pain in a different way. Actual alimentary
disturbances are very closely simulated, and sometimes it is difficult
to distinguish between a movable kidney on the right side and a chronic
appendicitis.

A great deal of attention has of late been given to _nephroptosis_ and
to the effects of _enteroptosis_, and their production. The peculiar
crises were long ago described by Dittel, and include sometimes a
feeling of suffocation, with a desire to loosen and remove clothing,
when, after lying down, the kidney resumes its position. When after
urination relief quickly follows, there is much to suggest kinking
of the ureter and distention of the renal pelvis. Much less frequent
features are jaundice, from contraction of adjacent viscera, and
persistent nausea from the same result, or hematuria from a disturbed
circulation. The more marked forms in women are usually accompanied
by certain neurotic features, which give them a feature to which they
are not properly entitled, while the entire digestive process and the
vasomotor innervation of the viscera seem more or less disturbed, with
consequent toxemia.

The actual indication of floating kidney is its _discovery by
palpation_, the degree of displacement being in some cases quite
noticeable; thus it may cross the middle line, or may be felt even
in the pelvis. In the female the kidney should lie above the twelfth
rib, posteriorly, and above the costochondral border of the eighth rib
anteriorly, and, therefore, not be easily palpated during respiration.
This statement is somewhat at variance with some of those contained
in the text-books on anatomy, the diagrams being all made from male
cadavers. It is of importance not merely in locating the organs, but
in fastening them in place, as all methods thus far devised leave much
to be desired in complete replacement. A kidney prolapsed only to the
waist-line can scarcely be sutured to the loin without displacing it
even farther backward. On the other hand, the kidney which lies near
the brim of the pelvis rarely causes acute symptoms, because, supported
from below, it enjoys accommodation of its ureter to its abnormal
relations, so that hydronephrosis rarely occurs. The truth is that in
most aggravated cases of nephroptosis nearly all the viscera have been
displaced downward, and Ingall’s suggestion to fasten in place at one
and the same time the kidney, the liver, the spleen, the stomach, and
the transverse colon is well founded, although difficult to carry into
effect.


=Treatment.=--Fixation of an abnormally mobile kidney is indicated
in every case where its displacement causes unpleasant symptoms, yet
simple as it is in theory it is neither easy nor always successful
in practice. To completely restore the kidney to place is to fasten
it higher than the natural routes easily permit, and requires either
resection of a rib or fixation of the kidney to one of the lower ribs,
a method which has been recommended and practised by some operators.
Because of the disappointment so often resulting from these operations
conservative practitioners have felt that by pressure from below, as by
an abdominal binder with a suitably placed pad, the kidney could be so
pushed upward and held as to be made comfortable. This may at least be
tried in the milder cases. The supports should never be put in place
until the patient is on her back and completely undressed. This method
of external support failing or proving unsatisfactory, the surgeon may
choose from many different methods the peculiar plan for _nephropexy_
or kidney fixation which he will adopt.

[Illustration: FIG. 636

Nephropexy. Method by sutures passed through both kidney and capsule.
(Hartmann.)]


=Nephropexy.=--These methods all have in common the intent to produce
adhesions between the kidney and its normal environment, by which it
shall be held in or near its proper place and prevented from dropping.
The kidney more than any other organ is held in a cushion of fat, and
it becomes a question to what extent this mass of surrounding fat shall
be removed. To take it all away considerably complicates the procedure;
to leave it is to not furnish the firmest possible surroundings for the
purpose. The patient should be placed either flat upon the abdomen or
turned well over on the side opposite that to be operated, a cushion
or bolster being usually placed beneath the abdomen and loin in such a
way as to push upward and into prominence the side to be attacked. The
incision employed may be parallel to the spine, about three inches away
from it, and carried down to the tissues outside the quadratus lumborum
and other spinal muscles. Most operators prefer an oblique incision,
made between the lower rib and the upper margin of the pelvis, its
centre about four inches from the spine, extending in either direction
two inches or more, in order to afford sufficient access. It is carried
down until the abdominal aponeurosis and muscles are exposed. These
are then divided and the perirenal fat, which is sometimes excessive
in amount, is exposed. The deep opening should now be stretched to
a size to permit the introduction of a hand, and exploration made
for the identification and retraction of the kidney. Much aid may be
afforded in this effort by the use of the other hand upon the outside
of the patient’s abdomen, which should all have been protected and
sterilized to permit such free manipulation. Sometimes it is easy to
find such a kidney, at other times and in persons of certain build it
is a difficult matter. It lies behind the peritoneum, and this should
never be opened during the effort. More or less of the perirenal fat
may be cleared away. The more or less elusive kidney being identified,
it should be seized with tenaculum forceps, which should secure only
its capsule and not injure its substance. With these it is drawn up
at least to the wound, or in some methods, it is withdrawn through it
and delivered upon the surface of the body. If sutures alone are to be
depended upon they may be placed after any one of a number of different
methods. The older method was to place the kidney as nearly as possible
in its normal relations and then unite the deep margins of the wound to
the capsule, and perhaps the cortex of the kidney, by a series of two
or three sutures on either side, either of chromic gut or of silk. The
theoretical objections which prevail against passing sutures through
the renal cortex are hardly well founded, and stitches may be so
placed, if desired, but they should not be drawn too tightly (Fig. 636).

Senn and others have endeavored to induce the formation of dense
adhesions by packing around the kidney with gauze, left _in situ_
for several days, whose presence should provoke the formation of
granulation tissue. In theory this works well, but in practise the
presence of the gauze is painful, its removal especially so, and the
wound must be left more or less open for the purpose. Since I have
learned of the harmlessness and the advantages of decortication I have
made a practise of decapsulating almost every kidney thus exposed, and
of endeavoring to utilize a portion of the capsule for the purpose
of support, as by cutting it into strips, which are threaded into
a needle, and then passed through the tissues, thus utilizing the
capsule for suture material, or by fastening it with sutures which
are not passed through the kidney substance. All in all I have had
best results from a combination of some such method as this with one
of suspension, for which purpose tapes or gauze are used and passed
beneath the kidney--one above the hilum and one below it--after it
has been delivered well into the wound, by which it is, first of all,
lowered into the position in which it is intended to hold it and
then maintained there, the ends being left hanging out of the wound,
where they are tied over a roll of gauze or something similar. This
provides the smallest amount of gauze, whose presence may provoke
granulation tissue, at the same time proving an efficient means of
support, and leaving trifling strips to remove when the time for their
removal has come. I have usually left them in place for nine or ten
days, by which time they are comfortably loosened by the presence of
granulations around them, and consequent moisture, so that they are
easily withdrawn, with a minimum of discomfort to the patient. Da Costa
has suggested an improvement on this by sewing the ends of strips of
gauze with chromic gut and letting these sewed ends be placed beneath
the kidney. In the course of time, as the catgut softens, the union
is separated, and the strips are easily withdrawn. If there be a
tendency in these tapes to slip from their desired position, they may
be attached to the capsule by a single suture of catgut, which will
have softened and disappeared before the time for their withdrawal has
arrived. Again in many of these instances the capsule which has been
stripped off, or more or less detached, may be utilized for the purpose
of fixation by suture with its own tissue.

Nearly all of these operations are without mortality, although they
are not yet as satisfactory as could be desired, the trouble inhering
partly in the fact that the kidney is not fastened as high up as it
should be, or else not in quite the same relative position, so that
there is some strain upon its vessels or upon its ureter. Every effort
should be made to imitate the original position as accurately as
possible. Methods theoretically more perfect, yet more complicated and
but little more advantageous, include fixation of the kidney to the
twelfth rib, by suture passing through the capsule and then around
the rib. No matter what method be adopted, it is necessary to keep
the patient in bed for several weeks after these operations, in order
that adhesions may not only form but may not be stretched by too early
change of posture.


TUMORS OF THE KIDNEY.

The kidney is the site of an occasionally benign and frequently
of a malignant tumor of some of the known varieties. The simplest
forms, like the fatty and the fibrous, are uncommon and deserve no
special consideration here. There is a so-called _adenoma of the
kidney_, which does not deserve this expression any more than does
the so-called adenoma of the thyroid, in that it is not built up of
the normal type of secreting gland, but represents something more or
less similar to it, perhaps only undergoing multicystic degeneration,
its commonest expressions being of congenital origin. The consequence
is the production of the so-called _congenital adenoma_ or _cystic_
or _multicystic_ or _polycystic kidney_, in which may be seen a
conversion of original renal tissue into a mass of cysts, surrounded
by degenerated kidney tissue, all semblance to the original being
lost, and the whole constituting a partial or complete invasion of the
organ, by which sometimes its proportions are enormously increased. The
condition is essentially of congenital origin, although its serious
clinical expressions may not occur for years. The result is to destroy
the renal function, to produce a growing mass, and to constitute an
essentially surgical condition to be relieved only by nephrectomy. (See
Fig. 637.) I recall one child of twenty-three months with a tumor of
this character, of such size and extent that it could only stand erect
when wearing from its neck a sort of suspensory in which the lower
part of the abdomen was contained. I removed this kidney by abdominal
section, the child recovering, and being at that time the youngest case
that had ever survived a nephrectomy. A number of years later a similar
condition developed in the other kidney, of which the child finally
died, it having passed during the last thirteen days of its life not
more than an ounce or two of urine.

Of the solid tumors of the kidney both _carcinoma_ and _sarcoma_
occur, the former usually as a secondary growth, the latter usually as
primary, although any form may be met. The sarcomas are more frequent
in early life and in general more common. On account of the kidney
having a well-marked capsule metastasis is not so common, in the early
stages, as from some other organs. These malignant tumors may attain
great size; some grow regularly in shape, others constitute most
irregular masses. The entire organ may be involved or only a part.

There are no indicative _symptoms of renal cancer_ that may not
be met in other conditions; the development of tumor, perhaps its
displacement, pain, and hematuria, though late, and, in proportion to
the rapidity of growth, enlargement of superficial veins and general
cachexia. When the tumor is large enough to press upon the vena cava or
upon one of the common iliacs there will be edema of one or both lower
extremities. The veins of the external genitals are more likely to
suffer early rather than late (Figs. 638, 639).

[Illustration: FIG. 637

Congenital cystic kidney; exterior and internal appearance; patient
forty-two years of age. (Schmidt.)]

[Illustration: FIG. 638

Cancer of kidney, intramural, as seen after dividing the organ.
(Israel.)]


=Hypernephroma.=--There is one peculiar variety of solid tumor of the
kidney which deserves special mention, the so-called hypernephroma.
These tumors consist essentially of adrenal tissue, although when they
develop within the kidney their occurrence there is due to the presence
of aberrant rests of the original suprarenal tissue. Gravitz, in 1883,
was the first to recognize their real character. Supernumerary adrenal
rests have been met with in many parts of the body, not alone in the
kidney and perinephric tissue, but in the broad ligament, along the
spermatic vessels, in the sexual glands of both sexes, in the liver,
the mesentery, and even the solar and renal plexuses. Their occurrence
in these localities may be explained by the close relationship between
the mesonephros and the origins of these various organs. Hypernephroma
has no pathognomonic signs or symptoms. It is usually a single tumor,
although both kidneys have been affected. When the organ is not so
involved as to mask all its original features the tumor will be found
beneath the capsule, varying in size from that of a pea to that of
a child’s head, its outer surface lobulated by depressed bands of
capsule, its color lighter than that of the surrounding kidney texture,
while projecting portions will be soft and almost cystic. When met with
in other parts of the body its gross characteristics are essentially
the same. Metastasis is very common, the tumor often extending along
the walls of the veins, or even more often partially filling them than
the lymphatics. A common method of extension also is by implantation
within the peritoneal cavity; for the secondary implantation occurs
most often along some portion of the urinary tract--_e. g._, the
bladder.[66]

  [66] It may assist in the recognition of hypernephromatous tissue,
  after removal, to remember that adrenal tissue has the property of
  decolorizing starch which has been turned blue by the addition of
  iodine. Crofton has shown how there may be put into a test-tube a 1
  per cent. starch solution colored with a drop of weak tincture of
  iodine. If to this solution hypernephromatous tissue be added the
  blue color changes gradually to a pink and then fades out.

[Illustration: FIG. 639

Infiltrating form of cancer of the kidney. (Israel.)]

Hematuria and renal colic are the most conspicuous features connected
with the growth of these tumors. The former often occurs during sleep,
and blood is passed in almost pure form, perhaps for a considerable
period of time, after which spontaneous recovery apparently takes
place, the trouble recurring at intervals.

There is but one method of treating hypernephromas, like other solid
tumors, namely, by complete extirpation, _i. e._, _nephrectomy_. Even
this may be too late, but should be undertaken, except in the most
unpromising instances. If the existence of metastatic involvement can
be determined even nephrectomy may be considered useless. (See chapter
on Cysts and Tumors.)


HYDRONEPHROSIS.

This term refers to a more or less permanent distention of the
kidney cavity by retention of urine, due to partial or intermittent
obstruction to its escape. An _intermittent_ form is common, which,
however, at almost any time may lead to some degree of enlargement,
while when the obstruction is permanent the resulting tumor becomes
practically a thin-walled cyst, which may contain an enormous amount
of fluid, more or less altered urine, which will contain, in addition
to the ordinary urinary elements, cholesterin crystals and other
adventitious products. Hydronephrosis, then, may be _congenital_ or
_acquired_ in origin, _intermittent_ or _permanent_ in character, and
_unilateral_ or _bilateral_ in location. Among the acquired causes
are strictures of any portion of the urinary tract below, either in
the ureter, the prostate, or the urethra; tumors of any kind making
pressure; movable kidney which permits of kinking; tuberculous diseases
which lead to chemosis of the mucosa and consequent obstruction; renal
calculi which plug the ureter; foreign bodies, blood clot, and the like
(Figs. 640 and 641).

[Illustration: FIG. 640

Hydronephrosis from obliteration of ureter by tuberculous disease.
(Tuffier.)]

[Illustration: FIG. 641

Hydronephrosis in first stage of development. (Rayer.)]

[Illustration: FIG. 642

Operative treatment of hydronephrosis or pyonephrosis. (Hartmann.)]

Until the infectious or suppurative element be added the urine is
in these cases but little changed. When infection is added the case
becomes one of _pyohydronephrosis_, and perhaps finally one of distinct
_pyonephrosis_. The symptoms produced at first are not very pronounced
and will vary with the exciting cause. If the result of acute
obstruction, renal colic is perhaps the most significant. When this is
accompanied by tumor in the region of the kidney the interpretation of
the phenomenon is easy. Sudden decrease in size of such tumor, with
unusually great escape of urine, is also pathognomonic of intermittent
hydronephrosis. The discovery and the history of a gradually increasing
tumor in which, when large, fluctuation can be determined, and in
which fluid is easily found with the aspirating needle, will permit a
differentiation of these pseudocysts from solid tumors of the kidney.
They are to be distinguished from _ovarian cysts_, from general
_ascitic accumulations_ within the abdomen, and from _perinephritic_
and _spinal abscesses_. Their location, which corresponds so closely
with that of the kidney, especially while they are small, their
gradual growth, the displacement of the abdominal viscera forward and
to their inner side, their enlargement downward and their fluctuating
character will usually provide features by which they may be accurately
recognized.


=Treatment.=--The _treatment_ of intermittent hydronephrosis in its
earlier stage may be accomplished by some measure less radical than
nephrectomy or nephrotomy, particularly when due simply to abnormal
movability or to pressure of some extrinsic growth. Hydronephrosis due
to obstruction by renal calculus may be relieved by removal of the
obstructing stone, but a hydronephritic cyst, which has attained large
size, in which practically all semblance to secreting kidney structure
has disappeared, should be _extirpated_, unless this should entail
too formidable an operation, in which case it should be freely opened
and drained until such time as it has contracted to a size justifying
enucleation (Fig. 642).


THE URETERS.

There are a few morbid surgical conditions of the ureters, so distinct
from those of the bladder below or the kidneys above as to require
separate consideration here. They are frequently involved in the
pyogenic and tuberculous infections, which spread along them in either
direction, but the chief surgical diseases deserving mention here are
_stricture_ and _calculus_.


STRICTURE OF THE URETER.

Stricture of the ureter may result from intrinsic or extrinsic lesions.
Thus it has been injured in operations upon the pelvic viscera, as in
parturition, and it is not infrequently pressed upon by neoplasms;
but the majority of its contractions are cicatricial, and are
consequences of ulceration or injuries done by calculi. Stricture of
the ureter is to be recognized rather by its consequences--_i. e._,
hydronephrosis--than by more direct symptoms. Its accurate location
is now possible by the use of the cystoscope and the ureteral bougie
or catheter. When by the cystoscope no urine is seen escaping from
the ureter one naturally infers its complete obstruction--in fact,
the degree of the latter is fairly estimable with this instrument.
However, with the passage of a bougie the trouble may be found. This
is particularly of value when the lesion is an impacted calculus, for
it indicates to the surgeon the level at which he should direct his
operative relief, a matter which may also be decided by a skiagram.

While in the hands of experts dilatation of the ureters may be
accomplished from below, it is usually beyond the ability of the
average surgeon. He has to decide, then, as to whether the ureter
should be exposed along its course, from the loin, extraperitoneally
along the groin, or by abdominal section. A ureter hopelessly entangled
in a mass of cancer may be turned into the other ureter or into the
bowel. A ureter fixed in a narrow, cicatricial band may be divided and
its upper end turned into the tube below the stricture by a process of
transplantation or anastomosis, which is one of the feats of modern
surgery; but a ureter hopelessly involved for a considerable portion,
or hopelessly diseased, will require nephrectomy, as the kidney above
it may be compromised and can probably be well spared.

Calculi impacted in the ureter are most commonly arrested at those
points where its caliber is normally smallest, just below its origin,
at the pelvic brim, and just above its orifice. The symptoms of
impaction are those of renal colic, already considered. It should be
sufficient that extreme pain and the escape of pus and blood in the
urine, accompanied by more or less distention of the kidney above,
are noted. If there be a history of previous attacks of this kind,
with the passage of small calculi, the diagnosis may be regarded as
positive. This may or may not be confirmed by the _x_-rays, or by the
catheterization of the ureter from below.

Gibbon has suggested _intra-abdominal exploration_ and palpation of
the ureter for the discovery and location of impacted calculi, and
recommends that when discovered they may be removed by extraperitoneal
incision, which may be lumbar, iliac, inguinal, vaginal, or even sacral
or rectal; while with the advantage of combined manipulation, the
operator having one hand in the abdominal cavity, the actual work is
more rapid and certain.

This procedure is not to be advised in every case by any means, but may
prove of advantage in doubtful cases, and especially in those where,
when the abdomen has been already opened, a stone is accidentally found
in the ureter, since when the latter is opened extraperitoneally it is
rarely necessary to suture it.

The _non-operative treatment of ureteral calculi_ has been considered
when speaking of renal calculi. The _operative treatment_, inversion
of the patient having failed, may consist of exposure of the upper
two inches of the tube, by an incision parallel to the twelfth rib,
and carried well forward and downward toward the middle of Poupart’s
ligament. Through such an incision the whole length of the ureter may
be reached. The opening is made down to the peritoneum, which is then
pushed toward the median line. On its posterior surface, adherent to
it, will be found the ureter. At the point where the stone is impacted
the ureter is to be divided and the stone removed. In theory sutures
should be inserted; in practice, they are rarely needed, as these
incisions usually heal kindly without them.

A stone impacted at the vesical orifice of the ureter may, in the
female, be removed after such dilatation of the urethra as shall permit
access, or it may be removed through the vault of the vagina. In the
male only the most expert manipulators within the bladder will attempt
its removal in this way without at least a perineal section.


OPERATIONS UPON THE KIDNEYS AND URETERS.

In addition to the operative procedures already described the principal
operation upon the kidney is _nephrectomy_. While this may be
_partial_, under rare circumstances, the procedure is so essentially
similar to the complete operation that it is only necessary to say that
if a portion of the kidney be removed, bleeding from spurting vessels
should be arrested by ligature, while the oozing, at first pronounced,
will soon subside under the application of hot water, after which
absorbable sutures may be used in sufficient number to approximate the
parts.

[Illustration: FIG. 643

Position of patient and various lines of incision for nephrectomy and
other operations upon the kidneys. _A_, the favorite method of approach
for most purposes. (Hartmann.)]

_Total nephrectomy_ is usually done by the lumbar route, the kidney
being exposed by an oblique incision extending obliquely downward from
near the spine, parallel to the lower rib, between it and the crest
of the pelvis, and as far forward as may be required for the purpose.
For removal of a large solid tumor a large opening should be made, and
the above incision may be extended in any required direction, or an
additional cut may be made wherever required. In fact, in attacking
some of the very largest growths it becomes necessary to apparently
almost bisect the patient in order to furnish sufficient space. As
the mass to be attacked lies behind the peritoneum it is rarely
necessary to open the peritoneal cavity. This is usually done only
by inadvertence or because of density of adhesions, and the effort
should then be made to at once close it temporarily or permanently.
Especially should every attempt be made to prevent contamination when
dealing with tuberculous or suppurative renal disease. Ordinarily the
abdominal opening does not extend nearer to the spine than the border
of the spinal muscles. These may, however, be divided if necessary. So
also may the deep fascia be divided in any direction, and, in fact,
the last rib may be removed _in toto_ if required. The kidney or the
tumor, having now been reached, should be isolated. If the condition be
cancerous as much of the surrounding tissue should be removed as the
case will permit; if otherwise, an enucleation of the kidney from its
more or less infiltrated bed will be sufficient. It is usually removed
with its capsule, but sometimes the latter is so adherent that it is
easier to enucleate the kidney itself from within it. Adventitious
vessels may enter the kidney, more especially from below. The surgeon
must be prepared, then, at any time to clamp and secure them if found.
Sometimes enucleation of the kidney is exceedingly easy; at other times
old adhesions or surrounding infiltration make it a matter of great
mechanical difficulty. The intent is to not only isolate it, but to
make such exposure of its pedicle that one may be securely protected
against hemorrhage. Incidentally the ureter should be examined from
above, by passage of a probe, or by injecting a colored solution, in
order to know later if it passes freely into the bladder. It is the
accurate securement of the renal vessels which is perhaps the most
necessary feature of the operation and upon which most depends. When
this is made impossible by extraordinary circumstances expedients must
be adopted, as, for instance, the use of an elastic ligature--_i.
e._, a piece of small rubber tubing, drawn tightly around the base
of the mass and secured by clamp, ligature, or suture, the intent
being to leave it for at least two or three days until it shall have
accomplished its work, and then either to remove it or to allow it to
loosen itself in time and come away.

[Illustration: FIG. 644

Nephrectomy. Complete delivery of kidney and ligation of its vessels
and ureter. (Hartmann.)]

Under some circumstances the surgeon may so complete the nephrectomy
that the external wound may be closed without drainage; but when there
has been contamination, as by escape of contents, either purulent
or urinary, or when a considerable mass of tissue has to be left
enclosed within an elastic ligature surrounding the stump, then an
opening should be left in order that slough may easily escape and
ample drainage be afforded. A reliable ligation of the renal vessels
should be made, which is best done with at least two ligatures, taking
the pedicle in parts, or else carefully isolating the vessels when
sufficiently exposed, and tying each one of them separately, after
which the whole group may also be enclosed in a single ligature. A
few operators have reported such accidents as tearing the renal vein
from the vena cava, and such a wound has been successfully sutured,
the patient recovering; this requires, however, both coolness and
resourcefulness in the presence of serious difficulty and danger.
Certain dense tumors can be removed by process of morcellation, _i.
e._, removal of a portion at a time, the separate pieces being cut away
with scissors or knife, as may be the more convenient, and hemorrhage
being controlled by clamps.

The _anterior_ or Trendelenburg route is rarely selected for
nephrectomy, but may be adopted when this procedure is made a part of
other abdominal work, or may be necessitated by the presence of a large
tumor in a small abdomen, as, for instance, in children. The abdomen
will be opened as for any abdominal tumor, either in the middle or to
one side, as may seem best. The tumor itself will so far displace the
viscera as to perhaps present at once beneath the knife. It may be
necessary to go through the peritoneum twice. After being thus exposed,
and the abdominal cavity protected, the balance of the operation is
again a process of enucleation, with securing access to the pedicle of
the tumor, where its vessels and the ureters may be found. These again
are ligated and the mass removed as though it were from the peritoneal
cavity. Posterior drainage may be added, although rarely necessary.

Other operations have been suggested to meet the needs of individual
cases. Thus _pyelectomy_, or removal of a portion of the dilated pelvis
of the kidney, has been performed by Murphy and others, the process
being essentially an excision of a portion of the sac wall and its
retrenchment by sutures. Plastic attachment of the dilated upper end
of a ureter to the floor of the renal pelvis has also been effected
in much the same way, as in a case reported by Murphy, where, after
opening the sac of the pelvis, the ureter was slit for a considerable
distance, while at the lower angle a V-shaped piece of the sac
was fastened into the ureteral opening, thus making a funnel-like
communication.

Again, as illustrative of some of the radical suggestions of recent
years, Watson has proposed that in instances of hopeless bladder
conditions, where the patient is made miserable, there should be a
turning out of both ureters on the loin, and the formation of two
_ureteral fistulas_, after which the patient may wear a drainage
receptacle, and in this way enjoy a comfort otherwise unattainable. He
has reported the case of such a patient, who has thus passed all the
urine for four years, and urine from one side for eleven years, who was
otherwise in comfortable health.

[Illustration: FIG. 645

Longitudinal suture of ureter. (Hartmann.)]

[Illustration: FIG. 646

Implantation or invagination of ureter with fixation and then with
circular sutures. (Hartmann.)]

[Illustration: FIG. 647

Longitudinal incision and transverse suture of ureter for stricture,
similar to the pyloroplastic method of dealing with pyloric stenosis.
(Hartmann.)]


=Operations upon the Ureters.=--The surgery of the ureters is also
quite modern, and has been worked out in the experimental laboratory.
That ureteral tissue will heal has been proved by Murphy, who has
remarked that “The peritoneum is the only tissue that unites as kindly
as does the ureter.” After accidental injuries during other operations
the ureter may be sutured almost as though nothing had happened. These
sutures should be made with fine round needles, and be placed closely
together. They should be made of fine silk or thread.

Not only end-to-end union but lateral anastomosis and even more
ingenious methods of transplantation and implantation are now in
vogue. Figs. 645, 646 and 647 illustrate some work in this direction,
and show what may be done by work quite similar to that done upon
the small intestines or the bloodvessels. More complete instances
of transplantation have been effected in connection with exstrophy
and carcinoma of the bladder, where, for instance, the ureters
individually, or the base of the bladder containing the ureteral
orifice, have been dissected out and implanted in the colon or the
rectum.[67]

  [67] In one case I carried out the following procedure, necessitated
  by cancer involving the urethra, the base of the bladder, the
  rectum, and the whole floor of the pelvis, in a female patient,
  the disease having attained a degree making urination or even
  catheterization impossible. I opened the abdomen, dissected out the
  _right ureter_ from the bladder, _implanted it into the appendix_,
  and then dissecting the left ureter in the same way _implanted it
  in the right_, the intent being to direct the whole urinary stream
  into the colon and thus spare the bladder. The operation was not
  finally successful. I afterward found that this method had been tried
  experimentally by Jacobson, of Toledo, but without success.




CHAPTER LV.

THE BLADDER AND PROSTATE.


Methods of recognition of surgical diseases of the bladder have been
vastly improved, as well as complicated, within the past few years. The
bladder has now been made accessible not alone to touch, as through
the rectum or vagina, or by incisions above or below the pubis, but
to sight, through the use of the _cystoscope_. It is furthermore
possible to detect foreign bodies within it by the Röntgen rays.
_Palpation_ is chiefly of value in thin persons, or when the bladder
is greatly distended; still, infiltration of the base of the bladder
can be detected through the vagina or through the rectum, as can also
certain foreign bodies. Much of value is learned by both chemical and
microscopic examination of the urine. This may be passed by the patient
or withdrawn by the catheter. It has already been indicated how much of
value can be learned by separating the urine drawn from each kidney.
The difficulties of this procedure are greater in the male than in
the female, owing to the complications in the requisite manipulation
of the instruments. Nevertheless there is no accurate method of such
estimation save by ureteral catheterization. The method of Harris,
by the use of the so-called segregator, is of occasional assistance,
but is never accurate nor always satisfactory. If the catheter alone
be used it should be of metal, if it be desired to have it serve the
purpose of a probe, as in the search for a foreign body (calculus
and the like) or as a means of estimating the size and shape of the
bladder. For the latter purpose an ordinary sound will serve as well,
preferably one with a short beak, ordinarily known as a stone searcher.
In cases of prostatic enlargement it is of great advantage to estimate
the amount of residuary urine after the patient has apparently emptied
his bladder. This may be withdrawn by a sterile catheter under aseptic
precautions. The use of the catheter is also necessary for lavage of
the bladder, a measure of great value in many cases.

The attempt will not be made here to picture nor go into a minute
description of the various forms of the _cystoscope_. Their use, like
that of the ophthalmoscope, requires special aptitude and training.
With the latter they are of great value; without them they confuse
and complicate. The cystoscope may be used for ordinary purposes of
inspection, for aid in introducing the ureteral catheter, or even
for photographic purposes, for it is now possible with the latest
instruments to photograph the image thus obtained of the bladder
interior. To one not accustomed to viewing the field seen in such an
instrument these revelations are of little interest. To the expert,
however, they may be made of the greatest value. Without further
description, then, allusions made below to the use of the instrument
must presuppose some familiarity with it, and the advantages and even
necessity of securing special training in its use.


CONGENITAL MALFORMATIONS OF THE BLADDER.

The lesser malformations of the bladder include mainly irregularity
in shape or the formation of _diverticula_, which are not extremely
rare. These are especially likely to be met during hernia operations.
I have repeatedly in operating for inguinal, and once in operating
for femoral hernia, found a diverticulum of the bladder complicating
the situation. Its possibility, then, should be borne in mind. It may
be thin and lie in such close relation to the hernial sac as to be
mistaken for the latter. When opened urine will escape and contaminate
the wound. It would probably be best to close the bladder opening and
discontinue the operation rather than run the risk of contamination of
the peritoneal cavity, postponing further work for a few days. As the
result of allantoic defects a _double bladder_ may be met, each perhaps
having one ureter opening into it. More or less complete partitions
in the bladder are more frequently met. These conditions could not
be appreciated previous to opening the viscus or the use of the
cystoscope.

More complete forms of acquired vesical hernia may be found in such
conditions as _cystocele_, common in women after perineal lacerations,
and frequently constituting a most serious condition.


=Ectopia or Exstrophy of the Bladder.=--By far the most serious and
extensive of the congenital malformations are those constituted by more
or less complete defects of the anterior portions not alone of the
bladder, but of the abdominal wall which should cover it, and which
are known as _ectopia_, _exstrophy_, or _extroversion of the bladder_.
Of this condition there are different degrees, from a small cleft just
behind the symphysis pubis, to that which is complicated by prolapse of
the remaining posterior wall, the umbilicus being situated just above
it, while the pubic arch itself is defective or rudimentary. Thus in
the male there is usually _epispadias_ of a more or less _rudimentary
penis_, while in the female the _clitoris_ is _cleft_ and the _vulva
more or less opened_, the urethra being defective or entirely
wanting, the vagina often small, and the uterus generally infantile.
Extreme cases of this condition constitute one of the most serious
and deplorable congenital defects which are not inherently fatal.
Obviously, with these conditions, there is constant escape of urine,
usually with complete mechanical impotence, although in the female
the ovaries are usually present, and practically always the testicles
in the male. In the latter the opening of the seminal ducts may be
frequently seen on the floor of the urethra, more or less concealed by
folds of cystic mucous membrane. The condition is much more frequent
in males than in females. The prostate is usually at least rudimentary
and may be wholly wanting. Occasionally the testicles are undescended.
Double uterus has also been seen in these conditions.

Regarding its causes there is but little known. Doubtless these have
to do with allantoic defects, but the allantois is such a temporary
organ that there would seem to be some other contributing cause not yet
recognized.

Among its most distressing features are not only the lack of control
of urine, but the irritation of the exposed mucous surfaces consequent
upon friction with clothing, or decomposition of urine and consequent
uncleanliness. There is, therefore, nearly always ulceration, with
extreme irritability and more or less constant suffering. It is not
strange, then, that for its relief surgeons have taxed their ingenuity,
or that adult patients, finding the conditions unbearable, are willing
to submit to even extreme measures.


=Treatment.=--So many operative measures have been devised that it is
impossible to include them all. First of all the procedure should be
adapted to the particular case. Much will depend, for instance, upon
the extent of the defect in the abdominal wall, or in the pubic arch,
and in the male upon the rudimentary condition of the penis or the
extent of the urinary canal.

Operations for this condition may be divided into _palliative_ and
_radical_--_i. e._, those which are intended to make it more tolerable
and those which are really entitled to the latter term. Thus if only
the exposed mucous surface can be covered with a skin covering, the
condition may be mitigated since a urinal or some device may be worn by
which its worst features may be controlled. Trendelenburg has recently
called attention to the fact that a wide separation of the pubic arch
not only weakens the pelvis, but constitutes a serious difficulty in
closing the defect. He has, therefore, combined direct operation with
separation of the pelvic bones at the sacro-iliac joints, afterward
enclosing the pelvis in a comprehensive bandage, or suspending the
patient in an apparatus in such fashion that the bony defect in front
shall be narrowed, if indeed it be not completely obviated. This, of
course, is a measure to be carried out in the early years of childhood;
in connection with it the bones may even be wired at the symphysis. In
fact immediately after the birth of such an infant the attempt should
be made to narrow the pelvis, by surrounding that part of the body
with a wide rubber band, which shall influence growth without too much
interfering with nutrition. Later subcutaneous osteotomy may be done if
necessary. At all events, the growing pelvis should be surrounded with
an enclosure by which a constant influence may be maintained.

The various _plastic operations_ for this defect have the common
purpose of affording a covering, which must unfortunately be without
a sphincter to guard the outlet of the cavity. The best that can be
accomplished, then, by plastic methods is the formation of a more
perfect cavity without affording sphincteric control. A theoretically
ideal method would be one which should permit raising of skin flaps
around the margin of the defect, and so turning them in that the skin
should vicariate as mucous membrane. These flaps when united, and
the anterior wall when thus formed, could be covered by other flaps
or by skin grafts; but from these flaps hairs will grow into the
bladder. These will become encrusted with urinary salts and an amount
of irritation be produced which may become not only intolerable but
locally destructive.

In the selection of any plastic method much will depend on the size
of the defect and its completeness, the condition of the surrounding
wall, and varying complications in the surrounding structures. The
general method above suggested will answer especially for the smaller
exstrophies. Beck has suggested an excellent device, namely, the
dissection from the pubes of the recti muscles, their insertions being
severed, and the partial division of the transversalis fascia until
the muscles are so mobilized that they can be reflected and united,
thus forming an anterior bladder covering. By a second operation these
partially formed flaps may be again dissected off from the wall and
a complete osteoplastic covering afforded. Practically no operation
for extroversion can be completed in one sitting. Frequently repeated
efforts have to be made, a little being accomplished at a time. One
of the greatest difficulties met with is securing primary union along
surfaces more or less bathed or in contact with escaping urine. These
flaps, even if united, may separate in a few days as a result of
this urinary maceration. Against this there is but little possible
provision, save perhaps by catheterizing both ureters, and emptying
them into a distinct receptacle.

[Illustration: FIG. 648

Roux’s autoplastic method of raising a perineoscrotal flap with which
to cover the defect. Lines of incision. (Hartmann.)]

[Illustration: FIG. 649

Roux’s autoplastic method of raising a perineoscrotal flap and its
fixation. (Hartmann.)]

More complicated methods of furnishing a complete cavity have been
devised by Rutkowski and Mikulicz, both of whom have suggested to use
a small loop of small intestine wherewith to complete the bladder
cavity. In each of these methods the abdomen is opened, a loop of bowel
brought down, a small portion completely separated by double division,
end-to-end anastomosis of the main part being then made, while the
separated part is in one method closed at one end, while the other
end is fitted over the exposed bladder surfaces as a sort of cap. The
method is exceedingly complicated and hazardous, and depends for local
success upon a sufficient blood supply to the intestinal loop, which
should be carefully ensured by caring for its vessels and mesentery. It
has, nevertheless, been successful.

A far simpler method, perhaps the simplest of all, is that of
Sonnenburg, which consists in extirpation of the bladder proper,
with plastic closure of the opening, while the ureters are carefully
separated and sutured into the upper portion of the urethral gutter.
This removes all urinary cavity and provides only for continuous
escape; but this latter is now provided in an accessible and convenient
place, while the wearing of a urinal permits the achievement of the
main purpose of the operation. Sterson operates upon young girls by
suturing the loosened ureters to the labia minora, which are then sewed
together in the median line, after which a urinal can be worn.[68]

  [68] Cantwell has suggested the following method for bladder
  exstrophy, namely, to pass catheters through a perineal fistula up
  into the ureters, then to dissect off the bladder wall, bringing it
  over a small rubber balloon, pushing the whole into position, and
  uniting the abdominal wall in front.

It has occurred to many operators to more completely divert the urinary
stream by displacing the ureters and turning them into the rectum or
the sigmoid. Operations for this purpose have been described especially
by Maydl (Fig. 650), and by Moynihan, while modifications have been
suggested by many others. In practically all of these procedures
catheters are first passed into the ureters for their identification
and control. Some would dissect out the trigone with both ureters, and,
making a sufficiently large opening in the rectum, would transplant
it in its entirety within that cavity, closing the opening. Moynihan
improved on this by making a vertical incision and entirely dissecting
away the bladder, separating it also from the prostate, thus completely
isolating it. Then the portion containing the ureters is held upward,
while at the bottom of the wound the rectum can either be seen or made
visible. The peritoneal reflection is then lifted upward from the
front of the rectum, which is opened along its anterior surface by an
incision perhaps three inches in length. Into this opening the bladder
is placed, being so reflected that its former anterior surface now
looks posteriorly. The ureters, instead of passing forward, now pass
backward and the catheters contained within them are passed into the
rectum and out of the anus. The edge of the bladder and the cut edges
of the rectum are carefully sutured, after which the abdominal wound is
closed. The sphincter is then stretched, while the catheters remain in
the ureters for four or five days.

[Illustration: FIG. 650

Maydl’s operation; diversion of ureters into rectum. (Hartmann.)]

A choice may be made, then, between some such method as that last
described or that of Peters, who dissects out the ureters, retaining
only a small circular patch of bladder wall, which is folded around the
orifice of each, the rest of the bladder being extirpated. Each ureter,
with its button of bladder wall, is then drawn through a small slip
in the rectal wall, made large enough to admit it, and the end of the
ureter is then left hanging for 1 or 2 Cm. into the rectum. It would
probably be better to hold the ureters in place by a stitch rather than
run the risk of their retraction; but care must be taken that these
stitches make no unnecessary constriction. Others have substituted the
sigmoid for the rectum, the procedure being otherwise the same, all of
these rectal implantations having for their purpose the utilization of
the rectum as a cavity, which may not only contain urine, but retain
it reasonably under control. In many respects they would be ideal were
it not for the attendant dangers. These are (1) those immediately
connected with an operation which is serious, and (2) those connected
with secondary infection of the kidneys, which seems to occur in almost
all cases, no matter how apparently successful at first.


INJURIES TO THE BLADDER.

Injuries to the bladder proper may be accompanied by those of the
parts without, or may be isolated. They divide themselves mainly into
_ruptures_ and _lacerations_, or _penetrations_ directly connecting
with the exterior. Among the causes which predispose to rupture and
other injuries may be mentioned intoxication, partly because it is
often accompanied by overdistention, and partly because of the partial
or incomplete insensibility of the patient. _Distention_, no matter how
permitted, is an important predisposing cause. The injuries usually
include blows, falls, and crushes, and gunshot or other perforations.

The location of the rent is more commonly in the upper and posterior
portion of the bladder--_i. e._, in its weakest part. Such tears
may vary from one-half to four inches in length. When _accompanying
fracture of the pelvis_ the peritoneum is more likely to be injured.

The most _significant symptoms_ are a desire to urinate and inability
to do more than perhaps expel a few drops of bloody fluid. Of course
the passage of any blood or bloody urine will suggest the occurrence of
such an injury. Patients are usually unable to stand upright, and also
show a strong tendency to flexion of the thighs. The introduction of a
catheter and the withdrawal of bloody urine do not necessarily settle
the question as to whether there has been any possible laceration.
Some surgeons have taught that normal urine is comparatively harmless
and that it is no more likely to produce infection than the catheter
used for diagnostic purposes; but this is not safe teaching today. A
clean metal instrument is of no more danger than a clean probe under
other circumstances. Weir has suggested a valuable test, consisting
of removal of all the urine possible, after which a measured quantity
of sterile fluid is injected. If on using a catheter again this be
all recovered it may be assumed that the bladder is not ruptured,
otherwise the contrary. If hours after the injury a catheter be used
and no urine secured, this fact will be most suggestive. The cystoscope
is usually disappointing, since a bladder so injured cannot often be
satisfactorily examined.

Another class of serious injury to the bladder includes the
_perforations_, such as may be effected by gunshot or stab wounds, or,
as in one case of my own, where a lad sat down upon an iron spike,
about three-quarters of an inch square and nearly six inches in length.
The point of the spike entered the anus, and the consequence of the
injury was a perforation of the anterior wall of the rectum and the
posterior wall of the bladder, with injury to its anterior wall without
complete perforation. Prompt operation saved this case, as it will most
such instances, although it was shown that a piece of his trousers had
been carried into and left in the bladder. I opened the abdomen above
the pubis, to be sure that the peritoneum was not injured, and then
drained by a tube passed into the anus and out just above the pubis,
after removing the piece of cloth. Prompt recovery followed.

The bladder may also be injured by rude manipulation of instruments,
especially the metal catheter, by one unaccustomed to using it, or when
serious difficulties are offered by prostatic enlargement.


=Treatment.=--Diagnosis or even serious suspicion of such injuries to
the bladder as above described require either perineal or abdominal
section, the choice of the procedure being based upon circumstances.
If there be reason to suspect intraperitoneal extravasation, then the
abdomen should be opened, carefully cleaned, the bladder rent sought
and sutured, the mucosa being first closed with hardened gut, while
the peritoneal aspect may be sutured with silk or thread. The bladder
should be drained, at least by retention of a catheter, passed if
necessary by perineal section, and the abdomen drained. In the female
drainage may be made through the cul-de-sac. If there be urinary
extravasation behind the perineum, then perineal section should be
made, and the bladder, thus freely opened, should be drained with
a sufficiently large tube; while in the female it will probably be
sufficient to dilate the urethra and insert a tube of sufficient size.
It is not always easy to discover an opening placed posteriorly in the
bladder wall, and after a wide exposure, with emptying and cleansing
of the pelvis, it may be of great assistance to place the patient in
the Trendelenburg position. Under rare circumstances the rent may be so
placed as to justify a suprapubic drainage of the bladder.


FOREIGN BODIES IN THE BLADDER.

Foreign bodies other than calculi occur in the bladder in consequence
of both accident and of design. The former are, _e. g._, represented by
pieces of broken catheter, while the latter are materials introduced
from without in consequence of sexual perversion, during intoxication,
or from some other vicious tendency. The latter occur more often in
girls and women, the former more often in men. In such a collection
of cases as was made by Poulet (_Foreign Bodies in Surgery_) almost
every imaginable object that could be introduced into the bladder is
mentioned. Some of these have slipped in accidentally after external
manipulation, as in masturbation, and some have been deliberately
introduced. Perhaps as common an object as any is the ordinary hairpin.
It is the short urethra of women which is made the much more frequent
resort for such practices than the long urethra of men, in which latter
foreign bodies are often entangled or arrested before they reach the
bladder.

Any object allowed to remain in the bladder will serve as a nidus for
the formation of a calculus, which will form in time, and it may result
that not until the removal of the calculus and examination of its
interior structure will the original foreign body be found.

All objects of this kind should be removed as early as possible
after their introduction. Such removal may be easy and accomplished
by dilatation of the female urethra, with or without the use of the
cystoscope; or the bladder may require to be opened, either above the
pubis, through the perineum, or through the vagina, in order that the
object in question may be extracted.


INCONTINENCE, RETENTION, AND SUPPRESSION OF URINE.

Students often confuse not only terms but conditions, and it is
necessary to be accurate in teaching regarding these subjects.
_Suppression of urine_ is purely a matter of cessation of renal
function, and _has nothing to do with the bladder_. _Retention of
urine_, on the other hand, has nothing to do with the kidneys, but is
purely a bladder affair. It may be due to spasm of the bladder outlet,
or to its obstruction by calculi, other foreign body, or by prostatic
enlargement, or it may be a consequence of paralysis of bladder muscle.
Such retention is the inevitable consequence of fracture of the spine,
since paraplegia is to be expected in such cases, and the condition is
to be atoned for by careful and _regular catheterization_. Retention,
again, is occasionally seen in hysterical patients. It furnishes the
distressing and sometimes permanent or even fatal consequences of
prostatic enlargement in old men. _No matter how produced, it must be
relieved_, for urine tends to accumulate and to distend the bladder,
which will finally burst unless the difficulty be sufficiently overcome
so that urine may in some way escape. Distention of the bladder under
these circumstances is recognized by the formation of a rapidly
increasing tumor, which finally rises to the level of the umbilicus,
fluctuates, and is accompanied or not by pain according to the nature
of the cause of retention. In paralytic cases there will be little or
no pain. In obstructive cases it will be agonizing.

By natural efforts final rupture of the bladder is usually prevented,
as after a certain degree of distention has been attained urine begins
to escape drop by drop. This is simply an _expression of an overflow_,
and is not to be confused with incontinence in the proper sense of
the term. It may be spoken of as _stillicidium_, due to retention.
The young and indifferent practitioner may mistake this escape of
urine for incontinence, which would be a most serious error. Under any
circumstances, when such a condition may possibly occur, the lower
abdomen should be palpated, when the presence of a distended bladder
should be instantly recognized. The first indication is for its prompt
relief by the use of the catheter, while the necessary catheterization
should be done with the usual precautions. When the passage of an
ordinary instrument is made difficult or impossible the cause of the
retention is usually thereby revealed, and may be shown to be so
serious as to necessitate further operative procedures.

When the bladder is distended and no catheter can be introduced it
is advisable to _aspirate_, the aspirating needle being introduced
through the sterilized skin just above the pubis, its point directed
toward the centre of the mass formed by the distended bladder. Repeated
aspiration may be necessary, and it has been suggested to make more
or less permanent use of such a tube or hollow needle. At present no
surgeon would continue this as a permanent measure, but simply as a
temporary relief, even if repetition be necessary, until more radical
procedure can be carried out. Whether this be the removal of a foreign
body or calculus, or of an enlarged prostate, it is indicated just the
same, the only exception to this statement being those cases already
too seriously involved to justify more than perineal section (cystotomy
for drainage). _Retention of urine, then, is always a preventable
condition, and its continuance is inexcusable._

_Incontinence_ implies a paralytic condition, usually of the expulsive
muscles, but sometimes of the sphincter apparatus in either sex, by
which urinary control is lost and urine escapes involuntarily. It
may be a temporary and occasional phenomenon, occurring under the
influence of strong excitement or during sleep, especially in children,
or it may be due to spinal disease or traumatisms, with paralysis of
the lower segments of the cord and nerves given off from them. When
originating in the latter way it is usually a hopeless condition,
but _nocturnal incontinence_ of children, or even of adults, or
that due to hysterical or other neurotic conditions, may usually
be benefited. For this purpose the surgeon should search for the
cause from which the reflex proceeds. This may be extreme acidity of
urine, the irritation of a tight prepuce in either sex, the presence
of worms, intestinal disturbances, or any one of a great number of
possible causes of disturbance of nerve control. Some of them permit
of surgical relief; others require simpler measures. Children thus
suffering should be given no fluid late in the evening, but should
be made to empty the bladder before retiring, and perhaps be aroused
once or twice through the night for the same purpose. In all cases
the urine should be examined and hyperacidity overcome. All forms of
genital excitement should be obviated. In the adolescent and in adults
thus annoyed, and in the insane, it has been shown to be of great
benefit to make a few intraspinal injections of sterile salt solution,
as for local anesthetic purposes, a little cerebrospinal fluid being
first withdrawn, and then from 2 to 10 or 15 Cc. of the solution being
introduced. This seems to have been empirically suggested by a French
surgeon, but has been found of value by Valentine and others, including
the writer.

The above forms of incontinence are to be distinguished from intense
irritability of the bladder, with frequent calls to empty it, which
accompany many such conditions as cystitis, tuberculosis, tumors,
calculi, and the like. This is the extreme irritability of local
disease rather than true incontinence. But there is also a form,
in women, characterized by falling away of the urethra and neck of
the bladder from the pubis, due usually to injuries received during
parturition, with consequent sacculation or dilatation of the urethra
and formation of a cystocele. (Dudley.) This may also be associated
with other results of perineal laceration. Here loss of urine is not
constant, but occasional or frequent. For its treatment the following
methods have been suggested: the injection of paraffin; partial torsion
of the urethra (Gersuny), _i. e._, a partial dissection of the urethra
and revolution upon its own axis, with subsequent suture, by which
incontinence may be overcome, but at the possible risk of sloughing.
Finally, Dudley has proposed the method of advancement of the urethra.
He makes a horseshoe denudation, between the meatus and the clitoris,
down on either side of the urethra, and nearly its entire length.
Its anterior end is then loosened sufficiently so that the meatus
can be drawn forward and secured below the clitoris by two sutures.
The balance of the wound is then closed, the effect of the operation
being to replace and retain the urethra and prevent its sagging. Other
surgical treatment, as for cystocele, laceration, etc., may be added as
needed.


CYSTITIS.

The condition of true _cystitis_ arises invariably either from the
_irritation of a foreign body_ or the _presence of bacteria_; the
former need not necessarily be large, and minute and irritating
crystals are often sufficient to produce at least some of its features.
Sooner or later, however, the germ element enters, and from that time
on cystitis is a bacterial infection. Furthermore this infection is
usually secondary, rarely if ever primary, and may come from without or
within. Thus it may be the consequence of the introduction of unclean
instruments; is a very frequent consequence of gonorrhea, including
all forms of urethritis; or may be the result of local tuberculous
processes or those travelling downward from the kidneys; or, again,
of more general toxic or septic conditions, such as typhoid and other
infectious fevers. Certain conditions predispose, such as the presence
of calculi or the occurrence of traumatism. Again, a bladder weakened
by overdistention or paralysis, as in cases of spinal injury, loses its
natural resisting power and succumbs to infection abnormally easily.
It should be emphasized that the absolutely healthy bladder wall is
resistant to all germ activity, but this resistance is easily lost or
modified in the presence of disease, either close by or distant. A
bladder whose normal shape has been greatly changed by enlargement of
the prostate is again rendered not only unhealthy, but incapable of
acting normally. It becomes, therefore, easily infected, and _cystitis
is a frequent accompaniment of prostatic hypertrophy_.

[Illustration: FIG. 651

Internal appearance of bladder in some cases of inveterate cystitis;
mucosa sacculated by columns of hypertrophied tissue. (Launois.)]


=Symptoms.=--The _cardinal symptoms of cystitis_ are three in number,
_i. e._, _pain_, _frequency of micturition_, and _pyuria_, the latter
being the consequence of changes in the urine, as well as in the
bladder wall, while the pain and the thamuria are expressions of
irritation, especially of the base of the bladder and the posterior
urethra. In fact, all the more violent expressions of cystitis are
found at the lower part of the bladder rather than in its upper
portion. Obviously, then, irritation of adjoining organs is more easily
accounted for, _e. g._, of the urethra, the seminal vesicles, the
prostate, and the lower ends of the ureters.

The _pain_ may be severe, and is especially complained of with each
act of urination. It is referred not only to the region of the bladder
proper, but along the urethra to the end of the penis in the male, and
down the thighs in both sexes. With frequency of urination there is
also distressing urgency, so that once the necessity be felt nothing
can restrain the promptness of the act. In fact so powerful is the
expulsive tendency that the tenesmus affects not only the bladder but
often the rectum, while the feeling or desire to urinate continues
after the bladder has been emptied of its last drop, even for several
minutes, and may cause the patient to sit in agony for some time.
The distress produced in acute cases of cystitis is excessive, and
sedatives and anodynes constitute no small part of the treatment.

The amount of _pus_ contained in the urine will vary with the degree
of acuteness and the stage of the disease. At first it is but slight,
but rapidly increases, until the urine may contain thick mucus and pus
up to one-third or more of its volume. Finally _blood_ may appear, by
whose appearance a serious degree of inflammation is betokened.

Later, at a variable date, the putrefactive element is introduced; and
when the urine begins to smell of ammonia--_i. e._, when _ammoniacal
decomposition_ has once begun--the bladder is thereby the more
irritated and the case made still worse.

No vesical mucosa left suffering from such acute inflammation will
remain unaffected in its tissue elements, but will rapidly become
more or less thickened. In fact the entire bladder wall undergoes a
process of thickening, from hypertrophy of its inner and its muscular
or middle coats, the latter due to extra activity in consequence of
the constant tenesmus. There results in time a marked _eccentric
hypertrophy_, whose result is really a contraction of the bladder
cavity and a distortion of its lining. Under these circumstances, also,
the mucosa becomes _sacculated_, and numerous little pockets, which may
contain decomposing urine, serve to complicate the situation; while,
finally, more or less _incrustation_ or _calculous degeneration_ and
implantation modify the character of the mucous coat. For all these
changes to occur requires time, but their combined effect is such
thickening and contraction of the bladder as to permanently alter it
and lead to a final _concentric_ hypertrophy.


=Tuberculous Cystitis.=--The picture presented by tuberculous disease
of the vesical mucosa is, in the beginning, one of miliary or
disseminated involvement; but later, when ulcerative changes have taken
place, the end results are scarcely different from those rehearsed
above, save that the ulcerative element is more predominant, and
there is great probability of involvement of the ureters or of any of
the adjoining organs. As conditions do not essentially vary, neither
do symptoms, and a diagnosis of tuberculous cystitis often must, in
the early stages, be reached by a process of exclusion, corroborated
perhaps by the cystoscope.


=Postoperative Cystitis.=--A different clinical type of irritation,
or mildly infective cystitis, is known to be a sequel of certain
operations, not alone those upon the pelvis. In the majority of cases
it occurs when catheterization has been required, the first event being
urinary retention, by which the bladder mucosa must be more or less
disturbed. It may be perhaps accounted for by the fact that the urethra
is practically never free from germs, which, in that canal, seem to
be innocent, but which, carried upward into an irritated bladder may
excite serious inflammation. These cases are perhaps more frequent
after pelvic operations for cancer. There seems, however, no doubt
but that repeated catheterization for several days lowers bladder
resistance.


=Treatment.=--When the occurrence of cystitis is imminent prophylactic
or preventive treatment is recommended. This should consist in
administration of large quantities of fluid, with urinary antiseptics,
in lavage of the bladder itself, and in reliable antiseptic precautions
in catheterization. Thus to operate upon a bladder which has long held
seriously infected or decomposed urine, without previously cleansing it
as much as possible, is simply to invite further trouble.

The medicinal treatment of cystitis, on which we mainly rely, consists
in dilution of the urine by large amounts of fluid ingested, in
overcoming hyperacidity by the administration of alkalies, and in
combating putrefactive conditions, so far as possible, by antiseptics
which are eliminated through the kidneys. Balsams have been long held
in great repute; but remedies like urotropin and other synthetic
compounds have taken their place. Of them all, and especially in the
presence of ammoniacal urine, urotropin and the alkaline salts of
benzoic acid seem most reliable. Excessive irritability may be overcome
by local measures, such as frequent hot rectal douches, hot sitz baths;
by quieting irritation of the genitospinal centres by administration,
_e. g._, of cannabis indica, in doses pushed to the physiological
limit; by local anodynes, as by opium suppositories, or in extreme
cases by general anodynes like morphine.

Theoretically a seriously infected bladder should be washed out and
cleansed as any other pus cavity, but when so inflamed the bladder
becomes so intolerant and exquisitely irritable that the mere act of
washing can only with difficulty be borne by the patient. Retention of
a catheter, which might be advisable under most circumstances, may also
be impossible for the same reason. The condition of a patient under
extremes of this kind is pitiable, and resort to general anodynes
unavoidable. Still it is possible with patience and the use of selected
drugs to gradually allay even a most acute cystitis. Confinement in bed
and an almost fluid diet are also necessary features of treatment.

If the introduction of an instrument can be borne it may be possible to
leave in the bladder some soothing solution after it has been washed,
such as a mild cocaine solution containing a little morphine, or olive
oil containing orthoform, or a mild preparation of ichthyol. Even if
these be retained but for a short time they will usually afford relief.

Finally in severe forms of cystitis the _bladder may be opened_ for
the purpose of giving it physiological rest, selecting either the
suprapubic or the median perineal route. The relief thus afforded is
usually gratifying, while drainage may be maintained until the local
treatment has been sufficiently effective to permit either spontaneous
closure of the drainage opening or its repair by suture. This measure
is known as _cystostomy for the relief of cystitis_.

Obviously if cystitis be due to the presence of any foreign body its
treatment becomes necessarily surgical, the same being true of those
forms due to or connected with hypertrophy of the prostate. It is
impossible to accomplish a cure here until the mechanical difficulty is
first overcome.


VESICAL CALCULUS.

In the urinary bladder as well as in the gall-bladder mineral
elements held in solution by the contained fluids are precipitated,
the consequence being the formation of _calculi_ or _stones in the
bladder_, which vary in size from the smallest concretions to those
weighing many ounces, and in number from one to scores, a large
proportion of these representing original concretions passed down
from the kidneys, _i. e._, minute renal calculi. Every calculus has a
nucleus, and in many instances this may be a clot, or clump of cells
encrusted with salts, which have formed within the bladder and not
come down from above. Such foreign bodies will become the nidus for
a calculus, while in vesical calculi are frequently found pieces of
catheter, of straw, chewing-gum, hairpins, and the like, which have
been introduced from without. These stones are constituted mainly
of the ordinary urinary salts, _i. e._, _phosphates_, _urates_, or
_oxalates_, deposited as described above. Much more rarely _cystin_ and
_xanthin_ are found. Instead of urates crystallized _uric acid_ will be
occasionally seen. The oxalates are mostly those of calcium, while the
phosphates are those of calcium, magnesium, or ammonium, more or less
combined. The first requisite for a calculus is a nidus, the second
the deposition of one or more of these salts. Calculi are sometimes
_composite_ in structure, some having a uric or urate nucleus becoming
later encrusted with phosphates. The oxalic calculi are exceedingly
hard and usually rough, being often spoken of as _mulberry_. They
rarely attain large size. The rapidly forming phosphatic calculi are
often so small as to disintegrate or break in the process of removal.
Thus there may be great differences in density of these stones. Their
formation is particularly favored by retention of alkaline urine, as in
many cases of prostatic enlargement.


=Symptoms.=--Discomforts and symptoms produced by bladder stone depend
upon their size, number, roughness, movability, and location. The
larger and rougher stones, which are more or less easily moved inside a
tender and irritable bladder, will cause a large amount of discomfort
and actual pain, while a small calculus, which may be formed within a
pocket or become encysted at some distance from the urethral opening
may remain unnoticed. The indications of calculi are essentially those
of cystitis, _pain_, _frequency of urination_, and _pyuria_, sometimes
with hematuria. The pain is local and referred, especially along the
urethra, to the glans in the male, and is often aggravated by the final
expulsive movements of the bladder at the termination of urination.
Local discomfort is aggravated by active exercise. Reflex pains have
been known in distant parts of the body. The frequency of urination is
increased by exposure to cold or by activity. Pyuria and hematuria do
not differ from those of non-calculous cystitis. A most significant
feature is sudden _stoppage of the urinary stream_, with more or less
pain. Statements to this effect, especially if accompanied by a history
of renal calculi in time past, are most suggestive.

Unless, however, particles of calcareous material have been passed the
positive diagnosis of calculus rests upon its detection by examination,
either with a _stone searcher_ or with the _cystoscope_. The former
is essentially a short-beaked, light sound, which may be more easily
manipulated after introduction within the bladder. In using it the
same precautions are taken as for catheterization or sounding, while
the deep urethra may be made less sensitive by a cocaine solution. The
instrument is introduced exactly as is a sound, and its beak is carried
completely into the bladder. Sometimes even before this has been
accomplished will be noted the rough, grating sensation which indicates
contact with a stone. At other times it is only after considerable
search that a small stone is “touched.” A stone easily found is within
the possibilities of unskilled manipulation, but to accurately examine
a bladder, especially behind a large prostate, is a fine art. For this
purpose the bladder should be partially distended with fluid, the
patient should be in the horizontal position, and the stone searcher so
manipulated that its beak may be made to traverse every portion of the
lower part of the bladder and to come into contact with its wall, for
only in this way can an encysted calculus be discovered. The beak must,
moreover, be rotated so as to be carried down into the pocket behind an
enlarged prostate, as in such pockets many calculi nestle. Some stones
are felt even in introducing a soft catheter; others are discovered
only after such manipulation as the above. Nothing but necrosed bone or
a foreign body can convey to the metal instrument, and through it to
the finger, the peculiar sensation produced by contact with a stone. By
attaching an auscultatory tube to the instrument a characteristic sound
may also be heard.

With the cystoscope in the hands of an expert it is possible to orient
one’s self definitely concerning the size and location of a calculus,
but much information can also be obtained by the use of the ordinary
searcher.

It has occasionally happened that calculi have been discovered by
accident, either during a suprapubic or some other pelvic operation.


=Treatment.=--The presence of vesical calculus being established,
there is but one rational treatment, _i. e._, its _removal_. It
remains, then, only to select the method of operation and to perform
it. Vesical calculi are removed by two general kinds of operations: by
_crushing and evacuation of fragments through the natural passages_,
or by a _cutting operation and extraction entire_. The former is known
as _lithotrity_, or, as now performed in one sitting, _litholapaxy_,
and the other as _lithotomy_, which may be performed either above the
pubis, through the perineum, through the vagina, or through the rectum.
Each method has certain obvious advantages. Thus _in favor of crushing_
there is freedom from an open wound, with its dangers of infection and
of hemorrhage, while it appeals to the sentiment of those patients who
“dread the knife.” One objection to it is that even when performed with
skill assurance cannot be given that the bladder shall be freed from
all calcareous particles, one of which may, by remaining, serve as a
nidus for another calculus. In _favor of the cutting operations_ are
their brevity, _i. e._, the celerity with which they may be performed,
the relief afforded by drainage, which can be carried out through the
lithotomy wound, and which is often indicated in bladders that have
been long tortured by the presence of calculi; while, finally, their
simplicity, at least in most instances, makes lithotomy attractive
to the operator of limited ability. It may be added that certain
calculi, especially of the oxalic type, are so dense and resistant that
even when secured in the grasp of an instrument they can scarcely be
crushed. It may be urged also that septic urine is just as harmful in a
bladder whose mucous membrane has been slightly injured here and there
in the process of crushing as in one which has been more or less opened
by a lithotomy.

Between cutting methods choice varies also according to the taste and
views of various operators, as well as the nature of the case. When the
prostate is large a suprapubic operation was held the simpler for the
removal of calculus, and this earlier teaching is not abandoned. In the
young the urethra is small and the bladder lies high in the pelvis,
and both these conditions favor the suprapubic method. Again it enjoys
repute because there is no danger of injury to the prostatic urethra
or the seminal ducts or vesicles, and because it leaves the genital
apparatus absolutely untouched. It is also free of possibility of harm
to the rectum, which was by no means unknown in the hands of the older
operators who resorted to the perineal route. But the removal of a
large stone by the suprapubic route entails an opening of considerable
size, and it is not unlikely that a large calculus may need to be
fragmented and removed in pieces rather than leave a large opening at a
point where urinary fistulas would likely ensue. It will be seen, then,
that even lithotomy is not always to be performed without crushing of
the calculus.

Of the perineal routes only two are in vogue today, the _median_ and
the _lateral_. The _median_ is resorted to for stones of moderate
dimensions, while the lateral will be required for large calculi. The
vaginal route is often selected in women, although, rather than make an
extensive opening between the bladder and the vagina, it will probably
be easier and better to dilate the urethra, and, through it, crush
a calculus which, in the female, could thus be made more accessible
than in the male. Therefore in the female the suprapubic route or a
litholapaxy is usually adopted. The operation through the rectum has
been long since abandoned.

After a calculus has been removed by crushing a self-retaining catheter
should be inserted, for at least a day or two, and the bladder
washed, while at the same time treatment for the cystitis, which is
still present, should not be discontinued. After opening the bladder
the wound is drained for at least a day or two. Drainage has this
disadvantage, that if long continued it leaves a urinary fistula, often
slow to close, but a metal, glass, or hard or soft rubber tube may be
placed in a median perineal opening, around which should be packed
gauze to check oozing, and left in this condition for two or three
days. Usually within a week after its removal the deep sphincters have
recovered their retentive power, and the patient can retain urine for
some time, while generally within two weeks the entire wound is closed.
In all these cases a sound or bougie should be passed at suitable
intervals for the purpose of preventing stricture formation in the deep
urethra at the site of the operation.

_Litholapaxy_ is performed by first crushing the stone between the
beaks of an instrument known as the _lithotrite_, which is constructed
in various forms, yet all conforming to one type, which is introduced
into the bladder through the urethra, after which its blades are
separated and manipulated until the stone is felt to be entangled
or secured between them. By a device at the handle the blades are
then locked, and screw power exerted, also from the handle, by which
the blades are forced together and the stone between them more or
less broken (Figs. 652 and 653). By repetition of this process each
fragment is seized separately and crushed until the bladder contains
more or less debris resulting from the manipulation. The lithotrite
is then removed and a _washing tube_ or catheter of large dimension
inserted, and connected with a so-called _washing bottle_, which is
compressible and permits a stream of water to be violently thrown into
the bladder, thus stirring up the fragments and particles, and which is
an instant later withdrawn by suction in such a way as to carry them
with it. Escaping into the washing bottle they drop by gravity into a
glass receptacle at its base, where they become at once visible. This
process is repeated until everything has been washed out of the bladder
which will come. The lithotrite is then substituted and the maneuver
repeated, and as many times as may seem desirable. In this way calculi,
especially soft ones of large size, may be disintegrated and removed
in small fragments. The final test of success is failure to aspirate
any more particles or to discover them with the cystoscope (Fig. 654).
The time consumed in the operation will depend on the operator’s skill
and the size or hardness of the stone. It is frequently performed
under local anesthesia, the bladder being injected with a weak cocaine
solution, or under spinal anesthesia.

_Lithotomy_, by either of the above methods, is performed by utilizing
a grooved sound known as a _staff_, which is first inserted into the
bladder, and serves not merely the purpose of a grooved director, but
to indicate the course of the urethra.

For the _suprapubic operation_ the staff is passed deeply, and its
handle depressed between the thighs, so that the end of the instrument
rises behind the pubis and carries the bladder up toward the surface.
A median incision above the pubis permits access between the recti
muscles to the prevesical space (space of Retzius), which is more
or less filled with fatty and connective tissue. If the bladder has
been previously distended with fluid and elevated on the point of
the staff, there is but little danger of wounding the peritoneum,
although its reflection may be sought and carried out of harm’s way.
It is a convenience to pass a silk suture with a stout, full-curved
needle through the bladder wall after it has been exposed, on either
side of the point of the staff which elevates it, and to pass this
through in such a way as to have thus a double loop, or two retractors,
by which it may be more conveniently manipulated after it has been
opened and would otherwise collapse. The bladder should be opened upon
the point of the staff, whose groove may then serve as a guide in
still further nicking or incising it, the silk sutures on each side
preventing it from collapsing as it otherwise would after the gush of
escaping fluid. The surgeon should now endeavor so far as possible
to dilate rather than to merely cut this opening, and thus give it a
size sufficient to permit the introduction of the finger, by which
intravesical exploration and orientation are effected. Calculi having
been identified and located, suitable forceps are then introduced, and
with them the stone or stones seized and withdrawn through the opening,
which may be stretched still farther for the purpose unless their size
make it advisable to crush them and remove them in fragments.

[Illustration: FIG. 652

Method of seizing the stone behind the prostate.]

[Illustration: FIG. 653

Ordinary position in seizing the stone.]

[Illustration: FIG. 654

Bigelow’s lithotrites, catheters, and evacuator.]

This is suprapubic cystotomy or epicystostomy, according to the purpose
for which it is intended. It serves not only for removal of calculi
but for extirpation of tumors, or enlarged prostates, and perhaps for
permanent drainage. By the silk loops at first introduced the bladder
wall may be attached to the abdominal wound, while other stitches may
be added to any desired extent. In most instances it is desirable to
reduce the opening, for which purpose buried and superficial sutures
may be used. As leakage, however, may produce infection it is customary
either to provide for drainage by insertion of a catheter through the
urethra, or by the implacement of a small tube, whose lower extremity
shall reach the base of the bladder and serve for drainage, which
latter may be made more effective by siphonage.


PERINEAL LITHOTOMY.

_Perineal section_ for exploration, drainage, or stricture is
practically accomplished as follows: The patient is first placed in
the so-called lithotomy position, _i. e._, upon the back with the
limbs flexed and knees parted, the feet or legs being held either by
assistants or in suitable leg holders upon the operating table. This is
the position in which nearly all perineal operations in both sexes are
made.

A grooved staff, with large curve and long beak, is introduced into the
bladder, and not only held in the vertical position by an assistant,
but in such a manner as to make its curve bulge the perineum as much
as possible toward the operator. The rectum, which should have been
previously thoroughly cleaned, may be utilized for identification or
for necessary assistance during the operation. The scrotum is held up
out of the way by the assistant who holds the staff. The perineum being
thus put upon the stretch may be most quickly opened by a straight,
sharp-pointed bistoury, which is inserted a little posteriorly to the
scrotal junction, its point driven through the tissues and made to
engage in the groove of the staff, from which it should not escape
until finally withdrawn. As the instrument is pushed backward the
handle is depressed; a triangular-shaped opening is thereby effected,
whose apex is in the membranous urethra and whose base occupies the
raphé of the perineum, to the extent of perhaps one and a half inches.
The entire incision may be made with one effort. Its effect is to open
the membranous urethra. Into the groove of the staff, the knife being
withdrawn, may be introduced either a species of grooved director or
the finger-nail of the index finger, which may be passed backward
and made to enter the prostatic urethra, while at the same time the
staff is withdrawn. If the prostatic urethra be constricted it will
be difficult to enter the bladder with the finger, otherwise it will
readily yield to pressure, and it is thus possible to enter the bladder
within a few seconds after the first incision is begun (Fig. 655).

It is preferable in all these cases to have first washed out the
bladder, and then to have filled it with a mild antiseptic solution.
This will escape instantly an outlet is made from below. If there is a
small calculus within the bladder the effect of the stream will be to
carry it toward this outlet, where it is identified by the finger.

The prostatic urethra will bear a considerable amount of gradual
dilatation, which will make it more than easily accommodate an ordinary
finger. In this way a sufficient channel is made, through which forceps
may be introduced and calculi of small or medium size withdrawn. They
should be seized as carefully as possible within the proper grasp of
these instruments, so that a minimum of laceration may be effected as
they are extracted. A small calculus will be easily removed; a large
and soft one may crumble in consequence of the pressure made upon it
during its extraction. In this event the fragments should be separately
removed, the bladder then repeatedly washed out, and the finger finally
used to make sure that no particles remain.

Whether one stone or several be present the opportunities for the
purpose of their extraction afforded by this median operation are the
same. The bladder having been emptied and washed out a self-retaining
drainage tube, or a hard rubber or metal perineal tube should be
inserted, with such gauze packing around it as may be necessary for
its retention and for the checking of hemorrhage. The intent of the
tube is a double one, it being intended to serve for easy drainage and
for gentle pressure. Sometimes the prostate is more or less torn in the
process of dilatation, and in this case will bleed more freely than is
comfortable. Such oozing may be checked by plugging gauze around the
drainage tube.

_Lateral lithotomy_ may be combined with median section, by
deliberately passing a blunt bistoury into the prostatic urethra, and
making with it an incision in the prostatic substance, the cut being
directed toward a point midway between the anus and the ischiatic
tuberosity, and carried to a depth of one-half or three-quarters of
an inch. This affords a much larger opening through which to remove
larger calculi. Obviously it will bleed more freely and will usually
require packing. The _old lateral method_ was to begin the external
incision at a point, in the middle line, a little behind the scrotum,
and direct it for one and a half or two inches backward and outward
to a point between the tuberosity and the anus. The incision was then
deepened through the perineal fascia until the index finger-nail of
the left hand could identify the staff within the urethra, after
which the urethra was opened at this point (_i. e._, just behind the
bulb), when the knife was again introduced and made to divide the
prostate obliquely as above. In this way the membranous urethra and
lateral aspect of the prostate were divided to the requisite depth. If
such incision be extended too far backward and outward the internal
pudic artery might be divided, which would at least be awkward and
necessitate ligature, and this would be somewhat difficult because it
would require further division of tissues.

[Illustration: FIG. 655

Second stage of lithotomy. (Erichsen.)]

The same management is required after lateral as after median
operation. Except only when a long and seriously inflamed bladder
requires almost permanent drainage the perineal tube should be removed
within forty-eight hours, and the external opening allowed to close as
rapidly as possible.


TUMORS OF THE BLADDER.

The most common benign tumor of the bladder is _papilloma_, which here
assumes almost invariably the villous form and grows even luxuriantly.
It may be solitary or multiple. In the beginning it is usually more
or less pedunculated, but may grow in great numbers, as in the mouth.
A class of denser tumors are the _fibromas_, which are covered by
a more or less thickened mucous membrane. _Myxomas_ grow mainly in
children. _Adenomas_ have been described, but are rare. _Dermoid cysts_
in or about the walls of the bladder have also been described. The
malignant tumors of the bladder are mainly of the epithelial type,
usually _adenocarcinoma_, of a somewhat peculiar type, due to malignant
degeneration of an original papilloma, an unfortunately common event
(Fig. 656).

[Illustration: FIG. 656

Villous tumor (papilloma) of bladder. (Musée Dupuytren.)]

[Illustration: FIG. 657

Tumor of bladder as seen with cystoscope. (Nitze.)]


=Symptoms.=--The symptoms due to tumor in the bladder do not differ
much from those of calculus, except that there is at first less
pain. In nearly all cases there will be _hemorrhage_, occurring
independently of exciting causes, as during sleep, not only abundant
but often frequent. In the early stages pain is rarely severe. In
cancer it is largely proportionate to involvement of the bladder wall
and the adjacent organs, and is more common in cases of basal tumors.
It is both local and referred. With a bladder filled or filling up
with a tumor mass there will be reduction of capacity and frequency
of urination, while in nearly all instances the essential features
of cystitis are superadded. The actual evidences of tumor are its
detection by the cystoscope, its discovery by vaginal or rectal
palpation, or its recognition by fragments discovered in the urine.

When the cystoscope is used in these cases it usually reveals the
location, size, vascularity, arrangement, and character of the tumor.
Its use, however, is often difficult or impossible, because the
manipulation by which the bladder is so distended as to permit its use
causes hemorrhage and obscurement of the field of vision (Figs. 657 and
658).

With the cystoscope has been recognized also an early condition of
_leukoplakia_, corresponding to that seen in the mouth and on the
tongue, which may be regarded as a precancerous condition.


=Treatment.=--The only treatment which can be made effective is
complete _operative removal_. There is no reason why any benign tumor
of the bladder should not be attacked, the most unpromising cases being
those of general papillomatous involvement, where only small areas of
the bladder mucosa are left uninvolved. Such a villous condition as
this is serious, and may later justify an effort at extirpation of the
bladder. _Palliative treatment_ will include the arrest of hemorrhage
(for which a few drops of turpentine oil are often effective), with
gentle lavage of the bladder and removal of clots, securing their
disintegration by injecting an emulsion of pepsin or of papain; while
tenesmus, irritability, and pain are to be controlled by cannabis,
suppositories, morphine, or whatever may be needed. In inoperable cases
cystotomy for drainage purposes may be the final measure for relief
purposes.

Radical measures include _opening of the bladder_, either above or
below the pubis, as the cystoscope may indicate; or the former,
when the cystoscope cannot be used, as it affords better means for
exploration. Through this opening, which may be made larger than for
mere exploratory or lithotomy purposes, and aided by artificial light
(small electric lights introduced by suitable mechanism, as within a
test-tube), there may be removed with scissors or curette, or even with
the finger-nail, by enucleation, such growths as are met, while in
nearly every instance it will be an advisable precaution to cauterize
their bases with the actual cautery. Through more extensive incisions,
with the patient in the Trendelenburg position and the prevesical space
widely opened, the bladder mucosa may be excised, and ample drainage
provided both by retention of a catheter and insertion of a siphon tube
through the lower part of the opening. The suprapubic route affords
better opportunities for thorough work than does the perineal, the
latter being suitable only for a limited class of cases.

[Illustration: FIG. 658

Illumination of anterior vesical wall by Nitze’s cystoscope.]

Finally comes the question of _extirpation_ or a _complete cystectomy_.
This radical and difficult measure has been added to the list of
possible surgical procedures. In a case of general papillomatous
disease it might be successful, but it is questionable whether any case
of cancer which would call for such a measure can be cured by it. The
operation has been done much oftener in women than in men, and usually
by a combined procedure of suprapubic opening, which may be vertical
or transverse, with attack from the vagina. If the vaginal wall be
involved it may also be cut away. The ureters should be isolated and
preserved, when, the affected tissues being removed, it becomes a
question of what to do with them. They may either be left to drain into
the vagina, which is thus utilized simply as a conduit, and which may
be closed later and the urethra thus utilized, a urinal being worn, or
they may be immediately or by a secondary operation turned into the
rectum. The latter procedure introduces fresh complications, though,
if successful, it would minimize the unpleasant features of such a
case.[69]

  [69] Symphysiotomy may, when required, be combined with suprapubic
  operation as in the case of young children, for removal of very large
  stones or tumors, as has been recently demonstrated by Palmer, of
  Persia.

It is thus possible to successfully extirpate the entire bladder
proper, conserving the ureteral orifices or not, as well as the
urethra, although the resultant condition can hardly be considered
brilliantly satisfactory.[70]

  [70] In a recent case I have been able to more easily effect this
  procedure by raising a flap, including the tissues of the mons,
  exsecting a portion of the symphysis containing the insertion of the
  recti, by oblique division, in such a way that when replaced the bone
  could not be easily displaced, and in this way uncovering the space
  of Retzius so that, by combined manipulation, it was easier to detach
  the bladder wall from its surroundings.


THE PROSTATE.

The prostate, with the duct extremities of the seminal vesicles, are
enclosed in a fibrous sheath or _capsule_, of more or less density,
which has been called by Belfield the broad ligament of the male.
In structure this body is composed of a mixture of adenomatous and
muscular (involuntary) fibers, with considerable connective tissue, so
that in many respects it is the homologue of the uterus. It not only
serves as the portal of the bladder, but through it pass the prostatic
urethra and the seminal ducts. Infection proceeding from either
direction may, therefore, travel along either one of several paths,
spreading disaster and causing a variety of troubles. Such infection
may be tuberculous, gonorrheal, or of the ordinary septic type. There
will ensue in consequence various forms of _prostatitis_: the _acute_,
which may lead to abscess, and the _chronic_, which will always lead to
hypertrophy.


ACUTE PROSTATITIS.

Acute prostatitis is generally the result of gonorrheal infection, the
consequence of extension from the urethra into the mucous follicles and
the prostatic structure. _Primary tuberculous_ disease in this location
is rare. _Septic infection_ comes either from the use of unclean
instruments, from the presence of infected urine, or from the extension
of cellulitis from some adjacent structure. It is not infrequently seen
in connection with deep and tight strictures and accompanying cystitis,
or in connection with the presence of small concretions, _i. e._,
prostatic calculi.

Acute prostatitis is an exceedingly painful affection, made so
particularly by inelasticity of the capsule, which affords no
accommodation for the swelling due to the inflammation. In addition
to the inevitable pain and tenderness the swelling will sometimes
practically close the urethra in such a manner that urination becomes
almost impossible. To nearly every case will be added some of the
symptoms of acute cystitis, which may have preceded the prostatitis.
Prostatic inflammation can be made known by the exquisite tenderness of
the organ, discoverable by digital examination through the rectum. This
feature, with tenderness in the deep perineum, and the above symptoms
make diagnosis easy.

According to the intensity of the lesion will be the liability to
suppuration. _Prostatic abscess_ is a frequent result, and its
presence is evidenced by accentuated pain and tenderness, with perhaps
considerable febrile disturbance. In some cases fluctuation can be
detected through the rectum. Such cases sometimes evacuate themselves
spontaneously, although often in an undesirable way, when left
untreated, or unrecognized, discharge taking place usually into the
rectum, but perhaps into the bladder or into the urethra. Should pus
burrow into the pelvis there will arise a deep pelvic cellulitis, with
probable disastrous consequences.

When _a prostatic abscess is suspected_ the patient should be
anesthetized, the sphincter dilated, the exploring needle used if
necessary, and any collection of pus, no matter how detected, should be
either completely emptied with the aspirator or by free incision.


CHRONIC PROSTATITIS.

Chronic prostatitis may be the residue of an acute lesion or the
gradual production of a mild but more or less constant septic
infection. It leads always to more or less enlargement, is often the
basis for the classic prostatic hypertrophy, and causes dull pain,
referred in various directions, often to the sacrum and the back,
with frequency of urination and escape of a viscid mucus, the natural
prostatic mucus in excess, which the patient will usually consider
semen, but which is really the product of the overworked prostatic
glands.

This last phenomenon is spoken of as _prostatorrhea_, and deserves
consideration not alone from the alarm with which patients often regard
it, but because it indicates a significant condition. A prostate whose
glandular structures have been unduly active will, in consequence,
enlarge; such a prostate is compressed with the passage of every hard
stool, the consequence being the expulsion of some of this fluid with
each act of defecation, a feature interpreted by too many patients
as _spermatorrhea_. The two conditions are to be differentiated in
clinical study, the former being common, the latter quite rare.
_Acute prostatorrhea_ is also frequently the consequence of more or
less prolonged sexual excitement. It corresponds essentially to a
chronic nasal catarrh, which is accentuated by exposure to cold or to
irritation of any kind, and is only the overflow of a natural fluid
under morbid conditions. With chronic prostatitis, furthermore, the
sexual appetite is often decreased, while sensations are more or less
disturbed, ejaculation being perhaps premature; the patient is often
made thereby despondent, and the case regarded by himself, or by
the quack whom he is led to consult, as at least incipient, perhaps
hopeless, impotence.

The physical _evidences of chronic prostatitis_ are enlargement, with
tenderness not only of the prostate itself, but of the seminal vesicles
above it, and often the appearance of a few drops of prostatic mucus
at the meatus after pressure or stroking of the prostate itself has
expelled them.


=Treatment.=--Removal of the cause is the secret of success; if this
be a stricture it may be divided and dilated; if cystitis, it must
be combated; if chronic constipation, it should be overcome; while
excesses, either alcoholic or sexual, should be controlled. Some one
or nearly all of these conditions will be seen in nearly every case of
this character. To other manipulative features may be advantageously
added a certain massage or “milking” of the prostate, at intervals of
five or six days, by which it is emptied of its accumulated secretion.
Equally beneficial is the occasional passage of a large sound through
the prostatic urethra and into the bladder. Its effect also is to
make pressure, while at the same time it stimulates and does good in
a way perhaps difficult of explanation. Irritation in the prostatic
urethra should also be controlled by occasional injections, with a
deep urethral syringe, of a drop or two of a ¹⁄₂ per cent. solution
of silver nitrate. Improvement in other respects may be expected from
constitutional, dietetic, and hygienic measures.


PROSTATIC HYPERTROPHY.

Many theories have been advanced as to the etiology of prostatic
enlargement. Those worthy of any consideration may be summarized as
follows:

  1. That it is of inflammatory origin;

  2. That it is due to senile and sclerotic changes;

  3. That it is produced by sexual excess;

  4. That it is due to ungratified sexual desire;

  5. That it is a secondary and degenerative change following disease
  of the bladder;

  6. That it is due to some perverted testicular secretion;

  7. That it is to be regarded as a normal senile change;

  8. That it is of catarrhal or septic origin secondary to bladder
  disease;

  9. That it is to be regarded as an adenoma.

Inasmuch as the prostate is to be regarded as essentially a sexual
gland, many cases of hypertrophy are the result of bad sexual habits
which produce continued congestion. Nevertheless the importance of
previous infections, _e. g._, gonorrheal, by which hypertrophy of
glandular and cell elements may be produced, cannot be overlooked.

Prostatic enlargement assumes one of three principal types:

  (_a_) True hypertrophy of gland elements, without interstitial
  participation;

  (_b_) The development of more or less distinctly encapsulated
  myomatous and adenomatous masses; and

  (_c_) A mixed condition involving both of these features.

In consequence the ensuing enlargement assumes one of the three
following clinical types:

  (_a_) An enlarged soft prostate;

  (_b_) A small contracted and sclerotic prostate;

  (_c_) A mixed type.

These types do not necessarily merge into each other, but may remain
distinct. There may be atrophy of glandular elements as a result of
hypertrophy of the muscle and fibrous elements, or _vice versa_.

Much confusion has arisen regarding the so-called _third lobe_, in
spite of the fact that the prostate is essentially a bilobed organ.
Whence has arisen the tendency to speak of the “third lobe,” or is
there such a thing? The explanation is that median enlargement is
a common expression of prostatic hypertrophy, occurring toward the
interior of the bladder at a point where the prostate has no capsule,
and where growth occurs in the direction of least resistance. That
morbid specimens show an apparent “third lobe” is true, but that such a
condition exists normally is a mistake. It should, therefore, be spoken
of as a _median enlargement_ (Fig. 659).

[Illustration: FIG. 659

General prostatic enlargement, with formation of a median overgrowth
and posterior pocket or sac. Illustrating how residual urine may be
retained, as well as the difficulties of all kinds of instrumentation,
_i. e._, an argument, therefore, for radical treatment. (Socin and
Burckhardt.)]

In addition to the more innocent and purely hypertrophic forms of
prostatic enlargement, it has been recently shown, especially by
Young, that the element of _cancer_ is present in a proportion of
cases hitherto quite unsuspected. It may begin as a small indurated
nodule, in one or both lobes, and while developing remains confined
for a relatively long period by the strong prostatic capsule. When it
extends, its line of invasion is upward toward the vesicles rather
than into the bladder. When the latter has become involved, if a
radical operation is to be practised, extirpation must include not
only the entire prostate, with its capsule, the urethra, the vesicles,
but the adjacent portion of the base of the bladder. Early diagnosis
in these cases is difficult, since it may occur at any age after
fifty years, and, being connected with hypertrophy, produces symptoms
masked by it, only the element of pain being more prominent. As the
condition develops pain becomes rather disproportionate, spreads to the
suprapubic region, and is intensified as the bladder fills. When pain
is referred also to the rectum and lower extremities it is a suspicious
symptom. The condition does not necessarily, at least at first, cause
enormous enlargement. Therefore the obstructive features vary. If the
portions involved can be left they will be found more dense and hard
than the surrounding tissue. One peculiarity of prostatic cancer is
that metastases occur more often in the bones than in the lymphatics.
Consequently the pelvic nodes are not so often affected. Ulceration and
intravesical tumor are rare.


=Diagnosis.=--Early diagnosis is based on rapidity of growth,
disproportionate pain, indurated contraction of the prostatic urethra
near its apex, and absence of intravesical enlargement, as shown by
the cystoscope. When there is much residual urine, without enlargement
of intravesical lobes, suspicion is strengthened. If after removal
of such prostate it should be shown to be more or loss dotted with
“seed calculi,” as is possible, instead of with cancer, the benefit
and relief to the patient would be none the less marked, while the
prognosis would be all the better.

Prostatic hypertrophy leads to a collection of phenomena spoken of as
_prostatism_. These include mechanical impediment to urination, with
consequent obstruction, sometimes with complete retention, and to the
consequences of the same in the direction of infection and cystitis,
with added features of pain, tenesmus, and pyuria. _Prostatism is a
matter of gradual development._ Its earliest symptoms are frequent
urination with occasionally some difficulty or slowness in the act.
From this as a beginning cases become gradually aggravated, until death
finally ensues from retention, rupture of the bladder, pyelonephritis,
or exhaustion in consequence of the pain and suffering entailed.

Prostatism may be imitated in persons whose prostates are not
perceptibly enlarged, in whom the difficulty and obstruction are due
to sclerosis and contracture of the vesical neck. This condition is
especially common in elderly men, subjects of arterial sclerosis. This
will account for instances of prostates which, on removal, are found
hard and sclerosed, and yet not enlarged enough to be obstructive.
If such a prostate could be divided by the cautery, benefit, even
permanent relief, might ensue. Therefore, such a condition might be
well attacked when diagnosticated (either by suprapubic operation
or by perineal section), with the use of the Bottini galvanocaustic
instrument, especially through a perineal opening.

Prostatic enlargement produces distortion of the prostatic urethra,
which becomes longer, smaller, and sometimes deviated, with elevation
of the level of the vesico-urethral orifice, and causes, by pressure
on veins, more or less disturbance of the return circulation.
Enlargement with impediment produces dilatation of the bladder, with
possible involvement of the ureters or the kidneys, and thickening of
the vesical walls, often with sacculation of its mucosa between its
disturbed muscle fibers.

Finally come the consequences of septic infection with ammoniacal
putrefaction of urine, pyuria, and perhaps pyelonephritis with uremia,
which will be terminal. While the condition is generally regarded as
belonging to the late years of life it may begin by natural processes
at the forty-fifth year, although uncommon before the fifty-fifth.

[Illustration: FIG. 660

Enormous prostatic hypertrophy, necessitating suprapubic cystotomy
because of impossibility of catheterization from below. (Socin and
Burckhardt.)]


=Symptoms.=--When a man past the middle years of life, previously
free from urinary difficulties, is aroused to urinate more frequently
than usual, especially at night, while the desire to urinate and the
natural feeling of relief at the conclusion of the act are more or
less perverted, the beginning of prostatism may be suspected. If in
addition to these features the urine shows fermentative changes, or
the presence of mucus or pus, the more or less disastrous consequences
of obstruction have begun. Symptoms similar to these may be caused by
the presence of calculus. It is therefore necessary to differentiate
between this and prostatic enlargement. This is first done by a careful
digital examination of the empty rectum, the index finger being gently
introduced and made to so completely palpate the prostate, through
the anterior wall of the rectum, that an accurate estimate of its
relative size, as well as of any marked irregularity, may be made.
If the prostate be enlarged the explanation is at once afforded.
If there be but little apparent change noted by this method the
surgeon should introduce a stone searcher. Manipulation with this,
in a bladder distended with fluid, should reveal the presence of a
calculus, or should indicate a lengthening of the prostatic urethra,
with such distortion, as might make the introduction of the instrument
difficult, while by further manipulation, its beak being gently
revolved, he learns whether behind the prostate there is a pocket
in which residual urine may be retained. The question of calculus
being settled the patient should now empty the bladder naturally and
as usual, after which a catheter should be introduced, in order to
withdraw such residual urine as may be retained, whose amount should
then be noted. This is a measure of the size of the postprostatic
pocket which the patient fails to empty, and in which decomposition
and pathological changes are especially likely to occur. Should such
a pocket be found in a case without noticeable other enlargement (as
detected through the rectum) it will indicate _intravesical growth_
and the formation of the so-called “third lobe” or “median bar,” as it
was formerly called (_i. e._, an outgrowth at the posterior end of the
prostatic urethra, projecting upward into the bladder, impeding alike
the exit of urine and the introduction of an ordinary instrument).
Those expert with its use may gain still further information of value
by use of the cystoscope.


=Treatment.=--The diagnosis thus established, the question of treatment
is raised. Views concerning what is best have been largely modified by
the operative methods recently introduced, and the advice given a few
years ago is now frequently modified. So long as surgical treatment
was unsatisfactory and incomplete it was to be postponed as long as
possible. Under those circumstances patients were taught to use the
catheter and established the “catheter habit.” Almost invariably they
became careless, and the catheter habit led invariably to cystitis.
Nevertheless circumstances may arise which make this good advice even
today, as in the presence of other and serious disease, or of anything
which makes radical operation inexpedient. Under such circumstances the
patient must be impressed as profoundly as possible with the necessity
for care and caution. If such a case has progressed to the stage of
almost complete retention then the catheter should be used at regular
intervals. If it be simply necessary to draw off residual urine once
a day, then it may be used at night, at which time it would be well
also to gently and carefully wash the bladder. It is possible in this
way to temporize for a variable length of time, and until more serious
conditions supervene.

When, however, the prostate has enlarged so conspicuously as to be not
only a constant impediment but a constant menace to the comfort and
even life of the patient, one is brought to seriously consider which
of the various mechanical methods for relief should be instituted.
The choice must now be governed by the physical condition and the
surroundings of the patient, as age, degree and character of the
obstruction, and the extent of septic infection. One has again to
choose between the most radical and usually the most satisfactory
method of _extirpation_ (_prostatectomy_), or one of the less radical
and palliative operations, such as the _Bottini operation with the
galvanocautery_.

A few years ago White and others laid great stress on the fact that
after removal of the testicles there was notable atrophy of the
prostate, and suggested the expedient of _double castration_ or
_orchidectomy_ for this purpose. The method proved disappointing,
although doubtless more or less effective in some cases, and so
objectionable to many patients, for obvious reasons, that it has been
practically abandoned. The less mutilating substitute of division and
exsection of a portion of each vas deferens (_vasectomy_) has for the
same reason been discarded.

When radical measures become necessary the choice should be made
between the _galvanocautery_ (_i. e._, canalization of the base of
the prostate and its median bar by means of the instrument devised
by Bottini) and the bolder and more radical method of _extirpation_
(prostatectomy). This _prostatectomy_ is done by either the
_suprapubic_ or the _perineal_ route. As between them there is often
room for choice, for reasons mentioned below. Each method has its
advocates and its opponents.[71]

  [71] The question of credit and priority for these operations has
  been of late much discussed. To McGill, of Leeds, and Goodfellow, of
  San Francisco, should be given most of the credit for the earliest
  perineal operations, while Fuller, of New York, who first performed
  the suprapubic operation in 1894, should probably be given credit
  for the latter, although it has been evidently unjustly claimed for
  Freyer, of London. Belfield, of Chicago, was also one of the earliest
  advocates of extirpation of the enlarged prostate.


=Suprapubic Prostatectomy.=--It is of assistance in this method to have
the empty rectum somewhat distended, and held up by the introduction
of a rubber bag, which may be later distended with water or with
air. By this means the prostate and floor of the bladder are pushed
upward toward the operator’s finger. This is, however, by no means
necessary, but simply advantageous. The first part of the operation is
essentially that described as suprapubic cystotomy. The bladder being
thus opened and the prostate carried upward by a sound, which should
have been inserted in the urethra, the finger first accurately notes
its dimensions and the direction of its enlargement. Blunt scissors are
now used, or the sharp finger-nail, for making an opening through the
mucosa and prostatic covering, _through the capsule_ of the latter,
down upon that body. This opening is preferably made near the urethral
entrance. The balance of the operation consists in blunt dissection
by the end of the finger, _i. e._, _enucleation_ of the prostate from
within its enclosing capsule and surrounding tissues (Fig. 661). More
or less disturbance of the basal structures is necessitated, but as
the surgeon becomes expert the amount of this disturbance becomes
relatively surprisingly small. In most instances it is possible also to
practically strip off the prostatic tissue from the urethra, so that
it is rarely necessary to tear or to cut across it in order to lift
the prostate out of its bed. In the average case it is possible in
this way to enucleate the prostate in a single piece, and to remove it
as an _entire organ_. If, however, it should prove too large for the
bladder opening which has permitted the procedure it would be better
to morcellate it, or so far divide it with scissors as to permit its
extraction piecemeal. Its removal leaves a bleeding cavity at the base
of the bladder, with torn and separated tissues, and a pocket where
the prostate used to lie, into which urine will be poured from above,
while it cannot ordinarily be at first easily emptied from the more or
less injured urethra connected with it. From this surface there will
be at first considerable oozing, mostly venous. Should this be serious
and prolonged a quantity of gauze may be packed into it through the
opening, and pressure thus made. Such packing should only be retained
for a few hours. Ordinarily it is sufficient to provide at once for
_drainage_. My own preference is to make double provision for this by
the passage of a catheter through the urethra, and by the insertion of
a drainage tube from above, whose lower end rests within the pocket. It
is a great desideratum to drain the urine as fast as it accumulates,
and, at the same time, to keep the patient dry. This is best effected
by a method described later, of complete _bladder siphonage_, which can
be resorted to in either form of operation. It is again advisable to
get the patient into the sitting posture, which should be done within
a day or two, or as soon as his strength will permit, in order that
gravity may assist in drainage. (See p. 1003.)

[Illustration: FIG. 661

Suprapubic prostatectomy. Process of enucleation by finger-tip of one
hand in the bladder, the other hand making pressure in the perineum.
(Hartmann.)]

When difficulty is met in enucleation assistance is derived by the
introduction of one or two fingers of the disengaged hand into the
rectum, by which certain manipulation can be effected from below that
will be of material help. Pressure in the perineum or manipulation of a
sound may also be of assistance.

So soon as satisfactory drainage through the urethra can be effected
the suprapubic tube should be removed, and the wound thus encouraged to
close.


=Perineal Prostatectomy.=--Perineal prostatectomy constitutes a
similar attempt at enucleation, effected from a different direction.
The patient now being in the lithotomy position, with the rectum not
only emptied but sterilized, the perineum is widely opened. While the
removal may be accomplished through a median incision it is better to
have ample room, therefore by a semilunar flap a sort of trap-door
should be raised, its apex downward, through which easy access to the
deep perineum is afforded. It is only necessary to divide the central
tendon of the recto-urethral muscles before the operator arrives at
the apex of the prostate and the membranous urethra. The latter, being
exposed at this point, is usually divided upon a grooved staff. Here,
at its junction, the capsule is usually divided by a free opening,
through which the finger-tip is insinuated and made to strip the
capsule from the prostate itself. By different operators instruments
have been devised which facilitate much of the subsequent work. Perhaps
the best of these is the double-blade retractor of Young, which, shaped
like a sound, can be opened after introduction, and made to serve
excellent purpose by traction upon its handles. If, now, the perineal
route have been large enough, and retracted sufficiently, the prostate
can be so pulled down into the wound as to be exposed to sight as well
as to touch. The effort is sometimes made to enucleate the prostate
entire and withdraw it whole, but usually to separate each lateral
mass by itself. It is advisable to seize with strong tenaculum forceps
and pull down the loosened portions of the organ, in order that it
may be more easily separated at its upper part; but it has now been
found unnecessary to either open the bladder above the pubis, or even
to expose it by an opening through the skin so that it may be pressed
down, traction from below taking the place of suprapubic pressure,
whatever is needed in the latter direction being effected through the
uninjured abdominal wall (Figs. 662, 663 and 664).

[Illustration: FIG. 662

First exposure of prostate after introduction of sound through opening
just in front of it. (Proust.)]

[Illustration: FIG. 663

Enucleation of a portion or all of the prostate by use of the index
finger. (Proust.)]

[Illustration: FIG. 664

Hemisection of prostate, each half being secured within the bite of
vulsellum forceps. (Proust.)]

The balance of the procedure must depend on the size and character
of the growth. To strip off a naturally adherent capsule is quite
easy, but to detach one which has become firmly adherent through
old inflammation or cancerous infiltration is sometimes extremely
difficult. Thus enucleation may sometimes be effected in two or three
minutes. The stripping and enucleating process should be carried around
the prostatic enlargement and into the bladder, and the effort should
be to make the smallest possible rent in the vesical mucosa, as well
as to separate prostatic tissue from around the urethra rather than
to tear or mutilate the latter. Experience and patience will permit
the accomplishment of this to a surprising degree. Morcellation may be
an aid in removing large masses, and no hesitation should be felt in
dividing a mass of tissue which does not come out easily through the
wound (Fig. 665).

[Illustration: FIG. 665

Prostate removed by the perineal route: _A_, lateral lobes; _B_,
intravesical growth particularly obstructing urethral entrance.
(Proust.)]

The organ once enucleated, there results a bleeding cavity, at the base
of the bladder, which, however, is now opened below and should drain
itself easily. If the surgeon’s finger and his instruments have been
kept, as they should have been constantly, within the prostatic capsule
there is no possibility of harm to the rectum, which, however, may be
utilized for assistance in the manipulation should it be required.
There remain, therefore, after enucleation the checking of hemorrhage,
provision for drainage, and suitable narrowing of the wound. The first
and second of these are usually combined by the insertion of a tube,
of sufficient rigidity to permit a gauze packing to be placed around
it. This should be connected exteriorly with a suitable drainage
tube, and bladder siphonage be provided. The wound around the tube is
closed by two or three deep sutures, usually of silkworm-gut, since it
tends naturally to close by pressure and requires but little further
attention.

The greatest harm likely to be done in this operation is _injury to the
seminal vesicles_, above the prostate, between which and the prostate
itself the surgeon may not distinguish, with _unnecessary mutilation
of the posterior urethra_. Occasionally, in spite of great care,
the rectum will be slightly lacerated. Injury or destruction of the
vesicles might lead to impotence, while mutilation of the urethra would
be followed by delay in repair, with uncertainty of subsequent bladder
action and control.

Subsequent treatment consists in removing both gauze and tube at the
earliest possible date, which should not be later than the fourth day;
after this irrigation may be given once or twice a day, with the least
possible use of instruments.

In either of these methods of prostatectomy the greatest reliance is to
be placed upon natural processes of repair. In some way, which seems
almost inscrutable, torn bladder and more or less mutilated urethra
come naturally together and connection is reëstablished.

After this brief description of operative methods there remains only
to contrast them. The especial advantages of the suprapubic method
are the total avoidance of perineal fistula, of disturbance of the
deep urethra, of the perineal structures, of the seminal vesicles,
and a minimum of disturbance of the entire basal portion of the
bladder, with a greater theoretical possibility of speedy restoration
of its function. It is the method of choice with certain operators
of large experience. It seems especially indicated in cases of
pronounced intravesical enlargement, but may be made difficult in obese
individuals.

In behalf of the perineal route must be alleged the advantage of
seeing much of what one is doing, of being really nearer to the field
of activity, and of more perfect control of the mass which is to be
removed, as well as the fact that the prostate is not an intravesical
organ.

Whichever method be adopted the patient should be encouraged to be up
and about as soon as possible. Subsequent bladder control comes with
varying rapidity to different patients. Urinary fistulas are not likely
to persist in patients who have not worn drainage tubes too long. After
two or three weeks it is advisable to pass a sound occasionally, in
order to maintain proper direction of the urethral canal and prevent
formation of stricture. Bladders in which there has been a serious
complication of cystitis should be irrigated through the openings so
long as they are maintained.

The operation of itself is not a very serious nor difficult measure. It
is too often performed on feeble or septic patients, as a last resort,
when it is too late.

The _galvanocaustic operation_ is done with an instrument devised by
Bottini, shaped like a lithotrite, with a movable platinum blade, which
can be heated to the desired degree by the electric current. This
instrument is introduced into the deep urethra until its beak enters
the bladder, after which the latter is turned half around; then the
electric current is turned on, the movable caustic blade gradually
withdrawn by a screw mechanism in the handle, and made to traverse a
distance of one inch to one inch and a half, previously measured, and
in such a way as to burn a channel through the floor of the prostatic
urethra, and through any median bar or obstruction which may exist.
This is the principle of its use. At one time it was popular, although
of late prostatectomy seems to have supplanted nearly every other
method. Nevertheless in certain cases it will be found of advantage.
I have preferred to combine it, in most cases, with a small perineal
opening, introducing the instrument after opening the membranous
urethra, and having it in this way much more completely under control.
Through the opening thus made subsequent bladder drainage can be
effected if desired. It permits also of more perfect exploration of the
bladder with the finger.


CANCER OF THE PROSTATE.

Extensive _cancerous involvement of the prostate_ puts a case beyond
the pale of operative surgery, except for palliative purposes, though
either perineal or suprapubic drainage may be made for final and
temporary relief, the case admitting of nothing else. As mentioned
above many apparently ordinarily enlarged prostates prove to contain
cancerous elements. It has been found that, when not too extensively
involved, prostatectomy in these cases gives as good results as in the
absolutely non-malignant.

[Illustration: FIG. 666

Siphon drainage of bladder, with Cathcart’s S-tube (its essential
feature). May be applied equally well to perineal or urethral tubes, or
to drainage of other cavities.]


BLADDER SIPHONAGE.

A matter of great importance and comfort for the patient is an
effective _siphonage of the bladder_ after it has been opened. This
has usually been accomplished by the use of a Y-shaped tube, one of
the branches connecting with a suitable reservoir for water, hung
above the level of the body, the other with a tube connecting with
the bladder, while from the lower end another tube connects with a
suitable reservoir on the floor. This is rarely effective, and can only
be made so by inserting the S-shaped tube devised by Cathcart in the
lower drainage tube. With this, and a suitable regulation of the flow,
the water can be made to escape, drop by drop, and make an effective
suction that completely fails without the use of Cathcart’s tube. The
device is illustrated in Fig. 666.




CHAPTER LVI.

THE MALE GENITAL ORGANS.

THE PENIS AND URETHRA.


The most common _congenital defects of the penis_ are connected with
elongation of the _prepuce_ or with abnormality in the construction of
the _urethra_. Aside from these, however, rare congenital abnormalities
have been met with, as, for instance, a _double_ or _bifid penis_, or
its almost complete _absence_. The former is perhaps to be regarded
as an atavistic condition, having its prototype in the kangaroo.
_Misplacement_ of the organ is usually apparent rather than real.


PHIMOSIS.

Except as produced in consequence of disease, _i. e._, by edema
or inflammation with swelling, _phimosis_ indicates a _congenital
condition_, either of elongation or constriction of the prepuce,
usually with adhesions to the glans. A considerable proportion of
male children are born with more or less complete conditions of this
kind. These are not so abnormal anatomically, but they lead to serious
complications later in life. An extremely tight prepuce is often
complicated with _stenosis of the meatus_, the combined result being a
practical stricture at the end of the urethra, through which the infant
has to strain with each act of urination. This is a common predisposing
cause of hernia. Whether the prepuce be adherent, or so constricted as
to make it a retentive sac, there will accumulate between it and the
sensitive mucous surface of the glans more or less _smegma_ which, as
it decomposes in the course of time, becomes excessively irritating,
and a fertile source of reflex disorders, involving even distant parts
of the body. Thus in young boys especially, convulsions, chorea,
epilepsy, and various other neuroses are produced, while, in addition,
its perpetuation produces a condition of unnatural excitability which
leads again to habits of masturbation or to sexual irritability and
unnatural excitability.

Every newborn male infant should be carefully examined in order that
the above condition, if present, may be remedied. This remedy will
consist, in mild cases, of forcible retraction of the elongated
prepuce, with separation of any adhesions uniting it to the glans.
Preputial _stenosis_ may be overcome in some cases by simply slitting
up the dorsum, which, if not too long, may be thus released and not
require circumcision. On the other hand a much elongated and contracted
prepuce should be sufficient justification for prompt circumcision. At
the same time any unnatural contraction of the meatus may be overcome
by trifling incision. If every boy baby were thus carefully inspected
and relieved, if necessary, there would be fewer reflex disorders in
young children.

Incidentally it may be said that, in lesser degree, the same thing may
apply to _girl infants_, in whom the clitoris, although small, should
nevertheless be freely uncovered by retraction of its miniature hood
or prepuce. When this is not easily possible it should be made so.
Disorders of the same general character as easily arise in girls, from
this same general cause, as in boys, nocturnal incontinence being a
frequent expression thereof. In my opinion the teaching of obstetrics
should not be considered complete without unmistakable reference to
these matters.

_Phimosis in the adult_ may be brought about by disease, especially in
connection with a prepuce already retentive, or elongated and difficult
of retraction. _Retained secretion beneath such a prepuce is a fertile
source of danger of all kinds_, as well of venereal infection as of
cancerous growth. Surgeons in the Orient have described calculi, even
of considerable size, found in this location as the result of retention
of matter which should not have been at all retained, this condition
being noted most often among the Chinese.

Infection, usually gonorrheal, of the concealed surface of the prepuce,
which has a distinctly mucous character, is known as _posthitis_; that
of the covering of the glans as _balanitis_; while, in effect, whatever
appears in this location will essentially be a _balanoposthitis_. If
such a condition do not easily subside by irrigation, with a small
nozzle introduced beneath the margin of the prepuce, it will then be
necessary to slit up the dorsum, or make a complete circumcision, in
order that the affected surfaces may be made accessible. The same is
true in cases of chancroid and even in cases of chancre; incision or
circumcision being justifiable whenever indicated.


PARAPHIMOSIS.

Paraphimosis implies an opposite condition, where the prepuce, having
been retracted, is caught behind the margin of the glans and cannot
be released nor brought forward. This may be the result of undue
effort to retract a very tight but otherwise normal prepuce, or is
frequently the result of an acute inflammation, where edema and solid
exudate so solidify the tissues as to make them inflexible and almost
immovable. In mild cases of paraphimosis cold applications, or pressure
with patient manipulation, may be sufficient to restore the proper
condition. An extreme degree of such constriction would threaten the
nutrition of the glans, to the extent even of possible _gangrene_, and
sloughing of some portion of the end of the penis is not an infrequent
result of a neglected condition of this kind. Under these circumstances
constriction must be released, it being usually sufficient to apply or
inject cocaine, and then with scissors or blunt bistoury nick or incise
the constricting ring, to a degree sufficient to release it and permit
the desired result; in one way or another this must be attained, else
more or less sloughing is sure to follow.

Other _rare malformations_ of the urethra include its more or less
complete _obliteration_, in some portion at least, or, more often,
its sacculation or dilatation in certain areas, the result being the
formation of pockets or pouches. Such abnormality may persist to adult
life, and finally contain a considerable amount of retained urine.


EPISPADIAS AND HYPOSPADIAS.

_Epispadias_ and _hypospadias_ constitute defects in the urethral
construction, so that urine escapes at some point much nearer the
body than normally intended. A complete degree of epispadias nearly
always accompanies extroversion of the bladder, already described.
Milder conditions may be met in any degree. In these cases the urethra
becomes a canal open above, and the glans is more or less defective.
Cases of epispadias may be divided into the _balanic_, where the
urethra terminates on the upper portion of the glans, and the _penile_,
where it terminates between the glans and the pubis; while cases of
hypospadias may be divided into _balanic_ and _penile_, similar to the
above, the _penoscrotal_, where the urethra opens at the junction,
and the _perineoscrotal_, where both the perineum and scrotum are
involved. While all of these defects are more or less mutilating
and unphysiological, none of them menace life. The physiological
requirements of either case demand conditions permitting normal
urination, and coitus to a degree permitting fecundation. (See Fig.
667.)

[Illustration: FIG. 667

Diagrammatic sections showing different varieties of hypospadias: 1,
hypospadias with imperforate glans; 2, hypospadias with blind canal
in glans; 3, with barrier placed between penile urethra and balanitic
groove; 4, typical case of hypospadias; 5, hypospadias with normal
meatus; 6, penile urethra opening below glans; 7, absence of the whole
inferior part of the penile urethra; 8, hypospadias with absence of
urethra through glans; 9, case of d’Arnaud; 10, case of Lacroix; 11,
case of Lippert with normal meatus. (Kauffmann.)]

[Illustration: FIG. 668

Hypospadias. Liberation of anterior urethra and tunnelling the glans.
(Hartmann.)]

[Illustration: FIG. 669

Hypospadias. Drawing the liberated urethra through the tunnel in the
glans. (Hartmann.)]

Most cases of hypospadias are accompanied by other defects on the
inferior surface of the penis and the scrotum, which, more or less,
bind them down and interfere with the normal method of urination as
well as of insemination. The indications, then, in such cases are to
straighten the penis and to restore the continuity of the urethra.
The former may be accomplished by transverse incisions through the
bands which cause the curvature, or, if necessary, division of the
intracavernous septum, or even of the sheaths of or the cavernous
bodies themselves. Wedge-shaped pieces of cavernosa have often been
successfully excised. The _restoration of the urethra_ is a much
more difficult matter, especially in an extensive case, to make it
sufficient for insemination. The methods may be grouped under simple
_canalization_ or _approximation and the construction of flaps_. Nearly
all of these methods are more or less simple in theory but difficult
in practice, and frequently unpromising because of the difficulties in
securing final union of tissues, no matter how neatly united, where the
same may be interfered with by the presence of urine or the occurrence
of erections. The former may be prevented by a perineal section,
with drainage of the bladder, and this is probably the best method
to adopt in nearly all of these cases. The latter is to some extent
overcome by drugs, but is sometimes produced by the local irritation of
the operation and the dressings. To describe all these methods would
require a long chapter. They have included efforts at _tunnelling the
glans_, by the passage of a trocar, maintaining the channel by keeping
within it some bougie or foreign body until its interior has healed,
then connecting this up with the balance of the urethra (Figs. 668 and
669). The urethral passage-way is rarely sufficiently wide to permit
of approximation of freshened edges by stitches, and these will almost
surely pull out. Therefore some more plastic method of formation of
flaps must be devised. Many ingenious expedients have been suggested,
among them the utilization of a strip of skin, dissected up on one
side, whose external surface is turned in and made to vicariate as
mucous membrane, while its raw surface, now faced outward, is covered
with another flap, raised either from the penis itself or from the
scrotum. It is the operations based on this general plan which have
given the best results in well-marked cases, and yet they have to be
conducted with great care. American surgeons, among them particularly
Beck, of New York, have done a great deal to advance the plastic
surgery of these parts and for these purposes. He, for instance, has
especially exploited the movability of the urethra, and shown how by
dissecting it out it may be drawn forward and made much more available.
Beck has suggested a similar method of displacement and reëmployment of
the urethra for epispadias.

_Epispadias_ is far more uncommon than hypospadias, occurring in
proportion of 1 to 150 cases of the latter, and is rarely seen except
in connection with vesical extroversion, except in minor degree, in
which the defect is simply a little grooving of the upper surface of
the glans. The best method of dealing with the urethra, in epispadias,
is to displace it, as suggested by Beck, separating the cavernous
bodies and dropping it down to its normal situation beneath them,
and uniting with this procedure more or less of the transplantation
suggested by him. It is surprising how much can be accomplished by
this method, even in extreme cases. The glans, if necessary, may be
tunnelled, and the anterior end of the urethra may even be given a
hypospadiac termination.


HERMAPHRODISM.

Hermaphrodism, spurious and actual, implies the existence of sexual
organs of both sexes in the same individual. It is a condition actually
existent in many of the lower forms of life, but its occurrence in
the human being is a matter of extreme rarity. There are numerous
malformations which, by the laity, are often mistaken for indications
of this condition, but the actual co-existence of both testicle and
ovary--_e. g._, which may perhaps be assumed as the true test--is
one of the rarest of all phenomena in human anatomy. _External
malformations which more or less simulate the appearance of the organs
of one sex in those of the other_ include such conditions in the
male, for instance, as atrophy of the penis, hypospadias, a more or
less complete division of the scrotum into halves, retained testicles
with atrophy of the external organs, and similar conditions by which
the external genitalia are made to appear divided or relatively too
small. In the female, on the contrary, may be seen occasionally an
_hypertrophy of the clitoris_, which causes it to assume almost the
proportions and even the erectibility of the male organ, while other
deformities of the vulva simulate more or less the scrotum. Again in
the female one meets occasional congenital absence of the uterus or
of the ovaries, or congenital atresia, or almost complete absence
of the vagina, or vulvas which are almost impassable by virtue of
exceedingly dense hymens, where the natural appearances are so
perverted as to mislead the ignorant. These are, however, cases of
_pseudohermaphrodism_, although in many of them there are certain
general changes in appearance, as of the breast, the figure, speech,
and even in manner, which are regarded as evidences of effeminacy in a
male individual, or of masculinity in a female.

Strange mistakes and errors have thus arisen, and children about whose
sex ignorant parents have been in doubt have been mistakenly brought
up, even to a point in life when it was sociologically almost too late
to remedy the error. Such cases require careful study for the actual
determination of sex, especially in young infants.

_True hermaphrodism is not to be denied_, as certain historical cases
have proved, and as has been demonstrated in certain individuals who
travel from city to city, exposing themselves for a consideration
for scientific examination. In general it is sufficient to say here
that true hermaphrodism is a rare possibility, while spurious or
pseudohermaphrodism is a condition not uncommonly met.


INJURIES TO PENIS AND URETHRA.

The great vascularity of the penis makes it peculiarly liable to
obstinate _hemorrhage_ in cases of incision or laceration. For the
same reason when strangulated, as may occur in some drunken orgy or
otherwise, it may swell enormously and quickly become gangrenous. An
actual _fracture_ of the _cavernosa_ has occurred, through violence
in the erected condition. Subcutaneous lacerations or contusions
may lead to extensive hemorrhages, possibly with gangrene as the
result. Any injury by which the _urethra is lacerated_, especially
torn across, will be followed by much hemorrhage, probably with
urinary extravasation, and perhaps great difficulty in establishing
the continuity of the channel. Under any circumstances _urinary
infiltration_ of any part, deep or superficial, is likely to be
followed by abscess and sloughing. An absolute _dislocation_ of the
penis is not unknown, it having been displaced beneath the integument
of the perineum, abdomen, or thigh, especially in extremely obese
individuals.

Urethral injuries are not all accidental. Some of them are the result
of design, or of the introduction of foreign bodies which cannot be
removed by the patient himself. Such articles may also be introduced,
during a drunken orgy, by another individual, or under conditions of
sexual perversion by the man himself; and such bodies as pencils,
slate-pencils, twigs, and almost every imaginable small object have
been found within the urethra. Again it has been seriously injured and
even punctured by the careless use of sounds, or by the wire stillette
of the old-fashioned linen catheter. Both the anterior and deep urethra
may be seriously injured by such accidents as falls upon the external
genitals, or upon the perineum, and serious deep lacerations, with
complete severance of the membranous urethra, and the infliction of
even greater damage, are by no means unknown in such cases.

[Illustration: FIG. 670

Perineal section for deep rupture of urethra. Posterior opening is
identified and catheter, which has been introduced from the meatus, is
guided through it into the bladder. (Lejars.)]

The first determination should be as to the presence of any foreign
body. This being eliminated an effort should be made to check the
hemorrhage, and to make sure that there is no such obstruction of
the urethra as to interfere with the freedom of the urinary stream.
The constant discharge of blood from the meatus, or the admixture of
blood with the urine, is always suggestive and should lead to careful
investigation. This should include not merely the gentle passage of
a sound or catheter, or at least attempt thereat, but perhaps an
inspection of the site of injury through the endoscope. When the injury
is compound, in the sense of being an external laceration, the deep
conditions are more easily ascertained. If with gentleness and yet
with difficulty a catheter can be passed through the injured portion
of the urethra it would be well to leave it _in situ_, at least for
several hours, perhaps for three or four days, in order that it may act
as a splint and the parts more kindly heal around it. If the urethra
be so lacerated as to not permit the passage of an instrument, the
safer course is an _external perineal section_, for the purpose of
temporary bladder drainage, or to find a deep tear, while a retrograde
catheterization may perhaps be practised, and an instrument introduced
and carried through in the reverse of the ordinary direction; this may
be possible even when ordinary methods fail. _Extravasation of blood_
may be extensive and serious, but extravasation of _urine_ is always
followed by disastrous consequences, which should be prevented by
external urethrotomy and bladder drainage.

These cases may not be seen until the dangers have already occurred.
If it should so happen, an effort should be made, by deep incision
and free dissection, to open up all pockets containing urine or blood
and to afford free outlet from the bladder. Under some of these
circumstances, especially when attempted at night with poor light, the
performance of an external perineal urethrotomy is by no means an easy
matter, since the torn urethra may be lost in ragged and infiltrated
tissues, and may sometimes be found only after long and tedious search.

What to do with a _torn urethra_, under these circumstances, is
sometimes a problem. If it be ragged and more or less torn away it
may sometimes be _resected_, and the ends re-united by sutures, if
necessary with a certain amount of dislocation of the urethra by
dissecting around it. Pringle and others have resorted to the fresh
urethra of the ox, for grafting into cases of recent or old defect,
as in instances of extensive deep rupture; as well as in cases of
hypospadias, with defect in the floor of the urethra throughout its
entire penile portion.

The _removal of foreign bodies_ from the urethra is not easy when
these have passed into its deeper portion. With special instruments
it is sometimes possible to grasp and extract them, although a
pointed extremity may interfere with the ease of removal. More harm
will come from leaving them than from removing them. Therefore when
their extraction is impracticable there need be no hesitation in
button-holing the membranous or the deep urethra, and by pushing the
object down toward the opening, there effecting its removal.

The urethral walls will take fine sutures, with every prospect of
repair, providing their vascular supply be not too seriously disturbed.
Therefore lateral or end-to-end _suture_ may be attempted whenever it
appears promising, but in such cases it would be well either to leave a
catheter for a few days or to make bladder drainage back of the injury.

_Cavernitis_ refers to an acute or chronic inflammation of the corpus
cavernosum on one or both sides. It may be the result of the exudate
connected with an injury or with the process of repair. It may ensue
in consequence of a local gonorrheal inflammation, or it may be
an induration due to chronic syphilis. The condition is one which
causes local tenderness rather than pain, while the induration causes
a perceptible lump or tumor, and infiltration of vascular tissue
interferes with symmetry during erection. Again pressure may cause some
ureteral obstruction. Cases of syphilitic origin are to be treated by
local inunctions of mercurial ointment, perhaps with ichthyol, which
are of benefit in any instance, while the internal administration of
the iodides is of more or less assistance. The non-specific cases yield
only to time and to massage.

_Gummas_ of the penis may assume the above type, but usually occur in
more distinct form, either in the cavernous bodies or between them.
An abruptly limited nodule in any such locality will always naturally
arouse suspicion of specific disease and lead to its appropriate
treatment.

Upon the glans and the prepuce, especially, _herpetic vesicles_
frequently appear, constituting an annoying local lesion, corresponding
minutely to the ordinary “cold-sore” upon the lip. This is known as
_herpes preputialis_. It is the result usually of uncleanly habits
or local irritation. It is of no consequence, save that in some
individuals it occurs frequently, with considerable local irritation.
The broken surface thus produced is liable to chancroidal or septic
infection, which constitutes its greatest danger, while such a sore,
irritated by caustics or injudicious applications, is sometimes
mistaken for a specific lesion. A chronic herpes may frequently prove a
precancerous lesion.

The _papillomas_, or _warty growths_, are frequently noted about the
glans and prepuce, being expressions of local irritation, while,
under the conditions of local warmth and moisture which prevail,
they luxuriate and may develop into _condylomatous masses_, known as
“_strawberry_” or “_mulberry_” growths, which may attain large size. In
the female they occur on all parts of the vulva and anal region; in the
male they rarely appear except as above.

All that such papillomatous growths require is complete excision or
extirpation (_i. e._ destruction), with cauterization of their bases
and subsequent local cleanliness. They are not infrequently referred
to as _venereal warts_, which, in effect, they usually are. The other
benign tumors of the penis are rare. Occasionally some dermoid cyst
or small fatty or fibrous growth may be seen. Sarcoma of the penis is
also rare, while epithelioma is not uncommon, constituting the ordinary
cancer of the penis.

_Epithelioma_ in this region has its origin around some portion of the
mucous surface of the glans, spreading in time to the prepuce, more or
less involving the entire organ, while by its rich lymphatic supply
involvement of the inguinal and other nodes happens early, whereby the
situation is sadly complicated. Epithelial cancer here evinces the
same local tendencies toward extension and destructive ulceration as
elsewhere, made more rapid by exposure to surface irritation. Its base
is indurated, even if sometimes everted; it grows irregularly, but
destroys everything with which it comes in contact.

Epithelioma of the penis should be recognized and extirpated early
to offer any prospect of success. It is usually as unpromising a
condition as epithelioma of the tongue, because of the early lymphatic
involvement. A lesion of limited area may justify local excision,
but a distinctly marked lesion can only be successfully treated by
amputation, at least of the anterior portion of the organ, perhaps of
the entire structure of the penis, and thus ensure complete eradication.

_Amputation of the penis_ is easily effected with a circular sweep
of the knife, or by an abrupt cross-section, there being but little
choice of method, the intent being only to save sufficient of the
organ so that cleanliness during and after the act of urination may be
maintained. When any portion of the pendulous organ is preserved the
margin of the divided skin should be attached to that of the urethra
by a series, say, of four sutures, placed at equal intervals, after
hemorrhage, which will be somewhat difficult of control, both from the
larger vessels and from the cavernosa, has been subdued. It may require
buried sutures through the divided cavernosa in order to permit of such
control.

If, however, it seem necessary to remove the organ close to the pubis
it will probably be found more desirable to make a more complete
dissection, taking out the corpora cavernosa entirely, and then making
a median incision in the perineum, dissecting out the urethra, bringing
it out through the wound, shortening it to the proper extent, and
fastening its termination to the skin margin, thus making, as it were,
a vulvar outlet, which will not interfere with urinary control, but
will permit urination to be satisfactorily accomplished, though only in
the sitting posture. This is usually known as Demarquay’s operation.


CIRCUMCISION.

In children this requires a general anesthetic; in adults it can almost
always be satisfactorily performed under local cocaine anesthesia; the
intent being to remove the redundant foreskin. A circular incision
is necessary, which may be made with knife or scissors. The parts
being prepared for operation, the prepuce is drawn forward, being
caught either with forceps or fingers of an assistant, and the little
circular amputation is made just in front of the corona of the glans.
The first incision extends through the skin, after which there remains
a cuff of mucous membrane, which is sometimes adherent to the glans,
as in children, or may be infiltrated with exudate, as by a concealed
chancroid or chancre beneath. Ordinarily this cuff is split in the
middle line of the dorsum and removed in halves, in order to avoid
any possible injury to the glans itself. The cut is made somewhat
obliquely from above downward and forward, the intent being to divide
it at the frenum, sufficiently far from the meatus in order to not
distort the latter by subsequent cicatricial contraction. These tissues
are sometimes inordinately vascular, and bleeding points need to be
quite carefully secured. In one case known to me an infant bled to
death from an unsecured vessel near the frenum, the operator having
neglected it at the time and having left the patient. In a clean case,
the vessels having been secured, a running suture of fine catgut should
unite the cut edges of the mucosa and of the skin. It is not necessary
to apply sutures in a venereally infected case, for raw surfaces
will also become infected, and would be best protected by immediate
cauterization, in which case primary union would be prevented.

The little procedure may be modified in various ways to meet individual
needs. After its performance there will occur considerable local
swelling and edema, which can be best kept under subjection by a
dressing moistened with cold saturated boric acid solution or its
equivalent. If the sutures have been too tightly applied there may be
a species of paraphimosis, with too much constriction, which would
require their division.


THE URETHRA.

In Chapter XII, on Gonorrhea, were described the usual specific forms
of urethritis, with their complications and results. To this chapter
the reader is referred for all data regarding gonorrhea as it involves
this passage-way, with its complications. Such lesions as _ulcers_ may
persist for some time, while the papillomatous outgrowths, polypi,
etc., connected with gonorrhea and gleet, which are not discoverable
from without, are now easily examined and estimated with the endoscope.
Specific ulcers of the syphilitic type, and virulent ulcers even of
the chancroidal type, also occur, usually within the first inch of
the urethra, causing more or less discharge, with local soreness, and
leading, unless promptly recognized, to cicatricial stricture formation.


STRICTURES OF THE URETHRA.

Strictures of the urethra may be of _traumatic_ origin, as when
produced by external accident, with or without laceration, or by the
introduction of foreign bodies, or the minor injuries inflicted during
their extraction. _Deep traumatic stricture_ is the result of serious
injuries to the perineum. The common type of urethral stricture is the
consequence of one or more attacks of _gonorrhea_, which, not having
been promptly cured, has merged into so-called _gleet_, and this into
these inevitable consequences, with more or less infiltration of the
peri-urethral tissues, and subsequent encroachment upon the caliber of
the urethra, either by irregular new tissue formations or well-marked
annular constriction. In addition to the above conditions there is
also known a _spasmodic_ stricture, due to involuntary contraction of
the muscular fibers encircling the urethra, and of the deeper perineal
muscles which concern it. Otis held that such urethral spasm is a
frequent accompaniment of a contracted meatus, and taught that the
best method to deal with it is by first enlarging the meatus, as may
be easily done with a simple bistoury, under local cocaine anesthesia
(_meatotomy_), and the subsequent passage of instruments of proper size.

To persistent and well-marked contraction of the urethra is given
the term _organic stricture_, and such a stricture is generally the
consequence of injury or disease, whereas purely spasmodic stricture,
mentioned above, is a not infrequent occurrence in perfectly chaste
individuals.

_Organic stricture may be single or multiple_, of large or small
_caliber_, or even _impassable_ and impermeable--that is, from before
backward--so that even while urine may leak through, drop by drop,
from behind it seems impossible to introduce an instrument from the
front. In aggravated cases three or four inches of the urethral canal
may be involved in lesions of this kind, which constitute a formidable
condition for satisfactory treatment. The ordinary non-traumatic
organic strictures are all in front of the prostate and more common
near the meatus. The size of a stricture is determined either by
the _urethrometer_ devised by Otis, or, more simply, by determining
the diameter of the bulbous bougie which may be made to easily slip
through it, the latter being the common method. These instruments are
indicated by numbers, which refer to the millimeters in circumference
of the bulb; thus No. 27 implies that the bulb has a circumference
of 27 Mm. The bulbous instrument is far better for examination than
the sound, since it indicates the exact depth as well as the length
of the strictured passage, and gives a better idea of its density or
resilience. (See Figs. 671 and 672.)

The _indications of stricture_ are difficulty in micturition, even
to the degree of impossibility, persistence of gleety discharge, and
slowness or impossibility of ejaculation, while sometimes cicatricial
tissue can be felt from the outside.

The strictured urethral canal should be restored to normal dimensions
at the earliest practicable moment. This may be effected through
gradual dilatation with a conical steel sound, passed at intervals
of two or three days, or rapidly, by the improved instrument of Otis
known as the _dilating urethrotome_, which, being passed through the
stricture, has its blades expanded by a mechanism at the handle, while
the stricture when it is stretched is divided by the working of a
concealed blade. The Otis instrument is illustrated in Fig. 673.

A meatus too small to admit a suitable instrument should be incised to
the necessary degree.

Gradual dilatation may be employed in the milder cases, and has been
combined with a method of electrolysis, in which I have little faith.
No matter which method be adopted, the patient should be impressed with
the force of the old adage, “Once a stricture always a stricture,”
and should be warned that the occasional passage of an instrument
is necessary for a long period, and that while he may be taught the
procedure he should not neglect it. This is true alike of every method
of treatment.

[Illustration: FIG. 671

Bulbous sound.]

_Divulsion_ was a method employed during the past generation of
rupturing a stricture by forcible separation of the blades of a divided
instrument, tearing it instead of neatly cutting it, thus inflicting
a maximum instead of a minimum of local damage. Every divulsion thus
led to a subsequent stricture formation. The procedure has been
abandoned. Now by the employment of the Otis instrument, or one of its
substitutes, the stricture is first found, then penetrated with the
instrument, and divided to an extent easily regulated, thus permitting
exact work, which is preferable to the older methods of drawing a large
blade along the urethral tract.

[Illustration: FIG. 672

Otis’ urethrometer.]

In _tight strictures_ the operator proceeds at first with small
_filiform bougies_ made of _whalebone_, with which, sometimes after
considerable effort with a bundle of them in the urethra, trying one
after another, he may succeed in passing one and causing it to enter
the bladder. The others are then withdrawn. It may now be possible to
thread over the whalebone a perforated tip made for the urethrotome,
and thus to slip the latter down into the depths over the fine bougie
as a guide, and then to push it farther, using now more force because
it must necessarily follow the urethral canal. When, however, what
seems to be judicious manipulation by this method is unsuccessful the
metal instrument should be withdrawn, the whalebone bougie remaining
_in situ_, and thus serving as a guide for that which is now made
necessary, namely, _external urethrotomy_.[72]

  [72] Van Hook has recommended the following excellent expedient for
  the discovery of the urethral canal when apparently lost in the
  depths of a dense, deep stricture: He gives a dose of potassium
  iodide two or three hours before the operation. During the latter,
  and when seeking the proximal end of the urethra, he drops a little
  acetate of lead solution at the point where the urine is expected to
  appear. The formation of the bright-yellow lead iodide will mark the
  actual appearance of the urine and indicate its source.

[Illustration: FIG. 673

Otis’ dilating urethrotome.]

_External urethrotomy_ is essentially a median perineal section,
carried down at least to the urethra. It is done preferably with a
_guide_, usually a fine bougie. With it the urethral channel may be
easily identified; without a guide, in aggravated cases, it is often
a difficult matter to identify and dissect out the urethra, and then
to find its tortuous passage-way and follow it into the bladder.
Patience and a knowledge of the anatomy of the perineum will lead
to success. Sometimes extensive dissections are necessary, and the
perineal wound needs to be widely retracted in order to better expose
the deep tissue. Once the urethra is identified it may be followed in
each direction, and the case should not be left until the entire canal
has been restored to its normal caliber. In these cases it is best to
leave a self-retaining catheter in the perineal wound for at least a
day, after which it is sometimes of benefit to introduce a catheter
through the meatus, and leave it in the urethra for two or three days.
Such a urethra is an infected channel, and must be so cared for that no
retention or infection of fresh wounds occurs.


PERINEAL ABSCESS.

Perineal abscess is the not infrequent consequence of a very tight
and deep stricture, having its beginnings as a _folliculitis_, with
subsequent extension and perforation, with escape of urine, and
sometimes with the formation of acute, diffuse phlegmon, which may
even extend into the scrotum or to the abdominal wall. Ordinarily it
constitutes a circumscribed collection of pus. Such a phlegmon when
neglected may be followed by extensive burrowing of pus, or local
sloughing, with gangrene, and partial or complete destruction of the
external genitals. When such a phlegmon occurs above the triangular
ligament there will be swelling about the prostate, with edema of
the anterior rectal wall, while the prostate itself may become later
involved. Such a collection may terminate as an _ischiorectal abscess_,
associated with _perineal fistulas_.

The inevitable results of such conditions have two or three disastrous
tendencies, such as burrowing of pus and the formation of urinary
fistulas, sometimes at considerable distance from the urinary channels.
The same is true in traumatic cases, for in such cases there may be the
expression of an old and neglected stricture. To the chronic condition
may be added that of tuberculous infection.


=Treatment.=--The _treatment of such abscesses and fistulas_ is based
upon the principles of evacuation of pus and restoration of the urinary
canal to its proper size. This may be an easy or a difficult task, but
it should be accomplished by whatever method will permit it with the
least damage to tissues. When urinary infiltration threatens gangrene
extensive incisions should be made. When the scrotum is swollen, as
it may be to enormous dimensions, free opening should be made into it
to permit escape of serum and pus if present. Even the surrounding
tissues, including the penis, may be enormously edematous. This
swelling will rapidly subside when pressure upon the deep veins has
been relieved, _but pus, no matter where present, must be evacuated_.


URINARY FEVER.

Instrumentation of any kind within the urethra may, in some
individuals, be followed by what has been called _urethral_ or _urinary
fever_, including chill, pyrexia, with sometimes the development of
an acute inflammatory affection, either of the urethra or even of
the kidney, with not only retention but actual suppression of urine.
These manifestations are ordinarily regarded as due to toxemia, but
are sometimes difficult to explain, because their violence seems so
disproportionate to the amount of intervention. Thus I have known an
individual to die, of apparently acute uremia, within four days after
the painless passage of a sound for dilatation of an old stricture, the
same not being followed by any blood or local disturbance.

These accidents were more prone to occur before the introduction of
antiseptic methods in all urethral instrumentation. At present they
are much rarer than in former days. Nevertheless the passage of any
instrument, even for legitimate examination, as for stone, may be
followed by unpleasant consequences. These are preventable to some
degree as well as curable, by antiseptic local measures, as well as by
the administration of quinine or urotropin, especially the latter, with
sitz baths and perhaps general antifebrile measures, while any local
disturbance thus set up is to be treated on general principles.


THE TESTICLES, THE CORD, AND THE VESICLES.

The testicle is originally formed by differentiation from the Wolffian
bodies, at a level above the pelvis. Its _migration_ from its original
location into the pouch where it normally belongs is known as the
_descent of the testicle_. When it fails to appear at the external
ring it is spoken of as _retained testicle_, and when detained outside
the ring above its proper level the condition is referred to as
_incomplete descent_, these being purely arbitrary terms. The reasons
for incompleteness of the descent are as little understood as those for
its completion, and have but little reference to clinical surgery.

The surgical anatomy of the testicle may be only briefly considered
here. Each is essentially a double organ, consisting of the _testis_
proper, the secreting portion, with its more or less complete double
peritoneal covering (originally peritoneum), and the _epididymis_,
or conducting portion, variable in size, and corresponding to the
parovarium in the ovary in respect that it is subject to cystic
degeneration. The pathway made by the testicle as it passes from the
abdominal wall should be completely obliterated. When unobliterated it
facilitates the occurrence of hernia, while when partially obliterated
cystic dilatations of the enclosed portions (_hydroceles of the
cord_) occur. The lowermost portion of the accompanying peritoneal
pouch is normally left as a closed sac, which constitutes the cavity
of the tunica vaginalis testis. In the ordinary standing posture the
epididymis occupies toward the testis proper the same relative position
that the heel does toward the anterior part of the foot, _i. e._, it
lies to its posterior and inner sides. While both portions of the organ
may be involved in acute or chronic diseases, each of them may be by
itself involved with a minimum of disturbance of the other.


RETAINED TESTICLE, OR CRYPTORCHIDISM.

As above indicated failure in descent varies in degree from complete
absence from sight and touch to a presentation of the testicle at
a point where it can be both seen and felt but still at too high
a level. Ordinarily the condition is symptomless, its only signs
being those above rehearsed. Strange to say the condition sometimes
passes unrecognized until adult life is reached. Commonly it is early
discovered. Pain is felt only when friction or traumatism lead to
the same unpleasant sensations which would be produced by pressure
upon a normal organ. Thus a testicle retained at the external ring
may be irritated by the clothing, and has been many a time mistaken
for an incomplete hernia, upon which a truss pad has been applied
with inevitably resulting suffering. While accompanying malformations
in other parts of the body may be found it does not follow that the
individual may not be otherwise perfectly developed.

It is usually held that an incompletely descended testicle is more
or less functionless; often it is at least more or less atrophied.
Its functional capacity varies. It is usually more or less surrounded
by a cavity formed from the peritoneum. While the condition is
ordinarily one of minor importance, it has been established by numerous
observations that retained testicles are relatively prone to undergo
malignant degeneration.[73]

  [73] In the pathological museum of the University of Buffalo I
  deposited specimens illustrating this fact, one testicle forming
  a tumor as large as the patient’s head, the other as large as a
  cocoanut. These were both successfully removed from an adult, and
  without the patient developing any subsequent evidence of malignant
  infection. It is thus important in every case of intrapelvic tumor in
  the male to examine the scrotum and be sure that both testicles are
  in their proper position.


=Treatment.=--The proper early treatment of cryptorchidism has been
a matter of dispute, some advising to leave the condition entirely
untouched so long as it be not troublesome; others that early
intervention should be practised. If the organ be simply displaced and
not otherwise diseased, whatever be done may be limited to freeing it
from its abnormal surroundings and restoring it as nearly as possible
to the position where it belongs. If it be actually diseased it
should be removed. What may be accomplished will depend much upon its
movability and its blood supply.

Thus Keetley would liberate the testicle, when retained within the
inguinal canal, by division of the latter and lengthening of the cord
by blunt dissection, with division also of the lateral portions of
the gubernaculum near the pillars of the external ring and as far as
possible from the testicle. By traction upon this it is then often
practicable to bring the testicle down, without undue tension, to
the lower part of a new scrotal pouch, which is formed by making for
it a nest, as it were, with the finger, with an opening at its lower
extremity, through which forceps are thrust, passed upward and made to
seize the end of the gubernaculum, or through which a suture may be
passed for the same purpose. By means of this device the testicle is
now drawn downward into the scrotal pouch, where, being once present,
it is held by sutures, both direct and those which close the pouch
above it. It is then advisable to close the inguinal canal, as after a
hernia operation. In order to prevent upward traction on the scrotum
it is necessary to attach its lower end to the skin of the thigh, by a
suture which should remain for several days. If this be done on both
sides the limbs should be snugly bandaged together and movement of all
kinds prevented. Complete separation of the scrotum from the thighs
should not be permitted for several weeks, unless unavoidable.

Beck recommends an incision from the external ring three inches
downward along the cord, after which he opens the pouch of the
testicle, lifts it from its bed, pulls it down, carefully dividing
all bands of connective tissue or peritoneum which tend to immobilize
it. It is then deposited in a scrotal pocket, in which it is held
by a flap dissected from the outer margin of the inguinal ring, and
turned downward in such a way that it can be attached to the opposite
layer in semilunar shape. Thus a band of aponeurotic tissue is made
to surround the testicle “like a necktie,” the organ being retained
as in a buttonhole, the length of the flap being determined by the
extensibility of the cord. The inguinal canal is then closed as after
any other procedure.

_Other abnormalities_ of the testicle include _congenital atrophy_ or
_absence_, while in a few cases a _third testicle_ has been found,
it lying in contact with one or the other of the naturally separated
normal pair.


INJURIES TO THE TESTICLE.

Injuries to the testicle are of common occurrence, on account of their
exposed position, yet less common than would otherwise occur were it
not for their extreme movability. Aside from the lacerated, incised, or
punctured wounds which may be inflicted the testicle suffers most often
from _contusions_, always with resulting swelling, and sometimes with
considerable effusion, of which a large amount may be accommodated in a
distended tunica vaginalis.


HEMATOMA OF THE TESTICLE.

Hematomas of the testicle are also thus frequently produced. When
of a limited degree of severity spontaneous absorption of blood may
be expected, and should be favored by physiological rest, _i. e._,
confinement in bed, with elevation of the scrotum and the application
of water dressings. Large extravasations of blood, when fresh, may be
withdrawn by the trocar, but when clotted will require incision and
evacuation of clots, which should always be practised, as it leads to
great saving of time. Extravasation is usually followed by induration,
and more or less permanent enlargement, which will be slow to
disappear; absorption may be encouraged by the use of a weak mercurial
ointment.


TUBERCULOSIS OF THE TESTICLE.

Tuberculosis of the testicle simulates very closely that occurring in
the lungs, in that one may see a disseminated miliary process, with
subsequent coalescence and formation of caseous nodules, subsequently
breaking down into abscess cavities, while at the same time the
surrounding membranes, _i. e._, the tunica vaginalis, are involved,
and effusion (hydrocele) occurs just as in the pleural cavity. In
other words every appearance of pulmonary consumption may be imitated
within the small extent of the testicles and the epididymis. Of
these two parts the latter suffers much more frequently. Here are
caused irregular nodules, which may later unite, giving to the
entire epididymis a much enlarged, irregular shape, with induration,
frequently extending upward along the cord, and always tending so to
extend unless the disease be early seen and recognized. Too often
adhesions to the skin occur, with ulceration and formation of fistulas,
and perhaps more or less extensive ulcers, while in many instances
the entire length of the vas becomes infected, and frequently even
the prostate and corresponding vesicle become involved. By this time
there will be more or less involvement of the inguinal lymphatics, and
the patient may be already showing evidences of general tuberculous
infection, at least those of some serious constitutional impression
made by the local disease. One has to differentiate as between
tuberculosis, syphilis, and cancer, which may be difficult in the
early stages; but when the disease has extended beyond the epididymis
itself it is rarely difficult to recognize, unless entirely masked by
distention of the tunica vaginalis with fluid.


=Treatment.=--The treatment for tuberculosis of the testicle is
_extirpation_, _i. e._, _castration_, which includes the removal not
only of the diseased organ, but of all the tissues, including the skin,
to which it may be abnormally adherent, and of the spermatic cord,
which, if necessary, should be followed into the pelvis by a long
incision extending up along the inguinal canal. To remove a tuberculous
testis and leave a tuberculous cord is to accomplish very little, while
the latter, being an extraperitoneal tissue, may be followed with
relative safety, even to the depths of the pelvis. Local applications
in these cases give little relief. This teaching is at variance with
that of some writers, but is justified by experience.


SYPHILIS OF THE TESTICLE.

Syphilis occurs in secondary and tertiary manifestations, usually first
in the testis, sometimes in the epididymis, but always in the testicle
before the cord. It produces nodules which may be mistaken for those
of tuberculous trouble, but which often attain much larger size. They
are usually painless. Nevertheless a syphilitic testicle is sometimes
tender, and constantly so, to a degree causing no little annoyance.
The occurrence of nodules in the epididymis, in connection with other
evidences of syphilis, is regarded by some as pathognomonic. In this
location the condition yields readily to properly directed treatment.


CYSTS OF THE TESTICLE.

Cysts are frequently found along the course of the epididymis. Some
of them are expansions of the natural tubes of the paradidymis, while
others are distinctly new. _Dermoids_ are occasionally met, and either
of these may attain considerable size. Cyst of the epididymis proper is
to be distinguished from encysted hydrocele of the cord. All of these
purely cystic conditions are essentially innocent, and need similar
treatment. They may be evacuated and injected with an irritant like
pure carbolic acid, which is sometimes an effective way, or they are
better treated by _open incision_ with extirpation of the cyst, which
is, in the end, far the more satisfactory course to pursue.


EPIDIDYMITIS AND ORCHITIS.

Each of the separate portions of the testis may have its own nearly
self-limited inflammations and infections, or both may participate in
a common lesion. The most frequent cause of an acute _epididymitis_ is
gonorrhea, the infection travelling from the urethra along the vas, and
causing acute and well-marked swelling of the epididymis, which becomes
tender and painful in proportion to the amount of exudate. It may come
on early or late, during the course of the urethritis. The condition is
known to the laity as “swelled testicle.” It has been frequently called
orchitis, which is an error, since however much the testis may later
participate the primary trouble is in the epididymis. It may be easily
distinguished by palpation, the enlarged and hardened epididymis, often
very tender, being prominent behind the testis proper. The condition
may, however, be masked by the acute effusion likely to occur in the
tunica vaginalis, constituting a mild degree of acute hydrocele. This
may be expected in nearly all severe cases, and serves to increase the
size of the entire mass. A testicle thus affected may assume much more
than normal dimensions, and, becoming thereby much heavier, drag upon
the cord, which is its normal support. More or less fever and malaise
accompany the condition, part of which may be due to the toxemia of
gonorrheal infection. Usually but one side is involved. Both are rarely
affected simultaneously, but one may follow the other.

The acute stage of gonorrheal epididymitis persists for a week or ten
days, even under the best of treatment, and is followed by gradual
subsidence, characterized by amelioration of symptoms and decrease in
size.


=Treatment.=--This improvement is to be induced, first, by rest in
bed, with elevation of the scrotum, and the ordinary eliminative
treatment suitable for any febrile condition. Local relief may come
from the application either of heat or of ice-bags, the latter being
preferable, but will be made more effective by the application over the
scrotum of a mixture of two parts of olive oil with one part of methyl
salicylate, or of guaiacol reduced with equal parts of oil or glycerin.
The anointed surface should be covered with some impervious material,
and the dressing be changed every few hours. Later, as the acute
merges into the chronic condition, absorption may be stimulated by the
ordinary mercurial ichthyol ointment.

In some exceedingly acute cases suppuration ensues, the consequences
being a collection of pus in the epididymis, which will give the
ordinary signs and call for the usual evacuation which every collection
of pus demands. Epididymitis, more or less acute, has been known to
follow the introduction of the catheter or sound, even in cases so
far as known not previously infected. It is difficult to explain, but
requires the same treatment as above.


=Orchitis, or Inflammation of the Testis Proper.=--This condition is
rare except as an occasional complication of _mumps_, or, much more
rarely, of one of the other exanthems. Why after acute parotiditis
there should be a tendency to inflammation of the testis or the ovary
has never been fully explained. Nevertheless it is sufficiently
frequent to be well known to the laity, and is occasionally so
pronounced as to lead to actual atrophy, with loss of function of the
testis involved. In any true orchitis there will be considerable pain
and tenderness, because the testis proper is so tightly confined within
its tunica albuginea, _i. e._, a firm, inelastic membrane. By proximity
there will also be set up more or less involvement of the tunica
vaginalis, with effusion, so that some degree of acute hydrocele may be
looked for in every such instance.


=Treatment.=--The treatment of the condition above described consists
essentially in rest, with local soothing applications, of which perhaps
nothing will be more satisfactory than guaiacol, which, however, should
always be used with caution.


TUMORS OF THE TESTICLE.

_Dermoid cysts_ and _tumors_ and _teratomas_, _i. e._, those of
mixed type, are frequently met in this region. Their explanation is
doubtless afforded by the extreme complexity of the elements which
help to make up the part, while in the embryonic condition, and the
confusion of tissue elements which may then and there arise. These
growths of embryonic origin vary from single cysts to a mass of
cystic tumors, which may replace the organ, or constitute neoplasms
of large size, while some of the teratomas have features causing them
to resemble the mixed growths occasionally found within or about the
ovary. In this way is to be explained the occurrence in such masses of
hair, teeth, and other epiblastic elements, as well as of cartilage
or bone or other mesoblastic elements. Taken together these growths
constitute an interesting group for the pathologist to study. For the
surgeon, however, they require essentially the same class of treatment,
namely, _extirpation_, or, if this be impossible, complete removal of
the organ, _i. e._, _castration_. There should be no hesitation in
performing this upon any such growth, as no testicle thus affected
is likely to be functionable, and the individual suffers no possible
deprivation of potency by its removal.

The other benign and simple tumors, especially _fibromas_ and
_chondromas_, are occasionally met, and I have described one rare case
of large _lipoma_ within the limits of the testicle proper.


=Cancer of the Testicle.=--This includes, usually, sarcoma, developing
from the mesoblastic elements, although adenocarcinoma may be met here,
but as an extension from some growth occurring first in the skin or in
the immediate neighborhood. Deep cancer in this region is difficult
to at first distinguish from the induration produced by tuberculosis
or syphilis. In doubtful cases the therapeutic test may be tried in
order to differentiate it from the latter. From the former it is
usually separated by its more consistent and regular (_i. e._, its less
nodular) character. In all three cases the lymphatics of the groin
may be early involved, or perhaps not until late. As a rule cancer
is met in the later years of life, while the other conditions are
more frequently seen in the first half. In the more rapid cases there
will be considerable pain, with dilatation of the scrotal veins, and
evidences of constitutional involvement. Sarcoma may grow rapidly and
metastasis is almost invariably to the lungs.

Of tumors in the testicle, as of those in the breast, it may be said
that any new-growth which tends to enlarge, become more dense or
adherent, to spread, or to be accompanied by lymphatic involvement
_should be removed_; no mistake will be made in applying this rule
in these cases, especially if by the therapeutic test or otherwise
syphilis can be excluded. Malignant disease sometimes travels rapidly
up the cord, and the main fear is not so much of local recurrence as of
deep involvement within the pelvis. Cases of cancerous growth of the
testicle should be not only thoroughly extirpated from the scrotum, but
the _inguinal canal should be opened, and the cord followed as far as
possible and completely removed_.

Cases may arise where amputation of the scrotum may be justifiable
for the purpose of temporary relief, in order to avoid discomfort,
hemorrhage, or offensive ulceration.


HYDROCELE.

Strictly speaking the term hydrocele means accumulation of watery
fluid in any pre-existing cavity. By universal consent, unless some
other cavity be specified, the tunica vaginalis is understood. The
consequence is a more or less distended sac of serous fluid, which
first occupies a position in front, but finally is spread around the
lateral portion of the testicle, and may form a tumor the size even
of the individual’s head. It is an innocent collection of serum, but
the walls of such a sac will be thickened in proportion to its age and
size, and may in the course of time undergo such degenerations as the
calcareous, for instance, by which it becomes more or less infiltrated
or encrusted with calcareous material. Thus I have in my possession a
tumor of this kind, nearly the size and almost as hard as an ostrich
egg, the old tunic being converted practically into a shell.

_Acute hydrocele_ occurs, as above mentioned, in connection with the
acute infections, but is then ordinarily a matter of but a few days or
weeks.

Hydrocele, as usually implied by the term, is an exceedingly chronic
and almost painless affection, which may follow injury, but which
comes often without any known cause. Many theories have been advanced
to account for it, but none are generally satisfactory. These cases,
however, occur usually after the fortieth year of life, but may be seen
in the young. Their greatest unpleasantness is that produced by the
weight of the mass as it drags upon the cord and the scrotum.

The tumor is pear-shaped, and abruptly circumscribed at its upper
limit, below the external ring (unless there be also involvement
of the cord), and gives no impulse when the individual coughs. By
these features it is distinguished from hernia, for which it is
often inexcusably mistaken. A hernia is a distinct prolongation from
above, whereas a hydrocele terminates below the hernial outlet, and
by its smaller extremity. The distended sac will fluctuate, and will
return clear fluid upon puncture with a hypodermic needle, and is
so translucent that light may be transmitted through it when it is
interposed between a candle-flame and the surgeon’s eye. (Serious
thickening of the sac may interfere with the value of this test.)
A congenital form of hydrocele is also known, due to failure of
obliteration of the canal of Nuck, and it might be possible in some
such cases to get a slight impulse on coughing, as when the sac
connects with the abdominal cavity, in which case it should be possible
to gently press its contained fluid back into the abdomen above. In
most congenital cases there is a tendency to spontaneous cure, at least
to obliteration of the canal.

Occasionally both sides are involved, or the sacculation may be
multilocular, or accompanied by cystic extensions along the cord.


=Treatment.=--In regard to methods of treatment, but two will be
considered here, _aspiration with injection of carbolic acid_, and
_extirpation_. The former consists in the insertion of an ordinary
(small) trocar, which is thrust in from below upward, care being
taken that its point avoid the testicle, which is always found to the
posterior and inner side of the sac. Through this trocar the contained
fluid should be completely evacuated, so that the sac is practically
dry. Into it is now injected with some force from 2 to 6 Cc. of
absolutely pure carbolic acid, after which the trocar is instantly
withdrawn, pressure made upon the opening, and massage made upon the
scrotum and the contained testicle, in order to distribute the acid
freely over the serous surface. Its effect is to completely sear the
entire surface so that the mouths of all the absorbents are closed. In
this way danger of carbolic poisoning is quite avoided, a danger which
would be imminent were the acid reduced in strength. But little pain is
caused by the procedure. Its immediate effect is to produce exudate,
with some recurrence of swelling, which ordinarily rapidly absorbs,
while the exudate, coagulating, serves to produce obliteration of the
cavity of the sac. This is the carbolic method of Levis, who introduced
the acid as a substitute for the iodine formerly employed, upon which
it was a great improvement. For cases of moderate age, whose sacs are
not too thick, it often proves satisfactory. Having failed, or the case
being considered not adapted to it, the other method is that by open
incision and extirpation.

This _open method_ consists in making an incision through the skin,
down upon and into the sac, which, being thus instantly evacuated,
will collapse. It is now possible to make a more or less complete
enucleation of the sac wall, stripping it from the external tissues
to which it adheres, as it is not necessary to separate it from the
testicle itself. It has been found that when the major portion is
thus removed the condition is effectually combated. The cavity may be
drained with silkworm strands or with a small tube, but only for a
short time, if the technique have been correct.


THE SPERMATIC CORD.

The cord participates essentially by its contained _vas deferens and
lymphatics_ in the consequences of acute and chronic infections,
travelling in either direction, and thus it may be involved in
_tuberculous_, _syphilitic_, or _malignant disease_. These expressions,
however, are secondary and the conditions have been described above.
_Encysted hydrocele of the cord_ implies simple dilatation of an
incompletely obliterated canal of Nuck, by which there may be formed
along the cord one or more cystic expansions, causing tumors rarely
attaining a size greater than a pigeon’s egg, which are innocent
collections of fluid, corresponding to the ordinary hydroceles that may
occur below. They are ordinarily not difficult of recognition, and are
the most common form of neoplasms occurring in this region. They are
amenable to the same treatment as that described for hydrocele.


[Illustration: FIG. 674

Varicocele. (Hartmann.)]

SPERMATOCELE.

Spermatocele implies a cystic tumor in whose contained fluid, no matter
what its source, are found spermatozoa, which may be seen alive under
the microscope if examined immediately after removal. Spermatoceles are
usually found at the lower end of the cord and in close connection with
the testicle. Their occurrence is not uncommon, but somewhat difficult
to explain, for it implies connection, at least at some time, between
the structures of the cord and a more or less displaced seminiferous
tubule. Spermatoceles are rarely diagnosticated as such until
aspiration or evacuation and examination of their fluid contents, which
usually are of a milky appearance. In general they are to be treated
like any other cysts, and by the same methods.


VARICOCELE.

This exceedingly prevalent affection is the result of a varicose
condition of the pampiniform plexuses and of the spermatic veins. It
occurs in perhaps 10 or 12 per cent. of adult males, rarely before
puberty, and almost invariably upon the left side, varicocele upon the
right side being as rare as 1 in 500 cases. Its confinement to the left
side is explained partly by compression of the left spermatic veins
beneath an overloaded and distended sigmoid, and by the disadvantage at
which the blood current from the left spermatic vein empties into the
vena cava, this being on the left side at a right angle, while on the
right the angle is oblique. It has occasionally to do with accident or
injury, as well as with occupation or habit. It occurs more frequently
in those who are long in the saddle and in those who ride the bicycle
to excess. (See Fig. 674.)

Varicocele is usually of slow development, and discovered finally by
accident or by attention being drawn to these parts through quack
advertisements or misleading statements. The effect is to produce an
elongated mass of varicose veins, often described as feeling like a
“bag of angle worms,” occupying the lower portion of the cord and
extending down upon the back of the testicle. In the more advanced
cases the condition can be traced almost to the external ring, but
is always more marked low down than higher up. Sometimes it is so
extreme that the entire group of veins corresponds in bulk to a hen’s
egg; ordinarily it is but a fraction of this size. The consequence is
increase of weight and production of dragging sensation upon the cord,
often referred to the back, and displacement downward of the testicle,
with consequent elongation of the scrotum, which may so greatly relax
that it appears to be twice its normal length and contains this
varicose mass at its lower extremity. Such a condition will naturally
produce a certain degree of discomfort and annoyance, but _beyond this
it is innocent_, save that it is made to cause much mental anxiety,
mainly through ignorance, and has led thousands of victims to quacks,
for treatment for conditions dishonestly represented and treated as
both distressing and extreme. It is true that a large mass of enlarged
veins may in time produce some atrophy of the testicle; it is likewise
true, also, that virility or masculine potency may be to a trifling
extent limited in this way. It is not true, however, that impotence can
be so produced, because the affection is limited to but one organ, so
that the impotency of which many men complain is mainly of psychical
origin. Such individuals need explanations and advice as much as
treatment, although it is difficult to elevate many of them from the
condition of sexual hypochondria into which they gradually fall.

[Illustration: FIG. 675

FIG. 676

Resection of scrotum for varicocele. (Hartmann.)]


=Treatment.=--Treatment of varicocele may be _palliative_, _i. e._,
it may consist of suspension of the overloaded testicle and somewhat
relaxed scrotum within a well-fitting _suspensory bandage_, and this
suffices for most mild cases in normally minded individuals. When,
however, the condition preys deeply upon the mind or upon the body, or
when it is actually and anatomically advanced, then _radical operation_
is legitimate and humane. Of the many operations recommended in time
past only two will be described here, for it seems to me that all
subcutaneous and blind methods are bad in theory as in practise.

_Excision of the varicose veins_ is easily performed under local
cocaine anesthesia. It is done by incision below the external ring,
over the course of the cord, the cord itself being exposed for two to
three inches. Here the enlarged veins appear usually in a group (the
pampiniform plexus), and as such can be isolated and separated from the
balance of the cord, it being essential to _carefully exclude the vas_,
as injury to or division of this canal would naturally be followed by
impotence of that testicle. The veins involved being isolated to an
extent of two inches, are ligated above and below, the intervening
portion being then exsected, after which it is my custom to utilize the
catgut with which this ligation is effected, threading it on each side
into a needle, using each as a suture, thus providing two sutures, by
which the divided ends are approximated and tied together, the effect
being to bring the testicle up and make a more effective suspensory of
the cord itself.


=Shortening of the Scrotum.=--To the above procedure, when the scrotum
is much elongated and relaxed, may be added its _shortening by a
species of amputation_. The entire procedure may be practised as
follows: The scrotum being stretched downward is shortened by removing
one and a half to three inches from the lower end of the scrotal pouch
of skin and the contained connective tissue, including the septum.
In this way the tunical sacs and lower ends of the testicle will be
immediately exposed. The left testicle can now be drawn down, and the
operation, described above, of exsection of a portion of its veins, may
then be practised. This being completed the scrotal wound is closed
with sutures, with or without catgut drainage. The effect is to not
only remove the varicose veins, but to reduce the size of the scrotum,
and to make it, as it were, a suspensory of living tissue (Figs. 675
and 676).


THE SEMINAL VESICLES.

The lower ends of the vasa and the seminal vesicles themselves suffer
most commonly from the consequences of _tuberculous_ or of _gonorrheal
infection_, travelling in either direction, they being easily invaded
from the prostatic urethra along the seminal ducts. The consequence
is _seminal vesiculitis_, which produces a more or less tender
swelling, with discomfort referred to the lower end of the rectum,
and discoverable by digital examination above the prostate. When the
vesicles are distended or infiltrated they may be felt with the finger
in the rectum. In addition there may be on pressure more or less
discharge of fluid into the prostatic urethra, while the semen when
emitted may be more or less mixed with blood.

It is necessary usually to differentiate between prostatitis or
prostatic hypertrophy and vesiculitis.

Chronic involvement of the seminal vesicles may be best treated by a
species of massage or “milking,” by which retained contents are coaxed
along the ducts and into the urethra. Its local treatment is almost
impossible. When the conditions resulting from infection of either type
have become chronic and intractable we may take advantage of recent
advances and decide upon _removal of the vesicles_ by operation. Fuller
suggested that this be done by putting the patient in the knee-chest
position or a modified Sims position. While it is not difficult to
reach the vesicles through the rectum, the method has its disadvantages
and the perineal route is much the better. The operation is then
effected, much as is prostatectomy, by perineal opening and blunt
dissection between the rectum and the prostate, carried upward until
the vesicles themselves are reached, after which they may be curetted
or extirpated by a process of enucleation.[74]

  [74] In the treatment of infections of the seminal vesicles,
  particularly those of gonorrheal origin, Belfield has advised
  irrigation and drainage of the same through the vas deferens. He
  brings this up against the skin of the scrotum, where it is easily
  identified, and then, through a one to two-inch incision, made under
  local anesthesia, exposes the vas, into which the blunted end of a
  hypodermic-syringe needle may be introduced, by means of which a
  solution of any desired agent may be injected. This being thrown in
  the direction of the seminal current passes up through the vas and
  into the vesicle. He has even recommended in certain cases to attach
  the vas to the skin by a fine silkworm suture, and in this way to
  make a minute fistula, which can be used for the purpose as long as
  may be necessary. He considers the method invaluable in the treatment
  of chronic gonorrheal vesiculitis or the chronic infections of the
  seminal canal in the elderly, which are often mistaken for enlarged
  prostate, as well as in cases of recurrent epididymitis resulting
  from repeated invasion from behind. Thus he has seen benefit follow,
  in tuberculosis of the epididymis, from irrigation with carbolic
  solution. The amount injected into the vesicle should never exceed 2
  Cc.


SPERMATORRHEA.

Accurately defined this term refers to the escape of semen under
abnormal and involuntary conditions, an occurrence which is of great
rarity. Most cases of so-called spermatorrhea are, in effect, but
the escape of excessive or superfluous amounts of _prostatic mucus
(prostatorrhea)_, the fluid, whether it appear drop by drop or in
considerable quantity, being mistaken by the patient for semen. Thus
with the extrusion of a hard fecal mass there may be sufficient
pressure upon the prostate to express from it 1 Cc. or more of
this fluid. True spermatorrhea, on the other hand, rarely occurs
except in connection with disease of the vesicles or prostate, and
will then be recognized rather by the detection of spermatozoa in
the urine than from any phenomenon noticeable by the patient. All
statements, therefore, made by patients to the effect that they suffer
from involuntary escape of semen should be taken with the greatest
allowance, and will usually be found to be misleading.

All of this might lead up to a considerable discussion of matters
included within the domain of sexual physiology and hygiene, topics
which, however, cannot be afforded space in the present work; all
that can be said being that many patients are in need of accurate
information who suffer acutely in mind, and sometimes slightly in body,
for lack of it, and who are tempted by motives of delicacy to consult
quacks and charlatans rather than their family physician.


CASTRATION.

The only operation of importance upon the external genitals not yet
described is that of _castration_, _i. e._, removal of the testicle.
This is ordinarily a simple procedure, requiring, first, incision of
sufficient length. If the disease condition include the slightest
infiltration or involvement of the overlying skin a little or the
greater portion of it, as required, should be included in an oval
incision, in order that it may be totally removed. The testicle
and its coverings, being now exposed, are to be loosened from all
their surroundings, the organ pulled down, and the cord brought into
sight. If there be no reason for following up the spermatic cord it
is sufficient to surround it with a ligature (chromic gut), at a
convenient height above the testicle, after which the cord is divided
below it and the mass removed. In most instances, however, the disease
which calls for so much operating will require to be followed up along
the cord, and perhaps through the inguinal canal down into the pelvis.
This is done by continuing the incision in the proper direction,
isolating the cord, ligating bleeding vessels, and finally dividing the
cord itself at a point of election decided to be above the disease.
Previous generations were hesitant about including the entire cord in a
ligature, for fear of tetanus, but we now know that if the technique be
carefully carried out there need be no fear on this score. The diseased
mass being removed the wound is closed, with or without catgut drainage
at one or more points, as may be indicated.




CHAPTER LVII.

AMPUTATIONS.


Amputations are performed for (_a_) _the results of injury_, (_b_) _the
results of disease_, and (_c_) _removal of deformity or mutilation_, or
the possible results of congenital defects. While generally they are
measures of necessity, made such by traumatism or by actively advancing
disease, there are occasional instances where an individual decides
that an artificial limb will be more useful or that he will be freed
from an intolerable annoyance by the sacrifice. The principal diseases
which may require such mutilation are the exceedingly acute, _e. g._,
osteomyelitis, the slower destructive forms of ulcer, tuberculosis or
of sepsis, the gangrene caused by vascular or diabetic conditions, or
the slow involvement of tumors, usually malignant, but sometimes benign.

When a serious and mutilating injury has been received, if there have
been complete crushing of a limb or avulsion, of course no doubt exists
as to the necessity. Amputation is not now made for compound fractures
nearly as often as in former times, for if only the vascular supply
be good much may be done by resection of bone ends, wiring, or other
expedients; and the attempt should always be made to save a limb unless
it appear that even should the effort succeed the limb itself would be
too useless to justify the attempt. With the possibilities of modern
asepsis, and with immediate attention to the injury, the question of
what should be done with an injured limb is largely a question of
its blood supply. Extensive contusions with lacerations do not of
themselves necessitate amputation, neither does injury to the skin
unless it be most extensive.

It is unfortunate when vacillation or any misguided effort at
conservatism call for great delay. While this may sometimes be
advantageous, at other times the favorable moment has passed before
permission to amputate may be obtained. Should delay seem advisable the
surgeon should use his best endeavor to effect suitable antisepsis,
to provide physiological rest, and to preserve the circulation, all
of which require a thorough antiseptic technique, which will include
the removal of blood clot, of fragments, and of all tissue which
evidently cannot live, and suitable splinting or its equivalent, and
of everything that can be done by local warmth and general stimulation
to maintain the vigor of the circulation. When once infection has
occurred, and especially been allowed to spread, the possibility of
recovery inheres only in immediate amputation.

Such mutilations as necessitate immediate amputation are usually
accompanied by profound degrees of shock, as well as perhaps by other
complicating injuries, whose existence may change the whole complexion
of the case. For example, with a patient suffering from probably fatal
fracture of the skull one would hardly seriously discuss the matter of
immediate amputation of a foot; nevertheless he should take such care
of the local lower injury as to permit operation to be done under still
favorable circumstances should the head condition justify it. Wide
discretion is therefore called for in all these cases. Furthermore the
condition of lowered blood pressure or shock may be so extreme that the
operator is compelled to delay, for at least a certain time, in order
that by the employment of those measures already considered in the
chapter on this subject the circulation may be sufficiently restored to
make it adequate for the purpose, remembering that scarcely anything
predisposes to infection more than such lowered vitality. While
resorting to general stimulation, hypodermoclysis, or infusion, with or
without adrenalin, the use of such antiseptics should not be omitted,
as the local condition may require in order to combat what otherwise
may be actively occurring.

Amputations are sometimes referred to as _typical_, when done according
to long-established methods, or _atypical_, when the entire procedure
is planned to fit the necessities of the case. Amputation at a joint
is usually spoken of as _disarticulation_. Amputations, again, are
classified as (_a_) _immediate_, _i. e._, before complete reaction from
shock or within the first few hours; (_b_) _primary_, when done after
reaction has occurred, but before visible occurrence of inflammatory
changes, (_c_) _intermediate_, as done when suppuration is threatening,
but before its actual occurrence; (_d_) secondary, _i. e._, after the
occurrence of suppuration.

The _control of hemorrhage_ is one of the most conspicuous and
necessary features of any amputation method. Below the shoulder and at
the hip this may be effected by the old-fashioned _tourniquet_, or the
modern _elastic bandage_, which may or may not be combined with the
more complete _bloodless method_ with which Esmarch’s name will always
be connected. The pure rubber gum bandage, I believe, was introduced by
Martin, of Boston, but the method of its use for bloodless operations
upon the extremities is to be credited to Esmarch. The surgeon may
avail himself of this method in all suitable cases, but should
_never resort to it in septic or malignant disease_. It includes the
application of a Martin elastic bandage from the tip of the extremity
to the necessary height, by turns which shall make gentle and equable
pressure, gradually forcing the blood from the compressed tissues and
out of the limb, and up to a height where another elastic, or, at all
events, suitable constricting band is placed with a sufficient degree
of tightness to completely shut off access of blood. To so apply a
bandage in septic and malignant cases would be to coax septic and
malignant material into the veins, and would evince the worst possible
judgment. A sufficiently strong rubber tubing forms an effective
tourniquet, which, however, should be applied over a folded towel, or
in some manner so that it does not too deeply constrict and compress
the soft tissues of the limb. Instead of tying a knot it may be secured
with an ordinary clamp forceps.

The tourniquet should never be applied over the leg or forearm, for
it can here make no impression upon the interosseous vessels. Its
application should be begun by pressure upon the vascular, _i. e._,
the adductor side of the limb, so that venous choking may be avoided.
After it is once in place the limb should not be completely flexed nor
extended, lest the tissues firmly enclosed by the constriction be more
or less spontaneously torn; _nor should the tourniquet be too long left
in place_, as injury to the vessels is the possible result.

The bloodless method of Esmarch is furthermore subject to the
following disadvantages. It is sometimes followed by serious and
permanent paralysis of the limb, the result of prolonged or excessive
constriction and compression of the motor nerve trunks. Similar results
(in the arms) follow the use of crutches as well as of pressure of the
side of the operating table when the limbs are allowed to hang over it.
Again after removal of the bandage there is sometimes most pronounced
capillary oozing due to vasomotor paresis. This may be controlled by
the stimulation of hot irrigation or applications, and by more or less
massage of the limb. The dangers of forcing undesirable material into
the circulation have been mentioned, in addition to which should be
recorded the increased absorption of toxic substances.

When there is good reason for not using the elastic bandage, save as a
tourniquet, much of the desired effect may be obtained by holding the
limb for a few minutes in a vertical position, so that its contained
blood is drained out of it by gravity, after which the tourniquet may
be applied as before.

The cocainization of nerve trunks, as they are exposed and divided,
is one of the new measures for the prevention of shock for which we
are largely indebted to Crile. It has proved to be a most valuable
expedient which should not be neglected. (See Chapter XVIII.)

Under modern methods more is expected of an amputation stump than in
days gone by, and the first demand is that it shall be _useful_, to
which end it is necessary that it be both movable and that its end
be not too irritable, nor the scar too sensitive to stand at least a
certain amount of pressure. It is expected that suitable prosthetic
apparatus, _i. e._ artificial limbs, shall take the place of severed
lower extremities and of most arms or hands removed. The skill and the
mechanical ingenuity of the maker of artificial limbs have now reached
a point where most acceptable substitutes are thus provided, but for
them suitable stumps should be afforded by the surgeon, and there
should be coöperation from each direction. Thus it used to be held that
the bone end in every stump should be covered with periosteum, yet it
has been recently shown, especially by Hirsch, that such bone ends
are as acceptable, and perhaps more so, when stripped of rather than
covered with this membrane, the latter being sensitive, and there being
no advantage in the presence of such new bone as may be formed by its
preservation.

Many a good stump may be molded in various ways, but always provided
that the end of the bone be smoothly divided, and have no corners or
osteophytic outgrowths to make pressure upon the sensitive scar. For
this reason it should be manipulated as early as possible, and should
not be allowed to undergo the atrophy noticeable in stumps left after
old operations. If primary union be gained, so long as the cicatrix and
the nerve ends be kept out of the way, one may expect a stump which is
serviceable in every respect. The ideal method is that the skin and
the periosteum should retain their normal relationship, an ideal best
attained in the supracondyloid operation after Gritti’s method. Various
osteoplastic methods have been devised, first by Walther, in 1813,
and since him especially by Ollier, Pirogoff, Gritti, and Bier. The
latter would cover every bone end not merely with periosteum, but with
a bone flap so arranged that its lower surface is one normally covered
by periosteum. The introduction of the _x_-rays has permitted a more
thorough study of bone ends in stumps which are, on one hand, extremely
tender, or, on the other, extremely serviceable, and the osteoplastic
methods seem to conduce to the latter condition. Another matter of
great importance is to so _place the scar that it shall be neither
subject to pressure nor to traction_. If, therefore, the sawed surfaces
be covered with a periosteum which shall retain its normal relation to
its coverings, a minimum of disturbance in the scar is the result.

The value of early use of the stump and of accustoming it to pressure
is considerable, as atrophic stumps are tender, like other disused
parts, and there is, therefore, every reason for resorting to
prosthetic apparatus as early as possible. As Kocher puts it, the
following is the best procedure for the normal operation: “An oblique
incision, combined if necessary with a longitudinal one, in the form
of a racket or lanceolate incision through skin and fascia. After
retracting the elastic skin the muscles are divided obliquely down to
the bone. The periosteum is also to be divided obliquely. Periosteum
is then separated along with the superficial layer of the cortex of
the bone, by means of a sharp raspatory or chisel, or, when possible,
a flap of bone having a movable periosteal hinge is made by means of
the saw. Lastly, if only a thin shell of the cortex have been raised
up along with the periosteum, the end of the bone is simply rounded
off, while if a distinct flap of bone, by any osteoplastic method, have
been divided, the end of the bone must be sawed in a curved direction
so as to fit it. The periosteal or bony flap is sutured over the sawed
surface of the bone to its periosteum, and the stumps of the muscles
or tendons are sutured to each other, or to the surface of the bone
at a distance from the sawed surface. Finally the skin and fascia
are sutured; but in case where a periosteal flap or flap of bone and
periosteum cannot be obtained in normal relation to other soft parts it
is better to remove the periosteum entirely from the end of the stump,
to scrape out the medullary cavity, and to round off edges of the bone
as dentists do.”

While these methods give better results than those formerly in vogue,
they also consume more time; but the days of brilliancy and rapidity
in amputation are past, as time should be devoted to careful work,
except only in those cases where emergency demands the most rapid and
dexterous removal of a limb in the shortest possible time, and where
every other consideration is sacrificed to the principal interest of
preserving life.[75]

  [75] The following is taken from the article of Professor Matas in
  the third edition of “Surgery by American Authors.” It furnishes a
  brief but admirable introduction to the general study of amputation
  methods:

  “From Hippocrates to the time of Celsus the surgeon simply followed
  in the wake of Nature, never venturing to apply the knife for the
  removal of a limb except within the limits of the mortified tissues;
  and this seems to have prevailed for at least four hundred years.
  Celsus, the prince of Roman physicians, who lived shortly after the
  time of Christ, introduced the first innovation by cutting down to
  the bone between the living and the dead tissues. It is probable,
  according to the evidence furnished by his writings, that he was
  aware of the value of the ligature and that he applied it to control
  bleeding vessels. Archigenes, following closely after Celsus, was
  the first to attempt prophylactic hemostasis by applying a cord or
  band around the limb to control the hemorrhage during the amputation.
  With the fall of the Roman empire and the advent of the long night of
  the middle ages the Celsian method was lost in the general darkness
  and the old Hippocratic doctrines survived, and were maintained by
  the all-potent influence of Galen and his Arabian commentators. As
  late as the middle of the seventeenth century the only hemostatic
  was the actual cautery and boiling oil, though Guy de Chauliac had
  revived the teaching of Archigenes by constricting the limb, on
  a level with a joint, with a cord which was allowed to remain in
  situ, to ensure not only hemostasis, but a certain mortification of
  the stump. In cutting limbs huge chisels and mallets were used. At
  this period Botalli invented his guillotine, consisting of a sharp,
  heavy, axe, which, being allowed to fall from a height upon the
  limb, severed it instantaneously at a single blow. The revived or
  independent rediscovery of the ligature by Ambrose Paré in 1579, and
  the discovery of the circulation of the blood by Harvey, in 1628,
  led to the invention of Morel’s tourniquet (1674), more commonly
  known as the Spanish windlass, and to the familiar instrument,
  Pettit’s tourniquet, which (introduced in 1718) perfected the means
  of securing prophylactic and direct hemostasis. From this time
  onward the treatment of the stump began to receive more systematic
  attention. Instead of merely chopping off a limb, the soft parts were
  detached from the bone, so that this could be sawed off at a higher
  level, in order to avoid the conical projection of the stump which
  invariably resulted when the primitive methods were adopted. All the
  methods of amputation that followed--and these were numerous--aimed
  chiefly at celerity, to reduce the pain of the operation to a
  minimum; hence the rapid, circular section of the soft parts or the
  rapid transfixion methods which were so much popularized by the
  brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck,
  and others. These finally yielded, in this modern period, to less
  rapid but more conservative and perfected methods, which aim chiefly
  at the preservation of useful tissue and at securing the very best
  functional prosthetic stump for the patient. Such methods could only
  be perfected after the advent of anesthesia and antisepsis.”


AMPUTATION METHODS.

With a view to simplifying this subject as much as possible the
following methods alone will be considered: (1) The _circular_ with its
modifications, the _oblique_, the _elliptical_, the _ovoid_, etc.; (2)
the _flap method_; (3) the _mixed or skin flap and deep circular_.

Choice of method sometimes leaves much, sometimes nothing, to the
tastes or wishes of the operator. It should be based solely on the
primary consideration of saving life and the secondary consideration of
furnishing the most useful possible stump. To obtain the latter it is
necessary that the bone be amply covered, except that its coverings be
not adherent, that there be a minimum of disturbance of blood supply,
that nerves be drawn down and divided as far from the stump end as
possible, in order that they may not be entangled in the scar, and that
the scar be so planned for and arranged that it shall be _at one side_,
at all events in such position that no pressure shall be made upon it,
and, if possible, also no tension by muscle action.

Elasticity of skin and contractility of the muscles vary much in
different individuals, and it is not always easy to estimate either of
them previous to their division. Consequently it is much better to make
cuffs or flaps too long at first rather than too short. The existence
of previous disease will always modify these local conditions, but, in
general, the rule is laid down that the external flaps should be longer
than the bone by from one-third to one-half the diameter of the limb.


1. =Circular Method.=--The simple circular method is the simplest
and easiest of all. It may be so performed as to furnish a solid
musculotegumentary division, or skin cuffs may be made, which being
turned up, permit a further circular division of the muscles and other
tissues directly down to the bone. The former is preferable when
possible. With an ordinarily long amputating knife the skin, down to
and including the superficial fascia, is divided by one clean circular
incision, made in one stroke; then by further circular cuts the muscles
are divided in sections, the outer group being allowed to retract and
expose the deeper layers, which are then divided at a higher plane. In
this way the periosteum is reached. If sufficient time be afforded it
may be circularly divided at the level of the last incision through
the muscles, and then separated with a strong elevator or, as done by
Kocher, with a chisel, in order that some portion of the exterior of
the bone be raised with it. In this way a cuff of periosteum, or enough
of it to cover the bone end, is detached upward, to the level where
the bone itself is finally divided. The bone division is done with the
ordinary amputating saw, or with the wire or chain saw.

The _skin-cuff_ (Manchette) method differs in that the exterior flap
is made wholly of skin, which is dissected as a cuff nearly up to the
level of bone section, at which point the muscles are divided directly
down to the bone. In this method the skin, fat, and superficial fascia
should be raised together, and at no points separated from each other.

Modification of the cuff method, by which it is more easy to evert the
circular flap, is made by one or two _vertical incisions_, by which the
cuff is split some distance on one or both sides, thus transforming the
cuff proper into two nearly square skin flaps. At other times the first
method may be similarly modified, in which case we have to deal with
two square flaps, including not only the skin, but all the tissues down
to the bone.

Neudörfer still further modified the circular method for certain
purposes by first making an incision along the outer or least vascular
part of the limb, carrying the knife directly down to the bone,
retracting the wound edges, and thus exposing the bone, which is then
divided with a chain or Gigli saw. After the bone is divided the soft
coverings are lifted to a sufficient distance below the saw line to
ensure ample covering, then divided as above. The method is a slow
one and is especially serviceable for amputation of the thigh, at its
middle, for diabetic or senile gangrene, where it is so desirable to
protect vascular supply from injury (Fig. 677).

The so-called _elliptical method_ is practically a circular incision
carried obliquely around the limb, the upper and lower ends of the
ellipse being indicated by previous small incisions at the proper
height. The skin and superficial fascia are retracted from the lower
portion of the ellipse by turning them up to the level of the highest
point, at which level the muscles are divided transversely by a plain
circular incision. A modification of this method is the so-called
_ovoid_ or _racket_, which is simply an oval division with a pointed
end, the margins of the flap being united in the long axis of the bone.
This method is frequently applied in amputation of the fingers. (See
Fig. 683.)


2. =Flap Methods.=--Flaps are either _cutaneous_ or _musculocutaneous_.
In every case the skin surface must be larger than the muscular. They
are objectionable in that the skin flap is apt to slough, although
least so about joints. The flap method is advantageous in that one
flap may usually be made much longer than the other, and the longer
one so doubled over at its end as to place the scar out of harm’s way.
In certain injuries where the skin is much more injured on one side
of the limb than on the other the operator is compelled to resort to
flaps, unless he divide the limb much higher than might otherwise be
demanded. Double flaps may be _anteroposterior_ or _lateral_. A double
flap practically results from a circular incision, carried through to
the bone, with lateral division on either side, while a double flap
with one long member may be similarly furnished by an oblique circular
incision with the lateral prolongations.

[Illustration: FIG. 677

Neudörfer’s method of amputation by primary division of the bone,
before shaping the flaps. Neudörfer used the chisel, but one may use
the Gigli saw with special advantage in performing this operation. The
method is applicable to any portion of the upper or lower extremity,
especially in the continuity of the long bones. (Matas.)]

Flaps may be formed by _transfixion_, for which purpose a long,
sharp, amputating knife is required. Inasmuch as it makes an oblique
and irregular division of the principal vessels, which are in
consequence more difficult to secure, and by which nutrition of flaps
is endangered, it is not to be commended, save perhaps in certain
amputations about the wrist. A better method of making the flap is
to divide the skin and fascia with an ordinary stout scalpel, and
then, permitting them to retract, to divide the muscles obliquely
toward the bone in such a way as to leave a flap wedge-shaped at its
base. The anteroposterior amputations of the foot, thigh, and arm are
better performed in this way, each flap being in length preferably
three-fourths the diameter of the limb. (Matas.) An extension of this
method furnishes the possibility for various subperiosteal amputations
to be described below.

The _osteoplastic methods_ of today furnish desirable operative
procedures. One of the earliest of the good ones was Teale’s method,
as applied to the leg, of double quadrangular flaps, the anterior
being much the longer. A minor degree of this work includes simply
the preservation of a cuff of periosteum, which is supposed to afford
protection to the marrow cavity and a smoothly rounded bone end,
without adhesions to the overlying soft parts; but much more complete
operations are afforded by Pirogoff’s amputation at the heel, and
by Wladimiroff and Mikulicz’s amputation of the foot (practically
an exsection of the heel), or by Gritti’s and the other methods of
supracondyloid knee amputation, with preservation of the patella. Bier
and other foreign and domestic surgeons have also devised methods of
reflecting or raising bone flaps from the continuity of bone shafts,
which, being still connected by periosteal bridges, are so turned and
fastened in place as to furnish a complete bone end over the stump
(Figs. 678 and 679).

The choice of method must depend, to a large extent, on the character
of the case. Some injuries will leave parts so exposed that a portion
of a limb can still be utilized if only flaps be cut in an atypical
way. One need never hesitate to resort to these, especially about the
hand and upper extremity, where it is so desirable to save every inch
of tissue. It is not necessary to preserve every possible inch of
tissue in the foot and leg, as the makers of artificial limbs can adapt
an artificial leg to any kind of a stump. The intent in making these
statements is that while it is best to follow conventional methods
under ordinary circumstances, there need be no hesitation in departing
from them when occasion demands it.

[Illustration: FIG. 678

Bier’s osteoplastic amputation of the leg (procedure advocated by Bier
in 1897 and 1899): _F_, long anterior flap reflected on the tibia;
_A_, cross-section of tibia; _B_, periosteal flap after excision of
intervening section of bone; _C_, osteoperiosteal flap; _D_, projecting
border of periosteum to be sutured to tibial periosteum.]

[Illustration: FIG. 679

Bier’s osteoplastic amputation of the leg, with osteoperiosteal flap in
position.]

It is essential in caring for every stump, after the actual amputation
has been performed, (1) that _bleeding_ be absolutely controlled; (2)
that _nerve ends_ be placed out of the way of cicatricial entanglement;
(3) that proper _drainage_ be provided; (4) that the soft parts be
so brought _together_ as to unite in the promptest and most perfect
fashion. The possibility of the latter will depend very much on the
occasion for the operation and the condition of the tissues. Operating
in the presence of previous disease, as when the parts are inflamed
or edematous, or as when one amputates at a point where more or less
sloughing and separation of tissues have already occurred, the surgeon
cannot look for such primary repair as furnishes an ideal termination,
nor should he endeavor to make such close suturing or approximation
as he would otherwise attempt. In fact, under these circumstances, it
is often desirable to leave the wound widely open, perhaps packing it
with yeast, in order to hasten sloughing and secure healthy granulating
surfaces, which may be then brought together by secondary suture or
by suitable strapping and bandaging. Nothing worse can happen than
imprisonment of the debris resulting from the sloughing process.

But an amputation wound made with faultless technique, and in tissues
previously healthy, may be closed with a minimum of drainage, or often
without any, providing it be so closed as to leave no dead spaces in
which blood clot may accumulate. This requires careful _suturing_, by
numerous buried sutures, of muscle to muscle, tendon to tendon or to
periosteum, and the like, the wound being gradually closed from its
depth, and finally so bandaged that equable pressure shall be made,
with comfortable support, but without undue pressure at any point. In
aseptic cases animal ligatures and sutures (chromic gut) will prove
reliable and efficient. In septic cases it would probably be better to
trust to (secondary) silk, especially if parts are to be long exposed,
so that it can be later removed. For the superficial wound silkworm
sutures answer admirably.

For _drainage_ a gauze packing for the worst cases, one or two tubes
for ordinary cases, and for those which scarcely need it strands of
catgut or of silkworm-gut, or two or three little rolls of oiled silk,
will be sufficient.

In this country Link and in Germany Credé have practised the method
of bringing parts together merely by equable pressure and bandaging.
This has been of late modified by the use of strips of sterile adhesive
plaster; and in certain instances, everything else favoring, it has
given good results. It might be advantageously adopted in cases where
it is feared that it may be necessary to reopen the wound, as it would
permit an easy method of so doing.

_Dressings_ should be copious and snugly applied, and the limb involved
should be _immobilized_. Thus after a leg amputation it is well to bind
the leg and thigh upon a suitably arranged splint, physiological rest,
which is so essential to success, being in this way attained. The same
is also true of the arm.


AMPUTATIONS OF THE UPPER EXTREMITY.


=Amputations of the Finger and Thumb.=--It is desirable in the upper
extremity to save every portion which can be preserved and still
made useful. This is particularly true of the fingers, where every
half-inch adds to their usefulness. When it is possible the palmar
surface should be saved and made to cover the stump end, as it is not
only more sensitive but denser and stands wear better. This is equally
true of disarticulations or of divisions between the joint ends of the
phalanges, which are best exposed by bending the finger, cutting the
dorsal flap in this position, then stretching it and cutting the palmar
flap (Fig. 680).

The vessels and nerves lying on the lateral aspect should be secured
against hemorrhage, and cocaine solution introduced if local anesthesia
is being practised. It is important also to remember the arrangement
of the common palmar synovial bursa, with the digital prolongations to
the thumb and the little finger, and that the three middle fingers are
ordinarily shut off from it. Nevertheless if tendons be divided near
the hand, and short finger stumps be made, it is easy to infect this
common palmar bursa through retraction of the tendon and the consequent
opening up of a tunnel directly into that cavity.

[Illustration: FIG. 680

Typical amputation of finger in continuity (through a phalanx); long
palmar and short dorsal flaps. (Farabeuf.)]

[Illustration: FIG. 681

Typical or preferred method of disarticulating a finger by long single
palmar flap. (Farabeuf.)]

Figs. 680 and 681 illustrate the best methods of amputating fingers
through a phalanx or at the joints, while Fig. 682 shows the best
method of closing the wound. In this way a serviceable finger-tip is
preserved which will stand every irritation to which it will probably
be subjected.

When the finger is to be _disarticulated from the hand_ a modified
oval flap is preferable, with its long flap on the radial side and the
scar on the dorsum rather than in the palm. The _thumb_ is perhaps
best separated at an articulation by a single palmar flap, without the
preservation of the sesamoids which belong to its short flexor. Fig.
683 illustrates the various flaps and methods preferable at the bases
of the different fingers.

When two or more fingers have to be removed the incision should be
planned to meet the indications. When the first three fingers have to
be removed, with or without that portion of the hand to which they are
attached, leaving only the thumb and little finger, I have repeatedly
followed to advantage the suggestion of Lauenstein, and through a small
incision properly placed have, with cutting forceps, divided the first
and fifth metacarpal bones at about their middle, and have then given
to each of the remaining digits a quarter of a revolution toward each
other, in such a way that when their tips are flexed there was better
prehensile power, the hand acting similarly to a more perfect claw. If
they are to be maintained in this position during healing they must
be suitably held upon the splint to which the entire hand and forearm
should be attached.

[Illustration: FIG. 682

Stump resulting from the procedure shown in Fig. 681.]

[Illustration: FIG. 683

Illustrating various finger amputation. (Farabeuf.)]

[Illustration: FIG. 684

Removal of index finger. (Erichsen.)]

[Illustration: FIG. 685

Removal of little finger. (Erichsen.)]

[Illustration: FIG. 686

Results of amputation above metacarpo-phalangeal articulation in
middle, index, and ring fingers. (Erichsen.)]

[Illustration: FIG. 687

Hand after removal of metacarpal bones and three fingers, leaving thumb
and little finger. (Erichsen.)]

When an entire finger is to be removed it is a question whether the
metacarpal belonging thereto should also be sacrificed for cosmetic
purposes. In general this is undesirable except in the case of the
fifth metacarpal with the little finger. This is easily exposed by
lateral incision along the ulnar border of the hand, sufficient to
disclose the bone and permit its disarticulation from the carpus. The
same is also true, in at least some instances, of the thumb, but it is
unwise to expose the carpal joints to the possibility of infection when
this can be avoided; moreover, the deep palmar arch crosses just in
front of the bases of the second to the fourth metacarpals, where it
must be carefully avoided. If, then, the metacarpal is to be sacrificed
this should be done rather from the dorsal side, while for cosmetic
purposes alone it is usually sufficient to disarticulate the finger
at its base and then simply remove the head end of the corresponding
metacarpal. Figs. 688 to 692 furnish illustrations of how the incisions
may be best planned to effect either of these purposes.


=Hand Amputations and Wrist Disarticulations.=--While it makes but
little difference whether the metacarpals be disarticulated from the
carpus or the latter from the radial end, it is advisable to adopt
whichever line of separation will best meet the indications. For a
removal of the _hand at or near the wrist_ two flaps usually afford
the most serviceable method, the palmar tissues being preserved, if
possible, in order that they may cover the stump. This operation is
usually done for injury, and it is more than likely that one will have
to plan his flap according to the tissues which still are serviceable.

[Illustration: FIG. 688

Outline of amputation of fingers, with their metacarpals. (Modified by
Matas from Mignon.)]

In the lower part of the _forearm_ the flap method furnishes a
serviceable stump. As the elbow is approached the circular or
elliptical methods are preferable, as illustrated in Fig. 690.


=The Elbow.=--With _elbow disarticulations_ caution should be observed
to have flaps of sufficient length. The joint is opened more readily
from its radial side. The integument of the back of the elbow region
lies closely upon the bone, is thin, and retracts but slightly.
Anteriorly there is more muscular covering and consequently a tendency
to retraction. Therefore the anterior flap should be made longer than
might otherwise seem to be required. Here the ideal scar will be behind
the end of the humerus, but it is difficult to obtain because of the
tendency to drag it around beneath the end of the bone. An elliptical
incision, directed obliquely downward and forward, is the easiest
method and furnishes the best stump. The lower end of the posterior
part of the flap should be at a distance below the articulation, at
least equal to the transverse diameter of the joint itself, _i. e._,
in an adult nearly one hand-breadth from the line of the joint to the
point of dissection. (Matas.) (Fig. 690.)


=The Arm.=--The _arm_ furnishes that nearly cylindrical outline best
adapted for circular amputations. Here, as at the elbow, the greatest
retraction is on the flexor side. With the arm should be saved all that
is possible even up to its upper extremity.

Remembering the greater tendency of the flexors to contraction the
truly circular method should be modified to a somewhat elliptical
incision, in order to compensate for this difficulty, while an external
liberating incision is often of assistance. Abrupt transverse division
of the muscle down to the bone should be made after the oblique
incision of the skin.

[Illustration: FIG. 689

Outline of amputation of two fingers simultaneously with their
metacarpals; also thumb with its metacarpal. (Modified from Mignon.)]


=Disarticulation at the Shoulder.=--Until accurate methods of blood
control were introduced this was an amputation viewed usually with
disfavor, in spite of the fact that compression of the axillary artery
in theory is easy. The older methods comprised this compression, either
above the clavicle, or by exposure of the vessel and its proximal
ligation, or by opening and separating the joint and then seizing the
vessels within the inner flap, and controlling them by digital pressure
until their division. Now with the use of Wyeth’s pins and the elastic
bandage, effectual control may be secured without resorting to any
of the former expedients. If the removal is to be a high amputation,
just below the neck of the humerus, the method shown in Fig. 691, of
application of the tourniquet and its control by a constricting strap,
may be adopted.

If the surgeon expect to disarticulate he should resort to the pins of
Wyeth (_i. e._, to the use of long mattress needles), which are passed
through from above downward, or from the axilla upward, one of them
being passed anteriorly and the other posteriorly, and brought out at
corresponding points on the upper aspect of the shoulder, where, their
points being protected by sterilized corks, they serve to prevent
sliding of the elastic bandage or tourniquet, which is now placed
proximally to them, and is thus held more securely than is possible in
any other way.

[Illustration: PLATE LVII

  _1. Anterior oval or racquet incision for disarticulation of the
  shoulder by attacking the joint through the delto-pectoral groove
  (modified Spence’s operation)._

  _2, 3. Circular amputation of lower and middle thirds of arm
  transformed into double square, antero-posterior flap operation by
  unilateral or bilateral vertical incisions._

  _4, 5, 6, 7. Circular amputation at various levels of forearm,
  including the disarticulation at elbow. In all of these, one or two
  lateral liberating incisions, cut down to the bone, may be required,
  on ulnar or radial side, or both, to permit easy retraction of solid
  musculo-tegumentary antero posterior flaps._

  _8, 9. Circular amputation at lower third of forearm; lateral
  liberating incision should be added on ulnar side, or radial side, or
  both, according to tonicity of limb._

  _10. Long palmar projection of oval method in disarticulating hand._

Cutaneous Incisions in Amputations of the Upper Extremity (Ventral or
Flexor Side).]

[Illustration: PLATE LVIII

  _1. Racquet incision (Larrey) intradeltoid for disarticulation at
  shoulder._

  _2. Solid circular with liberating incisions for upper third._

  _3. Solid circular with liberating incisions for middle third._

  _4. Circular amputation at lower third of humerus; incision slightly
  favoring the flexor side, to compensate for greater retraction;
  two lateral liberating incisions, to facilitate retraction of
  musculo-cutaneous flaps from bone._

  _5. Neudörfer’s racquet incision for disarticulation at elbow;
  preferred in all cases in which a preliminary exploration of
  the elbow, as in advanced tubercular cases, is attempted before
  proceeding to disarticulate at elbow._

  _6. Elliptical or oval incision with long projection on flexor side
  to compensate for greater retraction of skin and muscles on flexor
  (ventral side); the longer end of the oval may be advantageously
  reversed, the long end on the exterior side, when the tissues on the
  flexor side are injured. Usually, a slightly elliptical circular,
  with two lateral liberating incisions, cut squarely to the bone with
  all the soft parts, including the periosteum, is the preferred method
  in this region._

  _7. Antero-posterior flap incision for amputation at lower third of
  forearm; tendinous region._

  _8. Oval or elliptical incision in typical amputation of the hand
  (radio-carpal disarticulation)._

Surface Tracings showing Some of the More Useful Lines of Skin Incision
in Amputations of the Upper Extremity (Dorsal or Extensor Surface).]

[Illustration: FIG. 690

Lines of amputation in lower third of forearm, of elbow, and lower
third of arm. (Modified from Mignon.)]

Circulation being thus controlled, a modified circular operation may
be made or a long external and superior flap cut, matching it with
another one dissected from the axillary aspect. In the former case the
circular incision is made on a level a little below the anatomical
axillary border. Then a cuff of skin being raised while the arm is held
in adduction, all the soft parts are divided to the bone and separated
from it. Now a liberating incision may be made from the anterior border
of the acromion to the coracoid process, then over to the deltoid
groove, and along it to the first circular incision. Through this all
the soft tissues surrounding the glenoid margin are separated, and then
the bone is enucleated by opening the capsular ligament, reserving
perhaps the detachment of the group of scapular tendons until the last.
If one have any fear as to the efficiency of his hemostatic precautions
he may secure the axillary vessels so soon as they are divided and
then proceed with the disarticulation as above. In some cases it may
be preferable to cut a wide flap from the deltoid region, preserving
that muscle or not as may be desired, and, after having thus exposed
the joint, make the disarticulation, separating the head of the bone
sufficiently to allow the passage of an amputating knife behind it
and down along the shaft to a distance sufficient to justify turning
it abruptly and toward the surface, and then cutting out the axillary
flap. The attempt should be to cut all the vessels at right angles
rather than obliquely.

Plates LVII and LVIII, prepared by Professor Matas, afford a synoptic
view of the more useful lines of skin incision in the principal
amputations of the arm and shoulder.


=Interscapularthoracic Amputations. Removal of the Entire Upper
Extremity.=--This includes removal not only of the arm, but of the
scapula and clavicle as well, or at least its outer portion. It is
not often required, and inasmuch as the circumstances which justify
it are seldom duplicated, a suitable method for each individual case
should be planned, rather than try to make one set of directions cover
them all. Much will depend upon whether sufficient skin can be saved
in order to cover the large defect thus made. In general, however,
an incision should first be made along the clavicle, exposing it and
dividing it near its middle. It is convenient to take out the middle
portion at this time, and in this way to afford ample room through
which a proximal ligation of the subclavian vessels may be made, they
being here carefully dissected out, secured by double ligation, and
divided. From the outer part of the above incision another is carried
downward and outward toward the deltoid groove and then beneath the
axilla to its posterior margin. The posterior flap is then furnished by
an incision continuous with the last one, which terminates below about
opposite the lower angle of the scapula, and is then continued upward
along the inner scapular border and over the shoulder until it reaches
the outer end of the incision first made. In this manner will be
furnished a sufficient covering. The balance of the operation consists
in the gradual separation of the entire mass from the outer wall of the
thorax. With a preliminary ligation of the subclavian vessels there
will be no hemorrhage which cannot be easily checked by pressure and
forceps.

The above, however, is only a general description, which may need to
be modified in most cases. If the amputation be done for injury all
the skin _which is still viable_ should be utilized, no matter how
shaped, while if done for disease the incisions may have to be modified
materially, taking more skin from one side and less from the other, in
order to avoid that involved in the disease process.

In the majority of cases the result is satisfactory, in spite of the
mutilation thus afforded.

[Illustration: FIG. 691

Esmarch’s elastic constrictor applied and held in place by a bandage
or a strap (Wyeth’s pins may also be used to hold the constrictor in
place) in high amputation of the arm. (S. Smith.)]


AMPUTATIONS OF THE LOWER EXTREMITY.

The most important physiological purposes of the foot are those of
support and locomotion, not mere tactile sensibility nor prehension.
Its purposes being different from those of the upper extremity, the
tenets previously held regarding the advantage of conservatism may be
changed to some degree, for a tender foot or leg-stump is sometimes
extremely annoying, even disabling, and it is in the end far better
to so plan an amputation of this extremity as to make the stump most
serviceable, without primary reference to its exact length. As in the
hand, foot-stumps should be covered with dense plantar (instead of
palmar) tissues, and the long flap should, therefore, be made from
the sole. When this is impossible it would be wiser to shorten the
stump. Moreover, as there will be constant friction upon the resulting
cicatrix, this should be placed in the most protected location, on the
dorsum of the foot.

The most important indication, then, in all foot amputations is to
_furnish a complete plantar flap and to place the scar on top of the
foot_.


=The Toes.=--Amputations of the _toes_ are, by virtue of their
shortness, nearly always disarticulations. The basal row of phalanges
should be preserved when possible, and even here the covering of the
stump should be as far as possible fashioned from the sole.

The _big toe_ may be removed by either internal or oval plantar flaps,
which should be long enough to cover the metatarsal head, otherwise the
latter must be decapitated. These same principles also apply to the
_little toe_. When all or most of the toes have to be severed it may as
well be done by a single dorsal incision, as seen in Fig. 692, which
will permit either their disarticulation or their removal along with
that of the ends of the metatarsals. These methods are shown in Figs.
692 and 693.

_Amputation of a toe with its metatarsal_ is best effected by a racket
incision. This may extend up to the posterior tarsal joint. Some have
recommended to enucleate the metatarsals subperiosteally, through
dorsal incisions, all the soft parts being scrupulously left behind.
With the first and fifth toes the scar should be so placed as to be
removed from the edge of the foot (Fig. 693).

_Partial amputations of the foot_ have been suggested and devised
in great numbers, and the subject has been greatly complicated by
the number of methods that were taught. Modern ideas of conservative
surgery have caused a complete departure from the anatomist’s standard,
and it has been shown that with aseptic technique there is no advantage
in disarticulating when it leaves irregular lines. As Matas says:
“As Agnew taught long ago in this country, and others elsewhere, the
skeleton of the foot must be considered a surgical unity, to be treated
by the knife and saw just as the femur and humerus would be, at the
exact point which will yield the longest and most useful stump to the
patient. What is essential in every case is the application of the
principle of plantar flaps--preservation and scar protection.”

Concerning the utility of many of these methods and the usefulness of
the resulting stumps we may learn more from the makers of artificial
limbs than from almost any other source. Thus, Truax, for instance,
who has had large experience as a mechanic, has given this advice,
as quoted by Matas: “Avoid amputation within three inches of the
ankle-joint; do not amputate between the metatarsal bones and the
junction of the lower and middle thirds of the tibia. At other points
save all you can, and you will in every case have done the best for
your patient.” Should one be rationally governed by this advice a large
number of amputation methods which cumber most text-books would be
discarded.

[Illustration: FIG. 692

1, simultaneous disarticulation of all the toes; 2, amputation of the
toes in their continuity. (Mignon.)]

[Illustration: FIG. 693

1, partial amputations of the third and fifth metatarsals; 2,
disarticulation of the first and fifth metatarsals. (Mignon and
Matas.)]

[Illustration: FIG. 694

Tracings of intratarsal amputations at various levels (outer side):
1, subastragaloid; 2, tibiotarsal; 3, tibiocalcaneal; the different
lengths of flaps shown in relation to skeleton.]

[Illustration: FIG. 695

Tracings of incisions in mediotarsal amputations and total amputation
of fifth toe. (Mignon and Matas.)]

For my own part I would advise to save all of a foot that can be saved,
providing a sufficiently long plantar or heel flap can be retained; but
if these are not available, then I would advise amputation, at least
three inches above the ankle.

I would advise, moreover, to discard the complicated rules and
technique of stilted methods and to use the saw whenever it can be
made useful, rather than to go farther back to a row of joints simply
because they are joints (Fig. 694).

Figs. 695 and 696 illustrate conservative modern methods, which are
perfectly available for most purposes, and from which departure need be
made only when peculiar circumstances obtain, which so complicate the
case that none of the ordinary rules would apply. A surgeon of judgment
and experience is competent to devise a flap for a given case, whether
it complies with standard methods or not. It seems to me, therefore,
worth while to describe only the so-called _mediotarsal disarticulation
of Chopart_, in which but the astragalus and calcis remain of the
proper bones of the foot. The joint line extends from just behind the
tuberosity of the scaphoid to the outer side of the body of the calcis,
where a tubercle can be usually felt. Across this line an incision is
carried obliquely over the dorsum of the foot. The plantar flap is the
long one, and the line of division is just behind the balls of the
toes. Two lateral incisions can be made to facilitate disarticulation
if desirable.

[Illustration: FIG. 696

1, disarticulation at the tarsometatarsal joint, showing length of
flaps; 2, disarticulation of the big toe in continuity. (Mignon.)]

This operation sometimes leaves the foot in a bad equinus position;
accordingly it is wise to make tenotomy of the tendo Achillis, as well
as to attach the dorsal or extensor tendons to the stump end. (See
Figs. 699 and 700.)


=Amputations of the Foot (Tibiotarsal).=--The former favorite method
of amputating the _foot proper_ was that of Syme, illustrated in Fig.
701. This preserved the plantar surface and tip of the heel, thus
forming a cutaneous hood, which was made to cover the lower ends of the
tibia and fibula, whose malleoli were usually removed close to their
terminations. The incision is made directly down to the bone, from
the apex of one malleolus across the sole and up to the other. Then
the foot is forced into extreme flexion and another incision carried
directly across the dorsum, by which the upper ends of the first are
joined. This permits opening the ankle-joint in front, after which the
lateral ligaments are divided and the astragalus dislocated forward.
The heel hood is next carefully separated from the calcis with the
knife, and it and all the parts retracted from the ends of the leg
bones, which are divided just above the articular surfaces, or the
latter may be left and the malleoli alone removed. Now the heel hood is
raised, made to cover the end of the leg, and united to the anterior
incision, drainage being made by a small opening on the outer side of
the tendo Achillis, as the plantar surface of the flap should not be
opened (Fig. 703).

[Illustration: FIG. 697

Lisfranc’s tarsometatarsal disarticulation. (Farabeuf.)]

[Illustration: FIG. 698

Stump after same.]

[Illustration: FIG. 699

Classical mediotarsal amputation (Chopart), showing length of plantar
flap. (Farabeuf.)]

[Illustration: FIG. 700

Stump after Chopart’s amputation. (Farabeuf.)]

[Illustration: FIG. 701

Syme’s tibiotarsal operation, showing part removed and lines of
section, before division of malleoli. (Farabeuf.)]

Fig. 702, the complement of Fig. 701, illustrates the appearance of
the stump after the completion of the disarticulation and before the
removal of the malleoli.

Pirogoff introduced a serviceable modification by obliquely dividing
the os calcis in front of the heel, turning up its sawed surfaces
without any dissection of the hood from the heel, and uniting its fresh
bone aspect with that made by removal of the articular ends of the leg
bones. This would seem to be preferable to Syme’s disarticulation,
affording a better walking stump. (See Figs. 704 and 705.)

A reverse of this operation was suggested by Mikulicz and Wladimiroff,
independently, and at about the same time, the heel being excised by an
incision across the sole and then behind the ankle, the calcis being
divided and its posterior end removed, while the articular surfaces
of the leg bones are also removed. The foot is then brought down so
that these surfaces can be brought in contact, it being expected that
after their reunion the individual will walk in the exaggerated equinus
position and upon the ends of the metatarsal bones. The operation is,
in effect, an exsection rather than an amputation, and is applicable to
but a very small number of cases, in which, however, it sometimes gives
excellent results. (See Fig. 707).

[Illustration: FIG. 702

Syme’s amputation after disarticulation of the foot at the ankle-joint.
The soft parts are being cleared from the malleoli preparatory to
sawing the malleoli and lower articular surface of tibia. (Farabeuf.)]

[Illustration: FIG. 703

_S_, line of incision for Syme’s operation; _P_, line of incision for
Pirogoff’s operation. (Erichsen.)]


=Amputations Of the Leg.=--Modern prosthetic methods have materially
changed the indications in amputating the leg. The pressure in
artificial limbs is not borne upon the end of the stump, but is rather
circumferential and borne by a conical socket. It is now, therefore,
an object to preserve as much of the limb as practicable, in order to
have better leverage or control of the artificial member. Consequently
the point of election is now the middle of the leg, unless the
amputation may be made even below this point. The objection to a short
leg stump is the inevitable flexion which the hamstring flexors will
produce; in such cases the pressure will be borne upon the knee, while
the appearance of the stump is by no means ideal. If, therefore, one is
forced to make a high amputation of the leg it would be far preferable
to make a good knee disarticulation, or, better still, a supracondyloid
amputation, with preservation of the patella, thus furnishing a stump
which affords perhaps the only exception to the general rule, _i. e._,
that weight cannot be borne upon the stump end.

[Illustration: FIG. 704

Skeleton of stump after Pirogoff’s osteoplastic amputation. The sawed
surface of the calcaneum in apposition with divided surface of tibia.
(Farabeuf.)]

[Illustration: FIG. 705

Stump after Pirogoff’s operation. The weight of the body must rest upon
the thick plantar skin of the heel and never on the thin skin of the
retrocalcaneal surface. (Farabeuf.)]

[Illustration: FIG. 706

Sections of bone in Pirogoff’s amputation and its modifications: 1,
oblique section of calcaneum to correspond with (1) oblique section of
tibia. (Gunther.) 2, curvilinear or concave section of calcaneum to
correspond with (2) convex section of tibia. (v. Bruns.) 3″, horizontal
section of calcaneum to correspond with (3) similar section of tibia.
(Pasquier Le Fort.) 3‴, vertical section of calcaneum to correspond
with (3) horizontal section of tibia. (Typical Pirogoff.) (Modified by
Matas from Mignon.)]

[Illustration: FIG. 707

Osteoplastic excision of foot. (Mikulicz.)]

Let us, then, consider but one or two amputations of the leg--that low
down or near the middle and that at the knee. Whatever the method it is
most desirable that the scar be kept off to the side, and especially
_away from the front of the shin_. This can be best accomplished by a
modified circular (Fig. 708) or a bilateral flap method (Fig. 711), or
by the oblique method with lateral incisions, which practically convert
it into an anteroposterior operation, while for certain instances the
method of Teale may be preferred, _i. e._, that with a long anterior
and short posterior flap, or its modification by which the flaps are
made more lateral, or the even long flap method of Bell.

[Illustration: FIG. 708

Modified circular amputation of upper third of leg. (Erichsen.)]

Whichever of these be selected, after division of the muscles and
exposure of the bone, it is usually helpful to retract the flaps,
whatever their shape, by a cloth retractor made of a piece of sterile
bandage torn into three strips, the middle of which should be inserted
between the bones of the leg, the interosseous membrane being divided
for this purpose; by this they are held more perfectly out of the
way during the act of dividing the bones. The anterior border of the
tibia, which is practically a sharp ridge, should be divided obliquely
(bevelled), either by a small oblique section before the transverse
division is made, or by effecting this later, in order that there shall
not remain a sharp point to project through the skin or be subject to
constant irritation. The tibia is usually divided transversely, with
the above exception. The fibula may be divided slightly obliquely. It
is customary, however, to make the division simultaneously, and to so
conduct the sawing process as to divide the fibula completely before
the last strokes of the saw cut through the tibia.

There is greater difficulty in the recognition and securing of vessels
in leg amputations than in any other, especially if they have been
divided obliquely. The principal vessels may be found from their known
anatomical location. They nevertheless sometimes tend to retract
and they must be followed up in order to properly secure them. The
accompanying nerve trunks should also be seized firmly, drawn down, and
divided two or three inches above the line of division of the other
tissues, in order that they may retract out of harm’s way. Every nerve
which can be recognized, even in the skin, should be thus treated.
Before closing the wound it is well, unless one is absolutely sure of
his work, to release the tourniquet and ascertain if any vessel which
would otherwise bleed be not yet secured. Oozing may be checked with
hot water, while muscle surfaces which leak too much blood may be
lightly enclosed within catgut sutures inserted with a curved needle.

Providing that these stumps have well-nourished flaps, and that no
sharp or angular bone ends interfere with subsequent comfort, and that
the scars be kept away from their lower surfaces, they serve their
purpose admirably.

Supposing, then, that amputation is to be about the middle, the first
incision, made with a stout scalpel, is begun at the anterior border
of the tibia and carried downward along it until it is turned abruptly
backward to the posterior aspect, and then upward until a point is
reached opposite that of commencement. The skin is dissected up for
perhaps an inch. Then the flap on the other side is cut after the
same fashion, after which, with a short or long knife, the muscles
are divided transversely or circularly down to the bone. Much will
depend now upon whether the desire is to resort to the more modern
osteoplastic methods or adhere to the old. In the latter case it is
well to separate the flaps for the necessary distance from the bone,
with or without the periosteum, dividing the bones after suitable
retraction, as above suggested. If preference be for an _osteoplastic
flap_ it is planned and made at this time, the bone being divided
at the same level as the muscles, and the amputation being thus
practically completed, after which the osteoplastic flap is arranged,
it being now necessary to carefully preserve the periosteal bridge
and to again divide the bone at the base of this periosteal flap,
this being the true end of the bone stump. In this case the fibula is
divided at a higher level.

It is perhaps less desirable to preserve periosteum in young children
than in adults, for if bone be permitted to grow too rapidly conical
stumps result, sometimes even with protrusion of bone ends. Ollier and
his pupil Mondan have shown that this so-called _atrophic elongation_
of bone is a consequence of abnormally rapid growth from the upper
epiphyseal direction, permitted by lack of pressure from below, and
that conical stumps will often happen in children in spite of every
precaution. Nevertheless it should not be encouraged, and for this
reason periosteum should not be preserved.

The _method of Teale_ was to cut a long anterior flap, raising the
coverings from the bone with the least possible disturbance, to divide
the bone at the high level, then to double the flap upon itself in such
a way as to bring the scar at a level one inch or more above the stump
end. Heine modified this slightly by raising the periosteum with the
rest of the anterior flap. In cases which permit such a long flap to be
formed from one aspect of the leg the method gives excellent results
(Fig. 709).

[Illustration: FIG. 709

Teale’s method of amputation.]

Bruns devised a method which is begun almost as an exsection, by an
oblique circular incision, with liberating lateral incisions, and
division of all the tissues over the inner border of the tibia and
the outer side of the fibula; after which, without disturbing skin
attachments in front, the periosteum is separated from the bones as
high as the liberating lateral incisions permit, and then the fibula
first and later the tibia divided. It is practically a subperiosteal
excision of the leg bones and affords a well-protected stump. In effect
it is an anteroposterior flap method.

[Illustration: FIG. 710

Stump after Stephen Smith’s amputation at knee.]


=The Knee.=--It was Brinton who, in 1872, suggested the preservation
of the semilunar cartilages in all knee disarticulations, as in this
way all the normal relations are preserved and retraction is prevented.
But the makers of prosthetic apparatus have urged to abandon all
true disarticulations, and to substitute for them the supracondyloid
method, which affords ideal stumps. Disarticulations are supposed to
produce less shock, less loss of blood, and less danger of sepsis from
opening up the bone-marrow, while muscle insertions are less disturbed
and the stump covering usually is mobile and not very sensitive. No
disarticulation should be thought of unless the joint involved be
free from disease and unless about it there be met sufficient healthy
integument to furnish a satisfactory flap.

For a true _disarticulation_ Stephen Smith’s bilateral method is now
almost universally adopted. Here the incision is begun one inch below
the tubercle of the tibia and is carried directly down to the bone,
downward and forward around the side of the leg, and then inward and
upward toward the middle of the popliteal space, the lateral flaps thus
made being nearly duplicates. The flaps thus cut out are completely
separated from the bone up to the joint level, where the ligaments
are divided, the joint being manipulated as may be necessary to best
expose them and facilitate division. In this operation the patella is
usually removed, the joint being opened by separating its ligament at
its insertion into this bone. One should remember that the internal
condyle is lower and longer than the external, and that the internal
flap should be perhaps made on this account a little the longer of the
two. Fig. 710 illustrates the stump resulting from this operation and
shows the cicatrix drawn up out of harm’s way and resting in the fossa
between the condyles. Fig. 711 illustrates the simple method by lateral
flaps.

[Illustration: FIG. 711

Amputation at knee by lateral flap. (Erichsen.)]


=Amputation of the Thigh.=--Under this head, rather than that of
amputation at the knee, should be described the _supracondyloid
amputations_ which give decidedly the best results of all, and which
are preferable to any others for the middle of the lower extremity.
Of these the best is that suggested by Gritti, which consists in not
only removing the condyles but sawing off the articular surface of
the patella, which is then drawn upward and applied to the end of the
femur, the division of the latter being made at a point above the
condyles, where the diameter of both bones will nearly correspond, this
latter perhaps being a suggestion of Stokes rather than of Gritti, who
did not divide the bone quite so high. (See Fig. 712.)

[Illustration: FIG. 712

Gritti’s osteoplastic supracondyloid knee amputation, patella utilized:
_a_, shaded parts are those brought in apposition; _b_, appearance of
Gritti stump after suture; _c_, correct apposition of patella to femur;
_d_, defective apposition. (Farabeuf.)]

Fig. 712 will best illustrate the intent of the method as well as its
performance. The incisions are planned much as in the Stephen Smith
disarticulation method, only they are placed higher, and the patellar
tendon is divided as low down as possible, or even separated from the
tibia, in order that it may be made of use in attaching the divided
patellar surface to the femoral end. The rest of the operation is
performed as by other methods, the attachment of the patella being
effected by tendon sutures, or, if necessary, by an ivory peg, or even
a metal tack or nail which may be left in place.

The beauty of this method is that the anterior surface of the patella
is preserved with its natural weight-bearing facilities and the bursa
between it and the skin, while the latter is undisturbed. On the end of
this stump as much weight can be steadily borne as when one ordinarily
kneels, and to it a most serviceable kind of artificial limb can be
attached, with which one may walk as though nothing had ever happened.

Another osteoplastic method, namely, that of Sabanejeff, is illustrated
in Figs. 713 and 714. In this instance the bone covering over the end
of the femur is taken from the upper end of the tibia, the patella
not being disturbed. It permits a lower division of the femur and the
formation of a stump which is of practically the same length as the
original thigh.

[Illustration: FIG. 713

Sabanejeff’s knee amputation. (Chalot.)]

[Illustration: FIG. 714

Stump made as in Fig. 713. (Chalot.)]


=Amputation of the Thigh above the Knee.=--For _removal of the thigh_
it is well to preserve as much of its length as possible, and yet not
at the expense of all other considerations. A thigh stump too short
is likely to be pulled awkwardly upward by the psoas muscle, and upon
such a stump it is difficult to secure an artificial limb tolerable
of control against such action of this muscle. On this account, then,
thigh stumps should be long. So far as the method is concerned the
circular, or some modification thereof, gives the best results in
the majority of instances. It may easily be modified into one of the
oblique methods, or liberating incisions may be used whenever they will
be of service. If it be absolutely necessary to make the amputation
high hemostasis can be secured by the same methods that are used in
hip-joint amputations. The dense and strong fascia lata, which lies
beneath the superficial fascia, should be divided at the same level
with the skin, since it serves admirably, when secured by a separate
set of sutures, to make a good covering for the ends of the muscles,
after these have been themselves carefully united by buried sutures.
The sciatic nerve should be especially sought, thoroughly stretched,
and divided high up. The vessels often evince a tendency to retract
within Hunter’s canal; it is not, however, difficult to separate the
vastus internus from the adductor longus, between which they lie, and
in this way gain access to them. Even for high work on the thigh one
may, if necessary, do as some have done at the hip, make a preliminary
ligation of the femoral artery. This may be especially serviceable as
an emergency measure, or in special cases of tumors which have attained
large size, are placed high up and call for somewhat atypical methods.


=The Hip-joint.=--Amputation here is essentially a _disarticulation_
and constitutes one of the usually formidable and serious operations
of major surgery. Although the joint itself is generally easily
reached there are many things to be considered in the performance of
this operation, of which the mere arthrotomy is by no means the most
important.

Preparations being all made, the first consideration is the _control
of hemorrhage_, for which several methods have been suggested,
but of which but two or three are in general use. Such procedures
as compression of the abdominal aorta, either with the hand or by
tourniquet, or of the common aorta through the rectum, with a lever, as
suggested by Davey, or with the hand, as suggested by Woodbury, or the
exposure of the common iliac, either within the peritoneum as practised
by McBurney, or externally, or exposing the common femoral above
Poupart’s ligament, are now adopted by very few surgeons. Langenbeck
used to be fond of preliminary ligation of the femoral where it is
most accessible in the groin, and this is probably the best of all of
these methods. But they have been all practically discarded since Wyeth
introduced the simple method of transfixing the limb with his pins (_i.
e._, long mattress needles or skewers made for the purpose), these
serving to hold in place an elastic cord or tourniquet (Fig. 715). This
has been found to be a great improvement on the suggestion of Senn, who
excised the femoral head and then compressed each half of the limb with
a separate elastic band.

[Illustration: FIG. 715

Wyeth’s bloodless method: pins inserted and tube applied.]

The directions for the use of Wyeth’s pins are simple. Here, as in
other cases, it may not be practicable to use the elastic bandage from
the lower end of the limb, but one may at least elevate the limb and
thus coax the blood out of it by gravity or by gentle manipulation.
While it is still in this position one of the long pins is introduced
just below the anterosuperior spine and a trifle to its inner side, and
made to emerge on a level with and about three inches from the point of
its entrance. The other needle is inserted just to the inner side of
the saphenous opening, and below the level of the crotch, and brought
out about one inch below the tuberosity of the ischium. Corks should
then be placed upon them so as to protect the needle points. Next a
piece of elastic tubing or band is placed around the limb above these
pins and tightened, each turn being made a little tighter, so as to
absolutely control the circulation. The effect of this is felt upon
practically every vessel in that part of the body, and if the method be
properly practised it affords absolute security.

The surgeon now has his choice of various methods of disarticulation,
either that by anteroposterior flaps or lateral flaps, or by the
circular, with the free liberating lateral incision; or he may devise
any method of his own which will best meet the indication in a given
case. Fig. 715 illustrates the employment of Wyeth’s pins and the
first circular incision made as for the circular method. Of these
all the latter seems preferable when circumstances permit. It should
be combined with a sufficient lateral incision, which should be made
to pass well over the great trochanter. The cuff raised through this
incision should extend down to the deep fascia and up to the level of
the lesser trochanter, at which level the deeper tissues are divided
transversely or by a circular cut.

It is well next to lay down the knife and secure the large vessels,
after which the deep muscles are separated from the upper end of the
shaft and the proximity of the joint, while the entire limb may be
still used as a lever in so stretching the joint capsule as to better
expose and divide it. So soon as the capsule has been opened, and the
entrance of air thus permitted, it will be easy to expose and divide
the teres ligament, after which the balance of the disarticulation is
easily effected. The large nerve trunks are now sought, retracted, and
divided high up, all visible vessels are secured firmly, after which
the elastic constriction may be gradually released and any vessels that
spurt may still be secured. There will nearly always be troublesome
oozing from the cut ends of the large muscles, and here, if hot water
prove insufficient to check it, with large curved needles and catgut
sutures the muscle ends may be secured by ligature _en masse_, before
they are brought together for the purpose of closing the stump.

Whatever the method selected as perfect a closure of the wound as
possible should be made, with ample provision for drainage. By careful
deep suturing, with tiers of buried sutures, it is possible to avoid
leaving dead spaces at any point except perhaps the acetabulum. Through
retaining sutures may also be used to advantage. It is most desirable
to so plan the incisions and the closure of the wound as to keep them,
so far as possible, away from the region of the perineum. Therefore the
longer the inner flap or inside of the stump the better. As conditions
which necessitate removal of the limb at the hip-joint are always
serious, and have each their own peculiarities, any method which will
best serve the purpose should be used.

Plates LIX and LX, designed by Prof. Matas, afford the best and
briefest epitome of the choicest amputation methods which can be
furnished.


THE STUMP.

An amputation having been effected, and the stump closed, there is
still occasion to consider how it may best be treated to fit it for its
future purposes. When entire chapters, or even small monographs, can be
written on the subject of “diseases of stumps” it would appear that the
consideration is not one of merely trifling import.

A _good stump_ has a regular outline, with a protected scar, and
should be firm, yet mobile, and without tender or sensitive surfaces.
It should constitute the lower end of a truncated cone, and needs to
be of sufficient length to permit leverage within the socket of the
artificial limb which will be fitted about it.

A stump failing in these characteristics is a _bad_ stump, the features
which especially tend to make it bad being undue conicity (Fig. 716)
or sensitiveness of surfaces, ulceration from friction, or, worse yet,
occurring without it, and neuralgia from inclusion of nerve ends, or
from bone ends which present osteophytic outgrowths and thus distort
and displace tissues (Fig. 717). Acute osteomyelitis occurs in stumps,
as do slower carious processes which may call for re-amputation,
perhaps even at a distance. The stump is for a long time more or
less tender and troublesome, and its owner may be a sufferer from
hyperesthesia or perverted sensations.

The possibility of the production of a conical stump in children as the
result of _atrophic elongation_ was mentioned early in this chapter.
While this cannot always be prevented it may sometimes be foreseen,
and one should be prepared at any time in such cases to circumcise the
bone, forcibly retract the tissues, and then divide the bone ends on a
higher level.

[Illustration: PLATE LIX

  _1, 2. Circular for middle and upper thirds of thigh._

  _3. Circular for lower third of thigh, showing tendency of circle
  to incline downward on adductor side to compensate for greater
  retraction._

  _4. Incision for Gritti’s or Carden’s amputations at knee (single
  anterior flap)._

  _5, 6. Stephen Smith’s bilateral flaps (posterior racquet)._

  _7. Antero-posterior flaps, cut solid to the bone, the soft parts
  being elevated from the periosteum (Marc See, von Brun’s method).
  This is the author’s preferred method for leg only, simplified by
  making a simple circular with two lateral liberating incisions on
  fibular and tibial sides._

  _8, 9, 10. Circular with posterior racquet extension to form
  bilateral flaps (Stephen Smith)._

  _11. Guyon’s supra-malleolar amputation._

  _12. Lines of Syme’s amputation._

  _13. Inner aspect of Roux’s tibio-tarsal amputation; also
  subastragaloid._

  _14. Medio-tarsal amputation (inner aspect)._

  _15. Tarso-metatarsal disarticulation (inner aspect)._

  _16. Disarticulation of toe with its metatarsal._

  _17. Disarticulation of big toe; in front of this lines for
  amputating first or terminal phalanx by long plantar flap._

The Right Lower Limb, Internal Lateral View (Surface Incisions).]

[Illustration: PLATE LX

  _1. Low circular with external incision (Furneaux Jordan) or at a
  higher level (gluteo-femoral furrow) applicable to Wyeth’s method of
  disarticulating hip._

  _2. Circular incision with tendency to racquet posteriorly in middle
  third amputations._

  _3. Circular with posterior vertical incision in amputation of lower
  third of thigh._

  _4. Long anterior flap for supra-condyloid amputation of thigh._

  _5. Racquet incision with long anterior flap for extreme upper third
  of leg. Note long posterior tail, which facilitates upward retraction
  of a solid musculo-cutaneous flap cut down to the periosteum,
  resembling a bilateral flap operation (Stephen Smith). The same
  incision cut a little higher is most serviceable in disarticulating
  at the knee._

  _6. Long-hooded anterior flap, with posterior racquet (Stephen Smith
  and Bier’s osteoplastic)._

  _7. Amputation by equal antero-posterior flap (Marc See, von Bruns)._

  _8. Amputation by long anterior and short posterior flaps (Teale’s
  principle)._

  _9. Amputation of leg at extreme lower third, practically a circular
  amputation converted into a solid antero-posterior flap by liberating
  incisions on fibular and tibial sides._

  _10. Guyon’s supra-malleolar amputation of leg._

  _11. Medio-tarsal and intra-tarsal amputations (Chopart and its
  derivatives)._

  _12. Tarso-metatarsal amputation (Lisfranc and derivatives)._

Surface Outlines of Amputations Practised in the Lower Extremity.]

An exquisitely neuralgic stump is usually made so by the entanglement
of nerve ends and their subsequent enlargement into so-called
_amputation stump neuromas_ (which are histologically fibromas), from
pressure upon nerve terminals. Under these circumstances their excision
through incisions planned for the purpose, or the exsection of a
portion of the nerve trunk at a higher level, may be necessitated (Fig.
717).

[Illustration: FIG. 716

Extreme case of conical stump.]

[Illustration: FIG. 717

Neuromatous endings of nerves in a stump.]

[Illustration: FIG. 718

Ideal stump.]

[Illustration: FIG. 719

Bad stump, because posterior flap was cut too short, and there has been
great retraction of all soft tissues. (Farabeuf.)]

While patients may prefer disuse of a stump for as long a time as
possible the judicious surgeon will prepare it as rapidly as he may
for early application of the expected artificial limb. Inasmuch as leg
stumps allowed to hang downward become cyanotic and edematous it is
well to keep them bandaged, and the makers of artificial limbs prefer
to have the bandages kept wet. When the stump is healed, passive motion
of the remainder of the limb should be begun, in order that there
may be a minimum of stiffening of joints. If, then, such a stump be
bathed, massaged, moved, and then bandaged with comfortable snugness
with cold, wet bandages, over which oiled silk may be fastened, and if
this be done at least once each day, the stump will be prepared for the
artificial limb, on the average, in two to three months. One should
not wait for this expiration of time if it be thoroughly healed; or,
on the other hand, he may have to wait much longer under unfortunate
circumstances; but the above general principles of treatment and
general statements will be found to prevail. Figs. 718 and 719
illustrate the difference between good and bad stumps, while Plates
LIX and LX (reproduced from Matas) furnish the surface outlines for
selection of the various amputations of the lower limb.


CINEPLASTIC OR CINEMATIC AMPUTATIONS OF THE UPPER EXTREMITY.

The most pronounced and illustrative of recent methods is perhaps the
“cinematic” or “cineplastic” procedure of Vanghetti. This Italian
surgeon proposed a prosthetic method, in 1898, which is illustrated in
Figs. 720, 721 and 722. He has shown that tendon terminations may be
left exposed in stumps, under favorable conditions, and so utilized
as to serve remarkably useful purposes--though under exceptional
conditions. For a description of these methods the reader is referred
to his monograph. (G. Vanghetti, _Plastica e Protesi Cinematiche_,
Empoli, 1906.)

[Illustration: FIG. 720

FIG. 721

FIG. 722

Results of Vanghetti’s “cinematic” method, with preservation and
utilization of tendons.]




INDEX.


  A

  ABDOMEN, diseases of, diagnosis of, 768
    distention of, in appendicitis, 856
    drainage of, 776
    general considerations and conditions of, 767
    inflation of, 769
    inspection of, 768
    measurement of, 769
    operation on, technique of, 773
    palpation of, 768
    bimanual, 769
    wounds of, gunshot, 214, 232

  Abdominal aorta, aneurysm of, 346
      ligation of, 356
    cavity, irrigation of, 775
    diseases, diagnosis of, 768
    incisions, closure of, 777
    operations, after-treatment of, 777
      embolism following, 784
      hemorrhage after, 780
      peritonitis following, 780
      technique of, 773
      thrombosis following, 784
    viscera, general considerations and conditions of, 767
    wall, abscess of, 783
      actinomycosis of, 783
      burns of, 783
      carcinoma of, 784
      contusions of, 781
      cysts of, congenital, 783
      endothelioma of, 784
      epithelioma of, 784
      erysipelas of, 783
      fibroma of, 784
      foreign bodies in, 783
      gangrenous cellulitis of, 783
      hematoma of, 781
      injuries of, 781
      lacerations of, 781
      osteomyelitis of, 783
      phlegmons of, 783
      sarcoma of, 784
      suppurative spondylitis of, 783
      syphilis of, 783
      tuberculosis of, 783
      tumors of, 783
        vascular, 784
      wounds of, gunshot, 783
        penetrating, 781

  Abscess of abdomen, 783
    atheromatous, 73, 339
    bone, 419, 425
      treatment of, 426
    of brain, 567
      prognosis of, 569
      symptoms of, 568
      treatment of, 573
    of breast, 757
    classification of, 58
      acute, 58
      cold, 58, 112
      gravitation, 58
      metastatic, 59
      subacute, 58
      subfacial, 59
      subperiosteal, 59
    cold, 112
      peri-articular, treatment of, 399
    collar-button, 319
    definition of, 58
    frontal, 569
    of heart wall, 733
    ischiorectal, 879, 1013
    of liver, 911
      symptoms of, 912
      treatment of, 912
    lumbar, 114
    of lung, 734
    of mesentery, 939
    metastatic, 59, 91
    occipital, 569
    of pancreas, 949
    parietal, 569
    peri-appendicular, 860
    perilaryngeal, 704
    perineal, 1013
      treatment of, 1013
    perinephritic, 961
    perirectal, 879
      treatment of, 879
    peritracheal, 704
    perityphlitic, 860
    of prostate, 994
    psoas, 114
    of rectum, 879
      treatment of, 879
    renal, 957
    retropharyngeal, 114, 682
    signs of, 60
    of spleen, 941
    subphrenic, 753
      treatment of, 754
    symptoms of, 60
    temporosphenoidal, 569
    of tonsils, 662
    treatment of, 60

  Abstraction of blood, 182

  A. C. E. mixture, 198

  Accommodation, defects of, 604

  Acetabulum, migration of, 453

  Acetonemia, 82

  Acetonuria, 82

  Acheilia, 638

  Achondroplasia, 432

  Acid intoxication from anesthetics, 203

  Acinous carcinoma, 290

  Acoustic nerve, neurofibroma of, 584

  Acromegaly, 437

  Acromial process, fracture of, 494

  Actinomycis, 109
    fungi, 55

  Actinomycosis, 109
    of abdominal wall, 783
    of bone, 432
    of breast, 759
    definition of, 109
    diagnosis of, 110
    of face, 640
    of intestines, 827
    of kidneys, 964
    of liver, 914
    of lung, 732, 734
    of mesentery, 939
    of mouth, 657
    organism of, 109
    prognosis of, 110
    pus in, 109
    of skin, 308
    of thorax, 729
    of tongue, 659
    treatment of, 110

  Adenocarcinoma, 285
    of bladder, 992
    of pancreas, 953

  Adenoids of pharynx, 679
    treatment of, 680

  Adenoma, 284
    of bladder, 992
    of breast, 760
    of kidney, 969
      congenital, 969
    of liver, 914
    of pancreas, 953
    of rectum, 885
    sebaceous, 285
      cysts, 285
    of thyroid, 712

  Adenosarcoma, embryonal, 268

  Adventitious bursæ, 263

  Ainhum, 76

  Air embolism, 38
    of veins, 363

  Aleppo boil, 309

  Alimentary canal, infection through, 49

  Allantoic cysts, 260

  Alveolar sarcoma, 274
    suppuration, 664

  Alypin, 207

  Amastia, 755

  Amazia, 755

  Amputations, 1023
    of arm, 1032
    atypical, 1023
    control of hemorrhage in, 1024
    of elbow, 1031
    of finger, 1029
    of foot, 1037, 1041
      Bruns’ method, 1042
      partial, 1034
      Teale’s method, 1042
    of forearm, 1031
    of hand, 1031
    of hip-joint, 1045
      Davey’s method, 1045
      McBurney’s method, 1045
      Woodbury’s method, 1045
      Wyeth’s method, 1045
    interscapularthoracic, 1033
    of knee, 1043
      Gritti’s method, 1044
      Sabanejeff’s method, 1044
      Stephen Smith’s method, 1043
    of leg, 1039
      Bier’s osteoplastic, 1028
      circular, 1041
      Pirogoff’s method, 1040
    of lower extremity, 1034
    mediotarsal of Chopart, 1037
    method of, 1026
      circular, 1026
      flap, 1027
      osteoplastic, 1027
    of penis, 1010
    of shoulder, 1032
    stump after, 1046
        bad, 1046
        good, 1046
      neuromas, 1047
    supracondyloid, 1043
    of thigh, 1043
      above knee, 1044
      Gritti’s method, 1043
      Stokes’ method, 1043
    of thumb, 1029
    tibiotarsal, 1037
    of toes, 1034
    typical, 1023
    of upper extremity, 1029
        cineplastic, 1048
        entire, 1033
    of wrist, 1031

  Anastomosis of arteries, aneurysm by, 344
    gastric, 816
    of intestines, 842

  Anastomotic varix, 364

  Anel’s method of treating aneurysm, 347

  Anemia, 30
    pernicious, 30
    primary, 30
    secondary, 30
    splenic, 31

  Anesthesia and anesthetics, 192
    A. C. E. mixture, 198
    accidents from, 201
      arrested respiration, 202
          treatment of, 202
      cardiac failure, 201
    acid intoxication from, 203
    administration of, 193
    anesthol, 200
    chloroform, 195
      accidents from, 196
      action of, 196
      administration of, 197
      death from, 196
    choice of, 200
    dangers of, 201
    discovery of, 192
    ether, 193
      accidents due to, 194
      action of, 194
      narcosis by rectum, 195
      petroleum, 199
      sequels from administration of, 195
    ethyl bromide, 198
      chloride, 199
        local use of, 199
    intraspinal, 207
    local, 205
      alypin, 207
      anesthesin, 207
      beta-eucaine, 207
      cocaine, 205
      liquid air, 205
      nervanin, 207
      orthoform, 207
      stovaine, 207
    magnesium salts, 209
    management of, 192
    methylene bichloride, 198
    morphine, 205
    nitrous oxide gas, 200
    scopolamine, 205
    somnoform, 199

  Anesthesin, 207

  Aneurysmal bruit, 341
    varix, 363
    of abdominal aorta, 346
    arteriovenous, 344
    of axillary artery, 345
    of carotid artery, 345
        external, 345
        internal, 345
    cirsoid, 278, 339, 344
    classification of, 342
    diagnosis of, 345
    diffuse, 339, 342
    dissecting, 339, 342
    false, 339, 343
    of femoral artery, 346
    fusiform, 339, 343
    of heart, 732
    hernial, 339
    of iliac artery, 346
    of innominate artery, 345
    intracranial, 345
    of liver, 914
    of neck, 701
    of orbit, 592
    progress of, 341
    pulsation of, 341
    racemose, 344
    rupture of, 341
    sacculated, 339, 342
    spontaneous, 339
    of subclavian artery, 345
    traumatic, 339, 343
    treatment of, 346
      by extirpation, 348
      by introduction of wire, 348
      by ligation, 347
        Anel’s method, 347
        Brasdor’s method, 347
        Hunter’s method, 347
        Wardrop’s method, 347
      by open division, 347
      by opening and suture, 348
    true, 339
    varicose, 339, 342, 363

  Angina, Ludwig’s, 658, 703
    Vincent’s, 703

  Angiocholitis, desquamating, 919

  Angioma, 277
    arterial, 278
    capillary, 277
    cavernous, 277
    of omentum, 935
    of orbit, 592
    plexiform, 278
    of veins, 366
      treatment of, 367

  Angiosarcoma, 275

  Angiotribe, control of hemorrhage by, 236

  Ankle, dislocations of, 544
    excision of, 414

  Ankyloblepharon, 603

  Ankyloglossum, 652

  Ankylosis, 403
    contractures, 403
    of hip, 404
    of jaw, 667
    of knee, 404
    treatment of, 405
    true, 403

  Annular thrombosis, 35

  Anthrax, 106
    bacillus of, 54
    definition of, 106
    incubation in, 107
    postmortem appearances in, 107
    prognosis of, 107
    prophylaxis of, 108
    symptoms of, 107
    treatment of, 107

  Antisepsis, 243

  Antiseptic applications, 248
    solutions, 248

  Antiseptics, toxic, 175

  Antitoxin treatment of tetanus, 101

  Antrum of Highmore, operations on, 611

  Anus, absence of, 873
    artificial, 839
    congenital defects of, 872
    fissures of, 876
    imperforate, 873
    malformations of, 872

  Aorta, abdominal, aneurysm of, 346
      ligation of, 356

  Aplasia cranii, 547

  Aponeurotomy, 327

  Apoplectic cysts, 952

  Apoplexia neonatorum, 564

  Apoplexies, compression, 560

  Appendicitis, bacteriology of, 852
    causes of, 854
    chronic, operation for, 866
    complications of, 855
    diagnosis of, 857
      from acute obstruction of bowel, 858
        pancreatitis, 858
      from cholecystitis, 857
      from colitis, 857
      from enterocolitis, 857
      from floating kidney, 858
      from gastric ulcers, 857
      from intestinal ulcers, 857
      from lead colic, 858
      from mesenteric embolism, 858
        thrombosis, 858
      from peritonitis, 857
      from psoas abscess, 859
      from pyosalpinx, 858
      from ruptured extra-uterine pregnancy, 858
      from strangulated hernias, 858
    McBurney’s point in, 855
    recurrent, 854
      operation for, 866
    symptoms of, 859
      acute, 855
        abdominal distention, 856
        bowels, 856
        jaundice, 856
        muscle spasm, 855
        pain, 855
        pulse, 856
        temperature, 856
        tenderness, 855
        tumor, 856
        vomiting, 856
    treatment of, 861
      non-operative, 862
      operative, 862
        indications for, 862
    in typhoid fever, 859

  Appendicostomy, 850

  Appendicular colic, 853

  Appendix, vermiform. _See_ Vermiform appendix.

  Aprosopia, 638

  Arlt’s operation for blepharoplasty, 602

  Arm, amputation of, 1032

  Arrow poisoning, 173

  Arterial angioma, 278

  Arteries, abdominal aorta, aneurysm of, 346
        ligation of, 356
    aneurysm of, 339
      by anastomosis, 344
      arteriovenous, 344
      cirsoid, 339, 344
      classification of, 342
      diagnosis of, 345
      diffuse, 339, 342
      dissecting, 339, 342
      false, 339, 342
      fusiform, 339, 343
      hernial, 339
      progress of, 341
      pulsation of, 341
      racemose, 344
      rupture of, 341
      sacculated, 339, 342
      spontaneous, 339
      traumatic, 339, 343
      treatment of, 346
      true, 339
      varicose, 339, 344
    axillary, aneurysm of, 345
      ligation of, 355
    brachial, ligation of, 355
    calcification of, 339
    carotid, aneurysm of, 345
      common, ligation of, 351
      external, aneurysm of, 345
        excision of, 352
        ligation of, 352
      injuries, 563
      internal, aneurysm of, 345
        ligation of, 352
    circumflex, ligation of, 359
    epigastric, ligation of, 359
    facial, ligation of, 352
    fatty degeneration of, 339
    femoral, aneurysm of, 346
      ligation of, 359
    iliac, aneurysm of, 346
      common, ligation of, 356
      external, ligation of, 357
      internal, ligation of, 357
    innominate, aneurysm of, 345
      ligation of, 350
    ligation of, 350
      gangrene from, 73
    lingual, ligation of, 352
    middle meningeal, injuries of, 563
    occipital, ligation of, 352
    popliteal, ligation of, 360
    radial, ligation of, 356
    subclavian, aneurysm of, 345
      ligation of, 354
    surgical diseases of, 337
    temporal, ligation of, 35
    thyroid, inferior, ligation of, 353
    tibial, anterior, ligation of, 360
      posterior, ligation of, 360
    ulnar, ligation of, 356
    vertebral, ligation of, 353

  Arteriorrhaphy in treatment of aneurysm, 348

  Arteriosclerosis, 339

  Arteriotomy, 183

  Arteriovenous aneurysm, 344, 564

  Arteritis, 338

  Arthrectomy, 400

  Arthritis, 382
    chronic, 386
      treatment of, 386
    deformans, 387
      treatment of, 389
    gonorrheal, 392
    postgonorrheal, 152, 392
      of jaw, 667
    rheumatoid, 387
    syphilitic, 385
    tuberculous, 393
      diagnosis of, 398
      pathology of, 394
      symptoms of, 397
      treatment of, 398

  Arthropathic joint disease, 394

  Arthrotomy, 400

  Artificial respiration, 204
      Howard’s method, 204
      Marshall Hall’s method, 204
      in shock, 180
      Sylvester’s method, 204

  Ascites, chylous, 368

  Ascitic tuberculous peritonitis, 791

  Asepsis, 243
    sterilization, 243
      by boiling water, 244
      of dressings, 247
      by formalin, 244
      fractional, 244
      of hands, 245
      by heat, 243
      of instruments, 246
      by mustard flour, 245
      of sponges, 247
      of suture materials, 247

  Aseptic wound fever, 85. _See_ Surgical fever.

  Aspergillus fungi, 56

  Aspiration, paracentesis by, 184

  Asthma, thymic, 163

  Astomia, 638

  Astragalectomy, 467

  Astragalus, dislocation of, 544

  Atheroma of arteries, 339

  Atheromatous abscess, 73, 339
    cysts of neck, 707
      of skin, 310
    ulcer, 339

  Atresia of rectum, 872

  Atrophic elongation of bones, 436

  Atrophy of bone, 422
    of brain, 578
    definition of, 26
    of muscles, 332
      treatment of, 332
    pathological, 26
    physiological, 26
    senile, 26
    of skull, 547
    of testicle, 1015
    trophoneurotic, 27
    of veins, 361

  Auricle, rodent ulcer of, 606

  Auricles, supernumerary, 605, 638

  Auto-intoxication, 79
      cause of, 79
      ferments in, 79
      intestinal putrefaction in, 81
      osmotic pressure of blood in, 80
      potassium salts in, 80
      treatment of, general, 83
        venesection in, 80
      urea in, 80, 81

  Axilla, syphilis of, 751
    tuberculosis of, 751

  Axillary artery, aneurysm of, 345
      ligation of, 355


  B

  BACILLUS aërogenes capsulatus, 55
    anthracis, 54
    bubonic plague, 54
    chancroid, 55
    coli communis, 53
    diphtheriæ, 54
    lepræ, 54
    mallei, 54
    œdematis maligni, 54
    pneumoniæ, 54
    proteus, 53
    pyocyaneus, 53
    of Rauschbrand, 55
    of rhinoscleroma, 54,
    tetani, 54
    of tuberculosis, 54
    typhi abdominalis, 53

  Bacteria of pus formation, 51
        facultative pyogenic, 53
            bacillus aërogenes capsulatus, 55
              anthracis, 54
              bubonic plague, 54
              chancroid, 55
              diphtheriæ, 54
              lepræ, 54
              mallei, 54
              œdematis maligni, 54
              proteus, 53
              pneumoniæ, 54
              of Rauschbrand, 55
              of rhinoscleroma, 54
              tetani, 54
              tuberculosis, 54
              typhi abdominalis, 53
        obligate pyogenic, 52
            bacillus, pyocyaneus, 53
              coli communis, 53
            colon bacillus, 53
            diplococcus pneumoniæ, 53
            micrococcus gonorrhœæ, 53
              lanceolatus, 53
            tetragenus, 53
            staphylococcus pyogenes albus, 52
              aureus, 52
              epidermidis, 52
            streptococcus erysipelatus, 52
              pyogenes, 52

  Bacterial determination of pus as an indication to treatment, 57

  Balanitis, 149, 1005

  Balanoposthitis, 149, 1005

  Bandage, elastic, for control of hemorrhage, 234

  Bandaging, 189
    kinds of, 189, 190, 191
    materials used in, 191

  Banti’s disease, 31, 942

  Barbadoes leg, 372

  Barrel-shaped chest, 719

  Barton’s head bandage, 191

  Basedow’s disease, 713

  Bassini’s operation for hernia, 902

  Bastard clap, 148

  Bed-sores, a cause of gangrene, 74

  Bees, poisoning by, 172

  Bell’s palsy, 640

  Bellocq’s cannula, 681

  Bennett’s fracture, 506

  Beta-cocaine, 207

  Beta-eucaine, 207

  Bichat, fatty ball of, 641

  Bier’s osteoplastic amputation of leg, 1028
      permanent hyperemia in tuberculosis, 120
      treatment of tuberculosis of joints, 399

  Biett’s collarette, 131

  Bifid penis, 1004
    tongue, 652

  Biliary calculi, 922
      diagnosis of, 925
      symptoms of, 924
      treatment of, 926
    colic, 922
      symptoms of, 924
    ducts, stricture of, 921
    fistulas, 917
      intestinal, 917
      pathological, 917
      postoperative, 917
    passages, catarrh of, acute, 918
          treatment of, 918
        chronic, 918
      injuries of, 918
      operations on, 927
      perforation of, 921
      ulceration of, 921
        symptoms of, 922
        treatment of, 922

  Billroth’s chain-stitch suture, 241

  Biskra button, 309

  Bladder, adenocarcinoma of, 992
    adenoma of, 992
    calculi of, 986
      symptoms of, 986
      treatment of, 987
    congenital malformations of, 977
    dermoid cysts of, 992
    ectopia of, 978
      treatment of, 978
    examination of, 977
    exstrophy of, 978
      treatment of, 978
    fibroma of, 992
    foreign bodies in, 982
    inflammation of, 984
      symptoms of, 984
      treatment of, 985
    injuries to, 981
      treatment of, 981
    myxoma of, 992
    papilloma of, 992
    siphonage of, 1003
    tuberculosis of, 118
    tumors of, 992
      symptoms of, 992
      treatment of, 992
    wounds of, 233

  Blastomycetic dermatitis, 309
    lesions of mouth, 658
    pus, 56

  Blennorrhea, 146. _See_ Gonorrhea.

  Blepharitis, 601
    marginalis, 601

  Blepharoplasty, 602
    Arlt’s method for, 602
    Dieffenbach’s method for, 603
    Fricke’s method for, 603
    Richet’s method for, 603

  Blood, abstraction of, 182
      by arteriotomy, 183
      by cupping, 183
      by leeching, 183
      by venesection, 182
    extravasation of, gangrene from, 73
    foreign bodies in, 35
    formed elements of, 29
    glycogen in, 33
    infusion of, 185
      intravenous, 186
    iodine reaction of, 33
    osmotic pressure of, in auto-intoxication, 80
    microörganisms in, 35
    platelets, 30
    surgical pathology of, 28
    transfusion of, 185

  Bloodvessels, injuries of, 216
    suture of, 349
      end-to-end, 350
      lateral, 349
    wounds of, 216

  Boils, 304
    oriental, 309
    treatment of, 304

  Bones, abscess of, 419, 425
      treatment of, 426
    achondroplasia, 432
    acromegaly, 437
    actinomycosis of, 432
    atrophic elongation of, 436
    atrophy of, 422
    caries of, 427
    cavalryman’s, 331
    cavities, filling of, 431
    cranial, acromegaly of, 548
      injuries of, 552
      leontiasis of, 548
      osteomyelitis of, 548
      periostitis of, 548
    dancer’s, 331
    diseases of, parasitic, 432
      trophoneurotic, 432
    epiphysitis of, acute, 421
    exostoses of, 441
    fencer’s, 331
    fibroma of, 438
    fragility of, 435
      senile, 436
    hydatid disease of, 432
        treatment of, 432
    hyperostoses of, 441
    hypertrophy of, 422
    injuries of, 218
    leontiasis of, 438
    myeloma of, 442
    myxoma of, 441
    necrosis of, 428
      pathological, 428
      toxic, 428
        treatment of, 428
      traumatic, 428
    osteoarthropathic hypertrophiante pneumique, 436
    osteoma of, 441
    osteomalacia of, 434
      prognosis of, 434
      treatment of, 435
    osteomyelitis of, acute, 416
        complications of, 419
        diagnosis of, 419
        etiology of, 419
        organisms at fault in, 417
        pathology of, 416
        prognosis of, 418
        symptoms of, 418
        treatment of, 419
      chronic, 421
        tuberculous, 423
      latent, 421
    osteoporosis of, 422
    osteopsathyrosis, 435
    osteosclerosis of, 422
    ostitis deformans, 436
    Paget’s disease of, 436
    periostitis, acute infectious, 420
          causes of, 421
          treatment of, 421
      albuminosa, 421
    rachitis, 433
    rider’s, 331
    sarcoma of, 441
      treatment of, 441
    sequestrum formation of, 429
      treatment of, 429
    of skull, incomplete formation of, 547
    syphilis of, 135, 426
    transplantation of, 431
    tuberculosis of, 116, 422
      acute miliary, 423
      pathology of, 423
      symptoms of, 423
      treatment of, 425
    tumors of, 438
      cartilaginous, 440

  Boric acid, toxic effects of, 175

  Bow-leg, 465
      treatment of, 465

  Brachial artery, ligation of, 355
    plexus, operations on, 623

  Brain, abscess of, 567
      symptoms of, 568
      prognosis of, 569
      treatment of, 573
    atrophy of, 578
    compression of, 560
      symptoms of, 561
      prognosis of, 562
      treatment of, 562
    concussion of, 559
      treatment of, 559
    contusion of, 559
      symptoms of, 560
      treatment of, 560
    cysts of, congenital, 578
    foreign bodies in, 565
    hernia of, 566
      treatment of, 566
    prolapsus of, 566
      treatment of, 566
    substance, injuries of, 564
      lacerations of, 564
        prognosis of, 564
        symptoms of, 565
    syphilis of, 138
    tumors of, 582
      symptoms of, 583
      treatment of, operative, 585

  Brasdor’s method of treating aneurysm, 347

  Breast, abscess of, 757
    actinomycosis of, 759
    adenoma of, 760
    anomalies of, 755
    cancer of, 761
      treatment of, 763
    contusions of, 756
    cysts of, 760
    fibroma of, 760
    hemorrhages from, 755
    hypertrophy of, 756
    inflammation of, 756
    injuries of, 756
    lipoma of, 760
    neuralgia of, 758
      treatment of, 758
    nipple of, chancres of, 759
      eczema of, 316
      fissure of, 756
      Paget’s disease of, 316, 756
    operations on, 764
    syphilis of, 759
    tuberculosis of, 759
      treatment of, 759
    tumors of, 760
      treatment of, 760

  Bronchocele, 712

  Brophy’s operation for cleft palate, 654

  Bruns’ method of amputation of foot, 1042

  Bubo, chancroidal, 144
    syphilitic, 128

  Bubonic plague, bacillus of, 54

  Bubonocele, 893

  Bunion, 263, 311
    radical cure of, 333 (note)
    treatment of, 311

  Burba, exostosis, 272

  Burns, 300
    of abdominal wall, 783
    of face, 639
    of respiratory passages, 675
    treatment of, 301

  Bursæ, adventitious, 263
    prepatellar, 263
    surgical diseases of, 332
    synovial, 332
    syphilis of, 136
    tuberculosis of, 116

  Bursal cysts of neck, 707

  Bursitis, acute, 333
    chronic, 333


  C

  CALCIFICATION of arteries, 339
    of thrombus, 36
    of veins, 361

  Calculi, biliary, 922
      diagnosis of, 925
      symptoms of, 924
      treatment of, 926
    of nose, 672
    pancreatic, 954
    of tonsils, 663

  Calculus, renal, 965
      diagnosis of, 965
      symptoms of, 965
      treatment of, 966
    of ureter, 973
    vesical, 986
      symptoms of, 986
      treatment of, 987

  Canal of Nuck, hydrocele of, 261

  Cancer. _See_ Carcinoma.
    en cuirasse, 289, 784

  Cancerous ulcers of intestines, 827

  Cancers of branchiogenic origin, 698, 709

  Cancrum oris, 75, 658

  Capillary angioma, 277

  Capsulotomy, 956

  Caput succedaneum, 549

  Carbolic acid, toxic effects of, 175

  Carbuncle, 305
    of neck, 704
    treatment of, 305

  Carcinoma, 289
    of abdominal wall, 784
    acinous, 290
    of breast, 761
      treatment of, 763
    characteristics of, 289
    colloid, 289
    corset, 289
    diagnosis of, from sarcoma, 293
    duct, 290
    encephaloid, 289
    of esophagus, 744
    of gall-bladder, 927
    general considerations of, 294
    of heart, 336
    of intestines, large, 870
      small, 828
        treatment of, 828
    jacket, 289
    of jaw, 668
    of kidney, 969
    of liver, 914
    of lung, 732
    of lymph nodes, 289, 376
    mesentery, 939
    miliary, 289
    pancreas, 953
    prostate, 1002
    rectum, 886
      treatment of, 887
    relation of, to other diseases, 295
    scirrhus, 289
    of skin, 315
    of spine, 462
    of spleen, 943
    of stomach, 801
      symptoms of, 802
      treatment of, 803
    of testicle, 1017
    of thorax, 730
    treatment of, 295
      liquid air in, 296
      radium in, 296
      toxins of erysipelas in, 296
      ultraviolet light in, 296
      _x_-rays in, 297

  Cardicentesis of pericardium, 336

  Cardiolysis, 337

  Cardiospasm, 798
    operation for, 808
    symptoms of, 798
    treatment of, 798

  Caries of bone, 427
    dental, 657, 664
      treatment of, 665
    of hip, 452
      diagnosis of, 454
      prognosis of, 454
      symptoms of, 453
      treatment of, 454
    of spine, 444

  Carotid arteries, aneurysm of, 345
      common, ligation of, 351
      external, excision of, 352
        ligation of, 352
      injuries of, 563
      internal, ligation of, 352
    body, diseases of, 709

  Carpus, dislocations of, 536

  Cartilages, semilunar, dislocation of, 543

  Castration, 1022

  Cataract, 597

  Catarrh of biliary passages, acute, 918
          treatment of, 918
        chronic, 918

  Catarrhal cholecystitis, 919
    ulcers of rectum, 876

  Catgut, sterilization of, 247

  Catheterization, 186
    catheters used in, 186
    complications of, 187
    ureteral, 958

  Catheters, care of, 186

  Cautery, actual, 184

  Cavalryman’s bone, 331

  Cavernitis, 1009

  Cavernous lymphangioma, 278
    tumors, 277

  Cecum, cancer of, 870

  Celiotomy, 773

  Cellulitis, gangrenous, of abdominal wall, 783
    of orbit, 592
    of scalp, 545

  Celluloid thread, sterilization of, 248

  Cementoma, 281

  Cenencephaloceles, 577

  Centipedes, poisoning by, 172

  Cephalalgia, treatment of, 582

  Cephalhematoma, 263
    neonatorum, 549

  Cephalocele, 576
    treatment of, 578

  Cerebellar tumors, treatment of, operative, 585

  Cerebral conditions in rickets, 162
    palsies, 478
      treatment of, 478
    sclerosis in rickets, 162

  Cervical lymph nodes, affections of, 705
    plexus, deep posterior, operations on, 618
    sympathetic nerve, operations on, 618

  Chalazion, 601

  Chancre, diagnosis of, from chancroid, 145
    of nipple, 759
    of rectum, 876
    syphilitic, 126

  Chancroid, 144
    bacillus of, 55
    bubo in, 144
    diagnosis of, 144
      from chancre, 145
      from herpes, 145
    extragenital, 145
    mixed, 145
    phagedenic, 144
    prognosis of, 145
    treatment of, 145

  Chancroidal bubo, 144

  Charbon, 106. _See_ Anthrax.

  Charcot’s artery of hemorrhage, 564
    disease of elbow, 390

  Cheek, tumors of, dermoid, 641

  Cheiloplastic operations, 648

  Chemotaxis, 41, 44
    negative, 45
    positive, 45

  Chest, concussion of, 721
      treatment of, 722
    contusion of, 721
      treatment of, 722
    wounds of, 722
      treatment of, 723

  Chilblains, 299

  Chimney-sweeper’s cancer, 287, 316

  Chin, galoche, 638
    malformation of, 638

  Chlorosis, 31

  Cholangiostomy, 928

  Cholangiotomy, 928

  Cholangitis, acute, 918, 920
      treatment of, 918
    chronic, 918
    suppurative, 919
      diagnosis of, 920
      symptoms of, 919
      treatment of, 921

  Cholecystectomy, 929

  Cholecystendysis, 930

  Cholecystenterostomy, 928

  Cholecystitis, acute, 919
      diagnosis of, 920
        from appendicitis, 857
      phlegmonous, 920
      symptoms of, 919
      treatment of, 921
    chronic catarrhal, 919
    gangrenous, 920
    obliterans, 919

  Cholecystostomy, 929

  Cholecystotomy, 929

  Choledochenterostomy, 928

  Choledochostomy, 928

  Choledochotomy, 928

  Cholehepatopexy, 933

  Cholelithiasis, 922
    diagnosis of, 925
    symptoms of, 924
    treatment of, 926

  Cholelithrotrity, 928

  Cholera, secondary infection in, 166

  Chondritis, 683

  Chondroma, 271
    of jaw, 668
    of testicle, 1017
    of thorax, 730
    treatment of, 272

  Chondrosarcoma, 274

  Chopart, mediotarsal amputation of, 1037

  Chordee, 149

  Chorion epithelioma, malignant, 292

  Choroid, tuberculosis of, 595

  Chromicized gut, 247

  Chromocystoscopy, 958

  Chylocele, 372

  Chylothorax, 735

  Chylous ascites, 368
    fistula, 368
    hydrocele, 372
    hydrothorax, 368

  Chyluria, 373

  Cicatrices, horns growing from, 283

  Cicatricial keloid, 70

  Ciliary body, diseases of, 598

  Circumcision, 1010

  Circumflex artery, ligation of, 359

  Cirrhosis of pancreas, 950

  Cirsoid aneurysm, 278, 339, 344

  Clap, 146. _See_ Gonorrhea.
    bastard, 148

  Clavi, 311

  Clavicle, dislocations of, 529
      congenital, 718
      treatment of, 529
    fractures of, 493
      treatment of, 493

  Cleft palate, 652
    operation for, 654

  Clitoris, hypertrophy of, 1007

  Clove hitch knot, 241

  Club-foot, 465
    congenital, 466
      treatment of, 466

  Coagulation necrosis, 57

  Cocaine, 205

  Cocainization, intraspinal, 207

  Coccidioidal granuloma, 309

  Coccodynia, 636

  Coccygeal sinus, 635
    tumors, 627
      congenital, 635

  Coccygodynia, 636

  Cohnheim’s embryonal hypothesis of cause of tumors, 256

  Cold abscess, 112
      diagnosis of, 113
      lumbar, 114
      peri-articular, treatment of, 399
      psoas, 114
      retropharyngeal, 114
      treatment of, 114

  Colic, biliary, 922
      diagnosis of, 925
      symptoms of, 924
      treatment of, 926
    renal, 964
      treatment of, 964

  Colitis, diagnosis of, from appendicitis, 857

  Collapse, 177

  Collar-button abscess, 319

  Colles’ fracture, 503
      treatment of, 504
    law in syphilis, 139

  Colloid goitre, 713

  Coloboma, 600

  Colon bacillus, 53
    syphilis of, 869
    tuberculosis of, 869

  Colopexy, 850

  Colostomy, 874, 888

  Coma carcinomatosum, 82

  Compression apoplexies, 560
    of brain, 560
      prognosis of, 562
      symptoms of, 561
      treatment of, 562

  Concussion of brain, 559
      treatment of, 559
    of chest, 721
      treatment of, 722
    of spine, 628
      treatment of, 629

  Condyles, fracture of, 498

  Condylomas, 282, 312

  Congenital abnormalities of testicle, 1014
    adenoma of kidney, 969
    affections of thyroid, 710
    anomalies and defects of kidneys, 955
      of intestines, large, 869
        small, 822
      of neck, 698
      of pancreas, 944
      of spleen, 940
      of ureters, 955
    coccygeal tumors, 635
    conditions of skull, 547
    cysts of abdominal wall, 783
      of brain, 578
    defects of anus, 872
      of diaphragm, 752
      of lips, 638
      of mouth, 652
      of penis, 1004
      of rectum, 872
    dislocations, 526
      of hip, 471
        diagnosis of, 473
        treatment of, 474
    displacements of liver, 910
    hernia, 890
      diaphragmatic, 897
      inguinal, 897
    hypertrophy, definition of, 26
    lymphangioma of ear, 606
    macroglossia, 652
    malformations of bladder, 977
      of ear, 604
      of esophagus, 737
        treatment of, 738
      of respiratory passages, 671
      of stomach, 793
      of thorax, 718
    occlusion of lymph vessels, 369
    rickets, 161
    tumors of scalp, 546
    varices, 364
    venous nevus, 367

  Congestion, 19
    neuroparalytic, 20
    neurotonic, 20
    results of, 22
      acute swelling, 22
      chronic swelling, 22
      gangrene, 22
      nutritional changes, 23
      resolution, 22
    treatment of, 23

  Conical stump, definition of, 27

  Conjunctival sac, diphtheria of, 599
      gonorrhea of, 599

  Continuous suture, 241

  Contractures of muscles, 332
    treatment of, 332

  Contusions, 211
    of abdominal wall, 781
    of bloodvessels, 216
    of brain, 559
      symptoms of, 560
      treatment of, 560
    of breast, 756
    of chest, 721
      treatment of, 722
    of face, 639
    of muscles, 329
    of testicle, 1015
    treatment of, 212
    of viscera, 219

  Copremia, 83

  Coracoid process, fracture of, 495

  Cord, spermatic. _See_ Spermatic cord.
    spinal. _See_ Spinal cord.

  Cornea, diseases of, 598
    syphilis of, 137

  Corns, 311

  Corpora cavernosa, syphilis of, 138

  Corpus cavernosum, inflammation of, 1009

  Corrosive sublimate, toxic effects of, 175

  Counterirritation, 183
    by actual cautery, 184
    by rubefacients, 183
    by seton, 184
    by vesicants, 184

  Cowperitis, 150

  Coxa vara, 475
      diagnosis of, 476
      symptoms of, 476

  Coxitis, 452

  Cranial bones, acromegaly of, 548
      injuries of, 552
      leontiasis of, 548
      osteomyelitis of, 548
      periostitis of, 548
    meningoceles, 263
    nerves, injuries of, 612
    rickets, 547

  Craniectomy, 580

  Craniofacial sinuses, accessory, operations on, 608

  Craniotabes, 547
    rachitica, 162

  Craniotomy, 580

  Cranium, injuries of soft parts of, 551
    operations on, 587
    septic affections within, 567
        abscess of brain, 567
        encephalitis, 513
        leptomeningitis, 572
        meningitis, 571
        pachymeningitis externa, 572
          interna, 572
        sinus phlebitis, 571
          thrombosis, 570
    trephining of, 587
    wounds of, gunshot, 565
        treatment of, 565

  Crile’s pneumatic suit in shock, 180

  Croupous exudates, 23

  Crural nerve, anterior, operations on, 623

  Cryptogenetic septicemia, 87

  Cryptorchidism, 1014
    treatment of, 1014

  Cupping, 183

  Cutaneous horns, 283, 311
      growing from cicatrices, 283
      nail, 283
      sebaceous, 283
      treatment of, 311
      warty, 283
    myxoma, 276

  Cylindroma, 275
    of skin, 315

  Cystic degeneration, 264
      of testicle, 260
    kidney, 969

  Cysticercus, 310

  Cystinuria, 82

  Cystitis, 984
    gonorrheal, 151
    postoperative, 985
    symptoms of, 984
    treatment of, 985
    tuberculous, 985

  Cystoma, ovarian, 284

  Cystoscope, Nitze’s, 993

  Cystoscopic examination, 958, 977

  Cysts, 259
    of abdominal wall, congenital, 783
    apoplectic, 952
    of bladder, 992
    of brain, congenital, 578
    of breasts, 760
    degeneration, 264
    dermoid, 264
    glandular, 261
    hydatid, 263
    hydroceles, 261
    of iris, 594
    of liver, hydatid, 913
        treatment of, 913
    of lung, echinococcus, 732
      hydatid, 732
    lymph, 278
    of mesentery, 940
    of neck, 707
      atheromatous, 707
      bursal, 707
      dermoid, 707
      sanguineous, 701, 707
      thyrohyoid, 707
    neural, 263
    of omentum, 935
    of orbit, dermoid, 593
      parasitic, 593
    of pancreas, 951
      diagnosis of, 952
      symptoms of, 952
      treatment of, 952
    pseudo-, 262
    retention, 259
    sebaceous, 285
    of skin, 310
      atheromatous, 310
      echinococcus, 310
      sebaceous, 310
      treatment of, 310
    of spine, 627
    of spleen, 943
    of Stenson’s duct, 641
    of testicle, 1016
    of tongue, retention, 659
    tubulo, 260


  D

  DACRYO-ADENITIS, acute, 599

  Dacryocystitis, 600
    treatment of, 600

  Dacryopic cysts, 262

  Dactylitis, 136

  Dancer’s bone, 331

  Davey’s method of amputation of hip-joint, 1045

  Deciduoma malignum, 292

  Degeneration, cystic, 264

  Delhi boil, 309

  Delirium tremens, 174
      treatment of, 174

  Dental caries, 657, 664
      secondary infection in, 169
      treatment of, 665

  Dentigerous cysts, 666

  Dermatitis, blastomycetic, 309
    calorica, 299
      treatment of, 299
    of radio-active origin, 303

  Dermatolysis, 313

  Dermoid cyst of bladder, 992
      of neck, 707
      of omentum, 935
      of orbit, 593
      of scalp, 546
      of testicle, 1016
    tumors of cheek, 641
      of lung, 732

  Dermoids, 264
    ovarian, 267
    sequestration, 265
    tubulo, 266

  Desault’s bandage, 190

  Desmoids, 271
    treatment of, 271

  Diabetes a cause of gangrene, 74

  Diaphragm, congenital defects of, 752
    paralysis of, 753
    rupture of, 721, 753
      treatment of, 722
    tumors of, 753
    wounds of, 725, 753
      treatment of, 726

  Diaphragmatic hernia, 897
      acquired, 897
      congenital, 897

  Dieffenbach’s operation for blepharoplasty, 603

  Digital compression for control of hemorrhage, 235

  Dilatation of stomach, 793, 795
      acute, 795
        symptoms of, 796
        treatment of, 796
      chronic, 796
      operation for, 811

  Diphtheria, bacillus of, 54
    of conjunctival sac, 599
    of mouth, 657
    secondary infection in, 168

  Diphtheritic exudates, 23

  Diplococcus pneumoniæ, 53

  Disarticulations, 1023

  Dislocations, 524
    of ankle, 544
    of astragalus, 544
    of carpus, 536
    of clavicle, 529
      treatment of, 529
    complicated, 524
    compound, 524
    congenital, 524, 526
    diagnosis of, 525
    of elbow, 534
      treatment of, 536
    of fibula, 544
    of foot, 544
      treatment of, 544
    habitual, 524
    of hand, 536
    of hip, 537
      classification of, 537
      congenital, 471
        diagnosis of, 473
        treatment of, 474
      signs of, 538
      symptoms of, 538
      treatment of, 539
      unreduced, 542
    of jaw, 667
      lower, 527
        treatment of, 528
    of knee, 543
      symptoms of, 544
      treatment of, 544
    of larynx, 528
    of lens, 604
    metacarpophalangeal, 536
      treatment of, 537
    of nerves, 624
    of patella, 543
      treatment of, 543
    pathological, 524, 526
    of penis, 1008
    of radius, 536
    recurrent, 524
    of ribs, 529
    of semilunar cartilages, 543
    of shoulder-joint, 530
      anterior, 530
      diagnosis of, 532
      downward, 530
      posterior, 530
      subclavicular, 531
      subcoracoid, 531
      subglenoid, 531
      subspinous, 532
      symptoms of, 532
      treatment of, 532
        Kocher’s method, 533
      upward, 530
    of spine, 631
      treatment of, 632
    of sternum, 528
    symptoms of, 525
    of tendons, 330
    of tibia, 543
    traumatic, 524
    treatment of, 527
    of ulna, 536
    of wrist, 536

  Dissecting aneurysm, 339, 342

  Diverticulitis, 822

  Diverticulum, Meckel’s, 262, 822
    pharyngeal, 262
    vesical, 262

  Downes’ electrothermic clamp, 236

  Drainage tubes, sterilization of, 248

  Dressings, sterilization of, 247

  Duct carcinoma, 290
    salivary, fistulas of, 649
      foreign bodies in, 648
    thoracic, injuries to, 725
        treatment of, 726

  Duodenal ulcers, 825
      symptoms of, 825
      treatment of, 826

  Duodenostomy, 806

  Duodenotomy, 928

  Dupuytren’s contraction, 319
      treatment of, 320

  Dysenteric ulcers of intestines, 827

  Dysentery, secondary infection in, 166


  E

  EAR, auricles of, supernumerary, 605
    congenital malformations of, 604
    epithelioma of, 605
    external auditory canal, diseases of, 607
    foreign bodies in, 606
    keloid of, 605
    lymphangioma of, 606
    middle, diseases of, 607
    neoplasms of, 605
    overlapping, 605
    papilloma of, 605
    rodent ulcer of, 606
    syphilis of, 137
    tumors of, 605

  Ecchondroses, 272

  Echinococcus cyst of lung, 732
      of skin, 310

  Ectasine, 85

  Ecthyma, 132

  Ectopia of bladder, 978
      treatment of, 978

  Eczema of nipple, 316

  Edema, definition of, 22
    gangrene from, 73
    of glottis, 699
    of larynx, 683
    malignant, 75, 108
      bacillus of, 54
      definition of, 108
      postmortem appearances of, 108
      prognosis of, 108
      symptoms of, 108
      treatment of, 108

  Edematous ulcers, 67

  Effusion, definition of, 22

  Elbow, amputation of, 1031
    Charcot’s disease of, 390
    dislocations of, 534
      treatment of, 536
    excision of, 410

  Electroconductivity of urine, 959

  Electrothermic clamp, 236

  Elephantiasis, 370
    of hand, 370
    of leg, 370
    of penis, 370
    of scrotum, 371
    of vulva, 371

  Elongation of nerves, 612
    of uvula, 682

  Embolism, 38
    air, 38
    fat, 39
      prognosis of, 40
      symptoms of, 40
      treatment of, 40
    following abdominal operations, 784
    gangrene from, 73
    of mesenteric vessels, 938
    of veins, 363

  Embryonal adenosarcoma, 268
    hypothesis of the cause of tumors, 256

  Emphysema, gangrenous, 75, 108

  Emprosthotonos, 100

  Empyema of appendix, 860
    definition of, 62
    of gall-bladder, 919
    of lung, 736

  Encephalitis, 573

  Encephalocele, 576
    of orbit, 593

  Encysted hydrocele of testicle, 260, 261

  Endarteritis, 338

  Endocarditis, secondary infection in, 169
    ulcerative, in septicemia, 88

  Endoscope, use of, 158

  Endothelioma, 274
    of abdominal wall, 784
    of jaw, 668
    of liver, 914
    of lung, 732
    of orbit, 593
    of thyroid, 712

  Endotracheal goitre, 713

  Enterocele, 892

  Enterocolitis, diagnosis of, from appendicitis, 857

  Enteroplication, 850

  Enteroptosis, 967

  Enterosepsis, 83

  Enterostomy, 789, 849

  Entropion, 601

  Enucleation of globe of eye, 596

  Eosinophilia, 30

  Epicanthis, 600

  Epidermoids, 264

  Epididymitis, 151, 1016
    treatment of, 1017

  Epigastric artery, ligation of, 359

  Epiglottis, diseases and injuries of, 683

  Epilepsy, Jacksonian, 581
    treatment of, 581

  Epiphysitis, acute, 421

  Epiplocele, 892

  Epispadias, 1005
    balanic, 1005
    penile, 1005

  Epistaxis, 680
    treatment of, 681

  Epithelial molluscum, 312
    odontomas, 281

  Epithelioma, 286
    of abdominal wall, 784
    diagnosis of, from tuberculosis, 293
    of ear, 605
    of face, 640
    of jaw, 668
    of larynx, 687
    lymph nodes in, 286
    malignant chorion, 292
    microscopic appearances of, 285
    of orbit, 593
    of penis, 1010
    seats of, 286
    of skin, 315
      diagnosis of, 315
      treatment of, 315
    suprarenal, 292
    of tongue, 660
      treatment, 660

  Epulis, 270, 668

  Equinia, 105. _See_ Glanders.

  Erectile tumors, 277

  Erethistic ulcers, 66

  Eruptions in septicemia, 88

  Erysipelas, 93
    of abdominal wall, 783
    definition of, 93, 94
    diagnosis of, 95
    epidemic form, 93
    etiology of, 93
    idiopathic, 93, 94
    of mouth, 657
    organism relation to streptococcus, 93
    pathology of, 93
    phlegmonous, 75, 93
    postmortem appearances of, 95
    prognosis of, 95
    of scalp, 545
    symptoms of, 94
    toxin in treatment of carcinoma, 296
    traumatic, 93, 94
    treatment of, 95
    wandering, 94

  Erysipelatous laryngitis, 95
    pneumonia, 95

  Erythroblasts, definition of, 29

  Esmarch’s bandage, 234

  Esophageal bougies, 743
    hemorrhoids, 365
    snare, 740

  Esophagectomy, 745

  Esophagismus, 742

  Esophagoscope, 740

  Esophagotomy, 745

  Esophagus, anatomy of, 737
    cancer of, 744
    diverticula of, 737
    externalization of, 746
    foreign bodies in, 739
        treatment of, 740
    hemorrhage of, 744
    malformations of, 737
    operations on, 745
    perforation of, 742
    resection of, transthoracic, 745
    rupture of, 741
    stricture of, 742
    wounds of, 741

  Esthiomene, 876

  Estländer’s cheiloplastic operation, 648

  Ether, 193
    accidents from, 194
    action of, 194
    administration of, 195
    narcosis by rectum, 196
    petroleum, 199

  Ethmoidal sinus, operations on, 610

  Ethyl bromide, 198
    chloride, 199
      local use of, 199

  Eucaine, 207

  Excision of ankle, 414
    of elbow, 410
    of fingers, 412
    of foot, 415
    of hand, 412
    of heel, 414
    of hip, 412
    of joints, 407
    of knee, 413
    of shoulder, 409
    of wrist, 411

  Exophthalmic goitre, 713
      treatment of, 714

  Exophthalmos, 594
    treatment of, 594

  Exostoses, 272
    of bone, 441

  Exstrophy of bladder, 978
      treatment of, 978

  Extragenital chancre, 127, 145

  Extravasation of blood, gangrene from, 73

  Exudates, 23
    croupous, 23
    difference between hyperemic and inflammatory, 23
    diphtheritic, 23
    fibrinous, 23
    interstitial, 23
    mixed, 23
    mucous, 23
    parenchymatous, 23
    serous, 23

  Eye, accommodation of, defects of, 604
    globe of, enucleation of, 596
    muscles of, defects of, 604
    nerves of, disturbances of, 604
    sclerotic of, rupture of, 604
    syphilis of, 136, 597

  Eyeball, injuries of, 603
      treatment of, 604

  Eyelids, blepharitis, 601
      marginalis, 601
    chalazion, 601
    coloboma, 600
    ectropion, 602
      Arlt’s operation for, 602
      Dieffenbach’s operation for, 603
      Fricke’s operation for, 603
      Richet’s operation for, 603
    entropion, 601
    epicanthis, 600
    hordeolum, 600
    stye of, 600
    trichiasis, 601
    xanthelasma, 601


  F

  FACE, absence of, 638
    actinomycosis of, 640
    arteries of, ligation of, 352
    burns of, 639
    contusions of, 639
    epithelioma of, 640
    gangrene of, 640
    malformations of, acquired, 639
    nerves of, injuries of, 640
    operations on, 642
    syphilis of, 640
    tuberculosis of, 640
    tumors of, 641
    ulcers of, 640
    wounds of, 229, 639

  Facial artery, ligation of, 352
    bones, fractures of, 489
    nerve, operations on, 616
    neuralgia, 640
    palsy, neuro-anastomosis for, 616
    paralysis, 640

  Facultative pyogenic organisms, 53

  Farcy, 105. _See_ Glanders.

  Fasciæ, contraction of, 319
      treatment of, 320

  Fat embolism, 39
      prognosis of, 40
      symptoms of, 40
      treatment of, 40

  Fatty degeneration of arteries, 339
      of veins, 361

  Fecal fistula, 839
    impaction, intestinal obstruction from, 832

  Feet, arthritis deformans of, 388

  Fehleisen’s coccus, 93

  Felon, 328

  Femoral artery, aneurysm of, 346
      ligation of, 359
    hernia, 895
      treatment of, 908

  Femur, fractures of, 509
      diagnosis of, 511
      lower end, 513
          treatment of, 513
      prognosis of, 511
      shaft, 513
      treatment of, 512

  Fencer’s bone, 331

  Fetal infection, 48
    rickets, 181, 433

  Fibrin, 28

  Fibrinoplastic tuberculous peritonitis, 791

  Fibrinous exudates, 23

  Fibro-adenoma, 284

  Fibro-epithelioma, 282

  Fibrokeratomas, 311

  Fibroma, 269
    of abdominal wall, 784
    of bladder, 992
    of bone, 438
    of breast, 760
    desmoids, 271
    epulis, 270
    of jaw, 668
    keloid, 270
    of liver, 914
    molluscum, 313
      treatment of, 313
    of nasopharynx, 679
    of nerves, 622
    psammoma, 271
    of testicle, 1017
    of thorax, 729

  Fibrous odontomas, 281

  Fibula, dislocations of, 544
    fractures of, 519
      treatment of, 521

  Figure-of-8-bandage of leg, 189

  Filaria medinensis, 309

  Filiform warts, 311

  Finger, amputation of, 1029
    excision of, 412
    trigger, 320
      treatment of, 320

  Finney’s pyloroplasty, 810

  Finsen light in treatment of cancer, 296

  Fissured ulcers, 66

  Fissures in ano, 876

  Fistula, 63
    causes of, 63
      congenital, 63
      foreign bodies, 63
      necrosed material, 63
      preëxisting abscess, 63
      traumatic destruction of tissue, 63
    chylous, 368
    definition of, 63
    fecal, 839
    lacrymal, 600
    treatment of, 63

  Fistulas, biliary, 917
    gastric, 801
    of lips, 638
    perineal, 1013
      treatment of, 1013
    rectal, 880
      treatment of, 880
    of salivary ducts, 649

  Fistulous ulcers, 66

  Flat-foot, 468

  Floating liver, 910
      symptoms of, 910
      treatment of, 911

  Follicular odontomas, 281
      compound, 281

  Folliculitis, 149, 307, 1013

  Foot, amputation of, 1037, 1041
      Bruns’ method, 1042
      partial, 1034
      Teale’s method, 1042
    club-, 465
      congenital, 466
        treatment of, 466
    dislocations of, 544
      treatment of, 544
    excision of, 415
    flat-, 468
    fractures of, 523
    Madura, 110
      treatment of, 110
    ulcer of, perforating, 66, 310

  Forearm, amputation of, 1031
    fractures of, 501
      treatment of, 501

  Foreign bodies in abdomen, 783
      in bladder, 982
      in blood, 35
      in brain, 565
      in esophagus, 739
        treatment of, 740
      in knee-joint, 402
      in pharynx, 673
        treatment of, 673
      in rectum, 874
      in respiratory passages, 672
      in salivary ducts, 648
      in stomach, 794
        operations for, 806
        symptoms of, 794
        treatment of, 794
      in tonsils, 663
      in urethra, 1009

  Formalin gut, 247

  Fractures, 479
    Bennett’s, 506
    of clavicle, 493
      treatment of, 493
    Colles’, 503
      treatment of, 504
    comminuted, 479
    complete, 479
    compound, 480
      treatment of, 487
    delayed union in, 485
    dentated, 479
    depressed, 479
    diagnosis of, 481
      by fluoroscope, 482
      by skiagram, 482
    extra-articular, 479
    of facial bones, 489
    of femur, 509
      diagnosis of, 511
      prognosis of, 511
    of fibula, 519
      treatment of, 521
    fissure, 479
    of foot, 523
    of forearm, 501
      treatment of, 501
    green-stick, 479
    gunshot, 480
    of hand, 507
    of humerus, 495
      condyles of, 498
        external, 499
        internal, 499
      epicondyles of, 497
      intercondyloid, 499
      shaft of, 496
      supracondyloid, 497
      surgical neck of, 496
      treatment of, 495
    of hyoid, 491
    impacted, 479
    incomplete, 479
    intra-articular, 479, 482
      -uterine, 481
    of larynx, 491, 676
    of leg, 518
      treatment of, 521
    longitudinal, 479
    of malar, 489
    of maxilla, inferior, 490
        treatment of, 490
      superior, 489
    multiple, 479
    non-union in, 485
    of nose, 489
    oblique, 479
    of olecranon, 501
    partial, 479
    of patella, 516
      treatment of, 517
    pathological, 479
    of pelvis, 507
      treatment of, 508
    of penis, 1008
    of radius, 502
      lower end of, 503
          treatment of, 504
      and ulna, 503
    repair of, 483
    ribs, 491
      symptoms of, 492
      treatment of, 492
    of scapula, 494
      acromion process of, 494
      coracoid process of, 495
      surgical neck of, 495
    single, 479
    of skull, 549, 552
      base of, 556
        diagnosis of, 557
        prognosis of, 557
        treatment of, 558
      vertex of, 552
        comminuted, 552
        diagnosis of, 554
        gunshot, 553
        splintered, 552
        treatment of, 555
    of spine, 629
    spiral, 479
    spontaneous, 434
    of sternum, 491
      symptoms of, 492
      treatment of, 492
    of thigh, 509
    of tibia, 518
      treatment of, 521
    transverse, 479
    traumatic, 479
    treatment of, 486
    of ulna, 501
      treatment of, 501
    of wrist, 507
    of zygoma, 489

  Frambœsia, 308

  Frank’s method of gastrostomy, 807

  Fricke’s operation for blepharoplasty, 603

  Friedländer, bacillus of, 54

  Frontal abscess, 569
    sinus, operations on, 609

  Frostbite, 302, 639
    gangrene from, 73
    treatment of, 302

  Fungi, 55
    actinomycis, 55
    aspergillus, 56
    leptothrix, 56
    Madura foot, 56

  Fungous granulations in tuberculosis, 115
    hematodes, 276
    ulcers, 66

  Funicular hernia, 891
    hydrocele, 261

  Furuncle, 304
    definition of, 60
    treatment of, 304

  Fusiform aneurysm, 339, 343


  G

  GALACTOCELE, 760

  Gall-bladder, anatomy of, 915
    cancer of, 927
    empyema of, 919
    fistulas of, 917
    hour-glass, 916
    malformations of, 916
    operations on, 927
      after management of, 932
      anastomotic, 932
    tumors of, 927

  Gall-ducts, operations on, 928

  Gallstones, 922
    diagnosis of, 925
    intestinal obstruction from, 833
    symptoms of, 924
    treatment of, 926

  Galoche chin, 638

  Ganglion, 327

  Gangræne oris, 75

  Gangrene, 22, 73
    angioneurotic, 76
    bed-sores a cause of, 74
    causes of, 73
      constitutional, 74
      infectious, 75
      local, 73
      traumatic, 73
    from chemical agents, 74
    from edema, 73
    from embolism, 73
    from frostbite, 73
    from extravasation of blood, 73
    from ligation of arteries, 73
    from thrombosis, 73
    from tumors, 74
    of face, 640
    foudroyante, 75, 108
    definition of, 73
    diabetic, 74
    dry, 76
    gazeuse, 108
    gross appearances of, 76
    hospital, 75
    of lung, 734
    moist, 76
      line of demarcation in, 76
    mummification in, 76
    noma, 75
    phagedenic, 77
    senile, 76
    signs of, 77
    of spleen, 941
    spontaneous, 76
    symmetrical, 74, 76
    symptoms of, 77
    of tongue, 659
    treatment of, 77
    visceral, 76

  Gangrenous cellulitis of abdominal wall, 783
    cholecystitis, 920
    emphysema, 75, 108
    pancreatitis, 946
    septicemia, 108
    stomatitis, 75, 658

  Gaspard, putrid fever of, 81

  Gasserian ganglion, operations on, 614

  Gastrectasis, 796

  Gastrectomy, 813

  Gastric anastomosis, 816
    dilatation, 793, 795
    fistulas, 801
      intra-abdominal, 801
    tetany, 798
    ulcer, 799
      diagnosis of, from appendicitis, 857
      operations for, 811
      symptoms of, 800
      treatment of, 800

  Gastritis, phlegmonous, 804
      symptoms of, 804
      treatment of, 805

  Gastro-enterostomy, 799, 811, 817

  Gastrojejunostomy, 816

  Gastropexy, 797, 811

  Gastroplication, 811

  Gastroptosis, 793, 797
    Rovsing’s operation for, 813
    treatment of, 797

  Gastrorrhaphy, 806

  Gastrostomy, 806
    Frank’s method, 807
    Witzel’s method, 807

  Gastrotomy, 794, 806

  Genitalia, chancroid of, 144
    syphilis of, 138

  Genito-urinary tract, infection through, 49

  Genu valgum, 463
    varum, 463

  Giant-cell sarcoma, 274

  Gigli saw, 588

  Gila monster, poisoning by, 172

  Gingivitis, interstitial, 657
    ulcerative, 664

  Glanders, 105, 308
    diagnosis of, 106
    etiology of, 105
    incubation in, 105
    organism of, 105
    prognosis of, 106
    symptoms of, 105
    treatment of, 106

  Glands, salivary, inflammation of, 649
      tumors of, 650

  Glandular cysts, 261, 284

  Glaucoma, 597
    treatment of, 597

  Gleet, 155. _See_ Gonorrhea,
    chronic.

  Glioma, 279
    of retina, 595

  Glossitis, 658

  Glottis, edema of, 699

  Gluteal hernia, 897

  Glycogen in blood, 33

  Glycosuria, 945
    a cause of gangrene, 74

  Goitre, 283, 712
    colloid, 713
    endotracheal, 713
    exophthalmic, 713
      treatment of, 714
    malignant, 715

  Gonococcus myositis, 331
    pyemia, 152
    septicemia, 152
    tendovaginitis, 331

  Gonorrhea, 146
    chronic, 155
      treatment of, 156
    classification of, 148
    complications of, 149
      balanitis, 149
      Cowperitis, 150
      cystitis, 151
      epididymitis, 151
      folliculitis, 149
      gonorrheal rheumatism, 152
      lymphangitis, 151
      peri-urethritis, 149
      postgonorrheal arthritis, 152
      prostatitis, 150
      treatment of, 152
    of conjunctival sac, 599
    course of, 149
    diagnosis of, 147
    of joints, 392
    of lymph nodes, 376
    secondary infection in, 169
    of seminal vesicles, 1021
    of testicles, 151
      treatment of, 151
    treatment of, 152
    in women, 158
      treatment of, 159

  Gonorrheal proctitis, 875
    rheumatism, 152
    synovitis, 385

  Grafting of nerves, 612
    of tendons, 324

  Granny knot, 241

  Granulation tissue, relation of, to infection, 96

  Granuloma, coccidioidal, 309
    of thorax, 729

  Graves’ disease, 713

  Gritti’s method of amputation of knee, 1044

  Groin, spica bandage of, 189

  Guinea worm, 309

  Gumma of penis, 1009
    of syphilis, 133

  Gummas of tuberculosis, 114

  Gummatous syphilide, 134

  Gums, retrocession of, 657

  Gunshot wounds, 220
      of abdomen, 232
      of bladder, 233
      of chest, 722
      diagnosis of, 225
      of face, 229
      foreign material in, 224
      of head, 228, 565
        treatment of, 565
      of heart, 231
      hemorrhage from, 223
      of joints, 228
      key-hole, 225
      of kidney, 233
      localizing symptoms, 223
      multiple, 224
      of neck, 229
      pain from, 223
      prognosis of, 225
      of respiratory passages, 675
      shock from, 223
      of small intestines, 823
      of spinal column, 230
      of spleen, 233
      of thorax, 230
      treatment of, 225


  H

  HALL’S, MARSHALL, method of artificial respiration, 204

  Halstead’s operation for cancer of breast, 766
      for hernia, 904

  Hammer-toe, 321
    treatment of, 321

  Hand, amputation of, 1031
    arthritis deformans of, 388
    dislocations of, 536
    elephantiasis of, 370
    excision of, 412
    fractures of, 407

  Hands, sterilization of, 245

  Harcourt inhaler, 197

  Hare-lip, 638
    operation for, 645

  Head, arteries of ligation of, 352
    injuries of, 545
      previous and during birth, 549
        caput succedaneum, 549
        cephalhematoma neonatorum, 549
        depression of skull, 549
        fractures, 549
    surgical diseases of, 545
    wounds of, gunshot, 228, 565
      treatment of, 565

  Heart, aneurysms of, 732
    carcinoma of, 336
    malposition of, 334
    rupture of, 336, 732
    surgical diseases of, 334
    tumors of, 336
    wall of, abscess of, 733
    wounds of, 334, 733
      gunshot, 231
      suture of, 335 (note),
      treatment of, 335

  Heel, excision of, 414

  Hematoma of scalp, 218
    of testicle, 1015

  Hematorrhachis, 625, 634
    treatment of, 634

  Hematomyelia, 625, 634
    treatment of, 634

  Hematuria, 959
    treatment of, 959

  Hemiglossitis, 659

  Hemoglobin, 33

  Hemorrhage after abdominal operations, 780
    from breast, 755
    control of, 234
      in amputations, 1024
      by angiotribe, 236
      by chemical agents, 235
      by cold, 235
      by destructive methods, 236
      by digital compression, 235
      by elastic bandage, 234
      by electrothermic clamp, 236
      by forced flexion, 235
      by gelatin, 235
      by heat, 235
      by ligature, 236
      by hemostats, 236
      by mechanical means, 236
      by pressure, 235
      by styptics, 235
      by torsion, 236
      by tourniquet, 234
    of esophagus, 744
    from gunshot wounds, 223
    intracranial, 563
    intra-ocular, 604
    intra-orbital, 592
    of larynx, 683
    secondary, 237
      signs of, 237
      treatment of, 237
    of spinal cord, 625, 634
    subdural, 564
    traumatic intraventricular, 564

  Hemorrhagic pancreatitis, 946
    ulcers, 66
      treatment of, 72

  Hemorrhoidal veins, phlebitis of, 362

  Hemorrhoids, 364, 882
    esophageal, 365
    treatment of, 883

  Hemostats, control of hemorrhage by, 236

  Hemothorax, 736

  Hepatic abscess, 911
      symptoms of, 912
      treatment of, 912

  Hepaticostomy, 928

  Hepaticotomy, 928

  Hepato-cholango-enterostomy, 932

  Hermaphrodism, 1007

  Hernia, 890
    acquired, 890
    causes of, 890
    cerebri, 566
      prognosis of, 566
      treatment of, 566
    classification of, 890
    congenital, 890
    diaphragmatic, 897
      acquired, 897
      congenital, 897
    femoral, 895
      treatment of, 908
    funiculi umbilicalis, 896
    funicular, 891
    gluteal, 897
    incarceration of, 892
    infantile, 891
    inflamed, 892
    inguinal, 893
      congenital, 894
      direct, 893
      indirect, 893
      treatment of, 908
    inguinoproperitoneal, 898
    interstitial, 898
    ischiatic, 897
    Littre’s, 898
    lumbar, 897
    of lung, 725
    of muscles, 330
    obturator, 897
    ovarian, 897
    pelvic, 897
    perineal, 897
    postoperative, 896
      treatment of, 909
    properitoneal, 891, 897
    reducibility of, 892
    retroperitoneal, 891, 897
    Richter’s, 898
    scrotal, 895
    signs of, 892
    strangulated, diagnosis of, from appendicitis, 858
      intestinal obstruction from, 829
    strangulation of, 892
    symptoms of, 893
    taxis in, 899
    traumatic, 890
    treatment of, 898
      Bassini’s operation, 902
      Halsted’s operation, 904
      Kocher’s operation, 904
      McArthur’s operation, 904
      Park’s operation, 905
      radical cure, 901
    umbilical, 896
      treatment of, 909
    varieties of, 893
    ventral, 896
      treatment of, 909

  Hernial aneurysm, 339

  Herpes, diagnosis of, from chancroid, 145
    preputialis, 1009
    zoster, 728

  Heteroplasty, 602

  Highmore, antrum of, operations on, 611

  Hip, ankylosis of, 404
    caries of, 452
      diagnosis of, 454
      prognosis of, 454
      symptoms of, 453
        muscle atrophy, 453
          spasm, 453
        pain, 453
      treatment of, 454
    dislocations of, 537
      classification of, 537
      congenital, 471
        diagnosis of, 473
        treatment of, 474
      signs of, 538
      symptoms of, 538
      treatment of, 539
      unreduced, 542
    excision of, 412
    -joint, amputation of, 1045
      Davey’s method, 1045
      McBurney’s method, 1045
      Woodbury’s method, 1045
      Wyeth’s method, 1045
    tuberculosis of, 424

  Hodgen suspension splint, 515

  Hodgkin’s disease, 376
      diagnosis of, 377
      symptoms of, 377
      treatment of, 378

  Hordeolum, 600

  Hornets, poisoning by, 172

  Hour-glass gall-bladder, 916
    stomach, 793

  Housemaid’s knee, 333

  Howard’s method of artificial respiration, 204

  Hueter’s incision in excision of elbow, 410

  Humerus, fractures of, 495
      condyles of, 498
        external, 499
        internal, 499
      epicondyles of, 497
      intercondyloid, 499
      shafts of, 496
      supracondyloid, 497
      surgical neck of, 496
      treatment of, 495

  Hunterian chancre, 127

  Hunter’s method of treating aneurysm, 347

  Hutchinson’s teeth, 140

  Hydatid cysts, 263
      of liver, 913
        treatment of, 913
      of lung, 732
      of omentum, 935
      of spleen, 943
    disease of bone, 432
        treatment of, 432

  Hydatidiform mole, 292

  Hydramnios, 263

  Hydrarthrosis, 386

  Hydrencephaloceles, 577

  Hydroceles, 261, 1018
    of canal of Nuck, 261
    chylous, 372
    of cord, 261
    encysted, of spermatic cord, 1019
      of testicle, 260
    funicular, 261
    of neck, 261
    ovarian, 261
    treatment of, 1018

  Hydrocephalus, 263, 578
    meningeus or externus, 578
    prognosis of, 579
    in rickets, 162
    treatment of, 579
    ventriculorum or internus, 578

  Hydrocholecyst, 259

  Hydrometra, 259

  Hydronephrosis, 971
    treatment of, 973

  Hydrophobia, 102
    diagnosis of, 104
    dumb, 103
    furious form, 102
    incubation in, 103
    paralytic type of, 103
    postmortem changes in, 104
    symptoms of, 103
    treatment of, 104
    virus of, 102

  Hydrops, 333

  Hydrothionemia, 82

  Hydrothorax, 736
    chylous, 368

  Hygroma, 333

  Hyoid bone, fractures of, 491

  Hyperemia, 19
    active, 20
    of dilatation, 21
    of paralysis, 21
    passive, 21
    results of, 22
      acute swelling, 22
      chronic swelling, 22
      gangrene, 22
      nutritional changes, 23
      resolution, 22
    treatment of, 23

  Hyperinosis, 28

  Hypernephroma, 292, 970

  Hyperostoses of bone, 441

  Hyperplasia, definition of, 22, 25

  Hyperthyroidism, 713

  Hypertrophy, 25
    of bone, 422
    of breast, 756
    of clitoris, 1007
    congenital, 26
    of lips, 638
    pathological, 26
    physiological, 25
    of prostate, 995
      diagnosis of, 996
      symptoms of, 997
      treatment of, 998
    senile, 26
    of skin, 311
    of spleen, 941
    of thymus, 717, 751
    of thyroid, acute idiopathic, 711
      intra-uterine, 711
    of tonsils, chronic, 662
    of veins, 361

  Hypinosis, 28

  Hypodermoclysis, 186

  Hypognathy, 638

  Hypopyon, 62, 598

  Hypospadias, 1005
    balanic, 1005
    penile, 1005
    penoscrotal, 1005
    perineoscrotal, 1005

  Hypostatic inflammation, 47
    pneumonia, 21


  I

  IDIOPATHIC erysipelas, 93, 94
    hypertrophy of thyroid, 711
    pyemia, 91

  Ignipuncture, 184

  Ileus, 828

  Iliac artery, aneurysm of, 346
      common, ligation of, 356
      external, ligation of, 357
      internal, ligation of, 357

  Imperforate anus, 873
    rectum, 872

  Implantation dermoids, 266

  Incised wounds, 214
      of bloodvessels, 216

  Incontinence of urine, 982

  Indolent ulcer, 66

  Indurated ulcer, 67

  Infantile hernia, 891
    scorbutus, 161

  Infection, auto-, 79
    circumstances favoring, 46
        association of organisms, 46
        fetal infection, 48
        habits and environment, 47
        hereditary influence, 46
        local predisposition, 47
        preëxisting disease, 47
        virulence of organism, 46
    classification of, 50
      mixed, 51
      primary, 50
      pyogenic, 51
      secondary, 51
      terminal, 51
      tertiary, 51
    relation of granulation tissue to, 96
      of lymph nodes to, 96
    sources of, 48
      alimentary canal, 49
      from flies, 50
      from within system, 50
      from without, 50
      genito-urinary tract, 49
      milk in lacteals, 50
      mucous membranes, 48
      respiratory tract, 49
      skin, 48
      tonsils, 49

  Inflammation, 43
    ameboid movement of cells in, 43
    as cause of tumor, 256
    of bladder, 984
      symptoms of, 984
      treatment of, 985
    of breast, 756
    chemotaxis in, 44
    of corpus cavernosum, 1009
    diapedesis of leukocytes in, 43
    hypostatic, 47
    of iris, 598
    of jaw, 667
    of kidney, 956
    of larynx, 683
    leukocytic increase in, 44
    of mediastinum, 728
    opsonins in, 44
    of pancreas, 946
    phenomena of, 43
    of prostate, 994
    of rectum, 875
    of salivary glands, 649
    specific irritants in, 45
    of spleen, 941
    of stomach wall, 804
    of thymus, 717
    of tongue, 658
    of veins, 361

  Influenza, secondary infection in, 167

  Infra-orbital nerve, operation on, 613

  Infusion of blood, 185
      intravenous, 186

  Ingrowing toe-nail, 318

  Inguinal hernia, 893
      congenital, 894
      direct, 893
      indirect, 893
      treatment of, 908

  Inguinoproperitoneal hernia, 898

  Inhaler, Harcourt’s, 197

  Innominate artery, aneurysm of, 345
      ligation of, 350

  Insane, othematoma of, 605

  Insanity, traumatic, surgical treatment of, 582

  Instruments, sterilization of, 246

  Intercondyloid fracture of humerus, 499

  Intercostal neuralgia, 728

  Interrupted suture, 241

  Interscapularthoracic amputations, 1033

  Interstitial exudates, 23
    gingivitis, 657
    hernia, 898
    pancreatitis, 950

  Intestinal biliary fistulas, 917
    diverticula, 262, 822
    ulcers, diagnosis of, from appendicitis, 857

  Intestine, large, anomalies of, 869
      cancer of, 870
      obstruction of, 870
        from intussusception, 870
        from volvulus, 870
      stricture of, 870
      syphilis of, 869
      tuberculosis of, 869
    operation on, 840
      anastomotic, 842
      appendicostomy, 850
      colopexy, 850
      colostomy, 849
      enteroplication, 850
      enterostomy, 849
    small, 822
      actinomycosis of, 827
      cancer of, 828
        treatment of, 828
      malformations of, acquired, 823
        congenital, 822
      obstruction of, acute, 828
          from bands, 833
            fecal impaction, 832
            gallstones, 833
            intestinal loops, 834
            intussusception, 829
              causes of, 830
              symptoms of, 831
              treatment of, 832
            invagination, 829
            neoplasms, extrinsic, 833
              intrinsic, 833
          peritonitis, 833
          slits and apertures, 834
          strangulated hernias, 829
          strictures, 832
          volvulus, 832
        postoperative, 834
        symptoms of, 834
        treatment of, 836
        chronic, 838
          symptoms of, 838
          treatment of, 839
      stricture of, 827
        obstruction from, 832
        symptoms of, 828
        treatment of, 828
      syphilis of, 827
      tumors of, 828
      ulcers of, 825
        cancerous, 827
        duodenal, 825
          symptoms of, 825
          treatment of, 826
        dysenteric, 827
        tuberculous, 827
          symptoms of, 827
          treatment of, 827
        typhoidal, 826
          symptoms of, 826
          treatment of, 826
      wounds of, 823
        gunshot, 823
          symptoms of, 824
          treatment of, 824
    suture of, 840
      Lembert’s, 841
      Murphy button, 844

  Intoxications, acid, from anesthetics, 203
    acute, 174

  Intra-abdominal gastric fistulas, 801

  Intracanalicular adenofibroma, 285

  Intracranial aneurysm, 345
    development, defects of, treatment of, 580
    hemorrhage, 563
    suppurations, treatment of, 573
    tumors, 582
      symptoms of, 583
      treatment of, operative, 585
    vessels and sinuses, injuries of, 563
          aneurysms following, 564
          sources of, 563
          subdural hemorrhage, 564
          traumatic intraventricular hemorrhage, 564

  Intracystic villous papilloma, 282

  Intralaryngeal tumors, 686
      symptoms of, 687
      treatment of, 687

  Intramammary abscess, 757

  Intra-ocular hemorrhage, 604
      tumors, 594

  Intra-orbital hemorrhage, 592

  Intraspinal cocainization, 207
    hemorrhage, 634
    treatment of, 634

  Intratracheal tumors, 686

  Intra-uterine hypertrophy of thyroid, 711
    rickets, 432

  Intraventricular hemorrhage, traumatic, 564

  Intubation of larynx, 693

  Intussusception of intestines, large, 870
      small, 829

  Invagination, intestinal obstruction from, 829
    of rectum, 881
      treatment of, 882

  Iodine gut, 247
    reaction of blood, 33
    toxic effects of, 175

  Iodoform, toxic effects of, 175

  Iris, cysts of, 594
    inflammation of, 598

  Iritis, 598

  Irritation as cause of tumor, 255

  Ischiatic hernia, 897

  Ischiorectal abscess, 879, 1013

  Ivy poisoning, 173


  J

  JACKSONIAN epilepsy, surgical treatment of, 581

  Jarvis’ snare, 678

  Jaundice in appendicitis, 856

  Jaws, ankylosis of, 667
    dislocation of, 667
    inflammation of, 667
    lower, dislocations of, 527
        treatment of, 528
    operations on, 668
    osteomyelitis of, 667
    periostitis of, 667
    postgonorrheal arthritis of, 667
    synovitis of, acute, 667
    tumors of, 668

  Jejunum, peptic ulcer of, 816

  Joints, ankylosis of, 403
      treatment of, 405
    arthritis of, 382
      chronic, 386
        treatment of, 386
      gonorrheal, 392
      osteo-, 387
        treatment of, 389
      postgonorrheal, 392
      syphilitic, 385
      tuberculous, 393
        diagnosis of, 398
        pathology of, 394
        symptoms of, 397
        treatment of, 398
    diseases of, arthropathic, 394
      neuropathic, 389
        diagnosis of, 392
        treatment of, 392
      osteopathic, 394
      surgical, 379
    excision of, 407
      of ankle, 414
      of elbow, 410
      of fingers, 412
      of foot, 415
      of hand, 412
      of heel, 414
      of hip, 412
      of knee, 413
      of shoulder, 409
      of wrist, 411
    hysterical, 392
      treatment of, 392
    inflammation of, 382
    injuries to, 380
    knee-, foreign bodies in, 402
    movable bodies in, 401
        diagnosis of, 402
        symptoms of, 401
        treatment of, 402
    pannus of, 395
    scrofula of, 393
    sprains of, 380
      symptoms of, 380
      treatment of, 380
    synovitis of, 382
      acute, 383
        treatment of, 383
      chronic, 386
        treatment of, 386
      dry, 383
      gonorrheal, 385
      purulent, 383
        symptoms of, 383
        treatment of, 385
      treatment of, 385
    syphilis of, 135
    wounds of, gunshot, 228, 381
        amputation in, 381
        excision in, 381
      penetrating, 381


  K

  KAHLER’s disease of bone, 442

  Kangaroo tendons, sterilization of, 248

  Karyokinesis, 44

  Keel-shaped chest, 718

  Keller’s method of extirpating varicose veins, 366

  Keloid, 270, 312
    cicatricial, 70
    of ear, 605
    treatment of, 271, 313

  Keratosis of skin, 314
      treatment of, 314

  Key-hole wounds, 225

  Kidney, abscess of, 957
    absence of, 955
    actinomycosis of, 964
    adenoma of, 969
      congenital, 969
    anomalies of, 955
    calculi of, 965
      diagnosis of, 965
      symptoms of, 965
      treatment of, 966
    carcinoma of, 969
    cystic, 969
    decapsulation of, 960
    floating, diagnosis of, from appendicitis, 858
    hemorrhage from, 959
      treatment of, 959
    horseshoe, 955
    hydronephrosis of, 971
      treatment of, 973
    hypernephroma of, 970
    infection of, 956
    inflammations of, 956
    injuries to, 955
    movable and floating, 966
        symptoms of, 967
        treatment of, 967
    multicystic, 969
    operations on, 974
    pain in, 956
    polycystic, 969
    pus in, 961
      treatment of, 961
    pyohydronephrosis of, 972
    pyonephrosis of, 972
    sarcoma of, 969
    surgical, 956, 957
      symptoms of, 957
      treatment of, 957
    syphilis of, 138, 964
    tuberculosis of, 118, 961
      diagnosis of, 962
      symptoms of, 961
      treatment of, 963
    tumors of, 969
    wounds of, gunshot, 233

  Knee, amputation of, 1043
      Gritti’s method, 1044
      Sabanejeff’s method, 1044
      Stephen Smith’s method, 1043
    ankylosis of, 404
    arthritis deformans of, 388
    dislocations of, 543
      symptoms of, 544
      treatment of, 544
    excision of, 413
    housemaid’s, 333
    -joint, foreign bodies in, 402
      tuberculous disease of, 456
          treatment of, 456

  Knock-knee, 463
      treatment of, 464

  Knots, 242
    clove hitch, 241
    granny, 241
    reef, 241
    Staffordshire, 241

  Kocher’s operation for hernia, 904
      on tongue, 661
    treatment of dislocations of shoulder-joint, 533

  König’s cheiloplastic operation, 648
    incision for excision of ankle, 415

  Kyphosis, 444


  L

  LACERATIONS, 212
    of abdominal wall, 781
    of bladder, 981
    of bloodvessels, 216
    of brain substance, 564
        prognosis of, 564
        symptoms of, 565
    of lung, 721
      treatment of, 722
    of urethra, 1008

  Lacrymal fistula, 600
    tract, diseases of, 599

  Lacteals, milk in, infection through, 50

  Laminectomy, 636

  Langenbeck’s operation on tongue, 662

  Laparotomy, 773
    exploratory, 773

  Laryngeal phthisis, 684
    polypi, 686

  Laryngectomy, 689

  Laryngismus stridulus, 164
      in rickets, 162

  Laryngitis, erysipelatous, 95

  Laryngoceles, 707

  Larynx, chondritis of, 683
    dislocations of, 528
    edema of, 683
    epithelioma of, 687
    fracture of, 676
    hemorrhage of, 683
    inflammation of, 683
    intubation of, 693
    malformations of, 671
    operations on, 688
    papilloma of, 686
    perichondritis of, 683
    sarcoma of, 687
    strictures of, 684
      symptoms of, 684
      treatment of, 684
    syphilis of, 138, 686
      treatment of, 686
    tuberculosis of, 684
      treatment of, 685
    wounds of, 675
      treatment of, 675

  Leeching, 183

  Leg, amputations of, 1039
      Bier’s osteoplastic, 1028
      circular, 1041
      Pirogoff’s, 1040
    elephantiasis of, 370
    figure-of-8-bandage of, 189
    fractures of, 518
      treatment of, 521

  Leiomyoma, 277

  Lembert’s suture, 841

  Lens, dislocation of, 604

  Leontiasis, 438

  Leprosy, 308
    bacillus of, 54

  Leptomeningitis, 572
    diagnosis of, 573
    prognosis of, 573
    suppuration, 572
    symptoms of, 572
    traumatic basilar, 572
    treatment of, 753

  Leptothrix fungi, 56

  Leukemia, 32
    lymphatic, 32
    pseudo-, 32
    splenomedullary, 32

  Leukocytes, classification of, 30
    count, differential, 32
    definition of, 29
    diapedesis of, 43
    migration of, 43
    physical properties of, 40

  Leukocytosis in septicemia, 88

  Leukoderma, 131

  Leukokeratosis, 137

  Leukopenia, 30

  Leukoplakia, 137, 659
    treatment of, 659

  Ligation of arteries, 350
      abdominal aorta, 356
      axillary, 355
      brachial, 355
      carotid, common, 351
        external, 352
        internal, 352
      circumflex, 359
      epigastric, 359
      facial, 352
      femoral, 359
      gangrene from, 73
      iliac, common, 356
        external, 357
        internal, 357
      innominate, 350
      lingual, 352
      occipital, 352
      popliteal, 360
      radial, 356
      temporal, 352
      thyroid, inferior, 353
      tibial, anterior, 360
        posterior, 360
      ulnar, 356
      vertebral, 353

  Ligatures, 236
    fate of, 237

  Lingua plicata, 652

  Lingual artery, ligation of, 352
    nerve, operations on, 616

  Lipoma, 269
    of breast, 760
    dolorosa, 269
    subcutaneous, 269
    subserous, 269
    subsynovial, 269
    of testicle, 1017
    of thorax, 729

  Lips, absence of, 638
    congenital defects of, 638
    fistulas of, 638
    hypertrophy of, 638
    operations on, 645

  Liquid air, 205
      in treatment of cancer, 296

  Lister’s incisions in excision of wrist, 411

  Litholapaxy, 987, 988

  Lithotomy, 987, 988
    perineal, 990

  Lithotrity, 987

  Litigation spine, 628

  Littre’s hernia, 898

  Liver, abscess of, 911
      symptoms of, 912
      treatment of, 912
    actinomycosis of, 914
    adenoma of, 914
    aneurysms of, 914
    carcinoma of, 914
    congenital displacements of, 910
    cysts of, hydatid, 913
        treatment of, 913
    endothelioma of, 914
    fibroma of, 914
    floating, 910
      symptoms of, 910
      treatment of, 911
    injuries of, 911
    sarcoma of, 914
    syphilis of, 138, 914
    tumors of, 914
    wounds of, 911

  Lizards, poisoning by, 172

  Lock finger, 320
      treatment of, 320

  Lockjaw, 97. _See_ Tetanus.

  Lordosis, 461

  Ludwig’s angina, 658, 703

  Lumbar abscess, 114
    hernia, 897

  Lumpy jaw, 109

  Lungs abscess of, 734
    actinomycosis of, 732, 734
    carcinoma of, 732
    decortication of, 750
    dermoids of, 732
    echinococcus cysts of, 732
    empyema of, 736
    endothelioma of, 732
    gangrene of, 734
    hernia of, 735
    hydatid cysts of, 732
    laceration of, 721
    rupture of, 725
    sarcoma of, 732
    syphilitic gumma of, 732
    tumors of, 732
    wounds of, 724
      treatment of, 726

  Lupus vulgaris, 306

  Luxation, 524. _See_ Dislocations.

  Lymph cysts, 278
    nodes, 375
      arrangement of, 369
      carcinoma of, 376
      cervical, affections of, 705
          treatment of, 706
        syphilis of, 705
        tuberculosis of, 705
      gonorrhea of, 376
      in Hodgkin’s disease, 376
      injuries and diseases of, 368
      relation of, to infection, 96
      syphilis of, 376
      tuberculosis of, 376
      tumors of, 378
    vessels, arrangement of, 369
      injuries and diseases of, 368
      occlusion of, 369
        acquired, 369
        congenital, 369

  Lymphangiectasis, 370

  Lymphangioma, 278
    cavernous, 278
    circumscriptum, 374
      treatment of, 374
    of ear, congenital, 606
    lymph cysts, 278
    lymphatic nevus, 278
    of skin, 315
      treatment of, 315
    treatment of, 279

  Lymphangitis, 374
    chronic, 375
    gonorrheal, 151
    treatment of, 375

  Lymphatic chlorotic constitution, 163
    constitution, 163
    leukemia, 32
    nevus, 278

  Lymphatics, tuberculosis of, 116
    tumors of, 378

  Lymphatism, 163

  Lymphedema, 369

  Lymphocytosis, 30

  Lymphodermia perniciosa, 164

  Lymphoma, 378
    malignant, 32

  Lymphorrhagia, 372

  Lymphosarcoma, 273, 378

  Lyssophobia, 104


  M

  MCARTHUR’s operation for hernia, 904

  McBurney’s method of amputation of hip-joint, 1045
    point in appendicitis, 855

  Macrocheilia, 373, 638

  Macroglossia, 373, 660
    congenital, 652

  Macromelia, 373

  Macrostoma, 638

  Madura foot, 110, 309
      fungi, 56
      treatment of, 110

  Malar bones, fractures of, 489

  Malformations of anus, 872
    of bladder, 977
    of chin, 638
    of ears, congenital, 604
    of esophagus, acquired, 737
      congenital, 737
      treatment of, 738
    of face, acquired, 639
    of gall-bladder, 916
    of intestines, large, 869
      small, acquired, 823
        congenital, 822
    of larynx, 671
    of nasal septum, 671
    of nose, 676
    of nostrils, 671
    of pharynx, 671
    of rectum, 872
    of respiratory passages, acquired, 671
        congenital, 671
        treatment of, 671
    of soft palate, 671
    of sternum, 718
    of stomach, acquired, 793
      congenital, 793
    of teeth, 652
    of thorax, 718, 719
    of tongue, 652

  Malgaigne’s operation for hare-lip, 647

  Malignant edema, 108. _See_ Edema, malignant.
    pustule, 106. _See_ Anthrax.

  Mania, traumatic, 175

  Marasmic thrombosis, 36

  Mastitis, 756
    chronic, 757
      treatment of, 758

  Mastodynia, 758

  Mastoid disease, 574
    operation, 575

  Matas’ method of treating aneurysm, 348

  Maxilla, inferior, fractures of, 490
        treatment of, 490
    superior, fractures of, 489

  Maxillary sinus, operations on, 611

  Measles, secondary infection in, 167

  Meatotomy, 155

  Meckel’s diverticulum, 822

  Median nerve, operations on, 623

  Mediastinitis, 728
    treatment of, 728

  Mediotarsal amputation of Chopart, 1037

  Megaloblasts, definition of, 29

  Melanoma, 275
    of skin, 316
      treatment of, 317

  Melanosarcoma, 275

  Melon-seed bodies, 322

  Meningeal artery, middle, injuries of, 563

  Meningitis, 571
    treatment of, 572

  Meningocele, 576
    cranial, 263
    spinal, 625

  Meningomyelocele, 626

  Mercurial necrosis of bone, 428

  Mercury, toxic effects of, 175

  Mesarteritis, 338

  Mesenteric phlebitis, 362

  Mesentery, absence of, 939
    actinomycosis of, 939
    anatomy of, 937
    cancer of, 939
    cysts of, 940
    embolism of, 938
    injuries of, 938
    syphilis of, 939
    thrombosis of, 938
    tuberculosis of, 939
      treatment of, 939

  Metacarpophalangeal dislocations, 536
      treatment of, 537

  Metastasis, 91

  Metastatic abscess, 91
    osteomyelitis, 92

  Metatarsalgia, 470
    treatment of, 470

  Methylene bichloride, 198

  Microblasts, definition of, 29

  Micrococcus gonorrhœæ, 53
    lanceolatus, 53
    tetragenus, 53

  Microörganisms in blood, 35

  Microstoma, 638, 652

  Mikulicz’s disease, 650

  Milk in lacteals, infection through, 50
    leg, 362

  Milzbrand, 106. _See_ Anthrax.

  Molluscum contagiosum, 312

  Morphine, 205

  Morrison’s operation on omentum, 936

  Mortification, 73. _See_ Gangrene.

  Morton’s disease, 470
      treatment of, 470

  Mother’s marks, 367

  Mouth, absence of, 638
    actinomycosis of, 657
    bacteria of, 657
    blastomycetic lesions of, 658
    congenital defects of, 652
    diphtheria of, 657
    erysipelas of, 657
    injuries of, 658
    syphilis of, 657
    tuberculosis of, 657
    wounds of, 658

  Movable bodies in joints, 401
        diagnosis of, 402
        symptoms of, 401
        treatment of, 402

  Mucous membrane, infection through, 48
      syphilis of, 132
      tuberculosis of, 115
    polyp, 283

  Mulberry growths, 282

  Multicystic kidney, 969

  Mumps, secondary infection in, 168

  Murphy button, 820, 844

  Muscles, atrophies of, 332
      treatment of, 332
    contractures of, 332
      treatment of, 332
    contusions of, 329
    of eyes, defects of, 604
    hernia of, 330
    injuries of, 218
    myalgia, 330
      treatment of, 331
    myositis, 331
      calcificans, 331
      ossificans, 272, 331
      syphilitica, 136, 331
      tuberculosa, 331
    paralytic affections of, 332
      treatment of, 332
    parasitic affections of, 332
    rupture of, 329
      treatment of, 330
    sprains of, 329
    strains of, 329
    syphilis of, 136, 331
    tuberculosis of, 331
    wounds of, 330

  Musculospiral nerve, operations on, 623

  Myalgia, 330
    treatment of, 331

  Mycetoma, 309

  Mycosis fungoides, 308

  Mycotic phlebitis, 90

  Myeloid, 274

  Myeloma of bone, 442

  Myosarcoma, 274

  Myositis, 331
    calcificans, 331
    gonococcus of, 331
    ossificans, 272, 331
    syphilitica, 136, 331
    tuberculosa, 331

  Myotomy, 327

  Myxoma, 276
    of bladder, 992
    of bone, 441
    cutaneous, 276
    neuromyxoma, 276
    polypi, 276


  N

  NAIL horns, 283

  Naphthalin, toxic effects of, 175

  Nares, anterior, plugging of, 681

  Nasal cavities, neoplasms of, 677
        symptoms of, 678
        treatment of, 678
    deformities, 676
    polypi, 677
    septum, malformations of, 671
      submucous resection of, 677

  Nasopharynx, fibroma of, 679

  Neck, aneurysms of, 701
    canal of, hydrocele of, 261
    carbuncles of, 704
    congenital anomalies of, 698
        treatment of, 698
    cysts of, 707
      atheromatous, 707
      bursal, 707
      dermoid, 707
      sanguineous, 701, 707
      thyrohyoid, 707
    hydroceles of, 261
    injuries of, 698
    muscles of, injuries of, 700, 701
    nerves of, injuries of, 700, 701
    phlegmons of, 700, 703
      diagnosis of, 703
      treatment of, 703
    tumors of, 706
    veins of, wounds of, 700
    wounds of, 698
      air-embolism in, 699
      gunshot, 229

  Necrosis of bone, 428
      pathological, 428
      toxic, 428
        treatment of, 428
      traumatic, 428
    coagulation, 57
    of skull, 549

  Nephritis, chronic, treatment of, operative, 959
          indications for, 960
    septic, 956
      symptoms of, 957
      treatment of, 957

  Nephrolysis, 960

  Nélaton’s incision in excision of elbow, 410
    operation for hare-lip, 647

  Neoplasms of ear, 605
    intestinal obstruction from, 833
    of nasal cavities, 677
    of spleen, 943

  Nephralgia, 956

  Nephrectomy, 960, 974

  Nephrolithotomy, 966

  Nephropexy, 968

  Nephroptosis, 967

  Nephrotomy, 960

  Nervanin, 207

  Nerves, acoustic, neurofibroma of, 584
    anterior crural, operations on, 623
    brachial plexus, operations on, 623
    cervical plexus, deep posterior, operations on, 618
      sympathetic, operations on, 618
    cranial, injuries of, 612
    dislocation of, 624
    elongation of, 612
    of eye, disturbances of, 604
    of face, injuries of, 640
      operations on, 616
    fibroma of, 622
    fifth, operations on, 613
    Gasserian ganglion, operations on, 614
    grafting of, 612
    infra-orbital, operations on, 613
    injuries of, 217
    lingual operations on, 616
    median, operations on, 623
    musculospiral, operations on, 623
    optic, tumors of, 593
    peripheral, diseases and injuries of, 622
    radial, operations on, 623
    resection of, 613
    sciatic, great, operations on, 623
    seventh, operations on, 616
    spinal accessory, operations on, 617
    stretching of, 612
    supra-orbital, operations on, 613
    suture of, 612
    tibial, operations on, 623
    trunks, upper, injuries to, 725
    treatment of, 726
    tumors of, 622
    ulnar, operations on, 623
    wounds of, 612

  Nervous system, syphilis of, 138

  Nettle, stinging, poisoning by, 173

  Neural cysts, 263

  Neuralgia of breast, 758
      treatment of, 758
    facial, 640
    intercostal, 728

  Neurectomy, 612

  Neuro-anastomosis for facial palsy, 616

  Neurofibroma of acoustic nerve, 584
    of skin, 313

  Neuroma, 280
    amputation, 1047
    malignant, 280
    plexiform, 280, 622

  Neuromyxoma, 276

  Neuroparalytic congestion, 20

  Neurorrhaphy, 612

  Neurotonic congestion, 20

  Nevi of tongue, 659

  Nevus, 277
    lymphatic, 278
    pigmentosus, 314
    venous, 367
      congenital, 367

  Newborn, tetanus of, 97, 99

  Nipple, chancre of, 759
    eczema of, 316
    fissures of, 756
    Paget’s disease of, 316, 756

  Nitze’s cystoscope, 993

  Noma, 75, 658

  Normoblasts, definition of, 29

  Nose-bleed, 680
    calculi of, 672
    fractures of, 489
    malformations of, 676
    operations on, 644

  Nostrils, malformations of, 671


  O

  O’DWYER’s intubation tubes, 693

  Obligate pyogenic organisms, 52

  Obstruction of intestines, acute, 828
        from intussusception, 829
          causes of, 830
          symptoms of, 830
          treatment of, 831
        from invagination, 829
        from strangulated hernias, 829
        from volvulus, 832
    large intestines, 870

  Obstructive thrombosis, 36

  Obturator hernia, 897

  Occipital abscess, 569
    artery, ligation of, 352
    cephalocele, 576

  Occlusion of lymph vessels, 369
        acquired, 369
        congenital, 369

  Odontoma, 281
    cementoma, 281
    composite, 281
    epithelial, 281
    fibrous, 281
    follicular, 281
      compound, 281
    of jaw, 668
    radicular, 281
    of teeth, 665

  Oïdiomycosis, 310

  Oïdium albicans of thrush, 657

  Oiled silk, sterilization of, 248

  Olecranon, fractures of, 501

  Oligocythemia, 29

  Ollier’s incision in excision of elbow, 410
        of hip, 411
        of knee, 413
        of shoulder, 410
        of wrist, 411

  Omentopexy, 936

  Omentosplenopexy, 936

  Omentum, anatomy of, 934
    cysts of, 935
    injuries of, 935
    operations on, 936
    torsion of, 935
    tumors of, 935

  Onychia maligna, 318

  Operations, abdominal, 773
    on biliary passages, 927
    on breast, 764
    for cure of hernia, 901
    on esophagus, 745
    on face, 642
    on gall-bladder, 927
    on intestines, 840
    on jaws, 668
    on kidneys, 974
    on larynx, 688
    on lips, 645
    mastoid, 574
    on nose, 644
    on omentum, 936
    on prostate, 998
    on spine, 636
    on spleen, 943
    on stomach, 805
    thoracoplastic, 748
    on thorax, 746
    on tongue, 661
    on trachea, 691
    for tumors of brain, 585
    on ureters, 976

  Ophthalmitis, sympathetic, 595
      treatment of, 596

  Opisthotonos, 100

  Opsonins in inflammation, 44

  Optic nerve, tumors of, 593

  Orbit, aneurysms of, 592
    angioma of, 592
    cellulitis of, 592
    cysts of, dermoid, 593
      parasitic, 593
    encephalocele of, 593
    endothelioma of, 593
    epithelioma of, 593
    injuries of, 592
      treatment of, 593
    sarcoma of, 593
    syphilis of, 597
    tumors of, 593
      cystic, 593
      vascular, 593
    wounds of, 592

  Orchitis, 1017
    treatment of, 1017

  Oropharynx, syphilis of, 137

  Orthoform, 207

  Osseous system, surgical diseases of, 416

  Osteo-arthritis, 387
    treatment of, 389

  Osteo-arthropathic hypertrophiante pneumique, 436

  Osteogenesis imperfecta, 435

  Osteoma, 272
    of bone, 441
    of jaw, 668
    of skull, 548
    of thorax, 730

  Osteomalacia, 434
    prognosis of, 434
    treatment of, 435

  Osteomyelitis of abdominal wall, 783
    acute, 416, 548
      complications of, 419
      diagnosis of, 419
      etiology of, 419
      organisms at fault in, 417
      pathology of, 416
      prognosis of, 418
      symptoms of, 418
      treatment of, 419
    chronic, 421
      tuberculous, 423
    of jaw, 667
    latent, 421
    metastatic, 92

  Osteopathic joint disease, 394

  Osteoporosis, 422, 436
    adiposa, 416

  Osteopsathyrosis, 435

  Osteosarcoma, 274

  Osteosclerosis, 422

  Ostitis deformans, 436

  Othematoma of insane, 605
    traumatic, 605

  Otis’ dilating urethrotome, 157, 1012
    urethrometer, 1012

  Ovarian cystoma, 284
      glandular, 284
      papillary, 284
    dermoids, 267
    hernia, 897
    hydrocele, 261
    papilloma, 282

  Ovary, tuberculosis of, 118

  Overlapping ears, 605

  Ozena, 137, 671


  P

  PACHYDERMATOCELE, 313

  Pachymeningitis externa, 572
    interna, 572

  Paget’s disease of bones, 436
      of nipple, 316, 756

  Palate, cleft, operation for, 654
    soft, diseases and injuries of, 682

  Palsy, Bell’s, 640
    facial, neuro-anastomosis for, 616

  Palsies, cerebral, 478
      treatment of, 478

  Panarthritis, tuberculous, 395

  Pancreas, abscess of, 949
    adenocarcinoma of, 953
    adenoma of, 953
    affections of, acute, 946
      chronic, 950
        diagnosis of, 951
        treatment of, 951
    anomalies of, 944
    calculi of, 954
    cancer of, 953
    cirrhosis of, 950
    cysts of, 951
      diagnosis of, 952
      symptoms of, 952
      treatment of, 952
    injuries to, 947
    neoplasms of, 951
    non-traumatic surgical diseases of, 946
    sarcoma of, 953
    tumors of, 953

  Pancreatic cysts, 262

  Pancreatitis, acute, 946
      diagnosis of, 947
        from appendicitis, 858
      symptoms of, 947
      treatment of, 948
    chronic, 950
    gangrenous, 946
    hemorrhagic, 946
    interstitial, 950
    subacute, 949
      diagnosis of, 949
      symptoms of, 949
      treatment of, 950
    suppurative, 946

  Pannus of joints, 395

  Panophthalmitis, 595
    treatment of, 595

  Papillary cystoma, 284

  Papilloma, 282
    of bladder, 992
    cutaneous horns, 283
    of ear, 605
    of larynx, 686
    ovarian, 282
    of penis, 1009
    of tongue, 659
    treatment of, 283
    villous, 282
      intracystic, 282
    warts, 282

  Paracentesis, 184
    by aspiration, 184
    by incision, 185
    of pericardium, 336, 733
    by tapping, 185

  Paraffin cancer, 316

  Paralysis, diaphragmatic, 753
    facial, 640
    hyperemia of, 21
    of nerve of eye, 604

  Paralytic affections of muscles, 332
          treatment of, 332

  Paraphimosis, 1005

  Parasitic affections of muscles, 332
    cysts of orbit, 593
    diseases of bone, 432

  Parathyroids, diseases of, 710

  Parenchymatous exudates, 23

  Parietal abscess, 569
    thrombosis, 35

  Park’s club-foot brace, 469
    operation for hernia, 905

  Paroöphoritic cysts, 260

  Parovarian cysts, 260

  Patella, dislocations of, 543
      treatment of, 543
    fractures of, 516
      treatment of, 517

  Pelvic hernia, 897

  Pelvis, fractures of, 507
      treatment of, 508
    rachitic, deformities of, 162

  Penis, absence of, 1004
    amputation of, 1010
    balanitis of, 1005
    balanoposthitis, 1005
    congenital defects of, 1004
    dislocation of, 1008
    double, 1004
    elephantiasis of, 370
    epithelioma of, 1010
    fracture of, 1008
    gumma of, 1009
    herpes of, 1009
    injuries of, 1008
    misplacement of, 1004
    paraphimosis of, 1005
    phimosis of, 1004
    posthitis of, 1005
    warts of, 1009

  Peptic ulcer of jejunum, 816

  Perforating ulcer of foot, 310

  Perforations of biliary passages, 921
        symptoms of, 922
        treatment of, 922
    of esophagus, 742

  Peri-appendicular abscess, 860

  Peri-arteritis, 338

  Peri-articular cold abscess, treatment of, 399

  Pericanalicular adenofibroma, 285

  Pericarditis, 733

  Pericardium, cardicentesis of, 336
    paracentesis of, 336

  Perichondritis, 683

  Perigastritis, 804

  Perilaryngeal abscess, 704

  Perilymphangitis, 374

  Perineal abscess, 1013
      treatment of, 1013
    fistulas, 1013
      treatment of, 1013
    hernia, 897
    lithotomy, 990
    prostatectomy, 999

  Perinephritis, 961
    symptoms of, 961
    treatment of, 961

  Periostitis, acute, 548
      infectious, 420
        causes of, 421
        treatment of, 421
    albuminosa, 421
    of jaw, 667

  Peripheral nerves, diseases and injuries of, 622

  Perirectal abscess, 879
    treatment of, 879

  Peritheliomas, 275

  Peritoneum, diseases of, 785
    tuberculosis of, 116, 118

  Peritonitis, 785
    circumscribed, 786
    classification of, 786
    consecutive, 786
    diagnosis of, from appendicitis, 857
    diffuse, 786
    following abdominal operations, 780
    intestinal obstruction from, 833
    prevention of, 251
    putrid, 786
    symptoms of, 786
    traumatic, 786
    treatment of, 787
    tuberculous, 786, 790
      ascitic, 791
      fibrinoplastic, 791
      treatment of, 791
      ulcerative, 791

  Peritracheal abscess, 704

  Perityphlitic abscess, 860

  Peri-urethritis, 149

  Pes cavus, 471

  Petroleum ether, 199

  Phagedenic chancroid, 144
    ulcers, 66

  Phagocytosis, 30, 40

  Pharyngeal diverticula, 262

  Pharyngotomy, external, 664
    subhyoid, 664
    transhyoid, 664

  Pharynx, adenoids of, 679
      treatment of, 680
    foreign bodies in, 673
      treatment of, 673
    malformations of, 671

  Phimosis, 1004

  Phlebectases, 364

  Phlebitis, 361
    acute, 361
    chronic, 362
      symptoms of, 362
      treatment of, 363
    mycotic, 90
    obliterans, 362
    sinus, 362, 571

  Phleboliths, 36, 362, 364

  Phlegmasia alba dolens, 362

  Phlegmonous affections of rectum, 879
        treatment of, 879
    cholecystitis, acute, 920
    erysipelas, 75, 93
    gastritis, 804
      symptoms of, 804
      treatment of, 805

  Phlegmons of abdominal wall, 783
    of axilla, 751
    of neck, 700, 703
      diagnosis of, 703
      treatment of, 703

  Phosphorus necrosis of bone, 428

  Phthisis, laryngeal, 684

  Pigeon-breast, 162, 718

  Piles, 364, 882
    treatment of, 883

  Pilonidal sinus, 635

  Pirogoff’s amputation of leg, 1040

  Pituitary adenomas, 285

  Pleura, rupture of, 724
    wounds of, 724
      treatment of, 726

  Pleurosthotonos, 100

  Plexiform angioma, 278
    neuroma, 280, 622

  Pneumatocele of scalp, 545
      treatment of, 546

  Pneumocele, 725

  Pneumonectomy, 750

  Pneumonia, bacillus of, 54
    erysipelatous, 95
    secondary infection in, 167

  Pneumopericardium, 337

  Pneumotomy, 750

  Poikilocytes, definition of, 29

  Poisoning, arrow, 173
    by bees, 172
    by hornets, 172
    ivy, 173
    by lizards, 172
    by scorpions, 172
    by snake-bites, 171
    by spiders, 172
    by wasps, 172

  Poliomyelitis, anterior, 477

  Polycystic kidney, 969

  Polycythemia, 29

  Polyhydronephrosis, 972

  Polymastia, 755

  Polymazia, 755

  Polyp, mucous, 283

  Polypi, 276
    laryngeal, 686
    nasal, 677
    rectal, 885

  Polypoid degeneration, 678

  Popliteal artery, ligation of, 360

  Porencephalon, 580
    in rickets, 162

  Port-wine mark, 277

  Posthitis, 1005

  Postgonorrheal arthritis, 152, 392
    of jaw, 667

  Postoperative biliary fistulas, 917
    cystitis, 985
    hernia, 896
      treatment of, 909
    mania, 175

  Pott’s disease, 444
      causes of, 445
      complications of, 446
      diagnosis of, 448
      laminectomy in, 637
      prognosis of, 448
      sequelæ of, 446
      symptoms of, 445
      treatment of, 448
        by apparatus, 448
        by forcible reduction, 450

  Powell’s electric saw, 588

  Prepatellar bursæ, 263

  Procidentia, 881
    treatment of, 882

  Proctitis, 875
    gonorrheal, 159, 875
    symptoms of, 875
    treatment of, 875

  Profeta’s law in syphilis, 139

  Prolapse of rectum, 881
      treatment of, 882

  Prolapsus cerebri, 566
      prognosis of, 566
      treatment of, 566

  Pronated foot, 468

  Propagated thrombosis, 36

  Properitoneal hernia, 891, 897

  Prostate, absence of, 994
    cancer of, 1002
    hypertrophy of, 995
      diagnosis of, 996
      symptoms of, 997
      treatment of, 998
    inflammation of, 994
    operations on, 998

  Prostatectomy, perineal, 999
    suprapubic, 998

  Prostatic adenoma, 285

  Prostatitis, 150
    acute, 994
    chronic, 994
      treatment of, 995

  Prostatorrhea, 994, 1022

  Protozoa, 56

  Pruritus ani, 878
      treatment of, 879

  Psammoma, 271

  Pseudocysts, 262

  Pseudoleukemia, 32

  Psoas abscess, 114

  Ptosis, 604

  Puerperal state, secondary infection in, 169

  Punctured wounds, 213

  Pus, absorption of, 62
    bacterial determination of, as an indication to treatment, 57
    blastomycetic, 56
    clinical characteristics of, from different agencies, 57
    encapsulation of, 62
    formation, bacteria of, 51
        facultative pyogenic, 53
        obligate pyogenic, 52
    ichorous, 59
    pointing of, 58
    sanious, 59
    subfacial, collection of, 59
    subperiosteal, collection of, 591

  Pustular syphilides, 132

  Pustulocrustaceous syphilides, 132

  Putrid fever of Gaspard, 81

  Pyarthrosis, metastatic forms of, 384
    treatment of, 399

  Pyelectomy, 976

  Pyelitis, 956
    symptoms of, 957
    treatment of, 957

  Pyelonephritis, 956
    symptoms of, 957
    treatment of, 957

  Pyemia, 90
    chronic, 92
    complications of, 91
    idiopathic, 91
    postmortem appearances of, 92
    prognosis of, 92
    pyarthrosis of, 92
    spontaneous, 91
    symptoms of, 91
    treatment of, 92
    wound, 92

  Pylephlebitis, 362, 918

  Pylorectomy, 813

  Pyloric stenosis, operations for, 808

  Pylorodiosis, 808

  Pyloroplasty, 808
    Finney’s, 810

  Pylorus stenosis of, 799
      symptoms of, 799
      treatment of, 799

  Pyogenic organisms, facultative, 53
      obligate, 52

  Pyonephrosis, 961, 972
    treatment of, 961

  Pyopericardium, 336

  Pyorrhea alveolaris, 664

  Pyosalpinx, diagnosis of, from appendicitis, 858

  Pyothorax, 736


  R

  RACEMOSE aneurysm, 344

  Rachitis, 161. _See_ Rickets.

  Radesyge, 308

  Radial artery, ligation of, 356
    nerve, operations on, 623

  Radicular odontomas, 281

  Radium in treatment of cancer, 296

  Radius and ulna, fractures of, 503
    dislocations of, 536
    fractures of, 502
      treatment of, 504
    lower end of, fractures of, 503

  Railway spine, 628

  Ranula, 261, 660

  Rauschbrand, bacillus of, 55

  Raynaud’s disease, 74

  Rectal fistulas, 880
      treatment of, 880

  Rectovaginal fistula, 839

  Rectum, abscesses around, 879
      treatment of, 879
    adenoma of, 885
    atresia of, 872
    cancer of, 886
      treatment of, 887
    congenital defects of, 872
    ether narcosis by, 196
    examination of, 871
    fistula of, 880
      treatment of, 880
    foreign bodies in, 874
    imperforation of, 872
    inflammation of, 875
    injuries of, 874
    invagination of, 881
      treatment of, 882
    malformations of, 872
    phlegmonous affections of, 879
      treatment of, 879
    polypi of, 885
    prolapse of, 881
      treatment of, 882
    strictures of, 877
      treatment of, 877
    syphilis of, 138
    tumors of, 885
    ulcers of, 876
      catarrhal, 876
      chancroidal, 876
      symptoms of, 877
      syphilitic, 876
      treatment of, 877
      tuberculous, 877
      typhoid, 877

  Reef-knot, 241

  Regnoli-Billroth operation on tongue, 661

  Reindeer tendons, sterilization of, 248

  Renal abscess, 957
    actinomycosis, 964
    calculus, 965
      diagnosis of, 965
      symptoms of, 965
      treatment of, 966
    colic, 964
      treatment of, 964
    syphilis, 964
    tuberculosis, 961

  Repair, process of, 67
      cells in, embryonal, 67
        epithelioid, 67
        formative, 67
        giant, 68
      granulation tissue in, 67
      karyokinetic activity in, 68
      scar formation in, 69
    of wounds, 215
      by first intention, 215
      granulation tissue in, 215
      by second intention, 216
      by third intention, 216

  Resection of esophagus, transthoracic, 745
    of nerves, 613

  Respiratory passages, burns of, 675
    foreign bodies in, 672
    fractures of, 675
    infection through, 49
    injuries of, 675
    malformation of, 671
      treatment of, 671
    wounds of, gunshot, 675

  Retention cysts, 259
    of urine, 982

  Retina, detachment of, 604
    glioma of, 595

  Retromammary abscess, 757

  Retroperitoneal hernia, 891, 897

  Retropharyngeal abscess, 114, 682

  Rhabdomyoma, 274, 277

  Rheumatism, gonorrheal, 152

  Rheumatoid arthritis, 387

  Rhinoliths, 672

  Rhinophyma, 313, 641
    treatment of, 314

  Rhinoplasty, 644

  Rhinoscleroma, 308, 641
    bacillus of, 54

  Ribs, dislocations of, 529
    fractures of, 491
      symptoms of, 492
      treatment of, 492
    malformations of, 718

  Rice-grain bodies, 322

  Richet’s operation for blepharoplasty, 603

  Richter’s hernia, 898

  Rickets, 161
    causes of, 161
    cerebral conditions in, 162
    congenital, 161
    cranial, 547
    deformities of bones in, 162
    fetal, 161, 433
    hydrocephalus in, 162
    laryngismus stridulus in, 162
    pathology of, 161
    porencephalon in, 162
    symptoms of, 162
    treatment of, 162

  Rider’s bone, 218, 331

  Riedel’s lobe, 910

  Riggs’ disease, 664

  Rodent ulcers, 66, 67, 288
      of auricle, 606

  Roe’s operation for pug-nose, 645

  “Rose, the,” 93. _See_ Erysipelas.

  Roseola syphilitica, 131

  Rotz, 105. _See_ Glanders.

  Round-cell sarcoma, 273

  Rovsing’s operation for gastroptosis, 813

  Rubber tissue, sterilization of, 248

  Rubefacients, 183

  Ruptures of bladder, 981
    of diaphragm, 721, 753
    of esophagus, 741
    of heart, 336, 732
    of lung, 725
    of muscles, 329
    of pleura, 724
    of stomach, 794
    of trachea, 699
    of veins, 363


  S

  SABANEJEFF’s method of amputation of knee, 1044

  Sacculated aneurysm, 339, 342

  Sacro-iliac disease, 452
    treatment of, 452

  Saddle-nose, 489, 639, 644

  Salivary calculi, 651
    ducts, fistulas of, 649
      foreign bodies in, 648
    glands, inflammation of, 649
      tumors of, 650

  Saphenous vein, internal, extirpation of, 366

  Sapremia, 86
    chronic, 87
      treatment of, 87
    symptoms of, 86
    treatment of, 87

  Sarcoma, 273
    of abdominal wall, 784
    alveolar, 274
    angiosarcoma, 275
    of bone, 441
      treatment of, 441
    chondrosarcoma, 274
    cylindroma, 275
    diagnosis of, from carcinoma, 293
    endothelioma, 274
    general characteristics of, 275
    giant-cell, 274
    of jaw, 668
    of kidney, 969
    of larynx, 687
    of liver, 914
    of lungs, 732
    melanosarcoma, 275
    myeloid, 274
    of omentum, 935
    of orbit, 593
    osteosarcoma, 274
    of pancreas, 953
    round-cell, 272
    of skin, 316
    spindle-cell, 273
    of spleen, 943
    of thorax, 730
    of thyroid, 712

  Sardonic grin, 100

  Sayre’s incision in excision of hip, 411

  Scabbard trachea, 713

  Scalds, 300
    treatment of, 301

  Scalp, cellulitis of, 545
    erysipelas of, 545
    hematoma of, traumatic, 218
    pneumatocele of, 545
      treatment of, 546
    tumors of, 546
      acquired, 546
      benign, 546
      congenital, 546
      gaseous, 545
      malignant, 546

  Scapula, fractures of, 494
      acromion process, 494
      coracoid process, 495
      surgical neck, 495

  Scarlatina, secondary infection in 167

  Sciatic nerve, operations on, 623

  Scleroderma, 313
    pathology of, 313
    treatment of, 313

  Sclerosis, cerebral, in rickets, 162

  Scoliosis, 459
    etiology of, 460

  Scopolamine, 205

  Scorbutus, infantile, 161

  Scorpions, poisoning by, 172

  Scrofula of joints, 393

  Scrofuloderma, 306

  Scrotal hernia, 895

  Scrotum, elephantiasis of, 371
    shortening of, 1021

  Scurvy, 160
    pathology of, 160
    symptoms of, 160
    treatment of, 160

  Sebaceous adenomas, 285
    cysts, 285
      of skin, 310
    horns, 283

  Seborrheic warts, 312

  Sédillot’s operation on tongue, 662

  Semilunar cartilages, dislocations of, 543

  Seminal vesiculitis, 1021

  Septicemia, 87
    complications of, 88
    cryptogenetic, 87
    eruptions in, 88
    gangrenous, 108
    leukocytosis in, 88
    postmortem evidences of, 88
    spontaneous, 87
    symptoms of, 88
    treatment of, 89
    ulcerative endocarditis in, 88

  Septicopyemia, 90

  Sequestration dermoids, 265

  Sequestrum formation in bone, 429
          treatment of, 429

  Serous exudates, 23

  Seton, counterirritation by, 184

  Shingles, 728

  Shock, 177
    diagnosis of, 179
    from gunshot wounds, 223
    symptoms of, 179
    treatment of, 179
    types of, 179

  Shoulder, amputation of, 1032
    excision of, 409
    -joint, dislocations of, 530
      anterior, 530
      diagnosis of, 532
      downward, 530
      posterior, 530
      subclavicular, 531
      subcoracoid, 531
      subglenoid, 531
      subspinous, 532
      symptoms of, 532
      treatment of, 532
        Kocher’s method, 533
      upward, 530
    spica bandage of, 190

  Sialoadenitis, 649

  Sialolithiasis, 651

  Sigmoidopexy, 870

  Silk, sterilization of, 248

  Silkworm gut, sterilization of, 248

  Sincipital hydrencephalocele, 577
    meningocele, 577

  Singer’s nodes, 686

  Sinus, 63
    accessory craniofacial, operations on, 608
    causes of, 63
      congenital, 63
      foreign bodies, 63
      necrosed material, 63
      preëxisting abscess, 63
      traumatic destruction of tissues, 63
    ethmoidal, operations on, 610
    frontal, operations on, 609
    intracranial, injuries of, 563
    maxillary, operations on, 611
    phlebitis, 362, 571
      symptoms of, 571
    pilonidal, 635
    sphenoidal, operations on, 610
    thrombosis, 570
      diagnosis of, 570
      prognosis of, 571
      symptoms of, 570
      treatment of, 573
    treatment of, 63

  Skin, actinomycosis of, 308
    appendages of, 317
    carcinoma of, 315
    cylindroma of, 315
    cysts of, 310
      treatment of, 310
    epithelioma of, 315
      diagnosis of, 315
      treatment of, 315
    grafting, 187
      Thiersch method, 188
    hypertrophies of, 311
    infection through, 48
    infections of, acute, 304
      chronic, 306
    keratosis of, 314
      treatment of, 314
    lymphangioma of, 315
      treatment of, 315
    melanoma of, 316
      treatment of, 317
    sarcoma of, 316
    syphilis of, 130, 308
      tertiary, 133
    tuberculosis of, 115, 306
    tumors of, benign, 311
      malignant, 315
    vascular growth of, 314
      treatment of, 314
    xanthoma of, 314

  Skull, acute osteomyelitis of, 548
      periostitis of, 548
    aplasia cranii, 547
    atrophy of, 547
      senile, 547
    bones of, incomplete formation of, 547
    congenital conditions of, 547
    craniotabes, 547
    depression of, 549
    diseases of, non-inflammatory, 547
    fractures of, 549, 552
      of base, 556
        diagnosis of, 557
        prognosis of, 557
        treatment of, 558
      of vertex, 552
        comminuted, 552
        diagnosis of, 554
        gunshot, 553
        splintered, 552
        treatment of, 555
    necrosis of, 549
    osteoma of, 548
    rachitis of, 162
    surgical anatomy of, 550
    wounds of, incised, 552
      penetrating, 552

  Sloughing ulcers, 66

  Smith, Stephen, method of amputation of knee, 1043

  Snake-bites, 171
      symptoms of, 171
      treatment of, 171

  Soft palate, malformations of, 671

  Somnoform, 199

  Sounds, bulbous, 155

  Spasmotoxin, 98

  Specific irritants in inflammation, 45

  Spermatic cord, encysted hydrocele of, 1019
      malignant diseases of, 1019
      spermatocele, 1019
      syphilis of, 1019
      tuberculosis of, 1019
      varicocele, 1019
        treatment of, 1021

  Spermatocele, 1019

  Spermatorrhea, 1022

  Sphacelus, 73. _See_ Gangrene.

  Sphenoidal sinus, operations on, 610

  Sphygmomanometer, use of, 177

  Spica bandage of groin, 189
      of shoulder, 190

  Spiders, poisoning by, 172

  Spina bifida, 625
      occulta, 626
      treatment of, 626

  Spinal column, diseases and injuries of, 625
      sprains of, 628
        treatment of, 629
    cord, hemorrhages of, 625, 634
      injuries of, differential diagnosis of, 635
      syphilis of, 138
      tumors of, 621
        diagnosis of, 622
        symptoms of, 621
        treatment of, 622
      wounds of, gunshot, 230, 624
        penetrating, 624
    meningocele, 625

  Spindle-cell sarcoma, 274

  Spine, arthritis deformans of, 388
    cancer of, 462
    caries of, 444
    concussion of, 628
      treatment of, 629
    curvatures of, forward, 461
      rotary, lateral, 459
          etiology of, 460
          prognosis of, 460
          treatment of, 460
    cysts of, 627
    dislocation of, 631
      treatment of, 632
    fractures of, 629
      diagnosis of, 629
    injuries of, 629
      differential diagnosis of, 635
    kyphosis of, 444
    lordosis of, 461
    operations on, 636
    Pott’s disease of, 444
        causes of, 445
        complications of, 446
        diagnosis of, 448
        prognosis of, 448
        sequelæ of, 446
        symptoms of, 445
        treatment of, 448
          by apparatus, 448
          by forcible contraction, 450
    spondylitis of, 444
      traumatic, 462
    spondylolisthesis, 462
      diagnosis of, 463
      symptoms of, 462
      treatment of, 463
    tuberculosis of, 424
    typhoid, 462
    wounds of, gunshot, 624
      penetrating, 624

  Spirochæta pallida, 123

  Splay-foot, 468

  Spleen, abscess of, 941
    anomalies of, 940
    carcinoma of, 943
    cysts of, 943
    displacements of, 942
    gangrene of, 941
    hypertrophies of, 941
    injuries of, 941
    neoplasms of, 943
    operations on, 943
      splenectomy, 943
      splenopexy, 942
      splenotomy, 943
    sarcoma of, 943
    syphilis of, 138
    wounds of, 233

  Splenectomy, 943

  Splenic anemia, 31
    fever, 106. _See_ Anthrax.

  Splenitis, suppurative, 941

  Splenomedullary leukemia, 32

  Splenomegaly, 942

  Splenopexy, 942

  Splenotomy, 943

  Spondylitis, 444
    suppurative, of abdominal wall, 783
    traumatic, 462

  Spondylolisthesis, 462
    diagnosis of, 463
    symptoms of, 462
    treatment of, 463

  Sponges, sterilization of, 247

  Sprains of joints, 380
      symptoms of, 380
      treatment of, 380
    of muscles, 329
    of spinal column, 628
        treatment of, 629

  Sprengel’s deformity, 458

  Staffordshire knot, 241

  Staphylococcus pyogenes albus, 52
      aureus, 52
      epidermidis, 52

  Staphyloma, 598

  Staphylorrhaphy, 654

  Status lymphaticus, 163
      diagnosis of, 164
      treatment of, 165
    thymicus, 163

  Steatomas, 310

  Stenosis, pyloric, operations for, 808

  Stenson’s duct, cysts of, 641

  Stercoremia, 83

  Sterilization by boiling water, 244
    of dressings, 247
    by formalin, 244
    fractional, 244
    of hands, 245
    by heat, 243
    of instruments, 246
    by mustard flour, 245
    of sponges, 247
    of suture materials, 247

  Sternum, dislocations of, 528
    fractures of, 491
      symptoms of, 492
      treatment of, 492
    malformations of, 718

  Stillicidium, 982

  Stokes’ method of amputation of thigh, 1043

  Stomach, anastomosis of, 816
    cancer of, 801
      symptoms of, 802
      treatment of, 803
    dilatation of, acute, 795
        symptoms of, 796
        treatment of, 796
      chronic, 796
      operations for, 811
    fistulas of, 801
    foreign bodies in, 794
        operations for, 806
        symptoms of, 794
        treatment of, 794
    hour-glass, 793
    injuries of, 793
    leather-bottle, 793
    malformations of, acquired, 793
      congenital, 793
    nerves of, 793
    operations on, 805
      gastrectomy, 813
      gastro-enterostomy, 811, 817
      gastrojejunostomy, 816
      gastrorrhaphy, 806
      gastrostomy, 806
      gastrotomy, 806
      pylorectomy, 813
    pylorus of, stenosis of, 799
        symptoms of, 799
        treatment of, 799
    rupture of, 794
    syphilis of, 795
    tetany of, 798
    tuberculosis of, 795
    tumors of, 801
    ulcer of, 799
      symptoms of, 800
      treatment of, 800
    wall of, inflammation of, 804
    wounds of, 794
      penetrating, operations for, 805

  Stomatitis, 657
    gangrenous, 75, 658
    ulcerative, 657

  Stovaine, 207

  Strains of muscles, 329

  Strangulated hernia, diagnosis of, from appendicitis, 858
      intestinal obstruction from, 829

  Strawberry growths, 367

  Streptococcus erysipelatis, 52
    pyogenes, 53

  Streptothrix maduræ, 100

  Stretching of nerves, 612

  Stricture of biliary ducts, 921
    of esophagus, 742
    of intestines, large, 870
      obstruction from, 832
        symptoms of, 828
        treatment of, 828
      small, 827
    of larynx, 684
      symptoms of, 684
      treatment of, 684
    of rectum, 877
      treatment of, 877
    of ureter, 973
    of urethra, 1011

  Struma, 283, 712
    fibrosa, 284
    parenchymatosa nodosa, 284

  Strumitis, 717

  Stye, 600

  Stypticin, 235

  Styptics for control of hemorrhage, 235

  Subclavian artery, aneurysm of, 345
      ligation of, 354

  Subclavicular dislocations, 531

  Subcoracoid dislocations, 531

  Subcutaneous tubercle, painful, of skin, 313

  Subdiaphragmatic abscess, 753
      treatment of, 754

  Subdural hemorrhages, 564

  Subglenoid dislocations, 531

  Subhyoid pharyngotomy, 664

  Subluxation, 524. _See_ Dislocations.

  Submaxillary angina, infectious, 703

  Subphrenic abscess, 753
      treatment of, 754

  Subspinous dislocations, 532

  Subungual exostoses, 272

  Sunburn, 303

  Suppression of urine, 982

  Suppuration, 57

  Supracondyloid amputations, 1043
    fracture of humerus, 497

  Supra-orbital nerve operations on, 613

  Suprapubic prostatectomy, 998

  Suprarenal epithelioma, 292

  Surgical diseases, 79
      common to man and animals, 97
    fever, 85
      cause of, 85
      diagnosis of, from poisoning by drugs, 85
      erysipelas, 93
      pyemia, 90
      sapremia, 86
        chronic, 87
      septicemia, 87
        cryptogenetic, 87
        spontaneous, 87
    methods, 177
    principles, 177
    sequelæ of disease, 166
      cholera, 166
      dental caries, 169
      diphtheria, 168
      dysentery, 166
      endocarditis, 169
      gonorrhea, 169
      influenza, 167
      measles, 167
      mumps, 168
      pneumonia, 167
      puerperal state, 169
      scarlatina, 167
      syphilis, 169
      typhoid fever, 167
      variola, 169

  Sutures, 240
    Billroth’s chain-stitch, 241
    of bloodvessels, 349
      end-to-end, 350
      lateral, 349
    continuous, 241
    of heart wounds, 335 (note)
    interrupted, 241
    of intestines, 840
    modified plate, 241
      quill, 241
    of nerves, 612
    removal of, 242
    of tendons, 324
    transfixion, 241

  Swelling, acute, 22
    chronic, 22

  Sylvester’s method of artificial respiration, 204

  Symblepharon, 603

  Sympathectomy, 714

  Sympathetic ophthalmitis, 595
      treatment of, 596

  Syncheilia, 639

  Syncytioma, 292

  Synovial cysts, 262

  Synovitis, 382
    acute, 383
      treatment of, 383
    chronic, 386
      treatment of, 386
    dry, 383
    gonorrheal, 385
    of jaws, acute, 667
    purulent, 383
      symptoms of, 383
      treatment of, 385
    treatment of, 385

  Syphilides, 130
    pustular, 132
      ecthyma, 132
      rupia, 132
    pustulocrustaceous, 132
    squamous, 131

  Syphilis, 122
    of abdominal wall, 783
    of axilla, 751
    of bones, 135, 426
    of brain, 138
    of breast, 759
    of bursæ, 136
    of cervical lymph nodes, 705
    chancre, 126
      bubo, 128
      diagnosis of, from epithelioma, 127
      dry papule, 126
      extragenital, 127
      Hunterian, 127
      lymphatic involvement in, 128
      mixed, 127
      pathology of, 128
      superficial erosion, 127
      treatment of, 128
    in children, 139
      Colles’ law, 139
      Profeta’s law, 139
    of colon, 869
    constitutional, 129, 132
    of cornea, 137
    of corpora cavernosa, 138
    of ear, 137
    eruptions of, 130
      papular, 131
        lenticulo, 131
        miliary, 131
      pustular, 132
      pustulocrustaceous, 132
    evolution of, 123
    of eye, 136, 597
    of face, 640
    of genitalia, 138
    gumma of, 133
    Hutchinson’s teeth in, 140
    induration of, 126
    initial lesion in, 126
    of intestines, 827
    of joints, 135
    of kidneys, 138, 964
    of larynx, 138, 686
      treatment of, 686
    lesions of, 124
    of liver, 138, 914
    of lymph nodes, 376
    manner of contagion of, 123
    of mesentery, 939
    of mouth, 657
    of mucous membranes, 132
    of muscles, 136, 331
    of nervous system, 138
    of orbit, 597
    of oropharynx, 137
    primary lesion, location of, 125
    of rectum, 138, 876
    secondary infection in, 169
      lesion, 129
    secretions of, 124
    of skin, 130, 308
    of spermatic cord, 1019
    of spinal cord, 138
    of spleen, 138
    of stomach, 795
    teeth in, 140
    of tendons, 136
    tertiary, 132
      of skin, 133
    of testicle, 138, 1016
    of tongue, 659
    of tonsils, 662
    treatment of, 140
    ulcer of, symptoms of, 125
    of uvula, 683
    of vascular system, 135
    virus of, 123

  Syphilitic arthritis, 385
    bubo, 128
    gumma of lung, 732

  Syphilodermas, 130

  Syringomyelia, 621

  Syringomyelocele, 263, 626


  T

  TABES mesenterica, 939

  Tænia solium, 310

  Tagliacozzi’s method of rhinoplasty, 644

  Talipes, 465
    calcaneus, 471
    equinovarus, 466
      treatment of, 466
    equinus, 470
      causes of, 470
      treatment of, 471
    valgus, 468
      etiology of, 468
      treatment of, 469

  Talma’s operation on omentum, 936

  Tapping, paracentesis by, 185

  Tarantula, poisoning by, 172

  Tarsectomy, 467

  Tartar on teeth, 657

  Tattoo marks, 318, 720

  Taxis, 899

  T-bandage, 191

  Teale’s method of amputation of foot, 1042

  Teeth, caries of, 657, 664
      treatment of, 665
    cysts of, 666
    eruption of, faulty, 665
    extraction of, 666
      accidents from, 666
      instruments required, 666
    malformations of, 652
    odontoma of, 665
    re-implantation of, 667
    tartar of, 657
    tumors of, 665

  Telangiectasis, 277

  Temporal artery, ligation of, 352

  Temporomaxillary joint, ankylosis of, 667
      dislocation of, 667
      postgonorrheal arthritis of, 667
      resection of, 668
      synovitis of, acute, 667

  Temporosphenoidal abscess, 569

  Tendon sheaths, tuberculosis of, 118

  Tendons, dislocation of, 330
    grafting of, 324
    injuries of, 218
    ligation of, 326
    surgical diseases of, 321
    suture of, 324
    syphilis of, 136
    transplantation of, 324

  Tendoplasty, 322

  Tendosynovitis, 321
    chronic, 322
      treatment of, 322
    suppurative, 321
      treatment of, 321

  Tendovaginitis, gonococcus of, 331

  Tenorrhaphy, 324

  Tenotomy, 327

  Teratomas, 268
    embryonal adenosarcoma, 268
    of thyroid, 712

  Tertiary syphilis, 132

  Testicle, absence of, 1015
    atrophy of, 1015
    cancer of, 1017
    chondroma of, 1017
    congenital abnormalities of, 1014
    contusions of, 1015
    cystic degeneration of, 260
    cysts of, 1016
    epididymitis, 1016
      treatment of, 1017
    fibroma of, 1017
    gonorrhea of, 151
    hematoma of, 1015
    hydrocele of, encysted, 260
    injuries to, 1015
    lipoma of, 1017
    orchitis, 1017
      treatment of, 1017
    retained, 1014
      treatment of, 1014
    syphilis of, 138, 1016
    tuberculosis of, 118, 1015
      treatment of, 1016
    tumors of, 1017

  Tetanin, 98

  Tetanotoxin, 98

  Tetanus, 97
    cephalicus, 99
    chronic, 100
    death in, 100
    diagnosis of, 101
      from hysteria, 101
    etiology of, 97
    hydrophobicus, 99
    of newborn, 97, 99
    parasitic nature of, 98
    postmortem appearances in, 100
    prognosis of, 100
    toy-pistol, 97
    treatment of, 101

  Tetany, bacillus of, 54
    gastric, 798

  Thecitis, 328

  Thiersch method of skin grafting, 188

  Thigh, amputation of, 1043
      above knee, 1044
    fracture of, 509
      diagnosis of, 511
      prognosis of, 511
      treatment of, 512

  Thoracentesis, 736, 746

  Thoracic duct, injuries to, 725
        treatment of, 726
    viscera, injuries to, 724
    walls, diseases of, 726

  Thoracoplastic operations, 748

  Thoracotomy, 747
    drainage in, 747
    irrigation in, 747

  Thorax, actinomycosis of, 729
    carcinoma of, 730
    chondroma of, 730
    fibroma of, 729
    granuloma of, 729
    injuries to, 721
    lipoma of, 729
    malformations of, 718, 719
    operations on, 746
    osteoma of, 730
    sarcoma of, 730
    tumors of, 729
      treatment of, 730
    wounds of, gunshot, 230

  Thrombo-arteritis, 91

  Thrombophlebitis, 37, 90

  Thrombosis, 34
    annular, 35
    causes of, 35
    following abdominal operations, 784
    gangrene from, 73
    infective, 36, 570
    marasmic, 36, 570
    mechanical, 36
    of mesenteric vessels, 938
    obstructive, 36
    parietal, 35
    primary, 35
    propagated, 36
    sinus, 570
      diagnosis of, 571
      prognosis of, 571
      symptoms of, 570
      treatment of, 573
    traumatic, 36
    valvular, 35

  Thrombus, calcification of, 36
    decolorization of, 36
    organization of, 36
    softening of, 37

  Thrush, oïdium albicans of, 657

  Thumb, amputation of, 1029

  Thymic asthma, 163

  Thymus, hypertrophy of, 717, 751
    inflammation of, 717

  Thyroglossal duct, 710

  Thyrohyoid cysts of neck, 707

  Thyroid arteries, inferior, ligation of, 353
    body, adenoma of, 712
      bronchocele, 712
      congenital affections of, 710
      endothelioma of, 712
      goitre of, 712
      hypertrophy of, acute idiopathic, 711
        intra-uterine, 711
      sarcoma of, 712
      struma of, 712
      teratomas of, 712
      tumors of, 711
    dermoids, 267

  Thyroidectomy, 715

  Thyroidism, 82

  Thyroiditis, 711

  Thyroids, accessory, 710

  Thyrotomy, 674, 688

  Tibia, dislocations of, 543
    fractures of, 518
      treatment of, 521

  Tibial arteries, ligation of, 360
    nerve, operations on, 623

  Tibiotarsal amputations, 1037

  Tic douloureux, 640

  Toe-nail, ingrowing, 318

  Toes, amputation of, 1034
    hammer, 321
      treatment of, 321

  Tongue, absence of, 652
    actinomycosis of, 659
    bifid, 652
    cysts of, retention, 659
    epithelioma of, 660
      treatment of, 660
    gangrene of, 659
    inflammation of, 658
    leukoplakia of, 659
      treatment of, 659
    macroglossia of, 660
    malformations of, 652
    nevi of, 659
    operations on, 661
      Kocher’s, 661
      Langenbeck’s, 662
      Regnoli-Billroth’s, 661
      Sédillot’s, 662
      Whitehead’s, 661
    papilloma of, 659
    ranula of, 660
    syphilis of, 659
    -tie, 652
    tuberculosis of, 659
    tumors of, 659

  Tonometer, use of, 177

  Tonsillotomy, 663

  Tonsils, absence of, 662
    calculi of, 663
    enlarged, 662
    foreign bodies in, 663
    hypertrophy, 662
    infection through, 49
    syphilis of, 662
    tuberculosis of, 662
    tumors of, 664

  Torsion, control of hemorrhage by, 236
    of omentum, 935

  Torticollis, 457
    diagnosis of, 458
    pathology of, 457
    treatment of, 458

  Tourniquet for control of hemorrhage, 234

  Toxic antiseptics, 175

  Toy-pistol tetanus, 97

  Trachea, operations on, 691
    rupture of, 699
    scabbard, 713
    tumors of, 687
    wounds of, 699

  Tracheal tugging, 345

  Tracheocele, 707

  Tracheotomy, 691

  Trachoma, 599

  Transfixion suture, 241

  Transfusion of blood, 185

  Transhyoid pharyngotomy, 664

  Transplantation of bone, 431
    of tendons, 324

  Transudates, 23

  Trauma as cause of tumor, 255

  Traumapnea, 724

  Traumatic abscess of brain, 567
    erysipelas, 93, 94
    fever, 85. _See_ Surgical fever.
    hematoma of scalp, 218
    hernia, 890
    insanity, surgical treatment of, 582
    intraventricular hemorrhage, 564
    mania, 175
    neuroma, 280
    othematoma, 605
    peritonitis, 786
    spondylitis, 462
    thrombosis, 36

  Treatment of abscess, 60
      of bone, 426
      of brain, 573
      of liver, 912
      of rectum, 879
    of actinomycosis, 110
    of acute catarrh of biliary passages, 918
      cholecystitis, 921
      pancreatitis, 948
    after abdominal operations, 777
    of adenoids of pharynx, 680
    of aneurysm of abdominal aorta, 346
    of angioma of veins, 367
    of ankylosis, 405
    of anthrax, 107
    of arthritis, chronic, 386
      deformans, 389
      tuberculous, 398
    of atrophy of muscles, 332
    of biliary calculi, 926
    of boils, 304
    of bow-leg, 465
    of bunions, 311
    of burns, 301
      _x_-ray, 304
    of carbuncle, 305
    of carcinoma, 295
      of breast, 763
      of intestines, 828
      of rectum, 887
      of stomach, 803
    of cardiospasm, 798
    of caries of hip, 454
    of cerebral palsies, 478
    of cervical lymph-node affections, 706
    of chancre, 128
    of chancroid, 145
    of cholelithiasis, 926
    of chondroma, 272
    of chronic affections of pancreas, 951
      pancreatitis, 950
      prostatitis, 995
      sapremia, 87
      tendosynovitis, 322
    of cold abscess, 114
        peri-articular, 399
    of compression of brain, 562
    of concussion of brain, 559
      of chest, 722
      of spine, 629
    of congenital anomalies of neck, 698
      club-foot, 466
      dislocation of hip, 474
    of congestion, 23
    of contraction of fasciæ, 320
      of muscles, 332
    of contusions, 212
      of brain, 560
      of chest, 722
    of cryptorchidism, 1014
    of curvature of spine, 460
    of cutaneous horns, 311
    of cystitis, 985
    of cysts of pancreas, 952
      of skin, 310
    of dacryocystitis, 600
    of delirium tremens, 174
    of dental caries, 665
    of dermatitis calorica, 299
    of desmoids, 271
    of dilatation of stomach, 796
    of dislocations, 527
      of clavicle, 529
      of elbow, 536
      of foot, 544
      of hip, 539
      of jaw, 528
      of knee, 544
      metacarpophalangeal, 537
      of patella, 543
      of shoulder, 532
      of spine, 632
    of duodenal ulcers, 826
    of Dupuytren’s contraction, 320
    of ectopia of bladder, 978
    of epididymitis, 1017
    of epistaxis, 681
    of epithelioma of skin, 315
      of tongue, 660
    of erysipelas, 95
    of exophthalmic goitre, 714
    of exophthalmos, 594
    of exstrophy of bladder, 978
    of fat embolism, 40
    of fibroma molluscum, 313
    of fistula, 63
      of rectum, 880
    of floating liver, 911
    of foreign bodies in esophagus, 740
        in pharynx, 673
        in stomach, 794
    of fractures, 486
      of clavicle, 493
      Colles’, 504
      of femur, 513
      of fibula, 521
      of forearm, 501
      of humerus, 495
      of inferior maxilla, 490
      of leg, 521
      of patella, 517
      of pelvis, 508
      of radius, 504
      of ribs, 492
      of skull, base, 558
        vertex, 555
      of sternum, 492
      of thigh, 512
      of tibia, 521
      of ulna, 501
    of frostbite, 302
    of furuncle, 304
    of gallstones, 926
    of gangrene, 77
    of gastric ulcer, 800
    of gastroptosis, 797
    of glanders, 106
    of glaucoma, 597
    of gonorrhea, 152
      complications, 152
      of testicles, 151
      in women, 159
    of hammer-toe, 321
    of hematomyelia, 634
    of hematorrhachis, 634
    of hematuria, 959
    of hemorrhage, 234
      secondary, 237
    of hemorrhoids, 883
    of hernia, 898
      of brain, 566
      femoral, 908
      inguinal, 908
      postoperative, 909
      umbilical, 909
      ventral, 909
    of Hodgkin’s disease, 378
    of hydatid cysts of liver, 913
      disease, 432
    of hydrocele, 1018
    of hydrocephalus, 579
    of hydronephrosis, 973
    of hydrophobia, 104
    of hypertrophy of prostate, 998
    of hysterical joints, 392
    of injuries of eyeball, 604
      of orbit, 593
      to thoracic duct, 726
      to upper nerve trunks, 726
    of intestinal obstruction, acute, 836
        chronic, 839
    of intraspinal hemorrhage, 634
    of intussusception, 832
    of invagination of rectum, 882
    of keloid, 271, 313
    of keratosis of skin, 314
    of knock-knee, 464
    of laceration of lung, 722
    of leptomeningitis, 573
    of leukoplakia, 659
    of lock finger, 320
    of lymphangioma, 279
      circumscriptum, 374
      of skin, 315
    of lymphangitis, 375
    of Madura foot, 110
    of malformation of esophagus, 738
      of respiratory passages, 671
    of malignant edema, 108
    of mastitis, 758
    of mastodynia, 758
    of mediastinitis, 728
    of melanoma of skin, 317
    of meningitis, 572
    of metatarsalgia, 470
    of Morton’s disease, 471
    of movable and floating kidney, 967
      bodies in joints, 402
    of myalgia, 331
    of necrosis of bone, 428
    of neoplasm of nasal cavities, 678
    of neuralgia of breast, 758
    of neuropathic disease of joints, 392
    of orchitis, 1017
    of osteo-arthritis, 389
    of osteomalacia, 435
    of osteomyelitis, 419
    of panophthalmitis, 595
    of papilloma, 283
    of paralytic affections of muscles, 332
    of perforations of biliary passages, 922
    of perineal abscess, 1013
      fistulas, 1013
    of perinephritis, 961
    of periostitis, 421
    of perirectal abscess, 879
    of peritonitis, 787
    of phlegmonous affections of rectum, 879
    of phlegmons of neck, 703
    of piles, 883
    of pneumatocele of scalp, 546
    of Pott’s disease, 448
    of procidentia, 882
    of proctitis, 875
    of prolapse of brain, 566
      of rectum, 882
    of pruritus ani, 879
    of pyelitis, 957
    of pyelonephritis, 957
    of pyemia, 92
    of pyonephrosis, 961
    of renal calculus, 966
      colic, 964
    of retained testicle, 1014
    of rhinophyma, 314
    of rickets, 162
    of rupture of diaphragm, 722
      of muscles, 330
    of sacro-iliac disease, 452
    of sapremia, 87
    of sarcoma of bone, 441
    of scalds, 301
    of scleroderma, 313
    of scoliosis, 460
    of scurvy, 160
    of septic nephritis, 957
    of septicemia, 89
    of sequestrum formation, 429
    of shock, 179
    of sinus, 63
      thrombosis, 573
    of snake-bites, 171
    of spina bifida, 626
    of spondylolisthesis, 463
    of sprains, 380
      of spinal column, 629
    of status lymphaticus, 165
    of stenosis of pylorus, 799
    of strictures of intestines, 828
      of larynx, 684
      of rectum, 877
    of subphrenic abscess, 754
    of suppurative tendosynovitis, 321
    of surgical kidney, 957
    of sympathetic ophthalmitis, 596
    of synovitis, 385
      acute, 383
      chronic, 386
      purulent, 385
    of syphilis, 140
    of talipes equinovarus, 466
      equinus, 471
      valgus, 469
    of tetanus, 101
    of torticollis, 458
    of traumatic insanity, 582
    of trigger finger, 320
    of tuberculosis, 120
      of bone, 425
      of breast, 759
      of joints, 398
      of knee, 456
      of kidneys, 963
      of larynx, 685
      of mesentery, 939
      of peritoneum, 791
      of skin, 307
      of testicle, 1016
    of tuberculous hydrops, 399
      ulcers of intestines, 827
    of tumors, 258
      of bladder, 992
      of brain, 585
      of breast, 760
      of larynx, 687
      of spinal cord, 622
      of thorax, 730
    of typhoid ulcers of intestines, 826
    of ulcerations of biliary passages, 922
    of varices, 365
    of varicocele, 1021
    of varicose veins, 365
    of vascular growths of skin, 314
    of vesical calculus, 987
    of warts, 312
      venereal, 312
    of wounds, 238
      of chest, 723
      contused, 212
      of diaphragm, 726
      gunshot, 225
      of head, 565
      of heart, 335
      of intestines, 824
      of larynx, 676
      of lung, 726
      open, 239
      of pleura, 726
      punctured, 214
    of wryneck, 458
    of xanthoma of skin, 314

  Trephining of cranium, 587

  Trichiasis, 601

  Trigger finger, 320
      treatment of, 320

  Trismus, 97. _See_ Tetanus.

  Tropacocaine, 207

  Trophoneuroses, 310

  Trophoneurotic atrophy, 27
    diseases of bone, 432

  Tuberculides, 307

  Tuberculin in tuberculosis, 121
      dose of, 121
      manner of preparation, 121

  Tuberculosis, 111
    of abdominal wall, 783
    of axilla, 751
    bacillus of, 54
    of bladder, 118
    of bone, 116, 422
      acute miliary, 423
      chronic tuberculous osteomyelitis, 423
      pathology of, 423
      symptoms of, 423
      treatment of, 425
    of breast, 759
      treatment of, 759
    of bursæ, 118
    of choroid, 595
    cold abscess in, 112
        diagnosis of, 113
        lumbar, 114
        psoas, 114
        retropharyngeal, 114
        treatment of, 114
    colon, 869
    degenerative changes in, 111
    diagnosis of, 120
      from epithelioma, 293
    of face, 640
    fungous granulation in, 115
    giant cells in, 111
    gummas in, 114
    of joints, 393
      diagnosis of, 398
      pathology of, 394
      symptoms of, 397
      treatment of, 398
    of kidney, 118, 961
      diagnosis of, 962
      symptoms of, 961
      treatment of, 963
    of knee-joint, 456
      treatment of, 456
    of larynx, 684
      treatment of, 685
    lupus, 115
    of lymph nodes, 376
        cervical, 705
    of lymphatic structures, 116
    of mesentery, 939
      treatment of, 939
    method of healing, 112
        absorption, 112
        calcification, 112
        caseation, 112
        encapsulation, 112
        suppuration, 112
    miliary tubercles in, 111
    of mouth, 657
    of mucous membrane, 115
    of muscles, 331
    of ovary, 118
    paths of infection, 119
    of peritoneum, 116, 118
    of rectum, 876
    of seminal vesicles, 1021
    of skin, 115, 306
      folliculitis, 307
      lupus vulgaris, 306
      painful subcutaneous, 313
      scrofuloderm, 306
      treatment of, 307
      verruca necrogenica, 306
      verrucose, 306
    of spermatic cord, 1019
    of stomach, 795
    of tendon sheaths, 118
    of testicle, 118, 1015
      treatment of, 1016
    of tongue, 659
    of tonsils, 662
    treatment of, 120
      constitutional, 120
        tuberculin in, 121
      local, 120
        amputation in, 121
        Bier’s permanent hyperemia, 120
        excision in, 121
        ignipuncture in, 121
        iodoform injections in, 120

  Tuberculous cystitis, 985
    hydrops, treatment of, 399
    panarthritis, 395
    peritonitis, 786, 790
      ascitic, 791
      fibrinoplastic, 791
      treatment of, 791
      ulcerative, 791
    ulcers of intestines, 827
        symptoms of, 827
        treatment of, 827

  Tubulo cysts, 260
      allantoic, 260
      of vitello-intestinal duct, 260
      of Wolffian body, 260
    dermoids, 266

  Tumid ulcer, 67

  Tumors, 255
    of abdominal wall, 783
        vascular, 784
    albus, 393, 456
    of bladder, 992
      symptoms of, 992
      treatment of, 992
    of bone, 438
      cartilaginous, 440
    of brain, 582
      symptoms of, 583
      treatment of, 585
    of breast, 760
      treatment of, 760
    of cheek, 641
    classification of, 259
      connective tissue, 269
      cysts, 259
      dermoids, 264
      epithelium, 281
      of nerve elements, 279
      teratomas, 268
    clinical observations of, 257
    coccygeal, 627
      congenital, 635
    comparative pathology of, 256
    connective tissue, 269
        angioma, 277
        chondroma, 271
        exostoses, 272
        fibroma, 269
        lipoma, 269
        lymphangioma, 278
        myoma, 277
        myxoma, 276
        osteoma, 272
        sarcoma, 272
    cysts, 259
      glandular, 261
      hydrocele, 261
      pseudo-, 262
      retention, 259
      tubulo, 260
    derived from epithelium, 281
        adenoma, 284
        carcinoma, 289
        epithelioma, 286
          malignant chorion, 292
          suprarenal, 292
        fibro-adenoma, 284
        fibro-epithelioma, 282
        goitre, 283
        hydronephroma, 292
        mucous polyp, 283
        odontoma, 281
        ovarian cystoma, 284
        papilloma, 282
        struma, 283
    dermoids, 264
      ovarian, 267
      sequestration, 265
      tubulo, 266
    of diaphragm, 753
    of ear, 605
    embryonal hypothesis of Cohnheim, 256
    of face, 641
    of gall-bladder, 927
    gangrene from, 74
    of heart, 336
    heredity of, 256
    inflammation as cause of, 256
    inoculation experiments on, 257
    of intestines, 828
    intralaryngeal, 686
    intra-ocular, 594
    intratracheal, 686
    irritation as cause of, 255
    of jaw, 668
    of kidney, 969
    of larynx, 686
    of liver, 914
    local infectivity of, 257
    of lung, 732
    of lymphatics, 378
    metastasis of, 257
    microscopic appearances of, 257
    of neck, 706
    of nerve elements, 279
        glioma, 279
        neuroma, 280
    of nerves, 622
    nomenclature of, 258
    of omentum, 935
    of optic nerve, 593
    of orbit, 593
      cystic, 593
      vascular, 593
    of pancreas, 953
    parasitic theory of, 256
    of rectum, 885
    of salivary glands, 650
    of scalp, 546
      acquired, 546
      congenital, 546
      gaseous, 545
    of skin, benign, 311
      malignant, 315
    of spinal cord, 621
        diagnosis of, 622
        symptoms of, 621
        treatment of, 622
    of stomach, 801
    of teeth, 665
    teratomas, 268
    of testicle, 1017
    of thorax, 729
      treatment of, 730
    of thyroid, 711
    of tongue, 659
    of tonsils, 664
    of trachea, 687
    trauma as cause of, 255
    treatment of, 258
      of operable, 259

  Typhoid fever, secondary infection in, 167
    spine, 462
    ulcer of intestines, 826
        symptoms of, 826
        treatment of, 826
      of rectum, 876


  U

  ULCER, 65
    atheromatous, 339
    of auricle, rodent, 606
    of biliary passages, 921
        symptoms of, 922
        treatment of, 922
    callous, 67
    causes of, 65
      constitutional, 66
      local, 65
      traumatic, 65
    duodenal, 825
      symptoms of, 825
      treatment of, 826
    edematous, 67
    erethistic, 66
    of face, 640
    fissured, 66
    fistulous, 66
    of foot, perforating, 310
    fungous, 66
    gastric, 799
      diagnosis of, from appendicitis, 857
      operations for, 811
      symptoms of, 800
      treatment of, 800
    healthy, 66, 67
    hemorrhagic, 66
    indolent, 66
    indurated, 67
    inflamed, 67
    of intestines, 825
      cancerous, 827
      diagnosis of, from appendicitis, 857
      duodenal, 825
        treatment of, 826
      dysenteric, 827
      tuberculous, 827
        treatment of, 827
      typhoidal, 826
        symptoms of, 826
        treatment of, 826
    irregular, 66
    irritable, 66
    livid, 67
    peptic, of jejunum, 816
    phagedenic, 66
    process of repair in, 67
    of rectum, 876
      catarrhal, 876
      chancroidal, 876
      symptoms of, 877
      syphilitic, 876
      treatment of, 877
      tuberculous, 876
      typhoid, 876
    regular, 66
    rodent, 66, 67, 288
    sloughing, 66
    treatment of, 70
    tumid, 67
    undermined, 67
    of urethra, 1011
    venereal, 144. _See_ Chancroid.

  Ulceration, 65. _See_ Ulcers.

  Ulcerative endocarditis in septicemia, 88
    gingivitis, 664
    stomatitis, 657
    tuberculous peritonitis, 791

  Ulna, dislocations of, 536
    fractures of, 501
      treatment of, 501

  Ulnar artery, ligation of, 356
    nerve, operations on, 623

  Umbilical hernia, 896
      treatment of, 909
    vein, phlebitis of, 362

  Upper extremity, amputations of, 1029
        entire, 1033

  Uranoplasty, 654

  Urea in auto-intoxication, 80

  Ureteral catheterization, 958

  Ureters, anomalies of, 955
    calculus of, 973
    operations on, 976
    stricture of, 973

  Urethra, congenital defects of, 1004
    epispadias, 1005
    foreign bodies in, 1009
    hypospadias, 1005
    injuries of, 1008
    lacerations of, 1008
    strictures of, 1011
    ulcers of, 1011

  Urethritis, 147
    gonorrheal, in women, 159

  Urethrometer, 155
    Otis’, 1012

  Urethrotome, Otis’ dilating, 157, 1012

  Urine, electroconductivity of, 959
    incontinence of, 982
    retention of, 982
    suppression of, 982

  Uveitis, 596, 598

  Uvula, elongation of, 682
    syphilis of, 683


  V

  VALVULAR thrombosis, 35

  Vanghetti’s cinematic method of amputation, 1048

  Varices, 364
    congenital, 364
    symptoms of, 365
    treatment of, 365

  Varicocele, 364, 1019
    treatment of, 1021

  Varicose aneurysm, 339, 342
    veins, 363
      extirpation of, 366
      symptoms of, 365
      treatment of, 365

  Variola, secondary infection in, 169

  Varix, anastomotic, 364
    aneurysmal, 363
    compound, 367

  Vascular growth of skin, 314
        treatment of, 314
    system, surgical diseases of, 334
      syphilis of, 135

  Veins, air embolism of, 363
    angioma of, 366
      treatment of, 367
    atrophy of, 361
    calcification of, 361
    fatty degenerations of, 361
    hemorrhoidal, phlebitis of, 362
    hypertrophy of, 361
    inflammation of, 361
    injuries of, 217, 363
      treatment of, 364
    mesenteric, phlebitis of, 362
    rupture of, 363
    umbilical, phlebitis of, 362
    varicose, 363

  Velpeau’s bandage, 189

  Venereal ulcer, 144. _See_ Chancroid.
    warts, treatment of, 312

  Venesection, 182

  Venous nevus, 367
      congenital, 367

  Ventral hernia, 896
      treatment of, 909

  Vermiform appendix, actinomycosis of, 852
      anatomy of, 851
      cysts of, 852
      diseases of, 851
      empyema of, 860
      foreign bodies in, 852
      inflammation of, 851
      tuberculosis of, 852
      tumors of, 852

  Verruca necrogenica, 306

  Verrucæ, 311

  Vertebral artery, ligation of, 353

  Vesical calculus, 986
      symptoms of, 986
      treatment of, 987
    diverticula, 262

  Vesicants, counterirritation by, 184

  Vesicovaginal fistula, 839

  Villous papillomas, 282
      intracystic, 282

  Vincent’s angina, 703

  Viscera, wounds of, 219

  Vitello-intestinal duct, cysts of, 260

  Volvulus, 832, 870

  von Langenbeck’s incision in excision of elbow, 410
          of wrist, 411

  von Mosetig-Moorhof’s incision in excision of elbow, 410

  Vulva, elephantiasis of, 371
    gonorrhea of, 158


  W

  WAGNER’s osteoplastic resection of cranium, 590

  Wandering erysipelas, 94
    liver, 910
      symptoms of, 910
      treatment of, 911

  Wardrop’s method of treating aneurysms, 347

  Warts, 282, 311
    filiform, 311
    seborrheic, 312
    treatment of, 312
    venereal, treatment of, 312

  Warty horns, 283

  Wasps, poisoning by, 172

  Weir’s operation for saddle-nose, 644

  Wens, 285

  White swelling, 393

  Whitehead’s operation for hemorrhoids, 884
      on tongue, 661

  Whitlow, 328

  Witzel’s method of gastrostomy, 807

  Wolffian body, cysts of, 260

  Woodbury’s method of amputation of hip-joint, 1045

  Woolsorters’ disease, 106. _See_ Anthrax.

  Wounds of abdominal wall, gunshot, 783
        penetrating, 781
    of bladder, 981
    of chest, 722
      treatment of, 723
    contused, 211
      of bloodvessels, 216
      of tendons, 218
      treatment of, 212
      of viscera, 219
    of diaphragm, 725, 753
      treatment of, 726
    of esophagus, 741
    of face, 639
    fever, aseptic, 85. _See_ Surgical fever.
    gunshot, 220
      of abdomen, 232
      of bladder, 233
      diagnosis of, 225
      of face, 229, 639
      foreign material in, 224
      of head, 228, 565
      of heart, 231
      hemorrhage from, 223
      of intestines, 823
      of joints, 228, 381
      key-hole, 225
      of kidney, 233
      localizing symptoms of, 233
      multiple, 224
      of neck, 229
      pain from, 223
      prognosis of, 225
      of respiratory passages, 675
      shock from, 223
      of small intestines, 823
      of spinal cord, 624
      of spine, 230, 624
      of spleen, 233
      of thorax, 230
      treatment of, 225
    of heart, 334, 733
      suture of, 335 (note)
      treatment of, 335
    incised, 214
      of bloodvessels, 216
      of skull, 552
    of intestines, 823
    lacerated, 212
      of bloodvessels, 216
      of muscles, 218
    of larynx, 675
      treatment of, 675
    of liver, 911
    of lung, 724
      treatment of, 726
    of mouth, 658
    of muscles, 330
    of neck, 698
    of nerves, 612
    open, treatment of, 239
    of pancreas, 945
    penetrating, of joints, 381
      of chest, 722
      of orbit, 592
      of skull, 552
      of spinal cord, 624
      of spine, 624
      of stomach, 805
    of pleura, 724
      treatment of, 726
    punctured, 213

  Wounds, punctured, of abdomen, 214
      treatment of, 213
    repair of, 215
    of respiratory passages, 675
    of stomach, 794
    of trachea, 699
    treatment of, 238
      drainage in, 239

  Wrist, amputation of, 1031
    dislocations of, 536
    excision of, 411
    fractures of, 507

  Wryneck, 457
    diagnosis of, 458
    pathology of, 457
    treatment of, 458

  Wyeth’s exsector in excision of joints, 409
    method of amputation of hip-joint, 1045


  X

  XANTHELASMA, 601

  Xanthoma of skin, 314
    planum, 314
    treatment of, 314
    tuberosum, 314

  X-ray burns, 303
      treatment of, 304
    in treatment of cancer, 207


  Y

  YAWS, 308

  Yeasts, 55


  Z

  ZYGOMA, fractures of, 489




  Transcriber’s Notes


  Inconsistent and archaic spelling, hyphenation and capitalisation
  have been retained, also in anatomical and medical terminology and in
  proper names, except as mentioned under Changes made below.

  Depending on the hard- and software used to read this text, not all
  elements may display as intended.

  Page 195, ... that 5 per cent. is more than adequate ...: appears
  to be contradicted by the remainder of the sentence; possibly 5 per
  cent. is an error for .5 per cent.

  Page 275, Fig. 80: There is no line in the source document to
  indicate item a.

  Page 411, ... two lateral incisions, with through drainage ...:
  possibly an error for ... thorough drainage.

  Page 425, ... absorbents are eared or closed ...: as printed in the
  source document; possibly erroneously.

  Page 534, ... the section on fractures of the elbow-joint ...: there
  is no such section in the book; these fractures are discussed under
  fractures of the arm and the forearm.

  Page 1037, Fig. 696: reference numbers 1 and 2 are not present in the
  illustration.


  Changes made

  Some obvious minor typographical, lay-out and punctuation errors and
  inconsistencies have been corrected silently.

  Footnotes, tables and illustrations have been moved out of text
  paragraphs; some of the wider tables have been split or otherwise
  re-arranged to fit the available width.

  Plate I: the heading PLATE I has been inserted as in other plates.

  Page 25: ... their lumen marrowed ... changed to ... their lumen
  narrowed ....

  Page 229: (See Chapter XXXV.) changed to (See Chapter XXXVI.)

  Page 234: (See Chapter LVI.) changed to (See Chapter LVII.)

  Page 266, 267: Numbers 2 and 3 inserted before subsection headings
  Tubulodermoids and Ovarian Dermoids and Teratomas.

  Page 278: (See Aneurysm, Chapter XXVIII.) changed to (See Aneurysm,
  Chapter XXIX.)

  Page 293: ... will be found in Chapter IX. changed to ... will be
  found in Chapter X.

  Page 332, caption Plate XXX: Chapter XXVII changed to Chapter XXVIII.

  Page 352, ... the diagastric upward, or divided ... changed to ...
  the digastric upward, or divided ....

  Page 552: _Splintered or Comminuted Fractures._ changed to
  =Splintered or Comminuted Fractures.=

  Page 599: ... the site of tumors either nor-malignant ... changed to
  ... the site of tumors either non-malignant ....

  Page 650: Mukulicz has described ... changed to Mikulicz has
  described ....

  Page 767: ... as it were as a punishment for forgetfulness or
  intention ... changed to ... as it were as a punishment for
  forgetfulness or inattention ....

  Page 824: Blood may occear in the vomitus ... changed to Page 824,
  Blood may occur in the vomitus ... (possibly the phrase was intended
  to read Blood may appear in the vomitus ...).

  Index: Some page numbers and (spelling of) some entries changed to
  conform to the main body of the text.