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AN INDEX 
 
 OF 
 
 SUEGEET 
 
 BEING 
 
 A. CONCISE CLASSIFICATION OF THE MAIN FACTS AND 
 
 THEORIES OF SURGERY, FOR THE USE OF SENIOR 
 
 STUDENTS AND OTHERS 
 
 W**** by 
 
 **[. *\ { 
 
 e 
 
 C. B. KEETLEY, F.R.C.S., 
 
 SENIOR ASSISTANT SURGEON TO THE WEST LONDON HOSPITAL ; SURGEON TO THE SURGICAL AID SOCIETY 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 1883 
 
fa 
 
 Gift 
 F. W p„f„. 
 
 Trow's 
 
 Printing and Bookbinding Company 
 
 201-213 East Twelfth Street 
 
 New York 
 
$0 
 
 THE COMMITTEE 
 AND TO MY COLLEAGUES ON THE STAFF 
 
 OF THE 
 
 WEST LOFDON HOSPITAL 
 $l)is little Book is tUebicatcb 
 
 AS A TOKEN OF RESPECT AND FRIENDSHIP 
 
PREFACE 
 
 This book is intended to be read by the senior student shortly 
 before he goes in for his final examination, and after he has carefully 
 studied a complete text-book of surgery. When I was about to pre- 
 sent myself at the final examination for the Fellowship of the College 
 of Surgeons, I felt the need of some such work. I had read not only 
 more than one manual, but several special treatises and various essays. 
 I had had at least ordinary opportunities of practical work, and I do 
 not think I had wasted them. But I had made no complete series of 
 surgical notes, nor could I possibly have made such a series without 
 having unduly narrowed my reading or trespassed on the time spent in 
 the hospital wards. And this very narrowing, still more this very 
 trespassing, would have made me unqualified to make a good note- 
 book at all. For, to make good notes, one should have some practi- 
 cal experience and some breadth of view. How many men have had 
 to put aside as useless the notes once laboriously made, but made with 
 unripe knowledge, and with the bad judgment which such immaturity 
 implies ! 
 
 I am not dissuading students from taking notes while reading. 
 The practice is highly to be commended for various reasons ; for in- 
 stance, it rivets the attention — an essential part of memory — and it 
 frequently results in a note-book of high value, well worth reperusal. 
 But the more honestly that note-book is made, the more likely will 
 the student be to find the examination drawing swiftly near and his 
 reading creeping along but slowly. He feels compelled to desert his 
 note-book, and frequently his text-book too. He either skims on to 
 the end of the latter, haste and anxiety preventing him from thought- 
 fully studying it, or he leaves it altogether for the smallest " Intro- 
 duction" to surgery in the language. Now an "Introduction" or 
 " Elementary Handbook " has its proper place in education ; but that 
 
VI PREFACE. 
 
 proper place is not the time just before a final examination, especially 
 when it comes in to thrust out a more profound and elaborate treatise. 
 
 If the student knew that there was a short book accessible, con- 
 taining the main facts and theories of surgery put concisely, classified 
 and arranged in due order, and without superfluous explanation, he 
 would be able to really study his familiar text-book up to the last 
 month before his examination, relying upon such a short book to give 
 form to any knowledge which then remained nebulous in his mind. 
 
 These considerations convince me of the justness of the purpose of 
 my book. Of its execution I will say nothing. The shortcomings of 
 a book which, insignificant as it is, deals with questions of life and 
 death, can scarcely be excused ; they can only be lamented and con- 
 demned. But as I am convinced that it will do much more good than 
 evil, and I believe I have done my best, I publish the work hopefully. 
 These shortcomings would have been much greater if it had not been 
 for the help in revision which has been given by Messrs. Alfred 
 Street, Mills, Dunn, Alfred Back, Firth, and Charles Paget. Mr. 
 Street has gone over the whole book. I cannot thank him too 
 warmly. My friend and pupil, Mr. Charles H. Taylor, has made the 
 Index of Names. 
 
 Messrs. Doean, Lyons, and Julee have added contributions on 
 Ovariotomy, Toothache, and Ophthalmic Surgery respectively. 
 
 Mr. Juler desires acknowledgment to be made of the help given by 
 Mr. W. Adams Frost and Mr. W. Langdon, in the revision of the 
 article on Ophthalmic Surgery. 
 
 Finally, I will express a hope that the practitioner, as well as the 
 student, will occasionally find the book useful as a handy little work 
 of reference. 
 
 20 Princes Street, Hanover Square, 
 London, W., September, 1881. 
 
INDEX OF SURGERY. 
 
 Abdomen, Contusions of. — Always examine patient very carefully, 
 but gently. Diagnose whether the viscera are injured or not. Three 
 things protect against injury to the deeper structures, viz. : 1, thick and 
 muscular abdominal walls ; 2, empty state of the viscera ; and 3, the 
 patient's foreseeing and expecting the blow. 
 
 The parietal effects of a blow on the abdomen are : 1, rupture of mus- 
 cle ; 2, mere bruising (which, however, may be very serious in extent) ; 3, 
 rapture of the peritoneum, with consequent extravasation of blood into 
 peritoneal cavity. Rupture of a muscle causes temporary paralysis, swell- 
 ing, etc. Sometimes the separation of the parts may be felt. Abscess may 
 follow contusion, burrow widely, and cause most troublesome sinuses. 
 Hemorrhage from ruptured peritoneum may be fatal. The collapse so 
 produced is distinguished from the effect of ruptured intestine by the 
 absence of great pain and vomiting, and by positive signs of internal 
 hemorrhage. 
 
 A blow on the abdpmen may cause serious and even fatal collapse 
 without visceral injury, possibly by damaging the abdominal sympathetic 
 system. Treatment. — Attend to collapse, internal hemorrhage, inflamma- 
 tion, and suppuration on general principles. Avoid purgatives. In case 
 of peritonitis, use leeches, warm moist applications, and a liberal allowance 
 of opium. Mercury in case of sthenic inflammation. When there is 
 injury to a viscus, the particular one injured depends chiefly upon the 
 place where the force is applied. Each viscus presents special symptoms. 
 Liver and stomach most commonly suffer. 
 
 Rupture or Livee. — Symptoms. — Pain in hepatic region, signs of internal 
 hemorrhage, peritonitis, bilious vomitings, white stools. Traumatic sac- 
 charine diabetes (Bernard). 
 
 Rupture of Gall-Bladder. — Great pain, collapse, and anxiety. Rapid 
 death. 
 
 Rupture of Stomach. — Bloody vomiting, local pain, and general signs 
 of abdominal injury. 
 
WOUNDS OF. 
 
 Rupture of Intestines. — Bloody stools and general signs of abdominal 
 injury. Most frequently affects the jejunum. Emphysema. 
 
 Ruptured Spleen. — Severe internal hemorrhage. 
 
 Ruptured Kidney. — Pain and bruise in loins. Blood, and, if an abscess 
 should form, pus in urine. Vomiting, retraction of testicle, numbness of 
 thigh. Less hopeless than injury of the other viscera. 
 
 Ruptured Ureter has occurred, causing a large accumulation of urine 
 on the same side of the abdomen : recovery. 
 
 Ruptured Bladder. — Vide Bladder, Rupture op. 
 
 Treatment of Ruptured Viscera. — Perfect rest, warm and moist applica- 
 tions to seat of pain, leeches if pain be severe, opium in small and repeated 
 doses, a minimum diet — starvation if the intestines are believed to be 
 wounded — then give frequent small nutrient enemata. No purgatives. 
 Ice to suck. 
 
 Abdomen, Wounds of. — Are either superficial or penetrating. Pene- 
 trating are of four classes : 1, without either injury or protrusion of 
 viscera ; 2, with protrusion only ; 3, with injury and without protrusion ; 
 and 4, with both injury and protrusion. 
 
 Superficial Wounds. — Their Treatment. — Keep sides in apposition by 
 sutures and a suitable position of the body, but beware of confining blood 
 or discharge. 1, always secure the bleeding-point in severe hemorrhage, 
 enlarging wound if necessary ; 2, in slighter hemorrhage do not close 
 wound till bleeding stops ; 3, open wound freely at least sign of suppura- 
 tion. Part of abdominal wall which is wounded is liable to become seat 
 of hernia. Foreign bodies of enormous size may be hidden away in these 
 wounds. 
 
 Simple Penetrating Wounds. — Sometimes marked by escape of reddish 
 serum. If sutures should be required, place them close to or through 
 peritoneum, give opium, and apply general principles of practice. Prog- 
 nosis fairly good. 
 
 Wounds with Protrusion of Uninjured Viscera. — Cleanse and return 
 protrusion ; if necessary, snick edge of wound to make room. Omentum, 
 if much injured, may be cut off after ligaturing. See that the herni- 
 ated viscera are fairly and entirely passed into abdominal cavity, and not 
 slipped between muscles. Gangrenous bowel : leave it in situ to slough, 
 and form artificial anus. 
 
 Wounds with Injury and without Protrusion. — Very serious. Possible 
 escape of urine, fseces, bile, or gas through external wound. Extravasation 
 into peritoneal cavity not invariable. Other symptoms and treatment like 
 those of contusion of abdomen with rupture of viscera. ■ Vide above. 
 
 Wounds with both Injury and Protrusion. — Treatment. — Restrain hemor- 
 rhage by ligature or clamp. Do not be anxious to return solid viscera if 
 they are at all seriously injured. Sew up wounds of intestine with silk or 
 strong catgut. Glover's suture, unless the wound be lacerated or involve 
 
ABSCESS. 3 
 
 much of bowel's calibre ; then stitch bowel to edge of external wound to 
 form artificial anus. Allow no food, except ice and barley-water, for 
 three days. See also Peritonitis (Traumatic), Fistula (Gastric and Bil- 
 iary), Artificial Anus. 
 
 Abscess. — A circumscribed collection of pus. Two chief kinds, acute 
 and chronic. Term " cold " is sometimes used as synonymous with chronic, 
 and sometimes means a chronic abscess which has formed without any 
 noticeable signs of inflammation. 
 
 Acute Abscess. — Causes. — Injury, irritation of a foreign body, follicular 
 obstruction, absorption of poison, especially by lymphatics, and some 
 obscure constitutional conditions. Symptoms. — Chills, rigors ; tempera- 
 ture often rises suddenly to 104°. Local symptoms of inflammation. 
 Throbbing pain, which becomes more dull and aching as pus forms. 
 (Edema of skin. Fluctuation. The swelling, which is at first hard, 
 gradually softens in centre. Pointing of abscess : . the cuticle rises, the 
 skin ulcerates or sloughs, and bursts. Terminations. — 1, when opened 
 either surgically or spontaneously, its walls fall together and it closes ; 2, 
 a sinus or fistula remains ; 3, acute abscesses sometimes cause serious mis- 
 chief by opening into blood-vessels and serous cavities. Diagnosis. — An 
 acute abscess can scarcely be mistaken. Treatment. — Local rest very im- 
 portant ; general rest in serious cases. Treat cause if possible. Warm 
 moist applications. Quinine internally. Calomel (5 to 10 grains) if the 
 tongue is not clean. Indications fgr Opening. — 1, when in sheath of a ten- 
 don ; or 2, under strong fibrous membranes ; or, 3, anywhere else where 
 pus is likely to burrow instead of coming to the surface ; 4, near a joint ; 
 5, under the periosteum ; 6, when pressure is likely to be dangerous ; 7, 
 when it may cause some direct obstruction to some passage ; 8, when 
 caused by some noxious infiltrating fluid, e.g., urine ; 9, when a spon- 
 taneous opening would produce deformity, e.g., in neck ; 10, when near 
 anus. After abscess is open, employ pressure, if necessary, to prevent 
 fistula ; but poulticing usually suffices as a dressing. Method of Opening 
 Acute Abscess.— 1, By Paget's or Syme's knife or lancet; 2, by Hilton's 
 method when deep and in a dangerous situation. ''Hilton's Method." — 
 Incise skin and deep fascia, then push a director on into abscess ; lastly, 
 pass a pair of dressing-forceps along director, and when they have entered 
 the cavity, open the blades. Opening to be dependent, parallel with any 
 neighboring important structures, and free. 
 
 Chronic Abscess. — Causes. — Dead bone : all causes of acute abscess, 
 quod vide. Scrofula. Constitutional debility. Signs. — A swelling, at first 
 hard, afterward soft and fluctuating, usually situated near a lymphatic 
 gland, or in some special situation, e.g., in the psoas muscle, or in loose 
 cellular tissue, e.g., that of buttock. Often a certain amount of pain and 
 tenderness ; often evident disease of bone. Pressure on nerves may cause 
 pain or spasm. Abscesses near mucous canals sometimes, but rarely, 
 
4 ADENOCELE, ADENOMA. 
 
 become emphysematous. Course. — Often very tedious, usually tends to 
 burst, either through skin or into some internal cavity, but usually the 
 former. May remain stationary for years ; and may contract while its con- 
 tents partly degenerate, partly are absorbed. Constitutional Effects. — 
 Usually little or none till it opens and its contents are exposed to the air. 
 Then, if the abscess be of any size, decomposition of its contents tends to 
 occur with high fever. Vide Hectic Fever, Septicaemia, etc. Liability to 
 burrow, to open into important vessels, and to cause injurious pressure 
 effects. Diagnosis. — From, 1, innocent and malignant tumors ; 2, aneu- 
 risms. 1, in cases of doubt, use trochar, grooved needle, or aspirator. 2, 
 vide Aneurism. Prognosis depends upon size, position, age of patient, 
 curability of cause, and upon treatment. Middle age most hopeful. 
 Treatment. — Eemove cause, vide Caries. If there is no great tensive pain, 
 or if there is no reason to suspect that burrowing is going on, opening 
 may be delayed. An effort may be made to obtain resolution by counter- 
 irritation, iodine, mercurial plasters, and rest. Various modes of open- 
 ing : 1, by knife ; 2, by trochar and canula ; 3, aspirator ; 4, caustics. 
 Free openings, counter-openings, drainage-tubes, repeated partial evacua- 
 tions by aspirators, etc. Antiseptic treatment, quod vide. Dangerous septic 
 symptoms, a probable consequence of prematurely opening a chronic 
 abscess. 
 
 Puerperal Abscesses occur after parturition ; are probably pysemic in 
 nature. Locality. — Iliac fossa, orbit, joints, thigh, etc. 
 
 Acupressure. — Four chief modes : 1, a long needle is thrust right 
 through flap and made to bridge over artery ; 2, a short needle, with a 
 twisted wire through eye to extract it by, is thrust into soft tissues on 
 each side of and made to bridge over artery ; 3, the vessel is compressed 
 between a needle and a loop of wire, like the common hare-lip suture ; 4, 
 needle is thrust through soft tissues beside artery, then twisted down upon 
 the artery through an arc of a circle, and thrust into the neighboring soft 
 tissues again. Advantages of acupressure. — No foreign body is left in 
 wound more than a day or two, as, after that time, the needles are re- 
 moved. A few hours suffice for small arteries. Acupressure does capitally 
 in scalp-wounds and when varicose veins burst. Vide Pirrie's and Sir 
 James Simpson's writings. 
 
 Adenitis. — Vide Glands, Diseases of. 
 
 Adenoeele, Adenoma. — Glandular Tumor. A growth, the whole or 
 part of whose structure resembles that of some gland. (But the term 
 " Lymphoma " is usually applied to any tumor resembling lymphatic gland. ) 
 When not pure these tumors are called Adeno-sarcoma, Adeno-myxoma, 
 etc. Occurrence.— In the "mucous polypi" of the nose, rectum, and 
 uterus, vide Polypi ; in thyroid gland, vide Bronchocele ; in parotid, lips, 
 tonsils, and skin. Physical Character. — Movable, rounded, ovoid, or lobu- 
 lated. Growth, variable in rapidity. Treatment. — Divide capsule and 
 
AMPUTATION". 5 
 
 enucleate in suitable cases. Also refer to articles Polypi, Bronchocele, 
 Breast Tumor, etc. 
 
 Amputation. — (When through a joint, it is termed Disarticulation.) — 
 When required. — For incurable and disabling disease, deformity, or injury 
 of the part ; for disease which would take too long time in recovery ; to 
 save life when nature would find it easier to heal the amputation wound 
 than to cure the disease or injury ; for aneurism below or even above the 
 site of operation ; for secondary hemorrhage. 
 
 General Principles. — 1, Eemove no more of a limb than is necessary; 
 2, obtain sufficient coverings for the stump ; 3, arrange that the cicatrix 
 shall not He on the end of the bone ; 4, do not take hopelessly unsound 
 tissue into the flaps ; 5, take every precaution to check hemorrhage and to 
 prevent its recurrence ; 6, cut the large blood-vessels transversely ; 7, 
 remember the paramount importance of dressings and after-treatment. 
 
 Instruments. — 1, Knives appropriate to each case ; 2, saw ; 3, bone- 
 forceps ; 4, lion-forceps ; 5, common scalpels ; 6, artery-forceps ; 7, dissect- 
 ing-forceps ; 8, ligatures ; 9, needles and sutures ; 10, dressings, sponges, 
 retractors, towels, water, etc. 
 
 Assistants. — 1, Chief, who sponges, secures arteries, etc., usually stands 
 opposite operator ; 2, holds part to be removed ; 3, secures main artery, 
 unless tourniquet be used ; 4, hands instruments when wanted ; 5, chlo- 
 roformist. Number of assistants of course depends greatly on supply 
 accessible. 
 
 Methods. — 1, Circular ; 2, oval ; 3, flap ; 4, mixed of skin-flaps and cir- 
 cular cut through muscles. 
 
 Steps. — 1, Divide soft parts ; 2, saw bone (avoid splintering, cut off 
 spiculae) ; 3, tie vessels and trim soft tissue ; 4, adjust flaps and insert 
 sutures ; 5, apply first dressings. 
 
 Circular Amputation. — 1, Sweep through skin and fat and dissect up 
 for half diameter of limb, turning edge of knife slightly away from skin to 
 avoid scoring the vessels which supply the skin-flap ; 2, sweep through 
 muscles, "retracting" all the time; 3, still having the muscles well re- 
 tracted, one or two inches, and having divided the periosteum by a sweep 
 of the knife, saw through bone. Finish as directed above. 
 
 Oval Amputation. — See amputation of finger at metacarpo -phalangeal 
 joint. 
 
 Flap Amputation. — Three varieties : 1, Double Flap ; 2, Rectangular 
 (Teale's) ; 3, One Long Flap. 
 
 Double Flap may be lateral, antero-posterior, or oblique. Cut thin 
 flaps from without inward, but thick and fleshy ones by transfixion. Flap 
 containing vessels to be cut last, and vessels cut long. 
 
 Eectangular Flaps (Teale's).— AM the soft tissues down to the bone in- 
 cluded in the flaps. Main artery to be in short flap. Ends of flaps square. 
 Long flap : its length and breadth each equal half the circumference of 
 
O AMPUTATION. 
 
 the limb. Short flap : its length equals one-fourth that of long flap. 
 Bones sawn exactly at angle of union of flaps, without any retraction. 
 
 Spence's Operation (a modification of Teale's). — No posterior flap ; re- 
 traction instead. Anterior flap simply hangs down over bone. 
 
 Lister cuts an anterior rounded flap two -thirds diameter of limb in 
 length ; skin and enough muscle to cover bone. Posterior rounded flap 
 (one-third limb's diameter), all skin. Posterior muscles cut as short as 
 possible (to free flaps from effects of their contraction). Retract soft parts 
 for two inches, and saw bone. 
 
 Single Flap amputation. — Vide amputation at phalangeal joints of 
 fingers. 
 
 Skin-Flaps and Circular Incision through Muscles. — Cut two skin-flaps 
 by dissecting from without inward. Then finish as in circular amputation. 
 
 Hemorrhage during amputation to be prevented temporarily by digital 
 pressure on main artery, by tourniquet, or by Esmarch's bandage. 1 After- 
 ward, ligature by silk, hemp, or catgut — torsion or acupressure is to be 
 employed. Sponging with cold or with hot water to stop oozing. 2 Actual 
 cautery to check obstinate bleeding from bone. 
 
 Muscles retract greatly in traumatic cases, but veiy little in limbs 
 affected with old disease. Knife to be used' with a free sawing motion. 
 Parts to be relaxed during transfixion. Commence sawing the bone by 
 drawing the saw back to make a groove. 
 
 Mortality after Amputation. — 1, Chief causes : 1, shock ; 2, secondary 
 hemorrhage ; 3, pyaemia (in nearly half the fatal cases) ; 4, erysipelas ; 5, 
 phlebitis ; 6, congestive pneumonia. Besides which, 7, hospital gangrene, 
 8, sloughing of stump, and, 9, tetanus, occasionally carry off patient. 
 Pyaemia most common after traumatic, rare after chronic disease cases. 
 
 Circumstances affecting Patient's Chance of Recovery. — Two classes : 1, 
 constitutional conditions ; 2, circumstances of operation itself. Class 1 : 
 age, general health, and hygienic conditions. Child's twice as good as a 
 young man's, three times as good as an old man's. Class 2 : seat of 
 amputation, structure of bone sawn through ; whether amputation is for 
 injury or disease ; nature of the affection ; time after the injury. Diseased 
 kidneys, town life, amputation high up a limb, amputation for injury, or 
 through much cancellous tissue of bone — all these darken the prognosis. 
 Nature of disease : after chronic disease, prognosis good ; malignant or 
 tuberculous disease, bad ; acute suppurative disease of joints, very bad ; 
 amputation of expediency, very bad. Time after injury : primary or 
 secondary. Primary are such as are done within thirty hours of the in- 
 jury. Secondary are amputations done after suppuration has occurred. 
 
 1 For a resume of the advantages of Esmarch's bandage, see London Medical 
 Record, 1874, p. 271. 
 
 2 See Practitioner, February, 1879. 
 
AMPUTATION. < 
 
 Primary always more dangerous than secondary, except in amputations of 
 the upper extremity done in civil practice. Death after primary amputa- 
 tion usually caused by shock, hemorrhage, or exhaustion ; after secondary, 
 by erysipelas, pyaemia, etc. 
 
 Amputation at Ankle. — Pirogoff's. — Kesembles Syme's. But the lower 
 incision extends from one malleolus to the other across the sole of the foot, 
 and inclines forward and downward ; while the os calcis is sawn through 
 obliquely, downward and forward, just behind the articular surfaces for 
 the astragalus. The posterior piece of the os calcis is then placed in ap- 
 position with the tibia, whose articular surface is previously sliced off. 
 The resulting stump is longer than Syme's ; but if the tarsus is diseased 
 there is a liability to return of the disease in the os calcis. 
 
 Syme's Amputation. — Inner angle of incisions is three-quarters of an 
 inch below and behind inner malleolus ; outer angle exactly opposite outer 
 malleolus. Upper incision has an angle of 45° to sole of foot ; lower in- 
 cision inclines downward and somewhat backward. Os calcis may be dis- 
 sected from heel-flap either before or after disarticulation at ankle, i.e., 
 either from below or from above. Syme dissected out os calcis from be- 
 low, and disarticulated afterward. Avoid scoring flap. The anterior tibial 
 and both plantar arteries, and not the posterior tibial, are divided. 
 
 Arm, Amputation of. — Upper Arm. — Double flap by transfixion often 
 employed. Also circular and mixed operation. Arteries divided ; brachial, 
 superior profunda, and inferior profunda. 
 
 Forearm. — In upper and lower thirds prefer skin-flap and circular 
 through muscles (T. Smith). Arm to be held either supine, or midway 
 between supination and pronation. Arteries. — Kadial, ulnar, anterior and 
 posterior interosseous. 
 
 Elbow-Joint, Disarticulation at. — Seldom done. Best to cut a large an- 
 terior flap (Lister). 
 
 Fingers, Amputation of. — Usually done by disarticulation. To remove 
 the second or third phalanx, cut a single palmar or double (palmar and 
 dorsal) flaps. As the heads of the bones form the knuckles, the articula- 
 tions are just in front of the knuckles. In case of injury, here as else- 
 where, " cut according to your cloth." 
 
 Metacarpophalangeal Disarticulation. — So called "oval," really "pyri- 
 form " incision. Commence half an inch posterior to head of metacarpo- 
 phalangeal joint, carry incision right round palmar surface of base of finger 
 and back again. Divide lateral ligaments, twist the bone out of its place 
 and remove it. Extensor tendon should be cut by first incision. Kemoval 
 of head of metacarpal makes hand more sightly, but much weaker. 
 
 Foot, Amputation through. — Choparfs. — Between scaphoid and cuboid 
 on the one hand, and astragalus and calcis on the other. Long plantar 
 flap, reaching to roots of toes ; very short dorsal flap. Incisions commence, 
 on inner side, just behind prominence of scaphoid ; on outer side, one inch 
 
8 AMPUTATION. 
 
 behind base of fifth metatarsal bone. Beware of opening ankle-joint. Dis- 
 articulate before cutting plantar flap. Plantar flap to be longer on inner 
 than outer side. Arteries. — Dorsalis pedis, plantar, and digital. 
 
 Be Lignerolles' . —Removes all the bones of the tarsus, except the as- 
 tragalus. Heel and dorsal flaps. ' 
 
 Hancock's. — Leaves the astragalus and posterior end of os calcis, on the 
 principle of PirogofPs. 
 
 Lisfranc's (commonly called Hey's)* — Between tarsus and metatarsus. 
 Long plantar flap, reaching to roots of toes, longer on inner than on outer 
 side. Dorsal incision nearly transverse, with only slight convexity forward. 
 Ends of incisions, on inner side, one inch before tubercle of scaphoid ; on 
 outer side, just behind base of fifth metatarsal. In disarticulating, remem- 
 ber dovetailing of second metatarsal bone into cuneiform bones, and the 
 obliquity of cuboido-metatarsal joint. Cut plantar flap from behind for- 
 ward after disarticulation, but cut its borders deeply down to bone when 
 commencing operation. Arteries. — Dorsalis pedis, plantar, and digital. 
 
 Hand, Amputation through. — Not a single bone should be unnecessarily 
 removed. The flaps have usually to be taken from where soft tissues are 
 most available. 
 
 Hip-Joint, Amputation at. — Three ways : 1, long anterior flap ; 2, dou- 
 ble flap, anterior and posterior ; 3, lateral flaps. Use Lister's tourniquet 
 for aorta, or Davy's lever per rectum ; let patient's buttocks project be- 
 yond edge of table, tie body and sound limb to table, have three assistants, 
 and stand on left side of limb. Assistants : 1, takes charge of flap and 
 pays greatest attention to instantly stopping all hemorrhage ; 2, manipu- 
 lates limb : he has mainly to prevent locking of operating-knife, especially 
 by keeping great trochanter out of the way ; 3, controls tourniquet. 
 
 Long Anterior Map Operation. — Left hip : transfix from a point midway 
 between ant. sup. spine of ilium and great trochanter to another point 
 just in front of tuberosity of ischium. Knife should pass behind femoral 
 vessels and lay open hip- joint. Eight hip : transfix in the same way, but 
 in the opposite direction. Other operative procedures same for both right 
 and left limb. Length of flap, eight or ten inches. Next, draw knife 
 across capsule of joint, opening it freely. Divide ligamentum teres and 
 external rotators. Cut vertically downward through remaining soft parts. 
 
 Manipulations by Assistant having Charge of Limb. — 1, while anterior flap 
 is being formed, flex slightly, adduct, and rotate inward. Then extend 
 and rotate outward, till, the ligaments being divided, head of femur leaves 
 its socket with a sucking noise. Then, again slightly flex, adduct, and ex- 
 tend forcibly. Absence of posterior flap favors drainage. Arteries. — Fe- 
 moral, profunda, obturator, sciatic and minor branches. 
 
 1 Highly pra'sed by Nelaton. 
 
 2 Hey's operation differs from Lisfranc's in that the former saws through the 
 second metatarsal bone. 
 
AMPUTATION. y 
 
 Double-flap Amputation. — Manipulations and proceedings resemble pre- 
 ceding ; but there are two naps : anterior, five inches ; posterior, four 
 inches long. In cutting posterior flap, have limb rotated inward to clear 
 great trochanter. 
 
 Lateral Flaps. -'-External is composed of skin. Internal, of skin and 
 muscle, is cut from within outward. Angles, where flaps join, are : in 
 front, just outside femoral vessels ; behind, close to tuberosity of ischium. 
 
 When done for injury, amputation at hip-joint is almost always fatal ; 
 when for disease ; three recover out of five. 
 
 Knee-Joixt, Disarticulation at. — Chief methods : 1, anterior skin-flap ; 
 2, antero -posterior double flaps, either the anterior or the posterior being 
 the longer ; 3, long posterior flap (usually including flesh); 4, lateral skin- 
 flaps ; 5, anterior and posterior skin-flaps, with circular incision through 
 muscles. The patella is generally left ; then the tendon of the quadriceps 
 extensor may be divided. Incisions in lateral flap method begin one inch 
 below tubercle of tibia. Flaps to be somewhat square. Cartilage to be 
 left, unless diseased. Mortality. — For disease, one in three. 
 
 Leg, Amputation of. — Any one of the ordinary methods can be used ; 
 but double skin-flaps and circular through muscles are very good. Care 
 should be taken not to lock the knife between the two bones, and not 
 turn its edge upward in cleaning between the bones. The sharp anterior 
 edge of the tibia should be bevelled off with the saw. Sawing through 
 the fibula should always be completed before the division of the tibia. 
 Mortality. — For disease, one in twelve ; for injury, 60 per cent. 1 
 
 Penis, Aaeputation of. — Clover's clamp or tape to check hemorrhage. 
 Corpus spongiosum to be cut half an inch longer than C. cavernosa. Value 
 of galvanic cautery ecraseur. Urethra to be split into three and sewn to 
 skin. Skin to be divided higher up than the " corpora," i.e., the very re- 
 verse of the principle adopted in amputating a limb. 
 
 Shoulder- Joint, Amputation of. — Three chief methods, viz.: 1, lateral 
 flaps ; 2, anterior and posterior flaps ; 3, oval incision. But, in cases of 
 extensive injury to upper arm, almost any operation may be expected to 
 give a satisfactory stump. 
 
 Lateral Flaps. — Transfix in cases of injury. Cut from without inward 
 when for disease. Knife, narrow-bladed. Three assistants : 1, holds the 
 limb ; 2, raises the flap ; 3, follows the knife as it cuts behind the hu- 
 merus, and grasps the inner flap with the axillary artery. Subclavian may 
 be compressed. ( Position of operator : for right limb, stand before ; for left 
 limb, stand behind. Right side : enter knife midway between acromion 
 and coracoid process. Left side, enter well behind spine of scapula, at 
 
 1 These statistics of amputations are average, and, of course, differ from those of 
 some exceptionally successful surgeons. Moreover, surgical operations have been 
 steadily increasing in safety for years, thanks to Lister and others. 
 
10 AMPUTATION. 
 
 posterior border of axilla. Outer flap should contain most of deltoid 
 Secondly, open capsule, divide muscles attached to great tuberosity (arm 
 rotated inward) and subscapularis (arm rotated outward). Thirdly, having 
 dislocated head of humerus, pass knife behind it and cut down for a dis- 
 tance of three inches, keeping close to inner side of* bone (so as not to 
 divide artery too soon). Then complete inner flap by turning edge of 
 knife inward and cutting through. Arteries. — Axillary, circumflex, sub- 
 scapular, etc. 
 
 Oval Amputation. — When uncertain whether to resect joint or ampu- 
 tate, perpendicular incision may be made as for resection (quod vide), and 
 the joint examined. Then, if desirable, the limb can after all be removed 
 by cutting obliquely right around the limb from and to the lower end of 
 the longitudinal incision. This is Spence's plan. 
 
 Mortality. — For disease, one in two ; for accident, one in three. 
 
 Thigh, Amputation of. — Methods. — 1, Gritti's ; 2, Carden's ; 3, Spence's; 
 4, lateral flaps (Vermale's) ; 5, circular ; 6, double flap by transfixion ; 7, 
 mixed ; 8, Teale's. 
 
 GrittVs. — Done "just above condyles with an anterior flap, in which the 
 patella is preserved, its surface being sawn and applied to the cut surface 
 of the femur." Incision extends from upper end of fibula to inner side of 
 joint, reaching downward below patella. 
 
 Gardens. — Through the condyles. Single anterior flap. Circular cut 
 through deeper parts. Slight retraction of them before sawing bone. 
 Advantages. — The medullary canal not being opened, there is less risk of 
 pyaemia. The skin of knee is accustomed to bear weight of body in kneel- 
 ing, etc. Arteries. — Popliteal and some of its branches. 
 
 Spence's. — Long anterior ; no posterior flap ; circular cut through mus- 
 cles ; retract two inches and saw bone. 
 
 Lateral Flaps. — Not to be recommended. This operation and the other 
 modes of amputating thigh all done in the ordinary way. Arteries. — Fem- 
 oral, profunda, external circumflex, anastomotica magna if flap reaches low 
 down, muscular branches. 
 
 Mortality of Amputation of Thigh. — After injury, three in five (much 
 more in military- practice) ; after disease, one in three. But, for chronic 
 knee-joint disease, it is particularly safe. 
 
 Thumb, Amputation of. — 1, At Carpo-metacarpal Joint. — Incision along 
 dorsum of metacarpal bone, commencing at palmar side of trapezio- 
 metacarpal joint, and ending at web of thumb. Flap from ball of thumb, 
 by transfixion. Eight thumb : transfix first. Left thumb : transfix after 
 making dorsal incision. Operator should stand beside the hand or fore- 
 arm, not in front of it ; otherwise his own left hand will get in his way. 
 Beware of locking knife under sesamoid bones ; and keep close to meta- 
 carpal bone, to avoid wounding radial artery. Arteries. — Dorsales and 
 arteria magna pollicis. 
 
ANAESTHESIA. 11 
 
 2, Thumb at Metacarpo-phalangeal Joint— Oval amputation. 
 
 Toe, Great. — At Tarso-metatarsal Joint— Two methods, flap and oval. 
 
 1. Flap. — Cut a flap from whole length of inner side of metacarpal 
 bone. Better not transfix for this. Then transfix between first and second 
 metacarpals, and cut downward right through web of toes. If possible, 
 save base of metacarpal bone ; otherwise divide tendon of peroneus longus 
 aud disarticulate. Beware of sesamoid bones, and of dividing commu- 
 nicating branch between dorsalis pedis and external plantar artery at 
 base of interosseous space. Artery divided always. — First digital. 
 
 2. Oval Amputation. — Commence incision half-an-inch posterior to 
 where the bone is to be divided or disarticulated. 
 
 Toes. — Amputated in same way as fingers. 
 
 Anaesthesia. — The term usually applied to the production of insensi- 
 bility to pain for surgical or medical reasons. This state is induced for 
 five purposes : 1, to relieve the pain of operations or examinations ; 2, to 
 facilitate such proceedings as the reduction of dislocations and herniae ; 3, 
 where spasm interferes with diagnosis ; 4, where hysteria or malingering 
 is suspected ; 5, as a curative agent, e.g., in puerperal convulsions. 
 
 Anaesthetics are either general or local. General anaesthetics in ordinary 
 use : 1, chloroform ; 2, ether ; 3, a mixture of chloroform, ether, and 
 alcohol ; 4, bichloride of methylene ; 5, nitrous oxide gas. 
 
 Their physiological action consists in paralyzing temporarily almost all 
 the nerve-centres, except those necessary to maintain life. 
 
 Advantages and Disadvantages peculiar to Each. — Nitrous oxide is the 
 least dangerous, but it is inconvenient for long operations. It is, par ex- 
 cellence, the anaesthetic for short operations. Bichloride of methylene has 
 a quick action and causes little vomiting. Recovery is rapid ; but it is 
 more dangerous than ether, and perhaps as dangerous as chloroform. It 
 is used in ophthalmic surgery and for ovariotomy. Chloroform has a 
 quick and powerful action, is comparatively agreeable to take, and seems 
 safe enough for children ; but, for adults, is more dangerous than ether. It 
 frequently causes vomiting. Ether is safe and powerful, and not much 
 slower than chloroform when properly given. On the other hand, the 
 patients sometimes require strong assistants to manage them in the stage 
 of excitement ; and in old bronchitics bronchial irritation is produced. As 
 air should not be mixed with ether, it is not adapted for operations about 
 the mouth. The mixture of alcohol, chloroform, and ether is much liked 
 at Guy's Hospital. (Chloroform has been said to be quite safe for par- 
 turient women, but several deaths have been recorded.) 
 
 Modes of Administration.' — Always see that all buttons and braces about 
 neck and chest are loose. In bloody operations about the mouth the 
 patient should sometimes be turned on his side. Prone position permis- 
 sible if required. Carefully watch respirations and pulse, especially the 
 former. 
 
12 ANAESTHESIA. 
 
 1. Chloroform. — Recumbent position. Clover's inhaler. Other inhaL 
 ers. Piece of lint. ToweL Allow free access of air. Commence gently. 
 Pour 3 ss. upon the towel to begin with. 
 
 2. Ether. — Best administered in a towel folded conically with a sponge 
 at the bottom, or in a cone of mackintosh lined with felt. Two ounces 
 are not too much to begin with, and the drug should be administered 
 boldly, especially in the stage of excitement. If the drug be pushed 
 vigorously then, complete anaesthesia usually follows immediately ; if in- 
 decision or timidity be displayed, the patient's struggles last a long time. 
 No air should be allowed to get under the apparatus, which should be 
 held firmly down over mouth and nose. Patient may pull it off, unless 
 assistants are arranged before commencing so that they may be ready to 
 restrain the patient the moment restraint is necessary. § j. of ether is to 
 be put into the cone from time to time. The patient's face is red and con- 
 gested, and his breathing apt to be stertorous. Much saliva is secreted. 
 
 2a. — It is an excellent plan to administer, successively, nitrous oxide 
 and ether, a mixture of the two, and lastly ether alone. Mr. Clover has 
 contrived an apparatus which answers this purpose admirably. No stimu- 
 lant should be given before administering ether. Pure anhydrous, washed 
 ether always to be used. Eobbins' ether for local anaesthesia is dangerous. 
 
 3. The Mixture, of alcohol 1 part, chloroform 2 parts, and ether 3 
 parts, is to be given like chloroform ; but the air should not be allowed to 
 mix quite so freely with the vapor (?). 
 
 4 Bichloride of Methylene. — 3 j. is placed in Rendle's apparatus. This 
 is a cone of leather lined with flannel, has small perforations at the apex, 
 and is held close over the mouth and nose, as in giving ether. If a second 
 drachm is afterward used to prolong the anaesthesia, the effects resemble 
 those of chloroform. 
 
 5. Nitrous Oxide Gas. — Is given perfectly pure, from a bag, which is 
 replenished from an iron bottle, which contains the gas compressed to a 
 liquid state. The appearances produced are somewhat alarming, for the 
 blood is temporarily "unoxygenated," like venous blood. But this is not 
 really dangerous. 
 
 Causes of Danger from Anaesthetics. — 1, sudden stoppage of respiration, 
 either from paralysis of nerve-centre, or from mechanical obstruction, e.g., 
 falling back of the tongue, or passage of blood into larynx ; 2, sudden 
 paralysis of the heart. But it would appear that heart disease does not 
 contra- indicate anaesthetics ; and ether is a powerful cardiac stimulant ; 3, 
 shock. 
 
 Precautions. — 1, Do not push the anaesthetic too much at first. Be 
 careful about the quantities used ; 2, allow plenty of air with chloroform ; 
 3, recumbent position, especially with chloroform, though not required 
 with gas ; 4, loosen all tight coverings on chest and neck ; 5, have ether of 
 the right quality ; 6, it should be possible to let a free supply of fresh air 
 
ANEUEISM. 13 
 
 into the room if necessary ; 7, administrator should confine his attention 
 to the administration only ; 8, he should carefully watch the pulse and 
 respiration — the former most closely with chloroform, and the latter with 
 ether. 
 
 Treatment of Dangerous Symptoms. — Pull the tongue out of the mouth. 
 Clear the throat out if there be any suspicion that blood or vomited food 
 is obstructing the larynx. This failing, tracheotomy may be found justifi- 
 able. Artificial respiration. Galvanism : one pole on the throat near the 
 phrenic nerve ; the other in pit of stomach. Hot affusion to head. Per- 
 pendicular position, with head downward. As much fresh air as possible. 
 
 Local Anaesthetics. — Extreme cold produced : 1, ice and salt ; or, 2, 
 ether-spray. Use twice as much powdered ice as salt, in a gauze bag. 
 Useful for small operations on the skin or about the nails, excision of 
 small epitheliomata, etc. 
 
 Aneurism. — A considerable dilatation of an artery, or any hollow 
 tumor communicating with the interior of an artery. 
 
 Classification. — According to the relation of its sac to the wall of the 
 artery, into : 1, true ; 2, false ; and 3, dissecting aneurism. According 
 to its shape, into fusiform and sacculated. And, according to its apparent 
 cause, into spontaneous and traumatic. Cirsoid aneurism and varicose 
 aneurism not usually included in this classification. 
 
 A true aneurism used to always mean one whose sac consisted of all 
 three arterial coats. The term, rarely now used at all, often means merely 
 that the sac is formed chiefly by the wall of the artery. False, in the same 
 way, may mean either that the sac is wholly, or that it is chiefly, formed 
 of tissues outside the artery. Dissecting aneurisms are formed when the 
 blood burrows between the coats of an artery. 
 
 Causes. — Dilated arteries are almost always found to be atheromatous 
 (vide Atheroma of Arteries) — 1, occupation : soldiers, sailors, employ- 
 ments where severe and prolonged efforts are required irregularly. 
 Soldiers are chiefly liable to thoracic, sailors to subclavian and axillary 
 aneurisms (probably from climbing, etc. ) ; 2, abuse of alcohol ; 3 syphilis : 
 the liability of soldiers is partly attributed to the latter two causes, and 
 partly to the strain on the thoracic organs, caused by the old-fashioned 
 stock and knapsack ; 4, strains ; 5, age : very rare in childhood, common- 
 est between thirty and forty ; 6, traumatic aneurisms are caused by direct 
 wounds. • 
 
 Pathology. — An idiopathic aneurism begins by the dilatation of a dis- 
 eased part of the wall of some artery. The whole wall may be so softened 
 as to dilate ; but usually the inner coat is ulcerated, and then, from the 
 first, the aneurismal sac consists only of the outer and part of the middle 
 arterial coat. But always, before the tumor reaches the size of an average 
 orange, all trace of distinction between the arterial walls and the sur- 
 rounding tissues is lost in its sac. In the meantime, wherever the inner 
 
14 ANEURISM. 
 
 coat of the artery is absent, the blood tends to deposit layer after layer of 
 fibrin : the outer layers, after a time, have become organized and pale, while. 
 the inner are still soft and dark-colored. Fusiform aneurisms have the 
 inner coat of the artery most sound, and only a few shreds of fibrin ad- 
 here to their walls. The wall of an aneurism itself tends to thicken and 
 strengthen. Adjacent parts are pressed upon, nerves are irritated or par- 
 alyzed, ducts obstructed, bones absorbed. 
 
 Symptoms. — Patient generally applies for advice either because of the 
 swelling, or of the pain caused by the pressure of the tumor ; but the 
 earliest symptoms are generally those of slight muscular weakness of the 
 limb. Tumor, in the course of some artery, soft at first, harder as it pro- 
 gresses. Pulsation, expansive. Bruit, loud and rasping, or soft, or alto- 
 gether absent. Pulse below aneurism weak. Often oedema, neuralgia, 
 spasm or paralysis from pressure on veins or nerves. Compress artery 
 above, tumor less tense or smaller ; compress artery below, tumor may 
 become larger or more tense. The tumor can often be partially emptied 
 by pressure. 
 
 Diagnosis. — May be confounded with tumors, or abscesses in the 
 course of large arteries ; malignant tumors of bone ; or mere enlargement 
 and relaxation of the artery. It is always to be borne in mind that the 
 pulsation of an aneurism is heaving, while that of a vascular tumor is usu- 
 ally sudden and more abrupt ; also, that aneurisms do not always pulsate, 1 
 and that when an aneurism is emptied by pressure, it gradually returns to 
 its full size. Diagnosis from Tumors and Abscesses pressing on the Artery. — 
 1, such swellings mostly have no bruit ; 2, their pulsation is an equable 
 rise and fall, and not expansive ; 3, an abscess probably shows signs of 
 suppuration (but an aneurism may suppurate too) ; 4, the tumor can often 
 be dragged off the artery which communicates to it its pulsation. 
 
 Diagnosis from Pulsatile Tumors of Bone. — 1, Bruit in pulsatile tumor 
 rarely so well marked, and often absent ; 2, pulsation more sudden and 
 less expansive ; 3, signs are often to be found in the state of the neighbor- 
 ing bone : thus, a plate of bone may be felt in the tumor. Pulsatile tu- 
 mors may dilate the bone : aneurisms cut a clean hole through bone ; 4, 
 these tumors being almost always cancerous, may be accompanied by other 
 signs of cancer. Diagnosis from Aneurismal Dilatation. — By the absence of 
 all marked symptoms of a genuine aneurism. a 
 
 Prognosis. — Spontaneous cure does sometimes occur, but very rarely. 
 Without treatment a fatal event from bursting of the sac is to be expected. 
 With treatment the patient's chance depends mainly on the situation of 
 
 1 For diagnoses, etc. , of aneurisms which do not pulsate, see Holmes, in British 
 Medical Journal, Jan., 1880, and Morrant Baker, in St. Bartholomew's Hospital Re- 
 ports. 1879. Auscultate and observe the effect of pressure on the main artery. 
 
 2 From Holmes's System, vol. iii , p. 455. 
 
ANEURISM. 15 
 
 the aneurism, partly on its cause, the fitness of the case for operation, and 
 on whether the aneurism be single or multiple. 
 
 Course. — Enlargement in size ; formation of layer after layer of coagu- 
 lum ; absorption, first of adjacent parts, and next of the aneurismal sac it- 
 self. Then one of the following terminations : 
 
 Terminations. — 1 (most common), rupture of sac and death ; 2, escape 
 of piece of clot, embolism beyond aneurism, and spontaneous cure ; 3, 
 suppuration of sac ; 4, flow of blood through aneurism checked by its own 
 growth and pressure on artery above ; 5, coagulation may go on to so 
 great an extent as to fill sac with fibrinous lamime, and stop pulsation and 
 further enlargement ; 6, the condition may remain stationary. All these 
 events, except the first and sixth, may cause spontaneous cure. But the 
 third may cause fatal hemorrhage. Aneurisms burst through serous mem- 
 branes with a large opening, causing instant death ; but through mucous 
 membrane and skin with a small opening, so that death is preceded by 
 several hemorrhages. 
 
 Treatment. — Classified into internal or medical, and external or surgi- 
 cal. Every method aims at producing a clot which shall stop the growth 
 of the aneurism, excepting the method of Antyllus. Surgical treatments 
 are : 1, ligature (Anel's, Hunter's, and Brasdor's operations) ; 2, pressure 
 (instrumental and digital) ; 3, flexion ; 4, use of Esm arch's bandage 
 (Reid) ; 5, acupressure and temporary ligature ; 6, manipulation ; 7, gal- 
 vano-puncture ; 8, coagulating injections ; 9, wire in the sac. 
 
 Ligature — Method of Antyllus. — Operation. — Command artery above 
 aneurism. Open sac and turn out clots. Find the arterial orifices open- 
 ing into it, and tie the artery above and below aneurism, controlling hem- 
 orrhage in the meantime by pressure with the fingers. When suitable : 
 1, in gluteal aneurisms ; 2, axillary aneurisms ; 3, traumatic aneurisms at 
 bend of elbow ; 4, when an aneurism has been opened accidentally ; 5, 
 when the sac has burst. 
 
 Hunter ian Operation. — Artery tied at point of selection above aneurism. 
 — Operation. — Instruments: scalpel, forceps, retractors, artery-forceps, liga- 
 tures, aneurism-needle, etc. Observe landmarks, incise or separate struc- 
 tures to expose sheath of vessel, make a very small opening in the sheath, 
 gently separate artery from sheath at point selected. Pass aneurism-needle 
 from the side where vein lies. The great advantages of Hunter's opera- 
 tion are that artery is most likely to be healthy, and certain to be accessi- 
 ble, at the part chosen. 
 
 Anel tied the artery immediately above the aneurism. 
 
 Brasdor's Operation. — Artery tied on the distal side of aneurism. 
 Chiefly applicable to carotid in aneurisms at root of neck. 
 
 Pressure. — Either (1) direct, i.e., upon the aneurism itself — very unu- 
 sual ; or (2) upon the artery. Effected either by the fingers or by mechan- 
 ical contrivances, e.g., Carte's tourniquet, or P. H. Watson's weight com- 
 
16 ANEURISM. 
 
 pressor. The treatment by Esmarch's bandage should be classed as a 
 treatment by pressure. Under anaesthesia almost any aneurisms, except 
 the thoracic, may be treated by compression ; and certain thoracic aneu- 
 risms might, perhaps with advantage, be treated by distal compression of 
 the carotid, etc., on the principle of Brasdor's operation. Statistics of re- 
 sults much better than those of ligature. But prolonged, unsuccessful 
 compression sometimes appears to make worse the prognosis of a subse- 
 quent operation for ligature. 
 
 Prepare the patient by rest in bed and limited diet (both as to fluids 
 and solids). Chloral if necessary. Bandage limb, shave seat of pressure 
 and dust it with hair-powder. If pressure be instrumental and there be 
 room, apply two instruments to the artery and use them alternately. Keep 
 bed-clothes well off the tourniquets. Patient may sometimes be instructed 
 to manage his own treatment. Anodynes if necessary. Use the minimum 
 pressure absolutely necessary to check the flow of blood. Keep it up con- 
 tinuously, even during sleep, if the patient can be got to bear it. In com- 
 pressing the abdominal aorta or the iliacs, it is best to produce anaesthesia 
 and keep it up for hours. Aneurisms may thus be cured by one spell of 
 compression. 
 
 Digital compression requires relays of assistants. A weight should be 
 suspended so as to press down on the assistant's fingers, and supply the 
 compressive force. Duration of pressure treatment very variable — often a 
 month ; in some cases cure has resulted in a few hours. 
 
 Many valuable papers on, and cases of treatment of aneurism by com- 
 pression, are to be found in the Dublin Medical Journal. 
 
 3. Flexion. — Especially applicable to aneurisms situated in the flexures 
 of joints, e.g., popliteal, and on the superficial aspect of the artery. Bend 
 the limb, not too acutely at first, and fix it thus with straps, buckles, or 
 bandages. Rest in bed and restricted diet as accessories. Slight simulta- 
 neous compression of artery above sometimes advisable. (See Ernest Hart : 
 "Medico-Chirurgical Transactions," vol. xlii., p. 405.) 
 
 4. Esmarch's bandage should be applied under anaesthesia, and may be 
 kept on for two hours or more. But one application for one hour has 
 sometimes been found quite sufficient. (Dr. "W. Reid, R.N.) 
 
 Notes on Special Aneurisms. — Aorta, Aneurism of — Thoracic. — See 
 medical works. Usually treated by rest and restricted diet (Tufnell's treat- 
 ment). Galvano-puncture and distal ligature {i.e., of the carotid) have 
 both been employed beneficially. 
 
 2. Abdominal Aneurism. — May be either of aorta or of one of its 
 branches. Diagnose from "hysterical pulsation, " from pulsating cancer, 
 and from abscess. In hysterical pulsation there are no true aneurismal bruit 
 and no tendency to progress, but there are concomitant signs of nervous 
 disorder. The other sources of error may be avoided by applying general 
 principles, and watching a doubtful case for a short time. Treatment must 
 
ANKYLOSIS. 17 
 
 generally be medical ; but success has attended compression of abdominal 
 aorta under anaesthesia for several hours (Murray: " Medico-Chirurgical 
 Transactions," vol. xlvii.). Directions for tying the iliac arteries will be 
 found under Arteries. 
 
 Axillary Aneurism. — Generally treated by ligature of subclavian (third 
 part]. Compression of subclavian. Operation of Antyllus recommended 
 by Syme. 
 
 Carotid Aneurism. — Commonest seat — bifurcation of common carotid. 
 When seated at root of neck, tie distally (Wardrop's and Brasdor's opera- 
 tion). 
 
 Femoral Aneurism. — Comparatively common, and admirably suited for 
 treatment by compression. If ligature is resorted to, external iliac must 
 be tied for aneurism of common femoral. 
 
 Gluteal Aneurism. — Usually traumatic, and singularly liable to be mis- 
 taken for abscess. Suitable cases for such treatment as galvano-puncture. 
 " Many cases, I have no doubt, might be cured by compression of the aorta 
 or common iliac artery under chloroform." — Holmes. Compression per 
 rectum might be also suggested. See also Holmes, Lancet, July 11, 1874. 
 
 Orbital Aneurism. — Usually common aneurism, but very exceptionally 
 " cirsoid." Symptoms. — Besides pulsation, there are displacement of the 
 eyeball and loss of sight. Treatment. — Spontaneous cure possible. Com- 
 press carotid digitally. Other treatment dangerous, but may be unavoid- 
 able. Ligature would have to be applied to the common carotid. Befer 
 to Kivington : " Medico-Chirurgical Transactions," vol. lviii. 
 
 Subclavian Aneurism. — Ligature of the innominate and of the first part 
 of the subclavian artery have been always fatal, excepting in one case. 
 Therefore, subclavian aneurism is best adapted for the diet and rest treat- 
 ment, or for galvano-puncture, or for manipulation. Amputation at the 
 shoulder-joint is in some cases justifiable. Willett has suggested a com- 
 bination of amputation at the shoulder-joint with ligature of the carotid. 
 
 Ankle- Joint, Disease of. — Swelling causes prominence of and fluctu- 
 ation beside extensor tendons. Diagnose from disease of tarsus. In the 
 latter case there is free movement at the ankle under anaesthetics. Prog- 
 nosis is the more favorable because general exercise can be combined with 
 local rest. 
 
 Ankylosis. — Three kinds : 1, extra-articular fibrous ; 2, intra-articular 
 or ordinary fibro us or false ankylosis ; and 3, bony or true ankylosis. In the 
 first case there are not, in the second there are, fibrous bands within the 
 joint. First case results from inflammatory thickening of surrounding 
 parts, contracted ligaments and tendons, etc. Often there is a combina- 
 tion of all three. Diagnosis. — In osseous ankylosis there is no motion 
 whatever ; in intra-articular fibrous there is some motion, which is checked 
 more abruptly than in extra- articular. Anaesthetics may be required. 
 Sayre tries to move the joint vigorously for two minutes under chloroform. 
 2 
 
18 ANTRUM, DISEASES OF. 
 
 If, within twenty- four hours, any swelling result, the ankylosis is; of course, 
 not bony. Causes. — Joint-disease, etc. Osseous ankylosis usually caused 
 by traumatic disease. Treatment. — 1, Preventive : proper passive motion 
 applied in time. If ankylosis is inevitable, select the best position ; 2, 
 Curative : 
 
 1. Fibrous Ankylosis. — Passive motion, friction, douches, steam-baths, 
 screw- splints, weights. Anaesthetics : subcutaneous rupture. Take a short 
 hold (near the joint), and try to rupture by flexion. Tenotomy. Division 
 of tight fascia. 
 
 2. Osseous Ankylosis. — Do not interfere, if possible. Fresh disease 
 may be excited, or the operation may be fatal. " Subcutaneous resection." 
 Sawing, drilling, fracturing ; cutting out wedge-shaped piece of bone ; 
 fracturing shaft of bone just below joint. Little more than a good position 
 usually aimed at. 
 
 Antiseptic Treatment, The. — Almost always means Lister's method 
 only. Principles. — 1, an open wound does worse than a subcutaneous 
 wound, because atmospheric germs enter it and produce fermentation, re- 
 sulting in irritation, decomposition, etc., which again lead to inflammation, 
 blood-poisoning, etc. ; 2, certain substances, e.g. , carbolic acid, destroy 
 these germs. Details. — Spray, carbolized instruments and hands, carbolized 
 catgut, protective next wound, gauze (usually eight folds), mackintosh just 
 beneath uppermost layer of gauze. Sometimes use a drainage tube, then its 
 end must be well concealed by gauze. Carbolized bandage, elastic band- 
 age in certain cases, safety-pins. Explanation of details. — Spray (strength 
 1-40); carbolizing the hands, etc., prevents access of live germs ; protective 
 protects from the irritating properties of carbolic acid ; gauze absorbs and 
 disinfects discharge ; mackintosh prevents discharge from soaking through 
 to the surface, and thus establishing a channel of disinfection. Lotion for 
 washing instruments, etc. (strength 1-40). Dressing should be removed 
 under spray and redone from time to time, according to amount of dis- 
 charge, which should not, if possible, be allowed to soak quite through. 
 In absence of spray-producer, and in the case of accident wounds, wash the 
 surfaces with lotion (1-40). Antiseptic " veil " and irrigation, substitutes 
 for spray. Boracic and salicylic acid, thymol, and ol. eucalypti have been 
 used instead of carbolic acid. Strength of lotion for use in steam spray- 
 producer, 1-20 ; steam dilutes it to 1-40. 
 
 Antrum, Diseases of, may be classified into Cystic Disease of, Sup- 
 puration in, and Tumors of Antrum. 
 
 Antrum, Cystic Disease of. — Firstly, there is the form known as Dropsy 
 of the Antrum, not owing to obstruction of antro-nasal orifice, but to cystic 
 disease of the mucous membrane ; simple or multiple cysts ; bulging into 
 nose, mouth, orbit, and cheek ; thinning of bone, even to crackling. Con- 
 tents : thin, brownish, serous, with cholesterine. Treatment. — Catheterize 
 through nose, or tap through anterior wall from mouth, ,pr draw a diseased 
 
ANUS. 19 
 
 tooth and tap through its socket. Eestore shape of cheek by pressure with 
 a pad. A second variety, called * DentigeroiJLS Cysts," connected with mal- 
 placed teeth. Small ones common. Large ones cause absorption of neigh- 
 boring parts. Treatment — Open and remove the contained teeth; stufii 
 cavity with lint till it begins to granulate. If cyst be large, remove part 
 of its wall 
 
 Antrum, Suppuration of. — Causes. — Carious teeth, blows. Signs. — Swell- 
 ing, pain, puffiness of neighboring soft parts ; perhaps escape of pus into 
 nose. Treatment. — Kemove the offending tooth and perforate through its 
 socket, or extract second molar, or perforate canine fossa with a carpenter's 
 gimlet. Wash out with Condy or carbolic lotion. Keep a free exit for the 
 pus. Kestore symmetry by pressure. 
 
 Antrum, Tumors of, include, strictly, above-mentioned cysts; also fi- 
 brous, sarcomatous, osseous, cartilaginous, fatty, erectile, and carcinoma- 
 tous (epithelial and encephaloid) ; fourth, fifth, and sixth kinds very rare. 
 Diagnosis practically has only to be made between (1) simple and (2) 
 malignant disease ; or between (1) malignant and witjrin the antrum, and 
 (2) malignant and extending beyond the antrum. If an operation is pro- 
 posed, it should also be determined, if possible, where the tumor began, 
 e.g., behind the antrum or not. In doubtful diagnosis from cysts, deter- 
 mine by perforation. Malignant tumors (1) grow rapidly, (2) early affect 
 submaxillary glands, (3) protrude early into neighboring cavities, forming 
 a fungus. Point of Origin. — Tumors of malar bone spread over upper 
 jaw; intra-antral tumors expand it on all sides ; post-antral tumors push 
 it bodily forward without distorting it. Treatment. — Operative or pallia- 
 tive. Question of operation. — If the soft structures of the cheek are not 
 freely movable over the tumor, and if the glands are affected, do not 
 operate ; nor if disease be malignant, advanced, and post-antral in origin. 
 In simple disease remove no more of the maxilla than the side diseased. 
 For the operation, vide Excision of Upper Jaw. 
 
 Anus, Artificial. — See Colotomy. 
 
 Anus, Cancer of, usually spreads from rectum. If primary, commonly 
 epithelioma. May be excised at first. See Cripps on Cancer of Rectum. 
 
 Ano, Fistula in. — Causes. — It is the sinus left by an ischio-rectal 
 abscess, quod vide. Varieties and Signs. — Complete and incomplete, former 
 opens both inside and outside anus ; blind internal and blind external. 
 Sometimes there are several openings ; outer opening usually within one 
 inch of anus ; granulation often projecting from it ; course of fistula feels 
 hardened and thickened ; purulent discharge ; tenderness ; history of 
 former abscess ; constitution often phthisical. Prognosis. — Permanent 
 cure difficult if the openings be numerous and phthisis coexist. Ordinary 
 cases easily remedied. Treatment. — Introduce first a probe, then a direc- 
 tor. Make blind fistula complete. Then slit up, on the director, the 
 bridge of skin and sphincter covering fistula. Precede operation with a 
 
20 ANUS. 
 
 purge and an enema. Dress with oiled lint, pad, and T-bandage. Check 
 severe hemorrhage with styptics and pads. Galvanic cautery. Ligature. 
 Elastic ligature. Coexistence of phthisis does not usually contraindicate 
 operation. 
 
 Anus, Fissure of, usually accompanied by Anal Ulcer. Causes. — Female 
 sex: debility, cachexia, dirty habits, eczema. Signs. — Burning pain after 
 defecation, sometimes lasting for hours ; seat of pain, chiefly sacro-iliac 
 articulation ; genito-urinary irritation ; purulent, bloody and mucous exu- 
 dation ; patient feels and looks worn and despondent ; on examining anus 
 carefully (a speculum may be required), one or more small ulcers or fis- 
 sures seen, generally very tender ; sphincter very irritable and spasmodic ; 
 ulcer usually near coccyx and just within anus. Treatment. — Cleanliness ; 
 soap and water ; zinc ointment ; glycerine of tannin ; nitrate of silver ; 
 anodyne and astringent suppositories ; division of ulcer or fissure and 
 superficial fibres of sphincter to depth of one-eighth of an inch. Kest in 
 bed for some time after operation. 
 
 Anus, Imperforate (including congenitally malformed rectum). — Six 
 kinds. Case 1. Congenital narrowness of anus. Treatment. — Notch and 
 introduce sponge-tents. Case 2. Complete closure of anus ; rectum nor- 
 mal. Treatment. — Crucial incision ; no plug required. Case 3. Closure 
 of rectum by a membranous septum ; anus normal. Treatment. — Pass an 
 ear-speculum up to the septum ; pass a tenotomy-knife through speculum, 
 and, cutting in the median line, with an inclination toward the sacrum, 
 divide the septum. Case 4. Complete absence of anus. Case 5. Ab- 
 sence of a considerable part of the rectum ; often a fibrous cord instead. 
 Treatment. — In Cases 4 and 5 an attempt may be made to dissect up to the 
 rectum as follows : Operation. — Keep in mind small size of pelvis and 
 relations of bladder and internal iliac vessels ; empty bladder ; incise 
 exactly in the position of the anal depression ; crucial incision ; cut be- 
 yond the posterior margin of the depression ; cut deeply with first inci- 
 sion ; introduce finger with the point upward and backward. Generally the 
 cul-de-sac of the bowel can be felt when the child cries, or when the abdo- 
 men is pressed upon by the assistant. Puncture upward and backward ; 
 enlarge with probe-pointed bistoury ; bring mucous membrane of gut 
 down to external wound, if possible ; keep open at first with a suppository. 
 If the operation fails, never plunge a sharp instrument blindly into the 
 pelvis, but perform Littre's operation. Vide Colotomy. Case 6. Kectum 
 may communicate with or open into vagina, bladder, or urethra. TreaU 
 ment for Case 6. — Plastic operation ; operation for artificial anus ; or nil. 
 Colotomy sometimes causes a mere communication to close up, and all the 
 faeces to pass per anum. 
 
 Ani, Prolapsus, is really a prolapse of rectum, usually of its mucous 
 coat only. Causes. — Constitutional weakness. Rectal, genital, and uri- 
 nary irritation causing straining. Piles. Polypi, urinary calculi, worms, 
 
ARTERIES. 21 
 
 phimosis, constipation. Age of childhood. Signs. — Protrusion of a ring 
 of mucous membrane, becoming dark and turgid if allowed to remain pro- 
 lapsed. Strangulation, suppuration, and even mortification may occur. 
 Treatment. — Eeduce prolapse at once. Eegulate bowels ; mild aperients, 
 Friedrichshall water, " effervescing citrate of magnesia." Eecumbent posi- 
 tion after, or even during defecation. Astringent injections, alum, tannin, 
 iron. Tonics, iron, strychnia. Always seek for and remove cause. In 
 bad cases, ligature parts of the prolapsus, or paint it with strong nitric 
 acid, bathing afterward in cold water. Incise freely a strangulated pro- 
 lapsus. Children should have one buttock pulled to one side obliquely 
 during defecation. This causes a tight fold of skin to support anus. 
 
 Arteries, Atheroma of. — Term applied to the effect produced on 
 arteries by a chronic or subacute inflammation. Causes. — In many cases, 
 unknown. Alcohol, syphilis. Common in advanced age. Atheroma is 
 common where an artery pulsates against a bony surface (A. Barker). 
 Signs. — During life such arteries as the radial and temporal are often 
 found hardened and even looped. Liability to aneurisms and rupture of 
 the arteries. Pathology. — Begins by a deposit of cells in the inner, where 
 it joins the middle coat. This inflammatory new formation takes one of 
 three courses : either (1) it softens down into molecules and fat and 
 causes an ulceration of the tunica intima ; or (2) it organizes into a fibrous 
 thickening ; or (3) it undergoes a calcareous degeneration. It is in the 
 first case that aneurism is most likely to occur. In the smaller vessels it 
 is the muscles which ossify. When the disease attains a high grade, the 
 arteries bulge out, various stages found together at same time. In the 
 smallest arteries the process affects chiefly the adventitia. In the largest 
 arteries (which are almost void of muscle) it affects almost entirely the 
 intima. Atheroma pulp consists of molecular and fat granules, cholester- 
 ine, crumbs of carbonate of lime, and haematoidin crystals. Effects of 
 Atheroma. — Secondary hemorrhage. (Acupressure recommended for athe- 
 romatous arteries.) Gangrene. Aneurism. 
 
 Arteries, Ligature of. — Arteries are tied either in the continuity or at 
 a point wounded or severed. 1. Ligature in the Continuity. — Operation 
 generally done at a point selected, because, 1, it is not too near a diseased 
 part of the vessel (e.g., an aneurism) ; 2, it is not so far off an aneurism 
 that collateral circulation would at once nullify the operation ; 3, it is not 
 close to the origin of a large branch, the rush of blood through which 
 would prevent coagulation and cause secondary hemorrhage. Operation. 
 — Learn well the superficial and deep landmarks, and the anatomy of the 
 part. Mark out the vessel's course. Incise the skin and superficial fascia 
 equally and sufficiently. A director may be used for the deep fascia. 
 Avoid superficial veins ; avoid opening sheaths of muscles. " The surgeon 
 should not at the commencement occupy himself with looking for the 
 artery, but should seek the first marked point of guidance, then the 
 
22 ARTERIES. 
 
 second, then the third, and so on to the end " (Bryant). Handle of knife 
 will push muscles, etc., aside. Retractors. Feel artery pulsate. Open- 
 ing in sheath to be small, and made with knife-blade held on a plane just 
 superficial to the artery, that is, "on the flat." Insinuate aneurism-needle 
 round artery. Draw out ligature with forceps. In tying, press down 
 knot with tips of forefingers ; do not lift vessel from its bed. Cut one 
 end of a silk ligature short, and both ends of a catgut one. Close wound 
 and dress. Before actually tying ligature, make sure that you have sur- 
 rounded the artery, the whole artery, and nothing but the artery. Needle 
 should be passed between the artery and its vein. Process of Repair, etc. — 
 The two inner coats are divided by the ligature and retract a little. A clot 
 forms up to the nearest branch. Lymph is effused around the ligature. 
 In the most favorable cases the lymph and the clot organize ; and the cut 
 arterial coats grow together, so that when the outermost coat is ulcerated 
 through, a new barrier has been formed against hemorrhage. But these 
 processes may wholly or partially fail. Then there is more or less danger 
 of secondary hemorrhage. Dangers. — Secondary hemorrhage from above 
 cause, or from suppuration. Gangrene, from non-establishment of collat- 
 eral circulation, from injury to, and consequent coagulation in, the vein, 
 or from suppuration of an aneurismal sac. Erysipelas and other accidents 
 to which all wounds are liable. 2. Ligature of an Artery open in a Wound. 
 — Be careful not to include neighboring nerve. Beef -knot. Hemp, silk, 
 and catgut ligatures. Carbolized catgut is absorbed or organized, and 
 scarcely, if at all, acts like a foreign body in the wound. One end of a 
 hemp or silk ligature must be left hanging out of the wound. 
 
 Axillary. — Very rarely tied. Line of artery. From just internal to 
 coracoid process, curving outward and downward to commencement of 
 brachial artery. Divide skin and pectoralis major. Beware of vein and 
 brachial plexus. 
 
 Ligature or Special Artekies. — Abdominal Aorta. — 1st method : incise 
 the abdominal wall as in ovariotomy. Divide the peritoneum covering the 
 aorta, and pass the ligature. 2d method : make an incision like that for 
 ligature of common iliac, and proceed as if for ligature of that vessel, but 
 keep a little higher. Doubtful whether operation is ever justifiable. For 
 details, vide larger works. 
 
 Brachial. — In middle of upper arm. Line of incision, inner edge of 
 biceps. Avoid basilic vein and internal cutaneous nerve ; open deep fas- 
 cia ; look out for median nerve ; artery usually lies just beneath it, but 
 may be superficial to it. Remember occasional high division of brachial. 
 
 Carotid, Common. — Position : head back, face turned away at first. 
 Place of selection : just above omo-hyoid {i.e., level of cricoid cartilage). 
 Line of artery, sterno-clavicular articulation to midway between mastoid 
 process and angle of jaw ; incise skin along anterior border of sterno- 
 mastoid three inches ; platysma ; deep fascia. Raise head, relax and re- 
 
ARTERIES. 23 
 
 tract sterno-mastoid ; look for omo-hyoid ; carotid sheath with descendens 
 noni. As a rule, jugular -vein and vagus nerve not seen. 2. In tying 
 artery low down, divide partially sterno-mastoid, sterno-hyoid, and sterno- 
 thyroids. Fatality. — 40 percent.: in ordinary cases one in three. When 
 operation is for hemorrhage, 56 per cent. die. When for aneurism, on 
 Brasdor's method, only one in four. For affections of the nervous system, 
 only one in thirty-four. Chief Dangers.- — Brain symptoms and secondary 
 hemorrhage. 
 
 Carotid, External and Internal. — Ligature of common carotid preferred. 
 For external carotid proceed as follows : line of incision same as for com- 
 mon carotid ; incision from angle of jaw to thyroid cartilage ; freely incise 
 any glands which may be in the way ; tie and divide cutaneous veins ; 
 look for hypoglossal nerve ; tie the artery between origins of supra-thyroid 
 and lingual arteries. 
 
 Femoral. — The common femoral rarely tied ; ligature of external iliac 
 preferred. Incise in line of artery ; crural branch of genito-crural nerve ; 
 open sheath ; tie about one inch below Poupart's ligament ; pass needle 
 from within outward. 
 
 Superficial femoral tied in two places : 1. At apex of Scarpa's triangle. 
 Position : abduction and rotation outward ; knee flexed ; line of artery, 
 from middle of Poupart's ligament to front of inner condyle ; incise skin 
 3-4 inches at junction of upper and middle thirds of thigh ; divide fat ; 
 avoid saphena vein ; divide fascia lata well to inner side of sartorius, so 
 as not to open sheath of that muscle ; retract sartorius outward ; feel for 
 sheath of artery ; branch of ant. crural over sheath ; open sheath ; clean 
 artery with point of director ; pass needle from inner side. 2. In Hun- 
 ter's canal. Done when operation in Scarpa's triangle fails. If done at 
 lower end of Hunter's canal, draw sartorius to inner side ; incision in the 
 same line as when artery is tied in Scarpa's triangle, but longer, and of 
 course lower down thigh. Other steps similar to first operation. Fatal' 
 ity. — One in four. Syme was successful twenty-three times in suc- 
 cession. 
 
 Iliac y Common. — Line of artery : from half -inch to left of umbilicus to 
 middle of Poupart's ligament. Incision, from end of last rib downward 
 and forward to crista ilii, and then forward above and parallel to crest of 
 ilium as far as anterior superior spine ; divide muscles and transversalis 
 fascia, using finger as a director ; roll up peritoneum and intestines out of 
 way, and tie artery. Second method : incise skin first from outside in- 
 ternal abdominal ring, parallel to Poupart's ligament, three or four inches 
 toward ant. sup. spine of ilium ; then continue incision with a curve in- 
 ward toward umbilicus, and proceed with muscles and transversalis fascia 
 much as in first method. Kemember relation to veins, ureter, and sper- 
 matic vessels. Fatality. — Very great — twenty-five in thirty-two ! Chief 
 causes : exhaustion and hemorrhage. 
 
24 ARTERIES. 
 
 Iliac, External. — Line of artery same as common iliac. Incise skin half 
 an inch above Poupart's ligament from just external to internal abdominal 
 ring outward in a curve three inches long and parallel to the ligament ; 
 divide muscles and transversalis fascia carefully ; push up peritoneum ; 
 separate artery from vein ; pass needle from within outward ; the higher 
 up the artery is to be tied, the farther must the outer end of the incision 
 be extended upward and inward, the incision thus becoming like that for 
 the common iliac. Beware of seven dangers : 1, wound of epigastric ar- 
 tery ; 2, wound of spermatic cord ; 3, laceration of peritoneum ; 4, punc- 
 ture of external iliac vein ; 5, of circumflexa ilii vein ; 6, ligature of genito- 
 crural ; 7, too free disturbance of subperitoneal cellular tissue. Fatality. 
 — One in three. Chief causes : gangrene, hemorrhage, and peritonitis. 
 
 Iliac, Internal. — Steps of operation as for common iliac. Trace inter- 
 nal iliac from bifurcation of common iliac ; scratch artery clean with finger- 
 nail and director ; pass ligature three-quarters of an inch from origin. 
 Beware of ureter, vein, and peritoneum. Fatality. — One in two. 
 
 Innominate. — Incision along anterior border and sternal end of sterno- 
 mastoid ; divide as much of sterno -mastoid as may be necessary to expose 
 carotid, and trace carotid downward to innominate. Fatality. — Only one 
 case has recovered. In it the carotid and vertebral were also ligatured 
 (Smyth's case). 
 
 Lingual. — Line of artery : just above greater cornu of hyoid bone ; in- 
 cision horizontal, with centre opposite end of greater cornu of hyoid bone ; 
 look for hypoglossal nerve ; artery crosses beneath it ; divide hyo-glossus 
 muscle from hyoid bone : artery is thus exposed. Object. — Usually to 
 check hemorrhage from cancer of tongue. 
 
 Radial. — Line of artery : from inner side of biceps tendon at bend of 
 elbow to half an inch internal to styloid process of radius. ligature in 
 upper third : incision in line of artery. Separate supinator longus from 
 pronator teres, and tie. Lower third : divide skin and deep fascia to outer 
 side of flexor carpi radialis. 
 
 Subclavian. — Tied only in third part of its course. Raise patient on 
 a pillow, head back, face turned away, arm pulled down ; incise along 
 clavicle, pulling skin down over it; divide border of stemo-mastoid if neces- 
 sary ; deep fascia ; retract external jugular ; separate vessels and cellular 
 tissue beneath deep fascia without using knife -blade ; feel for scalene tu- 
 bercle and scalenus anticus. Subclavian lies behind them ; brachial plex- 
 us and subclavian vein ; pass needle from below upward. Fatality. — 
 Nearly one in two. Chief causes : hemorrhage, gangrene, intrathoracic 
 inflammation, " sloughing or suppuration of aneurism." 
 
 Tibial, Anterior. — Line of artery : from head of fibula to midway be- 
 tween two malleoli. Upper or middle third : divide skin in line of vessel ; 
 look for a white Hue in deep fascia, marking outer border of tibialis anti- 
 cus ; divide the line and separate tibialis anticus from ext. long. dig. 
 
ASPHYXIA. 25 
 
 above, and from extensor prop. poll, below ; nerve superficial ; patient 
 should put tibialis anticus into action before anaesthesia. Lower third : 
 artery nearly superficial. 
 
 Tibial, Posterior. — Upper half: two methods — 1 (Guthrie's), perpendicu- 
 lar incision, six inches long, through middle of gastrocnemius, soleus and 
 deep (submuscular) fascia ; artery lies on tibialis posticus ; nerve crossing 
 superficially and obliquely from within outward. 2d method : incision, 
 three-quarters of an inch behind and parallel to posterior border of tibia, 
 down to tibial origin of soleus. Separate soleus from bone, divide sub- 
 muscular fascia, and find artery immediately beneath it. 
 
 Near Ankle. — Artery lies beneath thick deep fascia, rather nearer mal- 
 leolus than heel. Incise over it. 
 
 Ulnar. — Line : from middle of bend of elbow, curving inward slightly, 
 to outer side of pisiform bone. Upper half: incise obliquely over course 
 of vessel and well to inner side of arm ; find outer border of flex, carpi 
 ulnaris ; divide it from flex, sublimis, and find artery between superficial 
 and deep flexors ; inner border of flexor sublimis may be found in thin 
 people by putting that muscle in action. 
 
 Above Wrist. — Divide skin and deep fascia just outside tendon of flex, 
 carpi ulnaris. Nerve on the inner side. 
 
 Asphyxia. — Causes. — 1, Compression of chest ; 2, compression of 
 lungs by air in pleura ; 3, traumatic compression of trachea, as in garrot- 
 ting ; 4, foreign body in air-passages ; 5, immersion in some fluid, in- 
 cluding (a) water (drowning), (b) some inert gas, (c) some poisonous gas ; 
 6, disease, including (a) pressure by aneurism, oedema glottidis, accumu- 
 lation of mucus, etc., (b) paralysis of respiratory muscles. Hanging may 
 be classed with Cause 3. Appearances. — Lividity, swelling of face, perhaps 
 bleeding from nose or mouth. Post-mortem : engorgement of right side 
 of heart, emptiness of left side of heart ; arteries contain venous blood ; 
 abdominal viscera engorged ; lungs not peculiar when there has only been 
 mechanical obstruction ; but in drowning they are filled with frothy water, 
 doughy and heavy, and the air-tubes are choked with frothy and bloody 
 water and mucus. Brain sometimes hypersemic, especially after hanging 
 or suffocation. Prognosis. — Almost hopeless after five minutes' submer- 
 sion. Remember, a person may be immersed some time without being 
 submerged. Recovery has taken place after three-quarters of an hour of 
 asphyxia (Weeks). Prognosis much worse if water has got into the lung. 
 
 Treatment. — In drowning, hold the patient's head downward for a few 
 seconds to begin with. In hanging or choking, bleed from jugular. If 
 there is obstruction to passage of air through mouth or nose, open trachea. 
 Then friction, warmth, warm bath (100°), ammonia to nostrils ; but begin 
 at once artificial respiration, and continue it. Artificial respiration by 1, 
 inflation from mouth to mouth ; 2, bellows ; 3, split sheet ; 4, Marshall 
 Hall's method ; 5, Sylvester's ; 6, Howard's ; 7, inhalation of oxygen ; 8, 
 
26 BAR AT NECK OF BLADDER. 
 
 galvanizing phrenic nerve. With bellows, 15 cubic inches should be in- 
 troduced 12 times a minute. Oxygen was successfully administered after 
 three-quarters of an hour's asphyxia, in Weeks' case. 
 
 Sylvesters Method. — Lay body on back, on a plane inclined slightly 
 toward feet ; cushion under head ; head in line with trunk ; tongue drawn 
 forward ; grasp arms just above elbows and draw upward till they nearly 
 meet above head ; there retain them for two seconds ; then depress them 
 again and press them firmly for two seconds against the sides, combined, 
 if possible, with pressure on lower part of sternum ; repeat about fifteen 
 times per minute. Remember, artificial respiration is to be attended to 
 the first thing ; warmth and friction are secondary ; the endeavors should 
 be kept up for at least three or four hours, even without any encouraging 
 signs. 
 
 In hanging, besides asphyxia, there is usually some apoplexy as well as 
 injury to the spinal cord. 
 
 Aspiration. — The aspirator is an exhausting syringe, used for drawing 
 off fluids without admitting ingress of air, and in exploring for purposes 
 of diagnosis. The needle should be pressed in with a screwing motion, 
 and the taps should be managed carefully and without hurry. 
 
 Atheroma. — Vide Abteeies, Atheroma of. 
 
 Atheromatous Tumors. — Vide Tumoks (Cysts). 
 
 Back, Sprains of. — Usually occur in neck or loins, often affect inter- 
 vertebral ligaments ; tumefaction, rarely ecchymosis, stiffness, tenderness ; 
 in severe cases, patient lies on his side, semi-flexed ; hsematuria when the 
 kidneys are hurt ; occasionally symptoms of paralysis ; if such persist, in- 
 travertebral hemorrhage, inflammation of the meninges, or injury to the 
 cord, are indicated. Causes. — Falls on head or buttocks, railway collisions, 
 Rugby football, etc. Diagnosis. — From fracture or dislocation, line of 
 spinous processes straight ; tenderness more or less diffuse ; patient can 
 probably, though with pain, raise himself into the erect position, straight- 
 ening his spine. Prognosis. — Good, even when there is hsematuria ; even 
 severe paralysis sometimes passes off in a day or two, but danger of inflam- 
 mation spreading to meninges of cord. This danger is greatest in atlanto- 
 axial region. See Spinal Meningitis, Fracture, Hemorrhage, etc. Treatment. 
 — Rest. See Sprains. Actual cautery and Corrigan's button or Sayre's 
 jacket in obstinate cases. 
 
 Balanitis. — Inflammation of glans penis or lining membrane of pre- 
 puce. Causes. : — Gonorrhoea, phimosis, dirty habits, ill-health. Treatment. 
 —Warm water, zinc ointment, astringent lotions, nitrate of silver. A 
 chancre may coexist. 
 
 Bar at Neck of Bladder. — Definition. — "Any bar" at the inferior as- 
 pect of the neck of the bladder, and not prostatic in its nature. Extremely 
 rare. Treatment. — Relieve accompanying chronic cystitis ; occasionally 
 pass a large catheter. Vide Thompson and Guthrie. 
 
BITES OF POISONOUS SNAKES. 2t 
 
 Barbadoes Leg. — See Elephantiasis Arabum. 
 
 Bath, Continuous Water-Bath, or Immersion Treatment of 
 
 wounds and compound fractures. Temperature varies ; cold water delays 
 the healing, but prevents blood-poisoning ; in compound fractures the 
 limb is placed in a fenestrated plaster case, made water-tight with shellac, 
 cement, or collodion. Used at Berlin. 1 
 
 Bed-Sores attack the skin over hard prominences, e.g., sacrum, ischial 
 tuberosities, trochanters, condyles of knees, elbows, and the heels. First 
 the skin reddens, then an abrasion may form, then a slough ; in bad cases 
 even spinal canal may be opened. Causes. — Predisposing are debility, 
 continued fevers, especially typhoid, paralysis, old age ; exciting causes are 
 continued pressure, irritation of faeces and urine, the under sheet and night- 
 shirt not being kept smooth by the nurse, etc. Prognosis. — Depends chiefly 
 upon whether the cause can be removed or not. Treatment. — Preventive 
 measures are good nursing, dry, smooth draw-sheets, water-beds or cush- 
 ions, frequent change of position. The buttocks, etc., should be rubbed 
 twice a day for five minutes with camphorated spirit, or with a mixture 
 of olive oil and brandy (equal parts) ; or bathe the part with hydrarg. 
 perchlor. in sp. vin. rect. (gr. ij.-jj.); prominences should be covered 
 with amadou plaster ; when an abrasion forms, apply collodion and try to 
 take off the pressure ; when a slough is forming, use a thick poultice ; 
 when slough separates, use stimulants, e.g., resin ointment, balsam of Peru 
 on cotton-wool. Prone position sometimes necessary. 
 
 Bees, Stings of. — Treatment. — Rubbing with olive-oil, strong liquor 
 ammonias, indigo, eau de Cologne, vinegar, flour, etc. ; remove the sting if 
 it can be found ; ice. 
 
 Biceps Humeri, Contraction of. — Treatment. — If the arm can be ex- 
 tended under anaesthetics, keep it so for some time on a splint ; otherwise, 
 tenotomy may be required ; but manipulation, patiently practised, will often 
 succeed. 
 
 Biceps Humeri, Division of Tendon of. — Insert knife on inner 
 side, pass it beneath the tendon, and cut outward and toward the skin ; 
 press brachial artery away during operation. 
 
 Biceps Femoris. — In dividing this, pass tenotome in parallel to, and 
 keep it close to the tendon. 
 
 Bites of Poisonous Snakes. — Symptoms. — Local, are rapid swelling, 
 redness, lividity, phlyctenular filled with sanious fluid ; swelling spreads, 
 whole body assumes a jaundiced hue ; resemblance to ordinary phlegmo- 
 nous erysipelas ; but " the first symptom, in nearly all cases, appears to be 
 a general shock to the nervous system " — faintness, tremor, great depres- 
 sion, sometimes stupor, loss of sight, vomiting, trismus, and general in- 
 
 1 It lias been found that it causes the lips of the wound to swell greatly, and some- 
 times, therefore, to prevent escape of discharge. — London Medical Record. 
 
28 BLADDER. 
 
 sensibility ; great local pain. Pathology. — First effect is a shock to the 
 nervous system ; second is a diffuse cellulitis, spreading from the wound. 
 It appears that virulent snake-poison may be applied to slight abrasions, 
 to denuded muscle, cartilage, periosteum, to mucous membrane, and even 
 to the medullary cavity of bones, with no more effect than local irritation, 
 though the same poison inoculated into the subcutaneous cellular tissue 
 would be rapidly fataL Prognosis. — Depends on relative size of snake and 
 victim, on situation of wound (worst when on face or trunk), and, of 
 course, on kind of snake. — See G. Busk, in "Holmes's System." Treatment. 
 — Ligature above part bitten ; sucking wound ; caustics, actual cautery ; 
 excision ; injection of wound with ammonia or carbolic acid ; injection of 
 ammonia into the veins (Halford) ; Liq. ammon. fort., TT[x., ad aquse fort., 
 TT^xx., to be injected into a large vein near the wound ; rubbing with olive- 
 oil. The strength must be kept up with milk, eggs, wine, soups, etc. ; the 
 spirits must be cheered. 
 
 Bites of Rabid Animals. — See Hydrophobia. 
 
 Bladder, Atony of, arises from muscular weakness of old age, or after 
 fevers, or paralysis, or from continued obstruction by enlarged prostate or 
 organic stricture. It must not be confounded with actual paralysis. 
 Symptoms. — Retention, or else incontinence of urine, caused by the over- 
 flow of the bladder. Treatment. — Catheterism twice a day ; cold douche 
 and frictions to lumbar spine, and injections of cold water. Electricity. 
 Sometimes strychnine when a spinal affection seems to be the cause. Prog- 
 nosis. — Depends upon curability of the cause and upon duration of the 
 
 Bladder, Cancer of. — Epithelioma is very rare, and slow in its progress. 
 Scirrhus is most rare, except as an extension from neighboring organs. 
 Encephaloid is more common. Symptoms. — Frequent and difficult mictu- 
 rition ; pain in neck of bladder, often extending to loins and hips as well 
 as perinseum ; hemorrhage usually sudden and copious ; frequent and 
 continuous oozings are more characteristic of villous growth (Thompson) ; 
 enlargement of pelvic and lumbar glands ; sometimes cancer-cells are found 
 in urine ; growth may be felt per rectum or by catheter ; cachexy. Prog- 
 nosis. — Encephaloid cases last, on an average, twelve months ; Brodie has 
 known a duration of seven or eight years. Treatment. — Attend to general 
 health, state of bowels, appetite, etc. Use anodynes, especially subcutane- 
 ous morphia injections, with no niggard hand ; morphia suppositories ; 
 alcoholic stimulants. For the hemorrhage, cold, rest, and injections, silver 
 nitrate, gr. ss. to § j., iron, and other local astringents. Recumbent pos- 
 ture in some cases. Some tumors in the female bladder are accessible for 
 operation. 
 
 Bladder, Catarrh of. — Chronic inflammation with mucopurulent secre- 
 tion. Causes. — Generally either stricture, calculus, or enlarged prostate ; 
 often paralysis; atony, ulceration, tumors, cancer; a sequel of acute cys- 
 
BLADDER. 29 
 
 titis ; may arise from disease of neighboring parts, anus, rectum, vagina, 
 and uterus; gout, gonorrhoea, foreign bodies, and, in fact, any irritant 
 which can affect the bladder. Symptoms. — Frequent micturition ; urine 
 ammoniacal, fetid, mixed with stringy mucus, deposits phosphates; the 
 general health gradually gives way; pain, generally dull and radiating 
 along perinaeum, anus, urethra, etc. Pathology. — The mucous membrane 
 is thickened and congested, and the subjacent muscular tissue hypertro- 
 phied. Prognosis. — Eecovery may take place in recent cases, but old cases 
 generally die eventually, worn out, or else in a typhoid state. Treatment. 
 — 1. Local : wash out bladder with warm water, or solutions of acetate of 
 lead (-J- gr. to 1 oz.), argent, nitrat. (-J gr. to 1 oz.), nitric acid (TT[|- to f j.) ; 
 the strength may be gradually increased. P. P. White, of Dublin, uses 
 4 gr. borax to 8 oz. of "very hot water." When the urine is fetid, car- 
 bolic acid (TTij. to I iv.). Manipulate very gently, and inject only 2 or 3 oz. 
 at a time. Counter-irritation ; croton-oil or iodine to pubes, linseed and 
 mustard poultices to pubes. 2. Internal remedies : anodynes by mouth 
 and rectum. Aperients. Buchu, uva ursi, pareira brava, triticum repens, 
 iron. Dr. Gross strongly recommends copaiba and cubebs when the se- 
 cretion is excessive. Demulcents : decoctions of marsh-mallow, linseed, 
 Irish moss, elm-bark, or barley. The urine should be made neutral, if acid. 
 Diet is very important : light, nutritious, farinaceous ; milk and fish. Eest 
 horizontally ; warm clothing ; warm climates. In severe cases the litho- 
 tomy incision has been made by Gross, Wheelhouse, Teevan, and others. 
 
 Bladdee, Dilatation of, without hypertrophy, sometimes exists. 
 
 Bladdek, Extroversion or. — A congenital malformation, in which the 
 anterior wall of the bladder and the adjacent part of the abdominal wall 
 are absent. More common in males than in females. Symptoms. — The 
 red mucous membrane of the posterior wall of the bladder presents in the 
 pubic region as a flattened tumor, on which the orifices of the ureters may 
 be found ; umbilicus absent ; epispadias ; urine always dribbling ; conse- 
 quent excoriations and urinous odor ; impotence in the male. Treatment. 
 — Zinc ointment for excoriations ; urinals carefully fitted to the case. Kad- 
 ical cure by operations of Ayres, Wood, or Holmes. Skin-flaps are turned 
 down from the neighboring parts — groins, scrotum, etc. — and united so 
 that one surface of skin turns toward bladder, the other outward. T. 
 Smith's operation — ureters into rectum. 
 
 Bladder, Foreign Bodies in. — Treatment. — Urethral forceps, lithotrite, 
 operation as for median lithotomy. 
 
 Bladder, Hypertrophy of, arises from obstruction to the passage of 
 urine, and from continued irritation. Commonly coexists with catarrh. 
 Its existence can be inferred from that of its causes. Treat the catarrh 
 and remove the causes. 
 
 Bladder, Acute Inflammation of, usually affects trigone. Causes. — 
 Predisposing are male sex, adult age, cold weather and season, intemperate 
 
30 BLADDER. 
 
 habits, urinary obstruction. Common exciting causes are wounds, e.g., 
 lithotomy ; calculi, intemperance, stricture, gonorrhoea, injury during 
 parturition, protracted retention. Other causes are blows on perinaeum 
 or hypogastrium, stimulant diuretics, e.g., cantharides ; blisters, catheter- 
 ism, lithotrity. Symptoms. — Pain locally, affecting perinaeum, pubes, 
 groins, sacrum, thighs ; extreme irritability of bladder ; urine voided spas- 
 modically as soon as it enters bladder. In severe cases, such as those 
 which may follow lithotomy, there are rigors, often delirium, extreme local 
 tenderness, and great danger. In milder cases, such as often result from 
 gonorrhoea, the symptoms are chiefly local. Urine deposits mucus and 
 pus ; in severe cases it is bloody. Pathology. — Usually commences at, and 
 is often confined to neck of bladder ; mainly affects mucous membrane ; 
 this is thickened and congested ; in protracted cases it gets dark in color. 
 Occasionally lymph is exuded so as to form false membrane. Prognosis. — 
 The mild form yields to treatment. The virulent form, especially in shat- 
 tered constitutions, is often fatal, death being sometimes preceded by 
 gangrene. Treatment. — Cathartics: castor-oil, black draught, or calomel; 
 diaphoretics ; demulcent drinks, flavored with a little lemon-juice ; all 
 drinks to be tepid ; opiate suppositories and enemata ; colchicum in gouty 
 cases. Hot baths ; linseed and mustard poultices to the abdomen and 
 perinaeum ; fomentations ; leeches (five, ten, or more) to the perinaeum 
 and margin of anus. Cupping the loins when there is pain in that region. 
 Retention should be watched for and may require catheterism. Painting 
 hypogastrium and perinaeum with T. iodi. 
 
 Bladder, Inversion of. — Four cases have been recorded. Occurs in 
 female children only. 
 
 Bladder, Irritability of the, always a symptom only, though its impor- 
 tance has given it the rank of a disease. Causes. — 1, Disease of the urinary 
 apparatus : vesical catarrh, stricture, prostatic disease, foreign body, tu- 
 mor or calculus in bladder, disease of kidney or ureter, gonorrhoea ; 2, 
 state of urine, most common in elderly males ; 3, diuretics, cantharides ; 
 4, venereal excesses, onanism, a long and narrow prepuce ; 5, indigestion, 
 ascarides, hemorrhoids, fistulae, prolapsus ani, pruritus ani ; 6, nervous 
 disorders, hysteria, depressing emotions, excessive mental exertion ; 7, 
 debility from many causes ; 8, exposure to cold ; 9, ovarian and uterine 
 diseases. Symptoms. — Frequent micturition, but the total amount of urine 
 passed not excessive. Prognosis. — Good, when the cause can be removed. 
 The disease is intractable in weak, scrofulous subjects. Treatment. — Re- 
 move the cause, if possible ; any way, treat the cause. Ext. belladonnae, gr. 
 one-sixth per diem ; copaiba ; tinct. cantharidis ; buchu ; pareira brava. 
 Farinaceous diet. 
 
 Bladder, Neuralgia of. — Very rare. Sometimes reflex, and depending 
 on conditions of the liver, kidney, nerve-centres, etc. 
 
 Bladder, Paralysis of. — A name applied to loss of power of the bladder, 
 
BLADDER. 31 
 
 from nervous affections. Weakness from injury or disease of its muscular 
 walls is called atony (which see). Causes. — Injuries or diseases of the 
 spinal cord and brain ; reflex paralysis from operations, especially those for 
 hemorrhoids ; shock ; debilitating diseases, especially continued fevers ; 
 sexual excesses, especially in old men ; mechanical injury, e.g., in protracted 
 parturition ; over-distention ; severe inflammation ; hysteria. Symptoms. — 
 Firstly, retention, and then incontinence also. Paraplegia often present. 
 The distended bladder forms an abdominal tumor. Prognosis. — Depends 
 chiefly on cause. Sometimes fatal, even when promptly relieved. Treat- 
 ment. — Pass a full- sized catheter ; only partially empty bladder at first, if 
 the distention be great ; regular catheterism twice a day ; cathartics ; tonics ; 
 strychnine ; cantharides ; iron ; quinine ; arsenic. Electricity. Counter- 
 irritation : cold douche. If possible, avoid catheterism in hysterical cases ; 
 try ordinary remedies for hysteria. 
 
 Bladder, Puncture of. — 1, Supra-pubic : incise skin for half an inch in 
 middle line, just above pubes ; then plunge in curved trochar downward 
 and backward ; leave a soft catheter in the wound. 2. Per rectum : guide 
 a curved trochar on the left index finger in the rectum, till the point can be 
 placed against the bladder, in the middle line just behind the prostate. 
 During this first step, keep the trochar quite sheathed ; then project the 
 point, and plunge the instrument into the bladder ; leave in a soft catheter. 
 
 Bladder, Kupture of. — The bladder is generally full at the time, and 
 the patient often intoxicated. The usual causes are the passage of a heavy 
 wagon over the abdomen, a fall or blow on the hypogastrium, a wound, or 
 extreme retention of urine. Symptoms. — Sudden and violent pain in the 
 pelvis or hypogastrium ; great desire to urinate, but no urine passes ; the 
 catheter readily enters the bladder, but draws off only a small quantity of 
 urine, which may be bloody. Collapse, then peritonitis. Prognosis. — 
 Almost always fatal, except where there is an open wound, with the 
 peritoneum uninjured. Treatment. — Use a catheter open at the extreme 
 tip, to keep the viscus empty ; do not pass it far into the bladder ; use the 
 proper remedies for peritonitis, especially opium and warm applications, 
 but avoid depletory measures. If you feel sure of your diagnosis, it is 
 justifiable to open the abdomen antiseptically, wash it out, and sew up a 
 rent in the bladder. 
 
 Bladder, Stammering of, or, rather, of urinary organs. — A condition in 
 which, without any more visible organic disease than exists in stammering 
 of the vocal organs, the sufferer cannot micturate freely at will. The stam- 
 mering is usually aggravated by anything which directs the patient's atten- 
 tion to the act of micturition, or which makes him "nervous," or by 
 temporary disorder of digestive or urinary organs. Treatment. — Strengthen 
 general health, attend to digestion and state of urine. Teach patient to 
 pass a. catheter for himself, so that he may be free from fear of retention. 
 (Paget's Clin. Lect.) 
 
32 BOILS. 
 
 Bladder, Tubercle of, seldom, if ever, occurs except with tubercle of 
 other urinary organs. Symptoms. — Those of ulceration in a tuberculous 
 patient. Treatment. — That of tuberculosis : anodynes ; rest. 
 
 Bladder, Tumors of, are : 1, fibrous ; 2, villous ; or 3, cancerous and not 
 villous. The first may cause no symptoms, or, if unfortunately situated, 
 those of obstruction or irritation. The second causes constant hemorrhage, 
 which is generally at last fatally exhausting. For the third, see Cancer of 
 the Bladder. The catheter must be gently used where there is obstruc- 
 tion ; mild astringents and rest for hemorrhage ; strength to be supported 
 by chalybeates, good diet, etc. In women, vesical tumors may sometimes 
 be felt and removed through the urethra. The villous growth is some- 
 times the cause of severe pain, and may or may not be cancerous. 1 
 
 Bladder, Washing out, may be done either with a double-current 
 catheter or with Clover's apparatus, with Bigelow's apparatus, or with a 
 syphon -tube. 
 
 Bleeding". — Venesection. Veins used : median-cephalic, median-basilic, 
 external jugular, saphena veins near ankle, veins of scrotum. Instruments 
 required : bleeding-tape or bandage, bowl, lancet, pad, sponge, and water. 
 Apply tape to middle of upper arm, tight enough to congest veins, but not 
 to affect pulse. Hang arm down a little while ; then choose spot and 
 apply thumb just below it. Pass lancet gently and obliquely into vein, 
 and enlarge opening without deepening incision ; draw off enough blood. 
 If necessary, make patient work his hand, opening and shutting it. Fi- 
 nally, apply pad over wound ; fix it with the tape ; put arm in sling for two 
 days. In opening external jugular, put the pad just above the clavicle, 
 and cut in the direction of the fibres of the sterno-mastoid. Bathe the 
 veins of the scrotum with warm water before and after opening them. 
 Arteriotomy. — Cut the temporal artery, or its anterior branch, half in two 
 transversely ; when enough blood has flowed, divide it completely, and 
 apply a pad and bandage. 
 
 Blennorrhcea=Gleet, vide Gonorrhcea. 
 
 Boils. — Causes. — Debility or plethora (but these causes are probably 
 never sufficient when uncomplicated) ; change of diet ; excessive perspira- 
 tion ; hydropathy ; sea-bathing ; air of dissecting-rooms ; training ; spring 
 and early summer season ; diabetes ; diseased meat ; irritation of sexual 
 organs ; local irritants of various kinds, e.g., edge of a frayed shirt-collar ; 
 poultices. Symptoms. — The local appearances are well known. There is 
 rarely any fever. Sometimes premonitory symptoms, such as feeling of chilli- 
 ness, bad temper, etc. Pathology. — In the first instance, a boil is frequently 
 indistinguishable from an acne-spot. Indeed, in a person suffering from an 
 attack of boils, almost any acne-pimple can be irritated into a boil by 
 
 1 Papilloma of bladder is always attached to trigone between the two ureters 
 (Rindfleisch). 
 
BONES, DISEASES OF. 33 
 
 persistent friction, or by exposure to some continuous irritant, such as 
 the sea-water constantly wetting the wrists of fishermen. A boil is a local 
 cellulitis, often spreading from an inflamed sebaceous follicle ; and the 
 reason of this spreading is, in most cases, not the specific nature of the 
 original cause, but persistent local irritation. As it is quite as easy to 
 protect from local irritation, and to check the acne, as to cure the specific 
 cause of boils, if there be one, I hold that this view of boils is of practical 
 importance. The " core " of a boil is a central slough of cellular tissue. 
 Treatment. — Local. Soap-plaster. Poultices or water- dressing should be 
 avoided, as they bring out fresh boils. Incision (complete) of very pain- 
 ful ones. Ext. belladonna and glycerine on lint. Blind boils may be 
 aborted by the application of a strong caustic to the commencing vesicle ; 
 strong carbolic acid locally (Eade of Norwich). General Treatment. — Reg- 
 ulate the diet. When any poison appears to have been absorbed, use 
 eliminative treatment, e.g., purgatives, Turkish bath ; moderate exercise ; 
 light clothing ; arsenic ; yeast, one tablespoonful three times a day. See 
 Smith's article in Holmes' " System," vol. v. Bathe part where the boils 
 chiefly appear, with water as hot as it can be endured, and, above all, re- 
 move every cause of local friction or chafing. 
 
 Bones, Diseases of, resemble those of the soft tissues, but are remark- 
 able for the extreme slowness with which the pathological changes usually 
 take place. 
 
 Note. — The pathology of the varieties of inflammation in bone and 
 periosteum will be given collectively, for the sake of convenience and 
 clearness. 
 
 Bone, Atrophy of. — Causes. — Injury, e.g., fracture ; chronic inflam- 
 mation ; disuse, e.g., in the case of the bone of a stump ; old age, e.g., 
 atrophy of the lower jaw ; pressure, e.g., that of a tumor. Pathology. — 
 The bone becomes not only smaller, but its cancellous and medullary 
 spaces enlarge ; a certain amount of fatty degeneration is frequent. 
 
 Pathology of Osteal and Periosteal Inflammations — Pathology of 
 Acute Periostitis. — Attacks chiefly the long bones, especially the femur ; 
 medulla may be coincidently inflamed. In a typical case, in which both 
 periosteum and medulla are affected, the vessels of each are highly in- 
 jected, and the intervascular tissue infiltrated with young corpuscles ; this 
 stage may end in complete resolution, in ossification of some of the inflam- 
 matory new-formation ; or, as in most cases unfortunately, it may end in 
 suppuration ; then the skin reddens, the oedema becomes marked, and 
 neighboring joints swell ; the suppuration separates the periosteum, not 
 usually from the whole shaft, but frequently from half of it, though often 
 only on part of the circumference ; except in rare instances in small chil- 
 dren, necrosis is now inevitable. See Necrosis of Bone. 
 
 Pathology of Chronic Periostitis. — It is often accompanied by superficial 
 inflammation of the bone itself. The two layers of the periosteum (in- 
 
34 BONES, DISEASES OF. 
 
 ternal, fibrous, and external, cellulo vascular) cannot be separated from 
 each other, but are swollen, infiltrated with young cells, and traversed by 
 dilated capillaries ; they are easily separated from the adjacent bone, 
 whose surface is generally covered with small nodules of new bone ; the 
 general opinion is that these nodules (osteophytes) grow from the perios- 
 teum ; periostitis, with the formation of these osteophytes and without 
 suppuration, is usually syphilitic. When suppuration occurs, it may be 
 without any destruction of bone, caries, or necrosis ; but usually the bone 
 is rough and gnawed, often to a considerable extent ; this occurs especially 
 in strumous periostitis. Then again, in other cases of chronic periostitis, 
 a soft, fluctuating swelling forms, consisting not of pus, but of granula- 
 tions springing from carious bone ; these cases are often also strumous. 
 
 Pathology of Caries. — Chronic inflammation causes the corpuscular and 
 vascular elements of the soft parts of bones to increase at the expense of 
 the earthy parts ; the young cells seem, as it were, to corrode the walls of 
 the lacunae, etc., in which they lie ; these corrosions, spreading and unit- 
 ing, may cause destruction to an indefinite extent ; the bone thus corroded 
 is dissolved, and is either absorbed or flows away in the discharges. 
 Around the region of caries is sometimes a zone of sclerosis, i.e., of bone 
 in which the inflammatory new material has ossified between the trabecule 
 of the original bone. The distinctive characters of strumous caries are 
 thus given by Walsham ("Surgical Pathology," p. 16) : "It is characterized 
 by the tendency of the inflammatory products to undergo caseous degenera- 
 tion, by the extensive destruction of the affected part, by the softened, 
 fatty, and oily condition of the bone around, by little tendency to the for- 
 mation of new bone, and by feeble efforts toward repair." 
 
 Pathology of Necrosis. — Dead bone is bloodless, and either white, or 
 else darkened by the action of air, pus, or blood ; on the surface lately con- 
 tinuous with living bone it is rough and corroded ; but on the free sur- 
 face, usually smooth. The process of separation of necrosed bone is as 
 follows : granulations form at the plane of contact of living and dead bone, 
 and these granulations dissolve the earthy medium still uniting the dead 
 to the living bone, thus setting the former free ; the soft tissues in con- 
 tact with dead bone loosen from it everywhere, and often a layer of pus 
 intervenes ; then the dead bone lies in an abscess-cavity. When part or 
 whole of the shaft of a long bone necroses, these same neighboring soft 
 parts, most especially the periosteum, proceed, as a rule, to build a shell 
 of new bone, within which the necrosed bone lies ; this shell is perforated 
 in one or more places by cloacae (passages for the egress of discharge) ; 
 the piece of necrosed bone is called the sequestrum ; it takes months to 
 separate from the living bone ; it is eventually either discharged or ab- 
 sorbed, or removed by operation, or it may remain even for years. So 
 long as it remains, the new bone around it usually grows thicker ; when it 
 is removed, the remaining cavity fills with granulations, which ossify ; 
 
BONES, DISEASES OF. 35 
 
 gradually the new bone, by a process of external absorption and internal 
 growth, gets to resemble more and more the shape and consistence of the 
 original bone whose place it is to take. Practically speaking, only the 
 smallest sequestra can be absorbed. In necrosis of flat, and of short, 
 spongy bones, there is small prospect of thorough reproduction ; in these 
 cases necrosis is usually combined with caries, and often with a chronic 
 constitutional disorder. Necrosis, when confined to the surface of a'bone-, 
 is called " superficial," and when to the interior of a bone, " central ;" in the 
 former the sequestrum is called an "exfoliation ;" central necrosis consti- 
 tutes almost an independent disease. 
 
 Pathology of Central Necrosis is the result of inflammation of the 
 deeper parts of a bone, and is usually accompanied by caries ; it leads to 
 a bone -abscess, to a simultaneous periostitis on the neighboring external 
 surface of the bone, and to a consequent apparent thickening of the bone. 
 Note : though central necrosis is pretty sure to lead to abscess, yet abscess 
 of bone does not usually imply necrosis. 
 
 Chronic Abscess of Bonk — First described by Brodie. Most usual 
 seat, head of tibia. Causes. — Obscure, sometimes injury. Symptoms. — 
 Those of ostitis and periostitis confined to a circumscribed locality. An 
 abscess is suspected because of the persistence of the symptoms, and be- 
 cause of the localized and circumscribed tenderness. Diagnosis and 
 treatment require the same proceeding, viz., trephining at the tenderest 
 spot. Generally the abscess is here very superficial. The trephine has in 
 some cases just missed the cavity. Holmes advises in such cases to per- 
 forate the walls of the trephi Tie-hole in several directions in search of the 
 pus. Prognosis is excellent when the trephine pierces the abscess ; other- 
 wise there is danger of abscess opening into a neighboring joint. 
 
 Inflammation of Bone. — Three chief varieties, according to part mainly 
 attacked, viz., ostitis, periostitis, and osteo-niyelitis. 
 
 1. Ostitis. — Inflammation may begin in the bone proper, without affect- 
 ing the periosteum or medulla at first. Causes. — Though it is often ex- 
 cited by an injury, there is usually some predisposing cause — syphilis, 
 struma, or simple constitutional debility. Symptoms. — Deep-seated, ach- 
 ing pain, worse at night, and other symptoms, all like those of periostitis. 
 Besults. — It usually ends in either caries or sclerosis, quod vide. Treat- 
 ment. — Counter-irritants, e.g., iodine, or warmth and moisture locally, or 
 cold applications. Treat cause ; iodide of potassium. Linear osteotomy 
 in bad cases — Erichsen. Linear osteotomy is the longitudinal division of 
 the part of the bone affected, down to the medullary canal, by a Hey's 
 saw. Mild counter-irritants, rest, and elevated position, perhaps gentle 
 compression and weak purgatives, are the best abortive treatment when 
 the disease is commencing. 
 
 2. Periostitis, Chronic or Subacute — Causes. — Syphilis, rheumatism, in- 
 juries ; may be secondary to ostitis, or spread from an inflamed articu- 
 
3G BONES, DISEASES OF. 
 
 lation. Symptoms. — Swelling, aching pain, worse at night ; heat ; skin 
 usually not reddened ; swelling mostly in the form of anode. Prognosis. — 
 Usually ends in resolution ; often causes thickening of the bone, growth of 
 osteophytes ; rarely ends in suppuration. Treatment. — See Ostitis. Also 
 an incision, subcutaneous or otherwise, to relieve a bad case. 
 
 Periostitis, Diffuse — Causes. — Age, usually about puberty ; sex, mostly 
 in boys ; generally follows injury ; strumous. The effusion strips the peri- 
 osteum from the bone, and almost always causes necrosis, sometimes of an 
 entire shaft of a long bone. Symptoms. — Femur or tibia usually affected ; 
 swelling, heat and pain, easily confounded with cellulitis or acute rheuma- 
 tism, but it does not spread over the joints above and below the bone ; 
 both local and constitutional symptoms very severe ; suppuration ; then 
 rigors, glistening skin, fluctuation, etc. For further course, etc., see Necro- 
 sis. Prognosis. — Highly dangerous ; death may occur before suppuration, 
 or may result from exhaustion or pyaemia afterward. Diagnosis. — From 
 acute rheumatism or cellulitis ; care only required ; no rheumatic affection 
 of heart, or any separate joint ; fever different, etc. Treatment. — Rest, ele- 
 vated position ; local applications, warm fomentations ; free incision when 
 abscess has fairly formed ; incisions to remove tension at an earlier period 
 usual. Such early incisions predispose to pyaemia (Billroth). Such inci- 
 sions can be made antiseptically. Vide also Necrosis. 
 
 3. Osteo-myelitis, or inflammation of the medulla of a bone, is extremely 
 rare, except as the result of direct injury, e.g., from compound fracture or 
 after amputation through a bone. Inflammation of a bone may be judged 
 to begin in the medulla if the swelling does not appear till some days after 
 the severe local pain ; there is always violent fever; the periosteum sepa- 
 rates from the diseased bone without being pushed off by suppuration ; the 
 prognosis and treatment resemble those of diffuse periostitis, only the for- 
 mer disease is even more serious ; authorities are divided as to whether a 
 limb, known to be affected with acute osteo-myelitis, should be amputated 
 or not ; a limited osteo-myelitis, after amputation and leading to a slight 
 necrosis, is frequent, and not necessarily serious. 
 
 Necrosis. — Causes. — The same as those of periostitis, ostitis, and osteo- 
 myelitis. Necrosis of the jaw occurs, less frequently now than formerly, 
 among workers in phosphorus ; and it is said that the phosphorus fumes 
 attack only those with unsound teeth. For immediate causes, see the sec- 
 tion on Pathology of Bone Diseases (supra). Symptoms and Diagnosis. — 
 Necrosis may be fairly presumed to have occurred when (1) inflammation 
 of a long bone or its periosteum has been acute or prolonged, while (2) 
 extensive hard thickening has taken place, indicating the formation of new 
 bone, and (3) the pus from any sinus existing is thick and yellow. In 
 caries, on the other hand, the spongy bones are the usual seat, the forma- 
 tion of new bone is usually slight, the pus thin and serous ; but the probe 
 is required to settle the diagnosis. If gently used it causes little or no pain 
 
BONES, DISEASES OF. 37 
 
 in necrosis, usually much pain in caries ; the sequestrum in necrosis feels 
 smooth and hard ; carious bone is rotten ; but it is to be remembered that 
 the probe may fail to reach the sequestrum, and that in a few cases enor- 
 mous thickening exists with caries only. The probe should be pressed 
 firmly against the sequestrum, to feel if it is movable and ready for " se- 
 questrotomy." Necrosis is sometimes found to have occurred without any 
 history of precedent inflammation. This is called " Quiet Necrosis." Vide 
 Paget's " Clinical Lectures," and Morrant Baker, in " St. Bartholomew's 
 Hospital Beports," vol. xiii. Prognosis depends on the acuteness of the in- 
 flammation, and on the extent of bone involved. Acute necrosis of the whole 
 shaft of a long bone is excessively dangerous. Pyaemia sometimes follows 
 the opening of the abscess. Treatment. — Treat the cause, e.g., struma ; be- 
 fore suppuration, try to cause resolution by counter-irritants, cold, etc.; 
 when abscess has fairly formed, open it ; some recommend incisions before 
 then, merely to relieve the tension of the periosteum. Billroth condemns 
 this plan, saying that it predisposes to pyaemia. When necrosis has actually, 
 taken place, you must wait till the sequestrum has loosened and then re- 
 move it, treating the general health in the meantime. Unless the seques- 
 trum can be felt loose, a very considerable time, even many months, had bet- 
 ter be allowed before attempting to remove it by operation. Operation for 
 Necrosis. — Tourniquet, or (much better) Esmarch's bandage ; sponges, etc., 
 scalpel, Hey's saw, cutting-pliers, necrosis-forceps, gouges, chisels, hammer, 
 probe, oiled lint, bandages, and minor instruments. Incise the soft parts' ; 
 it is often advisable to unite two sinuses by the incision. Cut a sufficient, 
 but no larger, opening in the sheath of new bone ; divide the sequestrum if 
 it cannot easily be removed whole ; plug the cavity with oiled lint. When 
 the whole shaft of a long bone has necrosed, it had better be removed as 
 soon as the acute symptoms have passed away, unless the epiphyseal car- 
 tilages have been involved in the inflammation. It may be desirable to 
 divide it in the middle by a chain-saw. A new shaft may be expected to 
 form, unless the epiphyseal cartilages have been destroyed ; in this case a 
 new shaft can only be expected when the sequestrum is left for a long time 
 in sitil. If the necrosis be extensive, and for some reasons cannot be re- 
 moved, while the patient's health is giving way, amputation must be done. 
 
 Hypertrophy of Bone is commonly the result of inflammation, which 
 may or may not be specific. The cause should be treated. The disease 
 may follow a blow. 
 
 Bone, Injuries of. — Blows are liable to cause atrophy in the old, and 
 strumous disease in the young and weakly ; they are sometimes followed 
 by hypertrophy. See Fractures, etc. 
 
 Mollities Ossium. — A disease allied to fatty degeneration of bone. 
 Causes. — Mostly attacks females ; age, middle life or later ; pregnancy. 
 Symptoms. — At first, rheumatic pains, then various bones soften and 
 bend, and afterward fracture. The general health is only injured by the 
 
38 BONES, DISEASES OF. 
 
 physical effects of the resulting fractures and deformities. The chest and 
 spine being deformed, the thoracic and abdominal viscera may be com- 
 pressed, and a distorted pelvis impedes delivery. Large quantities of 
 phosphates in the urine. Diagnosis. — From rheumatism, syphilis, and 
 cancer ; a bone fractured through the weakening effect of cancerous 
 deposit gives way suddenly without bending previously. Prognosis. — 
 Almost always fatal sooner or later, through weakening the power of the 
 constitution to resist intercurrent disorders ; rarely fatal through its own 
 cachexia ; cases of recovery are excessively rare. Treatment. — Tonics, 
 cod-liver oil, phosphates, attention to digestive functions ; special gymnas- 
 tics for the deformities. 
 
 Osteitis Deformans. — A very rare disease, lately described by Sir 
 James Paget in the " Medico-Chirurgical Society's Transactions." Chief 
 Characteristics. — General enlargement of the bones, with sufficient soften- 
 ing to permit slight loss of height (several inches) through arching of the 
 long bones of the lower extremities and bending forward of the head on 
 the breast ; ribs also thick and immovable ; skull thickened ; cranial 
 sutures obliterated ; compact substance greatly increased. According to 
 Butlin, the microscopic changes indicate that the disease is an inflamma- 
 tion rather than a new-growth. In this view Paget concurs, hence the 
 name " osteitis." But the frequent coincidence of sarcoma and carcinoma 
 with this affection is most remarkable. Little or no pain usually, only 
 clumsiness. Disease lasts for years, and death has often occurred from 
 the intercurrence of the above-mentioned malignant tumors. The usual 
 remedies for other forms of osteitis appear to be of no avail. The large 
 doses of pot. iod. and of arsenic, which have given Esmarch and Billroth 
 encouraging results in the treatment of new-growths, have not, to my 
 knowledge, been tried in this very rare disease. 
 
 Osteo- Aneurism, or Pulsating Tumor or Bone. — Almost always malig- 
 nant ; usually occurs in cancellous ends of long bones, in skull, and pelvis. 
 Symptoms. — A tumor, " oval, uniform, and elastic to the touch, growing 
 slowly ; " pulsation and a bruit (the latter sometimes, but rarely, absent). 
 Tumor may be partially emptied by pressure, and then the bony margin 
 of the cavity in which it lies may be felt. Crackling shell of bone some- 
 times felt over it. Diagnosis. — 1. The diagnosis of innocent from malig- 
 nant pulsating tumor : in the latter case there may be evidence of ma- 
 lignant disease elsewhere ; the tumors may be multiple ; the growth is 
 probably more rapid and the tumor painful. 2. From ordinary aneurism : 
 by considering the situation and the characters mentioned above. Progno- 
 sis. — Depends upon whether tumor is malignant or not. Treatment. — For 
 innocent cases try pressure on, or ligature of, the main artery ; Esmarch's 
 bandage might be tried ; innocent tumors have also been gouged out. All 
 other cases require amputation. 
 
 Sanguineous Tumors of Bone. — Vide Cystic Tumors. 
 
Scrofulous Disease op Bone. — Causes. — Vide Scrofula. Often follows 
 injury. Symptoms. — Swelling, usually of an indolent and chronic char- 
 acter ; superjacent skin commonly pale, hence the term "white swelling." 
 Other symptoms of scrofula : in a large proportion of cases some internal 
 organ is the seat of tuberculous or cheesy deposit. As the disease advances, 
 there are symptoms of caries and abscess, the latter often appearing far 
 away from the diseased bone. Most of the sufferers are children. The 
 mischief often spreads to neighboring joints, and the suppuration tends to 
 spread far and wide along intermuscular spaces, etc., before the abscess 
 bursts. Diagnosis rests on the local symptoms above given, and on the 
 presence or absence of other signs of the scrofulous diathesis. Prognosis. 
 — Local recovery may usually be expected (in about two years, according 
 to Stanley) if the general health holds out, but relapse is very common 
 both in the original seat of the disease and elsewhere. Treatment. — Gen- 
 eral treatment of scrofula. Locally : complete rest ; counter-irritation by 
 painting with iodine, etc., till abscess fairly forms, and even afterward 
 (Furneaux Jordan). There are special apparatus to give rest to special 
 parts of the body : e.g., for morbus coxae and for Pott's curvature, quod 
 vide. Eemove the diseased bone by operation in suitable cases. 
 
 Syphilitic Disease of Bone. — Usually, if not always, begins in the adja- 
 cent soft parts. Symptoms. — The first are usually pains like those of rheu- 
 matism, and worse at night. They are called " osteoscopic." Then nodes 
 are found. They are circumscribed, round or oval swellings, occurring 
 chiefly on such bones as are subcutaneous, but sometimes elsewhere, e.g., 
 upon the inner surface of the skull. The primary affection is in the peri- 
 osteum. Small tendency to suppuration. Production of new bone. Caries 
 and necrosis caused by more acute syphilitic periostitis. Three forms of 
 syphilitic ulceration of bone, viz., the annular, the tuberculated, and the 
 reticulated. Dry caries (caries sicca) is frequently syphilitic. Syphilis, 
 by destroying the bones, causes peculiar deformities in some parts, e.g., 
 flat nose, destruction of palate, etc. Syphilitic ozcena. Epilepsy from 
 pressure of intra-cranial nodes. Diagnosis. — Ulcerations have character- 
 istic syphilitic shape, appearance, and history. Syphilitic nodes are known 
 by their position, hardness, indolence, and liability to nocturnal pains. 
 Prognosis. — Good except in tertiary syphilitic ulceration ; bad cases of this 
 are sometimes quite incurable. Treatment. — Vide Syphilis. 
 
 Bone, Malignant Disease of. — True carcinoma of bone is said to be 
 always secondary, never primary. Most so-called " cancers of bone " are sar- 
 comata. For full details as to structure of " osteoid cancers," see Walsham 
 in "St. Bartholomew's Hospital Reports," vol. xv., and for full details as to 
 clinical history of malignant tumors of bone, see Butlin's lectures in British 
 Medical Journal for July, 1880. Sarcomata of bone commence either cen- 
 trally or subperiosteally. The latter are far more likely to recur and to 
 infect the system than the former. The lower end of femur and upper end 
 
40 BONES, DISEASES OF. 
 
 of tibia are the most common seats of central sarcoma. The lungs are the 
 usual seats of secondary infection. Both central and periosteal tumors of 
 bone frequently become ossified (osteo-sarcoma, osteo- chondroma, etc.). 
 However much the shaft of the bone may be affected, the articular cartilage 
 remains healthy. Some tumors are perfectly encapsuled, others infiltrate 
 every neighboring structure. The bone may give way at the seat of dis- 
 ease, a fracture thus resulting. When carcinoma of a bone does occur^ it 
 is usually encephaloid. Diagnosis. — Vide Cancer. Enchondroma and 
 even cancellous exostoses sometimes resemble malignant tumors in their 
 rapid growth. But they may be recognized by their hardness. Prognosis. 
 — As above mentioned, central sarcoma is less likely to recur than perios- 
 teal sarcoma. Frequently no recurrence takes place after thorough removal, 
 and these tumors occasionally reach a large size before infecting the sys- 
 tem. Treatment. — Excise, except when disease has infiltrated regions 
 which cannot be removed, e.g., certain parts of the skulL Unless the 
 tumor is evidently circumscribed, remove the whole bone. This generally 
 necessitates amputation at the joint above. But in cases of disease of the 
 lower end of the femur, it is not usual to exarticulate at the hip, that opera- 
 tion being so dangerous. Still, when the cancer is soft and diffuse, even 
 this risk should be run. 
 
 Tumors of Bone. — The innocent are enchondroma, exostosis, cystic, 
 fibrous, fibro-cystic, and hydatids. Vide the various articles, Tumor, Ex- 
 ostosis, Entozoa, etc. The great majority of innocent tumors of bone are 
 either exostoses or enchondromata. 
 
 Ulceration of Bone. — Vide Cartes. 
 
 Cartes. — Causes. — Predisposing are scrofula, syphilis, and constitutional 
 weakness, such as arises from old age. Exciting cause, often some injury. 
 Symptoms are those of ostitis leading to the formation of an abscess. 
 When this opens, a probe can often detect the softened bone. If the probe 
 will not reach the disease, the occurrence of certain deformities, e.g., Pott's 
 curvature, may offer a sure sign. Scrofulous caries usually attacks the 
 vertebras, articular epiphyses, phalanges, and metacarpal bones. Syphi- 
 litic ulceration affects mostly the tibia, cranium, sternum, hard palate, and 
 nasal bones. Diagnosis. — In the early stage the bone may not be recog- 
 nized to be diseased at all, or may be supposed to be merely rheumatic. 
 Prognosis. — Ulcers of bone often cicatrize : bad cases not veiy hopefuL 
 The younger the patient, and the less important the bone, the better the 
 prognosis. Danger of amyloid disease, and fatty degenerations of impor- 
 tant organs supervening. Treatment. — Constitutional for the scrofula or 
 syphilis, etc. Local : rest, elevation, the usual treatment of inflamed bone 
 at first, then that of chronic abscess. If the patient's general health be 
 tolerably good, and the locality of the disease suitable, the carious bone 
 may be removed by gouge, gouge-forceps, chisel, or Marshall's osteotrite. 
 Use of strong or slightly dilute nitric or sulphuric acids. When a bone is 
 
BREAST. 41 
 
 sufficiently diseased, resection (complete or partial) is sometimes justifi- 
 able, or amputation may be required, occasionally, to save life. 
 
 Bout onni ere Operation. — A term applied to a proceeding in which 
 a " button-hole " is purposely made in some part. It is done through the 
 soft palate, to facilitate the extraction of polypi, and into the urethra from 
 the perineum, in order to expose the commencement of an " impermeable 
 stricture." 
 
 Breast, Abscess of. — Three varieties : 1, supra-mammary ; 2, mam- 
 mary ; and 3, post-mammary. Abscess in the breast almost always at- 
 tacks suckling women in a feeble state of health, and generally soon after 
 delivery. First variety is the most common in other people ; subjects of 
 third variety are often tuberculous. Symptoms. — General symptoms of 
 abscess. Supra-mammary runs a quick course. Intra-mammary causes 
 the greatest pain. Post-mammary pushes the whole breast forward : in 
 it, too, the fluctuation is, at first, quite deep, and eventually several open- 
 ings often form. Treatment. — On general principles. Deep abscesses 
 should be opened as soon as fluctuation can be fairly felt. Line of incision 
 should radiate from nipple. Attention to the general health will usually 
 cure the fistulse which often remain. Quinine. 
 
 Breast, Amputation of. — Scalpel, forceps, artery-forceps, sutures, 
 sponges, dressings. Elliptical incisions parallel with fibres of pectoralis 
 major ; lower to be made first : separate gland from parts beneath before 
 making upper incision. Proper support and pressure required from dress- 
 ings. Drainage. Mortality, 10 per cent. 
 
 Breast, Atrophy of. — Occurs after middle age. It may be caused 
 by the occurrence of new growths. Breasts apparently atrophied may 
 perform their functions properly when called upon. 
 
 Breast, Cancer of.— Almost always scirrhus. May be encephaloid or 
 colloid ; or may be complicated with blood-cysts. Causes. — Obscure. 
 Age, middle and later life, especially from 40 to 50 years. Cancer in youth 
 mostly encephaloid. Sex — female. Depressing influences (?). Change 
 of life (?). Injuries. Family predisposition. 1 Follows chronic eczema of 
 the nipple. Symptoms. — Firstly, of scirrhus. A tumor, hard, nodulated, 
 heavy. Implication of neighboring tissues, retraction of nipple. Affection 
 of skin, which reddens and thickens, and afterward ulcerates ; severe 
 pain ; cachexia ; enlarged and hardened glands in axilla, afterward in 
 neck ; oedema of the arm ; occasional direct infection of the pleura. Con- 
 stitutional infection. Encephaloid of Breast begins as a soft oval tumor, 
 usually deeply placed, grows rapidly, may be mistaken for abscess ; feels 
 like several soft tumors together ; skin ulcerates ; fungus ; sloughing ; 
 bleeding; glandular infection, etc. Diagnosis. — Vide Tumors of Breast. 
 Prognosis. — Almost always recurs after removal. Average duration of 
 
 1 This exerts much less influence than is commonly believed. 
 
42 BREAST* 
 
 scirrhus, four years ; longer in old people. Treatment. — Palliative or 
 operative. 1. Palliative : pressure by Arnott's bags, or soft compressor 
 and bandages ; belladonna, atropine, and aconite externally ; poultices with 
 belladonna. For ulcerated stage, carbolic lotion with oakum ; opium ; 
 iodoform ; ol. eucalypt. ; terebene ; caustics for ulcerated surfaces. 2. 
 Operation : prospects doubtful as to whether it will lengthen life or not. 
 But Morrant Baker found in eighty-four cases, not operated on, duration 
 of life to be forty-three months, and in sixty-two cases operated on, fifty- 
 six and a half months. Operation certainly may be expected to free patient 
 from much discomfort and distress. When fatal, it is usually because of 
 erysipelas or pyaemia. Contra-indications to operation are, 1, considerable 
 affection of skin ; 2, of glands in axilla, or even slight affection of cervical 
 glands ; 3, affection of parts beneath breast ; 4, cancer in both breasts ; 5, 
 great cachexia ; 6, constitutional infection ; 7, very chronic course in old 
 people. Old age and weakness are not absolute contra-indications, nor is 
 ulceration, per se. For operation, vide Amputation of Breast. 
 
 Functional Disorders of Breast. — The milk may be excessive or de- 
 ficient, or (3) it may flow away (galactorrhea), or (4) may congest the 
 gland. For galactorrhea, tonics, iron, iodides ; externally, belladonna, 
 hemlock (and internally too, with opium). When milk curdles, and forms 
 hard lumps in the gland, use stimulating liniments. 
 
 Galactocele. — A milk-tumor, caused by the dilatation or by the rup- 
 ture of a duct. Always forms during lactation. At first fills and grows 
 larger each time the child sucks ; fluctuation ; no pain ; no discoloration 
 of skin ; afterward, fluid parts of contents tend to be absorbed. At this 
 last stage, the main element in diagnosis is often the history. Treatment 
 — Incise or puncture with a trochar and canula, obliquely from nipple 
 toward tumor. 
 
 Hyperesthesia of Breast and Neuralgia of Breast. — Causes. — Chiefly 
 lie in state of uterus, ovary, or other organs of generation ; weakness ; 
 "nervous temperament." Mostly young girls ; sexual depravity. Symptoms. 
 — Pain, variable, often intense, shooting into arm, neck and back ; super- 
 ficial tenderness, often exquisite ; sometimes redness and swelling ; swell- 
 ing of nipple. Diagnosis. — Rests on age and character of patient, on 
 variability of pain, and superficial nature of the tenderness, and on negative 
 signs. Treatment. — Remove the cause ; if necessary, use the speculum, 
 but avoid it if possible ; correct bad habits ; treat all disordered func- 
 tions ; use the ordinary remedies for restoring the tone of the nervous 
 system. Avoid handling and examining more than is necessary. Em p. 
 belladon. 
 
 Hypertrophy of Breast. — Two forms, viz., 1, firm ; 2, pendulous and 
 loose. Causes. — Unknown. Appears soon after puberty. Symptoms. — In 
 form 1, the breast projects, large and firm ; in form 2, the organ hangs 
 down relaxed, and may reach an enormous size. Both breasts generally 
 
BREAST. 43 
 
 affected. Neuralgia often occurs with it. Treatment. — Not very suc- 
 cessful Support and pressure. In extreme cases, amputation may be 
 done. 
 
 Inflammation of Breast. — May occur even in infancy, but most cases oc- 
 cur in suckling women. Causes. — Debility ; protracted suckling ; the 
 irritation of some disease of the nipple ; obstruction to a gland duct ; often 
 coincident with defective nipple. Symptoms. — Lobular induration, per- 
 haps owing to the obstruction of a duct : this is called a "lump, knot, or 
 coring of the milk ; " pain ; tenderness ; redness ; shivering ; feeling of illness. 
 The signs of mere inflammation may disappear after involving more of the 
 breast, or may give way to those of abscess. Treatment. — Locally : rest ; 
 support ; warmth ; moisture. If necessary, the milk had better be drawn 
 off General treatment : purgatives ; quinine ; belladonna locally ; general 
 rest also. 
 
 Lobular Induration of Breast. — See Painful Mammary Tumor. 
 
 Malformation of Breast. — The breasts may be absent, or may be ex- 
 cessive in number ; or they may occupy strange situations, e.g., the back 
 or groin. 
 
 Tumors of the Breast. — Under this head will be noticed such new 
 growths as are not carcinomatous, viz. : 1, chronic mammary tumor, in- 
 cluding "painful mammary tumor; " 2, cysts ; 3, fibromata ; 4, enchondro- 
 mata ; 5, osteomata. 
 
 1. Chronic Mammary Tumor — (Synonyms: Adenoma — "Hypertrophic 
 partielle" — Mammary Glandular Tumor — Hydatid Disease of the Breast (Sir 
 A. Cooper) — Sero-cystic Sarcoma). — The above names are not all strictly sy- 
 nonymous ; some, such as adenoma, are applied to growths, which to the 
 naked eye appear of a solid, fibrous nature ; others, e.g., sero-cystic sarco- 
 ma, are applied to tumors consisting chiefly of cysts with solid growths 
 inside them. These latter are really of a sarcomatous nature ; the true 
 " chronic mammary tumor " is more of the nature of adenoma. Causes. — 
 Age, most frequently from 20 to 30 ; great majority of cases occur in 
 single women; "blows, squeezes, lacteal irritation," "hysterical tempera- 
 ment," " uterine irritation," " sexual excitement of an irregular kind " (Erich- 
 sen). Symptoms. — Commence as a hard nodule, usually painless and 
 not inbedded in the mammary gland, but movable ; may be peduncu- 
 lated ; growth slow, but in rare cases very rapid ; mammary gland 
 may atrophy ; almost always single ; size, perhaps considerable in old 
 tumors ; tumors prominent, not attached to skin ; afterward ulceration 
 and fungation. Diagnosis. — 1, vide Lobular Induration of Breast; 2, from 
 cancer by (1) slow growth, (2) usual freedom from pain ; 3, non-implication 
 of skin ; 4, healthy state of glands ; 5, no retraction of nipple ; 6, outline 
 rounded ; 7, consistence rather elastic than strong ; 8, by mobility. When 
 a fungus forms, the hole in the skin is clean-punched. Prognosis. — 
 The true chronic mammary tumor usually grows slowly, and does not re- 
 
44 BRONCHOCELE. 
 
 turn if removed ; local recurrence is common in the case' of the sero-cystio 
 sarcoma. Treatment. — Absorbents, ointments of iodine and the iodides ; 
 pressure by air-bags and spring contrivances : these means are praised by 
 some, ridiculed by others. Excision ; the tumor may be simply enucleated, 
 or in very bad cases, especially of the fungating sero-cystic kind, the gland 
 may be removed as well. 
 
 Painful Mammary Tumor includes the cases often described as Lobular 
 Induration of the Breast, or the term may be applied only to such " chronic 
 mammary tumors " as are the subjects of severe paroxysmal pains. In 
 Lobular Induration of the Breast, one or more lobes, or the whole breast, is 
 thickened and hardened, but there is no tumor distinct from the breast, 
 and the hard part does not project ; therefore, the hand laid lightly on the 
 breast does not feel any tumor. Occurs mostly in single or sterile women ; 
 age, from 25 to 45 ; pain often shoots along course of intercostal cutaneous 
 nerves going to gland : tenderness on pressure over their course. Treat- 
 ment for such painful conditions. — Support, if the breasts hang down ; 
 pressure ; belladonna plaster ; the usual constitutional and local remedies 
 for neuralgia ; attention to the generative organs, which are often func- 
 tionally deranged. 
 
 2. Cystic Tumor of the Breast may be : 1, simple, or 2, multiple, or 3, 
 combined with sarcoma, or 4, sanguineous, or 5, hydatid, or 6, milk- cysts. 
 1. Simple cysts vary greatly in size and in tension ; they may be so hard as 
 to be mistaken for solid tumors ; diagnosis may be confirmed with a trochar 
 and canula ; may arise from obstructed ducts. 2. Multiple cysts are 
 rare, unless combined with solid growths. 3. Cysto-sarcoma : for its 
 symptoms and treatment see Chronic Mammary Tumor, of which it may be' 
 regarded as one form, the other being adenoma. 4. Sanguineous cysts 
 may cause bleeding from nipple. 5. True hydatids are very rare ; the 
 term " hydatid disease " used to be applied to sero-cystic sarcoma of the 
 breast. 6. Galactocele, vide above 
 
 3. Fibromata, 
 
 4. Osteomata, 
 
 5. Enchondromata, of breast, all extremely rare. 
 
 Male Breast subject to same diseases as female, but much less frequently 
 attacked. For "Cancer of Male Breast," refer, if necessary, to complete 
 papers by Milton (" Medico-Chirurgical Transactions," vol. xl.), and to 
 Wagstaffe ("Pathological Transactions," vol. xxvii.). 
 
 Bronohocele. — Two kinds : ordinary and exophthalmic goitre ; the 
 former may be endemic or sporadic, simple or cystic, and it may be acute. 
 Causes. — Immediate cause unknown, but certainly poverty and an unhealthy 
 mode of living greatly conduce to it. Character and Effects. — Enlargement 
 of the thyroid gland or part of it, fluctuating if cystic ; occasionally causes 
 dyspnoea, dysphagia, or loss of voice, or displaces neighboring parts ; cysts 
 usually contain serous fluid when single, grumous fluid when multiple. Ex- 
 
BUNION. 45 
 
 ophthalmic Goitre. — Pulsation, anaemia, prominence of eyeballs. Diagnosis 
 may have to be made from carotid aneurism. Treatment. — General hygiene ; 
 high, dry, breezy places ; iron, iodine internally and externally ; iodide of 
 potassium ; lead iodide and mercuric iodide ointments ; pressure ; tapping 
 cysts and injecting them with iodine or iron tincture ( 3 j- to 3 ij. with 
 water); pressure ; seton (dangerous); ligature of thyroid arteries ; excision 
 when pressure of tumor threatens death ; for acute bronchocele, if the 
 pressure gets dangerous, tap any cysts and divide the binding cervical fas- 
 cia. D'Ancona claims to have cured a case of exophthalmic goitre by gal- 
 vanization of the cervical sympathetic (Dublin Journal, February, 1878). 
 
 Bruise. — Possible After-consequences. — Abscess, contraction or shrivel- 
 ling (e.g., of the ear after hsematoma), permanent thickening, long-con- 
 tinued pain and tenderness, paralysis of nerve or muscle, necrosis or 
 hypertrophy of bone, a weakness and liability to disease. Treatment. — 
 Pressure, uniform, equable, and tight, especially by cotton-wool and 
 starch bandage ; stimulating liniments, ice, cold lotions ; or, in severe 
 cases, warmth and exclusion from the air. Rest. When the effusion re- 
 mains, try friction, kneading or pressure, or tap antiseptically. 
 
 Bubo. — Causes. — Syphilis (suppurating bubo caused by the soft chan- 
 cre), gonorrhoea, and any irritation about skin of external genitals. When 
 there has been no visible sore, the bubo is called a "sympathetic" one. 
 " Bubon d'emblee " means a syphilitic bubo from absorption of virus, with- 
 out intermediate ulceration ; scrofulous constitution or severe local disease 
 of genitals aggravates bubo. Symptoms. — Those of inflammation and some- 
 times suppuration of and around the inguinal glands ; suppuration may 
 greatly undermine and destroy skin ; chronic or acute. Diagnosed from 
 deeper abscesses by its connections, situation, history, and course. Prog- 
 nosis. — Proper treatment will often prevent abscess ; liability to slough and 
 open arteries. Treatment. — 1, to prevent abscess : rest, counter-irritation, 
 blisters, iodine-paint, ex. belladon. and glycerine on cotton-wool, pressure, 
 cold, leeches. General treatment for cause : attend to bowels, quinine, 
 iron. 2, when abscess forms : poultice, foment, then open freely ; destroy 
 rotten skin ; stimulating ointments, red oxide of mercury powder or oint- 
 ment, ung. resinae, caustics when required ; iodoform. 
 
 Creeping Bubo heals at one side, extends at other ; horse-shoe shape. 
 
 Bunion. — Thickening of bursa over head of metatarsal bone of great 
 toe ; occasionally the term is applied to any enlarged bursa on the foot. 
 Symptoms. — First a tender spot, then swelling, effusion, liability to inflam- 
 mation ; suppuration, sinus, large cavity with narrow orifice, thin discharge ; 
 distortion of toe outward, displacement of flexor longus pollicis tendon in 
 same direction ; changes like those of chronic rheumatic arthritis in the 
 subjacent joint, or more serious articular disease which may lead to fatal 
 inflammation of the foot ; may be starting-point of senile gangrene. 
 Prognosis. — Barely altogether curable when it has long suppurated. 
 
46 BURS^E. 
 
 Treatment. — Rest ; remove the pressure of the boot, which is always the 
 cause ; restore the toe to natural position by mechanical contrivance ; it 
 may be justifiable to divide tendons or ligaments ; corn plasters, soap 
 plasters ; iodine or ointments of iodides to produce resolution ; when dis- 
 charging, apply stimulating dressing, e.g., ung. resinse ; when inflamed, , 
 poultices, fomentations, etc. Nitrate of silver solution will harden tender 
 skin. 
 
 Burns, including Scalds. — Six degrees : 1, cutaneous hyperemia, 
 like slight erysipelas ; 2, blistering ; no mark left after recovery, except 
 occasionally a slight stain ; 3, true skin partly destroyed : cicatrix, but no 
 contraction ; 4, total destruction of true skin : possible or probable great 
 deformity ; 5, muscles, etc., destroyed ; 6, a whole thickness of a limb 
 charred. Symptoms of the last four degrees are locally those of in- 
 flamed and suppurating wounds casting off sloughs. Constitutional 
 Symptoms. — At first, those of shock or collapse ; then, within forty-eight 
 hours, commences the second stage (of reaction and inflammation). The 
 third stage (of suppuration and exhaustion) begins in about a fortnight. 
 In the inflammatory stage there are fever, and liability to various com- 
 plications, peritonitis, pleuritis, pneumonia, bronchitis, arachnitis, conges- 
 tion of brain, ulceration of the duodenum. The symptoms of these 
 special affections are not peculiar, but liable to be obscure. Third stage : 
 hectic, same visceral lesions as those of second stage. Inflammations are 
 of a low type. Erysipelas, pyaemia, and tetanus. Ulceration of the duo- 
 denum occurs most frequently in the second stage, and is found in 12 per 
 cent, of fatal cases of burns : its symptoms are epigastric tenderness (not 
 a valuable sign) and hemorrhage from the* anus. Prognosis. — Depends on 
 age, extent of surface injured, and, to a less degree, upon depth. Most 
 serious in young children. Treatment. — Locally: rest; protect part 
 from air ; cotton wadding, oil, linseed-oil and lime-water, zinc ointment ; or 
 rags dipped in and kept constantly wet with solution of silver nitrate 
 (gr. x. ad | j.), or with a concentrated solution of carbonate of soda ; 
 starch, flour, balsam of Peru, etc. Afterward the treatment of simple 
 ulceration. Guard against contraction from cicatrization. Vide Cicatrix. 
 Terebene, carbolic lotion, and oakum for offensive discharges. Don't irri- 
 tate by dressing too often. Constitutional treatment : in stage of col- 
 lapse, opium, morphia subcutaneously, full doses ; stimulants cautiously ; 
 warmth ; chloroform if necessary at first dressing. In later stages watch 
 for and, so far as the patient's state admits, treat the complications. 
 Warmth externally for convulsions. Opium for diarrhoea, but keep the 
 bowels regular. Bloodletting sometimes for the visceral inflammations. 
 Diet chiefly of milk. Judicious stimulants, good food and tonics often 
 indicated ; fresh air. 
 
 Bursae. — Situations of chief : acromion, olecranon, great trochanter, 
 tuberosity of ischium, beneath psoas, lower, superior, and outer parts of 
 
CALCULUS. 
 
 4? 
 
 patella, condyles of femur, popliteal space, tuberosity of tibia, and the os 
 calcis. They also occur on almost any hard prominence, especially if sub- 
 ject to pressure, and under any tendon which glides over bone. 
 
 Diseased Conditions of Burs^;. — Four, viz. : 1, simple enlargement with 
 fluid contents ; 2, enlargement and solidification ; 3, enlargement and 
 formation of melon-seed bodies ; 4, inflammation. As a type of all bursse, 
 let us take the 
 
 Bursa Patelue. — All the above diseases may occur here, and are the 
 result of undue and repeated pressure. Inflammation may follow a blow 
 only, but especially a blow on bursa already enlarged. 1. Simple Enlarge- 
 ment. — A globular swelling, obviously in front of patella or lig. patellae, 
 and therefore not in the joint. Fluctuation sometimes, or even transpa- 
 rency. Usually painless. Stiffness. Perhaps no trouble whatever. 2. 
 Solidification. — -May be judged by the feel, or detected after incision. 3. 
 Melon-seed bodies may cause a crackling feel. 4. Inflammation causes heat, 
 redness, etc., and leads almost always to abscess. Treatment. — For 1. 
 Remove cause, iodine or blistering externally, tapping simply, or with in- 
 jection of tincture of iodine ( 3 j.) ; seton; free incision with gentle but firm 
 compression. 2. Excise the solid bursa. In dissecting it out, remember 
 the absolutely close proximity of the joint. 3. Melon-seed bodies are to 
 be let out by incision if the bursa is troublesome. 4. For inflammation — 
 leeches, fomentations, poultices, rest, elevation, back-splint. When abscess 
 forms incise freely. Suppuration may cause cellulitis all about knee, 
 bursting of pus into neighboring tissues or joint, or disease of patella. 
 Enlarged bursa over olecranon often causes diffuse cellulitis of forearm. 
 Bursa in popliteal space, and beneath semi-membranosus, very liable to 
 communicate with knee-joint. Hence caution in tapping ; antiseptic. En- 
 larged bursa with liquid contents can be easily reduced by elastic pres- 
 sure. Bat this elastic pressure requires experience and care to be used 
 with perfect safety. 
 
 Calculus. — Urinary Deposits. — Table of two classes, organic and inor- 
 ganic : 
 
48 
 
 CALCULUS. 
 
 Organic and Inorganic Calculi — (Continued). 
 
 Name. 
 
 Characters. 
 
 Causes. 
 
 Symptoms. 
 
 Treatment. 
 
 e 
 
 
 
 i 
 
 1 
 
 O 
 
 Crystalline forms : 1, 
 quadratic octahedra ; 2, 
 dumb-bell crystals. 
 
 "Nervous exhaus- 
 tion ; " dyspepsia ; over- 
 work : mental distress ; 
 excess of saccharine food 
 or alcoholic liquors. 
 
 Those of the 
 causes. Occa- 
 sionally, loss of 
 sexual vigor, or 
 disorder of the 
 sexual func- 
 tions. 
 
 Treat the 
 causes. Regular 
 diet, exercise, 
 etc. Mineral 
 acids. 
 
 CO 
 
 « 
 
 1 
 
 ft 
 
 1. Phosphate of Lime. 
 — White, cloudy mass. 
 Crystals: spherules, 
 dumb-bells, rosettes, 
 oblique hexagonal 
 prisms. 2. Phosphate of 
 Ammonia and Magnesia 
 (triple phosphate). 
 Crystals (large) : trian- 
 gular, truncated prisms, 
 four-sided prisms, irreg- 
 ular six-sided plates ; 
 stellate crystals when 
 ammonia has been added. 
 
 Alkaline urine is the 
 immediate cause. It is 
 caused by injuries and 
 diseases of the bladder, 
 especially paralysis and 
 catarrhal inflammation s ; 
 renal inflammation ; spi- 
 nal injury or disease. 
 Nervous exhaustion; ex- 
 cessive use of alkalies ; 
 the alkalinity of the 
 urine is said to result 
 from the metamorphosis 
 of urea into carbonate of 
 ammonia. 
 
 Urine is of- 
 fensive, and of- 
 ten contains 
 muco-pus. 
 Signs of causa- 
 tive disease. 
 
 Treat the 
 causes. See Dis- 
 eases op Blad- 
 der, etc. 
 
 1 
 
 o 
 
 Small and delicate 
 crystalline spherules. 
 Drum-sticks. 
 
 The causes which de- 
 termine the change of 
 urea into carbonate of 
 ammonia. 
 
 No special 
 sympt oms 
 known. Depo- 
 sit rare. 
 
 Treat the con- 
 ditions which ac- 
 company it. 
 
 § 
 
 s 
 
 Urine a dirty red color; 
 after standing, a slightly 
 flocculent, brownish sed- 
 iment. Heat coagulates 
 the albumen. There may 
 be blood enough to form 
 a clot ; then the urine is 
 dark brownish red. Or 
 the blood may be quite 
 unmixed with the urine. 
 
 1. Kidney disease. Cal- 
 culi, congestion, inflam- 
 mation, injury, scurvy, 
 the Bilharzia capensis. 
 Malaria may cause inter- 
 mittent haematuria. 
 Blood from the kidney 
 is generally mixed uni- 
 formly with the urine, 
 and forms blood-casts. 
 2. Bladder affections : 
 injuries, stone, tumors. 
 Blood from bladder of- 
 ten flows pure after the 
 urine. 3. Urethra: 
 blood pure, and comes 
 before or with urine, or 
 without urine at all. 
 
 Those of 
 cause. Use 
 Heiler's test for 
 blood. Heat 
 urine, then add 
 KHO and heat 
 again. The 
 pho sphates 
 then fall down 
 with the color- 
 ing matter of 
 the blood. The 
 sediment has a 
 dirty red color 
 by reflected, 
 and a splendid 
 blood-red color 
 by transmitted 
 light. 
 
 Rest and inter- 
 nal styptics, e.g., 
 gallic and sul- 
 phuric acids, ace- 
 tate of lead with 
 opium. Dry cup- 
 ping the loins also 
 in renal haemor- 
 rhage. For vesi- 
 cal haemorrhage 
 use similar treat- 
 ment and local 
 remedies : ice to 
 perinamm and 
 epigastrium and 
 in rectum. Do 
 not catheterize 
 unless there is re- 
 tention of urine. 
 If the clots will 
 not come away 
 without interfe- 
 rence, use, cau- 
 tiously, Clover's 
 exhausting appa- 
 ratus for lithoto- 
 my, or a syringe 
 and full-sized ca- 
 theter. Ruspi- 
 ni's styptic. 
 
CALCULI. 
 
 49 
 
 Name. 
 
 Characters. 
 
 Causes. 
 
 Symptoms. 
 
 Treatment. 
 
 to 
 
 3 
 
 Pus-corpuscles, under 
 the microscope, are 
 spheroidal and granular. 
 The pus generally sub- 
 sides as a dense layer of 
 a v - pale greenish cream- 
 color," which can be 
 mixed thoroughly with 
 the urine by shaking. 
 Not affected by acetic 
 acid. Forms a translu- 
 cent jelly when liquor 
 potassas is added. The 
 urine is albuminous. 
 
 Abscess, ulceration, 
 or merely catarrh of any 
 part of the urinary pas- 
 sages. 1 . Pus from the 
 kidneys is usually dif- 
 fused throughout urine 
 passed. 2. Pus from 
 bladder is mostly mixed 
 with mucus. 3. Pus 
 from an abscess is usu- 
 ally variable in quantity, 
 and not equally diffused. 
 
 Those of the 
 cause. 
 
 Treat the 
 cause. 
 
 a 
 
 'a? 
 "S 
 
 Epithelial cells lining 
 urinary passages. See 
 works on general Anat- 
 omy. Often in form of 
 casts. 
 
 Kidney disease. Ul- 
 ceration or catarrh of 
 bladder. 
 
 Those of 
 cause. 
 
 Treat cause. 
 
 Fibrine is sometimes present in the form of flocculi. Or it may form 
 fibrinous casts of the tubuli uriniferi. For information about casts, vide 
 medical works on the kidney. Echinococcocysts are sometimes found in 
 the urine. Give turpentine in large doses. The above table has been con- 
 structed chiefly with the aid of Thompson, Druitt, and Niemeyer. In cancer 
 of the bladder cancer-cells and debris are sometimes found in the urine. 
 
 Calculi. — There are seven mineral substances of which urinary calculi 
 may be formed. A calculus may consist of several of these materials in 
 layers, or of one only. 1, Lithate of ammonia ; 2, lithic or uric acid ; 3, 
 oxalate of lime ; 4, xanthic or uric oxide ; 5, cystic oxide ; 6, phosphate of 
 lime ; 7, triple phosphate. For the causes of the presence of an abnormal 
 amount of some of these substances in the urine, see table of urinary de- 
 posits. The nucleus or centre of each calculus may be formed first in the 
 kidney or in the bladder, or it may be a foreign body. Poverty, certain 
 localities, and the male sex are great predisposing causes of stone in the 
 bladder. Negro race remarkably exempt. 
 
 Table of Calculi. 
 
 Name. 
 
 J'Sl 
 3 s 
 
 Physical Characters, etc. 
 
 Occurs rarely, except in chil- 
 dren. Gray, smooth, dusty, non- 
 laminated appearance. 
 
 Chemical Characters. 
 
 Soluble in boiling water. Add HC1 to solution 
 and you get a precipitate of uric acid. Heat with 
 potassium carbonate : ammonia escapes. Blow- 
 I pipe burns it away. 
 
 Smooth or warty. Yellowish 
 or brownish. Concentric struc- 
 ture. 
 
 Gives off no ammonia when heated with KHO. 
 Evaporate to dryness with nitric acid. Cool, and 
 acid a little NH 3 ; the characteristic deep purple- 
 red murexide is then obtained. Blow-pipe burns 
 uric acid away. 
 
50 
 
 CALCULI. 
 
 Table of Calculi — (Continued). 
 
 Name. 
 
 Physical Characters, etc. 
 
 Chemical Characters. 
 
 1 
 
 1 
 
 o 
 
 Rough, warty, "mulberry" 
 appearance. Very hard. Dark 
 "blood-stained." 
 
 Easily soluble in nitric acid. Boil long in a 
 solution of potassium bicarbonate, neutralize care- 
 fully with nitric acid ; then white precipitates can 
 be formed with solutions of lime, lead, or silver. 
 Blow-pipe reduces it, first to calcium carbonate, 
 then to quick-lime. Heat on platinum foil and it 
 chars. Then add HN0 3 and it effervesces. 
 
 o 
 
 Q 
 
 '■1 
 
 Has a wavy appearance, espe- 
 cially when fractured, Changes 
 color with age from pale yellow 
 to brown, gray, or green. Ex- 
 tremely rare. Contains sul- 
 phur. 
 
 Dissolves, in great part, in ammonia : its solu- 
 tion then deposits, by spontaneous evaporation, 
 six-sided prismatic and tubular crystals. Dis- 
 solve in strong caustic potash. Boil, and add a 
 little solution of lead acetate : a black precipitate 
 of sulphate of lead falls. 
 
 {5° 
 
 Section, lustrous bright 
 brown. Most extremely rare. 
 
 Has a peculiar deep yellow color, when its solu- 
 tion in nitric acid iB evaporated to dryness ; char- 
 acteristic. 
 
 Mixed 
 Phos- 
 phates of 
 Lime. 
 
 Chalky, soft, brittle, lami- 
 nated. 
 
 "Fusible calculus": melts in the blow-pipe 
 flame. Dissolve in nitric acid and add excess of 
 ammonia : white precipitate. 
 
 Phosphate of lime and triple phosphate very rarely occur separately. 
 
 Fibrinous calculi smell of burnt feathers when burnt, and are stained 
 bright yellow by nitric acid. 
 
 Uric acid forms the nucleus of most " alternating " calculi. 
 
 The nature of the stone, while still in the bladder, may be guessed at 
 by considering the urine and any deposit from it. The urates are formed 
 from acid, the phosphates from alkaline urine (vide Table of Urinary 
 Deposits). 
 
 Symptoms of calculus in the bladder. — (Often so trifling as to attract 
 no attention for a long time.) 1, Pain radiating from bladder to perinseum 
 and in glans penis, especially after micturition ; 2, riding or jolting may 
 aggravate the pain by shaking stone about ; less pain when prostate is 
 much enlarged ; 3, urine sometimes stops flowing suddenly ; 4, frequent 
 micturition ; 5, in children, incontinence of urine ; 6, blood in urine ; 7, 
 signs of vesical catarrh ; 8, prolapsus ani ; 9, priapism. Many of these symp- 
 toms are often absent. For physical signs we employ the process called 
 
 Sounding. — The sound should have a short, sharply curved beak, and is 
 best hollow. "Warm, oil, and introduce. Hold lightly and gently. Push 
 backward and forward, and from side to side. Then turn point down- 
 ward, to examine base of bladder. The finger in the rectum, or suddenly 
 letting the urine flow through the sound will sometimes assist. Points to 
 be ascertained : 1, presence or absence of stone ; 2, size ; 3, number ; 4, 
 nature ; 5, whether the stone is encysted or not ; 6, state of bladder as to 
 
CALCULI. ' 51 
 
 rugosity. Size and number are best found by seizing and measuring with 
 a lithotrite. Nature best judged by considering the urine and the patient's 
 age and constitution. Fallacies result from mistaking a fasciculated blad- 
 der or the feel of some bony pelvic prominence for a calculus. The stone 
 should be heard as well as felt. A stone may be hidden away in a sao 
 culus. It there keeps always in one position, and perhaps is only felt 
 occasionally or not at all. " The surgeon should always remember that 
 when irritation at the neck of the bladder arises from stone it is referred 
 to the glans penis ; when from disease of the bladder, to the organ itself ; 
 and when from disease of the prostate, to the perinseum or rectum" 
 (Bryant). 
 
 Treatment. — 1, Palliative : treat the complications, e.g., vesical catarrh ; 
 recumbent position ; decoction of triticum repens. 2, Operative : as lithon- 
 tripsis is not yet of any value, refer to articles Lithotomy, Lithotkity, and 
 
 LlTHOLAPAXY. 
 
 Calculus in the Kidney. — Causes. — Vide Table of Urinary Deposits. 
 Position. — They may occur as small infarctions in the tubules, or as stones 
 of various sizes, single or multiple, in the pelvis and calyces, often forming 
 a cast of the pelvis and its offsets. Symptoms and Course. — Pain in the 
 back ; blood, pus, or " gravel " in urine ; sometimes intense pain (renal 
 colic), caused by passage of a calculus down the ureter into the bladder ; 
 pyelitis. Treatment. — "When an abscess forms it has been found sometimes 
 practicable and justifiable to cut down upon and remove the stone. For 
 the renal colic, use opium boldly, chloroform, and warm baths. 
 
 Calculus in the Prostate. — Origin : either descends from bladder, or 
 forms first in prostate. Number, 1 to 100 ; size, grain of sand to cherry- 
 stone ; faceted ; color, various ; consistence, various ; structure, usually 
 concentric layers ; chemistry, phosphate (rarely carbonate) of lime ; posi- 
 tion, projecting into or near the urethra usually, but sometimes near 
 circumference of gland, and occasionally even partly in bladder and partly 
 in prostate. Symptoms. — Those of irritation, inflammation, or abscess of 
 the prostate, according to their effect ; semi-erection of penis, and dif- 
 ficulty in seminal ejaculation. Calculus can possibly be felt by sound in 
 the urethra or finger in rectum. Treatment. — Remove, if possible, by 
 urethral forceps, or operate as for median lithotomy ; but do not operate 
 when the calculi are small, very numerous, or only to be felt per rectum. 
 When operating, see if there be any calculus in the bladder also. 
 
 Calculus in the Urethra. — Usually descends from bladder, but may be 
 formed in siM (then usually behind a stricture). Symptoms. — Pain, ob- 
 struction, or retention of urine. If not relieved, dilatation of urethra, 
 extravasation, abscess, and urinary fistula, through which stone may pass. 
 Treatment— 1, Push forward with finger and thumb ; 2, extract with ure- 
 thral forceps, wax bougie, or some specially devised instrument, if neces- 
 sary slitting up meatus urinarius ; or, 3, push back stone to posterior part 
 
52 CANCER. 
 
 of urethra, and do median lithotomy. If there is not serious obstruction, 
 a little patience will sometimes allow the urine to wash the stone right to 
 the meatus within twenty-four hours. In other cases delay is highly 
 dangerous. 
 
 Calculus in Female has, besides many of those of male, these special 
 symptoms, viz. : 1, bearing-down pains ; 2, incontinence of urine. Diagnose 
 carefully from uterine disease, by sounding and vaginal examination. 
 Prognosis. — Liability to ulceration into vagina, and consequent vesico- 
 vaginal fistula. Treatment. — Kemove calculus. Three classes of methods, 
 viz. : 1, urethral dilatation ; 2, lithotrity ; 3, lithotomy. The dilatation is 
 best done with a screw three-bladed dilator (vide also articles Lithotomy 
 and Lithoteity). Danger of incontinence if the urethra is dilated too 
 much. The limits of size for dilatation should be a diameter of one to one 
 and a half inch for adults, and half as much for children. Slow dilatation 
 almost always followed by incontinence (refer to Walsham, " St. Bartholo- 
 mew's Hospital Reports," vol. xi.). 
 
 Cancer. — The term is commonly used as if synonymous with " malig- 
 nant," and therefore including other new growths besides " carcinomata." 
 Characters of Malignancy. — A cancer tends to 1, infiltrate neighboring tis- 
 sues ; 2, recur ; 3, affect lymphatic glands ; 4, be followed by secondary 
 deposits ; and if the cancer be left long enough, all these four events are 
 pretty sure to take place. Cancers also tend to soften and ulcerate, and 
 "there is scarcely a tissue or an organ which they may not invade." 
 Causes. — There can be little doubt but that hereditary influence has some 
 effect in this as in the liability to most other diseases. Still the cancer at 
 its origin is probably local, and various local irritations, such as blows, 
 smoking clay pipes, decayed and rough teeth, etc., can often be traced as 
 exciting causes. Soft cancer occurs chiefly in youth, hard cancer in middle 
 age. It is certain that affections at first pure chronic inflammation in their 
 nature sometimes pass into cancer. Symptoms. — Those of a new growth 
 differing from an innocent tumor in more or less of the following charac- 
 ters : 1, it tends to infiltrate ; 2, to involve neighboring tissues ; 3, to at- 
 tack neighboring lymphatic glands ; 4, it grows more rapidly than innocent 
 tumors ; 5, it is usually more painful ; 6, it tends to soften and ulcerate ; 
 7, it has the peculiar features of one of the varieties of cancer. Prognosis 
 (Vide Cancer of Breast, etc.). — Epithelial cancers kill, on the average, in 
 fifty-three months ; scirrhus in thirty-two (Sibley). Soft cancer is still 
 more rapid. Cancer kills by, 1, hemorrhage ; 2, interference mechanically 
 with vital organs ; 3, general infection of blood and consequent cachexia, 
 etc. Histology. — Every cancer consists of cells lying in the interstices of a 
 network of fibrous tissue ; the network may be close or open, strong or 
 weak ; the cells are of two kinds : one, the larger, are of epithelial origin ; 
 the other, the " small cell formation," of connective-tissue origin. It may 
 here be mentioned that the cells of a sarcoma are all of connective tissue 
 
CANCER. 53 
 
 origin, and primarily directly connected with the mesh- work in which they 
 He ( Vide Special Varieties of Cancer). Cancer-juice is fluid containing can- 
 cer-cells and often oil-particles and debris. Varieties of Cancer. — Some of 
 the sarcomata, and, indeed, exceptionally almost any kind of tumor may 
 have most of the characters of malignancy. In these cases, the characters 
 are usually so modified as to cause a condition spoken of as " semi-malig- 
 nant." But most cancers are carcinomata. There are five varieties of car- 
 cinoma, viz. : 1, hard ; 2, soft ; 3, colloid ; 4, squamous (ordinary) epithe- 
 lial ; 5, cylindrical epithelial cancer ; besides villous, melanotic, and osteoid 
 cancers. 
 
 Cancee, Hard — Scirrhus. — The fibrous part preponderates over the 
 cell elements. Pathology. — Hard, section concave, white or gray, dotted 
 with yellow points ; no defined margin ; juice. Either tuberous or infil- 
 trating ; "tuberous" means " forming a distinct nodule." When infiltrat- 
 ing, the neighboring parts are hard, adherent, and often drawn in ; infil- 
 tration of skin with tubercles, a very valuable clinical symptom. Parts of 
 the can6er often atrophy, or even slough. The cancerous ulcer is irregu- 
 lar, fetid, with thick, hard edges. Locality. — Breast, skin, rectum ; found 
 also in testicle, tonsil, eye, etc. 
 
 Cancee, Soft — Encephaloed. — Fibrous part small ; cells abundant ; 
 special characters of other varieties absent ; not distinct in nature from 
 scirrhus. If a scirrhus be removed, cancer often recurs as encephaloid. 
 Consistence, often as soft as, or even much softer than, brain ; color, white, 
 creamy, or blood-stained. When connected with bone or periosteum, 
 liable to contain bony plates or even a complete bony framework ; often 
 contains large blood-cysts ; may be encapsulated ; soft and fluctuating. 
 Puncture lets out blood and often cancer-juice as well. May ulcerate and 
 fungate as a bleeding mass ; grows fast, and is covered by large cutaneous 
 veins, owing to its obstructing deeper veins ; large vessels and nerves not 
 generally compressed ; amount of pain, variable ; " cancer of young life." 
 Locality. — Bones, female breast, eye, testicle ; attacks also uterus, bladder, 
 etc. 
 
 Cancer, Colloid — Alveolar Cancer. — Its carcinomatous nature doubt- 
 ful ; consists of a stroma of wide meshes, with rounded or oval nuclei ; 
 meshes contain a jelly-like substance, besides cells, some of which have 
 concentric laminae like an oyster-shell ; to the naked eye this cancer has a 
 markedly jelly-like appearance. Locality. — Peritoneum, ovary, breast, 
 limbs, parotid, rectum ; in alimentary canal, it is said to arise from Lieber- 
 kiihn's follicles. 
 
 Cancer, Squamous Epithelial, or ordinary epithelioma. — Least malig- 
 nant of the carcinomata ; cells flattened like those of epidermis ; tendency 
 to arrange themselves in "nests." First appearance, usually a hard lump 
 or wart, which may be dry for a long time, but usually ulcerates sooner or 
 later. Ulcer has hardened, elevated edges, and often an excavated base ; 
 
54 CANCER. 
 
 occasionally cauliflower-like ; glands slow to be affected ; infection of the 
 system slower still. Locality. — Places where skin and mucous membrane 
 meet, e. g., lips, eyelids, anus, etc. ; also warts on the skin, back of hand, 
 front of leg, prepuce (from irritation of soot), tongue. Life usually de- 
 stroyed by local causes. Cancer should be removed, even if glands are 
 somewhat enlarged, for the enlargement may be merely the result of irrita- 
 tion or inflammation. If done early, there is fair hope of non recurrence. 
 
 Cylindrical Epithelial Cancer occurs in mucous membranes. Both 
 primary and secondary deposits contain cylinders of cylindrical epithelium, 
 like the structure of mucous membrane itself. 
 
 Villous Cancer. — Vide Diseases of Bladder. 
 
 Osteoid Cancer. — Here not only the primary tumor has a skeleton of 
 bone, but bone also appears in the secondary deposits. 
 
 Melanotic Cancer is simply cancer with deposits of pigment in the cells. 
 Its primary seat is usually a part originally highly pigmented, e.g., a dark 
 mole. May be either carcinoma or sarcoma. 
 
 Treatment of Cancer. — Constitutional. Tonics, especially iron. Ano- 
 dynes necessary in later states. Diet ample and nutritious. Local treat- 
 ment. — Support and rest when not actively interfering with it ; layer of 
 cotton-wool and bandage ; iodine, opium, and: lead retard growth of tumor ; 
 amadou plaster ; for sloughing, a bread poultice with powdered charcoal ; 
 terebene ; wash ulcers with a weak solution of zinc chloride and laudanum ; 
 tepid lotion of chlorate of potash to be used frequently ; lotion of citric 
 acid said to be sedative to epithelial cancers. For oedema of a limb caused 
 by pressure, soft bandages. For hemorrhage, perchloride of iron, or 
 ligature of any bleeding artery, or bathing with water as hot as it can be 
 borne. For pain, extract of belladonna with glycerine, locally. Apply to 
 a painful cancerous sore morphia and glycerine on lint, or iodoform ; 
 chloral or morphia internally. Question of operating. — Objects of opera- 
 tion — 1, to prolong life ; 2, to give an interval of ease and usefulness. 
 Keasons for not operating — 1, unhealthy condition of patient, e.g., severe 
 kidney or lung disease ; 2, diffuse and wide infiltration of a cancer ; 3, can- 
 cerous cutaneous tubercles ; 4, disease of glands which cannot themselves 
 be removed ; 5, considerable adhesion of a scirrhous breast to pectoral mus- 
 cle ; 6, more than one tumor (except in rare and chronic cases) ; 7, cancers 
 beneath scalp. If the conditions are favorable, the sooner the cancer is 
 removed the better. It should be removed freely, the neighboring parts 
 carefully examined, and, in many cases, treated with caustics, e.g., zinc 
 chloride (gr. xx. to f j.). Suspicious glands should be removed entire. 
 Ecraseur instead of knife in cancer of tongue, neck, or uterus, etc. ; gal- 
 vanic cautery to cancers of skin ; caustics ; Maissonneuve's caustic arrows ; 
 injection of dilute acetic acid (1 to 3), its efficacy doubtful. Injection of 
 bromine in alcohol (TT[. v. to § j.). Esmarch and Billroth have treated can- 
 cer with some success, by increasing doses of arsenic, long continued. 
 
CASTRATION. 55 
 
 Cancrum Oris (or Gangrenous Stomatitis). — A phagedenic ulceration 
 of the cheek in childhood (second to eighth year). Causes. — Usually a se- 
 quel of one of the exanthemata ; low, damp lodgings, bad air, food, etc. ; 
 mercury to excess in feeble constitutions. Symptoms. — Mild form marked 
 by small gray, sloughy, foul ulcers on inside of cheek, with red gums and 
 foul breath. The typical form presents a slough, reaching right through 
 cheek ; skin white, swollen, hard, with a red blush in centre. Internally, 
 a foul, sloughing ulcer, opening into mouth ; foul odor ; gums swollen and 
 ulcerated. Child suffers little, and dies comatose. Peculiar moving bodies 
 in blood in a case of noma ; 1 virulent infectiousness of such blood (San- 
 som). Prognosis. — Of the severe form, only one in twenty recovers. Treat- 
 ment. — Support strength by enemata if necessary ; nitric acid freely to 
 sloughing parts ; chlorate of potash lotion to mouth : quinine internally. 
 
 Carbuncle. — Causes. — Occurs chiefly in men over forty-five. Diabetes; 
 debility; (see also Boms). Character. — Inflammation of skin, and cellular 
 tissue beneath. May begin with a small pustule, but essentially proceeds 
 from a non- circumscribed sloughing of cellular tissue. Brawny, painful 
 swelling ; suppuration ; formation of several openings ; destruction of all 
 affected parts down to subjacent muscles and tendons — then gradual healing 
 and cicatrization. Constitutional disturbance more or less severe ; blood- 
 poisoning ; sometimes death from pyagmia, less frequently from exhaus- 
 tion. Treatment. — Support strength with tonics and good diet; fresh 
 air ; crucial incision (? ?) ; subcutaneous incision ; pressure by strapping 
 with plaster ; caustics ; destroy the centre of the carbuncle (about one- 
 fourth its area) by caustic potash ; strong carbolic acid. Paget recom- 
 mends emplastrum plumbi on leather, with a small hole in the middle, 
 for small carbuncles, and resin cerate under a poultice for larger ones. 
 Danger of hemorrhage when incisions are made. 
 
 Carbuncle, Facial. — Carbuncle attacking face, especially lips, is particu- 
 larly dangerous. It is so, probably, from causing phlebitis, which extends 
 to the cerebral tissues. There is swelling of the cheek and nose, and 
 exophthalmia. Fatal cases present also symptoms of pyemia. Prompt 
 incision, and quinine to cinchonism recommended. 
 
 Castration. — Eequired for malignant or other hopeless disease of the 
 testicle. Scalpel ; forceps ; artery-forceps ; catgut ligature for scrotal 
 vessels ; whipcord ligature for cord ; suitable dressings. Hold testicle in 
 left hand, so as to tighten the scrotum ; incise skin, etc., from external 
 abdominal ring to bottom of scrotum, so as to expose testicles ; pull 
 down the cord, and put whipcord ligature right round it. In cancer 
 cases, dissect upward, and tie cord as high up as is safe. Cut cord a quar- 
 ter of an inch below ligature ; a touch or two of knife then liberates testi- 
 cle. Prognosis. — Operation very safe. Peritoneal process has been opened 
 in a child, causing fatal peritonitis. 
 
 1 Noma is a gangrene of the genitals of female children, analogous to cancrum oris. 
 
56 CHEST. 
 
 Catheterism. — See Stricture of the Urethra. 
 
 Cellulitis. — See Erysipelas. 
 
 Cephalhematoma. — A blood- extravasation, caused in child-birth. 
 Two kinds : 1, between aponeurosis and pericranium ; 2, between peri- 
 cranium and skull. Former is diffuse : the latter is circumscribed and 
 small, and never extends. across a suture. Treat on general principles. 
 
 Chancre. — See Syphilis. 
 
 Cheek, Congenital Fissure of. — Extremely rare. Accompanied by- 
 imperfect development of external ear. Treat by methods used for hare- 
 lip. 
 
 Cheloid. — Two kinds : 1, Cheloid of Alibert. A fibrous or fibro-cel- 
 lular outgrowth from a cicatrix, forming a tubercle, at first pink, after- 
 ward whitish. Tends to disappear spontaneously, especially in youth 1 
 Treatment. — Excise if hard and unsightly, or following puncture of the 
 lobule of the ear for earrings. Very liable to return. 2. "True Cheloid" 
 of Addison. " Not a tumor at all ; but a patch of hide-bound skin, in 
 which the skin, fascia, and muscles are adherent together, and the surface 
 is yellowish and covered with scales " (Holmes). 
 
 Chest, Injuries of. — Divided into (1) non-penetrating, (2) penetrat- 
 ing. Wounds of the soft parts present nothing special. Rupture of the 
 pectoral muscles sometimes takes place, as, for instance, by a falling man 
 catching at some support in his descent. For Fractures of the Ribs and 
 Sternum, vide article Fractures. 
 
 Chest, Penetrating Wounds of. — These will be noticed, according to 
 the parts injured, under the following heads : 1, wound of pleura ; 2, 
 wound of lung ; 3, hernia of lung ; 4, wound of pericardium ; 5, wound 
 of heart; 6, wounds of certain blood-vessels. 
 
 1. Wound of Pleura. — Rarely occurs without wound of lung. May pre- 
 sent all the local symptoms of wound of lung, except that any air expelled 
 from the wound by respiration is not churned up with blood into fine froth 
 Such air must, of course, have entered the pleural cavity from without the 
 chest. Treatment. — As for wound of lung. 
 
 2. Wound of Lung. — Signs. — Escape of air from wound, often churned 
 up with blood into froth ; pneumothorax ; hemothorax ; cough ; blood 
 and bloody froth coughed up ; emphysema. After-consequences (both of 
 this and the preceding injury). — Pleurisy; pneumonia; hydro thorax ; 
 empyema. Prognosis. — Bad, but very far from hopeless. If a week passes 
 over, hope is considerable. Treatment. — Perfect rest in bed on injured 
 side ; strap chest ; dress antiseptically ; low diet ; give iced milk ; avoid 
 stimulants, even to remove collapse. Collapse helps to stop hemorrhage, 
 which is the first great danger. If pulse rises, or inflammation threatens, 
 bleed. Vide also Pneumothorax, Emphysema, etc. 
 
 1 See Clinical Society's Transactions, 1880, p. 61. 
 
CICATEICES. 57 
 
 3. Hernia of Lung. — Two kinds : 1, primary ; 2, consecutive. Consecu- 
 tive comes on when the wound has healed. Primary should be reduced 
 so long as the lung-tissue is healthy and uninjured. Consecutive can only 
 be guarded by a shield. 
 
 4. Wound of Pericardium. — Signs. — 1, A likely position and direction 
 of wound ; 2, those of hemorrhage and shock ; 3, those of pericarditis, 
 viz., friction-sound, extended dulness on percussion, "thoracic oppression," 
 dyspnoea, anxiety, etc. Pulse small and frequent. Prognosis. — Not abso- 
 lutely hopeless. Treatment. — Cold locally and internally ; perfect rest ; 
 venesection ; digitalis and belladonna. 
 
 5. Wound of Heart. — When death is not instantaneous, the above re- 
 marks on wound of pericardium apply to those of heart, only the signs 
 are more severe. Tremor of the heart and disturbance of its action are 
 more marked. When death is instantaneous, patient either leaps up or 
 falls down, often uttering a shriek. A patient may live for years, even 
 with a foreign body in his heart. 
 
 6. Wounds of Thoracic Blood-vessels. — Those of aorta and vena cava 
 usually at once attended by fatal hemorrhage. Intercostal and internal 
 mammary arteries. Usually recommended not to attempt ligature, but to 
 trust to rest, cold, etc. Vanzetti's "uncipression." But " Surgical History 
 of War of Rebellion " says that these wounds demand " the rigorous appli- 
 cation of the rules for the management of wounded arteries, the exposure 
 of the bleeding point, and a proximal and distal ligature." In wounds of 
 the chest, with lodgement of foreign bodies, it can rarely be advisable to 
 make any dangerous search for them. Always consider instrument 
 wounding, and direction of wound. 
 
 Chest, Viscera Injured without External Wound. — Rare. Signs, treat- 
 ment, etc., may be inferred from notes above. 
 
 Chilblains. — Inflammation of skin owing to sudden change to or from 
 a frosty temperature. Occurs usually in females and children with feeble 
 circulation. Congestive stage and ulcerated or broken stage. Itching. 
 Symptoms aggravated by warmth, dietetic indulgence, and approach of 
 evening. Treatment. — Regular and free exercise, fresh air, healthy living, 
 well-fitting boots, straw or cork "socks" in soles of boots. Locally, in first 
 stage, stimulating liniments, friction with snow, painting with iodine, or 
 solution of sulphate of copper (gr. iij. to § j.) In broken stage, use water- 
 dressing at first, afterward collodium flexile or Peruvian balsam. Small 
 doses of laudanum, frequently repeated, stimulate the capillary circulation. 
 
 Chloroform. — Vide Anesthesia. 
 
 Cholecystotomy. — The gall-bladder has been excised by Marion 
 Sims ; result fatal. George Brown tapped the gall-bladder success- 
 fully. 
 
 Cicatrices. — Liable to neuralgia, contraction, ulceration, cheloid, epi- 
 thelial cancers, besides other rarer affections. 
 
58 CLUB-FOOT. 
 
 Cicatrices, Neuralgia of. — May arise from implication of a nerve, or 
 the bulbous end of a nerve in a contracted cicatrix. Separate the cicatrix 
 from the parts beneath, or, if necessary, excise the end of the nerve. If 
 such a cause cannot be found, treat on general principles. 
 
 Cicatrices, Contraction of. — Is a natural process, and results from the 
 escape of water from a new scar as it dries up and atrophies to ordinary 
 connective tissue ; most frightful deformities often result. Treatment. — 1, 
 Preventive ; hasten healing of large wounds by skin-grafting ; prevent con- 
 traction during and for some time after cicatrization by splints and ban- 
 dages. 2, Curative ; divide carefully the contracted bands ; keep the wound 
 stretched during recicatrization ; graft ; transplant large piece of skin in 
 suitable cases. When the contraction is merely linear, a V-shaped incision 
 can be made, and when the tongue of skin thus formed retracts toward its 
 base, the two outer sides of the V-shaped wound should be sewn together 
 at and near the apex of the V. Pressure by strapping will weaken and 
 make thin a thick cicatrix. 
 
 Cicatrices, Ulceration of. — Very liable to occur, especially in lower 
 extremities, and in old and feeble people. Such cicatrices should be pro- 
 tected from friction and damp. Treatment. — Stimulant applications ; rest ; 
 good living. 
 
 Cicatrices, Warty (that is, indurated and thickened). — May be blistered 
 or painted with iodine. Do not mistake epithelioma for these. 
 
 Cicatrices, Cheloid of. — Vide Cheloid. 
 
 Circumcision. — Done for phimosis in children and for various dis- 
 eases of the prepuce and glans penis in adults. With the penis in its nat- 
 ural position, apply a pair of long-bladed polypus-forceps exactly on a 
 level with the corona glandis, but inclined slightly forward rather than 
 perpendicularly ; as the glans slips back, compress the prepuce with the 
 forceps ; then slice off prepuce close to the forceps ; slit up mucous mem- 
 brane with scissors right to glans ; stitch mucus flaps to skin-flaps ; check 
 hemorrhage. In infants, instead of sutures, merely wrap a piece of lint 
 round behind corona and also over all the parts. Prognosis. — Fatal result 
 extremely rare. 
 
 Cirsoid Aneurism. — See Aneurism. 
 
 Clitoris, Hypertrophy of. — Occasionally large size ; danger of 
 hemorrhage when removing it. 
 
 Club-foot. — Four types : 1, talipes varus ; 2, talipes valgus ; 3, talipes 
 equinus ; 4, talipes calcaneus. Talipes equino-varus (a combination of 1 and 
 3) most common. Causes. — The cause of congenital talipes varus, or equino- 
 varus, is arrested development. At the commencement of their development, 
 the lower extremities are so placed that, if extended, the feet would point 
 backward ; hence they have afterward to rotate on their axes ; when this ro- 
 tation is not fully accomplished in the foot, club-foot results. Talipes valgus 
 is only another name for flat-foot, which results from excessive standing or 
 
CLUB-FOOT. 59 
 
 walking when the general strength is small ; the muscles, being then weak, 
 do not sufficiently assist the ligaments, which give way to the strain. In- 
 fantile paralysis leads to equino-varus, because that is the position in which 
 gravity places a foot uncontrolled by healthy muscles. Symptoms. — Pure 
 varus. — Very rare ; in it, only inner border of foot is raised, and anterior 
 part of foot is bent inward on posterior half. Equino-varus. — In this, the 
 heel is more or less raised ; in severe cases the bones are much altered : 
 the dorsum of the cuboid and fifth metatarsal bone sustains the weight of 
 the body. The scaphoid and inner edge of the metatarsus look upward ; 
 the inner malleolus almost touches the scaphoid, and the astragalus is 
 pushed outward. Fibula lies in a line behind tibia ; tuberosity of os 
 calcis looks upward ; in talipes calcaneus the heel is down and the front of 
 the foot up. The tendons contracted in each case will be mentioned under 
 the head of treatment. Course. — If left alone, patient learns to walk on 
 deformed foot ; callosities form where there is friction or pressure ; the 
 leg wastes ; the foot and leg thus get the peculiar clubbed appearance. 
 Treatment. — Mild cases do not require tenotomy ; employ friction, and 
 twist the foot for a quarter of an hour three times a day into its natural 
 position, pulling and fixing foot in position with strapping; strapping 
 combined with splints ; Barwell's elastic bands ; shoes, etc., for talipes. 
 The above contrivances used after tenotomy. Tenotomy. — For equinus, 
 divide tendo Achillis ; for equino-varus, tendo Achillis after tibialis posti- 
 cus and anticus (sometimes also plantar fascia, and some plantar muscles). 
 Valgus and calcaneus seldom require tenotomy (see Flat-Foot.) Tenotomy- 
 knives, blunt-pointed and sharp-pointed ; pads of lint ; hot- water can and 
 strapping ; bandage ; splint. Tendo Achillis. — Position, on face. Assistant 
 makes tendon tense ; pass a sharp-pointed knife beneath tendon, one inch 
 from insertion ; place left forefinger over it ; cut gently with sawing motion 
 toward skin ; assistant should relax when he feels that the tendon has 
 gone ; withdraw knife and instantly place finger over wound ; then put on 
 pad instead of finger, strap, bandage and splint. Tibialis posticus. — One 
 inch above inner malleolus. Inner edge of tibia. In fat infants, midway 
 between anterior and posterior borders of leg. Insert sharp tenotome half 
 an inch, so as to open deep fascia. Substitute blunt tenotome ; pass this 
 with one surface toward tibia, and other toward tendon. Assistant mean- 
 while holds foot inverted. Now foot is inverted, at same time edge of 
 tenotome is turned to tendon. If blanching of foot and much bleeding 
 show wound of post-tibial artery, merely pad and evenly bandage and con- 
 fidently expect good result. But postpone instrument treatment for a fort- 
 night. Tibialis anticus. — Merely extend foot, insert tenotome, and divide 
 tendon from behind forward. Peronei. — Sometimes divided for valgus. 
 Divide behind external malleoli or a little higher ; adduct foot. After-treat- 
 ment. — Three or four days after tenotomy, commence to extend by strap- 
 ping, splints, Scarpa's shoe, elastic bands, or some other mechanical con- 
 
GO COLOTOMY. 
 
 trivance, according to gravity of case. In infants, extension should be 
 effected in a month. In adults, three or four months may be occupied. At 
 first the instrument should be shaped to fit the deformity ; never force a 
 foot into an ill-fitting instrument ; attend daily to the case ; beware of 
 pressure-sores ; plaster-of -Paris bandages may be used instead of movable 
 apparatus. Process of Healing in a Divided Tendon. — The divided ends of 
 the tendon retract, and the neighboring cellular tissue presses in between 
 them, filling the interspace. In this cellular tissue corpuscles and lymph 
 (inflammatory new formation) are poured out, which organize into fibrous 
 tissue, uniting and exactly resembling in structure the divided tendon. 
 The process resembles that by which the external callus unites a fractured 
 bone. The advantage of tenotomy is that this new uniting medium is so 
 much more extensible than the original tendon. Many surgeons now put 
 up the foot in plaster-of-Paris as soon as the tendons have been divided : 
 and Ogston treats even severe cases of club-foot with plaster-of-Paris, and 
 without previous tenotomy. 
 
 Coeeydynia. — A painful affection of coccyx; female sex; generally 
 follows an injury — this injury may be received in parturition ; comes on 
 when coccygeal muscles are put in action, as by sneezing, coughing, walk- 
 ing, defecation, etc. Treatment. — If obstinate, divide all muscular and 
 ligamentous structures from borders and tip of coccyx. 
 
 Collapse. — See Shock. 
 
 Colotomy. — When Bequired. — In obstruction to the large intestine, as 
 from stricture of rectum (malignant or otherwise), or imperforate anus ; 
 in diseases of rectum or colon, e.g., ulceration, or recto-vesical fistula, 
 where it is desirable to prevent the irritation of faeces in the diseased 
 parts. Three operations, viz. : 1, Amussat's in right lumbar region ; 2, 
 Amussat's in left lumbar region ; Littre's in left groin. The left lumbar 
 operation is sometimes named after Callisen, who merely attempted, but 
 never effected, an operation. Amussat's in Left Lumbar Region. — Scalpel, 
 forceps, retractors, director, handled needles, etc. ; incision midway be- 
 tween last rib and crest of ilium, transverse or oblique, i.e., parallel to 
 nerves ; extent, 5 inches ; centre half an inch posterior to middle point of 
 crest of ilium (Allingham) ; outer edge of quadratus lumborum thus ex- 
 posed ; now divide, from quadratus outward, on a director, the muscles to 
 the extent of the skin wound (latissimus dorsi, obliquus extemus and in- 
 temus, and transversalis) ; secure vessels ; distinguish, if possible, trans- 
 versalis fascia from peritoneum ; divide fascia ; find colon ; pass two liga- f 
 tures through skin at both edges of wound, piercing colon on their way ; 
 make opening in bowel big enough to admit forefinger ; pull out hoops of 
 ligatures and divide them, thus making four ligatures ; tie each. Oil mar- 
 gins of wound and place patient in bed. Occasional difficulty in finding 
 bowel, especially when there is not complete obstruction and it is nearly 
 empty. Use of distending injection before operation. Bowel must not be 
 
CUT THKOAT. 61 
 
 sought for too far out from spine ; always lies in front of or below kidney. 
 Roll patient on his left side, keeping finger in wound, bowel will some- 
 times then fall upon finger ; not much danger of wounding peritoneum if 
 bowel be distended. Much danger of wounding peritoneum in infants, be- 
 cause descending mesocolon often exists. Operation in right lumbar re- 
 gion done in a similar manner. After-treatment. — Sedatives at first ; 
 dress with oakum ; protect edges of wound with zinc ointment ; india- 
 rubber bag and soft bandage afterward ; give good diet early ; if opening 
 contracts, use sponge-tents ; lower part of intestine should, after convales- 
 cence, be occasionally washed out with warm water. Prognosis. — Accord- 
 ing to Caesar Hawkins two-thirds recovered. But many more cases have 
 since been recorded, and the fatal cases appear to die not so much from 
 operation as from original disease ; therefore operation should be done in 
 time. 
 
 Cor^ussion n } of Brain.— Fide Head, Injuries of. 
 
 Condylomata. — Causes. — Mostly syphilis, gonorrhoea, and dirt. Path- 
 ology. — Papilliform, but sarcomatous or made of soft connective tissue in 
 structure ; non-recurrent ; infectious. Seat. — About anus, foreskin, pre- 
 puce, and mucous membrane of mouth. Treatment. — Touch with argent, 
 nit. ; zinc oxide, calomel, copper sulphate ; cleanliness, dryness ; wear pre- 
 puce back. 
 
 Contusion. — See Bruise. 
 
 Corns. — Causes. — Intermittent pressure, or friction from tight or over- 
 loose boots. Pathology. — At first a thickening of cuticle, then a bursa forms 
 beneath ; afterward cuticle may grow thin while fibrous structures be- 
 neath hypertrophy and form base of corn, or the pressure of the thickened 
 cuticle may cause absorption of the parts beneath ; tendency to inflame 
 and suppurate. Resulting lameness may lead to secondary effects. Treat- 
 ment. — Remove cause. Proper boots. Acetic acid, nitrate of silver, alka- 
 line solutions, soap, water-dressing, etc., to soften cuticle ; knife to remove 
 it. Open suppurating corns. Soft corns (i.e., those which form beneath 
 the toes) may be also cured by cotton wool between the toes, dusting with 
 zinc oxide or with French chalk, and by above remedies also. Boots should 
 be broad in sole, and straight along inner border. Belladonna plaster. 
 
 Coxalgia. — A term for hip-disease. 
 
 Cut Throat. — Usually suicidal. Position. — Generally opposite larynx, 
 which it of course opens, unless the wound be superficial. Dangers. — (A, 
 immediate) 1, hemorrhage ; 2, suffocation by blood-clot ; 3, suffocation by 
 a displaced solid structure ; 4, entrance of air into a divided vein. (B, 
 secondary) 1, exhaustion ; 2, erysipelas ; 3, abscess \ 4, some form of 
 blood-poisoning ; 5, bronchitis or pneumonia ; 6, secondary hemorrhage, 
 especially such as might be provoked by the patient tearing the wound 
 open afresh. (C, remote) 1, cicatricial stenosis ; 2, fistula. Prognosis. — 
 
62 DELIRIUM TREMENS. 
 
 "When a large vessel is wounded, death is usually almost immediate. In 
 other cases the prognosis would be hopeful, but for the unfavorable state 
 of body and mind usually coexisting in suicides. Treatment. — 1, Arrest 
 hemorrhage ; tie bleeding vessels ; 2, extract clots from air-passages ; 3, 
 if the injured parts cannot be brought into apposition without sutures, and 
 if these sutures will not interfere at all with drainage, use them. ' In most 
 cases sutures are not necessary ; place a bandage round the head and an- 
 other round the chest, and connect these in such a manner as to hold the 
 chin down toward the chest ; 4, in cases where the injury is such as to 
 seriously obstruct breathing through larynx, perform tracheotomy ; 5, 
 dress the wound with a mass of antiseptic gauze (of course, this is not 
 meant to keep the wound aseptic) ; 6, the patient must be diligently fed, 
 and if, from wound of the oesophagus or damage to the larynx, swallowing 
 is impossible or difficult, a tube must be passed down the gullet and food 
 passed through it. Be sure not to pass this tube into the trachea by mis- 
 take, a blunder easily made ; 7, see that the nursing is diligent, energetic, 
 and vigilant. 
 
 Cysts. — See Tumoes. 
 
 Deformities are of many different kinds, and are described elsewhere. 
 Vide articles Palate, Cleft ; Club-foot ; Cicateices, Contraction of ; 
 Joint Diseases ; Paealtsis, Congenital ; Spine, Curvature of, etc. 
 
 Delirium Tremens, though usually arising directly from prolonged 
 and excessive drinking, is not unfrequently produced by a wound or com- 
 pound fracture acting as an exciting cause in patients who have not lately 
 been guilty of great excess. Accessory causes are abstinence from food, 
 and any other depressing influence. Pathology. — "The striking appear- 
 ance," post-mortem, "is that of excessive serosity " in the ventricles of the 
 brain and between its membranes. Symptoms. — Tremor, especially ob- 
 servable in the hands and tongue. Wandering of the mind, usually limited 
 to delusions about certain things ; e.g., the patient, while knowing per- 
 fectly well where and with whom he is, yet fancies there is a demon or 
 some noxious animal in the corner of the room, or following him about 
 from place to place. His mind is ever recurring to these fancies, and he 
 frequently talks about them and insists upon taking measures to escape 
 from his imaginary enemies : his delirium is a fussy, " busy " one. He is 
 always in a state of dread, and is often inclined to suspect his friends of 
 harboring designs against him. In his active anxiety to escape from these, 
 he may do himself or even bystanders some injury. Hands unsteady. 
 Tongue not only tremulous, but coated, usually with a creamy fur. Bowels 
 confined. Breath foul, frequently alcoholic. No appetite. Sleeplessness, 
 which has usually existed as a premonitory symptom before the delirium 
 sets in. Diagnosis. — From (1) acute mania, (2) meningitis, (3) delirium 
 of fevers. Note the coolness and moisture of the skin, absence of fever and, 
 very likely, of pain in head. In the continued fevers, prostration has prob- 
 
DISLOCATION. 63 
 
 ably preceded the delirium, but thermometric observations and a considera- 
 tion of the history (which is, unfortunately, not always easy to get) should 
 settle the diagnosis. There is something very characteristic about the 
 manner of the delirium in Delirium Tremens. Prognosis. — If sleep can be 
 quickly procured, good. If not, and especially if the tongue gets dry and 
 brown, bad. Treatment. — Indications (1) to procure sleep, (2) to keep up 
 the strength. Watchful, firm and gentle, good-natured nursing. Milk, 
 strong beef-tea, and small quantities of nutritious solid food, if it can be 
 borne, at frequent intervals. Stimulants should either be forbidden alto- 
 gether, or else allowed only in small quantities at a time, and then only on 
 condition that food be taken with each draught. Beer is the best stimulant 
 in these cases. A dose of calomel (5-10 grains) justifiable at first. Mor- 
 phia subcutaneously. Hydrate of chloral (30 grains) repeated in two 
 hours, and then in another three hours. Digitalis in large doses has been 
 recommended. Mr. Holmes's remarks on treatment of Delirium Tremens 
 in his Treatise are very clear and instructive. 
 
 Diabetes, Traumatic, has followed injury to the brain, and then 
 sometimes passed off as the cerebral injury was recovered from. 
 
 Diphtheria is said to attack wounds when a layer of whitish false 
 membrane forms on them and is at the same time accompanied by slough- 
 ing. See Hospital Gangrene. 
 
 Dislocation. — Three kinds : 1, traumatic ; 2, congenital ; 3, sponta- 
 neous. In traumatic, the capsule is almost always ruptured. Complicated 
 Dislocations. — In these there is either fracture, or wound of skin, or of 
 large vessel, or of nerve, or several of these misfortunes. 
 
 Causes of dislocations. — 1. External force, which is (a) direct or (b) in- 
 direct. 2. Muscular action (e.g., usual in dislocation of lower jaw). Symp- 
 toms. — 1. Altered form of joint. Compare two sides of body. 2. Line of 
 direction of misplaced bone does not pass through the articular surface of 
 the other bone. 3. Lengthening or shortening of limb. 4. Altered posi- 
 tion of limb to trunk, e.g., projection of elbow from side. 5. Abnormal 
 distance between certain prominent points of skeleton, e.g., between in- 
 ternal condyle and olecranon. 6. Ecchymosis (rarely distinct at first, 
 sometimes absent). 7. Pain. 8. Inability to move the limb. Manual ex- 
 amination must finally settle the question in most cases, showing the 
 articular cavity empty and the head of the bone at some other point. 
 Anaesthesia may be necessary for a diagnosis, because of soft parts being so 
 swollen and tender. A soft crepitation sometimes caused by rubbing head 
 of bone on torn capsular ligaments and tendons, partly from the compres- 
 sion of firm coagula. Diagnosis.— 1, From dislocated articular fracture. 
 Easily made by an attempt at reduction. The latter is readily reduced, 
 but returns at once ; 2, from contusion and sprain. Examine carefully ; 3, 
 from relaxation of the capsule in paralyzed limbs. Here consider the 
 history, and make a careful local examination. 
 
64 DISLOCATION. 
 
 Capsular opening is of variable size. Escaped head of bone does not 
 always remain immediately opposite it. Occasional spontaneous reduction 
 by muscular action. 
 
 Mechanical Obstructions to Reduction. — 1, Contraction of muscles. Head 
 of bone may be caught between two contracted muscles ; 2 (a far more 
 frequent obstacle), a small capsular opening, or its occlusion by the en- 
 trance of the soft parts ; 3, certain tensions of the capsular or strengthen- 
 ing ligaments. Reduction. — Easiest immediately after the injury. Later, 
 anaesthesia often required. Manoeuvres depend on joint affected. Usually, 
 the assistants make the motions while the surgeon himself manipulates 
 head of bone. Often everything depends on correct anatomical knowledge. 
 Multiplying pulleys, Bloxam's dislocation tourniquet : these things now 
 only used under anaesthesia ; when they involve the application of straps 
 round the chest, they make anaesthesia more dangerous. If too great 
 violence is used — 1, patient may collapse ; 2, limb may mortify from the 
 pressure ; 3, great vessels or nerves may be ruptured ; 4, rupture of other 
 soft parts, as skin or muscle ; 5, fracture of bone ; 6, limb may be torn off. 
 These accidents occur mostly in attempting to reduce old dislocations. The 
 results of pressure best prevented by fastening the straps over a wet band- 
 age previously applied from below upward. Nerves and muscles are most 
 liable to rupture when adherent to deep cicatrices. Use of Malgaigne's 
 dynamometer to measure force employed. After-treatment. — Keduce 
 synovial inflammation, which always ensues, by moist bandages and cold 
 compresses. Passive motion : in shoulder, not for a fortnight ; in elbow 
 and hip, earlier. Too early motion may cause : 
 
 Habitual Dislocation. — When a joint has been several times dislocated, 
 it becomes extremely liable to dislocation. Treatment. — Long rest of the 
 joint. 
 
 Ikkeducible Dislocation. — Eestore the movements as far as possible by 
 passive and active exercise, otherwise the muscles atrophy. The anatom- 
 ical changes are as follows : The extravasation is reabsorbed ; the capsule 
 folds together and atrophies ; the soft parts about the misplaced head be- 
 come infiltrated with plastic lymph, and transform to cicatricial, firm con- 
 nective tissue, which partly ossifies ; the cartilage metamorphoses into 
 connective tissue, and adheres to the neighboring parts ; the surrounding 
 muscles suffer considerably from molecular disintegration and fatty meta- 
 morphosis. How long Dislocations are Reducible. — Depends on joint. Ball 
 and socket much longer than hinge-joints. Shoulder may be reduced after 
 years. Hip, even after two or three months, very difficult. Tenotomy has 
 been employed, but not very successfully, for the chief obstacle is the 
 firm adhesion of the head of the bone in its new position. Is reduction 
 of such old dislocations desirable? Often preferable to let patient simply 
 exercise limb well in its new position. Breaking up adhesions about the 
 head of the bone by rotating it forcibly (vide Anesthesia) may facili- 
 
DISLOCATION. 65 
 
 tate this. Pressure on brachial plexus may require excision of head of 
 humerus. 
 
 Complicated Dislocations. — 1, With fracture. Always attend to this, 
 and apply an apparatus till it has united, changing it and putting the joint 
 in a new position, say every ten days, to prevent stiffness. 2. "With com- 
 pound fracture. Kesect joint, or try to save it, using some thoroughly 
 antiseptic method. If there is considerable crushing and tearing of the 
 soft parts, amputation may be required. 
 
 Congenital Dislocations. — Distinguish from those caused during partu- 
 rition. Occur in most of the joints of the extremity, but especially in the 
 hip. Head of bone above and behind acetabulum. Generally readily re- 
 placed. Peculiar wabbling gait. If the dislocation is one-sided, patient, 
 lying on his back, turns the foot inward. Acetabulum is too shallow, and, 
 in adults, filled with fat. Ligamentum teres, if it exists, is abnormally 
 long. Head of femur too small. Articular cartilage usually completely 
 formed. Capsule very large and relaxed. Cure mostly impossible. Causes. 
 — Perhaps excessive quantity of fluid in joint, at very early period of uterine 
 life. Perhaps also extreme abduction in uterine life. Besult. — In course 
 of time, spinal curvature. Treatment. — It has been recommended that the 
 thigh should be kept for a very long time in a position of abduction {see 
 Medical Record y 1880). 
 
 Dislocation of Ankle. — Four directions ; outward, inward, backward, 
 forward. 1. Outward. — Accompanied by fracture of fibula above outer 
 malleolus and rupture of deltoid ligament or fracture of inner malleolus. 
 Same thing as " Pott's Fracture." Foot turned outward. Depression over 
 fracture of fibula. Treatment. — Dupuytren's splint (to iuner side), or 
 ordinary leg-splints. Keep foot well in, and sole at right angles to leg. 2. 
 Inward. — Accompanied by fracture of inner malleolus. Treat on same 
 principle as Pott's Fracture, only keeping foot well out. 3 and 4. Disloca- 
 tions backward and forward may be distinguished from fracture of leg- 
 bones by relation of malleoli to tarsal bones. After reduction, apply 
 starched bandages and mill-board, or some other firm apparatus. 
 
 Compound Dislocation of Ankle- Joint. — Eequires amputation if tibial 
 arteries be injured, or other important parts be much damaged. Other- 
 wise, remove small fragments, clean, set and dress. Primary excision of 
 the joint occasionally advisable. Ankylosis pretty certain. Use antiseptic 
 dressing. 
 
 Dislocation of Astragalus. — If simple, must be either backward or for- 
 ward. Latter has an inclination either outward or inward. Dislocation 
 directly outward or inward is always complicated with fracture of leg- 
 bones. Dislocation forward most common. Complete or incomplete. 
 Prominence of head of bone beneath skin in front of ankle. Malleolus of 
 side toward which the bone is inclined projects. Danger of skin slough- 
 ing from pressure. Treatment. — Flex knee to relax gastrocnemii ; extend 
 
G6 DISLOCATION. 
 
 foot and push astragalus into its place. This is tolerably easy in partial 
 dislocation. But complete dislocation may require anaesthesia and division 
 of tendo Achillis. Dislocation backward is very rare and difficult to re- 
 duce. Compound Dislocation. — Except in the most favorable cases, reduction 
 is not to be tried. The question lies between excision and amputation. 
 Decide and treat on general principles. In simple irreducible dislocation, 
 primary excision is not advisable. The bone may remain harmless in its 
 new place. 
 
 Dislocations of Separate Carpal Bones, especially of os magnum, can be 
 reduced by pressure, and generally require, for some time, apparatus to 
 prevent recurrence. 
 
 Dislocation of Clavicle. — At the Sternal End. — Three varieties, viz. : 
 
 1, forward ; 2, backward ; 3, upward. Forward most common ; others very 
 rare. The deformity is in each case so manifest that diagnosis is palpable. 
 In dislocation backward, end of clavicle presses on trachea, oesophagus, and 
 great vessels of neck. Treatment. — Extend shoulders backward, and band- 
 age to a splint applied to the back with a pad between splint and spine. 
 Difficulty of keeping bone in its place. Truss to press on head of bone 
 displaced forward. At the Acromial End. — Dislocation almost always up- 
 ward, but sometimes below acromion, or even below coracoid process. 
 Reduction easy by pulling shoulders backward. Here also difficult to keep 
 bone in its place. Gutta-percha or leather shoulder- cap, with a pad over 
 end of clavicle. Bandage in a line parallel to upper arm over shoulder 
 and elbow. Then bandage arm to side. 
 
 Dislocation of Coccyx may result from falls or during parturition. Re- 
 duce with the assistance of a finger in the rectum. 
 
 Dislocations of the Elbow. — I. Complete dislocation of radius and 
 ulna : 1, backward ; 2, forward — in the former there may be fracture of 
 the coronoid process, in the latter fracture of the olecranon ; 3, inward ; 
 4, outward. The latter two are rarely complete. 
 
 II. Ulna alone : backward only. 
 
 ILT. Radius alone : 1, forward ; 2, backward ; 3, outward ; 4, partial 
 forward. 
 
 IV. Ulna backward, with radius forward. 
 
 Injuries of elbow often obscured by great swelling. Following ex- 
 cellent directions, as to the points to be noticed in an injury to the elbow,- 
 are from Holmes (abbreviated) : 1. Is there transverse fracture of humerus? 
 
 2. Longitudinal or partial fracture of lower end of humerus ? e.g., of con- 
 dyle. 3. Distance between olecranon and internal condyle ? 4. Fracture 
 of olecranon ? 5. Are motion and position of head of radius normal ? 6. 
 Do axes of radius and ulna correspond in direction ? 
 
 Dislocation of Both Bones Backward. — Prominence of olecranon ; dis- 
 tance between it and internal condyle increased. Prominence of lower end 
 of humerus below fold of skin at front of elbow-joint. (In fracture of lower 
 
DISLOCATION. 67 
 
 end of humerus, the prominence of the upper fragment is above that fold.) 
 Fracture of coronoid process causes increased mobility, as well as crepitus. 
 
 Dislocation of both bones forward. — Arm is lengthened, and olecranon, 
 unless broken off, is on a level with condyles. 
 
 Dislocation of ulna backward. — Head of radius can be felt normal ; but 
 olecranon is too far back from internal condyle. 
 
 Dislocation of radius forward (most common of the three modes). — El- 
 bow somewhat flexed, and midway between pronation and supination. 
 Further flexion, as well as supination, very limited ; head of radius can be 
 felt displaced. After reduction, very liable to recur, because orbicular 
 ligament is ruptured. Not uncommon in childhood. 
 
 Dislocation of radius backward. — Head of bone can be felt behind ex- 
 ternal condyle. 
 
 Dislocation outward recognized by manipulation. 
 
 Causes. — Falls upon elbow or hand. Half the cases occur in boys. 
 
 Reduction of Dislocations of Elbow. — Can often be effected by merely 
 pressing the bones into position. Sometimes extension, and even anaes- 
 thesia, required. Dislocations two months old have been reduced, after 
 breaking down adhesions by forcible flexion and extension. In disloca- 
 tion of the radius, extend from the hand. Bending elbow across knee a 
 useful method of reduction. Compound Dislocations. — Amputation sel- 
 dom necessary. 
 
 Dislocation of Head of Fibula. — Extremely rare. 
 
 Dislocations of Fingers. — Are not common, and may be reduced by 
 extension. Amputation should never be done for compound dislocation, 
 unless the finger be hopelessly crushed. 
 
 Dislocation of Hip. — Four chief directions : 1, backward and upward 
 on dorsum ilii ; 2, backward into sciatic notch ; 3, downward into obtura- 
 tor foramen ; 4, inward on pubes. Other varieties, e.g., into perinseum, 
 are very rare. First form is most frequent. Causes. — The backward dis- 
 locations take place when a person is in a stooping position, and either 
 falls heavily on his feet, or is struck by a heavy weight falling on his back. 
 Dislocation into the thyroid foramen is caused by sudden and violent 
 abduction, and dislocation on the pubes by sudden and violent exten- 
 sion of the limb, especially if coincident with a blow on the back of the 
 thigh. 
 
 Anatomy. — The anterior part of the capsule, including Y-ligament of 
 Bigelow, remains wholly or partially unruptured in all ordinary disloca- 
 tions, and thus limits the position of the bone, interferes with reduction 
 by extension, and can be utilized in reduction by manipulation. The ob- 
 turator internus is a strong tendinous muscle ; and backward dislocations 
 are on the dorsum ilii, or toward the sciatic notch, according as they es- 
 cape from the acetabulum above or below that muscle respectively. In the 
 lower dislocation, the head of the bone is superficial to the obturator in- 
 
68 DISLOCATION. 
 
 ternus. Fracture of the acetabulum not uncommon, especially in dorsal 
 dislocation. 
 
 Symptoms. — 1. Dislocation on dorsum ilii. Hip looks widened. Pecu- 
 liar position of limb ; rotation inward : slight flexion of both hip and knee ; 
 axis of thigh intersects lower third of sound thigh ; ball of great toe rests 
 on instep or ankle of other foot ; heel raised. Abduction and external ro- 
 tation impossible ; stiffness and immobility under chloroform ; head of 
 bone makes a prominence in its new position ; trochanter is above a line 
 between ant. sup. spine of ilium and tuberosity of ischium (Nelaton's line). 
 Shortening, one, two, even three inches. 2. Dislocation in sciatic notch. 
 — Symptoms like those of dorsum ilii dislocation, only less marked. Axis 
 of thigh across opposite knee ; ball of toe on ball of other great toe. 
 Shortening, half to one inch. 3. Dislocation into thyroid foramen. — Body 
 bends forward ; foot points slightly outward ; a hollowness takes the place 
 of the trochanter. Lengthening, two inches. Head of femur perhaps dis- 
 coverable in its new position. 4. Dislocation on pubes. — In this and the 
 other rarer forms of upward dislocation, head of bone can be felt in its high 
 position ; flattening of hip ; abduction and eversion. Shortening one inch. 
 
 Diagnosis. — Of dislocation on dorsum ilii from impacted fracture of 
 neck of femur with inversion. Under anaesthetics, the former shows im- 
 mobility, the latter mobility. In the former the trochanter is behind, in 
 the latter it tends to He below the ant. sup. spine of ilium. 
 
 Reduction. — Each kind of hip-dislocation can be reduced in two ways, 
 viz., extension and manipulation. Extension method is partly based on 
 the idea that muscular contraction is the chief difficulty. But it is not so. 
 The main resistance proceeds from strong ligaments, and sometimes from 
 too small a hole in the capsule. Hence the advantage of manipulation. 
 Dislocation on dorsum ilii. — 1. Extension. Apply pulleys just above con- 
 dyles of femur, and extend knee across lower third of opposite thigh ; fix 
 pelvis with perineal band. 2. Manipulation. — Place patient on back, and 
 give anaesthetic completely ; grasp knee and foot ; flex well both knee and 
 hip, adduct thigh, rotate outward, and suddenly bring down the limb into 
 a straight line with body, If this fail, try again and again, or rotate in- 
 ward instead of outward. Dislocation toward sciatic notch. — 1. Extension. 
 Place patient on sound side ; apply perineal band and pulleys ; flex limb, 
 and draw it across opposite thigh. — 2. Manipulation. Same proceedings 
 as in dislocation on dorsum ilii. Dislocation into thyroid foramen. — 1. 
 Extension. A pelvic band pulls pelvis toward sound side. A perineal 
 band, working beneath it, is connected with pulleys which extend upward 
 and outward from the injured hip. The surgeon grasps the ankle of the 
 dislocated limb, and, dragging inward, thus pries the femur into the 
 acetabulum. Instead of the pelvic and perineal bands, the bed-post may 
 be placed in the patient's fork, and used as a fulcrum. 2. Manipulation. 
 Flex hip, abduct slightly, rotate strongly inward, adduct and straighten. 
 
DISLOCATION. 69 
 
 Dislocation on pubes. — 1. Extension. Extend limb, well abducted, down* 
 ward and backward ; at same time pull head of bone outward by a towel 
 round thigh just beneath groin. 2. Manipulation. Pull strongly on thigh 
 in line of axis of femur, at same time bending it on the abdomen ; rotate 
 inward, and bring down into a line with body ; or employ same manoeu- 
 vres as in thyroid dislocation. 
 
 Old Dislocations. — Reduction is tolerably safe to attempt up to twc 
 months. Afterward, danger of inflammation of joint or fracture of femu*, 
 
 Dislocation with Fracture of Femur. — Try to push head of bone into 
 place, or let bone unite, and then, in sixth week, attempt reduction. 
 
 Dislocation of Lower Jaw. — Usually bilateral. Causes. — Direct vio- 
 lence, or over-extension in gaping. Srjmptoms. — Bilateral : mouth widely 
 open and cannot be shut ; saliva dribbles ; speech and deglutition almost 
 impossible ; depressions where condyles ought to be ; prominences behind 
 and beneath malar bones. Unilateral : symptoms less marked ; chin in- 
 clines toward sound side ; depression in front of ear only on side dislo- 
 cated. Mechanism. — Two views. One, that it is caused by the coronoid 
 process locking against the malar bone ; the second merely attributes it 
 to excessive muscular action. — Prognosis. — If left unreduced, a certain 
 amount of motion returns, and the teeth can be made to nearly, if not quite, 
 meet. Reduction. — Firstly, disengage condyle by pressing downward 
 with thumbs, guarded by a towel, in mouth behind last molar teeth. Sec- 
 ondly, push chin backward and upward. Congenital dislocation is gener- 
 ally accompanied by other signs of imperfect development. Subluxation 
 is a kind of "catching" of the jaw, which the patient can easily remedy 
 for himself. It occurs in young people of relaxed fibre. General Treatment 
 — Tonics and time. 
 
 Dislocation of Knee. — Five kinds : forward, backward, inward, out- 
 ward, and dislocation of semilunar cartilage, called " subluxation." The 
 first four are unmistakable, from the obvious deformity. The lateral dis- 
 locations are most common and not complete. One or other condyle slips 
 over to the opposite half of the tibial surface. Dislocation of the tibia for- 
 ward is dangerous from pressure on popliteal vessels by femur. Sublux- 
 ation is marked by sudden and severe pain attacking joint, which then 
 remains semiflexed. Beduction. — Extend and rotate slightly. Compound 
 dislocation, except in favorable cases, requires amputation. Subluxation 
 is reduced by flexion, followed when the patient is off his guard by sud- 
 den extension, combined with slight rotation. While manipulating, press 
 firmly with one thumb on any tender spot. 
 
 Dislocation of Metacarpal Bones. — Rare, obvious, and easily reduced 
 by extension. 
 
 Dislocation of Metatarsus, if compound, may require amputation. 
 
 Dislocation of Patella. — Four kinds : outward (most common), in- 
 ward, edgewise, and upward. Causes. — A blow on the edge of the pa- 
 
70 DISLOCATION. 
 
 tella, or sudden muscular action. Signs, etc. — 1, Outward (most com- 
 mon) ; patella rests on outer side of external condyle, generally with outer 
 edge raised. 2, Inward : most rare, almost unknown. 3, Edgewise : either 
 inner or outer edge of patella is twisted into intercondyloid space, the 
 bone standing on its edge. 4, Upward: ligamentum patellae is alwa3'S 
 ruptured ; quadriceps extensor pulls patella upward. Reduction. — In first 
 two varieties flex thigh on abdomen; press outer or inner edge of pa- 
 tella, according as dislocation is outward or inward. The other edge is 
 thus raised and the bone freed, the quadriceps at once pulling it into 
 position. Case 3 often presents great difficulties. Anaesthesia. Manip- 
 ulation. Manipulation combined with bending leg and rotating it on axis 
 of tibia. Forcible flexion. Sudden and violent extension made by patient 
 himself. The cause of the difficulty said to be wedging of the superior 
 angle of the bone in the intercondyloid space. Shun any division of ten- 
 dons or ligaments. If dislocation be irreducible, wait, watch, and act ac- 
 cording to the course taken by nature. 4, Upward dislocation : treat 
 like fractured patella. 
 
 Dislocation of Lower Angle op Scapula. — Query as to pathology. 
 Slipping of latissimus dorsi or paralysis of serratus magnus. On latter 
 supposition use strychnine endermically (Erichsen) ; electricity; ortho- 
 pedic appliances. 
 
 Dislocation of Shoulder-Joint. — Five kinds: 1, downward, sub-cora- 
 coid ; 2, downward, subglenoid ; 3, inward, sub-clavicular ; 4, back- 
 ward, sub-spinous ; 5, upward. Sub-coracoid is far the most common, 
 sub-spinous very rare. Causes. — Predisposing : the natural shallowness 
 and free movement of the joint, previous dislocation, male sex, old age. 
 Exciting : falls on shoulder, elbow, or hand; muscular action. To pro- 
 duce the dislocation backward, the elbow has to be directed across chest 
 when falling, or else twisted inward. Signs. — Six common signs (Erich- 
 sen) : 1, flattening of shoulder ; 2, hollow under acromion ; 3, apparent 
 projection of this process, with tension of the deltoid ; 4, presence of 
 head of bone in an abnormal situation-; 5, rigidity; 6, pain in shoulder. 
 These resolve themselves into three simply : 1, head of bone is evidently 
 absent from its place beneath acromion; 2, it is present elsewhere; 3, 
 there are such signs as are common to dislocation of all joints, viz., stiff- 
 ness, pain, etc. 
 
 1. Sub-coracoid. — Head of bone under or slightly internal to coracoid 
 process. To feel it, raise the elbow. Elbow projects from side. Slight 
 lengthening, real or apparent, of upper arm; rarely slight shortening. 
 Stiffness ; movement only possible antero-posteriorly. 
 
 2. Sub-glenoid. — Much like sub-coracoid, but head of bone more dis- 
 tinctly felt in axilla, elbow projects more, and there is lengthening, one 
 inch. Marked symptoms of pressure on axillary vessels and nerves. 
 
 3. Sub-clavicular. — An extreme degree of "sub-coracoid." Promi- 
 
DISLOCATION. 7 1 
 
 nence of head of bone beneath clavicle. Elbow projects backward and 
 outward. 
 
 4. Subspinous. — Head of bone felt beneath spine of scapula. Elbow 
 outward and forward. 
 
 5. Upward. — Always complicated with fracture of acromion or cora- 
 coid. Consequently, injury and swelling likely to be severe. Shortening. 
 Crepitus and deformity. 
 
 Anatomy. — In the first three forms the inner and lower part of the 
 capsule is torn, and, if the displacement be great, either the great tuber- 
 osity of the humerus, or else some of the muscles attached to it ( supra - 
 and infra-spinatus and teres minor) have to give way. In sub-glenoid, 
 the sub-scapularis also goes. In sub-spinous, also, the sub-scapularis is 
 torn. In sub-spinous, head of bone lies between sub-scapularis and teres 
 minor ; in sub-glenoid, between sub-scapularis and long head of triceps ; in 
 sub-clavicular, on second and third ribs. 
 
 Diagnosis. — 1. From fracture of neck of humerus. This fracture is 
 never caused by anything but direct violence. Then there are the general 
 differences between fracture and dislocation. Both injuries may occur 
 together. 2. From mere paralysis of deltoid. Then, although there is 
 flattening, still head of bone is easily felt in glenoid cavity. 
 
 Reduction. — By heel in axilla; by manipulation; by pulleys; by knee 
 in axilla; by air-pad in axilla; by extension upward. Heel in Axilla. — 
 Patient lies on back. Surgeon sits with unbooted heel in injured axilla. 
 Extension made either by himself, or by assistants or pulleys. Anaesthesia. 
 Slight rotation of limb facilitates. Neither anaesthesia nor assistants 
 necessary in most cases. Manipulation. — Bring arm with a sweep round 
 in front of chest and face, then rotate inward whilst bringing the arm 
 down to the side again. This should be done by one hand of the surgeon, 
 while with the other he tries to press the head of the humerus into its 
 place. Anaesthesia helps. Pulleys. — Anaesthesia. Caution : danger of 
 rupturing nerves, axillary artery, etc. Forearm has been torn off. First 
 apply a wet bandage to the arm, then put on a clove-hitch over the band- 
 age, above the elbow. Extension should be slow and patient. Counter- 
 extension by a jack-towel, or by surgeon's heel or knee. Knee in Axilla. — 
 Patient sits on a chair. Surgeon places one foot on chair and the knee in 
 axilla. He then seizes the arm, extends a short time, and, lastly, steadying 
 the shoulder with left hand, uses the knee as a fulcrum on which to lift 
 humerus into its place. Or, as recommended by Flower in Holmes's 
 system, the surgeon can place his back against a door-post and have exten- 
 sion made through the doorway by assistants, while he steadies the shoul- 
 der with both hands. Mr. Cock placed an air-pad in the axilla and bound 
 the elbow firmly to the side. In three days the dislocation was found to 
 be reduced. All other attempts had previously failed. Extension upward 
 can also be made with the heel against the shoulder ; or extension outward 
 
72 DISSECTION WOUNDS. 
 
 with counter-extension from opposite wrist. Skey has shown that, owing 
 to the great mobility of the scapula, the real direction of the extending 
 force is much the same, whatever it may be apparently. 
 
 Compound Dislocation of Shoulder. — Rarity. Question of resection un- 
 certain. Antiseptic treatment. Complications. — 1, With fracture of neck 
 of humerus attempt reduction by manipulation, then treat fracture. If re- 
 duction impossible, put up fracture, and in sixth week (when union has 
 taken place) again attempt reduction. If rupture of axillary artery occur, 
 reduce dislocation first, and then tie both ends. 
 
 Dislocation of Thumb (Metacarpophalangeal Joint). — Almost always 
 backward. Signs. — Thumb is bent back. Head of metacarpal can be felt 
 projecting on palmar aspect, and base of first phalanx on dorsal aspect. 
 Main obstacle to reduction is engagement of neck of metacarpal between 
 two heads of flexor brevis pollicis, as in a button-hole. Reduction. — The 
 efforts are directed to disengage from flexor brevis pollicis ; bend the 
 metacarpal joint of the thumb well into palm of the hand, thus relaxing 
 the muscle ; now press the first phalanx of the thumb well backward, i.e., 
 hyperextend it ; at the same time pull the thumb downward, i.e., toward 
 the tips of the fingers ; lastly, flex the thumb (every joint) into the palm : 
 if this fails, the pulleys may be tried. Anaesthesia ; subcutaneous division 
 of one or both heads of flexor brevis, or lateral ligaments ; passing a blunt 
 hook through a small incision and hooking tendons of flexor brevis over 
 head of metacarpal bone. After reduction, keep thumb bent toward palm 
 for a day or two. 
 
 Dislocation of Wrist. — Extremely rare ; readily reduced. Diagnosis. — 
 From Colles's fracture ; in fracture the styloid processes go with the hand ; 
 in dislocation, they approach too near the finger- clefts. 
 
 Dissection Wounds. — Under this head we notice the lymphatic and 
 cellular inflammations and blood-poisoning produced by absorption of ani- 
 mal poison from dead bodies. Bodies lately dead much more dangerous 
 than those which have been long dead ; bodies dead from erysipelas, peri- 
 tonitis, puerperal and typhoid fevers especially dangerous. Peritoneal 
 fluid particularly poisonous after death from peritonitis. Not necessary 
 that there should be a skin wound. Poison absorbable through hair-fol- 
 licles or through unbroken skin. Signs and Prognosis. — Three grades of 
 severity : in the first the symptoms, except slight fever for a few days, are 
 trivial and almost confined to the limb poisoned ; in the second, there is 
 either severe cellulitis in the limb, or abscesses form in parts of the body 
 beyond the limb, or both these troubles may be present. This grade is 
 liable to pass into chronic pyaemia. The third grade is marked by violent 
 and sudden symptoms of septicaemia, and often terminates fatally in two or 
 three days. The point of inoculation usually looks angry and purulent, 
 and presents either a vesicle, a pustule, or a scab ; it is painful ; the lym- 
 phatics extending from it to the nearest glands are reddened, tender, and 
 
DYSPHAGIA. 73 
 
 Bometimes surrounded by inflamed and even suppurating cellular tissue 
 (phlegmonous erysipelas) ; these glands are tender and enlarged, and 
 abscesses tend to form around them. Chills, rise of temperature, and other 
 feverish symptoms come on within twenty-four hours. Symptoms such as 
 these are common to almost every case, but the further course is variable. 
 In the third grade of cases, within forty-eight hours, to quote Mr. Callender, 
 "the patient, flushed, anxious, restless, even delirious, is in a hopeless 
 condition, with prostration and rapid sinking." In the second grade, 
 there may be extensive cellulitis or the formation of numerous abscesses 
 near glands ; but so long as the disease is subacute or chronic, and 
 provided actual pyaemia does not occur, the prognosis is very hopeful. In 
 these cases the spirits are usually very low. In the first grade, recovery 
 takes place in a week or two, or even in a few days. Treatment. — If, while 
 dissecting, the hand should be wounded, grasp it so as to check the return 
 of venous blood, wash it, suck the wound, permit it to bleed freely, and let 
 a stream of cold water flow over it. If afterward signs of local poisoning 
 appear, give the limb complete rest, and the patient a country holiday, with 
 instructions to avoid any kind of exertion, for excitement of the cirulcation 
 apppears to drive poison from the wound inward. Cauterize the wound ; a 
 warm bath for the limb ; generous diet ; fresh air ; tonics ; purgatives ; rest 
 in bed for the severe cases ; to properly rest a limb, splints are necessary ; 
 mill-board and starch apparatus ; poultices. Open abscesses as they form. 
 
 Drowning. — See article Asphyxia. 
 
 Dura Mater, Fungus of. — A tumor springing from the dura mater, 
 and pressing outward through the cranium ; simple and malignant forms ; 
 the thin skull may be felt crackling over the tumor after it has pressed its 
 way through, and the tumor pulsates with the respiratory movements like 
 the brain. Before tumor appears externally, there are usually signs of in- 
 tracranial pressure, e.g., diplopia or even convulsions. Prognosis. — Eventu- 
 ally fatal, without treatment ; very unpromising with. Treatment — Moderate 
 compression gave relief in some cases. In suitable cases expose tumor by 
 a crucial incision ; enlarge opening in skull, if necessary, with trephine, and 
 remove tumor from dura mater, if possible. It is next to impossible to 
 diagnose, before operating, whether similar tumors spring from the dura 
 mater or from the cranium itself. Eefer to Louis on Fungous Tumors of 
 Dura Mater, " Sydenham Society's Translation." 
 
 Dura Mater, Irritation of. — Injuries of the head which cause this pro- 
 duce sj^mptoms such as contractures and convulsions on the same side of 
 the body.— See Duret on "Cerebral Traumatism," and an abstract by 
 Ferrier, in Brain for 1879. A very severe case of this affection recovered 
 under cold douche. — See " Transactions Clinical Society," 1879, p. 145. 
 
 Dysphagia is a symptom arising from obstruction to the oesophagus, 
 e.g., by pressure from aneurism, tumors, etc., or from ulcers, cancers, or 
 foreign bodies ; sometimes merely spasmodic. Vide (Esophagus. 
 
74 ELEPHANTIASIS ARABUM. 
 
 Eczema. — A superficial inflammation of the skin, with a tendency to 
 spread, and attended by the formation of minute vesicles, from which 
 escapes a discharge, usually serous. Three varieties : 1, eczema simplex, 
 or ordinary eczema ; 2, eczema impetiginodes, where the secretion is puru- 
 lent ; 3, eczema rubrum, where there is great redness and inflammation. 
 Eczema squamosum is a term applied when the transudation dries quickly. 
 Causes. — Three classes: 1, direct irritants, e.g., solar and tropical heat, the 
 water cure, mercurial inunction, irritation of parasites ; 2, venous obstruc- 
 tion, e.g., varicose veins in legs ; 3, constitutional causes ; sometimes con- 
 genital ; occasional connection with dyspepsia and disordered menstruation. 
 Scrofulous and rickety children are much disposed to eczema. Goui 
 Symptoms and Course. — Skin red and moist, the moisture exuding from 
 minute vesicles. Or, instead of moisture, a branny dryness. Itching. 
 Tendency to become chronic and to recur. Prognosis. — As a rule, quite 
 amenable to treatment. Treatment. — Ung. hydrarg. ammoniat. ; lotion of 
 hydrarg. perchlor. (gr. ij. ad 3 j.) ; ung. zinci. Scabs to be removed by 
 fomenting and poulticing, or by soaking in oil ; lotions of carbonate of 
 soda to check discharge. For very extensive eczema with great itching, 
 use the shower-bath two or three times a day for ten or fifteen minutes in 
 a warm room. For old cases with thickening of the skin, soft-soap, tar, 
 and caustic potash may be used ; rub the soft-soap in twice a day with 
 flannel, for three days, then stop, leaving the soap on for three more days, 
 then remove the soap by a bath. A few days after this, commence a 
 similar course again, and repeat till a thorough cure is effected. When 
 the eruption is dry and scaly, use tar ointment. Danger of tar-poisoning 
 (known by diarrhoea, vomiting, tarry odor of urine and vomit). When 
 soft-soap and tar are well borne, but do not cure, apply caustic potash 
 ( § j. aquse 3 ij.) once a week ; immediately afterward apply cold wet com- 
 presses to relieve the violent pain. Constitutional treatment often advis- 
 able. Laxatives, arsenic, Donovan's solution, iodide of potassium in 
 increasing doses. Vigorous local treatment should not be employed in moist 
 eczema of the face or scalp of children, or when the eczema appears to be 
 vicarious for other diseases. The probable cause should never be neglected. 
 In eczema of the legs from varicose veins, prescribe horizontal rest in mid- 
 dle of day, and support from rubber bandages or elastic stockings. Always 
 superintend the use of these bandages at first. 
 
 Elephantiasis Arabum. — Causes unknown. Occurs in hot coun- 
 tries, especially West Indies and South America ; rare in Europe. Symp- 
 toms. — Great hypertrophy of skin and subcutaneous areolar tissue of some 
 part of the body. Parts usually affected are lower extremities, scrotum, 
 labia, and face. Pathology.— -It appears to depend on obstruction of the 
 lymphatics and lymphatic glands. The arteries of the part are usually 
 much enlarged. Treatment. — Ligature of the main artery of the limb has 
 cured some cases, but failed in others. 
 
EPISTAXIS. 75 
 
 Elephantiasis of Scrotum. — Vide Scrotum, Diseases of. 
 
 Embolism. — Signifies the conveyance of some solid body, small or 
 large, by the current in a blood-vessel, till it stops and obstructs some ves- 
 sel ; this obstructed vessel may be an artery, or a vein, or a capillary, and 
 it may be in the systemic or the pulmonic circulation. The obstructing 
 body is called an embolus, and is usually a piece of fibrin washed from one 
 of the cardiac valves, or from the clot in an aneurism, or from an inflamed 
 vein. Where the embolus rests an abscess is apt to form. In regions 
 where the collateral circulation is poor, e.g., in the brain, death of the 
 parts whose blood-supply is obstructed by the embolus may occur. When 
 emboli are of a septic nature, they produce pysemic abscesses. Entozoa 
 have been known to constitute the emboli. 
 
 Emphysema. — In surgery, means only the passage of air into the 
 cellular tissue. Causes. — Mostly wounds of lung, especially by broken ribs. 
 Very rarely decomposition and consequent production of gas in a wound. 
 The air almost always passes first into the pleural cavity, and is pumped 
 thence by respiratory movements into cellular tissue. Symptoms and Course. 
 — The pecular crackling feeling is unmistakable and pathognomonic. Un- 
 less the air continues to pass into the cellular tissue, it is soon entirely 
 absorbed. The emphysema is first noticed near the wound, and spreads 
 thence often to great distances. The rupture of an air-cell in the lung 
 may cause emphysema of the mediastina and the neck. Treatment. — Treat 
 the cause ; put a pad over the wound. 
 
 Empyema. — Fluid, at first serum or blood, effused in the pleural 
 cavity, may become purulent. The condition thus produced is called an 
 empyema, and is described more fully in medical than in surgical works. 
 But I must call attention to the treatment by excision of part of a rib. — 
 (Peitavy : Medical Record, Aug., 1876 ; W. Thomas : Birmingham Medical 
 Be view.) 
 
 Enchondroma. — See Tumors. 
 
 Epis taxis. — Bleeding from the nose. Causes. — Congestion of mucous 
 membrane of nose ; this may result from catarrh, from a varicose condi- 
 tion of the nasal veins, the result of old catarrh, from congestion of the 
 liver, from heart disease, and even from dyspepsia. Childhood and pu- 
 berty are the usual ages, but middle life (from liver, heart, or kidney dis- 
 ease, etc.) is also subject. Epistaxis in old age sometimes appears to result 
 from weakness, which it of course aggravates. Blows ; hemorrhagic dia- 
 thesis ; vicarious menstruation. Prognosis. — Dangerous in old and weakly 
 people. Treatment. — Perfect rest, coolness, but extremities should be 
 warm ; bathing face with hot water to diminish congestion of mucous 
 membrane ; sometimes cold water acts better ; raising hands above head ; 
 head not to be held down over a basin ; injections of cold water, of hot 
 water (temperature 100°), of tinct. ferri perchlor., pure or diluted ; these 
 injections may be given by a syringe which directs the current backward. 
 
76 ERYSIPELAS. 
 
 Ice to the back of the head ; cold to the spine ; dry cupping between 
 shoulders ; plugging ; plugging posterior nares. Operation. — A piece of 
 -whip-cord is passed through the nose into the pharynx by means either of 
 Bellocq's sound or of an elastic catheter. It is then pulled from the phar- 
 ynx into the mouth by forceps, and a plug of compressed sponge or lint 
 tied to that part of the string now hanging out of mouth, but some dis- 
 tance from its end. Plug should be small and nicely shaped, or part of 
 it will irritate back of pharynx or even top of larynx. Now pull the string 
 back through the nose and guide the plug into the posterior nares. Nasal 
 and oral ends of string should be tied together and fixed on face with 
 strapping. When removed, plug is to be pulled back through mouth ; but 
 string should not be taken away till danger of recurrence seems to be gone. 
 
 Epithelioma. — See Cancer. 
 
 Epulis. — A term applied to fibrous, sarcomatous, and cancerous tu- 
 mors of the gums. Most are fibro-myeloid ; the less of the myeloid struc- 
 ture, the more innocent the growth. Symptoms. — Non-cancerous epulis ; 
 a fleshy red tumor of the gum ; teeth loosened and pushed forward ; size 
 variable ; sometimes ulceration. Cancerous epulis has the special marks 
 of malignancy, rapid growth, excavated ulcer, etc. Prognosis. — Neither 
 fibrous nor myeloid epulis usually returns if the bone from which it springs 
 be removed. Treatment. — Removal of tumor and attached alveoli with 
 cutting pliers and small saw. 
 
 Erysipelas. — A diffuse inflammation of the skin or subcutaneous areo- 
 lar tissue, or of both together, almost always attacking the neighborhood 
 of some wound. Three kinds, viz. : 1, simple ; 2, cellulo-cutaneous ; 3, 
 diffuse cellulitis. Causes. — Usually a wound which has been exposed to 
 unhealthy influences, e.g., septic virus, draughts of cold air, constant mech- 
 anical irritation, certain epidemic influences, contagion from an adjacent 
 case of erysipelas or puerperal fever. Predisposing causes are bad ven- 
 tilation, bad and insufficient food, dyspepsia, hospital air when impure, 
 depressed nervous system, want of cleanliness, diabetes, kidney disease, 
 alcoholism, contact of atmospheric germs with a wound. Signs. — 1. Sim- 
 ple Erysipelas. At first, rigors, fever, sudden rise of temperature, some- 
 times to 104°, symptoms of disordered digestive organs, e.g., furred 
 tongue, constipation, or diarrhoea. In about twenty-four hours, some- 
 times later, a rosy redness appears on the tract of skin affected. Margins 
 of redness either well- or ill-defined. It disappears on pressure. Slight 
 superficial swelling ; when the face or head are affected there is often con- 
 siderable oedema, especially of eyelids. Progress of fever is irregular, and 
 depends on whether rash spreads or not. Eecovery usually takes place in 
 mild cases in a few days, in more severe cases in a week or so, and is fol- 
 lowed by desquamation. Often the adjacent lymphatic glands enlarge be- 
 fore the erysipelas appears. The rash may spread all over the body (ery- 
 sipelas ambulans), or disappear in one place to reappear in another 
 
EXCISION OF JOINTS. 77 
 
 (erysipelas erraticum). These varieties are more serious. When there is 
 a wound, it ceases to secrete healthy pus for a time. Pain is rarely severe. 
 
 2. Cellulo-cutaneous Erysipelas (Phlegmonous erysipelas). — Constitu- 
 tional symptoms are as in simple erysipelas, but more severe. Redness 
 deeper. Swelling greater. Within a week the swelling becomes boggy, 
 and next fluctuates, indicating suppuration. Throbbing pain and perhaps 
 a slight subsidence of the symptoms may precede suppuration. Extensive 
 sloughing usually occurs. 
 
 3. Diffuse Cellulitis is always preceded by a wound, especially a dis^ 
 secting-wound or the bite of some venomous animal. The skin is not 
 much affected ; but the subcutaneous cellular tissue presents the same 
 oedema, swelling, hardness, bogginess, fluctuation, suppuration, and slough- 
 ing as are seen in phlegmonous erysipelas. The constitutional symptoms 
 are severe and usually of an asthenic type. Danger of pyaemia. 
 
 Pathology. — All the above forms are related, and are primarily inflamma- 
 tions of the lymphatics (lymphangitis), erysipelas simplex affecting only 
 the cutaneous absorbents. In the boggy stage of cellulitis and phleg- 
 monous erysipelas, the cellular tissue is distended with effusion, and parts 
 of it are approaching a state of mortification. Sloughing and suppuration 
 almost always follow. Great thickening and stiffness are often left after 
 the deeper varieties of erysipelas. Diagnosis. — Do not confound the red- 
 ness and oedema over an abscess beneath deep fascia with erysipelas. 
 Diagnose also fr om phlebitis. Prognosis. — Bad when the habits are intem- 
 perate, kidney or liver diseased, age old or very young, cause epidemic, 
 form erratic or recurrent, duration prolonged, or if very severe and occur- 
 ing in the head and face (or neck especially). Treatment. — Commence 
 with purge (calomel gr. v.-x.), salines, tinct. ferri perchlor. (TTL. xx. 4 ti3 horis). 
 Diet nourishing, but light ; avoid loading with more food than is digested. 
 Stimulants recommended by most authorities. Moderate temperature, 
 fresh air, but no draughts. Opium not well borne. Local treatment in 
 simple erysipelas, cotton-wool, flour, zinc oxide, especially for erysipelas 
 intertrigo, that is the form caused by two moist cutaneous surfaces rubbing 
 against each other. Caustics, circumscribing rings of argent, nit. or tinct. 
 iodine of very doubtful benefit. In the deeper varieties of erysipelas, fluc- 
 tuating spots should be opened, and tense parts marked with small incisions 
 (2 inches), before they fluctuate. Poultices. If incisions cause hemor- 
 rhage, stuff with dry or oiled lint. At commencement of erysipelas in 
 strong, otherwise healthy persons, with foul tongues, give an emetic. This 
 sometimes aborts the attack. Elevate position of part affected. 
 
 Excision of Joints. — The indications for excision and the conditions 
 of success vary with each joint. Objects of excision may be : 1, to merely 
 expedite recovery ; 2, to restore motion to an anchylosed joint ; or 3, one 
 of the various purposes for which amputation is done. Hence the choice 
 often lies between excision and amputation. 
 
78 EXCISION OF JOINTS. 
 
 Compaeison of Excision and Amputation. — Life is always to be consid- 
 ered before limb. Excision involves a larger wound and greater strain on 
 the constitution : hence it is bad for tuberculous and cachectic people. 
 Much depends on the particular joint. Excision safer than amputation at 
 shoulder and hip. Danger equal for the two operations at the elbow ; at 
 knee, excision is far more dangerous than amputation. At elbow and wrist 
 excision is, of course, far preferable to amputation, because it leaves the 
 hand. At knee, amputation is generally to be preferred, because of the 
 great danger of excision. Excision of ankle is often a good operation ; but, 
 if the tarsal bones are diseased, there is great danger of recurrence, and 
 removal of too much bone would leave too weak a foot. Operation. — In- 
 struments : knives, forceps, lion-forceps, saws (Butcher's saw, key-hole saw, 
 chain-saw, etc.), chisels, cutting-pliers, rasping instruments for scraping 
 off periosteum, retractors, directors, excision director. Esmarch's bandage 
 generally to be used. The following six directions are abbreviated from 
 Erichsen : 1, Make incisions sufficiently free, and parallel to important 
 parts, so as not to divide them ; 2, economize length of bone by use of 
 gouge ; 3, leave epiphyseal cartilage in children ; 4, do not open medullary 
 canal in adults ; 5, keep periosteum ; 6, do not confound new bone or bone 
 softened by inflammation, but otherwise healthy, with diseased bone, etc. 
 
 Process of Repair after Excision. — This is entirely analogous to the 
 process of repair after compound fractures. 
 
 Special Excisions. 
 
 Ankle- Joint, Excision of. — Disease should be limited to ends of leg- 
 bones and to astragalus. Operation. — Incisions two : one internal, along 
 edge of inner malleolus ; the other, external, along posterior border of 
 lower two inches of fibula, around outer malleolus and as far forward on 
 outer side of foot as within one inch of base of fifth metatarsal bone. Saw 
 and nip off inner malleolus through inner incision. Dissect soft parts suf- 
 ficiently away, pulling peronei tendons backward and downward, and keep- 
 ing close to bone to avoid posterior tibial artery. Cut off outer malleolus ; 
 push tibia out of external wound, and saw off its articular surface. Next 
 remove part or whole of astragalus, according to its condition. Dress the 
 wound and place the limb on a firm splint. Result. — Generally good. 
 Often a movable joint. Fatality 1 in 5 J, success greatest when disease is 
 of traumatic origin. 
 
 Elbow, Excision of. — In this joint, excision, if practicable, always pre- 
 ferred to amputation. A matter of opinion whether in mere suppurative, 
 synovial disease, the results of excision or of natural cure are the best ; 
 but in necrosis, excision should be done. Operation. — Use a strong knife- 
 and ordinary saw. Longitudinal incision 5 inches long, right down to 
 bone, with its centre opposite inner border of olecranon. Then with 
 scalpel separate soft parts from bones, proceeding carefully between ole- 
 cranon and internal condyle, and guarding ulnar nerve with nail of left 
 
EXCISION OF JOINTS. 79 
 
 thumb. Divide lateral ligaments, push end of humerus out of wound and 
 saw it .off freely. Then project ulna and radius, grasp olecranon with lion- 
 forceps, and saw both bones at level of neck of radius. Sometimes orbic- 
 ular ligament can be preserved with advantage. Some do whole operation 
 subperiosteally with aid of rasps. Subperiosteal resection of doubtful ad- 
 vantage. Results. — In good cases, a strong joint with all its natural move- 
 ments. After-treatment — Hinged splint. One contrived to permit supina- 
 tion and pronation useful. In a week's time, flex the elbow to a right 
 angle. When wound is nearly healed, use passive motions. 
 
 Hip-Joint, Excision of. — Indications for operation. See Disease of Hip- 
 Joint and Gunshot Wounds. Operation. — Incision, free semilunar with 
 convexity backward over posterior border of great trochanter and down 
 to bone. Follow neck of bone to head, open capsule, and let assistant, 
 by adducting, rotating inward and pushing upward, project head of femur 
 out of wound. Ligamentum teres may have to be divided. Joint very 
 rarely found dislocated. If femur be diseased, saw below trochanter. 
 Chain-saw useful. If acetabulum only be diseased, saw through neck of 
 femur and gouge acetabulum, or cut it with pliers. Pelvic fascia thor- 
 oughly separates acetabulum from pelvis. Acetabular disease requires 
 freer incisions. After-treatment. — Plaster apparatus ; long splints with 
 iron interruption ; mere extension by weight and pulley ; Say re's wire 
 breeches. In dressing the wound a stretcher, with a hole opposite the hip, 
 like that of Mr. Croft, is useful. For heavy adults a stretcher contrived 
 to slip easily , piecemeal, under the patient, and to leave the hips exposed, 
 is very useful. The stretcher being slipped under the patient, is lifted up 
 and placed with its two ends on two chairs beside the bed. A dressing- 
 pan being placed on the floor, the wound can be syringed, if necessary, 
 and dressed ; while, in the meantime, the bed-sheets are changed or 
 smoothed. Prognosis. — Many cases die, but probably not one-third of 
 these* perish actually from the operation. Without interference some of 
 the successful cases would have perished of the original disease. 
 
 Knee, Excision of. — Indications. See Disease of Knee-Joint. — Amputa- 
 tion almost always preferred for injury. Operation. — Nearly transverse in- 
 cision below patella from back of one condyle to back of other, and divid- 
 ing ligamentum patellae. Throw up soft parts from patella and front of 
 lower end of femur. Divide lateral ligaments on the condyles. Retract 
 soft parts and project femur. Saw through condyles below the epiphyseal 
 cartilage in children. Proceed very carefully, both in separating soft parts 
 from back of condyles and in making the last cuts with the saw, or popli- 
 teal artery may be wounded. Now push end of tibia upward and forward, 
 and saw it off close to articular surface in case of children. Make saw- 
 cuts through the two bones so to correspond that limb may be straight. 
 If they do not fit in this way after first sections, other sections must be 
 made. Carefully secure all bleeding vessels. After-treatment. — Put ap- 
 
80 EXCISION OF JOINTS. 
 
 paratus on at once. Some fixed contrivance, like P. H. Watson's combina- 
 tion of anterior iron splint with paraffine or plaster-of-Paris bandage, is 
 the best. Iron back-splint with foot-piece and interrupted side- splint. 
 Bavarian splint. Salter's swing. Packard's splint. 1 Do not disturb limb 
 for first few days. Recovery and repair are very slow, average eight 
 months. Some surgeons leave patella. Ankylosis should be osseous. An 
 outward bend of the limb is a common misfortune after this excision. 
 
 Excision of Os Calcts. — Lines of incision : 1. Along upper border of 
 os calcis from inner side of tendo Achillis to a little in front of calcaneo- 
 cuboid articulation ; this should divide the tendo Achillis. 2. Across sole 
 of foot, from anterior end of first incision. Disarticulate from cuboid 
 first, and from astragalus afterward. Beware of wounding posterior tibial 
 vessels. A very useful foot results. Prognosis is excellent. 
 
 Excision or Scapula. — Done for necrosis, caries, and morbid growth. 
 Partial or entire. Crucial or T-shaped incision. Hemorrhage occasionally 
 very serious. In removing the entire bone, divide the muscles attached to 
 posterior border at an early stage of the operation, and leave the subscap- 
 ular vessels till last. Tie the vessels as the operation proceeds. Prognosis. 
 — Danger not so great as might be expected. 
 
 Excision of Shoulder. — Done for gunshot wounds and compound dis- 
 locations, and occasionally may be justifiable in cases of bone disease or 
 innocent tumor. But, in cases of bone disease, the cure by natural anky- 
 losis affords a perfectly satisfactory result, which is not improved upon by 
 excision. Operation. — Incision. Longitudinal from just outside coracoid 
 process downward and outward for five inches, right down to bone. Open 
 capsule and divide muscles attached to tubercles of humerus, rotating out- 
 ward while cutting internal rotator (subscapularis), and vice versd. Arm 
 should at same time be brought across chest. Pull tendon of biceps aside. 
 Operator himself now seizes upper arm in his left hand and pushes head of 
 humerus out of wound. Clean soft parts from line of saw-cut. Saw. If, 
 upon opening the joint, amputation is judged expedient, make a circular 
 incision at the lower end of the longitudinal one, and disarticulate. Ex- 
 cision may be performed with a flap-incision, raising the deltoid. Glenoid 
 cavity rarely removed. Prognosis. — Very good. Useful limb. Fatality : 
 of fifty cases, in seventeen the glenoid cavity was interfered with, and in 
 thirty-three the head of the humerus only was touched ; of the seventeen, 
 seven died ; of the thirty-three, only one died. But in military surgery, 
 one in four died. 
 
 Excision of Tarsal Bones. — See Excision of Os Calcis, above. Excision of 
 these bones for disease requires a little knowledge of anatomy, and then 
 the surgeon had best be left to adapt his incisions to the particular case. 
 The astragalus may be removed very well by incisions similar to those 
 
 1 See Medical Record, 74, approved by F. H, Hamilton and L. A. Sayre. 
 
EXOSTOSIS. 81 
 
 given for excision of the ankle-joint. Its excision gives excellent results. 
 Excision of the smaller tarsal bones is often by no means a good substitute 
 for amputation. 
 
 Excisiox of Wrist. — Lister's method. Its description includes at least 
 twelve directions, besides the application of Esmarch's bandage. 1. Make 
 first incision (two are required) from dorsum of base of second metacarjDal 
 bone upward as far as base of styloid process of radius, always internal to 
 extensor secundi internodii pollicis. 2. On the thumb side of this incision 
 separate the soft parts from the bones, carefully because of radial artery. 
 At the same time divide the extensor carpi radialis brevior. 3. Sever 
 trapezium from rest of carpus with cutting-pliers. 4. Clean soft parts from 
 bones on ulnar side of incision. 5. Make ulnar incision near anterior edge 
 of ulna, and extending from two inches above styloid process to middle of 
 fifth metacarpal bone. 6. Raise all the soft tissues completely from the 
 dorsal surface of the carpus ; then, of course, the two wounds communi- 
 cate. In doing this the extensor carpi ulnaris should be severed from its 
 insertion. 7. Clean anterior aspect of carpus and ulna, cutting off pisiform 
 bone and hook of unciform bone, so as to leave them attached to the soft 
 parts. Do not go so far forward as to wound deep palmar arch. 8. Divide 
 ligaments and remove carpal bones (except trapezium) with forceps. 9. 
 Clean and saw off ends of ulna and radius. All cartilage of radio-ulnar 
 joint should be removed. 10. Cut off bases of metacarpals so far as they 
 are covered with cartilage. 11. Take away trapezium and base of first 
 metacarpal bone. 12. Cut off cartilage of pisiform and leave the rest, and 
 the hook of the unciform, unless they be diseased. The operation may be 
 shortly summed up thus : The whole carpus, except the pisiform and the 
 hook of the unciform, and also the adjacent cartilage-covered parts of the 
 radius, ulna, and metacarpal bones, are removed piece by piece, in the or- 
 der found most convenient, through two longitudinal incisions, one ulnar 
 and palmar, the other dorsal and radial. Besult. — Yery useful hand. After- 
 treatment. — Very important. Large lump of cork under palm of hand. 
 Flat wood palmar splint. Regular passive motion from the first. En- 
 couragement to active motion. 
 
 Exostosis. — Two kinds of true exostosis, and two allied bony growths. 
 True exostosis is either (1) spongy or (2) ivory. The alhed osseous 
 growths are the " exercise-bones," and other ossifications of tendons and 
 muscles, besides the "diffused osseous tumor." Causes. — Usually unknown. 
 Begin in youth, rarely after thirty; male sex. Pathology. — Spongy ex- 
 ostosis consists of cancellous bone covered with a thin layer of hyaline car- 
 tilage. The cartilage grows on its superficial surface, and keeps ossifying 
 on its deep surface. Ivory exostosis has the structure of compact bone, 
 but the Haversian canals are smaller, and the lacunas less regular. Growth 
 slow, and tends to stop, eventually, even without treatment. Seat. — Spongy 
 exostosis ; epiphyses of tibia, fibula, humerus, and femur, etc. Ivory ex- 
 6 
 
82 EXTRAVASATION OF URINE. 
 
 ostosis : bones of face and skull, pelvis, scapula, and ungual phalanx of 
 great toe. Characters and Symptoms. — They are recognized by their hard 
 bony feel, their immobility and their position. The ivory exostosis is es- 
 pecially round, nodulated, and smooth. The neck of the tumor varies in 
 size, and this is an important point in treating hard exostosis. They often 
 cause aching and pain in the limb, and may be serious from pressure on 
 important parts. Treatment. — They should be let alone, unless they cause 
 great deformity or pain, or press upon important parts. For they often 
 are dangerously near to joints, may even be covered by a pouch from # the 
 articular synovial membrane ; and the hard exostoses of the skull some- 
 times require great violence to remove them. An incision should be made 
 over the exostosis to be removed, and then saw, chisel, or cutting-pliers 
 applied. It is said that the neck need not be removed. But Stanley 
 writes : " Absolute security against the reproduction of an exostosis can 
 be obtained only by the removal of every part of its circumference." If 
 necessary, he adds, the potassa fusa or nitric acid may be used to produce 
 exfoliation of the base of the tumor. Diffuse bony tumor may require am- 
 putation of a limb or extirpation of an entire bone, and even then it has 
 been known to recur. Nothing can be done for " exercise-bones." 
 
 Extravasation of Urine. — When extravasation of urine is described 
 as a distinct disease, it usually means that which is caused by the urethra 
 bursting just behind a stricture. Rupture of the urethra from violence 
 causes similar symptoms. Extravasation into the pelvis, or into the peri- 
 toneal cavity, may result from rupture of the bladder, quod vide. Symp- 
 toms. — Patient has a stricture of the urethra with retention. Sudden sen- 
 sation of relief and, simultaneously, of something giving way in peringeum, 
 succeeded by stinging, burning pain in the part. Then swelling succes- 
 sively of perinaeum, scrotum, penis, and hypogastrium. Pain ; fever, which 
 soon assumes a low or " typhoid" character. Skin of parts affected dusky 
 red or purple. Rapid sloughing wherever the extravasated urine finds its 
 way. (Edema, emphysema. The retention itself is sometimes relieved by 
 this accident. Prognosis. — In some cases the urine again begins to flow 
 by the urethra, further extravasation ceases, abscesses form, and the 
 sloughs are cast off — the patient recovering. But it is generally considered 
 that, in most cases, operative interference is urgently demanded. Then 
 there is still great danger, first, from the acute gangrene, etc., and, lastly, 
 from the prolonged suppuration which ensues. The whole of both testicles 
 may be denuded by the sloughing ; but, if patient survive, the skin will 
 heal and contract over them. Anatomy. — It is almost always the bulbous 
 part of the urethra which gives way. Then the attachment of the deep 
 layer of the superficial fascia to the posterior border of the triangular liga- 
 ment, to the rami and body of the pubes, and to Poupart's ligaments, pre- 
 vents any passage of the urine into the thighs, ischio-rectal fossae, pelvis, 
 or buttocks. Treatment. — Indications : 1, to relieve the original reten- 
 
FEVER. 83 
 
 tion ; 2, to give vent to the sloughs and extravasation ; 3, to support the 
 strength. To relieve the retention, a catheter should be passed, if possi- 
 ble, and left in. The retention is sometimes relieved by the free incision 
 which should be made in the perinseum, to give vent to the urine and 
 sloughs. This free incision should always be made. In making it, place 
 the left forefinger in the rectum, to protect that structure, and cut up- 
 ward in the median line in the direction of the urethra. If the extravasa- 
 tion is considerable, other incisions should be made. Over the incisions 
 place a poultice, sprinkled with some antiseptic. To keep up the strength, 
 give abundant nourishment, tonics, and stimulants. 
 
 Face, Wounds of. — Eeadily heal. Greatest care should be taken to 
 prevent deformities. Eeplace even hopeless-looking flaps ; hare-lip pins ; 
 horse-hair sutures. Eemoval of pins and sutures early, lest they them- 
 selves should cause scars. 
 
 Fever, Hectic. — The fever which results from and accompanies 
 chronic diseases of an exhausting character. Causes. — Any chronic sup- 
 purative disease, especially abscesses connected with bone-disease which 
 have opened externally. Empyemata, chronic suppuration of mucous 
 tracts, of compound fractures, or of diseased joints, etc. Pathology. — Prob- 
 ably owing to the absorption into the blood of the products of inflamma- 
 tion or disintegration. Symptoms. — Remittent or intermittent daily. 
 Temperature rises toward afternoon or evening ; red circumscribed flush 
 on cheeks ; tongue dry ; skin dry and hot ; eyes bright ; slight excitement 
 and sleeplessness. This stage is followed nightly by profuse sweats ; to- 
 ward morning patient falls asleep ; on awaking he is still bathed in per- 
 spiration, but with the fever and high temperature either wholly or com- 
 paratively passed away. In the afternoon the same round of symptoms 
 recommences. In the later stages of hectic, the " colliquative " sweats, as 
 they are called, get more and more profuse and exhausting, and the fever 
 often recurs twice a day ; the mouth becomes aphthous and the legs cede- 
 matous. Mental state usually clear throughout ; range of temperature 
 generally between 99° and 102° ; diarrhoea is common. Prognosis. — De- 
 pends on the cause. Treatment. — If possible, remove cause, e.g., chisel 
 out carious bone ; make large abscess aseptic ; give abundant nourish- 
 ment, but do not overpower the digestion ; quinine in 5-grain doses ; sul- 
 phuric acid, iron, opium, strychnine, astringents ; give opium cautiously ; 
 its use is to relieve any coincident pain. Elevate the cedematous legs ; 
 flannel bandages carefully applied to these limbs ; astringents for the 
 diarrhoea. 
 
 Fevee, Inflammatory (or Surgical). — The fever which usually accom- 
 panies inflammations and injuries. No line can be marked out as separat- 
 ing this fever from septicaemia ; the two conditions pass imperceptibly into 
 one another ; in applying either name to a given case, one considers 
 whether the symptoms and facts point to the raised temperature, or to an 
 
84 ' FRACTURES. 
 
 absorption of septic material as being the chief direct cause of the phenom- 
 ena which the case presents. Causes and Pathology.— 1, The blood being 
 simply heated by passing through an inflamed and consequently heated 
 part ; 2, the blood being poisoned by absorption of some product of in- 
 flammation, whether decomposed or not. All the symptoms of inflamma- 
 tory fever and of its ally, septicaemia, can be produced by injection of pus, 
 putrid liquids, SH 2 , etc., into the blood or cellular tissue of animals. 
 Symptoms. — Usually within forty-eight hours, almost always within seven 
 days of an injury, the following symptoms may appear : increase of heat, 
 subjective, and evident also to the thermometer, frequent pulse, chilliness 
 or rigors, furred tongue, sleeplessness, excitement, even slight delirium ; 
 urine high-colored, deposits urates ; increased urea ; bowels confined. 
 The fever usually lasts a week. Persistence beyond a week denotes some 
 complication, e.g., abscess or erysipelas. If a complication cause the symp- 
 toms to recur after once disappearing, we have "secondary fever." Prog- 
 nosis. — No danger from the traumatic fever itself, provided complications 
 do not happen. In children, latent tuberculosis readily awakened by sur- 
 gical fever (Paget). Treatment. — See the treatment of wounds and the pro- 
 phylaxis of septicaemia. Saline refreshing drinks, fresh air, quiet, rest, etc. 
 
 Fistula. — See Anal Fistula, Lachkymal Fistula, etc. 
 
 Flat-foot. — Causes. — Prolonged standing or excessive walking in per- 
 sons of weak and relaxed fibre, synovitis of ankle, injury to ankle, gonor- 
 rhceal rheumatism of ankle, genu valgum. Pathology. — The ligaments 
 which brace up the arch of the instep are lengthened, the head of the as- 
 tragalus sinks through relaxation of the calcaneo-scaphoid ligament, and 
 the scaphoid tuberosity projects excessively ; in bad cases the metatarsus 
 is turned more or less outward, and the other edge of the foot turned up- 
 ward by the peronei ; ankle bends inward, hence the name talipes valgus. 
 Treatment. — Steel spring or india-rubber pad under arch of foot, the former 
 being let into sole of boot ; internal upright bar to support inner ankle ; 
 bad cases of talipes valgus require a horizontal bar for the attachment of 
 straps to correct abduction of metatarsus. Even division of peronei oc- 
 casionally required. Always strengthen general health ; avoid standing ; 
 and exercise systematically flexor muscles. Mr. Willett and myself have 
 succeeded in nine cases out of ten at least, merely by judicious exercise of 
 the leg-muscles (Evans's plan) combined with an india-rubber bandage 
 properly applied to the instep and ankle. 
 
 Perforating Ulcer of Foot. — Usually begins beneath a corn, tends to 
 perforate to dorsum of foot, is often attended by peculiar affection of the 
 nerves of the foot diseased, and is sometimes so difficult to cure as to lead 
 to amputation. Treat on general principles. Vide Ulcer and Sinus. 
 
 Fracture, Varieties. — The main peculiarities of fractures are ex- 
 pressed by the terms complete, incomplete, simple, compound, impacted. 
 Complete fractures classified into transverse, oblique, longitudinal, dentate, 
 
FRACTURES. 85 
 
 multiple, and comminuted. Incomplete include fissure, infraction, splinter- 
 ing, perforation. The usual name for infraction is green-stick fracture. 
 Lastly may be added separation of an epiphysis. Causes. — Predisposing : 
 1, an exposed situation, e.g., that of ossa nasi ; 2, bones of right side break 
 oftener than those of left ; 3, rough occupations of male sex ; 4, adult age 
 — bones of children are soft and less brittle ; 5, rickets ; 6, osteomalacia ; 
 7, absorption of part of thickness of bone by ulceration or abscess or tumor. 
 Exciting causes are either : 1, direct, or 2, indirect violence, or 3, muscu- 
 lar action. Symptoms. — 1, Pain ; 2, swelling ; 3, ecchymosis ; 4, crack felt 
 or heard by patient when fracture occurs ; 5, abnormal mobility ; 6, dis- 
 placement ; 7, crepitus; 8, loss of function ("paralysis") of the limb ; 9, 
 injury to neighboring soft parts, e.g., compression of brain by fracture of 
 skull. 8 and 9 are classed together as " rational " symptoms, the rest be- 
 ing called " sensual." Abnormal mobility is the only pathognomonic sign. 
 One or more of the above list may be absent, e.g., an impacted fracture 
 presents neither crepitus nor abnormal mobility. Swelling is due to ex- 
 travasation of blood at first, and afterward often to oedema and slight in- 
 flammation. Displacements are of several kinds, viz. : — angular, transverse, 
 longitudinal, and rotatory. In longitudinal displacement the fragments 
 usually overlap and thus cause shortening. In rare cases they are pulled 
 asunder ; thus lengthening, of course, results. A good example of rotatory 
 displacement is that which causes eversion of the foot in fracture of the 
 neck of the femur. Besides impaction, displacement of the fragments or 
 intervening blood may prevent crepitus. The soft crepitation caused by 
 effusions, especially those into tendinous sheaths, also the grating of cer- 
 tain rheumatic affections, must not be mistaken for crepitus. Diagnosis is 
 rarely difficult except when only one of two mutually supporting bones is 
 broken, or when there is impaction. In the former case there is little or 
 no deformity, in the latter no crepitus or increased mobility. Careful 
 measurement, inspection, or palpation usually settle the question. Prog- 
 nosis. — Simple fractures, when properly treated, almost always recover 
 without deformity. In some bones, e.g., the clavicle, slight deformity is 
 to be expected. Compound fractures are liable to numerous serious and 
 sometimes fatal complications. The chief of these are : 1, decomposition 
 in the wound ; 2, extensive gangrene of crushed or dead parts ; 3, pro- 
 gressive suppuration ; 4, accompanying protracted, exhausting fever ; 5, 
 erysipelas ; 6, septicemia ; 7, pyaemia ; 8, tetanus ; 9, delirium tremens. 
 The prognosis of a compound fracture may be to a great extent inferred 
 from what will be written about the question of amputation. Occasionally 
 a fracture resists all ordinary means employed to procure union — " un- 
 united fracture. " 
 
 Union in Fkactuke. — In the first week the surrounding soft parts are 
 found swollen and the seat of inflammatory effusion. More or less blood 
 is extravasated about the fracture and in the medullary cavity at the same 
 
86 FRACTURES. 
 
 point. Amount of escaped blood very variable. During the third week 
 the corpuscles or leucocytes which crowd the effusion, produce either 
 fibrous tissue or cartilage. Later still, soft young bone appears in — 1, the 
 medullary cavity ; 2, beneath the periosteum ; 3, outside the periosteum 
 in the periphery of the fibrous or cartilaginous swelling round the ends of 
 the bones (which swelling is called " callus "). A new periosteum forms 
 outside the callus. The bony callus consists entirely of spongy substance. 
 Subsequently the medullary cavity is restored, the excess of new bony 
 uniting material removed, and that which remains gradually becomes com- 
 pact and hard. When firmly and steadily set and supported, fractures 
 unite directly, new bone only being formed between and not around the 
 fragments. In other words, there is then no " provisional callus." Very 
 little callus in flat bones ; very little external, but a good deal of internal 
 (i.e., inside the spongy spaces), in spongy bones. The new ossification is 
 usually in fibrous tissue in adults, but is preceded by cartilage in children. 
 The cells which are the agents of the process escape from the blood-vessels. 
 Complete ossific union requires a period of one to two months. Bestora- 
 tion of the medullary canal and absorption of the external or provisional 
 callus requires four or five months more. Union in compound fractures 
 results from organization and ossification of granulations which grow from 
 the ends of the bones and from the neighboring periosteum. The process 
 is essentially the same as that of union of simple fractures. Frequently 
 the ends of the fragments die, and then the sequestra are cast off by the 
 growth beneath them of granulations which absorb the hard parts of the 
 adjacent living bone. Granulations possibly dissolve the lime salts of bone 
 by developing lactic acid. Many compound fractures have the external 
 wound healed so rapidly, that they really unite just like simple fractures. 
 A bare piece of bone does not usually begin to granulate till about eighth 
 to tenth day. In meantime, it is of a yellow color. Dead bone is white or 
 gray or blackish. Compound fractures require for uniting three times as 
 long as simple fractures. 
 
 Delayed Union and Non-Union of Fractures. — Occurs naturally in some 
 situations, as in intracapsular fracture of neck of femur, ditto of neck of 
 humerus, fracture of olecranon, and of patella. Causes. — Predisposing: 
 1, bad nutrition ; 2, debility from repeated hemorrhage ; 3, specific dis- 
 eases of blood, e.g., scurvy, the continued fevers ; 4, cancerous cachexia ; 
 5, osteomalacia. Local causes are : 1, too loose a dressing ; 2, too large a 
 gap of bone to fill up, perhaps owing to loss of a large portion ; 3, too 
 early motion. Too loose a dressing, and repeated meddling with and 
 disturbing a fracture, are by far the commonest causes. In ununited 
 fracture, as the condition is called, there is usually fibrous union, some- 
 times anew synovial membrane and actual false "joint." It is rare for 
 there to be no union at all between the fragments. 
 
 Treatment of Simple Fracture. — Three main indications : 1, reduction 
 
FRACTURES. 87 
 
 or setting ; 2, keeping in proper position till firm union has taken place ; 
 
 3, prevention or treatment of complications. Setting ; extension, counter- 
 extension, manipulation, relaxation of muscles by flexion of joints or by 
 anesthesia, occasional propriety of dividing tendons. Compound fractures 
 with protrusion may require skin wound to be enlarged or end of project- 
 ing fragment to be sawn off. Apparatus : two kinds, "fixed " and "mov- 
 able." The "fixed" are such as plaster-of-Paris, starch bandage, gum and 
 chalk, moulded mill-board, gutta-percha, poro-plastic, leather, Hyde's felt, 
 etc. The " movable " are the ordinary fracture -box, Cline's splints, Lis- 
 ton's splint, Mclntyre's splint, etc. The difference in the two varieties 
 consists in this — the " fixed " apparatus is moulded specially to the indi- 
 vidual case to which it is applied, while the " movable " splints can be 
 adapted by fitting and padding to various successive cases. Some of the 
 so-called " fixed " are not less movable than the other class. To all these 
 may be added the inclined plane, extension by weights or elastic bands, 
 support by sand-bags, etc. Great difference of opinion as to relative value 
 of the above apparatus. Many English, and more Continental surgeons 
 apply a solid firm dressing, such as the starched bandage and mill-board, 
 as soon as possible after the occurrence of a simple fracture, and after 
 most compound fractures too. Other English surgeons teach that this is 
 dangerous. In applying such a firm dressing, attend strictly to the follow- 
 ing rules : 1, place no bandage next the skin ; 2, Hue thickly with cotton 
 wool or wadding ; 3, include the joints both above and below the fracture ; 
 
 4, leave the toes or fingers bare, and never fail to examine them carefully 
 twenty-four hours after applying apparatus. Indications for cutting up 
 apparatus wholly or partially are : severe pain anywhere beneath it ; signs 
 of obstructed circulation in toes or fingers, or looseness of the apparatus. 
 Starched bandages tend to loosen and require trimming. In adjusting 
 any fracture -apparatus, carefully avoid disturbing fracture. Starched band- 
 age requires twenty-four hours to dry, plaster-of-Paris takes a quarter of 
 an hour to set ; borax will retard, and common salt hasten, setting of lat- 
 ter. Leather, poro-plastic, and mill-board are softened in hot water before 
 moulding. Starch should be applied with palm of hand after bandage has 
 been put on dry. Leather and gutta-percha are better adapted to angu- 
 lar parts, e.g., shoulder, than is mill-board ; but gutta-percha is rather 
 dear, and leather very dear. Salter's swing. Cradle to keep off bed- 
 clothes. With the use of a fracture-box or Cline's splints, correct position 
 is obtained by pads of lint or cotton-wool. For time of each application, 
 vide Special Fractures. Itching of skin is relieved by cleanliness, olive 
 oil, etc. Severe pain may require morphia subcutaneously ; but it is usu- 
 ally a sign that apparatus requires readjusting. Pain should never be 
 neglected. 
 
 Compound Fractures. — Special Notes on Their Treatment. — Question of 
 amputation. Consider, 1, cause of fracture (was there much crushing or 
 
88 FRACTURES. 
 
 twisting force ?); 2, main arteries or veins torn? 3, amount of hemorrhage; 
 4, condition as to collapse, reaction, etc. Depth and extent of bone-injury 
 should also be considered. Injury to nerves, even large ones, not of much 
 account. Eupture of large artery not an absolute indication for amputa- 
 tion. Will the limb be useful, even if patient does recover, or will it be in 
 the way ? 
 
 Always treat the wound in a compound fracture very gently. After first 
 dressing and cleaning, never probe or touch it if possible till the wound is 
 quite fistulous. Then, if necrosis is found, treat it like necrosis from os- 
 teitis. A firm starched or plastered bandage, applied as soon as possible 
 after accident, is the treatment. It should be thickly lined with cotton 
 wadding. Dress the wounds either by Lister's strict plan or with oakum. 
 Extensive discharge or large wounds may require a fracture-box, inter- 
 rupted or not. Generally, windows in a plaster bandage suffice. Attend 
 to complications as they arise. "Immersion treatment." 
 
 Treatment of Ununited Fracture. — 1, Eubbing fragments together ; 2, 
 blisters or iodine externally ; 3, firing neighboring skin ; 4, acupuncture 
 needles left for a few days in the false joint ; 5, electro- puncture ; 6, seton ; 
 7, scraping ends of fragments with a tenotomy-knife ; 8, excision of ends 
 of fragments ; 9, scraping back periosteum and then excising ; 10, sutures ; 
 11, driving in ivory pegs ; 12, metal screws. But in many cases, the pro- 
 longed application and skilful management of a plaster bandage are suffi- 
 cient. Attend to general health. Give phosphates. 
 
 Fractures United with Deformities. — Treatment. — If there is malposition 
 in a compound fracture, and the wound is healing rapidly, do not try to 
 rectify till the wound is healed. Eemedies for obliquity are bandaging, 
 extension by weights, manipulation, re-breaking (by flexion or extension), 
 cutting operations. Two cutting operations : 1, subcutaneous osteotomy. 
 Small incision down to bone. Gimlet-hole through bone. Insert key-hole 
 saw, and saw partially through, first one side, then the other. Lastly, 
 break the bone in two. 2. Antiseptic osteotomy. Of course bloody oper- 
 ations are dangerous, but the danger is very small with antiseptic treat- 
 ment. 
 
 Special Fractures. — Acetabulum, Fracture of. — Causes. — Great violence 
 applied to femur. Varieties. — Two. Firstly, fracture of rim of acetabulum ; 
 crepitus, dislocation of femur, probably easy to reduce, but very difficult 
 to keep in position. Secondly, fracture through bottom of acetabulum. 
 Head of femur may be driven through acetabulum into pelvis, and even 
 impacted. And there are, very likely, severe injuries to neighboring parts. 
 Treatment. — Extension ; rest ; long splint, weight, or fixed apparatus. 
 Prognosis. — Shortening of limb may be expected. 
 
 Acromion, Fracture of — Signs. — Flattening of shoulder ; inability, 
 entire or partial, to raise arm ; crepitus ; arm feels to patient as if drop- 
 ping off ; the fragments can be felt separated. Prognosis. — Union is not 
 
FKACTUKES. 89 
 
 unlikely to be ligamentous. Treatment. — Support elbow well, so as to 
 make use of bead of bumerus for a spbnt. Fix tbe arm as firmly as can be 
 done witbout binding it too closely to tbe side. 
 
 Clavicle, Fracture of. — Causes. — Almost always indirect violence, e.g., 
 falls on sboulder. Situation. — 1 (most common), great concavity ; 2, acro- 
 mial end, between or external to coracoclavicular ligaments ; 3, sternal end 
 (inside rbomboid ligament very rare). Character. — Oblique, wben from 
 indirect violence in adults ; transverse in cbildren ; transverse or comminu^ 
 ted from direct violence. Displacement. — 1, Fracture in middle of bone — • 
 outer fragment downward and inward beneatb inner fragment, tbe acro- 
 mial end being rotated forward ; 2, fracture of acromial end outside coraco- 
 acromial ligaments — outer fragment strongly forward, inward, and sligbtly 
 downward. Fracture between conoid and trapezoid ; deformity almost 
 nil, or else as in last variety (Gordon) ; 3, fracture of sternal end inside 
 rbomboid bgament — outer fragment borizontally forward, simulating dis- 
 location. 
 
 Additional Symptoms. — Flattening of sboulder, prominence of inner 
 fragment, crepitus, inability to raise arm, tenderness. Complications. — 
 Occasional injury to subclavian vein or bracbial plexus. Treatment. — Tbree 
 indications ; 1, keep sboulder and scapular fragment outward ; 2, correct 
 rotation forward of sboulder ; 3, elevate sboulders. Best results from re- 
 cumbent, supine position, for two or tbree weeks. Bandages, pads. Many 
 special apparatus. 
 
 Coccyx, Fracture of. — Causes. — Parturition, falls, and blows. Treatment. 
 — Begulate bowels. Best. 
 
 Colles's Fracture. — See Fracture of Kadius. 
 
 Coracoid Process, Fracture of. — Causes. — Blows ; dislocation of bume- 
 rus. Pi^ognosis. — Ligamentous union to be expected, it is said. Treat- 
 ment. — Best. Biceps and coracobracbialis to be relaxed by flexing elbow 
 and bringing arm across front of cbest. Uncomplicated fracture of cora- 
 coid process is extremely rare. 
 
 Facial Bones, Fracture of. — Cause. — Direct violence. Prognosis. — 
 Almost equally good in botb compound and simple fractures. Great de- 
 formity is sometimes unavoidable. Treatment. — See Fracture of Nasal 
 Bones, etc. 
 
 Femur, Fracture of. — Tbree main divisions : 1, of upper extremity ; 2, 
 of sbaft ; 3, of lower extremity. 1. Fracture of upper extremity, tbree 
 subdivisions, viz. : a, intracapsular fracture of neck of femur ; b, extracap- 
 sular fracture of neck of femur ; c, fracture of tbe trocbanters not involving 
 tbe neck. 
 
 Fracture, Intracapsular, of Neck of Femur. — Fracture altogether witbin 
 capsule of bip-joint. Causes. — Predisposing — old age, consequent senile 
 atropby and lessened obliquity of neck of femur. Exciting cause, very 
 trifling, e.g., slight fall, or even turning in bed. Almost all intracapsular 
 
90 FRACTURES. 
 
 fractures occur iu old age. More common in female sex. Signs. — 1, loss 
 of power : limb cannot be raised from the bed (except in rare cases) ; 2, 
 flattening in region of trochanter ; 3, trochanter rises above Nelaton's line ; 
 
 4, it moves, on rotation, in an arc of a circle smaller than on the sound side ; 
 
 5, crepitus ; 6, tenderness ; 7, eversion (except in rare cases) ; 8, shortening, 
 £ to 1 inch at first, later on, owing to capsule giving way, sometimes 2J 
 inches. Pathology. — Lower fragment usually outside upper. Very little 
 extravasation. Union. — By fibrous tissue. Sometimes nil, rarely osseous. 
 Diagnosis. — See Extracapsular Fracture. Prognosis. — The unavoidable 
 confinement to bed in some cases depresses the system fatally. In any case 
 lameness and shortening are to be expected. Treatment. — Bed for two or 
 three weeks. Pillows beneath knee. Then leather or poro-plastic splint 
 to hip ; crutches and gentle attempts to use. In strong constitutions, at- 
 tempt to obtain firmer union by longer rest and use of starch bandage. 
 Good diet. Water-bed. 
 
 Fracture, Extracapsular, of Neck of Femur. — Two kinds : 1, simple ; 2, 
 impacted. Fracture wholly, or partially outside capsule of joint. Cause. — 
 Direct and considerable violence. Signs. — Firstly, when not impacted : 1, 
 inability to raise limb ; 2, bruising and swelling of hip, indicating great ex- 
 travasation ; 3, crepitus at great trochanter, which may sometimes be dis- 
 tinctly felt to be in several pieces ; 4, great pain and tenderness ; 5, usually 
 very marked eversion, sometimes inversion ; 6, shortening, 1 J to 2J or even 
 3-j- inches. Secondly, impacted fracture. Symptoms less marked than if 
 there is no impaction. Less eversion ; little or no crepitus, only slight 
 shortening, not more than an inch. But there is local tenderness, fol- 
 lowed in a day or two by thickening over great trochanter. Treatment. — 
 Extracapsular fracture is to be treated on similar principles to those ap- 
 plied in treatment of fractured shaft of femur. Seek for union by securing 
 immobility with Liston's splint, etc. Compress trochanter with a belt round 
 hips. 
 
 Fracture of Trochanter Major.— Signs. — Local pain, tenderness, crepi- 
 tus, eversion, no shortening. Fracture of this without fracture of neck or 
 shaft of femur almost unknown. 
 
 Fracture of Shaft of Femur. — Classified according to position, whether 
 in upper, middle, or lower third. Signs. — Typical signs of fracture. 
 Displacement. — In upper and middle thirds the upper fragment inclines 
 forward and usually outward, lower fragment inclines inward and is ro- 
 tated outward. Causes of the displacement are : 1, muscular action of 
 psoas, iliacus, adductors, etc. ; 2, lower fragment forces upper fragment 
 outward at time of accident. Treatment. — 1, position merely ; 2, Liston's 
 splint ; 3, double inclined plane ; 4, extension by a weight ; 5, anterior 
 splint ; 6, starched bandage or other fixed apparatus. 1. Position. — Lay 
 limb on outer side, with knee bent. In infants, merely lay limb straight 
 out in bed, taking weight of clothes oft with a cradle (preserve body- 
 
FBACTUKES. 91 
 
 warmth in latter case). 2. Liston's splint. — Length, it should reach from 
 a hand's length below heel to a hand's breadth below axilla. Pad ankle 
 well. Turn bandage twice round ankle and instep, then fix foot to splint. 
 Avoid crushing the small toes. Bandage to just above the knee with 
 figures-of-eight. "Kettle-holder" on inner aspect of thigh. Perineal 
 band. Extension and setting. Apparatus for combining Liston's splint 
 with continuous extension by elastic bands or by weight and pulleys. 
 Sand-bags. Bottom of bed should be level. 3. Double-inclined plane. 
 
 4. Extension by weight. — Stirrup of wood and plaster. Strapping ex- 
 tending up to the knee. Bandage over strapping. Baise foot of bed on 
 blocks. Weight consists usually of sand-bags or tins of shot, 5 to 10 lbs. 
 
 5. Anterior iron splint. — May be combined with a plaster splint. 6. 
 "Fixed" apparatus: plaster-of-Paris, starch bandage, etc. Unless at- 
 tended to with great vigilance, liable to have very bad results in fractured 
 thigh. The hip should be thoroughly fixed — not an easy matter. Frac- 
 ture of femur, lower third, that is, near knee-joint. — Upper end of lower 
 fragment projects backward. Hence these cases should be treated with the 
 knee semi-flexed. 
 
 Compound Fracture of Femur. — Very dangerous. But amputation for 
 it is extremely fatal. Treat each case according to its own peculiarities. 
 
 Fibula, Fracture of. — Tibia acts as a splint, making diagnosis difficult. 
 Seek for crepitus and increased mobility by pressing fibula at different 
 points against the tibia. Occurrence frequent. Treatment. — Cline's (side) 
 splints, or some immovable apparatus. Fracture of fibula about two or 
 three inches above ankle, with rupture o.f internal lateral ligament and dis- 
 location of foot outward is called "Pott's Fracture." See Dislocation op 
 Ankle. 
 
 Fracture of Forearm may be of radius or ulna separately, or of both 
 bones. See Fkacture of Badius, Ulna, etc. 
 
 Humerus, Fracture of. — Nine kinds, viz.: 4 of the upper end, 1 of the 
 shaft, and 4 of the lower end. 
 
 Intracapsular of Neck of Humerus (anatomical neck, of course). — Cause. 
 — Direct violence. Signs. — Those of a severe injury to the shoulder-joint, 
 causing paralysis, swelling, etc., but very little shortening (^ inch) or de- 
 formity. Indeed, this fracture is diagnosed by the absence of the marked 
 symptoms of other fractures and of dislocation. Often impacted. When 
 not impacted, there is crepitus. Prognosis. — Expect bony union, with, very 
 • likely, excess of new bone. Treatment. — Pad in axilla, leather shoulder-cap, 
 bandage, and sling. Whole arm should be bandaged gently and evenly. 
 SJing should support hand rather than elbow in all fractures of humerus. 
 Impacted fractures not to be disturbed. 
 
 Extracapsular Fracture of Neck of Humerus, i.e., through surgical neck. 
 Signs. — Sharp end of lower fragment projects into axilla or beneath cora- 
 coid. But head of humerus remains in glenoid cavity. Distinct crepitus. 
 
92 FRACTURES. 
 
 Shortening, 1 inch. Pain from irritation of brachial plexus. Prognosis.-^ 
 In rare cases the bone atrophies. Treatment. — Bandage limb from linger 
 upward. Pad in axilla. Carry elbow forward and inward. Apply a 
 leather cap to shoulder and outer side of upper arm. Support hand, but 
 not elbow, with a sling. Erichsen's bent leather splint. 
 
 Separation of Upper Epiphysis of Humerus resembles accident last de- 
 scribed, but the upper end of the shaft forms a remarkable and smooth 
 projection beneath the coracoid process. The patient is usually very 
 young, and must be less than twenty. Treat like fracture of surgical neck. 
 
 Fracture of Great Tuberosity. — Cause. — Direct violence. Signs. — In- 
 creased breadth of shoulder. The tuberosity is dragged backward by the 
 muscles inserted into it, and the head of the humerus forward beneath the 
 coracoid (a semi-dislocation) by the pectoralis major, etc. Crepitus. Treat- 
 ment. — Pad in axilla and leather cap on shoulders, or rest in bed with the 
 arm extended. 
 
 Fracture of Shaft of Humerus. — Causes. — Direct violence, falls upon the 
 elbow, and, not rarely as compared with other bones, muscular action. 
 Signs. — Typical. Treatment. — Two or three splints, one being an angular 
 elbow-splint. Support hand, but not elbow, in a sling. Stromeyer's cush- 
 ion for compound fracture of humerus (vide Bryant's "Surgery," p. 942). 
 Danger of delayed union in fracture of shaft of humerus. 
 
 Fracture of Lower End of Humerus. — Four kinds: 1, transverse frac- 
 ture ; 2, fracture of either condyle ; 3, fracture between the condyles into 
 the joint (this is always combined with transverse fracture) ; 4, separation 
 of the epiphysis. Causes. — Usually, falls on the bent elbow. Signs. — 1, Of 
 transverse fracture. It may be either above or below the condyles. The 
 symptoms are given in the following diagnosis between it and the injury 
 with which it is most frequently confounded, viz., dislocation of radius 
 and ulna backward : 
 
 The Fracture. 
 
 1. Crepitus. 
 
 2. Easily reduced, but deformity at once 
 
 reappears. 
 
 3. Prominence of lower end of upper 
 
 fragment of humerus projects for- 
 ward above the bend of the skin in 
 front of the elbow- joint. 
 
 4. Internal condyle in normal relation to 
 
 olecranon. 
 
 The Dislocation. 
 
 1. No crepitus. 
 
 2. Not so easily reduced. But then does 
 
 not reappear. 
 
 3. Prominence of lower articular surface 
 
 of humerus projects forward beneath 
 the bend of the skin in front of the 
 elbow- joint. 
 
 4. Distance increased between internal 
 
 condyle and olecranon. 
 
 2. Signs of fracture of condyles. Pain. Crepitus produced by direct 
 manipulation, and by pronation and supination of forearm. 
 
 3. Signs of fracture between condyles into joints. Pain. Crepitus. 
 Effusion into joint perhaps considerable. The pathognomonic sign is the 
 increased breadth from condyle to condyle. 
 
 4. Signs of separation of epiphysis. Like those of transverse fracture ; 
 
FRACTUEES. 93 
 
 but the crepitus is softer, and the patient is necessarily young. In every 
 obscure case of injury to the elbow, make the patient place his hands one 
 above the other upon his head, then bring his elbows together and com- 
 pare them, using your eyes and fingers. Treatment of fractures of lower 
 end of humerus. Eeduce and put up in lateral angular splints, with 
 elbow at right angles and hand in sling. When elbow tends to displace- 
 ment backward, apply angular splint behind, and a short splint in front 
 of humerus. Passive motion in three weeks — in one week if the fracture 
 extends -into the joint. Complication of fracture of humerus, injury of 
 musculo-spiral nerve. See Injuries of Nerves. 
 
 Hyoid Bone, Fracture of. — Causes. — Direct violence: rarely muscular 
 action. Signs. — Crepitus, etc., with difficulty in swallowing, speaking, 
 and sometimes even in breathing. Reduce with one finger in patient's 
 mouth. 
 
 Jaw, Lower, Fracture of. — Cause. — Great and direct violence. Situation. 
 — Order of frequency, near canine tooth, at angle, at symphysis. Neck of 
 condyle and coronoid process are very unusual places. Occasionally mul- 
 tiple. Signs. — Pain, tenderness, mouth can scarcely be opened, saliva 
 dribbles, crepitus, deformity ; frequently bleeding, for the fracture often 
 opens through the mucous membrane of the mouth. Prognosis. — Union 
 often slow. Treatment. — The interdental splint cannot be too strongly 
 recommended. It should almost always be used. See that no tooth or 
 foreign body lies between the fragments, if the fracture is an open one 
 (see Lyon's " St. Bartholomew's Hospital Reports," 1879). Wire round 
 teeth damages them. Thomas drills the fragments and inserts a silver 
 suture. 
 
 Leg, Fracture of — See Fkactuee of Tibia and Fibula. 
 
 Metacarpus and Metatarsus, Fractures of. — Causes. — Direct violence. 
 Treatment. — On general principles. 
 
 Nasal Bones, Fracture of. — Occasional emphysema from coincident in- 
 jury to frontal sinuses. Difficulty in reduction and in preventing defor- 
 mity. A smooth silver female catheter may be inserted into the nostrils and 
 used to raise the depressed bone. Adams' and Gamgee's apparatus for pre- 
 serving the position of the bones. Vulcanized india-rubber dilator intro- 
 duced empty and then filled with water has great power to raise a flattened 
 nose. Above remarks apply both to fracture of nasal bones and of 
 septum. 
 
 Patella, Fracture of — Two kinds, one transverse and usually the result 
 of muscular action, or muscular action combined with violence ; the other 
 stellate, Y-shaped, or, perhaps, quite simple, but not transverse, and always 
 caused by direct violence. The former fracture often occurs in missing a 
 step whilst walking down-stairs, or in some similar and trivial manner. In 
 it the fragments generally separate widely, while in the stellate fracture 
 there may be little or no separation. Consequently the former always 
 
94 FRACTURES. 
 
 ends in fibrous union, the latter frequently in bony union. Sulcus be- 
 tween fragments in the transverse fracture. Great swelling and effusion 
 into knee-joint. Inability to extend knee. Treatment. — Rest in horizontal 
 position or with heel raised. Straight splint along back of limb. Elastic 
 straps to pull upper fragment downward and lower upward. Figure-of-eight 
 bandage. Calender's arrangement of weight, strapping, and pulleys. 
 Malgaigne's hooks. Malgaigne's hooks fixed into plaster after Spence's 
 plan. No doubt one of the chief indications is to reduce the effusion into 
 the knee-joint without delay. It has been recommended to do this with 
 the aspirator ; but it can be effected to a great extent by bandaging and 
 compressing, using plenty of cotton-wool. Hence a starch and mill-board 
 apparatus is useful. 
 
 Compound Fracture of Patella. — Very serious indeed, but not always 
 requiring amputation. 
 
 Pelvis, Fractures of. — May occur in part or parts of the os innominatum, 
 but, for practical purposes, are best classified into those which injure a 
 large part of the bone, e.g., the body or rami of the pubes, and those which 
 merely chip off a prominence like the ant. sup. spine of the ilium. The 
 former are very serious, from the violence often done to the pelvic viscera, 
 especially the bladder. Cause. — Usually a vehicle passing over the part. 
 Signs. — Crepitus, pain (inability to stand, in the first or serious class of 
 cases). Often signs of ruptured bladder, urethra, or rectum. Treatment. — 
 Pass a catheter to examine the state of the bladder. Rest in bed. Band- 
 age round hips and knees. Sometimes displaced parts may be set by man- 
 ipulating with the finger in the vagina or rectum. See also Fracture of 
 Acetabulum, Rupture of Bladder, etc. 
 
 Radius, Fractures of. — 1, Of head ; 2, of neck ; 3, of shaft ; 4, of lower 
 extremity. The first three are caused usually by direct violence, and pre- 
 sent usual signs of fracture/ viz., crepitus, pain, etc. Unless the ulna is 
 broken also, there is little deformity. Treatment. — For first three cases : 
 An angular splint to fix elbow and extend along back of forearm. Fore- 
 arm midway between pronation and supination. Short splint along pal- 
 mar surface of forearm. Splints should be flat and wide, so as to prevent 
 bandage from squeezing radius and ulna together. Fingers to be left free. 
 The fourth case, viz., fracture of lower end of radius, is called 
 
 Colles's Fracture. — Causes. — Falls on outstretched hand. Very rarely 
 direct violence. Especially frequent in old women. Signs. — Peculiar 
 spoon-shaped deformity. Prominence of styloid process of ulna. Crepitus 
 generally absent, or at least indistinct. Dorsal prominence is nearer the 
 hand than palmar prominence. Pain severe. Power of supination or 
 pronation lost. Anatomy. — Upper fragment occasionally impacted into 
 lower ; lower sometimes comminuted. Dorsal prominence formed by lower 
 fragment, palmar prominence by flexor tendons stretched over lower end 
 of upper fragment Position of fracture generally about one inch above 
 
FEACTUKES. 95 
 
 carpal articular surface of radius. Prognosis. — If the deformity can be re- 
 moved and the fracture perfectly set at first, all should be well. Other- 
 wise, deformity will be permanent, and stiffness of the wrist and fingers 
 may continue for many months. Diagnosis. — From dislocation of the wrist- 
 joint, by the fracture's not altering the distance between the styloid pro- 
 cesses and the knuckles. Treatment. — Every effort to be made to reduce 
 and set properly at commencement. Extension and counter-extension. 
 Bruce Clarke dissected a specimen in which reduction was easy, if the ex- 
 tensors of the thumb and carpus (radial side) were first relaxed by ap- 
 propriate movements of the hand and thumb. Apparatus used are of three 
 kinds : First, Nelaton's pistol-shaped splint, applied along palmar side 
 separately, or along dorsal side in conjunction with a short splint on pal- 
 mar side of shaft of radius. Thick dorsal pad opposite lower fragment. 
 Palmar pad thickest on radial border (the word palmar applies here to 
 the arm only, not the hand). Passive exercise of fingers after second week. 
 Second, long straight posterior and short anterior splint, padded like 
 Nelaton's apparatus. In this case the hand is often left entirely free, so 
 that the fingers may be exercised, and the weight of the hand may keep 
 the radial side of the wrist extended. Third, Gordon's splints. Hand 
 kept h\ prone position. Two straps. No bandages. Eidge on radial 
 side of palmar splint. " Overhanging lip " on radial side of lower end of 
 dorsal splint. Gordon says that impaction is uncommon in this fracture. 
 Lower fragment of radius occasionally, but rarely, displaced forward in- 
 stead of backward. Dr. L. S. Pilcher demonstrates that in Colles's fracture 
 the strong periosteum on the back of the radius remains untorn, and is 
 the main obstacle to the reduction of the fracture. To relax it, bend back 
 the hand and wrist. Then make slight extension in the line of the fore- 
 arm, accompanied by moderate pressure on the dorsum of the lower frag- 
 ment. Reduction is thus effected. The only apparatus Pilcher uses are 
 a broad band of adhesive plaster round the seat of fracture, and a sling 
 to support the arm. I can recommend this plan from my own experience. 
 
 Radius and Ulna, Fracture of Shaft of — Treat like fracture of either 
 bone singly. Green-stick fracture not uncommon. Splints to be wide, 
 and to be applied whilst hand is supinated. 
 
 Bibs, Fracture of — Causes. — Predisposing : old age. Immediate are of 
 three kinds : 1, direct violence ; 2, indirect violence, the chest being com- 
 pressed at one part the rib gives way at another, just as a spring or a stick 
 might ; 3, muscular action, as from violent coughing or severe labor. Sit- 
 uation. — Usually the convexity of the rib a few inches in front of angle. 
 Middle ribs most frequently broken, first and second ribs rarely, because 
 protected by clavicle. Signs. — Catching pam on inspiration or coughing. 
 Tenderness. Crepitus. Crepitus sometimes difficult to get, especially 
 when the fracture is beneath the thick muscles of the back. Press alter- 
 nately with the fingers of each hand, one on one side, the other on the other 
 
96 FRACTURES. 
 
 side of the supposed fracture. Take care to apply both hands to the same rib 
 Breathing shallow and abdominal. Other symptoms often arise from com- 
 plications, e.g., haemoptysis. Complications. — 1, Emphysema ; 2, pneumo- 
 thorax ; 3, hemothorax ; 4, haemoptysis ; 5, wounds of heart, pericardium, or 
 great vessels ; 6, wounds of intercostal vessels ; 7, etc., wounds of diaphragm 
 and abdominal viscera, liver, or spleen. 1 and 2 imply a wound of the 
 lung ; 4 implies either a wound or bruise of the lung. Emphysema is far 
 the commonest complication. Practically, cases of fractured rib are classi- 
 fied into those without and those with injury to the lungs. Secondary 
 complications are inflammations and empyema. Diagnosis. — When crepitus 
 cannot be obtained, consider generally all the symptoms present. Prog- 
 nosis. — If there is no visceral injury, speedy union with formation of pro- 
 visional callus maybe expected. If there is visceral injury, then prognosis 
 depends on its nature and amount. The danger in such cases is threefold : 
 firstly, shock ; secondly, hemorrhage ; thirdly, inflammation. Treatment 
 — Broad bandage round chest, prevented from slipping down by braces of 
 bandage across shoulders. Strapping all round chest, or extending merely 
 from spine to sternum over injured side. In some cases, bandaging appears 
 to press the sharp ends of the fragments inward ; it is then, of course, 
 contraindicated. In bad cases, rest in bed for a few days and moderate 
 diet. For treatment of complications, see articles Hemorrhage, Injuries of 
 Thorax, Lungs, etc. Treatment lasts a month. 
 
 Sacrum, Fracture of. — Causes. — Either severe crushing force applied to 
 the whole pelvis, or else gunshot wounds. Prognosis. — Very bad. Treat 
 each case with its complications on general principles. 
 
 Scapula, Fracture of. — Varieties. — Four, viz., 1, of body ; 2, of neck ; 3, 
 of coracoid process ; 4, of acromion (see Fracture of Acromion and of 
 Coracoid). 
 
 Fracture of Body of Scapula. — Causes. — Severe direct violence. Signs 
 (often obscure). — Pain, loss of power, crepitus, irregularity in spine of 
 scapula if fracture passes through that process. Treatment. — Bandage pad 
 over scapula, elbows supported by a sling. Prognosis. — Deformity not 
 unlikely. 
 
 Fractures of Neck of Scapula. — Two kinds, viz., 1, of anatomical neck, 
 i.e., external to coracoid ; 2, of surgical neck, i.e., internal to coracoid pro- 
 cess. In fracture of the anatomical neck, the symptoms resemble those of 
 dislocation of the head of the humerus into the axilla ; but the deformity 
 produced by the fracture, though easily reduced, at once recurs, and there 
 is also crepitus. Still, even these points will not distinguish fracture of 
 the anatomical neck of the scapula from dislocation of the humerus with 
 fracture of the glenoid fossa. .Fracture of the surgical neck can be recog- 
 nized by bearing in mind that the coracoid process goes with the separated 
 neck, and is detached from the body of the scapula. All fractures of the 
 necks of the scapula are excessively rare. Treatment. — Raise the elbow 
 
FRACTURES. 97 
 
 with a sling, and keep the parts at rest with a pad in the axilla and a 
 bandage round arm and chest. 
 
 Sternum, Fracture of. — Causes. — Great direct violence ; rarely indirect ; 
 occasionally, even muscular effort during labor. Signs. — Deformity, pain, 
 mobility, etc. Treat like a broken rib. 
 
 Tibia, Fracture of. — When the shaft of this bone is broken, the fibula 
 remaining entire, the deformity is almost or quite nil, and other symptoms 
 are very mild. Trace ridge of shin carefully with forefinger. Best treat- 
 ment, a plaster case. Separation of upper epiphysis may cause arrest of 
 growth. Fracture of internal malleolus is generally combined with dislo- 
 cation of foot inward or outward, quod vide. 
 
 Tibia and Fibula, Fracture of {Fracture of Leg). — Commonest Situa- 
 tion. — Junction of middle and lower third. Causes. — Violence, direct 
 or indirect, sometimes slight. Bare in children. Signs. — Typical and 
 unmistakable. Deformity. — Upper fragment projects forward and in- 
 ward in most cases. Tendency to eversion of foot (as in almost all frac- 
 tures of lower extremity). Treatment. — Handle carefully and set at once, 
 because of danger of converting simple into compound fracture, through 
 sharp end of upper fragment piercing skin. Set with great toe in line 
 with inner border of patella, so that recovery may not take place with 
 eversion of foot. Keep straight the line of the anterior border of the 
 tibia. Anaesthetize, if necessary. Division of tendo Achillis perhaps re- 
 quired in rare cases. Apparatus. — 1. Starch bandage and mill-board, 
 plaster-of-Paris, Bavarian splint, or some other fixed apparatus. See gen- 
 eral article on Fractukes, above. 2. Cline's splints (common lateral ones 
 with foot-pieces). 3. Fracture-box, i.e., two plain side-splints with back- 
 piece furnished with foot-board. 4. Mclntyre's splint. 5. When there is 
 much tendency to antero-posterior displacement, laying limb on its outer 
 side, with knee and hip flexed, is often successful. 6. Anterior wire-splint. 
 With most of these apparatus, some form of swing may be advantageously 
 used. Keep foot at right angles to leg. Duration of treatment, usually 
 five weeks before patient's limb may be trusted in a mere light gum and 
 chalk case. 
 
 Compound Fracture of Leg. — Two kinds : firstly, when a fragment 
 pierces a moderate wound in skin from within outward ; secondly, when 
 the wound is very large, or when it is produced by severe, crushing, exter- 
 nal violence. Practically, most cases can be thus classed, and the latter 
 are very much more serious than the former. Do not attempt to do what is 
 called "close the wound, and convert it into a simple fracture." If the 
 case is slight enough, you will not be able to prevent it from closing it- 
 self, unless you are meddlesome. Support the whole limb by plaster band- 
 aging over a layer of cotton wool, and immediately over the wound and 
 its neighborhood apply oakum, to absorb all discharge. Protect skin and 
 wound from irritation of tar in oakum by greasing with zinc ointment ; 
 7 
 
98 GANGLION. 
 
 or use Lister's antiseptic treatment. So-called "open treatment" is 
 scarcely more open as regards the wound than a thick layer of porous and 
 absorptive material like oakum ; though, of course, it is open enough to 
 noxious influences floating about the sick-room. But it is only just to 
 say that the " open treatment " has had excellent results under Humphry 
 and others. Hemorrhage can almost always be restrained by pressure. For 
 complications, erysipelas, abscess, pyaemia, etc., see articles on those subjects. 
 
 Ulna, Fracture of. — Three kinds — 1, shaft ; 2, olecranon ; 3, coronoid 
 process. Shaft. — Treat like fracture of shaft of radius. Fracture of Ole- 
 cranon. — Causes. — Falls on elbow ; rarely muscular violence. Signs. — 
 Swelling, ecchymosis, and tenderness. Fragment drawn up by triceps. 
 Treatment — Anterior splint, thickly padded in bend of elbow, so that the 
 limb may be slightly flexed. Passive motion in fifth week. Result. — 
 Union often ligamentous. Fracture of Coronoid Process. — Excessively rare. 
 Ulna dislocated backward from trochlea, easily reduced, but slips back 
 again directly. Treatment. — Posterior angular splint, straight splint in 
 front of humerus. 
 
 Frost-Bite. — Frost-bites vary in degree as much as burns and scalds. 
 Signs. — In severe cases : tingling, numbness, coldness, stiflness, white or 
 mottled appearance. Beaction is accompanied by inflammatory symptoms, 
 and by gangrene in the severer cases. The gangrene may be either im- 
 mediate, when it will be of the dry variety, or secondary to the inflam- 
 matory symptoms, when it will be moist. Treatment. — Besembles that of 
 burns; but the greatest care is required in restoring circulation to the 
 frost-bitten part. Cold room, friction with snow, or cold flannel or fur. 
 Stringently avoid hot water, fires, etc. In those cases where persons ex- 
 posed to cold are overcome with sleep, they should not be suddenly carried 
 into a warm atmosphere. Use friction and gradual warmth. 
 
 Ganglion. — Two kinds, simple and compound. Simple is said to arise 
 from a cystic enlargement of a cell in one of the fringes of synovial mem- 
 brane lining the sheath of the tendon (Paget), and it is also said to be 
 originally a partial " hernia" of the sheath of the tendon (Billroth). Any 
 way it is rarely found communicating with the tendon-sheath at all. It is 
 a fibrous sac, containing a fluid, usually jelly-like, sometimes quite serous 
 in consistence. Situation. — Most frequently over extensor tendons at back 
 of radial side of wrist. Appearrnce, globular, hard or fluctuating, trans- 
 parent swelling. It causes feeling of weakness and often pain. Treatment. 
 — 1. Bupture. Place patient's wrist on your knee, then steady it with 
 your fingers, while you squeeze, with ends of both your thumbs, the gan- 
 glion against a ridge of bone, beneath it. 2. Iodine paint or blistering. 3. 
 Pressure. 4. Subcutaneous puncture. Follow up both 1st and 4th method 
 of treatment with pressure by pad and bandage. 
 
 Compound Palmar Ganglion is a dilatation of a considerable part of a 
 tendon-sheath, or of several tendon-sheaths. Situation. — Palm of hand and 
 
GANGRENE. 99 
 
 lower part of forearm just above annular ligament. Similar compound 
 ganglia occasionally found in foot. Signs. —Fluctuating swelling above 
 and below anterior annular ligament ; crackling from melon-seed bodies 
 usually contained within. Treatment. — 1. Puncture with a trocar large 
 enough to let melon-seed bodies pass through its canula. Wash away 
 these bodies by injection with warm water. Inject tinct. iodini, 3 iss. .+ aquae 
 | iss. Let injection escape after two minutes. Then apply compress, splint, 
 and bandage. 2. Incisions above and below annular ligament. These 
 should be longitudinal. Antiseptic dressing very advisable. Gently re- 
 move melon-seed bodies by syringing with weak carbolic lotion. 
 
 Gangrene. — The term signifies the death of a part of the soft tissues 
 of the body. The dead part is called a " slough," and the term "sloughing" 
 is often applied indifferently to the diseased action which results in the 
 slough and to the reparative process by which the slough is afterward cast 
 off. Varieties. — Two main classifications: 1, into dry and moist; 2, into 
 traumatic and idiopathic. Causes. — A. Of traumatic gangrene : 1, mechanical 
 violence, e.g., crushing and disintegrating action of a cart-wheel passing 
 over a limb ; 2, mechanical pressure, e.g., bed-sore, and strangulation of a 
 limb by a tourniquet ; 3, chemical, e.g., the effects of corrosive acids, or 
 excessive heat or cold, or of extravasated urine. B. Idiopathic gangrene 
 has for its remote causes the following : 1, general anaemia, e.g., gangrene 
 has been known to follow excessive venesection ; 2, arterial obstruction from 
 embolism or thrombosis in cases of atheroma — this form usually occurs in old 
 people, and is called senile gangrene ; 3, specific fevers and their sequelae, 
 especially typhus, typhoid, and septicaemia ; 4, certain diseases, mostly inflam- 
 matory, e.g., carbuncle, phagedcena, etc. ; 5, poisons inoculated or swallowed, 
 e.g., ergot of rye, serpent's poison, etc. Certainly many of the above causes, 
 and probably all, act either by diminishing the supply of blood to the part, 
 or by obstructing its escape from the part, or by both ways combined. 
 Gangrene produced purely by diminished blood-supply is dry ; that caused 
 partly or wholly by obstructed return of blood is moist. Inflammation is 
 an aggravating element in most cases of gangrene, and an essential element 
 in many. Two or more of the above causes are frequently combined ; e.g., 
 senile gangrene results often from a wound of the toe of an old person 
 with atheromatous arteries. Pathology may be inferred to a great extent 
 from what has been said above concerning the causes, and what will be 
 said below about the symptoms. The appearances are primarily those of a 
 region where the vessels are either almost empty or else distended with 
 stagnant blood. Then, in the part itself, if blood can pass through it at 
 all, but always in its immediate neighborhood, inflammation occurs. Now, 
 if the part is exposed to the air, it next begins to decompose, and one 
 should notice that most of the so-called appearances of gangrene, e.g., foul 
 odor, are really signs of putrefaction in the gangrenous tissues. For a time, 
 the inflammatory and gangrenous process spreads. When it reaches its 
 
1 00 GANGRENE. 
 
 limits, the inflammation on its borders produces granulations between the 
 living and dead regions, which granulations, as it were, push off the dead 
 structures. In gangrene of embolic origin, emboli are found in the arteries. 
 The line where the gangrenous process stops and the wall of granulations 
 is formed, is called the line of demarcation. 
 
 Symptoms and Course. — 1. Dry gangrene. First appearance often a 
 brown spot on one toe ; this spreads, the parts affected gradually shrivelling 
 up, the skin wrinkling, and becoming brownish black. This process is 
 called " mummification." 2. Moist gangrene begins with signs of inflam- 
 mation. Then the swelling becomes boggy, skin mottled or violet. Bullae. 
 Discoloration spreads and deepens. Local insensibility. Fall of tempera- 
 ture locally. Emphysematous crackling. Foul odor. Extent of process 
 varies from part of toe to a whole limb. Either of above series of symptoms 
 observed in senile gangrene. Traumatic gangrene is always more or less 
 moist and inflammatory. If patient survives, the dead parts are cast off in 
 the way described above (Pathology), the tendons and fasciae giving way 
 last but one, and the bone absolutely last. Process of spontaneous separation 
 of any segment of a limb occupies months. Constitutional Symptoms. — In 
 traumatic gangrene, those of great prostration and fever of a low type. 
 In senile gangrene, they may be very slight, but usually they are those 
 of chronic septicaemia, viz., gradual exhaustion, feeble pulse, dry tongue, ner- 
 vous sensibility dulled, etc. Diagnosis. — Gangrene must be distinguished 
 from ecchymosis caused by blows, and from lividity the result of exposure 
 to cold. Prognosis. — Bad, unless part affected is small or a line of de- 
 marcation has formed. Worse when from constitutional than when from 
 purely local causes. 
 
 Treatment. — When only a small part, e.g., the end of a finger, is affected, 
 and when the cause is traumatic, treatment is purely local, otherwise it is 
 also constitutional. Local treatment. — Two objects : 1, to promote de- 
 tachment of the gangrenous parts ; 2, to prevent the gangrenous parts 
 from decomposing, and thus infecting the patient and his chamber or 
 ward. Use absorptive compresses of tow or oakum, wet with chlorine 
 water, carbolic lotion, etc., but not too wet. Charcoal powder. Iodoform. 
 Never drag off sloughs. Remove them gently when they are fully formed. 
 After separation of dead parts, treat like an ordinary granulating wound. 
 
 Question of Am,putation. — It is a very safe rule in civil practice never to 
 amputate till a line of demarcation has formed. Leave single toes to fall 
 off. "If the whole foot or leg be affected, do the amputation so that it 
 may be merely an aid to the normal process of detachment ; i.e., on the 
 borders of the healthy parts you try to dissect up only enough skin to 
 cover the stump, and saw the bone as near as practicable to the line of de- 
 marcation" (Billroth). 
 
 Constitutional Treatment. — Relieve pain with opium (up to gr. \ every 
 three hours) or morphia, subcutaneously. If these disagree, use chloral 
 
GASTROTOMY. 101 
 
 (gr. xx. 6 ti8 horis) or some other anodyne. Watch their effect well. Extent 
 to which you give or withhold stimulants and nourishment depends on 
 relative importance you attach to remediable weakness and inflammation 
 respectively, as factors in extending the gangrene. Nourishing food, 
 quinine, acids, gentian, camphor, or ammonia, are used as a rule ; but 
 Syme declared that in senile gangrene he got the best results from com- 
 paratively low diet. 
 
 Prophylaxis. — For gangrene threatening from excess of tension, use 
 free incisions. Gangrene from arterial obstruction, local warmth. Gangrene 
 from venous obstruction, elevation of limb, support by gentle, even 
 bandaging. — See also Bed-Sores. In severe crushes, where gangrene seems 
 inevitable, it is better to amputate before reactionary fever has set in, unless 
 indeed the limits of the parts hopelessly injured cannot be sufficiently 
 made out 
 
 Gastrotomy . — A term applied to two distinct operations, viz. : 1, 
 opening the stomach ; 2, opening the abdominal cavity only. 
 
 Gastrotomy, or operation of making opening into stomach. Called 
 " gastrostomy " when done for disease of the oesophagus. Indications. — 1. 
 When a foreign body has entered the stomach, and cannot safely either 
 pass through the pylorus or be vomited or extracted by the mouth. 2. 
 When an impervious stricture of the oesophagus is of traumatic origin. 
 Indication is then imperative. 3. In cases of cancer of oesophagus. In 
 these, though death has always speedily followed operation, yet patient's 
 sufferings have been much relieved. Prognosis. — Usually followed by 
 speedy death when done for disease of the oesophagus, 1 but very safe (1 
 death in 11) when done for foreign body. In former case, death is more 
 from advanced disease than from operation. Operation. — Scalpel, forceps, 
 ligatures, director, hooks, catch-forceps, retractors, handled needles, silk 
 ligatures, bits of bougie for quilled-suture. Incision, curved for 4 inches, 
 just internal to edge of left costal cartilages, from sternal extremity of 
 seventh intercostal space, downward and outward. Divide successive layers 
 on a director. Edge of left lobe of liver may be useful as guide to stomach. 
 Pull stomach out with finger and thumb. When quite certain of having 
 got the right viscus, seize it with catch-forceps, if gastrostomy is to be 
 done. Two double ligatures from side to side through lips of wound and 
 wall of stomach. Open viscus. Pull ligature loops out of wound and di- 
 vide them. Quills inside and out. Additional sutures at corners of wound. 
 Unless patient is much exhausted, feed by enemata only for first twenty- 
 four hours at least. When operating to remove foreign body, make open- 
 ing in stomach small, and sew up with continuous suture unless opening 
 spontaneously closes. 
 
 1 Two successful cases: Verneuil's, see Lancet, January 13, 1877 ; and Stanton's, 
 see Medical Press and Circular, December 29, 1880. Both were dressed antiseptically. 
 
102 t GONORBEKEA. 
 
 Gleet. — See Gonorrhoea. 
 
 Glioma. — See Tumors, Sarcomatous. 
 
 Glottidis, (Edema. — See Laryngitis. 
 
 Goitre. — See Bronchocele. 
 
 Gonorrhoea. — Definition.— Inflammation of mucous membrane of male 
 urethra or of female genitals, following impure sexual intercourse. I have 
 worded the definition as above, because, in practice, one applies the term 
 gonorrhoea to any urethritis following impure intercourse, whether there be 
 specific contagion or not. Causes. — 1. Specific infection by contact with 
 gonorrhceal or gleety secretion. 2. Irritation or infection by non-specific 
 secretion from a diseased mucus surface (?). Symptoms and Course. — Four 
 stages. 1. Premonitory. — Itching, swelling, and stickiness of meatus : oc- 
 curs about two to seven days after intercourse, and lasts twenty-four hourg, 
 more or less. 2. Inflammatory. — Scalding, discharge of pus, painful erec- 
 tions, chordee, tenderness along urethra, or confined to part actually in- 
 flamed. Occasionally spasmodic retention. Glans and prepuce swollen : 
 sometimes phimosis or paraphimosis. Duration one week to one month. 
 3. Inflammation passes gradually away, but a thick discharge remains. 4. 
 When only a thin serous discharge remains, called gleet. Pathology. — Ked- 
 ness, swelling, etc., of mucous membrane of urethra. Occasionally slight 
 excoriation or ulceration. Micrococci and vibriones have been found in 
 gonorrhceal pus, and perhaps infest the inflamed membrane itself. Parts 
 chiefly affected, fossa navicularis and bulbous part. Cause of chordee, ef- 
 fusion of lymph into corpus spongiosum, which effusion prevents lower 
 border of penis from extending proportionally during erection. Complica- 
 tions. — Bubo, balanitis, phimosis, paraphimosis, hemorrhage, cutaneous 
 rash, gonorrhceal rheumatism, epididymitis, cystitis, prostatitis, retention 
 of urine, chordee. All but chordee are noticed in separate articles. Treat- 
 ment. — Local and general. — Local is effected by (1) injections ; (2) soluble 
 bougies of cacao butter (Sir H. Thompson and Mr. W. T. Cooper J ) or of 
 "ice" (Abrath); (3) insoluble bougies, e.g., wax, ivory, etc.; (4) clay 
 bougies (Chiene); (5) powders insufflated (Wilders, Lancet, vol. i., p. 73). 
 There are also external local applications, such as cold sitz-bath, ice to 
 perinaeum, blisters (Milton), etc. Rules for Injecting. — Pass the nozzle 
 into the urethra, right up to the hilt, and press it home. Hold the glans 
 close up to it with the left finger and thumb. Inject slowly about half a 
 
 1 As cacao-butter bougies melt as soon as they enter the urethra, they differ little 
 from a thick fluid injection. They have these advantages, that they are sure to enter 
 the urethra, and that they remain there, but they do not distend the urethra, as a 
 properly administered fluid injection does, for several minutes. A soft and flexible 
 bougie which will slightly distend the urethra as long as may be desired can be made 
 as follows : Roll a square piece of antiseptic gauze, like a pipe-light, dip it into medi- 
 cated cacao-butter, or into medicated vaseline thickened by mixing with sperm or firm 
 paraffin. Use for gleet only. 
 
GONORRHOEA. 103 
 
 drachm. (There need be little or no fear of mischief from an ordinary in- 
 jection entering the bladder. It is unlikely to get so far at all.) Retain 
 the injection three to five minutes if possible. In most cases inject after 
 each urination. Injections. — As a basis, " strong " tragacanth mucilage is 
 excellent. It will remain in the urethra all night. The many urethral in- 
 jections which have been used successfully may be classed, more or less 
 accurately, as (1) antiseptics, (2) astringents, (3) sedatives, (4) cleansing. 
 Antiseptics : iodoform (gr. xxx. to tragacanth. emuls., § j.), carbolic lotion 
 (1 to 40), permanganate of potash (gr. j. to § x.), chloralum (gr. iij. to § j.), 
 borax (gr. v. to f j.), zinci chlor. (gr. j. to § j.). With these might be classed 
 also solutions of iodine, chlorate of potash, and many also of the astringent 
 injections, which are both astringent and antiseptic. Glycerine is con- 
 stantly combined with injections of all kinds, and its value possibly lies in 
 its power of checking fermentative changes. Secondly, astringent injec- 
 tions : tannic acid (gr. v. to § j.), zinci sulph. (gr. ij. to 3 j.), zinci sulpho-car- 
 bolat. (gr. ij to | j.), zinci acet. (gr. ij. to 3 j.), plumbi acet. (gr. ij. to § j.), ar- 
 gent, nit. (gr. i to 3 j. ). Also solutions of kino, catechu, and eucalyptus gum. 
 Thirdly, sedative injections : sedatives are almost always used in combina- 
 tion, e.g., liq. morph. acet.,TTl,. x.; glycerini acidi tannici, TTj,. xx.; aquse, § j. 
 Fourthly, cleansing injections, such as warm water, used in very acute gon- 
 orrhoeas. Many excellent injections are combinations. Such a one is the 
 French injection of M. Brou, containing probably calamine, opium, and 
 some vegetable decoction. Powders, such as zinci oxid., in suspension, 
 are believed to cling to the urethral surface. 
 
 Soluble bougies can be medicated with any of the above substances. 
 It is customary to place a piece of lint or cotton-wool over the meatus after 
 passing the bougie, and to fix it with strapping. 
 
 Insoluble bougies are sometimes dipped in an active agent, sometimes 
 used unmedicated, for gleet. 
 
 Modifications in Treatment according to the Stage of the Disease. — First 
 stage. " Abortive Treatment." Rest as much as possible ; at all events 
 avoid fatigue. Moderate diet. No stimulants. Frequent cold hip-baths ; 
 saline purgatives ; alkaline and demulcent drinks ; acetate of potash ; weak 
 astringent and antiseptic injections repeated as often as possible (acid, 
 tannic, gr. v. ; glycerini, Tl|. xx. ; aquae, 3 j.). Second stage. General treat- 
 ment same as first stage. But be more cautious about introducing irri- 
 tants into the urethra. Treat complications. For chordee : belladonna 
 extract along outside of corpus spongiosum, morphia and henbane suppo- 
 sitories ; warm baths ; sleeping draught at night. Sp. camph., 3 ss. doses, 
 internally. One minim of tinct. aconiti every hour will sometimes cut 
 short this stage. Third stage. Still prohibit stimulants and avoid fa- 
 tigue. Persevere with injections ; vary them if the case be obstinate. For 
 use of copaiba, etc., see below. Fourth stage (that of gleet). Continue in- 
 jections and general treatment, but improve diet. Change of air. Tonics, 
 
104 GONOBKHOEA. 
 
 e.g., iron, quinine, strychnia, gentian, etc. But gleet is so often kept up 
 by a slight stricture, that it is imperative to examine well the urethra in 
 obstinate cases, and to dilate it if necessary. It is a good rule, in treating 
 gonorrhoea, to inject after every act of micturition. Persons away from 
 home all day should use the compressible metal tubes, filled with injection, 
 and having a nozzle to enter the urethra, made, at my request, by Mr. 
 Cooper, of 26 Oxford Street. They should be carried in the coat side- 
 pocket. Mr. Watson-Cheyne urges that, in treating a gonorrhoea, the first 
 thing to aim at should be the destruction of the specific nature of the dis- 
 ease. To effect this he recommends a bougie (iodoform, gr. v. ; oL eucalypti, 
 gr. v. ; ol. theobromae, q. s.). Patient passes the bougie, and lies down for 
 six hours. Follow up with injections of emulsion of eucalyptus oil till a 
 slight simple urethritis remains. Then resort to some ordinary astringent 
 injection. The chief difficulties in curing a gonorrhoea arise from the dis- 
 obedience or impatience of the patient, who relaxes his attention to his 
 disorder as soon as it begins to improve, whereas he ought to persevere 
 with the treatment even for a week after the disease is apparently quite 
 cured. "Within that period, even half a glass of claret may cause a relapse. 
 The following rule is of prime importance. The surgeon should teach the 
 patient how to inject. He should administer the first injection himself ; 
 and, if it be effectively done, this first injection may strike the death-blow 
 of the gonorrhoea. A suspensory bandage should be worn as a prophylactic 
 against epididymitis. The ordinary one is often quite useless. The band- 
 age made by Messrs. Arnold, of West Smithfield, should be used. To 
 absorb the discharge, and keep the linen clean, an excellent application is 
 a thin layer of absorbent cotton-wool, stuck to gutta-percha tissue, and tied 
 to the penis by a piece of tape. Chastity is necessary in the first three 
 stages. Gleet is not always infectious, but abstinence from intercourse is 
 desirable even during this stage. 
 
 Copaiba, Cubebs, and Oil of Sandal Wood. — Copaiba not advisable 
 in the acute stage, cubebs best in first stage, oil of sandal wood good for 
 any stage. Dose of copaiba, 2 capsules three or four times a day, or 3 gr. 
 of the balsam made into an emulsion with yolk of egg, or floating on infu- 
 sion of roses, three times a day. Dose of cubebs : a heaped teaspoonful 
 four times a day mixed with soda-water. Cubebs and copaiba together ; 
 make the cubebs up into pills with copaiba balsam and white wax, and 
 give ten pills three times a day. Dose of sandal wood ; TT[. xv., ter die. 
 r>. 01. santalini, § ss.; sp. vini reel, 3 iss. M. ft. mist. S. — 3 j- ex aquae. 
 3 j., ter die. 
 
 Copaiba rash is papular, and sometimes resembles urticaria, sometimes 
 measles ; but there is no fever, and the rash is patchy, chiefly affecting 
 skin over joints. Warn patients of danger of gonorrhceal ophthalmia. 
 
 Gonorrhoea in Female. —Parts affected.^-V&gma. and vulva. Disease 
 may spread considerably, even up urethra to bladder, and, it is said, 
 
GUNSHOT WOUNDS. 105 
 
 through Fallopian tubes to peritoneum. Other complications are bubo, 
 labial abscess, and warty growths. Less common are metritis and ovari- 
 tis. Treatment. — Main special points are, to use large quantities of weak 
 injections pumped freely into vagina, to insert a piece of clean lint be« 
 tween the labia after each injection, and to prescribe rest, both local and 
 general 
 
 Groin, Chief Surgical Diseases of. — See table in Holmes's "Sys- 
 tem," vol. v., p. 999. 1. Psoas abscess ; 2, glandular abscess ; 3, abscess 
 from diseased hip ; 4, simple abscess ; 5, enlarged glands ; 6, cysts ; 7, en- 
 cysted hydrocele ; 8, common hernia ; 9, incarcerated hernia ; 10, strangu- 
 lated hernia ; 11, retained testis ; 12, varix of saphena vein ; 13, aneurism ; 
 14, malignant disease ; 15, other tumors. Of these, hernia alone is sometimes 
 resonant on percussion. Common hernia and varix of saphena are alone 
 completely reducible. Psoas abscess, encysted hydrocele, and retained 
 testis are or may be partly reducible. Abscesses, cysts, varix, and aneur- 
 ism may fluctuate. Abscesses (excepting psoas), inflamed glands, and in- 
 flamed aneurism show heat, redness, etc. Impulse on coughing may be 
 found in hernia and psoas abscess, and, much more rarely, in cysts, 
 strangulated hernia, retained testis, and some tumors. Holmes's table is 
 worth committing to memory. 
 
 Gums are affected by abscess (so-called gum-boil), by ulceration, and 
 by hypertrophy. Abscess arises from irritation of carious tooth. Foment ; 
 open when abscess has fairly formed ; attend to teeth. Ulceration is caused 
 by mercury, scurvy, syphilis, and, indeed, any other cause of stomatitis. 
 Remove cause. Wash with pot. chlorat.; paint with sol. argent, nil, gr. 
 x. to 5 j., or touch with solid argent, nit. Tonics and pot. chlorat. inter- 
 nally. Hypertrophy may require outgrowth to be snipped off. 
 
 Gunshot Wounds. — Belong to the class of contused wounds. Causes. 
 — 1, Mere explosions of powder ; 2, wadding ; 3, small shot ; 4, bullets 
 and slugs ; 5, cannon-balls ; 6, splinters of shells. 
 
 Pathology and symptoms are most conveniently described together 
 under the head of Characters. — Four chief forms of gunshot wound, viz.: 
 1. Simple contusions, caused by spent shot, or by " oblique impact." 
 Formerly attributed to " windage." May produce most severe internal 
 injuries with no visible damage to skin. 2. Superficial wounds, grooving, 
 not tunnelling the flesh. 3. Where bullet lodges. Particles of clothing, 
 etc., may enter with it. 4. Where the bullet pierces and escapes. Though 
 bullet escape, foreign bodies carried in with it may remain. Rifle-bullets, 
 as distinguished from musket-bullets, make cleaner and less contused 
 wounds, but smash and splinter bones, and pierce the body with a more 
 straight and undeviating course. They also cause greater shock. Shock, 
 — Depends much upon individual constitution. Is usually great. Pain 
 usually slight, often unnoticed. Hemorrhage. — Primary is rarely serious, 
 except when the largest vessels are wounded. Secondary is very common, 
 
106 GUNSHOT WOUNDS. 
 
 perhaps because of bad sanitary conditions to which an army is exposed. 
 Bums from powder may occur at close quarters. Examination. — First see 
 how many wounds there are. Then, at least in civil practice, examine pa- 
 tieut's clothes. Apertures -in them may indicate the direction of the wound ; 
 the absence of a piece of cloth may suggest its presence in the wound ; or 
 the exit of the bullet may, in rare cases, be proved by its being found 
 in the clothes. Then explore the wound with the finger carbolized. But 
 in gunshot wounds of the chest or abdomen, the surgeon should insert 
 neither probe nor finger, unless he is prepared to follow up his search, if 
 necessary, by operative measures. Place the patient in the attitude in 
 which he received his wound ; its direction can thus be better judged. 
 Examine carefully once for all. Counter -manipulation with the fingers of 
 the other hand to assist the finger in the wound. Instruments for De- 
 tection of Bullets. — Nekton's probe (porcelain head). De Wilde's electric 
 bell indicator. Krohne and Sesemann's electric indicator. Lecompte's 
 stilet-pince, which bites a piece off the supposed bullet. Objects of Exami- 
 nation. — 1, To search for foreign bodies ; 2, to ascertain direction and ex- 
 tent of wound ; 3, to estimate amount of injury done to certain parts, e.g., 
 fractured bones. 
 
 Apertures of Entrance and of Exit. — Former is cleaner and smaller than 
 latter, smaller even than the ball which made it. Latter is everted and 
 larger and lacerated. The quicker the passage of the ball the less are 
 these differences ; and they are sometimes nil. Only part of a bullet may 
 have escaped by the aperture of exit if a bone has been struck. Or a 
 split bullet may make its exit in two places. Bullet may rebound from a 
 bone and fall out of aperture of entrance. Course of slow bullets some- 
 times very peculiar. Healing. — 1. Small ring-shaped slough and gangren- 
 ous shreds thrown off. 2. Granulation and suppuration. Opening of 
 exit usually closes before that of entrance. Prognosis. — Depends entirely 
 on amount and position of injury. " The extensive tearing and crushing 
 caused by large missiles do not differ from other large crushed wounds 
 caused by machinery." Treatment— Principles of treatment same as those 
 of other contused wounds ; differences of detail chiefly depend on pecu- 
 liarity of surrounding circumstances. 
 
 1. In battle, check hemorrhage by pressure, apply extemporized splints 
 to fractured limbs, give stimulants in case of syncope, and convey patient 
 to place of first dressing. 
 
 2. Apply first dressings at a place previously selected. Here also re- 
 move all foreign bodies that are near the surface, and amputate limbs hope- 
 lessly crushed. Attach to each patient, before sending him on from here, 
 a card with short account of his case, stating, e.g., whether ball has been 
 extracted or a wound of the trunk is or is not perforating. Field officers 
 should ligature, if possible, every wounded vessel of importance (Long- 
 more). 
 
GUNSHOT WOUNDS. 10? 
 
 3. Convey patient to hospital. Here examine every patient, operate, 
 dress wounds, bed, and diet. Many wounded should not be kept collected 
 in one place. Extraction of Bullet. — Tiemann's forceps. Coxeter's extractor. 
 If violent measures would be required for removal of bullet, let it remain, 
 unless it is obviously setting up irritation. Dressing. — The main point is 
 not to actively close the wound, but to leave free room for the discharge to 
 escape. Tenax and oakum very good. 
 
 Gunshot Wounds of Special Parts. — Head. — Very dangerous, from the 
 diffused injury done to the brain and its membranes. Inner table fractured 
 more than outer. Frequent complication with meningitis, abscess, etc. 
 Gunshot wound of brain almost always fatal. Fracture with depression 
 usually fatal. Treatment. — Perfect rest, darkness, low diet. Cold locally. 
 Venesection may be useful. Trephining contraindicated. Do not mistake 
 a wound in which part of outer table of skull has been ploughed off for 
 fracture with depression. 
 
 Thorax. — Classification, diagnosis, complications, etc., much the same 
 as other wounds of chest. Non-penetrating wounds of any violence 
 almost sure to bruise lung. Penetrating wounds fatal nine times out of ten. 
 Treat like other wounds of chest. Allay firstly hemorrhage, secondly in- 
 flammation. To check bleeding from an intercostal artery, a large piece 
 of linen is laid over wound, " and the middle portion of this linen is pressed 
 into the wound by the finger, so as to form a kind of pouch; this pouch 
 is then distended by sponge or lint pushed into it until the pressure arrests 
 the bleeding ; on stretching out the corners of the cloth the pressure of 
 the plug will be increased" (Longmore). 
 
 Abdomen — Resemble wounds from other causes. But even non-pene- 
 trating wounds often fatal. Penetrating wounds. Ball may pierce more 
 than one viscus. The chief sign, sometimes the only sign, of penetration 
 is the extreme collapse. Recovery may take place ; then often a fecal 
 fistula. Gunshot wounds of bladder have often recovered. Proposal, 
 in case of injured viscera, to open the abdomen, search, clean, and 
 suture. 
 
 Extremities. —Injuries to soft parts only, usually do well, unless some 
 large artery or nerve be struck. Injuries to bones are remarkable for com- 
 minution, and frequency of longitudinal fissure into joints. Consequent 
 great liability to osteomyelitis and blood-poisoning. Impossible to be so 
 conservative in treatment as is usual in civil practice. The rule is to 
 amputate for fractures in middle and lower third of femur. Put up most 
 other fractures in immovable plaster case. In gunshot injuries of extremi- 
 ties, as of other parts, ordinary rules of surgery apply, only bearing in 
 mind the smashing and splintering and the special difficulties in after- 
 treatment. Hence, excision of knee and hip condemned by experience. 
 Shoulder, elbow, and ankle suitable for excision. Put up excisions in im- 
 movable plaster cases. In some cases of wounded knee-joint, an attempt 
 
108 HAEMOPHILIA. 
 
 may be made to save the limb ; here again a plaster case is necessary. 
 Fractured thighs not to be transported far to hospital. 
 
 Hematocele. — Effusion of blood into tunica vaginalis. Sometimes 
 unnecessarily classified into traumatic and spontaneous. Almost alwayg 
 traumatic, the cause being a blow or puncture. It is likely that hematocele 
 is often caused by a rupture of a varicosed vein. Slight violence is in 
 many cases sufficient to produce this. Witness the cause of Miss Neilson's 
 death — ruptured varix of Fallopian tube during an attack of gastralgia. 
 Hence blood escaped into peritoneal cavity. When a varicocele ruptures, 
 the blood, fortunately, is more likely to enter a less important serous sac, 
 the tunica vaginalis. Pathology. — Tunica vaginalis contains blood, which 
 usually remains fluid, only becoming gradually darker and thicker and full 
 of fibrinous shreds. Sometimes it coagulates more or less. Tunica vaginalis 
 thickens. At any period inflammation and suppuration may supervene. 
 Symptoms. — Gradual but rapid formation of a smooth, globular or pyri- 
 form, hard or semi-fluctuating, non-transparent, heavy tumor. Testicle 
 situated usually below and behind ; on firm pressure in that region, the 
 peculiar testicular pain is felt. Marks of bruising may appear in skin. 
 Painless, except when quite recent. Diagnosis. — From 1, solid innocent 
 enlargement of testis ; 2, solid malignant tumor of testis ; 3, hydrocele. 
 Case 1. Chronic orchitis begins usually with acute orchitis, or there ia a 
 history of syphilis or scrofula ; it comes on more gradually than hsema- 
 tocele. Case 2. Cancer begins more gradually, but enlarges more per- 
 sistently, and is painful ; lumbar glands enlarge sooner or later in cancer. 
 In both chronic orchitis and cancer thickening of cord is common. Case 
 3. As even hydroceles may be opaque, unless there is a history of severe 
 violence followed by a sudden swelling and ecchymosis, a final diagnosis 
 cannot be made without the trocar. Prognosis. — Only mild and recent 
 cases offer any reasonable hope of absorption. Old cases, after reaching a 
 certain size, usually remain stationary. Inflammation may occur at any 
 time. Treatment. — 1. When hematocele is recent. Rest in bed, applica- 
 tion of cold, elevation of pelvis and scrotum. 2. Later -• tap with trocar 
 and canula, and then support with pressure. 3. In old cases with thick 
 walls, or in any case when suppuration occurs, incise freely and empty. 
 Do this antiseptically. Operation not without danger. Hoewatocele of 
 the tunica vaginalis of the cord occurs but very rarely. Symptoms, eta., 
 can easily be inferred. Blow on part, ecchymosis, swelling, etc.. 
 
 Haematoma. — See Tumors. \ 
 
 Haematuria.— See Urine. 
 
 Haemophilia. — Hemorrhagic diathesis. A congenital tendency to 
 free bleeding after trifling injuries, or even no injury at all. Mostly 
 hereditary. Want of fresh air, of dry lodging, and of exercise said to in- 
 crease the diathesis. Attacks males more than females. Symptoms and 
 Course.— Bleeding from nose and mouth, with or without obvious exciting 
 
HEMOEKHAGE. 109 
 
 cause. Spontaneous ecchymosis beneath the skin. Bleeding often pre- 
 ceded by premonitory symptoms, such as vascular excitement, smell of 
 blood in nostrils, and pains in limbs. In intervals of hemorrhages, joints 
 swell and even inflame. Loss of blood produces anaemia. Pathology. — 
 "Probably abnormal thinness of the arterial walls " (Billroth). Prognosis. 
 — Most patients die young. Some seem to outlive the malady. Treatment. 
 — Employ every means to strengthen general constitution. To check 
 hemorrhages use ordinary means, and, in addition, in serious cases, give 
 sodse sulphatis, 5 ss., occasionally, and two to five grains of ergot every 
 half-hour. Turpentine in drachm doses. See Legg on Haemophilia. 
 
 Hemorrhage. — Hemorrhages are classified in several ways, viz., 
 firstly, according to their source, into 1, arterial; 2, venous ; 3, capillary; 
 and 4, parenchymatous. " Parenchymatous " is a term applied by the 
 Germans to hemorrhage from the tissues full of small arteries and veins, 
 e.g., the penis and the tongue. Secondly, hemorrhages are classified, ac- 
 cording to the time of their occurrence, into 1, primary (i.e., at time of 
 wound) ; 2, intermediate or recurrent (within a few hours) , 3, secondary 
 (i.e., a few days after wound). A third classification is into 1, traumatic; 
 2, spontaneous (vide Hemophilia). Surgeon-Major Porter described an 
 intermittent hemorrhage from malarial influence. Arterial hemorrhage 
 contrasted with venous hemorrhage : Arterial is florid and spurts in jets ; 
 venous is dark, and either does not spurt rhythmically at all or does so 
 only in relation with the acts of respiration. Arterial, however, is dark when 
 respiration is interfered with ; and venous is florid sometimes, when it wells 
 up from a deep wound and is thus exposed to the air before becoming visi- 
 ble. Natural Checks to Hemorrhage. — Arterial hemorrhage is stopped natu- 
 rally by 1, active contraction of vessel ; 2, passive contraction, consequent 
 on decrease of total quantity of blood in system ; 3, weakening of heart 
 caused by loss of blood ; 4, obstruction of vessel by clot. The first three are, 
 one or other, more or less accessory to the operation of the fourth cause. 
 Venous hemorrhage is stopped partly by causes similar to those which 
 check arterial hemorrhage, and partly by the action of the valves in the 
 veins. Capillary hemorrhage is stopped by the contraction of the connective 
 or other tissues in which the vessels are embedded, and by coagulation. 
 Hence, when these tissues are diseased, capillary and also parenchymatous 
 hemorrhage may be very troublesome. Pathology. — Natural changes in and 
 around a wounded vessel, a. If wound be partial and transverse, the wound 
 gapes ; bleeding is considerable and has to be checked ultimately by clotting, 
 which may not occur till syncope comes on and predisposes to it. b. Wound 
 longitudinal. Wound does not tend to gape. Hemorrhage is, therefore, 
 more easily checked by coagulation and contraction, c. Wound completely 
 dividing artery. 1. The ends of the artery retract into the sheath, sometimes 
 curling or twisting up ; 2, the ends contract ; 3, coagulation takes place 
 within the artery ; 4, coagulation occurs outside the artery, within and 
 
110 HEMORRHAGE. 
 
 sometimes without the sheath ; 5, organization of the clot or of part of it 
 finally, cicatricial contraction occurs in the newly organized tissue. Recur- 
 rent hemorrhages are caused by the returning force of the circulation, 
 which, when a patient becomes warm in bed, may be enough to open a 
 vessel not firmly closed. 
 
 General Symptoms of Hemorrhage. — 1, Face first pale, then blue ; 2, 
 pulse sinks ; 3, temperature sinks ; 4, dizziness ; 5, nausea or vomiting ; 
 6, eyes dazzled; 7, noises in ears; 8, fainting and unconsciousness; 9, 
 either the patient recovers or gets worse. In the latter event the following 
 set of symptoms are noticed : 1, face waxy ; 2, lips blue ; 3, eyes dull ; 4, 
 body cold ; 5, pulse thready, frequent ; 6, breathing incomplete ; 7, re- 
 peated swoonings ; 8, permanent unconsciousness ; 9, twitchings of arms 
 and legs ; then death. 
 
 Treatment. — Many cases require great decision, sound anatomical knowl- 
 edge, and sanguine courage for their proper treatment. Classification of 
 local remedies, seven chief classes, viz. : 1, ligature ; 2, torsion ; 3, acu- 
 pressure ; 4, compression ; 5, flexion ; 6, styptics ; 7, position. 
 
 Ligature. — Divided into 1, ligature at the bleeding point, and 2, liga- 
 ture of the artery above the wound, i.e., ligature "in the continuity." 
 General rule : In case of a vessel being wounded, cut down upon the 
 wounded point, tie the vessel immediately above and below the wound. 
 But in some cases such an operation would involve a deep and large in- 
 cision, e.g., in hemorrhage from upper part of posterior tibial artery ; and 
 in other cases, the artery is diseased at the spot bleeding. In such cases 
 the artery is often tied in the continuity. Materials used : silk, hemp, 
 catgut. Operation : Instruments required are scalpel, forceps, retractors, 
 director, artery, forceps (occasionally, also, aneurism needle), tenaculum. 
 In tying an artery at the spot wounded, a sufficiently free incision should 
 be made (usually by enlarging the wound which leads down to the artery), 
 and then each end of the bleeding artery should be seized and ligatured if 
 the vessel has been divided completely. But if the vessel has been only 
 punctured, two ligatures must be applied with the aneurism-needle, one 
 above and the other below the wound. Secure the ligature with a reef- 
 knot, pulling each end of the knot tight with the tips of the forefingers 
 pressed against it ; unless catgut be used, one end of the ligature is left 
 hanging out of the wound. To tie the artery in the continuity, see the di- 
 rections given under the head of Aneurism. Pathology ; the Effects of Liga- 
 ture. — Internal and middle coats, divided, curl up within external coat, 
 which is merely constricted. Formation of conical plug of fibrin. Inflam- 
 matory new formation (i.e., escape of leucocytes from blood-vessels into 
 and around clot and arterial coats, and their organization into fibrous tis- 
 sue). Tied artery eventually dwindles into fibrous cord. 
 
 Torsion. — Bryant's directions are : " The vessel should be drawn out, 
 as in the application of the ligature, and three or more sharp rotations of 
 
HEMORRHAGE. Ill 
 
 the forceps made. In large arteries, such as the femoral, the rotation 
 should be repeated till the sense of resistance has ceased ; the ends should 
 
 not be twisted off. In small arteries the number of rotations is of no im- 
 
 « 
 
 portance, and their ends maybe twisted off or not, as the surgeon prefers." 
 "When the vessels are atheromatous, or diseased, fewer rotations of the 
 forceps are required, the inner tunics of the vessels being so brittle as to 
 break up at once and incurve." The effects of torsion practically resemble 
 those of the ligature, but the inner coats curl up more in the former case, 
 sometimes forming a regular valve. Though torsion leaves no dead foreign 
 body in the wound like a piece of ligature, yet the bruised end of a twisted 
 artery is less likely to live and form adhesions than the less damaged end 
 of a ligatured artery. 
 
 Acupressure has been noticed separately. See Acupressure. 
 
 Compression. — Several forms : — 1, Tourniquet ; 2, digital ; 3, ordinary 
 bandages with or without graduated compress ; 4, elastic bandaging. Chief 
 kinds of tourniquet are Petit's and Signorini's ; Petit's is most used for 
 operations, and consists of a webbing band, with a pad and a screw for 
 tightening. It is usual to place a small compress, made of a small soft roll 
 of bandage or of lint, over the artery to be compressed. Signorini's tour- 
 niquet is used chiefly in the treatment of aneurism, and it consists of two 
 curved metal arms, with a screw-hinge between the two and a pad for the 
 artery at the extremity of one. Lister's tourniquet for the abdominal aorta 
 is on the principle of Signorini's. In applying any tourniquet it is neces- 
 sary to adjust it with great deliberation and care, otherwise the pad is very 
 liable to slip off the artery. One should mention here the lever used by 
 Davy, with great success, to compress the iliac arteries, per rectum. Digi- 
 tal compression is preferable in almost every case, 1, because of the liabil- 
 ity of all instruments to slip out of place ; 2, because the human finger is 
 so delicate, tender, and elastic when compared with a rigid tourniquet or 
 bandage. But it is difficult to obtain for this purpose, and expensive of 
 time and labor. In some cases, e.g., hemorrhage froin internal carotid into 
 pharynx, no other form of compression might be applicable. Digital is 
 often supplemented by the compression of a small sand-bag, placed upon 
 the finger, which sand-bag supplies the place of muscular force. Band- 
 aging. — In arterial hemorrhage from a limb, if an attempt be made to check 
 it by the bandage and compress, the joints should be flexed and the whole 
 limb bandaged. There is a form of compression called " plugging ; " for 
 instance, if a gluteal aneurism were opened freely in mistake for abscess, 
 the proximal end of the artery would very likely be in the pelvis and inac- 
 cessible ; then the aneurism would have to be stuffed with lint and the 
 pelvis bandaged, pro tern., while further measures were considered or un- 
 dertaken. 
 
 Flexion. — Is closely allied to compression, and should almost always be 
 combined with it. One objection to flexion is the disagreeably constrained 
 
112 HEMO RRH AGE. 
 
 position often unavoidable. To demonstrate the value of flexion, bend 
 the elbow strongly and feel the pulse at the wrist : it will be scarcely per- 
 ceptible. 
 
 Styptics. — 1, heat ; 2, cold ; 3, drugs, e.g., iron, tannic acid, gallic acid, 
 catechu, alum, matico, and many others. Heat. — The actual cautery is the 
 only form in which the books speak of heat as a styptic ; but, years ago, be- 
 fore commencing the study of medicine, I accidentally observed the power 
 which very warm, that is decidedly hot water (120° to 140° Fahrenheit), 
 has of closing small bleeding vessels. In hemorrhages from mucous 
 membranes, for example, those which Billroth calls " parenchymatous," I 
 believe hot water to be much more effectual than cold ; so, also, in oozing 
 from wounds. In major amputations it should be preferable because it is 
 less depressing than cold. 1 The actual cautery should be used at a black 
 heat, and held close to, but not touching the bleeding part. It causes an 
 eschar with a suppurating surface beneath. Cold is applied chiefly in the 
 form of ice or ice-water. The most powerful styptic drug is perchloride 
 of iron. The strongest tincture is usually employed, and it is often made 
 to saturate a compress. Thus, styptics, pressure, and flexion can all be 
 combined if desirable. Billroth speaks of turpentine as a most effective 
 but painful and heroic styptic. The above remedies should be supple- 
 mented by elevation of the part, general rest, and avoidance of anything 
 likely to excite the patient's circulation. General Treatment. — Is indicated 
 for the faintness and weakness caused by hemorrhage. Horizontal pos- 
 ture, ammonia, ether, wine. The application of Esmarch's bandage to 
 a limb has been suggested, to drive more blood into the vital centres 
 (Wharry). Transfusion. See Transfusion. 
 
 Secondary Hemorrhage. — Its causes are, 1, defect in the ligature itself ; 
 2, defect in the manner of tying it ; 3, the ligature's having been applied 
 too near an offset of the artery, so that collateral circulation has prevented 
 the formation of the usual fibrinous plug ; 4, atheroma ; 5, suppuration 
 or sloughing of the wall of the artery (which suppuration or sloughing is 
 sometimes the result of a contusion and sometimes of erysipelas) ; 6, vas- 
 cular excitement. The approach of secondary hemorrhage is usually insid- 
 ious, but it is frequently very sudden, and may be fatal even in a few min- 
 utes if the artery be large. Treatment of Secondary Hemorrhage. — Never 
 delay or temporize in these cases. The first thing to be tried is pressure, 
 and if properly applied it will rarely fail. The mode of application must 
 necessarily vary with the case, only it should always be firm and uni- 
 form ; the bandages, unless elastic, should be starched ; the compresses over 
 the bleeding-point should be carefully graduated, and, if the bleeding 
 artery be in a limb, the bandage should cover the whole of the limb. With 
 pressure should be combined perfect rest, elevation, and flexion. To se- 
 
 1 See Practitioner, February, 1879. 
 
HEMORRHOIDS. 113 
 
 cure rest, splints are sometimes useful. For vascular excitement, give 
 vascular sedatives, e.g., tinct. digitalis. Vide Treatment of Hemorrhage 
 in general. When these means fail, the choice then lies between ligature 
 of the bleeding vessel at the bleeding-point, ligature of the artery in the 
 continuity, digital pressure, and amputation of the limb. Some cases are 
 adapted for the use of the actual cautery, of styptics, or of acupressure. 
 Ligature of the artery in the continuity is to be deprecated, because it is 
 liable to be followed by gangrene, and is, moreover, far from a certain 
 remedy. Ligature at the bleeding-point is often useless, because the tis- 
 sues are there so diseased, or it is objectionable because it would involve 
 opening up a large stump nearly healed. Digital pressure is not always 
 readily obtainable. Certain cases are suitable for amputation. These cases 
 are secondary hemorrhage from the main arteries of the lower extremity, 
 when pressure, rest, elevation, flexion, and re-tying at the bleeding-point 
 have failed. In such cases, tying the main artery in the continuity is very 
 liable to be followed by gangrene, and re-tying at the bleeding-point is 
 often impossible from the depth of the wound and the state of the tissues. 
 Hemorrhoids. — Are essentially varices of the inferior hemorrhoidal 
 veins. Three varieties, viz.: 1, external; 2, internal; 3, intero-external. 
 Causes. — (a) Predisposing : everything which congests the portal system 
 or the hemorrhoidal tributaries of that system. Constipation, high living, 
 sedentary habits, liver complaints, indigestion, feeble circulation, inflam- 
 matory disease of the rectum or other pelvic or perineal parts, e.g., fistula, 
 pregnancy, relaxing climate. Early manhood and middle age. Uncom- 
 mon in young women. (6) Exciting causes : various forms of local irrita- 
 tion ; fits of intemperance in eating or drinking, dirt, use of rough irritat- 
 ing material for the person, sitting on cold slabs, drastic purgatives. It 
 will be observed that no sharp line separates some of the exciting from 
 some of the predisposing causes. Pathology. — All piles at first are merely 
 local congestions or vascular dilatations ; but eventually the blood-clots in 
 some part of them, and the connective tissue and vessels contained in them 
 hypertrophy. Usually a small artery lies in the centre. External piles 
 vary greatly in appearance, according as they are swollen or contracted. 
 In the former case they are almost globular and tense ; in the latter they 
 may be so shrivelled up as to look like mere folds of thickened skin. In- 
 ternal piles are classified into 1, longitudinal or fleshy, and 2, globular. 
 The former are usually " blind," that is, non-bleeding ; the latter are bleed- 
 ing piles. The former are sessile and dusky ; the latter are more vascular, 
 and therefore blue or red, and often pedunculated. The relative propor- 
 tion of arterial, venous, and fibrous material in piles varies greatly. Su- 
 perficial excoriation and ulceration common. Liability also to inflamma- 
 tion and strangulation. Symptoms. — Itching, irritation, and discomfort; 
 then tenesmus, pain in lumbo-sacral region and in testicles ; irritability of 
 bladder, disturbed nights, miserable bodily condition, and pinched-up 
 8 
 
114 HEMORRHOIDS. 
 
 countenance. When there is hemorrhage to any extent, anaemia, some- 
 times to the utmost degree, ensues. Hemorrhage often periodical : arte- 
 rial or venous or capillary, trifling or moderate, or sudden, copious, and 
 most injurious. Mucous or muco-purulent discharge. The latter indicates 
 ulceration. Complications. — Fistula, fissure, prolapsus, and the various 
 diseases which are so often the predisposing causes of the piles themselves. 
 Diagnosis. — From prolapsus, polypus, and condylomata. Vide these dis- 
 eases and compare symptoms. Treatment. — Remove cause, if possible. 
 Some cases obviously require operation ; others can plainly be cured by 
 gentler means. In a third class of cases, milder treatment should be tried 
 first, operation afterward, if necessary. General treatment : gentle exer- 
 cise alternating with rest on a cool hard couch ; temperate diet ; gentle 
 purgatives: conf. sennae co., sulphur, cream of tartar, Friedrichshall, Piillna, 
 Hunyadi Janos, etc. Enemata of cold water. Conf. piperis co. Conf. 
 pip. co. should always be combined with or followed by a laxative. Tonics 
 in suitable cases. Blue pill, taraxacum, etc., for the liver. Glycerine in 
 3 j. doses. When the piles have been cured, but anaemia remains, give 
 mist, ferri co. or pil. ferri co. freely. Local treatment. — I. Non- operative. 
 Cleanliness, but avoid irritating soaps ; glycerine soap and warm water ; 
 cold water. If piles prolapse at stool, return at once. Astringents : ung. 
 gallse co., astringent injections. Quantity : two ounces nightly. Strength : 
 tinct. ferri perchlor. TTj,. x. to aquae |j. Suppositoria acidi tannici. For 
 inflamed piles : foment, poultice, leech the neighborhood of the pile. When 
 a large clot forms in a pile, incise pile and turn out clot. Suppurating 
 piles : puncture when mature. Strangulated piles : reduced gently. Re- 
 lieve pain on general surgical principles. II. Operative treatment. Exter- 
 nal piles are excised ; internal are removed by, 1, ligature ; 2, cautery ; 3, 
 nitric acid. Excision of External Piles. — Seize with vulsellum forceps, 
 clamp, snip off with scissors curved on the flat, pass a cautery lightly over 
 stump, unclamp ; snip off any pendulous little fold of sldn ; pad of oiled 
 lint ; T-bandage. Ligature of Internal Piles. — Let the nurse empty patient's 
 rectum with an enema shortly before operation. Patient should sit over 
 warm water to relax the parts, and make it easier to protrude the piles. 
 He then lies on one side, and draws up his knees. Seize each tumor with 
 pile-forceps, cut through that side of it next skin with scissors, surround 
 base of tumor with a hempen thread, tie the pile very tightly. Cut ends 
 of ligature short, oil well, and push back the ligatured mass within the 
 anus again. Ligature separates in about a week. An anodyne is to be 
 given after the operation, and a laxative on the second day. Anaesthesia 
 often dispensed with. Dress with dry cotton wool. Cauterization of Inter- 
 nal Piles. — Preparation same as for ligature. Smith's clamp, ivory side 
 downward, snip off piles with scissors, sear bases with actual or with gal- 
 vanic cautery. Latter said to cause least after-pain. Unclamp gradually, 
 and cauterize any bleeding point. Suppository of morphia. Usual to 
 
HAND, DEFORMITIES OF. 115 
 
 anaesthetise during this operation. After-treatment same as for ligature. 
 Recovery quicker. Danger about the same, but in either case very little. 
 Nitric acid. — Suitable for sessile hemorrhoids. Apply with a piece of wood 
 through speculum. Concave clamp to protect healthy mucous membrane. 
 Galvanic cautery applied lightly answers admirably for sessile hemor- 
 rhoids. 
 
 Note. — When operating for hemorrhoids, avoid, as much as possible, 
 damaging the line where the mucous membrane joins the skin. "When 
 there is a fissure, operate on it first. 
 
 Hand, Deformities of (inclusive of fingers). — Four classes, viz.: 1, 
 deficiency, 2 ; excess, 3 ; webbed fingers, 4 ; contractions. It is rare to 
 find a finger or any part of the hand congenitally deficient. 
 
 Supernumerary fingers are frequent : one is the common number, and 
 it lies usually on ulnar side of little finger. Thumb may be bifid, or there 
 may be a supernumerary thumb. A finger may be too long or too short. 
 A very rare deformity is a double hand on the same wrist. 
 
 Contractions. — Four classes : 1, congenital ; 2, paralytic ; 3, traumatic 
 or cicatricial; 4, rheumatic. 
 
 Congenital contraction assumes the form called " clubbed hand," which 
 is analogous to clubbed foot, but very rare. 
 
 Rheumatic contraction bends the finger upon the palm and is, practi- 
 cally, the most important deformity of the hand. Causes. Either chronic 
 rheumatic diathesis, or the habit of pressing on some round-headed instru- 
 ment like a chisel or a walking-stick. Signs. — One or more fingers, espe- 
 cially the little one, is flexed, a tense subcutaneous fibrous band bridging 
 across from it to the palm. Pathology. — Chronic inflammatory thickening 
 and contraction of fibrous tissue between palmar fascia and sheaths of 
 flexor tendons. 
 
 Treatment. — Supernumerary fingers should be amputated, as their 
 proximal joint sometimes communicates with one of the normal metacarpo- 
 phalangeal articulations. In such a case the base of the supernumerary 
 finger may be left. If the operation is done at an early age, this stump 
 will not grow. 
 
 Clubbed hand can only be treated on the same principles as clubbed 
 foot, but with not nearly the same hope of success. 
 
 Treat rheumatic contractions in this way: Divide, subcutaneously if 
 possible, or else antiseptically, the contracted fibrous bands, carefully 
 avoiding any injury to sheaths of tendons. Then extend fingers on a splint. 
 Attend to the cause. See Adams's little book on this subject. 
 
 Webbed fingers, unless ingeniously treated, reunite after being cut apart. 
 Method 1. — Pass a metal ring through the base of the web and keep it 
 there till the aperture cicatrizes. Then complete the separation. Method 
 2. — Wrap a flap of skin taken from the back of one finger over the raw sur- 
 face of the other finger, and another flap of skin taken from the palmar 
 
116 HARE-LIP. 
 
 surface of the latter finger over the raw surface of the former, utilizing, of 
 course, the skin of the web itself. Method 3 (vide Barwell, Medical Press 
 and Circular, 1866, or Holmes's " System," v., 825). — In this, skin is taken 
 from the buttock. Method 4. — Gradual strangulation of the web by a 
 clamp. 
 
 Hanging. See Asphyxia. 
 
 Hare-lip. — Causes and Pathology. — Congenital. Many degrees of this 
 deformity. Single hare-lip and double hare-lip. The fissure is not central, 
 but corresponds, in single hare-lip to one side, and in double hair-lip to 
 both sides, of the intermaxillary bones. The intermaxillary are the bones 
 which form the front of the hard palate and alveoli carrying upper incisor 
 teeth. Hare-lips vary in depth from a mere notch in the edge of the 
 upper lip to a total lateral separation of the intermaxillary bones. The 
 deformity in hare-lip is homologous to a fissure which is normal in some 
 fishes, but it has no homology with the cleft in the lip of the hare. It 
 often coexists with cleft-palate. Male sex predisposes. Double hare-lip 
 almost always affects boys, and is ten times less common than the single 
 variety. The intermaxillary bones in double hare-lip often project for- 
 ward from the end of the nose, and are frequently only half-developed in 
 size. Treatment. — Operative only. Best time, third to fifth month of in- 
 fancy. Contraindicated during dentition or ill-health. Plastic operations 
 fail in syphilis (Verneuil). Chloroform unnecessary, and difficult to admin- 
 ister. If desired, anaesthetic vapor may be pumped through a catheter. 
 Child in a lying or sitting position on a table or on nurse's or surgeon's 
 lap. Secure his limbs by rolling him up lightly but firmly in a towel. 
 Assistant to check hemorrhage by holding each side of the upper lip be- 
 tween his finger and thumb. Surgeon sponges for himself, or lip may be 
 secured in T. Smith's forceps. Begin by separating, with the knife, the 
 two sides of the lip from the jaw subjacent, unless the former structures 
 be already very free. Then pare the edges of the cleft. Kemove enough, 
 especially from the apex of the cleft and from the junction of the cleft 
 with the edge of the lip. Then suture, strap, and put on Hainsby's truss. 
 The incisions are best made with a view to utilizing the "parings " of the 
 fissures. Vide diagrams in text-books. In double hare-lip the whole mar- 
 gin of the intermaxillary nodule is pared. When this nodule projects it 
 must, unless it is rudimentary, be broken at the base and bent back to the 
 level of the lip. If it is rudimentary it may be removed altogether, except 
 the skin which covers it anteriorly. This must be stitched back, either to 
 complete the nasal septum if that is deficient, or, otherwise, to fill the gap 
 in the lip. Modes of Suture. — 1. The "hare-lip" suture proper. Two 
 pins. Enter and exit one-fourth inch from fissure, pass deeply, nearly 
 reaching mucous membrane. Lower one secures coronary artery. Twisted 
 suture. Interrupted wire suture at red border of lip. Sharp ends of pins 
 nipped off. Pieces of lint placed beneath ends of pins. Strapping, broad 
 
HEAD, INJURIES OF THE. 117 
 
 at ends and narrow in middle, brought across lip. 2. The common inter- 
 rupted wire suture. This answers well for ordinary cases and is less likely 
 to leave scars. All pins should be removed on third day very gently, the 
 Up being well supported at the time and strapped immediately afterward. 
 Act of suckling, rather beneficial than otherwise, as it tends to close the 
 fissure. In order to bend back the intermaxillary bone when it projects, 
 instead of breaking its base it is a better plan to cut a V-shaped piece out 
 of the septum nasi 
 
 Head, Injuries of the. — Important, because almost all varieties are 
 liable to be complicated with cerebral mischief. Classification is primarily 
 anatomical. 1, Scalp injuries ; 2, fractures of skull ; 3, injuries of brain 
 and its membranes ; 4, injuries of cranial nerves. 
 
 L Scalp may be contused or wounded, or both. Contusions of Scalp. 
 — Very common. Extravasation may be diffused or circumscribed. Cir- 
 cumscribed extravasation occurs either, 1, above cranial aponeurosis ; 2, 
 just beneath it ; or 3, between epicranium and bone. A special kind of 
 scalp extravasation is Cephalhematoma, which lies mostly just beneath 
 epicranial aponeurosis and very rarely beneath epicranium. Signs. — Fluc- 
 tuation, hard and thickened margin, soft centre, rarely any discoloration. 
 Cephalhsematoma occurs in the newly born, and is caused by pressure of 
 maternal passages or of obstetric forceps. Its usual situation is over the 
 parietal bone. Fluid Contents. — Blood with its corpuscles more or less 
 disintegrated, its coloring matter more or less diffused and perhaps partly 
 crystallized, while its plasma is often partly coagulated. The coagulation 
 may entangle the coloring matter and leave the fluid contents pale' and yel- 
 low. Diagnosis. — From fracture. The hardened margin of an extravasa- 
 tion can usually be deeply pitted by steady and continued pressure. See 
 Fracture.- Treatment. — Cold and pressure. Afterward discutient lotions 
 (lotio ammonii chloridi, etc.). Only the most obstinate cases should be 
 aspirated or punctured by a small knife. After puncture apply antiseptic 
 dressings. When suppuration occurs, open freely and poultice. Scalp, 
 Wounds of. — Often contused and lacerated. Prognosis. — Very good even 
 in the most severe cases, because the vessels of the scalp lie chiefly super- 
 ficial to the aponeurosis. But, for the same reason, the blood-supply of 
 the cranium is sufficiently interrupted in extensive lacerations to cause 
 danger of necrosis with its consequences. Other dangers in scalp-wounds 
 are erysipelas, and accumulation of pus, causing puny swelling. Treatment 
 — Clean carefully and replace flaps accurately. Use sutures, if necessary, 
 but do not pass them through the aponeurosis. Experience of American 
 Civil War was in favor of sutures ("Medical and Surgical History War of 
 Rebellion"). Dressing should be just enough to support and protect from 
 draughts of cold air, without heating. Bleeding vessels can sometimes be 
 conveniently secured between a needle and twisted suture. Treat com- 
 plications on general principles, giving free exit for pus, etc. 
 
118 HEAD, INJURIES OF THE. 
 
 IL Fractures of Skull. — Classified in three ways : Firstly, into sim- 
 ple and compound ; secondly, into fractures of the vault and fracture of 
 the base ; thirdly, according to the physical characters of the fracture, 
 into fissures, starred, depressed, punctured, elevated, and comminuted 
 fractures. It should also be noted, when possible, what is the relative 
 amount of damage done to the inner and outer tables of the skull. Causes. 
 — Blows and falls on the head, and, though very rarely, indirect violence, 
 viz.: falls on the feet or blows on the lower jaw. The nature of the frac- 
 ture naturally depends greatly on the cause. See pathology following. 
 Anatomy and Pathology. — Position of fracture. This depends chiefly on 
 the point where the causative force has been applied, and on nature of 
 force. Sharp instruments cause depressed fractures at the point of con- 
 tact. Sometimes they only crack the outer table, while they depress the 
 inner. Heavy, softish bodies, e.g., sl bale of cotton, are likely to cause 
 fractures of the base. The skull has been divided into three "zones," and 
 evidence given to show that a blow on the vault of one zone is likely to 
 cause a fracture of the base of the same zone. The middle zone consists 
 of " the parietals, the squamous, and the anterior surface of the petrous 
 portions of the temporal, with the greater part of the basisphenoid." The 
 posterior and anterior zones include the rest of the skull. The middle 
 zone is the commonest seat of fracture. Shape of fractures (vide classi- 
 fication). A very common shape is a depression with three triangular 
 sides sloping downward till their apices meet in the centre of the depres- 
 sion. In fractures of the base, sutures — e.g., the petroso-occipital— are 
 sometimes torn open. Most fractures of the base are continuations of 
 fissures of some part of the vault. But a few appear to be genuine cases 
 of contre-coup. This is what is meant by contre-coup : Suppose a watch 
 lying with its face toward the table, and a weight to fall upon the back of 
 the watch. If the glass cracked, that would be a fracture by contre-coup. 
 In some of these cases, the base of the skull is said to be broken by con- 
 cussion with the atlas. One table is usually more damaged than the 
 other, and the least damaged lies toward the surface where the violence 
 has been applied, therefore the most damaged is almost always the inner 
 table. Extravasations within the cranium, damage to internal and middle 
 ears, and to cerebral centres and nerves, as well as membranes of brain, 
 very common. Signs and Diagnosis. — Obvious in compound fractures 
 with depression. In compound fractures without depression fissure looks 
 like a red line. One of the sutures must not be mistaken for a fissure. 
 Simple fractures without depression can only be recognized or suspected 
 indirectly through their complications. Simple fractures with depression 
 have to be distinguished from contusions with thick, hard margins. The 
 depression in fracture is generally more abrupt at one part of its margin 
 than another, while the hard margin of a contusion is usually tolerably 
 circular and uniform, as well as impressionable by steady pressure with 
 
HEAD, INJURIES OF THE. 119 
 
 the finger. Fractures of frontal sinuses, or of mastoid cells, often cause 
 emphysema. Signs of Fracture of the Base of the Skull — Bleeding from ear, 
 nose, or mouth, escape of cerebro-spinal fluid from the ear, 1 sub-conjuncti- 
 val ecchymosis, paralysis of cranial nerves, especially of the seventh pair. 
 Tenderness of mastoid process and ecchymosis in sub-occipital region in- 
 dicate fracture of posterior fossa, unless direct violence has been applied 
 to the tender and bruised parts. The anatomical explanation of the above 
 symptoms is obvious. Hemorrhage from the ear is the commonest of them. 
 A somewhat rare symptom of fractured skull is escape of brain-matter. 
 Cerebro-spinal fluid is very watery, saline, and contains only a trace of 
 albumen, and the faintest trace of sugar. When such a fluid escapes from 
 the ear directly after an injury, it is pathognomonic of fracture of the base. 
 Amount of fluid sometimes very considerable. 2 In diagnosing fracture of 
 the skull, always consider the brain-symptoms, if such are present, and 
 consider also the nature of the force which caused the accident. Serious 
 and long-continued cerebral symptoms following a heavy blow on the 
 head are usually caused by fracture and its complications. Prognosis. — 
 Depends usually altogether upon the amount of injury done to the brain. 
 In estimating this, consider the cause, the situation, and the shape of the 
 fracture, the age, habits, and health of the patient. The injury done by 
 sharp instruments is generally local and pretty manifest to the surgeon's 
 senses. Heavy, blunt, soft bodies are apt to severely concuss and contuse 
 the brain and fracture the base of the skull, while causing very little su- 
 perficial damage. Fractures of the base are usually, but not always, fatal. 
 Fractures with escape of brain- matter have been recovered from. Frac- 
 ture at root of nose may only affect anterior wall of frontal sinus. Young 
 children have no frontal sinus. Depressed, and especially punctured frac- 
 tures very liable to wound dura mater and brain. Kidney disease makes 
 wounds in this, as in other regions, very serious. Treatment. — In all cases, 
 rest, coolness, low diet, high, hard pillows beneath head. Ice locally, a 
 purgative at commencement. Vigorous antiphlogistic treatment the mo- 
 ment signs of inflammation appear. Leeches. Cold douche. Continue 
 observation of simple cases at least a month. Remove loose, depressed 
 pieces in comminuted fracture. Indications for Trephining. — They are 
 simply the occurrence and persistence, in spite of treatment, of symptoms 
 of local intracranial suppuration, or hemorrhage, or of cerebral irritation, 
 after a blow on the skull. Trephining is contraindicated in cases of dif- 
 
 1 In rare cases, cerebro-spinal fluid has been known to flow from nose or from a 
 fracture of the vertex. 
 
 2 E. W. Collins (Dublin Medical Journal, February, 1877) demonstrates that 1, 
 sugar is not constant in the fluid ; 2, when present, though reacting to Trommer's, 
 Moore's, and Bottgen's tests, it usually does not deflect polarized light, or ferment 
 with yeast ; 3, three constant characters of cerebro-spinal fluid are 1, very low specific 
 gravity, 2, almost complete absence of albumen, 3, comparatively large proportion of 
 sodium chloride. 
 
120 HEAD, INJURIES OF THE. 
 
 fused injury to the brain, and even in cases of depressed fracture unat- 
 tended by cerebral symptoms (vide Gamgee, in British Medical Journal, 
 1877). Bryant is "almost tempted to believe that depressed bone by 
 itself never gives rise to marked symptoms of compression, and that when 
 these are present hemorrhage exists with it." When there is a depressed 
 fracture, it is right to trephine as soon as ever cerebral symptoms appear. 
 Otherwise, ice-bags, leeches, etc., should have a fair trial first. When 
 there is comminution, depressed pieces can sometimes be raised by the 
 elevator or forceps only. See article Trephining. Further points are 
 touched upon in the next section, which is about — 
 
 HI. Injuries of the Brain and its Membranes. — These include extravasa- 
 tions of blood within the cranium, contusion and laceration, inflammation 
 and suppuration of traumatic origin, hernia cerebri ; and here also must 
 be noticed the conditions styled " concussion" and "compression." 
 
 Extravasations of Blood within the Cranium. — 1, Between dura mater 
 and bone ; 2, in cavity of arachnoid ; 3, on the surface of the brain be- 
 tween it and the arachnoid ; 4, in the substance of the brain or in its 
 ventricles. 1. Extravasation between dura mater and bone. Causes. — 
 Wounded blood-vessel, usually a branch of middle meningeal artery, some- 
 times a wounded sinus, especially the lateral sinus. Pathology. — The 
 effused blood forms a clot, often of enormous size and having very little 
 tendency either to be absorbed or to become encysted. This clot, when 
 large, causes a corresponding depression on the surface of the brain. 
 Signs. — May be nil if clot be small, or even in the case of a large hemor- 
 rhage, if it be poured out so gradually that " the brain has time to accom- 
 modate itself to the pressure." When symptoms are present they are those 
 of compression or of irritation. The most valuable evidence of extravasa- 
 tion exists when symptoms of compression come on, not immediately after 
 an injury, but after an interval of consciousness. For prognosis, treat- 
 ment, etc., see paragraphs about Compression. It is to be noted that 
 irritation of the nerves of the dura mater causes reflex convulsions and 
 contractures of the same side of the body as the injury to the head. 2. 
 Extravasation in cavity of arachnoid. Very common. Pathology. — When 
 not absorbed, has a tendency to form blood-cysts contained in a new fibro- 
 serous membrane which is attached to the parietal layer of the arachnoid, 
 and makes a depression on the surface of the brain. Signs and Diagnosis. 
 — Cannot be distinguished from other intra-cranial hemorrhages. Long 
 after the original injury, it is liable to cause headaches and mental irrita- 
 bility. Treatment, etc., see Compression and Cerebral Irritation. 3. Extra- 
 vasation on surface of brain, beneath visceral arachnoid. Accompanies 
 general cerebral injuries. Never encysted. May spread very widely. No 
 special signs. No special treatment. 4. Extravasations into substance of 
 brain or into its ventricles. Not to be distinguished from apoplexy except 
 by the history. Treatment, etc., as in Apoplexy. 
 
HEAD, INJURIES OF THE. 121 
 
 Contusion and Laceration of Brain. — Pathological Anatomy. — Minute 
 extravasations, sometimes few, sometimes numerous, sometimes occupying 
 only a limited portion of gray matter, sometimes diffused through greater 
 part of brain ; sometimes attended with very little injury to cerebral sub- 
 stance, sometimes followed by complete softening and disintegration, or, 
 after a longer interval of time, by atrophy of brain-substance. Situation 
 often opposite the part of cranium struck (contre-coup) . Usually middle or 
 anterior fossa of base. Lacerations are often complicated with large extra- 
 vasations. Symptoms. — Partial spasms and paralysis, occasionally coma. 
 Frequently concussion. None of these symptoms belong specially to cerebral 
 contusion and laceration, which are so difficult to diagnose satisfactorily 
 that their treatment, etc., will best be considered under the heads of con- 
 cussion, compression, cerebral inflammation, irritation, etc. 
 
 Encephalitis, Traumatic. — This includes meningitis, for, during life, in- 
 flammation of the membranes cannot be diagnosed from that of the brain- 
 substance ; though a shrewd guess may sometimes be formed by consider- 
 ing the exciting cause. Classified into : 1, acute, and 2, subacute or 
 chronic. Causes. — All injuries of the head. For even a scalp wound may 
 excite firstly, osteitis, and secondarily, meningitis and cerebritis. Neglect 
 of rest and of temperance after head injuries is very likely to excite inflam- 
 mation. Pathology. — Congestion of the parts inflamed. Firstly, yellowish 
 lymph and then pus appears on the inflamed membranes. Cerebral sub- 
 stance may soften and break down. Serous effusion into ventricles. When 
 the exciting injury is not very deep, e.g., most punctured fractures, the 
 membranes are chiefly affected ; but when it is general or deep, e.g., con- 
 tusion of brain, the cerebral substance may be the chief seat of inflam- 
 mation. Although the appearances are most marked at the actual seat of 
 injury, yet traumatic encephalitis generally spreads to a great part of the 
 brain and its membranes. In chronic cases, parietal and visceral layers of 
 arachnoid cohere. The amount of cerebral congestion is estimated post 
 mortem by the number and size of the red points visible on section of 
 the hemispheres. This test is not satisfactory, for it is influenced by the 
 relative fluidity of the blood and the pressure of serous effusion in the 
 ventricles. Signs. — 1, Acute. Severe pain in head, over-sensitiveness to 
 light and sound, noises in ears, one or both pupils contracted, partial 
 spasms and paralyses, epileptiform convulsions, usually, or at all events at 
 first, unilateral ; fever, pulse frequent, or variable, temperature raised 
 slightly at first, and raised more if suppuration come on. Yomiting. 
 Delirium. Lastly, coma, and death by exhaustion and compression. The 
 relative prominence of the symptoms catalogued above varies greatly in 
 different cases. In comatose stage pupils eventually dilate. 2. Chronic. — 
 When it comes on long after receipt of injury, there may be premonitory 
 signs, e.g., irritable temper, headaches, etc. The symptoms differ only 
 from those of acute inflammation in being less concentrated and severe. 
 
122 HEAD, INJURIES OF THE. 
 
 Diagnosis. — Traumatic intra-cranial inflammation can scarcely be con- 
 founded with any other disease if its causes and signs are carefully con- 
 sidered. Prognosis. — Very serious, especially if not treated promptly and 
 boldly. Treatment. — Cold locally, purging, calomel, venesection, leeching, 
 morphia. Venesection rarely used now. Leeching over temples and 
 mastoid processes very beneficial. But local cold is the most powerful 
 remedy. The cold douche is the most effective form, and it should be used 
 courageously and perseveringly. Ice-bags. Purging is highly praised. 
 Calomel and butter placed on tongue. Small doses of calomel and morphia 
 sometimes given, especially when furious delirium comes on a few days 
 after a head-injury. Dark room, head raised on high hard pillows, hair 
 cut short. For treatment when suppuration supervenes see following 
 paragraph. Probably many cerebral inflammations which have resulted 
 from wounds would have been prevented by antiseptic dressings. 
 
 Intracranial Suppuration. — Within the skull, as elsewhere, suppuration 
 is one of the " terminations " of inflammation ; it is practically very impor- 
 tant whether the pus be between the skull and dura mater, just beneath 
 the dura mater, or within the brain substance. Signs. — Not decisive. 
 Symptoms of compression gradually coming on during encephalitis and 
 accompanied by further rise of temperature, and rigors. At the same time 
 a coexistent scalp wound may become pale and dry, or Pott's puny swell- 
 ing may form. If the wound be deep enough, the bone may perhaps be 
 seen exposed by separation of pericranium. When these local signs are 
 present, it is not unlikely that the pus is lying just beneath that part of the 
 skull. Prognosis very bad ; to make it worse, pyaemia is a not unfrequent 
 complication. Treatment. — The main question is that of trephining. Dif- 
 ficulty of treatment consequent on difficulty of diagnosis. When above 
 symptoms are well-marked, trephining is clearly indicated. Then, if 
 brain is not found pulsating beneath exposed dura mater, that membrane 
 may be punctured. The knife has been plunged bodily into the brain it- 
 self, not without success. Operate antiseptically. 
 
 Hernia Cerebri.— Causes. — Wound of skull and dura mater, followed 
 by inflammation of part of brain immediately beneath it. More common 
 in children, and when aperture in skull is small than when it is large. 
 Pathology. — Inflammatory proliferation of connective tissue of brain, lead- 
 ing to a hernia of a substance whose structure is sometimes entirely like 
 that of granulation-tissue, brain-substance, and clotted blood, and some- 
 times of blood-clot only. Signs. — Hernia usually appears a few days after 
 injury, but may appear much later. Brown, or reddish-brown mass, pul- 
 sating synchronously with respiration, and increasing in size. Brain symp- 
 toms, sometimes very slight at first, are those of cerebral irritation and in- 
 flammation. In fatal cases, death ensues from the encephalitis. Prognosis 
 bad. Diagnosis. — From fungus of dura mater and fungus of cranium. 
 Former appears gradually, and is preceded by no fracture from external 
 
HEAD, INJURIES OF THE. 
 
 123 
 
 violence, latter does not pulsate. Treatment. — Protective and slightly 
 compressive. Shaving off is contraindicated. A hollow metal cap fitting 
 accurately. Any ordinary dressing, combined with compression by a soft 
 pad and bandage. 
 
 Compression and Concussion of Brain. — "Compression" and "Concus- 
 sion," two terms which represent each a peculiar and important assemblage 
 of symptoms, rather than a definite pathological state. Persons suffering 
 from concussion are, in common parlance, said to be stunned. Compres- 
 sion means a more alarming condition, in which the patient cannot be 
 aroused from stupor, and lies wholly or partially paralyzed. The presence 
 or absence of paralysis has been given as the distinguishing mark between 
 the two states. Still there are cases which partake so of the nature of both, 
 that no one would class them under either head, except persons endowed 
 with exceptional decision of character and indifference to both detail and 
 accuracy. The origin of the terms should always be borne in mind : 
 " concussion," of course, means " shaking " or " striking," and " compres- 
 sion " implies the pressure of something, e.g., blood, or pus, or bone, or 
 serum, on the brain. 
 
 Compression. — Pathology. — Depressed fracture of skull, extravasated 
 blood within the cranium, inflammatory thickening or oedema of the brain, 
 or pus within the cranium are found, besides in each case various condi- 
 tions such as are sketched in the above notices of contusion, intracranial 
 hemorrhage, inflammation, etc. Symptoms of Compression and Concus- 
 sion contrasted : 
 
 Compression. 
 
 1. Total insensibility. 
 
 2. Respiration stertorous, slow, and puff- 
 
 ing. 
 
 3. Pulse full, slow, labored. 
 
 Special senses paralyzed. 
 Pupils widely dilated, or, 
 
 sometimes 
 
 one dilated and the other normal or 
 contracted. 
 
 Stomach insensitive. 
 
 Sphincters may be paralyzed, but 
 bowels are torpid. 
 
 Bladder paralyzed. Consequent reten- 
 tion of urine. 
 
 Does not usually appear at moment of 
 injury, but afterward, and tends to 
 get worse. 
 
 Concussion. 
 
 1. Insensibility, from which patient can 
 
 usually be partly aroused. 
 
 2. Respiration feeble, like that of a person 
 
 in a faint condition. 
 
 3. Pulse weak, irregular, and often fre- 
 
 quent. 
 
 4. Special senses dulled. 
 
 5. Pupils variable but usually sensitive to 
 
 light. 
 
 6. Nausea as recovery is taking place. 
 
 7. Bowels relaxed, but sphincters not para- 
 
 lyzed. 
 
 8. Bladder can expel water. 
 
 9. Comes on instantaneously and passes off 
 
 gradually. 
 
 Concussion. — Pathology. — No thoroughly satisfactory evidence of con- 
 cussion's occurring without some bruising or laceration of the brain. 
 
124 HEAD, INJURIES OF THE. 
 
 Symptoms. — See table contrasting them with those of compression. Ter- 
 minations. — Recovery may be, and usually is, perfect ; or there remain 
 headaches, mental irritability, affections of the senses, weakness, impaired 
 virility, epilepsy. Concussion frequently passes into compression. See 
 Contusion and Laceration of Brain (p. 121). Treatment. — At first, warmth, 
 hot blankets, hot bottles, friction, and other gentle remedies for shock. 
 Alcohol contraindicated. And it should always be borne in mind that con- 
 cussion is not usually in itself dangerous, but that it is quite possible by 
 too vigorous and too stimulating a treatment to bring on hemorrhage or 
 inflammation. When reaction has taken place, if not before, precaution- 
 ary measures against hemorrhage, inflammation, etc., should at once be 
 adopted. See Precautionary Treatment of Fractures of Skull. 
 
 Treatment of Compression varies with the suspected or known cause, 
 whether extravasated blood, or depressed fracture, or inflammation, or 
 suppuration, or foreign body. But always attend to these points — 1, dark 
 room ; 2, head high ; 3, head shaved ; 4, head cool ; 5, low diet ; 6, see 
 that the bowels act freely, if necessary, placing a drop of croton oil in a 
 little sugar on the tongue. The treatments of inflammation and suppura- 
 tion are given above. The question of trephining for compression has 
 been answered in the affirmative or the negative, according as the intra- 
 cranial mischief is believed to be local and accessible or to be general. 
 But I am inclined to hold that the introduction of the antiseptic treatment 
 reopens this question, and that antiseptic trephining may be justifiable to 
 relieve general intracranial tension. 1 I must again also call attention to 
 the power of the cold douche long continued, e.g., for hours, over intra- 
 cranial inflammations. 
 
 Cerebral Irritation. — Pathology. — Probably laceration of brain. Symp- 
 toms.' 1 — Graphically described in Erichsen — 1, bodily ; 2, mental. Bodily : 
 attitude of general flexion — knees drawn up, elbows bent, etc. ; restless- 
 ness ; eyelids firmly closed ; no heat of head ; pulse weak and not fre- 
 quent ; rarely retention. Mental : irritable temper, desire to be let alone ; 
 muttering, frowning, grinding of teeth if disturbed. When these symp- 
 toms subside, the mind is left for a long time weak and fatuous. Treat- 
 ment. — On general principles ; rest, darkness, quiet, coolness, ice-bag, 
 patience. Chloral and even morphia may be given in some cases ; but 
 their effects should be keenly and cautiously watched. 
 
 IV. Injuries of Cranial Nerves. : — Causes. — Fractures of bones of skull, 
 extravasated blood, inflammatory effusion. Signs. — May be deduced from 
 consideration of functions of these nerves. Paralysis in most cases, spasms 
 in some. Disturbed nutrition of cornea and conjunctiva when fifth nerve 
 
 1 See Yeo, British Medical Journal, May 14, 1881 . 
 
 2 Not unlikely that the peculiarity of this set of symptoms is due rather to the part 
 
 injured than to the kind of injury. 
 
HERNIA. 125 
 
 is injured. Prognosis. — Usually unfavorable ; but when the paralysis or 
 spasms come on during attacks of intracranial inflammation, recovery may 
 take place on absorption of inflammatory effusion. Treatment.— 13 possible 
 remove the cause. Nerves most frequently affected are seventh and second 
 pairs. To complete these notes on injuries of the head, we must notice 
 traumatic osteitis of the cranial bones, which when acute is usually called 
 " inflammation of the diploe." Chronic osteitis of cranium follows any in- 
 jury (of course it is sometimes syphilitic) ; it may result in hypertrophy, 
 caries, or necrosis. Acute inflammation of cranium is very dangerous from 
 its liability to spread to membranes of brain. 
 
 Heart, Injuries of. See Injuries of Chest. 
 
 Hernia. — This word, which probably is derived from Greek ernos, a 
 shoot, is applied to the projection of a viscus through the wall of any of 
 the body-cavities, e.g., hernia cerebri, hernia of lung ; and, by extension, 
 it is given even to such phenomena as bulging of tunica intima of an artery 
 through an opening in the media and adventitia. But " hernia " used 
 without qualification refers only to hernia abdominalis. Causes. — Predis- 
 posing : 1. Sex, four times as often in males as in females. 2. Age, most 
 hernias develop before age of 35. 3. Occupation, habit of making violent 
 efforts. 4. Hereditary conformation, including patent tunica vaginalis 
 funiculi, abnormal laxity of mesentery, congenital defects of abdominal 
 walls. 5. General weakness of the system. 6. Excessive obesity and flab- 
 biness. 7. Pregnancy. 8. Defects in abdominal wall of traumatic origin, 
 cicatrices, etc. Observe that number 4 includes three causes. Cause 6 
 acts strongly if obesity rapidly diminishes. Exciting Causes.— Sometimes 
 a strain, or violent efforts often repeated. Cough. In male infants, the 
 application of a truss to an umbilical hernia may result in the production 
 of an inguinal hernia. Symptoms.— In earliest stage, merely "weakness " 
 locally, with slight fulness in erect position and impulse on coughing. 
 Then a soft, round or oblong tumor develops, reducible generally with a 
 gurgling noise. If containing omentum it is called " epiplocele," and may 
 be hard and lobulated. Hernise are opaque, and dull on gentle percus- 
 sion. Mode of appearance and growth, usually sudden in " congenital " 
 hernia, gradual in other forms. A hernia passes by a broad neck into the 
 abdomen. Subjective signs are dragging pains and dyspeptic feelings. 
 Herniae are often irreducible. Anatomy.— A hernia consists of (1) con- 
 tents, (2) sac, (3) coverings. Contents : intestine, omentum, or, more 
 rarely, one of the other abdominal or pelvic viscera, e.g., ovary, stomach, 
 gall-bladder. Fluid between sac and contents, variable in quantity. An 
 " enterocele " contains bowel only, an "epiplocele" omentum only, an 
 " entero-epiplocele " both. Sac is continuous with peritoneum. It is 
 identical with tunica vaginalis in " congenital " hernia ; but, in other cases, 
 is formed by gradual pushing out of a pouch of peritoneum. It consists 
 of a mouth, neck, body, and fundus. Mouth and neck are originally puck- 
 
126 HERNIA. 
 
 ered ; but, -with time, this puckering obliterates, and, still later, the neck 
 and mouth are apt to thicken and contract. Hence many cases of stran- 
 gulation. If a hernia be reduced before its sac has had time to grow old, 
 thickened, and adherent, the sac will be drawn up into the general peri- 
 toneal lining of the abdomen again. Diagnosis. — See special varieties of 
 hernia, especially inguinal and femoral. Prognosis. — In spite of the regu- 
 lar use of trusses, hernia usually persists throughout life. Fair prospect 
 of recovery in umbilical hernia of male infants, and in slight inguinal her- 
 nias promptly, patiently, and persistently treated. Congenital hernias are 
 most liable to strangulation, irreducible hernias to obstruction. Umbilical 
 hernias of women may attain enormous size, especially in fat, flabby women. 
 So also may other hernias, if neglected. Treatment. — Palliative, that is the 
 truss. Common truss, single or double, inguinal or femoral ; Salmon & 
 Ody's ; mocmain ; various pads, Wood's horse shoe pad, circular pyriform 
 and oval pads, water-pads, air-pads. Bag-trusses for irreducible hernia. 
 Spring of common truss encircles pelvis just below crest and anterior su- 
 perior spines of ilium. Salmon & Ody's has a ball-and-socket joint, with 
 a spring going half round body on side opposite to rupture. Mocmain has 
 a soft belt with a lever spring near the pad. Wood directs pad to be flat, 
 saying that rounded pads tend to dilate hernial apertures. For umbilical 
 hernia, pads with belts, corks, strapping, etc. See Umbilical Hernia. 
 
 Points to be noted in fitting a truss : 1, side of hernia (right or left) ; 2, 
 size of projection ; 3, size of hernial aperture ; 4, kind of hernia (inguinal 
 or femoral). Measurements : 1, girth of body midway between great tro- 
 chanter and anterior superior spine of ilium ; 2, distance between anterior 
 superior spine and hernial aperture ; 3, direction in which pressure should 
 be made. In fat, large-bellied people this is usually upward and back- 
 ward, in thin people it may be simply backward. The pressure of the 
 spring should be adjusted carefully. Infants should have two trusses, 
 that one may be worn while the other is being cleaned. Mocmain truss 
 probably most comfortable, but has very little strength. Persons who 
 have to make great efforts occasionally should have an extra strong truss 
 for such times. 
 
 Radical Cure of Hernia, Operative Treatment. — See Wood on Eupture, 
 or some large treatise on surgery. The operation is done only for ingui- 
 nal hernia. 
 
 Complications of Hernia, three primary ones, viz. : 1, obstruction ; 2, 
 strangulation ; 3, inflammation. Gangrene and ulceration are secondary 
 to one of these primary complications. 
 
 Obstructed Hernia. — In this condition the impediment to the transit of 
 fasces lies within the bowel, not external to it as in strangulation. But 
 the symptoms differ from those of strangulation chiefly in degree. When 
 obstruction is complicated with inflammation, diagnosis from strangulation 
 is very difficult. Umbilical hernise are the favorite seats of obstruction. 
 
HERNIA. 127 
 
 Pain, flatulence of tumor, increased tension and size of tumor ; on ma- 
 nipulation, gurgling may be produced and solid fecal matter felt. Fever- 
 ishness, nausea, vomiting. Treatment. — Poultices and aperient enemata. 
 Gentle purgations before vomiting occurs. 
 
 When an irreducible hernia is obstructed, it is sometimes called an 
 "incarcerated hernia." 
 
 Strangulated Hernia. — The herniated parts are so compressed at or 
 near neck of sac that the circulation of blood through their vessels and of 
 fecal matter through herniated intestine is obstructed. Predisposing 
 Causes. — Disordered or relaxed state of health. Sudden formation and 
 descent of a congenital hernia. Working without having the prudence 
 to keep up a hernia by a truss. Symptoms. — Local: pain, tenderness, 
 swelling, usually increased tension, uneasy feeling in hypogastrium, 
 dragging sensations from neighborhood of rupture. General : nausea, 
 anorexia, vomiting, constipation, tenesmus ; feverishness, flushed cheeks, 
 frequent pulse, furred tongue. Then vomiting gets worse, local tender- 
 ness increases, peritonitis comes on, patient collapses and dies. The 
 vomiting is rarely absent. It is of a characteristic nature. Large quanti- 
 ties of fluid are thrown out of the mouth with a sudden gush. This fluid 
 at first comes from stomach, then intestines, it is then called "fecal," 
 sometimes " stercoraceous. " Constipation is complete. Pathology. — Con- 
 striction of hernial tumor at point of strangulation, so that when the bowel 
 is liberated a distinct groove still remains, marking the line of stricture. 
 Changes which take place in strangulated bowel or omentum are, 1, con- 
 gestion and swelling ; 2, inflammation ; 3, gangrene. The signs of these 
 three stages will be given in describing the operation of herniotomy ; as 
 it is most important to bear them in mind during that operation. The 
 fluid in the sac will be described at the same time. Diagnosis. — Generally 
 easy. But, if the general symptoms of intestinal obstruction coexist with 
 any tumor in one of the recognized seats of hernia, unless that tumor is 
 known positively not to be a hernia, and unless the case is yielding to 
 other treatment, the surgeon should cut down upon the tumor. Very lit- 
 tle harm can result from the procedure. Strangulation is sometimes diffi- 
 cult to distinguish from mere obstruction with inflammation. In the 
 latter case there is less vomiting, always great local tenderness, and, in- 
 stead of absolute constipation, the occasional passage of flatus and liquid. 
 It is to be borne in mind that peritonitis may complicate without being 
 caused by a hernia. Treatment. — 1, Taxis ; 2, warm bath ; 3, opium ; 4, rest 
 in warm bed ; 5, anaesthesia ; 6, herniotomy. Although numbers 2, 3 and 
 4 are usually described as auxiliary to the taxis, I put them separately for 
 two reasons, viz.: 1, that they are in a few cases perfectly competent to re- 
 duce the hernia without the assistance of the taxis ; 2, that they are much 
 underrated now-a-days in consequence of the reaction against that sad 
 mistake which has allowed so many cases to pass beyond hope before 
 
128 HERNIA. 
 
 operation, and in consequence of the notion that these minor remedies act 
 only by relaxing the constricting bands ; whereas they may act directly on 
 the strangulated parts themselves by reducing the congestion and conse- 
 quently the size of the strangulated intestine. Some amount of circulation 
 must usually exist during the first stages of strangulation, or the intestine 
 would not live as long as it does. In every case, firstly make a short and 
 gentle application of the taxis. Secondly, give 20 minims of laudanum, 
 then a warm bath for a time proportional to patient's strength, and then 
 place him in bed between blankets. 
 
 Still keeping the patient warm in blankets, anaesthetise him, and try 
 the taxis gently again. If it fail this time, operate at once. The taxis. 
 Position of patient, supine with his legs drawn up. Bear in mind resist- 
 ing forces, viz. : 1, tightness of constricting ring or band, 2, swelling of 
 strangulated viscus. Manipulate hernia as nearly as possible into a line 
 with the axis of the ring which constricts it. Then compress it gently 
 but steadily and completely with the hands or with the fingers for a long 
 time. This may lessen its bulk. By-and-by, still keeping up this com- 
 pression with one hand, attempt with the fingers and thumb of the other 
 to manipulate the neck of the hernial tumor back into the abdomen. It is 
 said that in very thin persons assistance may be derived from insinuating 
 the finger end or nail beneath one edge of the constricting ring and pul- 
 ling it outward. When reduction takes place, bowel goes back suddenly 
 with a gurgle. Warm bath, average time twenty minutes. Laudanum, 
 dose twenty minims. Anaesthesia not only makes patient insensible to 
 pain of proceedings, but destroys any muscular resistance that he might 
 otherwise make. Practice of inverting patient during performance of 
 taxis. Aspiration of hernial tumor before taxis. 
 
 Herniotomy. — Usually classed as 1, herniotomy without opening sac ; 2, 
 herniotomy with opening sac. Both operations identical up to a certain 
 point. Scalpel, forceps, director, artery forceps, ligatures, retractors, hernia 
 director, hernia knife ; strong ligature to tie omentum. Empty blad- 
 der, shave, line of incision two to three inches long over neck of sac. 
 Observe the position of certain anatomical landmarks, e.g., spine of pubes, 
 Poupart's ligament, femoral artery. Skin may be divided by pinching up 
 and transfixing. Divide fascia, fat, and cellular tissue on director, layer 
 by layer down to sac. Before opening sac, feel for any constricting bands 
 external to sac and divide them if possible. If strangulation cannot be re- 
 lieved thus, proceed to open sac by pinching up a small part of it with 
 forceps and cutting it with knife held flatwise. Complete opening of sac 
 on a director. How to Distinguish Sac from Intestine. — The sac is a trans- 
 parent membrane without the special marks possessed by intestine, such 
 as arborescent arrangement of vessels, smooth, glittering surface, etc. It is 
 also thinner than intestine. The opening of the sac is almost always re- 
 cognized by the sudden escape of fluid. Division of Stricture. — Use left 
 
HERNIA. 129 
 
 index finger as a director, insinuate finger-nail under stricture, pass hernia 
 knife flat, along palmar surface of finger, through stricture, then turn its 
 edge upward and slightly inward and cut one-eighth to one-quarter of an 
 inch, i.e., a mere notch, no more. Reduction of the hernia is then effected 
 by manipulation like that of the taxis. If necessary the knife must be re- 
 introduced and the constricting band notched again. But there are certain 
 conditions under which it is not right to reduce the hernia after dividing 
 the stricture. It follows, of course, that when indications of these condi- 
 tions are present no attempt should be made to reduce a hernia without 
 opening the sac to see the actual state of things. Gangrenous bowel, bowel 
 manifestly ulcerated at the seat of stricture, and omentum inflamed or 
 bruised should not be returned into the abdomen. In the former two cases 
 an artificial anus will form. In the case of inflamed omentum its return 
 would probably set up general peritonitis ; therefore the practice is to tie 
 a stout ligature round its neck and cut the omentum off, merely leaving the 
 neck or stump of it to block up the hernial ring. Slight wounds of the 
 bowel do not contraindicate its reduction. The sides of a puncture can 
 be pinched up and ligatured. A larger wound would require the glover's 
 suture. Characters of the Serum in the Sac. — 1. Within a few hours, it is 
 pale yellow and clear. 2. After many hours, it becomes dark brown, but 
 clear. 3. When intestine is more inflamed, oedematous, and leathery, the 
 fluid is turbid and coffee-like. 4. As gangrene approaches, blood-clots, 
 lymph-flakes, and pus mix with the fluid. 5. When intestine gives way, 
 faeces and gas escape. Characters of the Intestine at Different Stages of 
 Strangulation. — First stage. Congestion, various degrees from mere swell- 
 ing and redness up to purple color with patches of extravasation, causing a 
 mottled look. Second stage. Inflammation, same appearances as those of 
 first stage ; but surface is dull and perhaps adherent, being covered wholly 
 or partially with lymph. Third stage. Gangrene ; more adhesive ; sur- 
 face duller ; color black or ashy ; sloughing and perforation about to 
 occur. 
 
 Artificial anus results when herniated bowel sloughs or is deliberately 
 and freely opened by surgeon. Possibility of former event happening- 
 even a week after reduction of hernia. Then adhesions prevent intra- 
 peritoneal extravasation. Pathology. — Two openings, one into intestine 
 above, other into intestine below. Former tends to enlarge, latter to 
 diminish. Tendency to prolapsus of mucous membrane. Irritation and 
 excoriation of skin. Spur between upper and lower portions of bowel. 
 Many cases recover spontaneously. When opening is high up in small 
 intestine, general nutrition suffers considerably by escape of chyle. Treat- 
 ment. — Zinc ointment round aperture ; bag to catch feces, or plug to retain 
 them temporarily ; cleanliness. When the condition persists, operate. 
 Divide spur gradually with Dupuytren's enterotome ; division should oc- 
 cupy several days. Then close artificial anus with hare-lip pins, after 
 
 y 
 
1 30 HERNIA. 
 
 paring edges. Fecal fistula is a very mild degree of artificial anus, which 
 usually closes spontaneously. Otherwise treat it on general principles. 
 
 Reduction en masse. — In the course of taxis, hernia disappears, but 
 symptoms of strangulation come on or remain. Bowel has slipped, not 
 back into peritoneal cavity, but sideways between peritoneum and muscles 
 of abdominal wall. Two varieties : in one, bowel bursts through a hole in 
 neck of sac ; in other, sac as well as bowel is misplaced. Signs. — If surgeon 
 himself causes the misfortune, he notes the absence of that sudden jerk 
 with which a hernia properly reduced usually disappears. The history 
 of the case points to the occurrence. Symptoms of strangulation remain 
 unrelieved. Treatment. — Operate ; open sac ; pull bowel out of its mal- 
 position ; divide stricture and reduce. An intra-parietal sac, a diverticu- 
 lum from the ordinary sac, sometimes exists. A hernia may be pushed 
 into it instead of into abdomen. 
 
 After-treatment of Herniotomy. — Chiefly negative. Rest in bed ; liquid 
 food till the bowels have acted ; opium unnecessary ; no purgatives; enema 
 if bowels do not act spontaneously within ten days. If peritonitis should 
 arise, it must be treated promptly and vigorously, like peritonitis from 
 other causes. 
 
 Irkeductble Hernia. — Causes. — 1, Adhesion ; 2, neglect of reduction 
 combined with hypertrophy of the herniated parts. Adhesions of the parts 
 uncovered by peritoneum make all hernia of the bladder and caecum 
 irreducible. Omentum is apt to become irreducible. Treatment. — Gradual 
 compression by a bag made to lace up, as advised by Langton. Combine 
 this with pot. iod. internally. 
 
 Special Hernia. — Birkett's classification : 
 
 I. In the Epigastrium. — 1. Diaphragmatic. 2. Epigastric. 
 
 II. In the Mesogastrium. — 1. Ventral (also in other regions). 2. Umbili- 
 cal. 3. Lumbar. 
 
 HI. In the Hypogastrium. — 1. In guino- scrotal (labial in female). 2. 
 Femoral. 3. Obturator. 4. Perineal. 5. Pudendal. 6. Vaginal. 7. Ischiatic. 
 
 Diaphragmatic Hernia.- — Three kinds, viz.: 1, congenital, left leaflet of 
 centrum tendineum usually absent ; 2, ordinary, abdominal viscera pass 
 through one of the naturally deficient parts of the diaphragm, usually 
 close to ensiform cartilage ; 3, traumatic, through a wound. Birkett adds 
 to these, cases of relaxed diaphragm bulging upward from pressure of 
 viscera below. Signs. — Malposition of viscera may be detected by ausculta- 
 tion and percussion. Occasionally symptoms of obstruction, strangulation, 
 or impeded respiration. Perhaps history of accident. J In traumatic and 
 congenital cases there is no sac. Prognosis. — Traumatic cases usually fatal. 
 Others may never even be suspected during life. Treatment. — Nil. 
 
 1 In one case the affected side of thorax was disproportionately large. — Garlik, 
 Pathological Transactions, 1879. 
 
HERNIA. 131 
 
 Epigastric and Ventral Hernia are to be recognized and treated on gen- 
 eral principles. 
 
 Umbilical Hernia. — Appears commonly either in infants or fat middle- 
 aged women. Umbilical hernia in infants, though termed "congenital," 
 differs from congenital inguinal hernia, in having to form its own sac by 
 pushing peritoneum before it. Coverings. — Skin, fat, and fascia usually 
 matted together. Neck of sac thickened and strong. Contents. — Various. 
 Stomach, small intestine, omentum. Often very large. Prognosis. — In 
 infants tendency is toward spontaneous cure. Obstruction a more com- 
 mon accident than strangulation. Treatment. — Cork and strapping ; pad 
 and bandage ; proper trusses or abdominal belts for severe cases. In 
 operating for strangulation divide the coverings very carefully. See also 
 treatment of hernia in general, above. 
 
 Inguinal Hernia, — Classification: I. Direct or internal. II. Oblique or 
 external, including (1) common or scrotal, (2) congenital, (3) funicular, 
 (4) infantile. Direct comes out internal to deep epigastric artery, i.e., in 
 triangle of Hesselbach. Oblique descends externally to deep epigastric 
 artery, i.e., comes down inguinal canal. Common scrotal hernia has a sac 
 altogether independent of tunica vaginalis, and usually lying anterior to it. 
 Congenital has for its sac the unclosed tunica vaginalis testis. Funicular.— =■. 
 "Hernia into the funicular process of the peritoneum," occupies the fu- 
 nicular portion of the tunica vaginalis, which peritoneal process has, in this 
 case, closed only at or near the external abdominal ring. Infantile or Encysted 
 Hernia. — This occurs when the tunica vaginalis is unobliterated from the 
 testicle up to the external abdominal ring. The sac lies enveloped in the 
 tunica vaginalis. "Hernia en bissac " is a kind of congenital hernia in 
 which the intestine has burst through a constricted part of the tunica 
 vaginalis. The tunica vaginalis may have been completely divided by a 
 septum at the seat of constriction before the hernia forced its way down- 
 ward. Bubonocele is an inguinal hernia which lies wholly in the inguinal 
 canal. Diagnosis of Congenital from the Ordinary Scrotal Hernia. — Congenital 
 hernia occurs in children and youths, appears suddenly, descends rapidly, 
 and envelops testicle. Ordinary hernia occurs in adult age, descends 
 slowly, and is separated from testicle. Infantile hernia, etc., are recognized 
 after death or during operation. In operating you divide, in common 
 scrotal hernia, congenital hernia, funicular hernia, hernia en bissac, one 
 serous layer ; in infantile or encysted hernia, three serous layers. In con- 
 genital hernia testicle is found in sac. Diagnosis of Hernia from other 
 Inguinal and Scrotal Swellings. — A. Inguinal swellings. — 1. Encysted hydro- 
 cele of cord, though often reducible, is otherwise altogether unlike a hernia, 
 being transparent, oval, very defined, and tense. 2. Undescended testis. 
 Testis is, of course, absent from scrotum. It gives the characteristic pain 
 on pressure, and is irreducible. Inflamed testis in this situation causes 
 symptoms like those of strangulated hernia. Still the vomiting is per- 
 
132 HERNIA. 
 
 sistent and continuous, not gushing. Diffused hydrocele of the cord, 
 hematocele of the cord, tumors of the cord, may, like elephantiasis scroti, 
 be left to the surgeon's common surgical knowledge and common sense 
 B. Scrotal swellings. — 1. Ordinary hydrocele. Begins at bottom of scrotum, 
 has usually no neck extending up into inguinal canal, is tense or fluctuat- 
 ing, transparent, without impulse, and generally of characteristic pyriform 
 or oval shape. But hernia and hydrocele may coexist. 2. Hematocele. 
 Cord defined, no impulse. Perhaps ecchymosis. 3. Varicocele. Worm- 
 like feel. Though reducible when patient is recumbent, yet appears again 
 when he stands up, in spite of finger placed over inguinal ring. 4. Tumors 
 of testis. Cord may be thickened but is usually clear. Testis itself in- 
 volved. Tumor heavy, opaque, perhaps hard and irregular. Of course no 
 impulse. Often pain. Treatment. — See that of hernia in general. Pad 
 of truss should cover whole of inguinal canal in oblique inguinal hernia, 
 and should never compress cord against pubes. In operating for strangula- 
 tion, constriction is mostly found either at neck of sac or at external ab- 
 dominal ring. 
 
 Femoral Hernia. — Hernia into the crural sheath. Almost always comes 
 through femoral, i.e., crural, ring. In a few rare cases has been seen ex- 
 ternal to femoral vessels. Occurs much more in women than in men. 
 But it must not be thought that inguinal hernia is uncommon in women. 
 In childhood and youth, hernia in females is almost always inguinal ; after 
 forty years of age it is usually femoral. For coverings, relations, etc., vide 
 books on anatomy. Signs. — General characteristics of hernia. Situation 
 of tumor : it appears below Poupart's ligament, just external to spine of 
 pubes, and, though at first descending, eventually turns upward and out- 
 ward in a direction parallel to Poupart's ligament. Femoral hernia is not 
 large usually, but occasionally attains an enormous size. Diagnosis. — 
 Sometimes difficult. From 1, enlarged glands ; 2, psoas abscess ; 3, varix 
 of saphena. Enlarged glands have no impulse, are often multiple, may 
 have an obvious cause, e.g., an inflamed bunion. Also they can usually be 
 felt to have no base like the neck of a hernial tumor. In psoas abscess 
 fluctuation can often be produced from one side of Poupart's ligament to 
 the other, that is from the thigh to the abdomen, and vice versd. It cannot 
 be reduced with a gurgle like a hernia. Manifest spinal disease may co- 
 exist. Varix probably extends some distance down saphena ; and, though 
 reducible in the horizontal posture, it rapidly returns in the erect, in spite 
 of the finger placed over the crural ring. Femoral and inguinal herniae 
 are distinguished from each other by their relations to Poupart's ligament 
 and the pubic spine, and by the state in which the inguinal and crural 
 rings are found. Although a femoral hernia may ascend, yet its neck is 
 always below Poupart's ligament. Prognosis. — Femoral hernia, very liable 
 to acute and fatal strangulation. Treatment. — Best truss probably moc- 
 main. In case of strangulation, flex and abduct thigh during taxis. In 
 
HIP DISEASE. 133 
 
 Operating, cut upward. Notch slightly because of danger of wounding 
 abnormal obturator artery. Seat of stricture may be falciform process of 
 Burns, Gimbernat's ligament, deep crural arch, or neck of sac itself. Use 
 of term "Hey's ligament" ought to be abolished as unnecessary and con- 
 fusing. 
 
 Obturator Hernia. — Very rare. Signs obscure. Fulness below Poupart's 
 ligament, beneath rather than internal to femoral vessels. Pain down 
 inner side of thigh. Femoral ring found normal. Age of patient usually 
 advanced. "Symptoms of obturator hernia may be those of chronic ob- 
 struction associated with emaciation." — Goodhart: "Pathological Transac- 
 tions," 1876. Operation for strangulation would be conducted on general 
 principles with due care of blood-vessels. It would resemble that for 
 femoral hernia, but fascia lata and pectineus would require incision. 
 
 Herpes. — A dermatitis resembling eczema, but different from it be- 
 cause the vesicular eruption is more marked and the actual cutaneous in- 
 flammation less marked than in eczema, and also because it runs a cyclical 
 course. Classified according to locality into herpes labialis, herpes pre- 
 putialis, etc., and according to form into common herpes, herpes circinatus, 
 herpes iris, herpes zoster. Causes. — Nervous origin of herpes zoster, con- 
 nection of herpes facialis with influenza and pneumonia, and of herpes 
 preputialis with temporary local irritation. (Eczema arises mostly from 
 chronic irritation.) Signs. — See definition. Vesicles appear in successive 
 crops, their contents grow turbid, then scabs form. These scabs fall off 
 within a fortnight. Burning pain. Febrile disturbance. Eruption may 
 correspond to distribution of some nerve. Herpes iris and circinatus 
 have smaller vesicles, spread concentrically, desquamate instead of scabbing, 
 and are usually of parasitic origin. Treatment. — Soothing and protective. 
 Cotton wool for herpes zoster. Zinc ointment for herpes preputialis. For 
 herpes circinatus (ring-worm), blistering fluid, which should be applied 
 quickly and then washed off at once with water. Ung. hydrarg. ammon., 
 or tinct. iodi., or lin. crotonis. See Alder Smith, on " Ring- Worm." 
 
 Hip Disease. — Morbus coxae. Disease of hip-joint. Causes. — Pre- 
 disposing are scrofula and the ages of childhood and early youth. Exciting 
 are local injuries, often very slight, and exposure to cold. Cause often un- 
 certain. Affections of the generative organs sometimes cause hip disease, 
 probably in a reflex manner. Varieties. — Hip disease has been divided 
 anatomically according as it affects the femur only or the acetabulum. In 
 many cases both are involved. Also it may be acute, subacute, or chronic. 
 Or it may be strumous or purely traumatic or rheumatic in origin. Prac- 
 tically it is rarely possible to say whether a given case is or is not strumous. 
 Some diseases of the hip-joint, e.g., chronic rheumatic arthritis, never 
 have the term "hip disease" applied to them. Symptoms. — Three stages : 
 1st, inflammatory ; 2d, stage of abscess ; 3d, stage of real shortening. In- 
 flammatory stage. Before the symptoms are well marked, the term " in- 
 
134 HIP DISEASE. 
 
 cipient" is used. Stiffness of joint. When patient lies on his back his 
 knee is bent upward. If an attempt be made to straighten it, the small 
 of his back becomes hollow, because the pelvis moves with the femur. 
 Wasting of limb, often a very early symptom : flattening of buttock and 
 obliteration of gluteal fold. Pain often referred to inner side of knee. 
 Pain is most severe when disease begins in the bone. Fulness over joint, 
 best marked when disease begins in synovial membrane. Apparent leng- 
 thening, sometimes apparent shortening, both due to rocking of pelvis. 
 Very rarely real lengthening, due to effusion into joint. Of course the 
 patient limps. 2d stage. Stage of abscess. The suppuration is some- 
 times entirely outside joint. Pus burrows, fluctuation occurs, sometimes in 
 one place, sometimes in another ; sinuses form. Probe very likely fails to 
 find dead bone. Sayre's vertebrated probe useful. Situation of sinuses 
 indicates situation of disease, whether acetabular or femoral (see " Path- 
 ology "). Before abscess opens, 3d stage has usually commenced. 3d stage. 
 Stage of real shortening. This results from the gradual destruction of head 
 and neck of femur by caries or necrosis, usually by caries. Top of tro- 
 chanter ascends above Nelaton's line, a line drawn from ant. sup. spine of 
 ilium to tuberosity of ischium. Abscesses or sinuses, lordosis, flexion of 
 thigh on abdomen, wasting of buttock and thigh and pain continue as in 
 former stages. The disease naturally terminates either in death from ex- 
 haustion or amyloid disease, or in recovery with ankylosis. The ankylo- 
 sis is in the flexed position and accompanied by a compensatory spinal 
 curve of the kind called lordosis. 
 
 Pathology. — Disease may begin either (1) in the bone near the joint, or 
 (2) in the soft tissues, synovial membranes, or ligaments of the joint. In 
 the latter case the disease is sometimes named " arthritic." It is a gener- 
 ally accepted doctrine now that the only joint disease which begins in the 
 cartilage is chronic rheumatic arthritis. For a description of the general 
 changes which take place in hip disease, see Diseases of Bones and of 
 Joints. Ligamentum teres soon gives way. Head of femur perishes by 
 caries or by necrosis. If acetabulum is affected, it is apt to perish par- 
 tially by necrosis, often becoming perforated. Even when head of femur 
 is destroyed remains of neck of femur rarely leave acetabulum. True dis- 
 location on dorsum ilii does occasionally occur, or, acetabulum being per- 
 forated, head of femur may slip through into pelvis. The natural tendency 
 is toward a cure by ankylosis. In acetabular disease, sinuses usually form 
 in buttock, or close to pubes. In femoral disease they usually open lower 
 down thigh, especially below and in front of great trochanter. Diagnosis. 
 —Most cases of hip disease are unmistakable. Sometimes difficult to dis- 
 tinguish incipient hip disease from other affections which cause pain about 
 the hip, accompanied by lameness, common rheumatism for example. In 
 fact many cases of hip disease do actually begin as rheumatic synovitis. 
 No disease of the parts about the hip causes such stiffness of the joint: 
 
HIP DISEASE. 135 
 
 that is a great point. Pain in the knee may lead off the attention to the 
 wrong place. Many affections, e.g., curvature of spine and hysteria, cause 
 rocking of pelvis and apparent shortening or lengthening. In healthy 
 people, the lower extremities are often slightly unsymmetrical. * But in 
 such persons if one leg is much shorter than the other, the feet will prob- 
 ably also be disproportioned. Comparative measurements should be taken 
 from ant. sup. spine of ilia to upper or lower end of patella or to inner 
 malleoli. Nelaton's line, Bryant's ilio-femoral triangle. Bryant's ilio- 
 femoral triangle is formed by a horizontal line across top of trochanter, a 
 perpendicular line from ant. sup. iliac spine downward, and an oblique 
 line from ant. sup. iliac spine to top of trochanter. The lines are equal 
 on both sides in normal persons. Enlarged bursa under psoas is very 
 rare ; and the pain, if present, is relieved not aggravated by flexing thigh 
 on abdomen. Hip- joint disease could hardly be accompanied by such 
 marked swelling over the joint without presenting characteristic and 
 marked symptoms. Hysteria must be diagnosed on general principles. 
 See Hysterical Diseases of Joints. It would really be a waste of space to 
 give the diagnosis of hip disease from psoas abscess, sacro-iliac disease, 
 and congenital dislocation ; for it may be assumed that the surgeon will 
 not try to diagnose a doubtful case without taking the patient's clothes off* 
 and manipulating carefully. Prognosis depends on stage of disease, origi- 
 nal constitution of patient, present condition of patient, on parts actually 
 diseased, and on age of patient. In first stage of disease, especially if 
 symptoms point to origin in joint itself, treatment may be expected to re- 
 sult in recovery with or without ankylosis in good position. Scrofulous 
 patients are very likely to become tuberculous elsewhere when the bone is 
 affected. When necrosis or caries has occurred, prognosis is very bad as 
 to life. It is worse in adults with acetabular disease. The only cases in 
 which recovery without ankylosis is to be reasonably looked for are those 
 in which the cartilage and bone have never been affected. Treatment. — 
 Rest of the joint essential. Sayre's splint is supposed to make rest in bed 
 unnecessary in many cases in which the disease has not too far advanced. 
 Extension by pulleys and weights (3 to 10 lbs., according to age and indi- 
 vidual peculiarity of patient). Long splint (long splint on sound side, 
 weight to diseased limb) ; Thomas' splint, plaster cases, leather cases, etc. 
 Treatment should be continued so long as there is any tenderness or sign 
 of active disease and for a little longer. Limb should be straightened 
 under chloroform, if weight fails to bring it down gradually and easily. 
 Inflammatory reaction after this manipulation may be treated by ice or by 
 hot poultice locally, according to which seems to act best. When there 
 are signs of struma, give cod-liver oil and iron. In suppurative stage, treat 
 abscesses and sinuses on general principles. Question of Excision. — When 
 
 1 See Garaon, Journal Anatomy and Physics. 1880. 
 
136 HYDROCELE. 
 
 suppuration continues, patient's exhaustion increases, and there is evidence 
 of bone disease ; and, especially if the patient's circumstances are so pooi 
 that he cannot get proper attention during long rest in bed, the surgeon 
 is justified in operating to remove the dead bone. Still the operation has 
 its dangers, and the resulting limb is likely to be shorter than after the 
 natural cure. Moreover it is very difficult, sometimes impossible, to thor- 
 oughly remove pelvic necrosis. For operation, vide article Excision. 
 
 Horns. — Vide Warts. 
 
 Housemaid's Knee. — See Burs.ze, Enlarged. 
 
 Hydatids occur in bones, breast, muscles, and other parts, and, in 
 surgery, are rarely diagnosed from other cysts till operation has let out 
 hooklets, etc. 
 
 Hydrocele. — An accumulation of serum forming a swelling in connec- 
 tion with the testicle or spermatic cord. Varieties. — 1. Hydrocele of the 
 tunica vaginalis testis (common hydrocele). 2. Hydrocele of the cord 
 (sometimes called " encysted hydrocele of the cord "). 3. Encysted hy- 
 drocele (frequently called " encysted hydrocele of the epididymis," or " of 
 the testicle "). 4. Diffused hydrocele of the cord. 5. Congenital hydro- 
 cele. 6. Infantile hydrocele. 
 
 Hydrocele of the Tunica Vaginalis Testis. — Causes. — Middle age, weak 
 constitution, and gout predispose. Injury and orchitis excite. In most 
 cases there has been no known exciting cause. Signs. — A scrotal tumor, 
 smooth, oval, pyriform, or globular (often constricted in the middle); elas- 
 tic, tense or fluctuating, transparent or semi-transparent (rarely quite 
 opaque). No connection with abdomen. Cord free near abdominal ring. 
 No impulse on coughing. Penis gets " absorbed," as it were, into tumor. 
 Diagnosis. — Vide Hematocele and Inguinal Hernia. Treatment. — 1, Pallia- 
 tive ; 2, radical cure. Palliative == tapping with trochar and canula, or mere 
 use of discutient lotions + suspensory bandage. In tapping, make out 
 position of testicle by palpation, by assistance of patient's sensations, and 
 by use of candle and stethoscope. Grasp tumor firmly in left hand, so 
 that testicle lies in centre of left palm. Plunge trochar obliquely upward 
 and backward into junction of middle and lower thirds of hydrocele. The 
 fluid usually collects again. Lotio ammonia? hydrochlor. ( 3 j. to § vj.) 
 used as a discutient. Eadical cure. — First empty the hydrocele, then in- 
 ject two drachms of port wine or of tinct. iodi and water, equal parts. Let 
 the injection flow out after a minute or two. Platinum canula should be 
 used for tinct. iodi. Lewis recommends carbolic acid and glycerine, aa, 
 3 ss., instead of iodine, and says it is less painful. Treatment by seton 
 not to be recommended. After-treatment. — Bed for two or three days. 
 Pathology. — A serous dropsy of the tunica vaginalis, probably of chronic 
 inflammatory origin. The radical cure acts by checking the secretion of 
 the tunica vaginalis, and rarely results in the production of adhesions. 
 
 Hydrocele of the Cord. — Its pathology is probably that of a dropsy of a 
 
HYDROPHOBIA. 137 
 
 small unobliterated part of the tunica vaginalis funiculi. It may some- 
 times be an independent cyst. Its appearances are quite characteristic. 
 It is transparent, feels like a pigeon's egg, only more elastic, and slips up 
 and down between the fingers with great mobility. You may fancy that 
 you have reduced it into the inguinal canal, when suddenly, in a humor- 
 ous way, it may be discovered half-way down the cord toward the testicle. 
 Occurs in the young. Diagnosis. — Only in rare cases, when it extends 
 right into inguinal canal, and patient is so fat as to hide transparency, can 
 this affection be mistaken for a hernia. Treatment. — Tap and inject with 
 tinct. iodi and water, equal parts. Before injecting be sure that the case 
 is not one of " congenital " hydrocele. 
 
 Encysted Hydrocele. — Signs. — Those of cyst attached to the testicle, 
 usually to the head of the epididymis. Pathology. — A cyst containing 
 sometimes pure serum, but frequently a mixture of serum and seminal 
 fluid. An opening has often been found between the seminal tubules and 
 the cyst. The cyst may originate from a dilated seminal tubule, or from 
 a dilated cavity in the connective tissue, or, according to Osborne, from 
 enlargement of the "hydatid of Morgagni." Treatment. — Same as that of 
 ordinary hydrocele. 
 
 Diffused Hydrocele of Cord. — Unknown to living surgeons. Described 
 by Pott. But hydrocele of cord sometimes receives this name if it forms 
 a long, rather ill-defined tumor. 
 
 Congenital Hydrocele. — Tunica vaginalis funiculi is open, as in hernia, 
 into tunica vaginalis testis, but. the open process contains peritoneal fluid 
 instead of intestine. Treatment. — Puncture with fine trochar, and then try 
 to close the opening by the pressure of a truss. 
 
 Infantile Hydrocele. — Occurs in infants in whom tunica vaginalis has 
 only closed at external abdominal ring. Treatment. — Discutient lotions. 
 Puncture. If it is certain that there is no communication with peritoneal 
 cavity, iodine injection may be employed in obstinate cases. Many cases 
 disappear with very little treatment. 
 
 Hydrophobia. — A disease which develops primarily only in the dog, 
 and from unknown causes ; but which is communicable by inoculation with 
 the saliva of dog, cat, man, or any other animal who may suffer from it. 
 
 Symptoms in Dog. — Two forms (or two stages?), viz.: 1, a raving mad- 
 ness ; 2, a quiet madness. Certainly these stages do sometimes follow 
 each other in the same dog. Or three stages may be distinguished : 1, of 
 dulness with restlessness ; 2, of fury ; 3, of paralysis. In the first stage 
 the animal wanders about in a fidgety, uncomfortable manner, is evidently 
 ill, and looks suspicious, unhappy, and distrustful. In the second stage, 
 much of the fury is evidently due to hallucinations. He bites, but it is 
 often at imaginary enemies, and he may still be mindful of his master's 
 voice. In the third stage, paralysis makes the voice muffled or inaudible, 
 the jaw drops, and the legs totter and fail. Finally death comes from ex- 
 
1 38 HYPERTROPHY. 
 
 haustion. The mad dog rarely shuns water, but laps it without swallow- 
 ing. 
 
 Hydrophobia in Man. — Proportion of bitten cases attacked, estimated 
 by Trousseau at one in two, by Billroth at one in twenty ! Period of in- 
 cubation : six weeks to more than a year. Rarely less than six weeks. 
 Symptoms. — Firstly, great irritability, excitement, and restlessness. Spasms 
 on attempting to swallow occur sometimes, but rarely, in this stage. Irrita- 
 bility and sensitiveness to light, sound, etc., increase and become excessive. 
 Soon the slightest causes produce spasms. Then gradually comes the fear 
 of water, together with unspeakable thirst. Sleeplessness. Terror of the 
 spasms and their causes. Actual madness occurs rarely. Appearance of 
 most fearful anxiety. Hoarseness. Frothing at the mouth. Severe tetanic 
 spasms now, from time to time, suspend respiration ; and, finally, in one 
 of these, the patient dies asphyxiated. Note the different ways in which 
 death occurs in the dog and in man, for in the former it comes by ex- 
 haustion. Diagnosis. — 1. From tetanus. In tetanus there is a certain 
 amount of persistent spasm, in hydrophobia there are intervals of complete 
 relaxation. Tetanus is also a quiet disease, so to speak, and is unac- 
 companied by horror of water, even although the sufferer may be unable 
 to drink. 2. From hysteric or neuromimetic hydrophobia. In the sham 
 disease there is dysphagia, but no alarming spasm of the respiratory mus- 
 cles. Prognosis. — Hopeless. Pathology. — Congestion of spinal cord has 
 been observed with collection of leucocytes around the capillaries. Treat- 
 ment. — All remedies hitherto tried have been vain. Suffering may be 
 alleviated by rest, darkness, and perhaps by anaesthetics. Try tracheotomy. 
 With regard to prophylaxis, cauterization should be done, early if possible, 
 but better late than never. Surgeons of great ability have named various 
 limits of time at which they say cauterization ceases to be of any use. 
 These limits differ considerably, and, in my humble opinion, it has yet to 
 be shown on what sufficient grounds they have been fixed. One may ask 
 for demonstration that the poison does not remain near the wound during 
 the period of incubation. Cauterization may be painful and obnoxious ; 
 but what are these considerations when compared with the faintest chance 
 of preventing the most horrible of diseases? Vesicles ("lyssi") appear 
 near frsenum linguae between third and twentieth day after bite. It has 
 been recommended to examine patient twice a day during this period, 
 and lay open and cauterize the lyssi as they appear. Trousseau supports 
 this recommendation. 
 
 Hypertrophy. — Increase in size of the tissues of a part, not the mere 
 natural result of growth in youth. Sometimes accompanied by increased 
 development of the individual microscopic constituents of the tissue : e.g., 
 when the gravid uterus enlarges, the individual muscle-cells also grow. 
 Causes. — Exercise, irritation, hypersemia, general over-feeding, special 
 over-feeding, certain special diseases. Irritation may be direct or indirect. 
 
HYSTERIA. 139 
 
 An example of indirect irritation as a cause is hypertrophy of breast from 
 uterine irritation. Irritation certainly acts partially, if not wholly, by pro- 
 ducing hyperaemia through reflex inhibition of vaso-motor system. By 
 special over-feeding is meant the excessive deposit of fat which may result 
 from taking fat-forming food to excess. As examples of hypertrophy from 
 special diseases, may be cited the large joints of rickety children and the 
 thickened skin in elephantiasis scroti. Treatment. — Kemove cause. Favor 
 venous circulation. Pressure. Treat special diseases. Operative meas- 
 ures. Vide various articles in this book on hypertrophy of particular or- 
 gans and parts. 
 
 Hysteria. — Hysteria is, according to custom, held to be in the prov- 
 ince of the physician, and the surgeon is called in when " this protean 
 malady " assumes the outward form of surgical disease. Hence the best 
 general articles on hysteria are to be found in medical treatises. From 
 the surgeon's point of view, Mr. Savory treats the subject graphically in 
 Holmes's "System," vol. i. Its essential nature. Paget has called it 
 " madness of the spinal cord ; " but its phenomena are, perhaps, more 
 easily explained on the supposition that it arises from "a nutritive de- 
 rangement of the general nervous system, both central and peripheral." 
 (Hasse, as quoted by Niemeyer). Causes.— No doubt a congenital predis- 
 position often exists. In most cases there is certainly to be found an ex- 
 citing cause in the form of chronic irritation of some system or organ of 
 the body, usually the genital organs. Uterine infarctions, ulcerations, and 
 flexions. Ovarian diseases. Abnormal sexual irritation, onanism. If you 
 want to cure your patient, do not let modesty or benevolent belief in hu- 
 man nature blind you. Do not ignore those causes which undoubtedly sec- 
 ond what is usually the prime cause ; but there is much less fear of this 
 error than of the error which consists in being satisfied with the discovery 
 of some psychical explanation of a given case, e.g., excessive intellectual ex- 
 ertion, or unhappy married life. The surgeon must judge the causation 
 from objective symptoms. Slight degrees of hysteria are not at all uncom- 
 mon in men ; but almost all marked cases occur in women. Usual age from 
 twelfth year to twentieth, and again at the "change of life." Sedentary 
 occupation. Town life. Bad training in childhood. Signs. — 1. Derange- 
 ments of sensibility. General hyperesthesia, "nervousness." Great acute - 
 ness of the senses. Idiosyncrasies. Desires for peculiar foods, objections 
 to common foods, etc. Neuralgias. Painful and tender breasts, migraine, 
 face-ache, and other pains. Clavus hystericus — that is, pain in one small 
 point in the head. Tenderness of the back. Severe pains and exquisite 
 tenderness in some joint or other. In contrast with above symptoms are 
 the frequent cases of real or pretended anaesthesia. Difficult to tell 
 whether some cases of hysterical anaesthesia are real or sham. Unnatural 
 consciousness of the actions of healthy organs of the body. Palpitations. 
 Sense of weight in epigastrium during digestion. Great thirst. Frequent 
 
140 IMPETIGO. 
 
 desire to pass water. 2. Hysterical convulsions. These vary in intensity 
 from slight local spasms to severe general spasms with opisthotonos or 
 other convulsive curvature of the spine. In these attacks patient never 
 loses consciousness. Yawning, laughing, crying, globus hystericus. Eruc- 
 tations. 3. Curvature of the spine. Affections of joints. 4. Derange- 
 ments of vaso-motor system. Cold hands and feet. Sudden and prolonged 
 flushing of the face. Hyperemia of kidney, causing large flow of limpid 
 urine, " urina spastica." 5. Mental symptoms. Rapid alternations between 
 grave and gay. General tendency is toward depression. Craving for sym- 
 pathy. It is this craving, probably, which produces a tendency to exagge- 
 ration and malingering. Of course all the above remarkable symptoms 
 cannot be looked for in the same case. Diagnosis. — Hysteric imitations of 
 organic disease are always imperfect ; because hysteria, if one may be 
 allowed to personify it, is quite ignorant of pathology and knows little of 
 anatomy. Hence pain rarely confines itself with accuracy to any defined 
 anatomical structure or region. In hysteric joint affections the skin over 
 the joint is often exquisitely tender, while deep, firm pressure upon the 
 joint itself may cause little or no pain. At the same time the limits of 
 that portion of skin which is tender bear no relation to the distribution of 
 any known nerve or vessel. Subjective symptoms last even for years with- 
 out producing any corresponding alterations in the structure of the affected 
 part. A hysterical patient describes her sufferings in a characteristic way. 
 It is not difficult to make her smile and talk with cheerfulness and liveli- 
 ness even when the subject is pain which she describes as "agonizing," 
 " unendurable," "excruciating." Hysteric spasms disappear under anaes- 
 thetics and often also during sleep. There are, also, concomitant general 
 signs of hysteria. Prognosis. — Some cases of hysteria resist all treatment. 
 Many of these have one foot across the narrow line which separates hysteria 
 from insanity. Treatment. — Treat the cause, whatever that may be. Moral 
 treatment : encourage and lead the patient to exercise her will. Hysteria 
 often attacks persons who have never in childhood been taught to con- 
 trol themselves. Sea-bathing, cold shower-baths, early rising, open-air life, 
 tonics, bromide of potassium. "Antispasmodics," valerian, asafcetida. 
 Electricity is invaluable in treating many neuromimetic {i.e., hysteric) dis- 
 eases. Contracted joints may be extended under ether and then fixed by 
 splints. For Hysteric Paralysis, try metallotherapy. 
 
 Impetigo. — It is nearly allied to eczema, and eruptions are common 
 which are intermediate between the two. But impetigo is a pustular, not 
 a vesicular disease, and forms thick crusts and scabs. Causes. — Chronic 
 irritation ; for instance, "grocer's itch," an impetigo of the hands, is caused 
 by constant contact with sugar. Dirt, lice, contagion, syphilis. Situation. 
 Usually head, hands, or face. Pustules usually correspond to hair-follicles. 
 Syphilitic impetigo occurs in large patches. Treatment. — Poultice to 
 fetch off scabs. Ung. zinci ; ung. hydrarg. ammon. ; ung. sulphuris, and 
 
IMPOTENCE. 141 
 
 mixtures of these ointments. Treat general health, and syphilis if present. 
 Sulphur baths. 
 
 Impotence. — Incapacity for sexual intercourse. Note the difference 
 between this definition and that of sterility. Impotence occurs in wom- 
 en as well as men. Causes. — 1. Original malformation of copulatory or- 
 gans ; marked epispadias or hypospadias ; absence or occlusion of vagina 
 and double vagina. 2. Accidental deformity of copulatory organs ; am- 
 putation of whole penis ; occlusion or obliteration of vagina by cicatricial 
 contraction. 3. Organic affections of the less superficial genito-urinary 
 organs ; spermatorrhoea ; varicocele ; castration. 4. Nervous influences. 
 The condition called " irritability with weakness " usually depends on both 
 third and fourth class of causes. When impotence is not the effect of 
 visible malformation, it almost always is the result of masturbation, very 
 rarely of sexual excess. Masturbation usually leads, in the first place, to 
 "irritability with weakness." Here ejaculation takes place before entrance 
 is effected, or else erection is impossible, and, consequently, copulation 
 impossible. This condition is not always the result of masturbation. 
 Disgust for the female, or the fear of sin or of contagious disorders, 
 doubtless causes it in some cases. Signs and Prognosis. — Some are given 
 in the preceding paragraphs. Sometimes the genitals are flabby, cold, and 
 small. If, in such cases, erections never occur, not even in bed in the 
 morning, the prognosis is not very good. But so long as erections occur 
 at all, the prognosis is very hopeful. Treatment. — Four principles : 1, 
 strengthen general health; fresh air, sleep, moderation in all things — in 
 exercise, in diet, and in mental work ; 2, avoid all unnatural excitement of 
 genital organs ; 3, treat any physical defect which can be found. If there 
 is the slightest sign of varicocele or relaxation of scrotum, give patient a 
 suspensory bandage; 4, to complete the cure — at all events, to demon- 
 strate the cure to the patient — requires the moderate and regular practice 
 of sexual intercourse for a short time. Of course, it is right that this 
 should be done in the marriage state. Paget writes : "Some will expect 
 you to prescribe fornication. I would just as soon prescribe theft or 
 lying, or anything else that God has forbidden. Celibacy does no harm 
 to mind or body ; its discipline is excellent : marriage can be safely 
 waited for." If the patient is already married, attend to the first three 
 indications, give some mysterious and harmless medicine, and forbid in- 
 tercourse for three weeks. "The nonchalance that he thus acquires 
 during sexual excitement, and inattention to the strength and duration of 
 the erections, render cohabitation possible, and he has the first successful 
 coitus during the time it was forbidden." Lallemand's porte-caustique. 
 A solution of argent, nit. (gr. v. to | j.) is applied to prostatic part of ure- 
 thra every day. This is a treatment now unjustly neglected. Faradiza- 
 tion of inner surface of thigh, of testicles, and lower part of spine. Con- 
 stant current to spine. "Positive pole over fifth dorsal vertebra, negative 
 
142 INFLAMMATION. 
 
 over sacrum, or perinaeum. Three or four sittings a week, one to three 
 minutes each." Battery, 20 to 30 Daniel's elements of medium size. 1 
 
 Incontinence of Urine. — Differs very much in cause and treatment, 
 according as it occurs in children, hysterical young people, or in adults. 
 Causes. — 1. In children : either wilful laziness or a genuine disease, prob- 
 ably partial anaesthesia of bladder. More remote causes are worms, cal- 
 culus, and struma. 2. In hysterical girls : vide causes of hysteria. 3. In 
 adults : a distended state of bladder, the result of paralysis. Those cases 
 in which the urine can only be retained in the bladder for a short time 
 may be classed with Irritability of the Bladder, quod vide. Treatment. — 
 1. Of incontinence in children : remove the cause ; treat the patient kindly, 
 rather encourage than frighten him ; avoid corporal punishment in chil- 
 dren ; flannel clothing at night ; wake the child every three hours to mic- 
 turate ; try cold douche to spine every morning. Extractum belladonna, 
 gr. -J, or tinct. belladonna, TTj, x. ter die. Tonics ; strychnine, canthar- 
 ides, chloral at bed -time. For hysterical incontinence, treat the hysteria. 
 Cold sitz-baths. For incontinence from paralysis, see Bladder, Paralysis 
 of. Incontinence also arises from enlargement of middle lobe of prostate. 
 See Prostate, Hypertrophy of. 
 
 Inflammation. — Definition. — When a structure is attacked with in- 
 flammation, there is active hyperaemia of the part itself, accumulation of 
 leucocytes outside its blood-vessels, and a disturbance of its nutrition. In 
 the case of a non-vascular part, the hyperaemia is in its immediate neigh- 
 hood, and, perhaps, the increase of corpuscles is due to the division of the 
 proper corpuscles of the part. So far there is nothing in the above defi- 
 nition to distinguish inflammation from the process of repair. And there 
 can be no doubt that the word " inflammation " is constantly used to name 
 action which is identical with the process of repair, e.g., in the case of 
 most slight localized " inflammations " terminating in what is called " ad- 
 hesion. " Inflammation is usually defined from " repair " by saying that 
 it is " an excess of action." This definition appears to be scarcely satisfac- 
 tory. When the surgeon says that a wound is inflamed, in ninety-nine cases 
 out of a hundred, if not in the whole hundred cases, the state of things 
 is probably this: Processes identical with those necessary to "repair" 
 have begun around the lymph-capillaries near the wound ; whereas the ac- 
 tion ought to have been confined to the actual base and borders of the 
 wound itself. The term inflammation, as commonly used in surgery, thus 
 does sometimes mean an excess of action, and sometimes means action 
 which it would be absurd to call excessive, as, for instance, in the very lo- 
 calized "inflammation" which so often prevents extravasation of faeces 
 through a wound of intestine. In the latter case the phenomena of " inflam- 
 mation " cannot be shown to differ from " repair." In the former they differ 
 
 1 See Dreschf eld, Practitioner, vol. xiii , p. 360. 
 
INFLAMMATION. 143 
 
 in this respect, namely, that the processes have spread from the region 
 where they might have been useful to the vessels around the neighboring 
 lymphatics, where they are worse than useless. 
 
 Caution. — I do not recommend the student under examination to trouble 
 himself about the immediately foregoing remarks. He will find most 
 safety in merely speaking of inflammation as a" perverted vital action " or 
 "modified nutrition," and then plunging instantly into a description of its 
 observed phenomena, etc. 
 
 Causes. — A. Predisposing : 1, plethora, especially if coincident with a 
 w r eak circulation ; 2, local congestion ; 3, impurity of the blood, such as 
 arises from kidney or lung disease ; 4, alcoholism ; 5, chronic inanition 
 (? does this cause inflammation or only modify it in an evil manner) ; 6, 
 atheromatous arteries ; 7, defective innervation ; 8, bodily state left after 
 certain zymotic diseases, e.g., measles and typhoid; 9, specific "diatheses,'* 
 e.g., gouty, strumous, and rheumatic ; 10, congenital peculiarities. The 
 above list could be amplified ad infinitum by going into detail, e.g., Cause 
 2 includes all the causes of oedema and dropsy, varicose veins, pressure of 
 tumors on veins, etc., etc. B. Exciting causes : 1, physical ; 2, chemicaL 
 Both these may be either of external or internal origin, e.g., a joint may 
 inflame from the physical irritation of a contusion, or of a loose cartilage, 
 or from the chemical irritation of an iodine injection or of gouty products. 
 The common practice of classing quite separately the morbid products of 
 the body itself is illogical ; for these products act either physically or 
 chemically ; 3, injuries or diseases of nerves ; 4, specific influences. Phys- 
 ical causes include blows, wounds, strangulation, etc. ; chemical include 
 effects of strong acids and alkalies, and of septic material. An example of 
 inflammation following nerve-injury is that of the eyeball which follows in- 
 jury of the ophthalmic nerve. Specific influences are such as syphilis, 
 small-pox, and measles. The action of heat and cold are partly chemical 
 and partly physical. 
 
 Phenomena. — Classical signs : pain, heat, redness, swelling. Pain. — 
 results from either tension or compression of nerve-fibrils. Its character 
 and intensity vary with the locality. Osteitis causes aching, phlegmonous 
 erysipelas causes throbbing pain, and superficial inflammations produce 
 burning, tingling pains. With pain is associated tenderness. In the 
 nerves of special sense, special sensations take the place of pain, e.g., tin- 
 nitus aurium in catarrh of the tympanum, while the intolerance of light in 
 ophthalmia is analogous to tenderness. Pain is often diffused, e.g., pain 
 throughout one side of face and head in toothache ; or reflected, e.g., pain 
 in knee from hip disease. Heat, — Inflamed parts, except in very chronic 
 cases, feel sensibly hotter than normal. According to Mr. Simon and Dr. 
 Montgomery, the blood leaves the inflamed part hotter than it enters it, 
 and the inflamed part is hotter than either the blood which flows into it or 
 the blood which flows out of it. Continental observations on this question 
 
144 INFLAMMATION. 
 
 have been numerous and conflicting. The subject of rise of general bodily 
 temperature is noticed under the head of Fever. Redness. — Due to hyper- 
 emia. Bright when there is active fluxion of blood to the capillaries of 
 the part, as is usual in acute inflammations ; dull, perhaps blue or brown- 
 ish red, when the congestion is more passive, as is usual in chronic inflam- 
 mations. When a non-vascular part inflames, the redness is observed in 
 the neighboring vascular region from which the inflamed part derives its 
 nutrition. Swelling. — Partly due to congestion, partly to effusion. Effu- 
 sion resembles in character liquor sanguinis, but it contains excess of 
 chloride of sodium and of phosphates. It also contains leucocytes and 
 even red blood-corpuscles. As a consequence of excess of chloride of 
 sodium in the effusion, there is a deficiency of that salt in the urine. The 
 characters of the effusion differ in different inflammations ; especially vari- 
 able is the amount of fibrin e. 
 
 Pathology. — Microscopic observation of an inflamed part, e.g., the web 
 of a frog's foot which has been exposed to irritation, shows appearances 
 which may be described under three heads, viz. : 1, disorder of circulation ; 
 2, exudation ; 3, stasis. After describing these, I shall consider the struc- 
 tural changes which tak« place in the constituents of the inflamed part. 
 1. Disorder of Circulation. — Dilatation of the arteries is the first phenom- 
 enon observed in an inflamed region. It is ordinarily preceded by no an- 
 tecedent contraction. It increases gradually for ten or twelve hours, and 
 remains at its maximum for many hours. Dilatation of the veins follows 
 at a long interval of time. The rate of circulation at the commencement 
 is increased, but this soon changes to the very reverse, viz., abnormal slow- 
 ness. The cause of the vascular dilatation is undetermined, but a very rea- 
 sonable hypothesis attributes it to inhibitory nervous influence. Billroth 
 thus states this view : " We actually know such phenomena from phys- 
 iology ; the obstruction of the heart's action by irritation of the vagus 
 nerve, of the movements of the intestines from irritation of the splanchnic 
 nerves, etc. Here a vaso-motor nerve-system is supposed which arrests the 
 contraction of the muscles ; could not such a vaso-motor nerve-system also 
 be supposed for the vessels — nerves, irritation of which lessens the tone of 
 the muscles of the vessels and thus renders the walls less capable of resist- 
 ing the pressure of blood ? " That local nerves have an unquestionable in- 
 fluence over the circulation in inflamed parts has been experimentally 
 proved (see Holmes's "System," vol. v., pp. 735-6-7-8). Ammonia when 
 used as an irritant to excite inflammation has this exceptional property— it 
 excites a preliminary arterial contraction before the ordinary vascular dilata- 
 tion. 2. Exudation. — As soon as the rate of circulation begins to slacken, 
 white blood-corpuscles or leucocytes begin to accumulate and loiter along 
 the side of the minute veins and capillaries. "In this way the vein be- 
 comes lined with a continuous pavement of these bodies, which remain al- 
 most motionless, notwithstanding that the axial current sweeps by them 
 
INFLAMMATION. 145 
 
 as continuously as before, though, with abated velocity. Now is the mo- 
 ment at which the eye must be fixed on the outer contour of the vessel, 
 from which (to quote Professor Cohnheim's words), here and there, minute, 
 colorless, button-shaped elevations spring, just as if they were produced by 
 budding out of the wall of the vessel itself. The buds increase gradually 
 and slowly in size, until each assumes the form of a hemispherical projec- 
 tion, of width corresponding to that of a leucocyte. Eventually the hemi- 
 sphere is converted into a pear-shaped body, the stalk end of which is still 
 attached to the surface of the vein, while the round part projects freely. 
 Gradually the little mass of protoplasm removes itself farther and farther 
 away, and, as it does so, begins to shoot out delicate prongs of transparent 
 protoplasm from its surface, in no wise differing in their aspect from the 
 slender thread by which it is still moored to the vessel. Finally, the thread 
 is severed and the process is complete. The observer has before him an 
 emigrant leucocyte" (Burdon-Sanderson). But although all the leucocytes 
 observed outside the vessels in the earlier stages of inflammation have prob- 
 ably escaped from the vessels, there is still reason to believe that later ac~ 
 cumulations of them are partially due to proliferation of the extra-vascular 
 corpuscles. 3. Stasis. — The phenomena of stasis occur at an uncertain 
 time during the course of inflammation, but they are not, as is sometimes 
 stated, the first in order of occurrence. They are twofold; firstly, the 
 blood current stops altogether, after getting gradually slower and then os- 
 cillating ; secondly, the colored corpuscles cohere to one another, and ad- 
 here to the sides of the vessels till they form an accumulation so dense 
 that the capillaries seem to contain no liquor sanguinis, but only corpuscles. 
 As similar occurrences take place even when milk is substituted for blood, 
 and as the blood drawn in inflammation shows no special arrangement of 
 its corpuscles, it is assumed that the phenomena of stasis are due to a 
 changed condition of the walls of the blood-vessels. 1 
 
 Structural Changes which Take Place in Constituents of Inflamed Tissues. 
 — In non-vascular tissue, such as that of the cornea and of cartilage, 
 the proper cornea and cartilage corpuscles proliferate. But numbers of 
 leucocytes migrate from the vessels around the cornea into its substance. 
 In cartilage the cartilage-cells multiply by division, and then cause the 
 absorption of the stroma in which they lie. In tendon and in muscle sim- 
 ilar changes have been observed. In the case of parts lined with epithe- 
 lium, such as mucous and serous membranes and glands, it is probable 
 that the greater part of the corpuscles of the inflammatory new formation 
 
 1 If the vascular walls permit much of the liquor sanguinis to leak through them, 
 the speed of that which remains in the vessel will be slowed. It is easy to see how re- 
 tardation of the current of liquor sanguinis would allow leucocytes to accumulate, be- 
 cause of the absence of the normal force which ordinarily washes them along the 
 blood-vessels.— See St. Bartholomew's Hospital Reports, 1878, p. 299. 
 10 
 
146 INFLAMMATION. 
 
 are escaped leucocytes ; but, at least in the case of epithelial membranes, 
 proliferation of epithelium appears to have been observed. 
 
 Further changes are described under headings noticed in the following 
 paragraph. 
 
 Terminations of Inflammation. — 1, Resolution ; 2, adhesion or organiza- 
 tion ; 3, suppuration, including abscess ; 4, ulceration ; 5, gangrene or 
 mortification. These processes are described respectively under the fol- 
 lowing heads : 1, 2, and 3, Wounds, Repair of ; 3, Abscess ; 4, Ulceration ; 
 5, Gangrene. 
 
 Treatment of Inflammation. — Consider it under heads — A, indications ; 
 B, remedial agents ; C, differences according to whether a case is acute or 
 chronic. A. Indications : 1, to remove all sources of irritation and all 
 predisposing causes ; 2, to lessen local action ; 3, to guard against or treat 
 promptly all complications, or evil consequences ; 4, to support the pa- 
 tient's strength during prolonged and exhausting cases ; 5, to relieve pain. 
 B. Remedial agents. These are either local or general. Local agents — 
 rest, cold, bloodletting, pressure, ligature or compression of artery sup- 
 plying inflamed part, incisions, antisepsis, warmth with moisture, astrin- 
 gent and stimulating drugs, counter-irritation ; and certain other agents 
 which will be noticed in considering the treatment of chronic inflamma- 
 tion. Constitutional agents are : rest, bloodletting, dieting, stimulation, 
 drugs, mercury, antimony, aconite, belladonna, purgatives, diuretics, colchi- 
 cum, iodide of potassium, quinine, opium, other anodynes ; diaphoresis ; 
 " spinal " ice-bags. Some of the agents in the above list overlap one 
 another, e.g., " diaphoresis" partly includes " antimony ;" but it is impos- 
 sible to devise a satisfactory list without this fault. 
 
 Best. — Bed, splints, slings, cradles, bandages (starch, plaster-of -Paris, 
 paraffin, glue, gum, silicate of potash). Position : elevation. Flexion or 
 extension. See Joint Diseases and Fractures. Gold. — Ice-bags, bags 
 through which a continuous stream of cold water can be made to pass, 
 irrigation, cold douche, wet-packing, evaporating lotions. Excessive cold 
 with wet involves danger of frost-bite. Local Bloodletting.— Leeches, cup- 
 ping, dry cupping, 1 incisions, scarifications, punctures, local venesection 
 (i.e., pricking veins near inflamed part). Pressure. — Bandages with sub- 
 jacent layer of cotton-wool ; elastic bandage, pressure regulated by means 
 of india-rubber bags containing water, 2 shot bags. Ligature, compression 
 or acupressure of artery of inflamed part or main artery of limb. Neudorfer 
 says eight minutes of pressure, three or four times a day, suffice. In- 
 cisions. — Though mentioned above in connection with local bloodletting, 
 are yet more frequently used to relieve tension. Extent and depth vary ; 
 usually they are about 1£ in. long by £ in. deep. Avoid vessels and nerves 
 
 1 Of course the dry-cupping is not really bloodletting, but its action is similar. 
 
 2 See Lancet, November, 1878. 
 
- INFLAMMATION. 147 
 
 of any size. Cut in axis of limb. Antisepsis. — See Antiseptic Treatment 
 and Wounds. Warmth with Moisture. — Poultices, fomentations, water-dress- 
 ing, spongiopiline. Astringent and Stimulating Drugs. — Extract of bella- 
 donna and glycerine, equal parts ; silver nitrate, tannic acid, and all the 
 various astringent, stimulant, caustic, and sedative drugs used in cutaneous 
 and throat medicine. Counter-irritation. — Vesicants, caustics, cautery, 
 moxa, issues, setons, friction, shampooing, poultices. 
 
 Constitutional Agents. — General Bloodletting. Indications for : Severe 
 inflammations of the contents of the head or thorax, following compara- 
 tively slight injuries and attended with a frequent, full, and hard pulse. 
 The bleeding should be full and free from a large vein (e.g., median-ba- 
 silic), but not pushed to fainting. Eepeat if necessary, and if immediate 
 result of bleeding be encouraging. Amount, usually about 10 ounces. 
 Diet. — Abstinence from food. Low diet. Former may be prescribed for 
 a day or two in some cases of abdominal injury and inflammation. Low 
 diet almost always beneficial. Stimulation. — Full diet ; extra nourishment. 
 For cases of low type, when the general weakness seems more threaten- 
 ing than the local inflammation. Drugs. — Mercury, antimony, aconite, 
 belladonna, purgatives, diuretics, colchicum, iodide of potassium, quinine, 
 opium, other anodynes. See some book on Therapeutics, and the notices 
 of inflammations of special parts or of specific origin in this book. Aconite 
 very valuable. Diaphoresis. — Effected either by drugs (antimony, Dover's 
 powder), or by hot-air baths, blankets, or other physical agents. Spinal 
 Ice-bag, Spinal Hot-water Bag. — According to Dr. Chapman, former, by par- 
 tially paralyzing vaso-motor system, increases the flow of blood to that 
 part of the body which corresponds to the region of the spine to which the 
 ice-bag is applied, e.g., pelvic organs become actively congested and feet 
 warm when ice-bag is applied to lower part of spine. On the other hand, 
 the hot-water spinal bag has an action the very reverse of this ; hence the 
 ice-bag can be used to obtain a derivative action, and the hot-water bag to 
 directly contract the arterioles of an inflamed part. 
 
 C. Differences in Treatment, according to whether the Inflammation is 
 Acute or Chronic. — In acute cases the indications are usually to save life, 
 to check the attack before serious local mischief has been effected, to pre- 
 vent the spread of a localized inflammation, and to relieve pain. In treat- 
 ing chronic cases the surgeon has rather to attempt the removal of what 
 may be termed pathological habits, and their evil effects. In acute cases 
 he employs such active agents as venesection, free leeching, and the ad- 
 ministration of drugs which powerfully affect the nervous and vascular 
 systems (e.g., opium and aconite). In chronic cases resort is had to pres- 
 sure, friction, counter-irritation, and stimulant or astringent drugs locally 
 (e.g., silver nitrate), with "alteratives" internally (e.g., mercury, iodide of 
 potassium, sarsaparilla). It is especially in many chronic cases that a 
 tonic and generous plan of treatment has to be adopted. In dealing with 
 
148 INTESTINAL OBSTRUCTION. 
 
 chronic inflammations always seek for some long-acting cause, or for some 
 specific influence (e.g., syphilis, struma, rheumatism). 
 
 Insects, Stings of. — See Bees, Stings of. 
 
 Intestinal Obstruction. — Causes. — 1, Intussusception ; 2, strangula- 
 tion by bands or by congenital diverticula ; 3, volvulus or twisting ; 4, in- 
 ternal herniae ; 5, strictures — malignant, cicatricial, or simple ; 6, pressure 
 of tumors or dragging of the bowel out of place ; 7, impaction of faeces or 
 of foreign bodies ; 8, pouching of intestine ; 9, intestinal paralysis. Ac- 
 cording to Pollock, of 135 cases 24 arose from intussusception, 36 from 
 bands, diverticula, and the like, 33 from intrinsic stricture, 8 from internal 
 hernia, 7 from concretions, calculi, and foreign bodies, 4 from volvulus of 
 sigmoid flexure, 3 from fecal accumulations, 9 from peritoneal adhesions, 
 tubercle, etc., and 8 were doubtful. Pathology. — 1. Intussusception. Por- 
 tion of intestine, usually lower end of ileum, becomes invaginated in the 
 portion immediately below it. If the case proceeds, the farther invagination 
 takes place chiefly at the expense of the lower, that is, the containing part 
 of the bowel ; e.g., an intussusception commencing at the lower part of the 
 small intestine will gradually absorb caecum, ascending colon, etc., till the 
 caecum appear even out of the anus. Of course a section of an intussus- 
 ception would show three concentric cylinders, of which the inmost and 
 middle present serous surfaces toward each other, while the middle and 
 outmost touch each other on their mucous surfaces. Between the inmost 
 and middle cylinders is the mesentery, tapering to a point at the lower 
 end of the involution and causing an arching of the involuted part of the 
 intestine toward its mesenteric border. The orifice at the lower end of 
 the central cylinder, namely that which opens into the bowel below the 
 disease, is a slit and not circular. Peritonitis and adhesions usually occur, 
 though often not till very late in the course of the case. Enteritis occurs 
 and causes mucous and bloody stools. The natural process of cure is for 
 the involuted intestine to inflame, become strangulated, slough, and come 
 away per anum. 2. Strangulation by bands or by congenital diverticula. 
 Bands are usually adhesions of inflammatory origin ; they are often at- 
 tached to diverticula. Diverticula are mostly found at the lower end of 
 the ileum. They originate either from a partial persistence of the omphalo- 
 mesenteric duct or from a hernia of the mucous coat of the bowel. 3. 
 Volvulus. Three varieties ; 1st, when bowel is rotated on its own axis, only 
 occurs in ascending colon ; 2d, when mesentery forms the axis and is 
 twisted into a cone, only occurs in small intestine ; 3d, when one coil of 
 intestine forms the axis round which another coil is bent. Most volvuli 
 occur in sigmoid flexure. Loose flabby mesentery usually found in these 
 cases. 4. Internal hernice. See Hernia. 5. Strictures. Almost all occur 
 in large intestine. Causes : cicatrices of tuberculous or of dysenteric ul- 
 cers, or of ulcers caused by irritation of foreign bodies ; inflammatory effu- 
 sion and contraction in the substance of the intestinal wall : cancer. The 
 
INTESTINAL OBSTRUCTION. 149 
 
 last cause is the most common. The pathology of the remaining causes 
 of intestinal obstruction need not be considered in detail here. 
 
 Signs. — Vomiting, constipation, abdominal pain ; constitutional depres- 
 sion ; there are modified and special symptoms added according to prime 
 cause. 
 
 Diagnosis. — 1st, from other diseases causing vomiting, constipation, 
 and pain ; 2d, of the particular nature of a given case of obstruction. 1st, 
 bear in mind possibility that the symptoms are caused by peritonitis, peri- 
 typhlitis, passage of a gall-stone, impaction of a calculus in the ureter. 
 Abstract of Mr. J. Hutchinson's memoranda for diagnosis : 1. If patient 
 be a child, and the onset of symptoms be sudden — probably intussuscep- 
 tion or peritonitis. 2. If an elderly person — impaction of faeces, or else 
 malignant disease (stricture or tumor). 3. Middle age — intussusception 
 and malignant disease very unusual. 4. Intussusception causes frequent 
 Btraining, passage of blood and mucus, incompleteness of constipation, 
 discovery of a sausage-like tumor, either per anum or through abdominal 
 walls. 5. Also in intussusception, parietes usually lax, and therefore it is 
 almost always possible to feel the sausage-like tumor by manipulation un- 
 der ether. 6. Malignant stricture. Old person, continued abdominal 
 uneasiness, repeated attacks of temporary constipation. Constipation 
 often not complete. 7. Tumor should be discoverable either through 
 parietes or else per anum or per vaginam. Beware of confounding with 
 scybalous masses. (Latter may probably be indented or pressed into a 
 different shape.) 8. If there have been repeated attacks of dangerous 
 obstruction with long intervals of perfect health, suspect diverticula, or 
 bands, or pouching with liability to twist (volvulus). 9. Abdomen hard 
 and distended from near commencement of case, peritonitis almost cer- 
 tainly. 10. Intestines visibly rolling about. Almost certainly no perito- 
 nitis. 11. The tendency to vomit is in proportion to (1) nearness of im- 
 pediment to stomach, (2) tightness of constriction, (3) persistence with 
 which food and medicine have been given by the mouth. 12. Vomiting 
 often absent in cases of obstruction in the colon or rectum. 13. Violent 
 retching and bile-vomiting often more troublesome in cases of gall-stones 
 or renal calculus simulating obstruction than in true conditions of the 
 latter. 14. Fecal vomiting can occur only when the obstruction is mod- 
 erately low down. When happening early in the case, it is very serious, as 
 it implies tightness of constriction. 15. Hand in rectum may obtain useful 
 information. 
 
 Treatment. — First question is that of gastrotomy* Indications for gas- 
 tromy are a tolerably clear diagnosis of intussusception, strangulation by 
 band, volvulus, or internal hernia. Of course in many of these cases 
 other means should have been fairly tried before resorting to abdominal 
 section. It is to be remembered on the one hand that most operations of 
 the kind have been fatal, while many cases presenting bad symptoms have 
 
150 ISCHIO- RECTAL ABSCESS. 
 
 recovered spontaneously ; on the other hand there are cases in which hope 
 of spontaneous recovery is out of the question. Antiseptic precautions 
 will diminish the risk. In cases of incurable stricture, an artificial anus 
 must be formed. Vide Colotomy. When exact seat of disease is doubt- 
 ful, operate in right loin. If upper part of large intestine be found 
 empty, bring a coil of small intestine into wound. In certain cases of 
 insuperable obstruction, in which the seat of disease is believed to be 
 above the caecum, small intestine may be opened through anterior abdom- 
 inal wall. Measures not Involving Cutting Operations. — In all early stages 
 and in all acute cases abstain entirely from giving either food or medicine 
 by the mouth. Make a careful examination under ether administered 
 fully. Copious fluid enemata. Insufflation of air. Latter, though good 
 in intussusception, not to be used where stricture is suspected. For 
 severe pain, give opium or morphia with belladonna. Employ abdominal 
 taxis, that is anaesthetize the patient, invert him, shake him, forcibly knead 
 abdomen, give enemata in inverted position, prescribe prone position with 
 pelvis elevated. 1 Operation should be done antiseptically. Seat of pain 
 may indicate seat of obstruction. Bands are usually found in umbilical 
 region. When the intestines are allowed to escape freely, considerable 
 difficulty in returning them is likely to occur. Still it is sometimes neces- 
 sary to allow it to a certain extent. Puncture is justifiable, to facilitate 
 their return in cases of difficulty. 
 
 Intussusception. — See preceding notice of Intestinal Obstruction. 
 
 Irrigation. — Practice of passing a continuous stream of water, usually 
 cold, over a wound. Various apparatus. Wide-necked bottle, with skein 
 of worsted or strip of lint acting like a capillary syphon. Tins and india- 
 rubber tubes. The bend where the india-rubber tubing passes over edge 
 of vessel may be prevented from closing tubing up by lashing the curve in 
 the tubing to a metal skewer bent into a gentle curve. Water may be 
 medicated. Object of irrigation is to remove injurious discharges as fast 
 as they are formed, and to keep down inflammation by action of cold. 
 
 Ischio-reetal Abscess. — Acute or chronic. Former usually occurs 
 in strong constitutions, latter in weakly persons. Symptoms. — Signs com- 
 mon to abscess everywhere. Chronic cases tend to spread nearly around 
 rectum, and to form sinuses which may on the one hand burrow into 
 buttock, and on the other become "fistulas in ano." Causes. — Blows, 
 kicks, falls, anal fissures, ulcerations, impaction of foreign body in rectum, 
 
 1 Judging from the appearances in a case in which gastrotomy was performed for 
 intussusception, I think that before going through the above proceedings, it would be 
 good, if the intussuscepted bowel had descended as low as the rectum, to attempt to 
 steadily compress the lower end of the intussusception for some time ; because in th« 
 above-mentioned case the difficulty in the evolution of the intussusception was 
 mainly caused by the swollen and congested state of its lower end. (Compare with 
 Mr. F. Jordan's mode of reducing paraphimosis.) 
 
JAWS, DISEASES OF* 151 
 
 phthisical constitution. Treatment. — Acute abscess requires poultices, 
 fomentations, and ordinary treatment. Chronic abscesses should also be 
 opened early by free incision, or great danger of fistula will be incurred. 
 Treat general health. 
 
 Jaws, Diseases of [Partly noticed under heading, Antrum, Diseases 
 or]. 
 
 Jaws, Closure of. — Causes. — 1 (very rare), ankylosis of tempero-maxil- 
 lary articulation ; 2 (usual), cicatricial contraction after burns, scalds, 
 cancrum oris, etc. Treatment. — In very slight cases the mouth may be 
 forced open, and cicatrix stretched by screw appliances. But in most cases 
 the only hope of relief lies in osteotomy. Two methods of osteotomy, one 
 from within mouth (Rizzoli's), the other from without (Esmarch's). In the 
 latter, which is preferred, a wedge-shaped piece of bone is cut out of lower 
 jaw anterior to cicatrix. Operation for temporo-maxillary ankylosis con- 
 sists in operating within the mouth, and cutting piece of bone out of 
 ramus of jaw. 
 
 Jaws, Necrosis of. — Causes. — Blows, exanthemata, syphilis, salivation 
 by mercury, chronic irritation of carious teeth, fumes of phosphorus. 
 Cause sometimes obscure. Signs. — Firstly, those of ostitis, pain like tooth- 
 ache, swelling, etc.; then suppuration, formation of sinuses, detection of 
 exposed bone, offensive discharge. Effect on general health usually greater 
 than necrosis elsewhere. Pathology. — That of other necroses. Phosphorus 
 necrosis is said to attack only where there are carious teeth ; but Langen- 
 beck denies this. Formation of new bone usually redundant ; but it tends 
 to waste when the sequestrum is removed. A sinus opening externally near 
 jaw sometimes merely signifies a carious tooth. Treatment. — Treat the 
 cause. Remove sequestrum when it has fairly loosened, but not before. 
 Avoid cutting skin if possible ; if unavoidable, make incisions below edge 
 of jaw, and, in males, where whiskers may cover scar. "Whole jaw has been 
 removed piecemeal through mouth. Gargles and lotions of Condy's Fluid, 
 borax, salicylic acid. In severe cases rest may have to be secured by band- 
 ages and gutta-percha or other splints. Tonics, soft nutritious food, fresh 
 air. Fit artificial teeth to new jaw. Specific remedies where indicated. 
 Lower jaw affected oftener than upper. Amorphous phosphorus does not 
 give off the injurious fumes. 
 
 Jaws, Tumors of, may be cystic, fibro cystic, fibrous, sarcomatous, car- 
 cinomatous, cartilaginous, fibro-cartilaginous, or osseous. A fibrous or 
 sarcomatous tumor connected with the periosteum of the alveoli is called 
 an "epulis." This has been noticed under that heading. Cystic tumors 
 are the most common, and are noticed among the diseases of the Antrum, 
 quod vide. Cartilaginous tumors are rare, but may be very large. Ex- 
 ostoses on the jaw are often of the ivory variety. Diagnosis. — See article on 
 Tumors in general. The chief point is to recognize innocency or malig- 
 nancy. Malignant growths increase rapidly, are usually softish, infiltrate 
 
152 JAWS, DISEASES OF. 
 
 neighboring parts, affect glands, are painful, and sooner or later tend to 
 fungate. Treatment — Open simple cysts by a very free incision, stuff 
 with lint, and allow to granulate up. Other tumors must be removed 
 thoroughly with knife, small saw, and cutting pliers. Bad cases may re- 
 quire removal of part or even whole of jaw itself. See Excision of Jaw. 
 
 Excision of Loweb Jaw. — Partial or complete. Done for tumor of the 
 bone. Incision.— Depends on extent of bone to be removed. Considerable 
 portions can be taken away through an incision entirely within the mouth. 
 Larger portions require an incision along the lower margin of the jaw and 
 chin. This, if necessary, may be extended upward in the median line to- 
 ward the lip ; but only tumors of rare magnitude justify division of the lip 
 itself. A tumor which reached from two inches above the zygoma nearly 
 down to the clavicle required a curved incision from the front of the ear 
 to and through the lower lip. Many tumors may be almost entirely 
 separated from their connections before even the facial artery need be 
 divided. In the large tumor above referred to, this artery was cut by the 
 last touch of the knife, and tied almost before it spurted. All bleeding 
 vessels should be secured without delay, as free hemorrhage is peculiarly 
 embarrassing in operations about the mouth. In the smaller tumors, a 
 tooth is extracted on each side of the growth, and the jaw partially sawn 
 through and partially divided by cutting forceps. When the symphysis 
 has to be removed, the tongue must be perforated and held forward by a 
 piece of whipcord, lest it fall back and close the glottis. This whipcord 
 may be removed after twenty-four hours. When the ramus is encroached 
 upon, disarticulation is necessary. Then keep the edge of the knife close 
 to the bone, lest the internal maxillary artery be divided. Strong forceps 
 may be useful. Depress the bone well, and open the joint from the front. 
 Do not divide or remove any more mucous membrane than can be helped. 
 It is worth remembering that, in case of dangerous hemorrhage after an 
 extensive operation of this kind, the external carotid, or even the bifurca- 
 tion of the common carotid, can easily be compressed between the finger 
 in the pharynx and the thumb on the skin of the neck. Anaesthesia should 
 be effected through Trendelenburg's trachea-tampon and tube or Mill's 
 apparatus. 
 
 Excision of Upper Jaw. — Complete or partial. Performed for tu- 
 mor of the bone. Complete excision. Incise skin, etc., down to bone 
 along a line through middle of upper lip, round ala of nose, up to near 
 inner canthus of eye, and lastly along lower margin of orbit. Very large 
 growths may require also a cut through cheek from angle of mouth to 
 malar bone. Turn this flap out and divide bone in the following places, in 
 whatever order may be found most convenient in each individual case, but 
 preferentially as follows : (1) zygoma, (2) outer wall of orbit into spheno- 
 maxillary fissure, (3) inner angle of orbit, (4) hard palate and alveolar pro- 
 cess, through socket of central incisor tooth, previously extracted. Effect 
 
JOINTS, DISEASES OF. 153 
 
 each division with cutting forceps ; but commence each, except the third, 
 with a narrow saw. Now apply lion forceps, depress the bone, separate 
 remaining adhesions with fingers rather than with knife, and wrench out. 
 Avoid unnecessary injury to soft parts of palate. The removal is compar- 
 atively easy in a child, because the sutures are much less firm (H. Marsh). 
 Arrest hemorrhage, pad the cavity, replace the cheek flap. Suture. Hare- 
 lip pins through lip. Prognosis. — Large majority of cases recover. Chief 
 dangers, hemorrhage and blood-poisoning. Death on operating-table per- 
 haps commoner in operations about jaw than in any others. 
 
 Partial Excision of Upper Jaw. — There are growths which affect so lim- 
 ited a part of the upper jaw that it would be barbarous to remove the 
 whole bone for them. The orbital part may be excised and the palate left, 
 or vice versa. Still more limited operations sometimes suffice. The ex- 
 ternal incision is done in the same line as that for total excision, but made 
 no longer than is necessary in each case. 
 
 Joints, Diseases of. — 1. Acute synovitis. 2. Acute suppuration (or 
 abscess, or acute suppurative synovitis). 3. Acute ostitis of a joint (inflam- 
 mation of the articular end of a bone). 4. Chronic synovitis, with which 
 is usually considered Hydrops articuli. 5. Chronic "joint disease." White 
 swelling. Strumous joint 1 (including both " pulpy degeneration of syno- 
 vial membrane," and "ulceration of cartilages"). 6. Chronic rheumatic 
 arthritis (rheumatic gout). 7. Acute rheumatism. 8. Gout. 9. Gonor- 
 rheal rheumatism. 10. Pysemic arthritis. 11. Puerperal rheumatism (from 
 7 to 11 commonly called specific inflammations). Loose cartilage. An- 
 kylosis. Neuralgia of joints. Neuromimetic or hysterical joint. "Of late, 
 great importance has been attached (especially by French surgeons) to 
 speaking, first, of diseases of the synovial membrane, then those of the 
 cartilage, articular capsule, and bone, corresponding to the anatomical con- 
 ditions. Correct as this division would be if it were only a question of 
 representing the pathological anatomical changes, it is of little use in prac- 
 tice. The surgeon always views inflammation of the joint as a whole, and 
 although he should know which part of the joint suffers most, this is only 
 a part of what he should know ; course, symptoms, and constitutional state 
 equally demand his attention and determine the treatment. Hence the en- 
 tire clinical appearance will determine the divisions of this, as of many 
 other diseases " (Billroth). 
 
 Acute Synovitis. — Causes. — Usually exposure to cold. Often blows or 
 sprains. Predisposing cause sometimes, e.g., syphilis, rheumatic constitu- 
 tion, etc. But specific inflammations are noticed separately. Joints least 
 
 1 These terms are used often as if quite synonymous. But some surgeons confine 
 the term "strumous" to cases in which they believe the patient is originally of a 
 scrofulous constitution; some surgeons would discard the term "strumous," al- 
 together ; and some even use clinically such terms as " ulceration of cartilage," just 
 as if such a term described a primary disease. 
 
154 JOINTS, DISEASES OF. 
 
 supplied with a covering of soft parts are most liable. Signs. — Pain, heat, 
 and swelling, but not usually redness. Great tenderness. Swelling has a 
 characteristic shape, bulging out exactly where the synovial membrane 
 would tend to pouch when distended. Fluctuation. Tension sometimes 
 great enough to prevent fluctuation. Feverishness. Pathology. — Synovial 
 membrane is actively congested, and cavity of joint distended with sero- 
 synovial fluid, usually clear, but occasionally containing a few corpuscles 
 or a little blood. Prognosis. — Altogether good, unless constitution be bad 
 or treatment neglected. Diagnosis. — Distinguish from acute inflammation 
 of any neighboring bursa. Consider position and shape of swelling and 
 history of case. Treatment. — Rest; splint or "fixed apparatus." Attend 
 to position according to joint affected. Cold. Pressure. Wet bandages. 
 Cotton wool compress and bandage over it. Leeches. Hot fomentations. 
 Dover's powders internally. For specific cases give specific drugs. 
 
 Acute Suppuration or Acute Abscess of Joint. — Causes. — Sometimes 
 one or more of the causes of ordinary acute synovitis. Sometimes the 
 opening into the joint of an abscess in the neighboring soft tissues or 
 bone. The commonest cause is a wound of the joint. Signs and Diag- 
 nosis. — Acute pain and swelling ; redness and oedema, which may disguise 
 fluctuation. Fixation in some position peculiar to each joint, e.g., flexion 
 and external rotation in case of knee-joint. High fever and rigors. After 
 a time 'fluctuation appears, not only in the joint, but often also in its neigh- 
 borhood (secondary abscesses). High fever continues. To distinguish a 
 superficial abscess near a joint from acute articular suppuration, notice 
 that in the former case the symptoms are so localized that some part of 
 the joint will be accessible to examination, and be found healthy. The 
 centre of an extra-articular inflammation will perhaps be noticed to corre- 
 spond to some bursa, or to some superficial injury. Prognosis. — Destruc- 
 tion of joint very probable. Danger to life great in old age, if joint be a 
 large one. Danger of pyaemia. Best result that can usually be expected 
 is ankylosis in good position. Complete recovery from early stage possi- 
 ble. Pathology. — In early stage, synovial membrane is red, greatly swollen, 
 puffy and infiltrated with corpuscles and serum. Contents of joints are 
 synovia mixed with more or less pus. In later stage, synovial membrane 
 is red, covered with fibrous rinds, and partly ulcerated ; the contents of 
 the joint are thick yellow pus, mixed with fibrous flocculi, the cartilage 
 is breaking down, and even the adjacent cancellous bone inflamed. Treat- 
 ment. — If called to the case early, and there is sufficient reason to believe 
 that the stage of actual abscess and synovial cavity filled with thick pus 
 has not been reached. Anaesthetize patient. Place the joint in a suitable 
 position. Pad both limb and joint freely with cotton- wool. Then apply a 
 fixed apparatus (plaster-of-Paris, or starch and millboard) from near the 
 extremity of the limb to a considerable distance above the joint affected. 
 Be extremely careful to bandage evenly. Place ice-bags over joint. Give 
 
JOINTS, DISEASES OF. 155 
 
 morphia subcutaneously. Elevate limb. Great benefit is often derived 
 from extension by weights. If the case is more advanced, or if it gets 
 worse under the above treatment, and if the evidence of abscess in the 
 joint is unmistakable, the question of opening the joint presents itself. 
 Grooved needle or aspirator may be used to confirm diagnosis. Unless a 
 drainage-tube is used, make free incisions, as Gay recommends. Anti- 
 septic precautions very desirable. Many cases calm down into a chronic 
 state. 
 
 Acute Ostitis of a Joint. — Inflammation of the Articular End of a Bone. 
 — Inflammation of spongy bone-substance adjacent to a joint is very 
 rarely acute ; though chronic joint disease frequently begins in the bone. 
 Causes. — Obscure, when the affection cannot be traced to injury. Signs 
 and Pathology. — Those of Ostitis, quod vide. Pain, heat, and swelling. 
 Redness combined with oedema when suppuration occurs. Synovial mem- 
 brane of adjacent joint becomes implicated. Effusion into joint. In child- 
 hood, whole articular epiphysis may separate. Partial necrosis more 
 probable in adults. Diagnosis. — The disease may be known to have begun 
 in the bone by the thickening of that part, ' and by the history. Prognosis. 
 — Danger of acute articular abscess, or in the event of acute inflammation 
 being allayed, of chronic destructive disease of the joint. Treatment. — See 
 Inflammation of Bone. Rest, elevation, cold, painting with iodine, etc. 
 Perhaps occasionally abscess may be prevented from opening into joint by 
 a timely opening from without. 
 
 Chronic Synovitis. Hydrops Articuu. — Causes. — Same as those of acute 
 synovitis, of which affection it is usually a sequel. Signs. — Almost always 
 attacks the knee. Young men most liable. Swelling and fluctuation of all 
 the synovial pouches of the joint. Little or no pain or tenderness. The use 
 of the joint is sometimes not much impeded, but it usually causes fatigue and 
 pain. Diagnosis. — From white swelling, by the absence of apparent thicken- 
 ing of the articular ends of the bones, of signs of ulceration of cartilage, 
 of the great wasting of the limb which almost always occurs in chronic 
 destructive disease of the joint, but above all by amount of effusion. In 
 early stage age should be considered. Hydrops occurs chiefly in young 
 adults, strumous disease mostly in children. Prognosis. — Little or no 
 danger of hydrops articuli leading to any serious joint disease. Relapse 
 after cure very common. Treatment. — Perfect rest, counter-irritation, and, 
 above all, compression with the strong elastic bandage. By means of a 
 soft elastic bag containing water and placed beneath the elastic bandage, 
 the pressure can be measured and regulated to a nicety, without removing 
 the bandage. I have found the hydraulic pressure of a column of water 
 twenty-eight inches high sufficient ; but this point must vary with the 
 
 1 It is not really the bone itself which is thickened, but the periosteum and soft 
 parts over it. 
 
156 JOINTS, DISEASES OF. 
 
 case. 1 Scott's dressing. Failing these methods, aspiration may be com- 
 bined with elastic pressure, or tapping with injection of iodine. In case 
 of knee-joint insert a trochar and cannula close to side of patella, draw off 
 fluid, inject tinct. iodi., aquae, aa 3 ss. Let iodine escape after three to 
 five minutes, according to amount of pain. Now put up limb as after 
 punctured wound of joint. Splint, swing, or starched bandage, etc. Iodine 
 injection is dangerous both to life and limb, and can very rarely be justifi- 
 able. Joint may be tapped and drained with antiseptic precautions. 
 
 Cheoxic Joint Disease. — White Swelling. Strumous Disease of Joints. 
 Including Pulpy Degeneration of Synovial Membrane, " Ulceration of Carti- 
 lage" (and Articular Ostitis when it leads to chronic degeneration of the 
 adjacent joint). — To any one more familiar with chronic joint disease in 
 books than in the human body, the above long heading may seem unneces- 
 sarily fraught with confusion. But I trust that it is not so ; for although 
 some of the above terms represent different conditions at the outbreak of 
 disease and for a short time afterward, yet these different commencements 
 almost always tend toward the same course and termination, viz., implica- 
 tion of every element of the joint, synovial membrane, cartilage, bone- 
 surface, and ligaments. There are numbers of diseased joints which, even 
 when exposed to the eye by excision, amputation, or death, do not reveal 
 the origin of their disorganization. Moreover, in deciding upon a plan 
 of treatment, one considers not so much what was the commencement as 
 what is the present state ; not what was, but what is, determines the 
 decision. Still it is true that the consideration of the past may throw 
 light on the future. Moreover, examiners sometimes base their questions 
 on anatomical pathology. Therefore care will be taken in the following 
 notes not to lose sight of anatomical distinctions. Causes. — Most cases 
 can be traced to blows or falls, or exposure to cold or wet. Strumous 
 constitution predisposes. As any acute inflammation of a joint may be- 
 come chronic, so every cause of acute may also be a cause of chronic 
 arthritis, including gonorrhoea and other specific influences. But it 
 is rare for gout, syphilis, or acute rheumatism to lead to destructive in- 
 flammation of a joint. Pathology. — Commencement may be in synovial 
 membrane (usually after blows, cold, or specific disease), or in ligaments 
 (usually after sprains), or in bone (often in strumous constitutions) ; but, 
 according to modern pathology, seldom or never in cartilage. When the 
 synovial membrane is affected primarily, the result is Brodie's "pulpy de- 
 generation of synovial membrane." In this disease, parts of the synovial 
 membrane swell, look cedematous, pulpy, reddish-gray, and soft This 
 condition spreads, eating up, so to speak, the underlying cartilage. The 
 microscopical structure of the pads and tufts of swollen synovial membrane 
 
 1 But to prevent relapse it is necessary to insist upon the patient's wearing a 
 common elastic bandage round his joint for months after leaving hospital. 
 
157 
 
 becomes identical with that of vascular granulations. ■ In the subjacent 
 layer of cartilage which is in process of conversion to the same granulation- 
 tissue, the cartilage cells themselves divide, proliferate, and assist in the 
 dissolution of the matrix of their own cartilage. In this way the pulpy 
 tissue reaches the bone. The process does not stop here, but the bone it- 
 self inflames, erodes, and now the joint is carious. In the meantime the 
 ligamentous structures of the joint have been softening, thickening, and, 
 in some places, perhaps, yielding to the encroachments of the pulpy tissue, 
 which may even pierce the skin and present externally as a fungous 
 granulation. At the same time that the synovial outgrowths are destroy- 
 ing the cartilage, destructive inflammation may appear in the articular 
 lamella of the bone, so that the cartilage is attacked both above and below, 
 like a whale between a " thrasher " and a sword-fish. When the disease 
 begins in the ligaments it is usually in the hip or knee joints, which have 
 internal ligaments. From these it spreads to either the synovial mem- 
 brane or the bone, or to both. Then the features of the case cease to 
 have anything to distinguish them from those of disease originating else- 
 where. The frequency with which disease begins in the ligaments is a 
 point not yet settled. Disease beginning in the bone. Ostitis is the com- 
 mencement of most cases which are genuinely strumous, and of many 
 cases which are not strumous at all. The prime appearances are those of 
 Inflammation of Bone, quod vide. Sometimes the joint becomes implicated, 
 because the inflammatory action in the articular lamella spreads to or 
 separates the cartilage. Sometimes necrosis or caries leads to abscess 
 which bursts into joint. The course of events leads to synovitis, which 
 spreads all round the joint, to pulpy thickening of the synovial membrane, 
 and to its usual results, as described above, on both faces of the joint. In 
 rare cases the bone becomes full of soft tuberculous matter. However the 
 disease may begin, if it go on, the ligaments give way, the ends of the 
 bones become displaced, and perhaps necrose wholly or partially. Sup- 
 puration and the formation of sinuses often do not occur, especially when 
 the patient, excepting his articular disease, is healthy. The most profuse 
 suppuration occurs in the weakest and most ill-nourished, or else when 
 acute suppurative synovitis becomes chronic. Symptoms and Course. — 
 Insidiousness of first stage (unless affection is a sequel of acute disease). In 
 case of joints of lower extremity, limping, occasional complaints of pain or 
 weakness. Surgeon soon detects signs of synovitis, marked much more 
 by thickening of synovial membrane than by effusion into joint. See 
 notices under names of individual joints, e.g., Hip-joint. Or the first 
 symptoms observable may be those of articular ostitis (see p. 155). The 
 limb assumes a peculiar appearance, distinguished by the swelling and 
 pallor of the diseased joint, and by the wasting of the muscles. The joint 
 assumes a bent position. At a later stage, dislocation takes place. Sup- 
 puration may occur at any time, or not at all. Sinuses. Fungous granula- 
 
158 JOINTS, DISEASES OF. 
 
 tions. When bone becomes affected, starting pains at night, excruciating 
 pain on sudden movement or on pressing joint-surfaces together. Some- 
 times secondary abscesses. Grating may indicate roughness of cartilages. 
 Necrosis may be guessed at from the history or from occurrence of marked 
 crepitus, but can only be certainly known when joint is open. Probe may 
 detect caries when granulations cover the diseased bone. Granulations 
 fungating through a sinus almost always indicate caries. Prognosis. — 
 Depends on (1) patient's constitution, (2) his nutritive condition, (3) his 
 command of time and money, (4) the joint affected, (5) the anatomical 
 origin of the disease, (6) the treatment adopted. Where there is also 
 phthisis or kidney-disease the case is almost hopeless. The state of nutri- 
 tion is the most important. Poor patients sometimes cannot afford to 
 wait till nature cures the disease, and prefer amputation : the surgeon can 
 rarely be justified in acting on this consideration. Moreover, fresh, healthy, 
 highland or sea air is denied to urban poor. Primary osseous disease is 
 of worse prognosis than synovial. Treatment — General and local. General. 
 — Indications : (1) to improve nutritive condition, (2) to obtain best pos- 
 sible conditions of fresh air, cheerful light, sound sleep, etc. In many 
 cases general rest, in the sense of total confinement to bed, not desirable. 
 Rather combine general, outdoor, moderate exercise with local rest. But 
 long intervals of repose and gentleness of exercise essential. Cod-liver oil, 
 iron, quinine, milk, etc., according to special features of case. Local Treat- 
 ment. — Indications : (1) perfect rest, (2) one or more of the following 
 remedies : A firm plaster case over a flannel bandage, and extending from 
 some way below to a considerable distance above the joint affected. In- 
 stead of plaster- of -Paris, starched bandage and millboard may be used. 
 Scott's dressing, i.e., ung. hydrarg. co., rubbed on joint and then strips of 
 pitch plaster spread on leather applied to it. Gentle uniform pressure with 
 elastic bandage such as "Martin's." Hydraulo-elastic pressure. Extension 
 by weights. Extension by Sayre's splints. Elevation. Suspension in 
 Salter's swing. Continuous cold ; ice-bags. Counter-irritation. "Firing." 
 Blisters. When acute exacerbations supervene, a few surgeons recommend 
 leeching. Perfect local rest not always desirable. A certain amount of 
 gentle or of passive exercise, combined with " shampooing " and the elastic 
 bandage, better for some cases {see Barwell in Practitioner, vol. xiii., 
 p. 365). At a certain stage arises the question of excision, or of excision 
 versus amputation. This is decided by considering (1) the joint affected ; 
 (2) state of general health; (3) state of kidneys, lungs, and liver; (4) the 
 stage of the disease ; (5) whether operation is required to save life or 
 merely to shorten period of illness and treatment. While excision may 
 frequently be useful in the elbow and hip, and sometimes in the wrist, it 
 can seldom be desirable in the shoulder (except after gunshot wound or 
 compound fracture) ; and some surgeons never excise the knee. See 
 articles Excision of Joint and Amputation. Swabbing out joint with dilute 
 
JOINTS, DISEASES OF. 159 
 
 sulphuric acid (one in three). Operative measures of any kind rarely 
 justifiable until joint is on the point of opening spontaneously. Suppura- 
 tion and free discharge do not counter-indicate plaster cases. Small win- 
 dows can be cut in the case. These windows should be really small, i.e., 
 not large enough to spoil the case as a uniformly supporting agent. 
 Sinuses may be slit up and loose pieces of necrosed bone removed. 
 
 Chronic Rheumatic Arthritis — Rheumatic Gout. — See Rheumatism. 
 
 Gonorrhoeae Rheumatism. — An affection of the joints occurring in the 
 course of a gonorrhoea. Relation of the two diseases uncertain. The 
 arthritis may be due to blood-poisoning, or to reflex irritation through 
 spinal cord ; for it seems that various affections of the genitals will cause 
 inflammations of the joints. Symptoms. — It usually attacks knee, hip, 
 wrist, ankles, especially knee. Pain, stiffness, swelling, heat ; various de- 
 grees of acuteness or of chronicity. Seldom goes on to suppuration and 
 disorganization of joint. Usually confined to synovial membrane and lig- 
 amentous structures. Pathology. — The appearances of synovitis, ostitis, or 
 abscess are not characteristic of their gonorrhceal origin. See above for 
 pathology of Synovitis, etc. Prognosis. — Considerable danger of ultimate 
 ankylosis. Often complete recovery. Relapse may occur if gleet return. 
 Treatment. — Cure the gonorrhoea or gleet. Make the urethra aseptic (see 
 Gonorrhoea). Treat the joint-affection according to the rules given above 
 for the particular form of joint-inflammation each case of gonorrhceal rheu- 
 matism may most resemble. "When chronic arthritis persists after gonor- 
 rhoea is cured, great benefit often derived from an elastic bandage, and 
 ten-grain doses of pot. iod. ter die. 
 
 Note. — The muscular pains often occurring in the course of a gonor- 
 rhoea are by some classified as a form of gonorrhceal rheumatism. Cure 
 the cause, and direct flannel to be worn. Chloral may be necessary at 
 night. Change of climate. 
 
 Loose Cartilages. — Causes. — 1. They grow, like warts, on the synovial 
 membrane, and afterward break off; (2) they are, in rare cases, chipped 
 off the joint cartilage itself. (3) There is also a theory of their formation 
 by a process identical with that of " Quiet Necrosis " (Paget's " Clinical 
 Lectures," p. 343, and Teale). Symptoms. — Liability to sudden and sicken- 
 ing attacks of pain, caused by certain movements, and followed by synovial 
 effusion. The loose cartilage may, in many instances, be felt near the 
 superficial aspect of the joint. These symptoms make the diagnosis quite 
 clear. Pathology. — Number usually single, but sometimes very numerous. 
 Shape rounded or flattened with rounded edges. Size from that of a shot 
 to that of a broad bean, or, in exceptional cases, much larger. Structure 
 rarely cartilaginous, usually fibrous. Joint most commonly affected, the 
 knee. Treatment. — 1. India-rubber bandage and moderation in exercise of 
 joint, especially restraint from violent motions. Perseverance in this may 
 cause permanent cessation of unpleasant symptoms, perhaps adhesion of 
 
160 KIDNEY, DISEASES OF. 
 
 the loose cartilage to a convenient part of the joint. 2. Operative. This 
 must be either subcutaneous or antiseptic. Subcutaneous excision. — Fix 
 the cartilage between the finger and thumb ; then pass a tenotome through 
 the skin at a distance, and with it divide the capsule of the joint until the 
 cartilage can be squeezed out into the areolar tissue. Fix it there by 
 strapping, etc., and place the limb on a splint, or in a plaster-of-Paris case. 
 A week afterward, if the surgeon choose, he may cut out the cartilage al- 
 together. — See Square, Medical Times, vol. ii, 1857. 
 
 Joints, Neuromimesis, or Hysteria of. — Diagnosis from " organic " 
 disease is based on the facts that, in neuromimesis, (1) the subjective 
 symptoms, pain, tenderness, etc., are often great while there is in the joint 
 no alteration -visible to the surgeon at all ; (2) the pain and tenderness are 
 often chiefly in the skin rather than in the joint itself ; (3) the patient 
 sometimes describes her sufferings in strong language, but in a cheerful 
 manner, as though the recollection of them was not so very painful after all ; 
 (4) stiffness and contractions disappear under anaesthetics ; (5) instead of 
 being hotter than the healthy joint, as in the case of inflammations, the af- 
 fected joint is often colder ; (6) other hysterical symptoms, and even a 
 manifest cause for them, may coexist. But bear in mind that hysterical 
 patients are not exempt from organic disease, and that " hysteria " itself 
 even sometimes leads to actual alterations in the joints. This is not sur- 
 prising, considering the intimate relations, pathologically as well as physi- 
 ologically, between the spinal cord and the joints. Treatment. — See Hys- 
 teria. Kefer to Paget's " Clinical Lectures." 
 
 Kidney, Diseases of. — Frequently complicate, and are produced by 
 bladder and urethra disorders, especially such as obstruct the flow of urine. 
 Amyloid kidney is a common result of prolonged suppurations and of 
 syphilis. According to Marcus Beck (his contributions to Erichsen's " Sur- 
 gery," ed. 7, vol. ii., should be carefully read), such diseased conditions of 
 the ureters and pelvis of the kidneys are met with in three chief forms, viz. : 
 1, the results of simple over-distension without acute inflammations ; 2, 
 acute inflammation without signs of over- distension ; 3, a combination of 
 the two. Simple chronic over-distension leads to dilatations with a certain 
 amount of thickening. The conditions of the kidney are classified as fol- 
 lows : 1, change resulting from pressure by urinary obstruction ; 2, acute 
 interstitial inflammation ; 3, acute interstitial inflammation with scattered 
 abscesses ; the result of former acute and subacute attacks, from which the 
 patient has recovered. 1. Pressure by Urinary Obstruction causes dilatation 
 of the kidney, absorption of the pyramids, cellular infiltration of the inter- 
 tubular tissue (interstitial nephritis), and little or no change in the tubules 
 themselves in the cortex. Capsule tough and adherent. In severe cases 
 even the cortex is almost entirely atrophied, so that the kidney becomes a 
 mere sac. 2. Acute Diffuse Interstitial Inflammation. — Kidney soft and 
 swollen ; capsule separates readily, but kidney-substance gives way during 
 
KIDNEY, DISEASES OF. 161 
 
 the separation. Surface mottled ; section also mottled ; cortex pale, but 
 pyramids much congested. Microscopically, great cellular infiltration be- 
 tween the tubuli. In many parts tubuli are seen compressed or destroyed. 
 Most infiltration around Malpighian bodies. 3. Acute Interstitial Nephritis 
 with Scattered Abscesses. — Frequently coincident with acute pyelitis and 
 putrid urine in pelvis of kidney. Kidney shows, in the parts affected, signs 
 of the condition described in the last paragraph (interstitial nephritis), and, 
 in addition, scattered groups of bright yellow spots. These spots are mi- 
 nute abscesses. In certain cases this disease may advance to general sup- 
 puration of the whole kidney. 4. Effects of Former Attacks from which the 
 Patient has Recovered. — These correspond to the changes which result from 
 interstitial inflammations elsewhere. In mild cases complete resolution is 
 possible ; but in more severe ones cicatricial fibroid changes make the kid- 
 ney contracted and tough, obliterating many of its glandular elements. 
 The capsule is hard to separate ; many small cysts lie beneath it ; the cor» 
 tex is greatly thinned ; but the pyramids are little altered. Causes of In- 
 terstitial Inflammation. — 1, tension ; 2, reflex irritation ; 3, septic matter in 
 pelvis of kidney. The origin of reflex irritation in these cases is usually 
 some disease in, injury to, or operation on the bladder and prostatic part 
 of the urethra ; but, in Beck's opinion, it is likely that, "in all cases of 
 operation on the urethra, there is a miniature representation of that intense 
 congestion of the kidney which is found in cases of death from suppression 
 of the urine after simple catheterism." 
 
 Symptoms of Kidney Disease in Surgical Aeeections of the Genito- 
 Ueinaey Organs. — Those of simple dilatation of the kidney are few. The 
 most important are increased quantity and diminished specific gravity of 
 the urine. The urine to be examined should be collected for twenty-four 
 hours. Subacute Interstitial Nephritis is often obscured by the affection 
 which has led to it, e.g., by vesical catarrh. But even in such circum- 
 stances a dry tongue, persistent nocturnal rises of temperature (rarely to 
 above 101° F.), emaciation, and occasional nausea, are ominous symptoms. 
 Urine copious ; its specific gravity usually low. 
 
 Acute Interstitial Nephritis with Scattered Abscesses. — Begins with rigor 
 and rise of temperature to 105° or 106° F. This may be repeated again 
 and again. Tongue like broiled ham. Sordes. Nausea, vomiting. Bajrid 
 emaciation. Possibly diarrhoea. So called "typhoid" symptoms. Ten- 
 derness over kidneys. Muttering delirium. Patient sinks ; but the pro- 
 found coma and convulsions of uremic poisoning are exceptional. " The 
 urine varies much. It usually becomes more or less bloody, and in rare 
 cases is suppressed, though much more frequently a considerable quantity 
 is passed up to the time of death." Much decomposed and mixed with 
 mucus, pus, and blood. Diagnosis has to be made from (1) pyaemia, (2) 
 peritonitis, (3) typhoid fever, (4) ague. "From pyaemia the diagnosis 
 is somewhat difficult, the most important point being the vomiting, the 
 11 
 
1G2 KNOCK-KNEE. 
 
 absence of secondary abscesses, the drowsy state into which the patient 
 soon falls, and the fact that the temperature often remains, for days before 
 death, below normal." The kind of vomiting and the course of tempera- 
 ture contrast with those of peritonitis. The temperature curves and the 
 absence of spots distinguish from typhoid. In ague there should be com- 
 plete intermissions. Prognosis. — In acute cases of "surgical kidney" 
 always bad, but most so in suppurative nephritis. Treatment of kidney- 
 disease complicating surgical cases. — Eest. Avoid every source of genito- 
 urinary irritation. If catheterism is unavoidable, use soft instruments, 
 thoroughly cleansed, oiled, and antiseptic. Treat the causes with mild 
 and gentle means. For interstitial nephritis, dry-cup the loins, give pur- 
 gatives, dress in flannel, stimulate the skin, e.g., by hot-air baths. Shun 
 surgical operations. 
 
 Knock-knee (Genu valgum). — A deformity in which the knee is 
 bent inward. Causes. — Rickets ; muscular weakness, combined with habits 
 of excessive standing, or of carrying heavy burdens ; lazy manner of walk- 
 ing and standing. About puberty a disease is liable to attack the epiphy- 
 seal cartilages, somewhat analogous to the rachitis of childhood. These 
 cartilages are then peculiarly liable to give way from the causes above 
 mentioned. Hence many cases of genu valgum, and even spinal curva- 
 ture. (See Mikulicz in v. Langenbeck's Archiv, xxiii., 3 to 4 ; and also 
 Busch: "Die Belastungsdeformit'aten der Gelenke," Berlin, 1880.) Anat- 
 omy. — The diaphyses of the femur and tibia grow faster on the inner than 
 on the outer side. Thus, the internal condyle is pushed downward, and 
 the inner part of the upper epiphysis of the tibia upward. At the same 
 time the diaphyses often grow curved, with the convexity inward. The 
 patella tends outward toward the external condyle. The internal lateral 
 ligament is relaxed in cases which commence at or near puberty, but not 
 in the knock-knee of rachitic children. Treatment. — In early age, the most 
 severe cases can usually be cured by judicious and persevering use of splints 
 or irons, and elastic force, combined with tonic medicines and hygiene. 
 But some plan of osteotomy has to be followed when the bones are hard. 1 
 Such operations are (1) Ogston's, (2) Chiene's, (3) McEwen's, (4) Beeves's, 
 on the femur, and (5) Barwell's, on femur, tibia, and fibula. M. Delore 
 forcibly bends the knee straight during anaesthesia, and then secures it in 
 a movable dressing. He says that this procedure separates the inferior 
 epiphysis of the femur. Dr. Ogston makes a small incision through the 
 skin and saws off the internal condyle subcutaneously, and then easily 
 brings the limb straight. McEwen chisels nearly through the femur above 
 the condyles, and then puts the limb straight. This is a very satisfactory 
 
 1 It is difficult to give any concise and precise rules or indications for osteotomy in 
 genu valgum. In each case the age of the patient, the amount of the deformity, its 
 duration, its cause, its precise anatomical nature, and the effect upon it of experi- 
 mental splinting, have to be considered. 
 
163 
 
 operation. Use antiseptics. Chiene's and Reeves's modes of operation 
 differ from Ogston's in that the former removes a wedge of bone and 
 therefore alters the joint-surface less, while the latter chisels up to, but 
 not through, the articular cartilage. ; Chiene uses the chisel. (See Oste- 
 otomy in Appendix.) 
 
 Labia. — The external genital organs of the female are liable to (1) 
 hypertrophy, (2) cystic tumors, (3) venereal diseases, especially warts and 
 ulcers, (4) epithelioma, (5) hematocele, (6) varix, (7) abscess, besides other 
 affections of less frequent occurrence. Affections of the labia are modified 
 by (1) the vaginal and vesical discharges to which they are so often ex- 
 posed ; (2) the hindrance to the circulation due to the dependent position 
 of relaxed or hyper trophied labia ; (3) the dirty habits of some patients. 
 In treating them, beware of severe parenchymatous hemorrhage. (See ar- 
 ticle Hemorrhage.) 
 
 Cysts of the labia are particularly frequent in young women, especially 
 shortly after marriage. They are commonly caused by hypertrophy of the 
 follicles of Cowper's glands. Lay them freely open and insert lint in the 
 cavity. 
 
 Hypertrophy of the labia or of the clitoris usually originates in venereal 
 inflammation, but persists after the cause is removed. Treatment. — Exci- 
 sion. Acupressure may be used to repress troublesome hemorrhage. 
 
 Congenital Cohesion of the Labia. — Easily remedied by tearing with the 
 handle of a scalpel. Oil the surfaces well, and instruct the nurse to keep 
 them separate with a piece of oiled lint for a few days. 
 
 Larynx, Diseases of. — Acute catarrh (acute laryngitis). Chronic 
 catarrh (including clergyman's sore- throat). (Edema glottidis, syphilitic 
 anections, phthisis, cancer, inflammation and necrosis of cartilages, tumorSj 
 foreign bodies, "nervous" disorders (including laryngismus stridulus). 
 
 Larynx, Acute Catarrh of — Acute Laryngitis. — Causes. — Cold, cold 
 with damp ; excessive shouting, speaking, or singing ; erysipelas spreading 
 inward to larynx. Mechanical and chemical irritants. Scalds. Acute 
 exacerbations sometimes supervene in cases of chronic catarrh. A larynx 
 diseased from any cause is more liable to acute inflammation than a sound 
 organ. Spread of a naso-pharyngeal catarrh to larynx. Influenza. Ex- 
 anthemata, e.g., measles, small-pox, typhoid. Symptoms. — Functional de- 
 rangements, viz., loss of voice or hoarseness. Pain in throat near hyoid 
 bone, perhaps tenderness in that region when swallowing. Tickling in 
 throat. Hacking cough. At first scanty, tenacious sputa, afterward looser 
 and more purulent. If the case progresses unfavorably, dyspnoea comes 
 on, and this is liable to sudden and most dangerous increase, during which 
 tracheotomy or laryngotomy may be necessary to prevent asphyxia. The 
 local symptoms are usually much more serious than the general. But 
 more or less fever is present. Pathology. — "Whole mucous tract of larynx 
 is not always affected. The appearances are like those of mucous catarrhs 
 
164 LARYNX, DISEASES OF. 
 
 elsewhere, i.e., swelling, redness, mucous, purulent, or sero-purulent ex- 
 udation ; occasionally, in severe cases, small submucous hemorrhages. 
 The dyspnoea mentioned above, when sudden, is partly or wholly spas- 
 modic. But the most dangerous kind results from great serous effusion in 
 the submucous tissue of the glottis, " oedema glottidis." After death the 
 appearances are much less marked than when shown by the laryngoscope 
 during life. Diagnosis. — Hoarseness, and occasionally dyspnoea, indicate 
 larynx as the seat of affection. Laryngoscope will exhibit actual state of 
 organ. Catarrhal laryngitis differs from croup in that, 1, the dyspnoea is 
 not persistent, and varies more ; 2, there is no false membrane ; 3, there is 
 usually less fever ; 4, a known cause and history may point unmistakably 
 to acute non-croupous laryngitis. Prognosis. — Very guarded, danger of 
 sudden and fatal dyspnoea. Laryngotomy and tracheotomy, while they 
 avert this danger, introduce others, such as pulmonary congestion. Re- 
 covery usually complete, but acute sometimes passes into chronic catarrh. 
 Treatment. — Rest in a room of uniform and warm temperature. Atmos- 
 phere charged with steam. Hot moist sponge to throat. Low diet. Milk 
 and soda-water. Avoid greasy food. Salt food and saline drinks benefi- 
 cial. Emetics : ipecacuanha, tartar emetic. Aconite (see Ringer's " Thera- 
 peutics," p. 399). Diaphoretics. Purgatives. Forbid attempts to speak or 
 whisper. If, in spite of treatment, dangerous dyspnoea should come on, 
 perform tracheotomy. (For (Edema Glottidis, see p. 165.) 
 
 Lakynx, Chronic Catarrh of — Chronic Laryngitis — Clergyman's Sore- 
 throat. — Causes. — Same as those of acute catarrh. But, in order to pro- 
 duce the chronic affection, they have to be applied in a milder form, and 
 more persistently or repeatedly. In addition to these, alcoholism, syphi- 
 lis, phthisis, and occupations in which the voice is frequently strained, 
 predispose to the affection. So also does a low tone of the nervous and vas- 
 cular systems. Damp, cold climates. Herpetic diathesis. Symptoms. — 
 Hoarseness ; weakness of voice ; voice also loses its firmness and becomes 
 uncertain, especially in the higher notes. Liability to intercurrent at- 
 tacks of acute laryngeal catarrh. Catarrh usually affects also the neigh- 
 boring mucous tract of the pharynx. Direct observation of the pharynx 
 with the unassisted eye, and of the larynx with the laryngoscope, shows 
 the mucous glands enlarged, a dusky, congested mucous membrane, small 
 varicose veins, and a glairy, mucous secretion clinging to parts of the re- 
 gion. A troublesome, tickling cough sometimes. Almost always a habit 
 of clearing, or rather of attempting to clear the throat by hawking. Thirst. 
 Frequently a hypochondriacal state which exaggerates the subjective symp- 
 toms. Often symptoms pointing to the cause of the chronic laryngitis, 
 e.g., signs of alcoholism. Pathology. — Inflammatory congestion and eventu- 
 ally thickening of the submucous tissue. Hypertrophy of the mucous 
 glands. A glairy mucous or muco-purulent secretion clinging to the mu- 
 cous membrane. Rarely ulceration, unless the disease has a specific cause. 
 
LARYNX, DISEASES OF. 165 
 
 Varicosities of the small vessels. Diagnosis. — Compare symptoms with 
 those of specific diseases of, and with those of ulcers and of growths in, 
 larynx. Prognosis. — Only good when the causes can be removed or a 
 change of climate can be obtained, or local treatment persistently carried 
 out for a long period by skilled hands. Treatment. — Kest from irregular 
 or much speaking or singing. All the ordinary precautions against catarrh, 
 viz. : — good thick boots, warm socks, dry clothes, dry lodging, dry climate 
 if possible. Exercise in fresh air without thick covering on throat, but 
 merely a thin tie or handkerchief. Regular habits. Avoid night air. 
 Open bowels. Moderate diet. No stimulants. In a few cases generous 
 diet is beneficial. Gargling with hot (not lukewarm) saline solutions, 
 especially of chlorate of potash ; sponging pharynx and glottis with soL 
 argent, nit. (gr. xx. to 3 j.). Inhalations of medicated sprays (especially ar- 
 gent, nit., gr. j.-x. to 3 j.), or of chloride of ammonium vapor. Painting 
 pharynx with glycerine of tannic acid. The health of the other organs 
 and systems of the body should always be inquired into carefully and at- 
 tended to. Chloride of ammonium, belladonna, mercury, sulphur, ipecac- 
 uanha, antimony, iodide of potassium, are all sometimes beneficial. 
 
 (Edema Glottidis. — Causes. — Usually some ulceration or deeper affec^ 
 tion of the larynx than mere non-specific catarrh, e.g., syphilitic disease of 
 the cartilages, small-pox. Sometimes erysipelas spreading inward from 
 face. Scalds. The oedema often supervenes quite suddenly in the course 
 of such diseases. Signs. — Firstly, there are the symptoms of the original 
 disease, e.g., hoarseness, loss of voice, cough ; then gradually or quickly, 
 signifying the occurrence of "oedema," there appears great dyspnoea, al- 
 most entirely inspiratory. This assumes a fearful form ; and the patient's 
 attitude and expression, as he exerts every muscle to get breath and avoid 
 the strangulation which appears to him imminent, are never to be forgot* 
 ten. Diagnosis. — From croup. The latter occurs in children, but oedema 
 glottidis almost always in adults. On pushing the finger boldly into the 
 pharynx, and feeling behind the back of the tongue, the epiglottis and ary- 
 taeno-epiglottidean folds may be felt ; the former as a median pear-shaped 
 swelling, and the latter as two lateral elastic swollen rolls of distended 
 membrane. In the cases where the oedema is unilateral, of course a swell- 
 ing will only be felt on one side. The swollen epiglottis is sometimes 
 visible. Pathology. — The oedema results from what is called collateral 
 fluxion, that is, from the active congestion which is apt to take place near 
 a centre of inflammation, especially an ulcer. Niemeyer aptly draws at- 
 tention to its analogy with oedema of the prepuce complicating a chancre. 
 The swellings may be pale or red, according to whether effusion or hyperae- 
 mia predominates. Treatment. — Scarify with a bistoury wrapped round 
 all but the point by lint or strapping. If the case is not urgent, croton oil 
 may be given ; and an emetic when there are many moist rales indicating 
 bronchial and pulmonary congestion. Warmth to the extremities. Pa- 
 
1GG' LARYNX, DISEASES OF. 
 
 tient should swallow slowly small bits of ice. Whether the symptoms are 
 urgent or not, he should be carefully watched and surgical assistance be 
 at hand ; for tracheotomy may be required very suddenly to save from in- 
 stant suffocation. ' When the above plan of treatment does not arrest the 
 disease, perform tracheotomy. The prognosis after operation is hopefuL 
 (See also treatment of Acute Laryngitis.) 
 
 Larynx, Syphilitic Aefections of. — Varieties. — (A) secondary affections — 
 erythema, condylomata, ulcers ; (B) tertiary affections — " papulo-tubercu- 
 lar elevations," ulcers, gunimata, perichondritis, necrosis of cartilages. Sec- 
 ondary -affections may be suspected from the altered voice, combined with 
 secondary eruptions elsewhere, especially in the fauces. They can be seen 
 with the aid of the laryngoscope, and require ordinary constitutional anti- 
 syphilitic treatment, aided in some cases by such local treatment as inhala- 
 tions of calomel vapor, sprays of chloride of ammonium and corrosive 
 sublimate, or applications of nitrate of silver. Fatigue of the voice should 
 be avoided. Tertiary affections of the larynx are more destructive and dan- 
 gerous. The papulo-tubercles affect any part of the laryngeal mucous 
 membrane, and, though occasionally causing dyspnoea, chiefly signify their 
 presence by affecting the voice. 
 
 Tertiary Ulcers of the larynx begin either superficially, or from soft- 
 ened gummata, or from perichondritis. "Usually multiple ; generally first 
 attack epiglottis. Spread in any or every direction, destroy vocal cords, 
 necrose cartilages. Cause dangerous and suffocative spasms. Symptoms. — 
 Hoarseness or loss of voice ; in many cases attacks of dyspnoea ; coincident 
 syphilitic history, and, usually, syphilitic appearance. Swallowing some- 
 times difficult from tendency of fluids to pass through glottis. Prog- 
 nosis. — In favorable cases, cicatrization takes place ; but, even then, voice 
 remains impaired, and a stricture of larynx may result, seriously impeding 
 respiration. So long as disease is active there is great danger of sudden 
 and fatal spasm. Diagnosis has to be made chiefly from phthisis and epi- 
 thelioma. Treatment. — W^here there is dyspnoea which cannot be rapidly 
 removed by milder means, it is dangerous to delay laryngotomy or trache- 
 otomy. Usually the former operation is to be preferred. Iodide of po- 
 tassium (grs. x. to xx. ter die) must be given ; cod-liver oil, tonics, best 
 hygienic conditions which can be obtained, are indicated. Locally, astrin- 
 gent, stimulant, and mercurial applications may be made with the aid of 
 the laryngoscope, e.g., strong solutions of sulphate of copper. McEwen 
 has lately (in British Medical Journal for July 24 and 31, 1880) demonstra- 
 ted that tracheal tubes introduced through the mouth may be used as a 
 substitute for tracheotomy or laryngotomy in cases both of disease and of 
 operation. Laryngeal strictures have been treated by the passage of metal- 
 lic and vulcanite instruments (Trendelenburg and Schrotter). 
 
LARYNX, DISEASES OF. 
 
 167 
 
 Tertiary Ulcer. 
 1. Attacks epiglottis first. 
 
 2. Progresses rapidly. 
 
 3. Little thickening. 
 4. 
 
 5. Expectoration thick, te- 
 nacious, yellowish. 
 
 Phthisical Ulceration. 
 
 Attacks first near arytenoid 
 cartilages. 
 
 Does not advance rapidly. 
 
 Great thickening. 
 
 Granular appearance of pos- 
 terior surface of epi- 
 glottis. 
 
 Expectoration frothy, thin, 
 muco-purulent. 
 
 Epithelioma. 
 
 Usually commences over 
 pharyngeal aspect of 
 arytenoids. 
 
 Progress slow. 
 
 Irregular thickening. 
 
 At first thin, often bloody. 
 
 Laryngeal Phthisis. — Vide medical works or special treatises. The 
 diagnosis mainly rests on the coexistence of pulmonary disease and of 
 hectic fever, on the absence of specific disease, such as syphilis, and on the 
 laryngoscopic appearances. The latter may show ulcerations, especially at 
 the back of the epiglottis and near the arytenoid cartilages. The disease 
 is tuberculous ; though it may be the result of local infection by phthisical 
 sputa passing over laryngeal mucous membrane. Treatment is addressed 
 locally to the ulcerations and chronic laryngeal catarrh (vide above), and 
 generally to the phthisis. 
 
 Larynx, Cancer of. ' — Affects chiefly male sex, and almost always occurs 
 in late middle life. Begins usually on left side. Primary cancer is about 
 as often encephaloid as epithelioma, seldom or never schirrus. The diag- 
 nosis has to be made from laryngeal phthisis and from syphilis. Phthisis 
 causes earlier and more complete loss of voice. Before there is much evi- 
 dent new growth it is next to impossible to distinguish laryngeal cancer 
 from syphilis. There are symptoms analogous to those of cancer else- 
 where, viz. : — pain, offensive odor, hemorrhages, glandular enlargements. 
 Treatment. — While the diagnosis is at all doubtful give an ti- syphilitic reme- 
 dies. Afterward, morphia subcutaneously for pain, carbolic acid inhala- 
 tions for fetor, atomized solutions of tannin for hemorrhages. But, above 
 all, tracheotomy, which in Fauvel's cases prolonged life, on the average, 
 two years in epithelioma and nine months in encephaloid. See treatment 
 of Cancer. The results of operation of extirpation of larynx have not yet 
 been encouraging. 
 
 Laryngeal Cartilages, Perichondritis and Necrosis of. — Causes. — 
 " Catching cold," syphilis, exanthemata. Indirectly, any cause of laryn- 
 geal ulceration ; for perichondritis may supervene on ulcer of larynx. 
 Patients are usually in a cachectic state. Signs, etc. — Firstly those of in- 
 flammation : pain very great. — Then suppuration : collection of pus may 
 cause intense dyspnoea. Lastly, necrosis of cartilage, which varies from 
 very trifling extent to the loss of whole cartilages. Portions of cartilage 
 are coughed up. Sinuses may form in neck. Cricoid cartilage most fre- 
 
 1 See especially : Fauvel's Traite Pratique des Maladies du Larynx. Paris 
 lahaye ; and a review of the same work in Medical Record, vol. iv., p. 476. 
 
 De- 
 
168 LARYNX, DISEASES OF. 
 
 quently affected. The immediate cause of the necrosis is usually sepa- 
 ration of inflamed perichondrium rather than inflammation of cartilage 
 itself. Diagnosis. — Easy when necrosis, with abscess or sinus, is fully 
 advanced. But earlier stages are accompanied by signs of laryngeal irri- 
 tation, which may resemble those caused by a foreign body. Use laryngo- 
 scope and consider history of case. Treatment. — On general principles. 
 Open abscess. Perform tracheotomy if dyspnoea is urgent and dangerous. 
 Treat syphilis if present. 
 
 Larynx, Innocent Tumors or. — Varieties. — Fibrous and fibro- sarcomatous 
 polypi, adenomata, papillomata, mucous cysts. Fibrous polypi and papil- 
 lomata are the most common. Other varieties, such as lipomata, occur 
 with extreme rarity. Cancerous tumors are described elsewhere. Posi- 
 tion. — Very rarely on the posterior wall (where ulcers are very frequent). 
 Signs. — Dyspnoea when the tumor is large enough or so situated as to be 
 liable to get between the vocal cords. When the tumor is above the glottis 
 inspiration is most likely to be obstructed, when below the glottis the dysp- 
 noea may be expiratory. Sensation as if foreign body were in larynx. 
 Sometimes secondary laryngeal catarrh : cough, hoarseness, aphonia. 
 Diagnosis. — Use laryngoscope. Treatment. — Kemoval through the mouth 
 in most cases. Sometimes the larynx has to be opened from the neck, by 
 median division of the thyroid cartilage for instance. In removing through 
 the mouth, snares, ecraseurs, laryngeal forceps, guillotines, and even gal- 
 vanic cautery are used. Of course the parts have to be made visible by 
 laryngoscope during operation, and no small skill is usually required. See 
 special notice of Laryngoscopy. Puncture cysts. Tracheotomy is done 
 prior to thyrotomy, and may be required, in case of severe dyspnoea from 
 tumor, merely to avert immediate danger of life. 
 
 Larynx (Trachea or Bronchi), Foreign Bodies in. — How They Gain En. 
 trance. — Through glottis, or, very rarely, through a wound. Children 
 most liable, from practice of playing with things in their mouths. Laugh- 
 ing or coughing whilst swallowing : the deep inspirations taken in those 
 actions suddenly draw food into the air-passages. Syphilitic ulceration 
 may impair laryngeal orifice or sphincters. General palsy of the muscles 
 which close the glottis. Palsy of the vocal cords is not in itself enough to 
 cause any danger of entrance of foreign body. Parts Where They Lodge. 
 — Sharp bodies usually stick in larynx, especially in or near the ventricle, 
 or just above the glottis. Of course, only bodies of limited size can 
 pass through glottis. Small, smooth, rounded bodies most likely to drop 
 into trachea or bronchi, especially into right bronchus. Septum between 
 bronchi is to left of middle line. Eight bronchus is larger than left. 
 Signs. — Depend (1) upon size of body, (2) upon its position, (3) upon 
 whether it is impacted or not, (4) upon its nature, whether sharp and 
 jagged or smooth and rounded. 1. A sufficiently large substance will 
 cause speedy suffocation unless removed. 2. Bodies near the glottis 
 
LARYNX, DISEASES OF. 169 
 
 usually cause acute irritation, spasm, cough, and choking sensation ; per- 
 haps hemorrhage and pain. Symptoms may be aggravated by each act 
 of swallowing. If not removed, ulceration, catarrh, or even abscess will 
 ensue. Impaction in the trachea causes signs mainly of impeded respira- 
 tion, but also produces general laryngo- tracheal irritation, and, eventually, 
 inflammation and ulceration. The interference with respiration, as well as 
 the tracheitis, soon affects the lungs. Bronchitis and pneumonia. When a 
 bronchus is the locality, the signs resemble those of foreign body in the 
 trachea ; but the pulmonary symptoms are confined to or most marked in 
 one lung. There is decrease or absence of respiratory murmur on the af- 
 fected side. 3. Bodies lying loose in the air-passages are apt, as they 
 from time to time come in contact with the glottis, to cause sudden and 
 violent paroxysms of choking and dyspnoea. 4. Of course, sharp and 
 jagged bodies produce greater irritation, and cause far greater danger of 
 ulceration, etc., than smooth ones. Diagnosis. — The history generally 
 makes this clear. Laryngoscope is very valuable. Lay stress upon the 
 sudden access of the symptoms without warning, and on the absence of 
 fever. Of course, when inflammation has resulted, fever will be present. 
 Prognosis. — Most grave, unless the body can be removed. The instances in 
 which substances have remained without producing serious consequences 
 are very rare. Sooner or later disease of the lungs ensues and proves 
 fatal. Treatment. — Measures must be taken to remove the foreign body. 
 In some cases the finger suffices to hook away an obstruction partly within 
 and partly without the larynx. In adults, the laryngoscope will some- 
 times enable forceps, hooks, or loops to be used successfully ; and, in 
 children, inversion of the body (applied by Mr. Brunei to himself) should 
 be tried, aided by succussion and by slapping the back. The remaining 
 proceeding is tracheotomy. And, when employing inversion, succussion, 
 etc., the surgeon should always be prepared to do tracheotomy at a 
 moment's notice. If the foreign body is in the trachea or bronchi, do 
 tracheotomy low down. If the foreign body be in the larynx, and cannot 
 otherwise be extracted, the tracheal wound may be extended upward, 
 even through the thyroid cartilage itself. If, when the wound has been 
 made, extraction cannot, even with the help of inversion and succussion, 
 be effected, the wound must be kept open in the hope that the patient 
 may shortly cough out the body. And a cannula must not be worn unless 
 the foreign body is known to be above the wound. 
 
 Rules for Laryngoscopy. 1 — 1. Position of patient : sitting, body and 
 head erect, knees together, head slightly thrown back. 2. Lamp : in line 
 with patient's ear, nine inches to left of his head. 3. Position of surgeon -. 
 opposite patient, with mirror properly adjusted to head and eye. 4 
 Mouth : wide open, 5. Reflect light upon fauces at correct focal distance 
 
 1 Abbreviated from Lennox Browne. 
 
170 LITHOTOMY. 
 
 of reflector. 6. Warm laryngeal mirror over lamp. Test it against cheek 
 or hand. 7. Direct patient to protrude his tongue. 8. Hold it between 
 thumb and index-finger, in napkin (thumb uppermost). 9. Hold laryngeal 
 mirror like a pen. 10. Place its back gently against uvula. 11. Move your 
 hand slightly toward patient's left, so as to keep it out of line of view. 
 12. Patient to draw a deep breath, and say " ah," " ur," " eh," or " ee." Be 
 always quiet and gentle ; encourage the patient ; let each examination be 
 short, even if unsuccessful. Be careful not to hurt patient's tongue, or to 
 burn his mouth, or to push either his uvula or the mirror against the back 
 of the pharynx. 
 
 Laryngotomy. — Steady larynx between thumb and forefinger of left 
 hand. Make a perpendicular incision through skin and fascia over crico- 
 thyroid membrane, and one inch long. Pass a sharp scalpel through 
 crico-thyroid membrane transversely. In the absence of a cannula (e.g., 
 in operations done with a penknife to prevent choking), turn the blade on 
 edge to hold open the wound. In operations done deliberately, of course 
 some tube must be introduced. See Tracheotomy. Tie any bleeding ves- 
 sel as soon as it is divided. 
 
 Lips are liable to congenital deformities (vide Hake-lip), to fissures, 
 chancres, epitheliomata, cysts, naevi, wounds, carbuncles, etc. See general 
 articles, e. g., Tumor, Cystic, etc. 
 
 Fissure of Lip. — Often syphilitic. Avoid laughing. Touch with argent, 
 nit. ; afterward use weak ung. hyd. nit., cold cream, etc. Antisyphilitic 
 remedies if necessary. Make a shallow cut through base in obstinate 
 cases. 
 
 Carbuncle of Lip is singularly fatal. See Carbuncle. 
 
 Litholapaxy (or Lithotrity, with immediate evacuation).— Professor 
 Bigelow, considering that the practice of leaving sharp fragments in the 
 bladder for weeks was more hurtful than the prolonged use of the litho- 
 trite, evacuating catheter and bottle ; being struck, moreover, by Otis' 
 emphatic announcements of the great calibre of the urethra — developed 
 this operation. He uses a special lithotrite, an evacuating catheter of a 
 size, if possible, of No. 30 (French), and an aspirating siphon, which 
 stands on a table and communicates with the evacuating catheter by an 
 india-rubber tube. Ether is given, and the sitting may be prolonged for 
 an hour. There are many details to be attended to. Vide a Paper by Bige- 
 low, in "Clinical Society's Transactions," vol. xii., 1879. Facts so far in- 
 dicate an excellent future for this operation. See also observations by Sir 
 H. Thompson and Mr. Cadge at the meeting of the British Medical Asso- 
 ciation, Cambridge, 1880. 
 
 Lithotomy. — Definition. — An operation in which the bladder is cut 
 into for the extraction of a calculus. Varieties. — Two kinds, viz., supra- 
 pubic and perineal (vaginal in the female). Varieties of perineal lith- 
 otomy, viz., (1) lateral, (2) median, (3) bilateral, (4) medio-lateraL Bilat- 
 
LITHOTOMY. 171 
 
 eral lithotomy is so rarely employed that we must refer to larger works 
 for a description of it. 
 
 Lateral Lithotomy (by far the commonest operation). — Instruments. — 
 " Staff," grooved on side or on convexity, lithotomy knife, lithotomy for- 
 ceps, scoop, bandages or straps to fix ankles and wrists, large metal syr- 
 inge, sponges, towels, catheter and lint for plugging wound if it should 
 be required. Stool or low chair for operator. Pocket case ; anaesthesia ; 
 razor and oil to shave perineum. Operation : place patient in lithotomy 
 position, bandaged or strapped (or the legs may be held in position by 
 two assistants). Buttocks to be well over end of table. The stone should 
 be detected whilst the patient is on the table, or else the operation should 
 be postponed. The surgeon sits at a convenient height, with his instru- 
 ments on a table close by, and an assistant to hand them (the latter should 
 be instructed as to the size and kind of forceps required, etc.). The sur- 
 geon passes the staff, and gives its handle to an assistant on the patient's 
 left. This assistant keeps the handle of the staff perpendicular, grasping 
 it firmly, but with the thumb upright. He should keep the concavity of 
 the staff pressed up against the symphysis pubis. Surgeon now incises 
 skin and fat from a point in median raphe one inch and a half in front of 
 anus, outward and backward, to midway between anus and tuberosity of 
 ischium. Incision may be extended backward in ischio-rectal region if 
 necessary. Deepen incision until the groove in the staff can be felt with 
 the tip of the left forefinger. Using the same finger and its nail as a 
 guide, send the point of the knife into the groove in the staff — of course 
 opening the urethra. Next glide the knife along the groove till it reaches 
 the bladder. The passage of the knife into the bladder is recognized by 
 the disappearance of the sense of resistance which is felt when the pros- 
 tate is being cut, and perhaps, also, by the escape of urine. 1 As the knife 
 glides along the groove, its handle should be depressed, so that the point 
 of the knife may never leave the groove till it fairly enters the bladder. A 
 neglect of this precaution may result in the knife getting between the 
 bladder and the rectum. Withdraw the knife, " lateralizing " it and 
 deepening the incision in the prostate during withdrawal. In case of a 
 large stone, knife may, during withdrawal, be moved out of groove of 
 staff a little to deepen incision. Insinuate left forefinger into bladder, 
 and, as soon as you are perfectly sure that your finger is in the bladder, 
 withdraw the staff, but not before. Take the forceps with your right hand 
 and pass them into bladder, along dorsum of left index-finger. When 
 they have reached bladder, open them, and, very likely, the gush of urine 
 which usually now takes place will wash the stone into the grasp of the 
 forceps. If this should not happen, care must be taken in seizing the 
 calculus not to include any vesical mucous membrane, and the calculus 
 
 1 See notice of Gritti's operation, in Appendix. 
 
172 LITHOTOMY. 
 
 should be so grasped that its long diameter may be in a line with the axis 
 of the forceps. In extracting stone, forceps should be pulled in a downward 
 and backward direction, and with a twisting movement. When wound is 
 very deep, blunt gorget may guide forceps into bladder better than index- 
 finger. When calculus is large, finger may be used to dilate incision of 
 prostate and neck of bladder, or a blunt-pointed bistoury may be used to 
 deepen prostatic incision. Sometimes stone can be more easily extracted 
 between forefinger and scoop than by forceps or by finger alone. If stone 
 breaks up, use of scoop and of syringe will be required. If stone is very 
 large, surgeon may have to purposely break it with a strong lithotrite, 
 and extract it piecemeal. When the last-mentioned proceeding has to be 
 resorted to, the prognosis is not very hopeful, not so much from the meas- 
 ure itself as from the state of things for which it has been required. The 
 bladder is now carefully explored for another calculus or for debris. In 
 case of hemorrhage, use a plug made like an umbrella, i.e., a piece of cath- 
 eter with lint or linen tied round it toward one end. This end is passed 
 into bladder, and lint or wadding pushed into the wound between the lint 
 and the catheter. The whole can afterward be withdrawn by pulling at the 
 lint. Tie the legs together, and send patient back to bed. The dangers 
 and accidents of lithotomy are (1) hemorrhage, (2) wounding rectum, (3) 
 missing the bladder with the knife, (4) leaving a calculus or a piece of cal- 
 culus in bladder, (5) pelvic cellulitis, (6) peritonitis, (7) cystitis, (8) ery- 
 sipelas, pyaemia, and other accidents common to wounds in general. Any 
 of the above complications may be fatal. But the great cause of death 
 after lithotomy is pre-existing kidney disease. After-treatment. — Merely 
 rest, warmth, cleanliness, and careful observation. Oil buttocks and 
 thighs while urine continues to flow through wound. 
 
 Median Lithotomy. — Allarton's form of the operation : 1, pass a grooved 
 staff into bladder ; 2, place left forefinger in rectum ; 3, feel with the same 
 finger for the apex of the prostate ; 4, enter a straight knife half an inch 
 in front of anus and direct its point to the urethra, just in front of apex of 
 prostate ; 5, with this knife cut upward a little, dividing small portion of 
 urethra ; 6, pass a probe-pointed director into the bladder, and withdraw 
 the staff; 7, gently insinuate finger along this director and dilate (or tear?) 
 prostate with the finger; 8, extract the stone with forceps. This opera- 
 tion is adapted for extraction of foreign bodies. 
 
 Several operators, including Buchanan and Teevan, use a rectangular 
 staff when performing lithotomy. At Guy's a " straight " staff is used. 
 N. B. Smith's ingenious apparatus is figured in Erichsen's " Surgery," ed. 
 vii., p. 778. For Bilateral and Medio-bilateral Lithotomy, see large works. 
 
 Supra-pubic Lithotomy, or " high " operation.— Instruments : scalpel, 
 artery forceps, dissecting forceps, curved staff, or metal catheter, retrac- 
 tors, lithotomy forceps. 1. Incise skin in middle line from pubes upward, 
 for three inches. 2. Dissect carefully downward and backward to reach 
 
LITHOTRITY. 173 
 
 bladder (which should contain several ounces of fluid), pushing away the 
 peritoneum if necessary, and keeping near the back of the pubes. 3. De- 
 press handle of staff which is in the bladder, so as to raise its point ; and 
 open bladder by cutting down on this point. 4. Enlarge incision in blad- 
 der toward its neck. 5. Extract with lithotomy forceps. Chief dangers 
 are from peritonitis and urinary infiltration, and they are immensely in- 
 creased by the bad state of the kidneys, usually found when the calculus 
 is large, and consequently when the supra-pubic operation is done. A 
 soft catheter should be left in the urethra till the wound becomes fistu- 
 lous. The supra-pubic operation can be done antiseptically. 
 
 Lithotrity. — Operation by which a calculus is crushed in the blad- 
 der and the fragments afterward extracted through the urethra. 1 Circum- 
 stances under which Suitable. — When (1) age is fifteen or upward, (2) stone 
 is less than one inch in diameter (if the other conditions are favorable 
 this limit may be considerably exceeded), (3) it is of soft or friable mate- 
 rial, e.g., phosphates, (4) urethra is healthy, (5) bladder and kidneys are 
 healthy, (6) prostate is normal. A combination of the above conditions 
 should make success certain. Noticing each individually, it may be ob- 
 served that lithotomy is safer when the age is under fifteen, when the 
 bladder and kidneys are diseased and the stone large or the stones numer- 
 ous, when the urethra is narrowed by a stricture and the bladder at the 
 same time not very healthy, and when the prostate is so enlarged as to 
 make manipulation of the lithotrite or removal of the fragments difficult. 
 But there are many cases in which the reasons for or against lithotomy or 
 lithotrity are very nicely balanced. The main considerations are, un- 
 doubtedly, age of patient and health of genito-urinary organs. A prac- 
 tised lithotritist is justified in crushing where a less experienced surgeon 
 ought to cut. Operation. — Instruments : lithotrite, Clover's syringe, linen 
 cloth on which to wipe lithotrite, oil, basin of water to receive fragments, 
 warm water to inject if required. Preparation. — Best and treatment of 
 vesical irritability, if present, for a short time before day of operation. 
 Bowels to be cleared. Bladder should contain four or five ounces of urine 
 or warm water. Becumbent position. Pillow beneath buttocks. Blank- 
 ets to keep trunk warm. Warm and oil lithotrite and pass it well into 
 bladder. Be extremely gentle throughout sitting. Seize stone by one of 
 two methods : I. Civiale's. — In this the calculus is picked up by the litho- 
 trite, just as a bird picks up a pebble with its beak. The following rules 
 are usually followed : I. In the case of small or medium-sized stone, (1) 
 pass the lithotrite, closed, to the back of the bladder ; (2) if the lithotrite 
 has touched or is touching the stone, rotate it slightly away from the stone 
 and withdraw the male blade ; rotate it back again to a little beyond its 
 
 Professor Dolbeau's "perineal lithotrity" is outside the above definition. Hia 
 operation is really a combination of lithotrity and lithotomy. 
 
1 74 LITHOTRITY. 
 
 original vertical position, and close the blades. The stone will probably 
 be caught ; (3) in any other case proceed to find and seize the calculus 
 systematically, thus: 1, withdraw the male blade, then half rotate (45°) 
 the lithotrite to the right, thus / and close ; 2, withdraw the male blade 
 again, then half rotate to the left, \, and close ; 3, rotate (90°) to the left, 
 horizontal, and close ; 4, rotate to the right horizontal. In each case with- 
 draw male blade before rotation, and also depress handle of lithotrite half 
 an inch, so as to slightly tilt up its blades ; 5, 6, search the sides of the 
 floor of the bladder by a still further rotation (135°), first to right, then to 
 left — before doing this depress handle of lithotrite one inch and a half ; 7, 
 having opened the blades, turn them to the inverted perpendicular and close, 
 at the same time depressing handle still farther. In this way the litho- 
 trite searches all round its own axis at intervals of 45°, and cannot well 
 miss anything. Every movement is to be conducted with extreme gentleness, 
 and, in particular, the centre of motion, when the instrument is moved at 
 all, should be the prostatic part of the urethra, where serious results would 
 be most likely to follow injury inflicted by rough manipulation. Small 
 stones usually lie toward the back of the trigone. IE. In the case of a 
 large stone, rotate away the blades to open them, as in the cases previously 
 noticed ; but do not open the lithotrite by pulling back the male blade ; 
 open it by pushing forward the female blade, leaving the male at the neck 
 of the bladder ; then rotate toward the stone and seize. IL English Mode 
 of Seizing Stone. — The handle of the lithotrite is raised so as to depress its 
 blades against the base of the bladder. The male blade is then with- 
 drawn, the handle being simultaneously raised a little more. If the cal- 
 culus does not then fall between the blades, tap the lithotrite lightly in 
 front or on one side, so as to try by the slight concussion to dislodge the 
 calculus. This failing, the blades may be rotated slightly, first to one 
 side, and then, if necessary, to the other. 
 
 The stone being seized, rotate the lithotrite a fourth of a turn on its 
 axis before crushing, so as to find if any mucous membrane has been ac- 
 cidentally trapped. Work always as near the middle of the bladder as pos- 
 sible, and always over the same spot. On this spot the fragments will fall, 
 and from it they can be picked up and further crushed, if necessary. No 
 sitting should last more than five minutes. 1 If pain is produced, the sit- 
 ting should be cut short. Sometimes one sitting will crush the stone com- 
 pletely. The smaller the stone and the healthier the bladder, the longer 
 each sitting may be made and the fewer are the operations which will be 
 required. The first sitting should be shorter than the others. Crush the 
 calculus by a series of short sharp turns of the screw. Usual interval be- 
 tween sittings three or four days. Throughout the process keep the posi- 
 
 1 This is the old rule, now upset by Bigelow's experience and teachings (see Litho- 
 lapaxy). 
 
LYMPHANGITIS AND LYMPHADENITIS. 175 
 
 tion recumbent, more especially in the interval between the first and 
 second sittings. It is at that time there is great danger of impaction of an 
 angular fragment in neck of bladder or in urethra. When removing lith- 
 otrite always previously see that the male blade is pushed home, and that 
 there is no fragment separating it from the female. The fragments and 
 debris may be left to be washed out by the urine, or partly brought away 
 through a silver catheter with a large eye in its concavity ; or they may be 
 washed out by means of Clover's syringe. 1 Finally, before pronouncing 
 the case complete, a most careful exploration of the bladder should be 
 made with a small lithotrite, lest a single fragment should remain to form 
 the nucleus of a new stone. The diet should be rather low, the drinks 
 demulcent and copious, the clothing warm. Morphia suppositories may 
 be useful. 
 
 Accidents and Complications of Lithotrity. — 1, Impaction of fragments 
 in urethra or in neck of bladder ; 2, retention of urine ; 3, cystitis ; 4. 
 renal irritation, and even suppression of urine ; 5, orchitis ; 6, abscess in 
 prostate ; 7, inflammation of veins around neck of bladder ; 8, pyaemia ; 
 ninthly, may be added effects of culpable clumsiness in operating, e.g., lac- 
 eration of the urethra or bladder. Impaction of fragments in urethra de- 
 mands instant treatment. If it occurs near bladder, endeavor to push back 
 fragment with large catheter. If it is nearer the meatus, attempt to ex- 
 tract it with Civiale's urethral scoop, using the greatest care and gentle- 
 ness. It may be necessary to open the urethra from without. Ketention 
 of urine is usually only temporary, and yields to warmth and liq. opii. 
 Cystitis may only be an aggravation of a condition existing before the op- 
 eration, or it may be due to sharp fragments, or to the atony of the blad- 
 der, which in old people may prevent the expulsion of the fragments. It 
 must be treated on general principles, one of which will be to remove the 
 cause. The application of this principle may demand the use of the lith- 
 otomy scoop or of Clover's or of Bigelow's syringe, or even the performance 
 of median lithotomy to remove the irritating fragments. The appearance 
 of unpleasant symptoms in the course of a lithotrity case is usually held to 
 indicate a prolonged interval between the sittings. Renal irritation de- 
 mands cupping to the loins, warmth, purges, etc. 
 
 Lungs. — See Chest, Injuries of. 
 
 Lymphatics and Lymphatic Glands. — Both are liable to inflam- 
 mation, to wounds, to hypertrophy, and to cancer. The former are also 
 subject to varix. 
 
 Lymphangitis and Lymphadenitis. — Inflammation of the lym- 
 phatics and their glands. Like other inflammations it may be acute, sub- 
 acute, or chronic. Most of the differences between these three forms are 
 such as are analogous to their differences in inflammation of other superfi- 
 
 1 See also Litholapaxy. 
 
176 LYMPHANGITIS AND LYMPHADENITIS. 
 
 cial parts. Causes. — Almost always, especially in the case of acute and sub- 
 acute forms, absorption of inflammatory or septic material from a wound or 
 pustule, or fissure or sore. According to Paget, the poison or irritant, at 
 all events in the instance of post-mortem virus, may be absorbed through 
 unbroken skin. Chronic glandular inflammation and enlargements are 
 scarcely distinguishable from strumous glands on the one hand, and from 
 lymphoma on the other ; they will, therefore, not be further noticed here. 
 Anatomy. — Chiefly deduced by analogy from observations on uterine 
 lymphangitis. Vicinity of lymphatics and glands is the seat of hyperemia 
 and plastic infiltration. This often leads in parts to local (rarely diffuse) 
 abscesses, including even deposits of pus in the lymphatics themselves. 
 The process usually ceases at the first glands on the upward course of the 
 lymphatics affected. The glands themselves become congested, swollen by 
 serous effusion, and crowded to obstruction with corpuscles. The main 
 terminations of lymphangitis are three: (1) resolution, (2) suppuration, 
 almost always with satisfactory recovery, (3) pyaemia, and then usually 
 death. Not ^infrequently cases of dissecting wound with lymphangitis and 
 abscesses in the track of the lymphatics affected, are wrongly spoken of as 
 pyaemia. If such cases were true pyaemia, recovery in them would scarcely 
 be so frequent as it is. The cellular thickening caused by lymphangitis 
 and adenitis is often very persistent, and the small erysipelatous patches 
 may enlarge vastly. Signs. — Track of inflamed lymphatics marked by red 
 lines, or red band, or by mere thickening and hardening of the lymphatic 
 cord. Often oedema in the neighborhood, or even of the whole region or 
 limb. Pain, tenderness, stiffness. In certain places frequently patches of 
 superficial cutaneous redness, similar to (possibly identical with) erysipelas. 
 Where suppuration occurs, there is softening, easily detected by drawing 
 the tip of the forefinger lightly over the part. The amount of fever and 
 gastric disturbance varies from nil to the highest grade. Usually a sud- 
 den rise of temperature, even to 104-5°. In the course of any wound, 
 rigors or such a temperature usually signify local lymphangitis. Diag- 
 nosis. — From phlebitis. Course of veins and of lymphatics not anatomi- 
 cally identical. No glands on the veins. Inflamed veins are " knotty." 
 Prognosis. — Usually in all respects good : but in the case of large opera- 
 tion wounds, compound fractures, and the like, signs of lymphangitis re- 
 quire very prompt attention ; and there are certain forms of blood-poison- 
 ing which first manifest themselves by lymphatic inflammation, and which 
 are singularly fatal. The fatality of such cases is usually due more imme- 
 diately to pyaemia, phlebitis, thrombosis, and embolism ; while its remote 
 cause is often either the intense septic malignancy of the absorbed poison 
 or perhaps local anatomical peculiarity, e.g., proximity to cerebral sinuses. 
 Treatment. — Rest, general and local ; elevation, fomentations, poultices, 
 pressure. Pressure, to succeed, should be very skilfully and gently ap- 
 plied. Equal parts of extractum belladonna and glycerine, on cotton- wool, 
 
DISEASES OF. 177 
 
 may be bandaged upon inflamed glands. Puncture as soon as softening 
 is distinct. Mercurial ointment, iodine paint, pressure, and " massage '' 
 (shampooing) for persistent thickenings. Attend to general symptoms. 
 Calomel and salines often valuable. As a rule, prefer low diet. 
 
 Wounds of Lymphatics almost invariably close by spontaneous coagula- 
 tion of lymph. Lymphatic discharging sinuses are very rare. Treatment. 
 — Pressure. 
 
 Vakix of Lymphatics. — Very rare. Treatment. — Pressure. 
 
 Meningocele. — A congenital hernia of the membranes of the brain. 
 When such a tumor contains brain, it is termed an encephalocele. Causes. 
 — Probably a combination of imperfect development of the skull -wall with 
 a tendency to hydrocephalus. Signs. — A tumor situated in the line of one 
 of the sutures, usually in the median line and toward the occiput, some- 
 times at the root of the nose, or even in the pharynx. Occasionally there 
 is a peduncle. Bluish, or color of natural skin, transparent, pulsating with 
 the brain and with respiration. Sometimes compression of it will cause 
 convulsions. More or less marked hydrocephalus almost always coinci- 
 dent. Prognosis. — Almost hopeless as to ultimate recovery. A small, 
 pedunculated tumor without symptoms of hydrocephalus would give the 
 most hope. Diagnosis from nsevus or from congenital cysts may be dirn- 
 cult. "The diagnosis" of meningoceles and encephaloceles '"'rests first 
 upon their congenital occurrence and position, at one of the membranous 
 portions of the fetal head ; next upon their fluid nature ; thirdly, upon 
 their considerable and decided increase in volume or tension, with strong 
 expiratory efforts ; fourthly, upon their reducibility in part or entirely ; 
 and fifthly, upon their sharing in the motions of the brain " (Holmes, in 
 his "System of Surgery," vol. v., p. 968). Treatment. — Support carefully 
 and gently with a smooth, soft pad and bandage. Puncture justifiable 
 when increase is continuous. Injection of iodine has been tried with 
 doubtful success. Annandale ligatured and excised successfully in a some- 
 what exceptional case. 
 
 Mollities, Ossiurn. — See Bone, Diseases of. 
 
 Muscles, Diseases of.— The chief are : 1, Atrophy and degenera- 
 tion ; 2, contractions ; 3, inflammation ; 4, paralysis ; 5, parasites (tri- 
 churiasis) ; 6, syphilitic affections ; 7, tumors. Some of the above are 
 primarily nervous affections, but they are mentioned here for the sake of 
 completeness. 
 
 Muscle, Inflammation of. — Chiefly occurs as an extension from inflam- 
 mation of neighboring parts, or as a result of injury, or of syphilis. Liable 
 to end in abscess, which may be very troublesome, especially in certain 
 parts, e.g., abdominal wall. Considerable pain and constitutional disturb- 
 ance. Treatment. — Local rest, poultices, etc. 
 
 Muscles, Ateophy and Degenekations of. — Four chief forms, viz., 1, 
 simple atrophy ; 2, granular degeneration ; 3, fatty degeneration ; 4, 
 12 
 
178 MUSCLES, DISEASES OF. 
 
 " waxy " degeneration. Simple atrophy is the form which occurs from dis- 
 use, e.g., in chronic joint disease. Microscopically there are abnormally 
 few striated muscle-fibres, and the appearance becomes more that of fibrous 
 tissue. Waxy degeneration occurs as a sequel of continued fevers. All 
 the forms of degeneration are found in progressive muscular atrophy. The 
 microscope shows in the case of fatty degeneration numbers of fat-cells in 
 the place of the muscle-fibres, and in the case of waxy degeneration a 
 "homogeneous, colorless, glistening mass." 
 
 Progressive Muscular Atrophy. — Vide medical works in which it is 
 most fully treated, e.g., those of Trousseau, Reynolds, Niemeyer, Charcot 
 ("Maladies du Systeme Nerveux "), etc. For treatment of atrophy, see that 
 of Paralysis of Muscles. 
 
 Muscles, Contractions of. — Causes. — 1, Inflammation of, or abscess in 
 the muscle ; 2, disease of nerves or nerve-centres ; 3, reflex irritation, e.g., 
 from worms (intestinal irritation), phimosis (sexual irritation) ; 4, " antag- 
 onism," i.e., contraction of one set of muscles because its opponents are 
 paralyzed ; 5, continued relaxation of a muscle, e.g., the state of the flexors 
 of a limb which has long been kept on an angular splint. Muscles in such 
 a state tend to become permanently shortened. Most cases of paralytic 
 talipes are probably caused by the limb permanently assuming a certain 
 position under the influence not, as was formerly supposed, of " true antag- 
 onistic " contractions, but of mere gravity ; 6, mal-development ; but a 
 muscle which has never been developed to its proper length cannot be 
 properly termed " contracted." The diagnosis of the affection is manifest ; 
 that of its cause depends chiefly on the history. Treatment. — In a few 
 cases it is sufficient to remove the cause, e.g., to circumcise for phimosis, 
 or to give santonin and scammony for worms. In mild cases, regular 
 manipulation by stretching or continuous mechanical extension may suf- 
 fice. But usually tenotomy is indicated. See Club-Foot. Tenotomy 
 should be followed by mechanical extension, either gradual or immediate 
 and total. 
 
 Muscles, Paralyses of. — Almost all cases which the surgeon has to treat 
 may be classified as : 1, those arising from injury to nerves {see Nerves, 
 Injuries of) ; 2, those arising from direct blows on a muscle ; 3, infantile 
 paralysis ; 4, Duchenne's disease ; 5, paralysis from disuse ; 6, neuromi- 
 metic or hysterical paralysis. Paralyses from direct injury require rest till 
 tenderness has disappeared ; afterward, manipulation, rubbing, kneading, 
 and passive exercise. 
 
 Infantile Paralysis. — Causes. — Can sometimes, but rarely, be traced to 
 catching cold. Almost, but not quite, exclusively a disease of childhood, 
 from infancy to the fourth year, inclusive. Four times as common in 
 summer as in winter (Sinkler). Similar, though perhaps not identical, 
 paralyses occasionally follow acute diseases, such as measles. Symptoms. — 
 Sudden commencement, usually - pith fever ; sometimes with severe cerebral 
 
MUSCLES, DISEASES OF. 179 
 
 symptoms (deafness, delirium, coma, general convulsions). Very rapidly- 
 developed, complete paralysis of certain parts, with entire relaxation of 
 the affected muscles. Parts affected, variable. Generally lower limbs. 
 Sometimes one or both arms, or separate muscles, e.g., deltoid. Serratus 
 magnus sometimes affected (Lees, " Clinical Society Transactions," 1879). 
 The muscles atrophy, the development of the bones is retarded, and, the 
 local circulation stagnating, the limbs become cyanotic. But the general 
 health and nutrition remain vigorous, and there is no affection of the 
 sphincters, nor any considerable disturbance of sensation. In the course 
 of time deformities result, e.g., talipes, contracted hip, etc. Pathology. — 
 Essentially an inflammation of the anterior horns of the gray matter of the 
 spinal cord, especially in the lumbar and cervical enlargements. Prog- 
 nosis. — Little or no danger to life or general health, except indirectly from 
 the crippling. But little hope of important benefit from treatment, except 
 orthopaedic. Treatment. — In early stages, treat the main affection vigor- 
 ously (of course, not forgetting patient's tender age). Strips of blister 
 along spine, near cervical enlargement in case of paralysis of upper ex- 
 tremities, near lumbar when legs are affected. Cathartics. Ergotine, bel- 
 ladonna, or pot. iod. internally. Prone position, if possible. Cold affusion 
 for severe head symptoms. Later on, galvanism. Constant current to spine 
 itself. Large electrodes, one to cervical or lumbar enlargement, other to 
 anterior surface of trunk. Alternate place of anode and cathode every two 
 minutes. Persevere at intervals for years (Erb). Faradic electricity to 
 affected muscles. Anode to spine or nerve-trunks ; cathode to muscles. 
 Fresh air, good diet, cod-liver oil, warm clothing to limbs. Massage, fric- 
 tion, "beating," sea-baths. Orthopaedic treatment and appliances. To 
 prevent the necessity for these, keep the paralyzed limb in a good posi- 
 tion when- at rest. Paralytic deformities are mainly caused by action of 
 gravity, but partially perhaps by antagonistic contraction of the stronger 
 muscles. 
 
 Duchenne's Disease, or Pseudo-Hypeeteophic Paralysis. — Cause unknown. 
 Age, childhood. Three stages : (1) of weakness of muscles of lower limbs ; 
 (2) of gradual hypertrophy of, successively, gastrocnemii, glutei, and lum- 
 bar muscles, weakness still persisting ; (3) of wasting and increased paraly- 
 sis. The muscular enlargement is due to growth of connective tissue 
 and fat. Idiocy often coexistent. Prognosis. — Bad. Quite hopeless in third 
 stage. Treatment. — Electricity; manipulation; "shampooing." 
 
 Paralysis from Disuse is practically identical with atrophy, and requires 
 shampooing, passive or active exercise, and perhaps stimulus of electricity. 
 
 Hysterical Paralysis. — Vide Hysteria. 
 
 Muscles, Tumors of. — Almost any variety may occur. Sarcomata prob- 
 ably most common. Ossifications of muscles themselves present appear- 
 ance of hard tumors. Such ossifications sometimes affect the adductors of 
 cavalry soldiers ("rider's bones"). Cysts. Cancer. The Trichina spiralis, 
 
180 NECK, INJURIES OF. 
 
 a nematoid worm, is a parasite which lies encysted in the muscles of pa- 
 tients affected with " Trichiniasis," as the affection is termed. 
 
 Muscles and Tendons, Bupture of. — Tendo Achillis and quadriceps ex- 
 tensor of thigh most often affected. Occurs chiefly in middle age. Treat- 
 ment. — Fix in a relaxed position for a fortnight. Resume use cautiously 
 and gradually. 
 
 Naevus. — Vide Tumors, Vascular. (Angiomata.) 
 
 Nails. — Chief Affections. — Ingrowth, onychia, hypertrophy, and psori- 
 asis. 
 
 Nail, Ingrown Toe, is really the overgrowth of the flesh at the side of 
 the nail, caused by pressure of boot and by not cutting the nail square. 
 Treatment. — Bad cases require perfect rest. With the point of a penknife 
 insinuate a little cotton-wool beneath the side of the nail and between the 
 edge of the nail and the overlapping flesh. Avoid cutting the nail. Poul- 
 tice and rest thoroughly if there is much inflammation. In a few cases 
 avulsion of the whole nail (of course, under either local or general anaes- 
 thesia) may be necessary. 
 
 Onychia. — An ulceration of the matrix of a nail. Varies much in sever- 
 ity. The worst cases are termed " Onychia maligna." Causes. — Bad con- 
 stitution ; weakly children especially liable ; local injury, neglect, syphilis. 
 Signs. — Ulceration sometimes confined to one angle of the matrix, some- 
 times extending along both sides and base of matrix. Nail blackens, 
 loosens, and peels on\ perhaps in strips. Sanious, foul discharge. Often 
 great pain. Treatment. — Bemove nail. Carry hand in a sling beneath 
 chin ; poultice a day or two ; then dress with ung. hyd. oxid. rubri, or 
 carbolic oil. Nitrate of lead. Ung. iodoformi would be worth trying when 
 inflammation is reduced. I£. Liq. arsenicalis, 3 iij., aquse ad. § ij. M. Ft. 
 lotio. Black wash. Internally give tonics and cod-liver oil. 
 
 Hypertrophied Nails should be removed, and measures be taken to 
 protect against local irritation. 
 
 Psoriasis of the Nails. — " The central part of the nail becomes thick- 
 ened, rough, and scabrous, and unnaturally convex ; the free edge is often 
 split ; the cuticular fringe at the bottom of the nail is ragged and re- 
 tracted, leaving a deep fissure between the nail and the skin of the finger. 
 The whole nail, in an extreme case, resembles the outside of the concave 
 shell of an oyster" (T. Smith). Treatment. — Smooth down with sand- 
 paper. Dress at the margin with equal parts of ung. picis liq. and ung. 
 hydrarg. ammon. Constitutionally give arsenic or antisyphilitics, as may 
 be indicated. Bemember that parasitic disease of the nails — "ring- 
 worm " — occurs, but with extreme rarity. May be detected by the micro- 
 scope. 
 
 Neck, Injuries of. — See Sprain ; Throat, Cut ; Spine, Dislocations 
 of, etc. 
 
 Neck, Congenital Fistula in, called " Branchial Fistula?," because they 
 
NERVES, INFLAMMATION OF. 181 
 
 are probably due to incomplete closure of the branchial clefts. Yery 
 small ; usually give exit to a serous discharge. 
 
 Neck, Tumors of, are usually enlarged glands, or abscesses resulting 
 therefrom. More rarely, adenomata, cysts, "hydroceles," aneurisms, or 
 cancers. See also Bronchocele. Lipomata not uncommon at back of 
 neck. 
 
 Neck, Hydrocele of. — A cystic tumor, usually situated at the base of 
 the posterior triangle. Contents. — Yellow or brown serous fluid. Diagno- 
 sis, — By fluctuation and transparency. Treatment — Tap and inject with 
 iodine. 
 
 Wry-Neck. — Depends on contraction of the sternomastoid. (Besides 
 true wry-neck, there are hysterical wry-neck and a spurious wry-neck, 
 caused by caries of the cervical vertebrae.) Causes. — Vide Muscles, Con- 
 traction of. Symptoms. — Distance from ear to sternoclavicular articula- 
 tion, shortened on side of contracted sternomastoid. Head bent over to- 
 ward, and face turned away from same side ; head also bent downward. 
 Contracted sternomastoid feels tense, especially when an attempt is made 
 to raise head. Lateral curvature of spine frequently a secondary result. 
 Arrested development of face on affected side. Other muscles besides 
 sternomastoid sometimes contracted, but not so firmly. Treatment. — 
 Divide sternomastoid subcutaneously, and afterward fix the head straight 
 or slightly inclined toward opposite side by a special machine, or by 
 strapping and bandages. A leather collar sometimes useful in mild cases. 
 Division of Sternomastoid. — Divide close to origin. Divide sternal and 
 clavicular heads separately. Turn edge of knife toward skin, first passing 
 blade beneath muscle. Do not insert knife too deeply, as death has oc- 
 curred several times frorn wounds of important vessels. After-treatment 
 must be persevered in for a month or two. Manipulation suffices toward 
 the latter part of the time. For hysterical wry-neck, division of sterno- 
 mastoid is generally rather prejudicial than useful. Treat on the princi- 
 ples laid down for Hysteria, q. v. In wry-neck from spinal caries, treat 
 the prime disease. 
 
 Nerves, Inflammation of. — (1) Acute, (2) chronic. Acute neuritis 
 is uncommon, and is marked by continuous pain, tenderness, and swelling 
 along the course of the affected nerve, and often by spasms of the muscles 
 connected with it. 
 
 Chronic Neuritis — Causes. — Exposure to cold and damp ; the same 
 causes combined with injury, injury alone, excessive fatigue, rheumatic 
 constitution. Symptoms. — Sometimes like those of acute neuritis, but 
 milder and more persistent. After death the nerve is found swollen, in- 
 jected, and occasionally suppurating. Treatment. — General and local an- 
 tiphlogistics ; rest ; position of relaxation ; leeching ; purgation ; iodide of 
 potassium. Specific remedies when rheumatism, gout, or syphilis is diag- 
 nosed. 
 
182 NOMA. 
 
 Nerves, Tumors of. — See Tumors, Neuroma. 
 
 Neuralgia. — Pain in the course of a nerve, and not caused by any 
 visible disease or injury to the parts supplied by that nerve. Causes. — 
 (1) Obscure injury to the nerve ; (2) foreign body irritating it ; (3) tumors 
 pressing on it ; (4) compression by contracted cicatrices ; (5) overfilling of 
 veins near nerves as they pass through long canals, e.g., infra-orbital 
 canal ; l (6) poisons in the blood, e.g., malaria, mercury, lead, copper, etc. ; 
 (7) neuralgia appears to be sometimes reflex, and to be caused by irrita- 
 tion of some other nerve than that affected. Lastly, in an immense num- 
 ber of cases, the cause is quite unknown. The exciting cause of a neuralgia 
 is frequently catching cold, or exercising the part subject to the com- 
 plaint. Pathology. — When any distinct anatomical change is found, the af- 
 fection is no longer called a neuralgia, but a " neuritis," or whatever may 
 be the nature of the change observed. During a neuralgic paroxysm, 
 there is generally local hypersemia. Symptoms and Course. — Extremely 
 various. Continuous or remittent or intermittent, short or enduring, cir- 
 cumscribed or diffuse, lancinating, aching, or burning. Often relieved, 
 sometimes aggravated by pressure. Tender spots occasionally found, e.g., 
 where lateral intercostal cutaneous nerves pierce the external intercostal 
 muscles in neuralgia of breast. Years sometimes do not suffice to remove 
 obstinate neuralgia. Treatment. — Treat cause. Iron in ansemia. Quinine 
 in remittent cases. Anti-rheumatics in rheumatic cases. Locally : linimen- 
 tum aconiti ; linimentum belladonna ; empl. belladonna? ; tinct. capsici ; 
 chloroform ; chloroform saturated with iodoform ; blisters ; ether -spray ; 
 hot fomentations ; ice ; ung. veratriae. Electricity, faradization ; con- 
 stant current. Also excision of nerves and nerve-ganglia. Intenmally. — 
 (Besides iron, quinine, etc., mentioned above) chloride of ammonium in 
 half -drachm doses ; phosphorus ; cro ton- chloral (gr. v. every three hours) ; 
 chloral; gelseminum ; chloroform; "tonga," in 3j. doses, three times a 
 day ; stomachics ; tonics, etc. Vide works on " Therapeutics ; " change of 
 air and scene ; hydropathy ; colchicum in gouty subjects. Sometimes 
 morphia subcutaneously seems to be the only resource. But such injec- 
 tions are contraindicated in cases of great debility, in advanced age, in 
 cerebral hypersemia, and in organic disease of the heart (Erb). 
 
 Nipple, Sore. — Solid nitrate of silver to any fissure. Ung. hyd. nit. 
 No soap, merely hot water in washing. Lotions of zinci sulph. or borax. 
 Leaden shields. Cure any aphtha of child's mouth. 
 
 Nipples, Retracted. — When merely a natural conformation, attempt 
 to bring out by repeatedly drawing with the breast-pump. 
 
 Noma. — See Cancrum Oris. Disease attacks external genitals of fe- 
 male children as well as mouth. 
 
 1 Henle, quoted by Niemeyer. 
 
NOSE, DISEASES OF. 183 
 
 Nose, Diseases of. — Those which require special notice are acne 
 rosacea, lipoma, lupus, epithelioma, chronic nasal catarrh, ozena, syphilis, 
 tumors (including polypi), and deformities. 
 
 Acne Rosacea. — Occurs chiefly in young women, in women of 50, and 
 in men advanced in life. Causes. — Indigestion. Disorders of sexual 
 system. Local irritation, e.g., from exposure to sun and weather. When 
 attacking old men the cause is usually spirit-drinking. Pathology. — Cuta- 
 neous hypertrophy and capillary congestion. Sebaceous glands not neces- 
 sarily affected. Treatment. — Remove the cause if possible. Regulate the 
 habits. Treat indigestion. Locally. — Ung. sulphuris iodidi. Lotio hy- 
 drarg. perchlor. (gr. ij. to f j.). Bathing with water as hot as it can be borne. 
 Abstinence from stimulants. Riding and driving exercise. The dilated 
 capillaries may be slit up and touched with liq. ferri perchlor. 
 
 Nose, Lipoma of. — Integumentary and subcutaneous hypertrophy of 
 alae and tip of nose. Variable in extent and size. Attacks old men. Fibro- 
 cellular and not fatty in structure. Treatment. —Removable by suitable 
 incisions. Slight danger of erysipelas. 
 
 Nose, Lupus of. — Vide Lupus. 
 
 Nose, Epithelioma of.— See Cancer. 
 
 Nasal Catarrh, Chronic. — Causes. — Residence in damp, cold localities, 
 repeated acute catarrhs, constitutional predisposition, struma, exposure to 
 draughts, irritating dust, irritation of nasal polypi (and specific causes — see 
 " Ozsena "). Signs. — Mucous membrane swollen, red, covered with secretion, 
 mucous or muco-purulent, moist or crusted. Sometimes a nasal tone of 
 voice. Nose may* be occluded by swelling of mucous membrane. Pharynx 
 usually also affected. Treatment. — Treat the cause. Nasal douche with 
 solutions of chlorate of potash, common salt, phosphate of soda, and car- 
 bonate of soda, in hot water (hot water is preferable to lukewarm). Use 
 douche twice a day. Solutions should be just strong enough to taste 
 saline. Later on, astringents should be added in small quantities to the 
 saline washes. Nose not to be blown for a short time after douching. The 
 same fluids may be applied with an atomizer instead of the douche. In- 
 halation of vapor of chloride of ammonium. Insufflation of powdered 
 alum, bismuth, and starch, etc. Iodoform powder sniffed up. Iodoform 
 in vaseline (gr. xx. to 3 j.) : applied with a small brush far up each nostril 
 (Lennox Browne and Brandeis). With regard to the douche, it should be 
 noted that Professor Roosa of New York strongly condemns it as too 
 dangerous to the ears ; and even Professor Cassells, who stoutly defends it, 
 never trusts patient to use it himself. Sleep with a high pillow. Moderate 
 diet. Fish and milk. Avoid stimulants. Cod-liver oil at night some- 
 times beneficial. Change of air and scene. Dry, elevated regions. In- 
 ternally, large doses of chlorate of potash. 
 
 Oz^na. — An habitual and offensive odor from the nose, often amount- 
 ing to a horrid stench, and almost always of a certain characteristic nature. 
 
184 NOSE, DISEASES OF, 
 
 Causes. — (1) Strumous ulceration, (2) syphilitic ulceration, (3) necrosis 
 from non-specific causes, (4) long-continued chronic catarrh, (5) foreign 
 bodies impacted, (6) merely a peculiar tendency to decomposition of the 
 nasal secretion. Seat of Disease. — Any part of nasal walls, or of sinuses 
 opening into nose. Amount of discharge very variable. Often all passe? 
 backward into pharynx. Prognosis. — Unless cause can be detected 
 and easily removed, ozsena is very difficult to cure. May last for years. 
 When complicated with bone disease, deformity a frequent result. Treat- 
 ment. — Antisyphilitics for syphilis. Cod-liver oil, iron, arsenic, etc., for 
 struma. Explore nasal cavity carefully with a strong light, a mirror, and 
 speculum. Eemove dead bone. Nasal douche with hot alkaline or salino- 
 astringent solutions (see Nasal Catarrh). Solutions of Condy's fluid. 
 Insufflation of mercurial powders — white or red precipitate, 2 grains to 1 
 drachm of sugar. Iodoform (see Nasal Catarrh). Pugin Thornton 
 strongly recommends spray ot solution of borate and carbonate of soda. 1 
 In syphilitic ozaena of infants, syringe out nostrils with hot saline solutions, 
 and afterward insert melted ung. hyd. nitrat. dil., or iodoform ointment. 
 Of course remove foreign bodies. Treatment of ozsena must be perse- 
 vering, and used twice or even three times a day. 
 
 Nose, Tumors of, are either (1) "mucous polypi," (2) "fibrous polypi," 
 (3) malignant, (4) cartilaginous, or (5) osseous. The first three are the 
 most common, especially the first. Causes. — As obscure as those of 
 tumors elsewhere ; but mucous polypi sometimes appear to arise from 
 long-existing chronic catarrh. Symptoms and Diagnosis. — Those of nasal 
 or nasopharyngeal obstruction, often combined with nasal catarrh and 
 leading to deformity of the face. Mucous polypi may usually be seen and 
 recognized by their pale, semi-transparent appearance and soft consist- 
 ence. Fibrous polypi cause hemorrhages, are red and firm, are usually 
 single, and are attached to the roof of the nasopharyngeal cavity. Malig- 
 nant tumors grow rapidly, bleed, fungate, infiltrate neighboring parts, 
 cause pain (often considerable), and cachexia. Cartilaginous and osseous 
 tumors are rare, and may be known by their consistence. Very rarely 
 certain extraordinary loose osseous tumors are found in the nose or the 
 adjoining sinuses. Pathology. — Mucous polypi are fibrocellular tumors, 
 or myxomata, or fibromyxomata. Fibrous polypi are fibrosarcomata or 
 pure sarcomata. Mucous polypi are usually attached to the outer side of 
 the nasal cavity, especially to the middle turbinated bone. Fibrous polypi 
 spring from the periosteum. They are usually attached toward the back 
 of the roof of the nose. See Cancer, for the structure of cancerous 
 tumors. Treatment. — Twist and tear out mucous polypi with polypus 
 forceps. Ordinary dressing forceps do not usually bite well enough. 
 
 1 B. Sodas carb., sodas biborat, aa 3 ij. ; liq. sodas chlorinates, 3 ss. to 3 ij. ; glycerini, 
 3 ].; aq. ad. § viii. 
 
STKICTUKE OF. 185 
 
 Afterward, to prevent or delay recurrence, prescribe tannin as snuff, or 
 else spray of solution of sulphurous acid. A. sulpkurosi (P.B.), j. to aquae 
 iij. Polypus snare. Nasopharyngeal polypi. Fibrous polypi, if they can- 
 not be snared, may require operations even of the first magnitude, e.g., 
 removal of superior maxillary bone. Other procedures involve cutting 
 through hard and soft palate, or slitting up nose close to middle line, or 
 Langenbeck's operation, which resembles excision of upper jaw, only that 
 bone, after being turned out, is replaced. Cancer requires excising like 
 fibrous polypus, unless too far advanced. 
 
 Abscess is an occasional cause of swelling in the nose, especially during 
 syphilitic disease. Open early. 
 
 Nose, Deformities of. — Congenital are very rare. Flattening from 
 syphilis or from accident is difficult to treat, especially the former. To 
 raise a nose depressed by fracture, instruments such as those of S. Gamgee 
 may prove useful. 
 
 (Esophagus, Foreign Bodies in. — May lodge in any part, but usu- 
 ally stop at commencement just behind cricoid cartilage. Symptoms. — 
 Local pain, especially on attempting to swallow. The character of the pain 
 and the presence or absence of dyspnoea depend on the nature and size of 
 the body. So also do the prognosis and treatment. A soft, soluble, or 
 macerable substance may pass eventually with little or no external assist- 
 ance, or may easily slip down before the probang. A pin may be caught 
 by the horse-hair probang, and a coin by the " coin-probang," or either 
 may be brought up by forceps, such as those of Bryant. But large 
 jagged bodies may demand a cutting operation ; and, when they cannot 
 be recovered by less serious means, cesophagotomy had better not be de- 
 layed. Urgent dyspnoea may demand laryngotomy or tracheotomy. Oil 
 the probangs and oesophageal bougies before using them. The fingers 
 are Useful, not only for examining the pharynx, but for hooking out for- 
 eign bodies from its lower end. If the foreign body reach the stomach, 
 keep the patient in bed, and give large quantities of bulky food, but no 
 drugs. 
 
 OEsophagotomy. — Scalpels, forceps (dissecting and artery), retractors, 
 director, probe, oesophageal forceps, or some other long curved instrument 
 to act as a staff passed down the oesophagus. Place a pillow beneath 
 shoulders. Incision for five inches along anterior border of sternomastoid 
 (left, unless foreign body project to right), with its centre opposite position 
 of foreign body. Proceed as in tying carotid ; but instead of opening 
 carotid sheath, retract it and its contents outward. Retract larynx the 
 other way. In opening oesophagus, . take care not to wound recurrent 
 laryngeal nerve. Feed for a few days through an oesophageal tube passed 
 through mouth and beyond wound. Prognosis very good. 
 
 (Esophagus, Stricture of. — Forms : 1, cicatricial after injury ; 2, idio- 
 pathic fibrous thickening ; 3, syphilitic ulceration ; 4, cancer ; 5, pressure 
 
186 PALATE. 
 
 of neighboring tumors. No. 2 is very uncommon ; No. 4 is, unfortu- 
 nately, not so. The most usual form of tumor to compress the oesopha- 
 gus is a thoracic aneurism. Signs. — The essential one is dysphagia — diffi- 
 culty of swallowing. This may come on so gradually as to be unperceived 
 until the power of swallowing anything but the smallest morsels has been 
 lost. More of less pain. Progressive emaciation. The most terrible 
 symptom to the patient is the feeling of unappeased hunger. Ulceration 
 is indicated often by fetor of the breath, or by the presence of blood on a 
 bougie passed gently. To diagnose the nature of the stricture, whether 
 cancerous or syphilitic or sinrple, consider the age, history, and collateral 
 symptoms of the patient— e. g., a tumor may be felt at the root of the neck, 
 or cancerous glands may be found in the neck, or examination of the chest 
 may discover indubitable symptoms of aneurism, and so on. The patient's 
 feelings are deceptive as to the locality of the stricture, he usually referring 
 it to beneath the manubrium sterni. Prognosis. — In many cases, death from 
 starvation, sometimes from hemorrhage or the spread of cancer. Difficult 
 to treat even a fibrous stricture successfully with bougies. Great gentleness, 
 tact, patience, and perseverance may succeed. Whenever the cause can be 
 removed, the prognosis is good, unless there be a severe ulceration, likely 
 to be followed by cicatricial contraction. Treatment. — First examine with a 
 well-oiled bougie. If one can be passed gently, try to gradually dilate, by 
 passing from day to day increasing sizes, unless the cause be manifestly pres- 
 sure from without, e.g., aneurismal. If the cause be clear, of course treat it. 
 In case of doubt, iodide of potassium and rest are generally worth a good 
 trial. Excision of cancer of the oesophagus has hitherto been unsuccessful ; 
 and gastrotomy {quod vide) has had discouraging results (two successes to 
 many failures), perhaps partly because it is mostly postponed till too late. 
 Life can be prolonged by nutrient enemata when swallowing has become 
 impossible. 
 
 Orbit. — An enlargement here may be aneurism (quod vide), or abscess, 
 or enlargement of lachrymal gland, or exostosis, or hydatids, or cancerous 
 or other tumor. 
 
 Ozaena. — Vide Diseases of Nose. 
 
 Palate. — Cleft Palate. — A congenital deformity, due to non-union of 
 palate plates of palate bones and superior maxillaries with their fellows, or 
 of the superior maxillaries with the premaxillaries, or to non-union of 
 the two halves of the soft palate. The amount of imperfection varies 
 from merely bifid uvula to a complete chasm from pharynx to face. Often 
 complicated with hare-lip. The parts affected are more or less stunted in 
 growth : hence width of cleft varies. Treatment. — An infant with cleft 
 palate cannot suck : hence it requires hand-feeding. But it should be 
 hand-fed with its mother's milk only for the first two months. Upon all 
 cases, except a few in which the cleft is too wide, a plastic operation must 
 be done. If possible, operate before the child has begun to talk. When 
 
PALATE. 187 
 
 the cleft is hopelessly wide, let a dentist fit the mouth with an " obtura- 
 tor " of gold or vulcanized rubber. 
 
 Staphylorrhaphy (for cleft of soft palate). — Essential steps of the opera- 
 tion are three, viz., (1) paring edges of cleft, (2) uniting them by sutures, 
 (3) incising to relieve tension. Chloroform children. Anaesthesia optional 
 in case of adults. Insert Smith's gag. (It is as well to see that this gag fits 
 on the day before the operation.) The edges are pared by means of long- 
 forceps and long-handled knife. Avoid unnecessary and rough spong- 
 ing, as it increases flow of saliva. Sutures are of horse-hair, catgut, silk 
 and silver wire. Their strength is in the inverse order in which they are 
 named here. The ends of silver wire may irritate the tongue. Alternate 
 sutures of horse-hair and silk answer well. The sutures are passed by 
 long-handled and curved needles. Startin's needle. Plan of passing 
 thread through one flap, then through loop of a thread already passed 
 through other flap, and lastly dragging it completely through by means of 
 this loop. There is a simple little instrument for twisting wire sutures. 
 Pass most of the sutures before tying one. Check bleeding before tying. 
 Bleeding rarely troublesome. Iced water, gentle pressure with small 
 sponge, and waiting a minute or two, suflice to check it. The accessory 
 incisions to relieve tension may be done (1) a few days before the opera- 
 tion, as suggested by Callender, or (2) just before the operation, or (3) 
 just after the operation. They are either (1) simply lateral cuts parallel 
 to the cleft and close to alveoli, or (2) more scientifically planned pro- 
 ceedings to divide levator palati and palatopharyngei. Palatopharyngei 
 divided by merely snipping across posterior pillars of fauces. Two ways 
 of dividing levator palati, viz., Fergusson's and Pollock's. Few people 
 competent to perform either with certainty after merely reading a verbal 
 description ; while any one can do either after half a minute's practical 
 illustration. Fergusson divided the perpendicular part of the levator pal- 
 ati midway between the Eustachian tube (its orgin) and the hamular pro- 
 cess, where it bends into the palate. Pollock divides the horizontal part 
 of the levator palati as it lies in the soft palate. Fergusson used a rectan- 
 gular knife, which he passed through the cleft in the palate. Pollock uses 
 a straight knife which he passes through the soft palate close to the hamu- 
 lar process (which can be felt with the finger). "If the palate will not 
 come easily together, two lateral oblique cuts may be made, one on either 
 side, above the highest suture, separating the soft from the margin of the 
 hard palate to a small extent" (T. Smith). 
 
 Hard Palate, Operation for Cleft of. — Kesembles, in princrple, that for 
 cleft of soft palate. Mucous membrane and subjacent periosteum are 
 scraped from lower surface of palate plates. Incisions are made along 
 alveolar border of palate, and the edges of the cleft pared. Then the 
 loose dependent flaps are brought together in the middle line, and united 
 by strong sutures. Beware of "buttonholing" the flaps in scraping 
 
188 PARACENTESIS THORACIS. 
 
 them. Various forms of raspatories may be used. In separating the flap 
 from the bones, work from without inward. 
 
 When to Remove Sutures. — Lower two on second day, the rest alter- 
 nately, according to position, on third and fourth day. Soft food till 
 union is complete. The less conversation the better. The last observa- 
 tions apply to both hard and soft palate. Cleft of both hard and soft 
 palate may be dealt with at one operation. 
 
 Palate, Non-Malignant Tumors of, are usually either (1) cystomata, or 
 (2) fibromata, or (3) papillomata. Abscess also occurs. 
 
 Palate, Ulceration of, a frequent result of syphilis, but not always spe- 
 cific. Treatment. — Mercurial gargles and specific remedies. 
 
 Palate, Perforation of, the result of disease (syphilis, more rarely 
 small-pox and measles) or injury, may require an obturator. 
 
 Paracentesis Abdominis. — Position of Patient. — On side near edge 
 of bed. An ink-mark may be made exactly in median line, midway be- 
 tween umbilicus and pubes, as patient lies on his back before turning him 
 on his side. Preparation. — Ascertain by percussion presence of fluid in 
 spot to be pierced. Bladder should be empty. Apply a broad flannel 
 belt round abdomen with its ends behind held by an assistant, who keeps 
 up gentle pressure while the fluid flows, and finally secures it. The tap- 
 ping may be done through a hole in it. Use a cannula with an india-rub- 
 ber tube leading into a bucket. Have ready strapping and pad of lint to 
 apply after operation. Incise skin at point where the trocar is to be 
 thrust in. Dangers. — (1) Hemorrhage, from not keeping to the middle 
 line ; (2) wound of bladder, from not emptying it ; (3) wound of bowel, 
 from not tapping in a thoroughly dull spot, or from plunging trocar in too 
 deeply ; (4) fainting. 
 
 Paracentesis Pericardii. — An operation of extreme delicacy. Use 
 the aspirator. Place of Puncture. — Fifth intercostal space, two inches from 
 sternum. Mark spot with ink. Use No. 1 or 2 Dieulafoy's needle. As- 
 pirator cock must be turned as soon as needle-point is beneath skin, so 
 that fluid may rush through needle the moment pericardium is opened. 
 Direct needle upward and inward, and hold it perfectly steady. 
 
 Paracentesis Thoracis. — Formerly done "with common trocar and 
 cannula ; now usually with an aspirator. Position of patient, sitting up in 
 bed. Preparations. — Ascertain by percussion, etc., presence of fluid. Place 
 taps of aspirator in proper position. Place of Puncture. — Fifth intercostal 
 space in mid-axillary line, or a lower space more posteriorly, e.g., seventh, 
 near angle of scapula. Both may be tried if fluid do not come through 
 the first. Operation. — Puncture skin with a lancet. Insinuate aspirator 
 needle with a twisting motion over lower rib, close to it (because inter- 
 costal artery is near upper rib). Then plunge needle smartly through 
 pleura ; turn cock of aspirator and collect fluid. Whether it is or is not 
 such a serious matter to admit air into the pleural cavity has been the 
 
PENIS. 189 
 
 subject of many papers and speeches. For references, see Neale's "Medical 
 Digest," p. 240. Dangers. — Wounding (1) intercostal vessels, (2) lung, (3) 
 diaphragm, (4) admission of air and consequent collapse of lung, empyema, 
 etc. (?), (5) rupture of pleura or capillaries by excessive suction with the 
 aspirator, (6) sudden death (see Medical Times, vol. ii., 1875, p. 382, etc.). 
 If it is desired to make a free incision, this is easily done by cutting along 
 a grooved needle used as a director. Keep close to rib below the space. 
 A counter-opening can be made either in the same way as the first, or by 
 the help of a long bent probe or director, inserted to be cut down upon. 
 Parotid Tumors. — Divided, for practical purposes, into (1) innocent, 
 
 (2) malignant. Former commence near lobe of ear as small, hard swell- 
 ings, perhaps originally enlargements of a lymphatic gland. They are 
 fibrocartilaginous. Increasing, they tend to grow outward as a square 
 mass, and inward so as to displace part or whole of the parotid. But can- 
 cerous tumors are more diffuse, more fixed, more painful, increase faster, 
 and tend to infect the lymphatics of the neck. Treatment. — A movable 
 tumor corresponding to the first description above given should be ex- 
 cised; a malignant tumor is fixed, and can rarely be advantageously 
 meddled with. In excising a parotid tumor, cut as much as possible in 
 the direction of the fibres of the facial nerve, and keep the edge of the 
 knife toward the tumor. Simple tumors can sometimes to a great extent 
 be shelled out. Facial paralysis, which sometimes follows these opera- 
 tions, is usually incurable. Kemember the size of the vessels embedded 
 in the parotid. Remember also position of Steno's duct, a wound of which 
 may cause salivary fistula. 
 
 Pelvis, Injuries of, are thus classified by Birkett: 1, Contusions 
 involving the soft parts in contact with the outside of the pelvis ; 2, frac- 
 tures and dislocations of the bones forming the pelvis ; 3, injuries of 
 those organs in relation with the pelvis which are connected with the func- 
 tions (A) of micturition, (B) of generation, male and female, (C) of defe- 
 cation. See Bladder, Rectum, Uketkra, Perineum, Fractures, etc. 
 
 Penis. — Most common affections are venereal. Others are congenital 
 malformations, usually slight ; phimosis and paraphimosis ; herpes pre- 
 putii, warts, elephantiasis, cancer, gangrene, priapism. 
 
 Penis, Congenital Malformations of. — (1) Hypospadias ; (2) epispadias ; 
 
 (3) deficiency of corpus spongiosum ; (4) the penis may be bound down to 
 the perinseum, between the testes, so as to arch forward during erection 
 (I have seen one such case, and I think Mr. Erichsen's case of "Adhesion of 
 Penis to Scrotum " was probably exactly similar) ; (5) adhesion between 
 glans and prepuce. 
 
 Hypospadias. — Urethra stops short on lower surface of penis. Slight 
 degrees common, and of no consequence. If it extend far backward, e.g., 
 so that the urethra opens near the root of the penis, both urine and semen 
 are emitted at right angles to the penis. But even in such cases paternity 
 
190 PENIS. 
 
 is not absolutely impossible. Plastic surgery is sometimes successful in 
 such cases (vide Wood, Medical Times, vol. 1, 1875 ; Jordan, Lancet, vol. 
 i., 1876). 
 
 Epispadias. — Urine flows from a groove on upper surface of base of 
 penis. Always combined with extroversion of bladder, q. v. , 
 
 In such a case as 4 (above) divide the adhesion. Congenital adhesion 
 between prepuce and glans may be torn asunder with any small blunt in- 
 strument. With malformations, the following condition may be classed 
 when congenital. 
 
 Phimosis. — Prepuce cannot be drawn back. Either congenital, or the 
 result of swelling, usually inflammatory and specific, of the prepuce (ac- 
 quired). Consequences of Congenital Phimosis. — Local irritation, balanitis, 
 calculous concretions between prepuce and glans. Urinary obstruction 
 and vesical irritation. Masturbation. Reflex convulsions, paralyses, and 
 contractions (Sayre). Even hip-joint disease (Barwell). Treatment of 
 Congenital Phimosis. — Circumcise. If circumcision be objected to, success 
 will generally attend steady efforts, repeated day by day, to draw back the 
 prepuce. Acquired Phimosis must be treated according to the indications 
 of each case. Generally rest in bed, cleanliness and patience suffice in an 
 acute case ; but occasionally it is absolutely necessary to either circumcise, 
 slit up, or forcibly dilate the prepuce. If the prepuce be itself inflamed, 
 it is best to merely slit it up in the dorsal middle line. 
 
 Paraphimosis. — The prepuce behind the glans strangles it, and cannot 
 be pulled forward by the patient. Treatment. — Invariable success, except 
 in old cases, may be expected from Mr. Furneaux Jordan's plan of com- 
 pressing the penis gently and patiently in the cavity formed by hollowing 
 slightly the palms of the two hands and then opposing them. Soon the 
 oedema yields, and then the paraphimosis is reduced by the fingers and 
 thumbs. The preliminary compression, if gently and patiently done, 
 makes bearable an otherwise intolerably painful procedure. 2. In case of 
 need, the following operation may be done : draw the glans forward, " then, 
 passing the point of a narrow-bladed scalpel into the sulcus on the dorsum 
 of the penis, make a perpendicular incision about one-third of an inch in 
 length through the integuments at the bottom of the groove directly across 
 it" (Erichsen). Thus the constricting band is divided. 
 
 Herpes Peeputii may be mistaken for chancre. Distinguishable by its 
 extremely superficial character, by the number of vesicles at first, and 
 afterward by there being nothing to see except excoriation and pus. Lasts 
 a few days. Readily cured by washing once a day with hot water and 
 dressing with zinc ointment. Patients subject to it should never use soap 
 to the part, but wash daily with water only and dry thoroughly. 
 
 Penis, Warts on. — For pathology, etc., vide Condylomata and Syphilis. 
 Treatment. — Snip off with scissors. Dress with cupri sulph. pulv. and 
 zinci oxid. Or keep constantly applied lint soaked in acid, nitric, dil., 
 
PEEINJEUM. 191 
 
 3 ij. ; aquae, Oj. In obstinately recurrent cases the prepuce should be worn 
 back and the glans kept exposed. 
 
 Penis, Cancer of. Epithelioma.' — (Scirrhus is extremely rare.) Usually 
 commences after middle life, on the glans, as a firm warty growth, with a 
 broad base. Its progress resembles that of cancer elsewhere, but it is 
 usually slow, and it seldom infects other organs. Treatment. — Thorough 
 excision. Amputation not necessary where a clean sweep can be effected 
 without so radical a measure. When there is sufficient doubt about the 
 diagnosis, give a fair trial to antisyphilitic remedies. 
 
 Penis, Gangrene of. — Besides the ordinary simple and specific inflam- 
 mations to which the organ is liable, Humphry instances the following as 
 recorded causes of gangrene : typhus and paraplegia. Spontaneous gan- 
 grene has been observed (Partridge). 
 
 Priapism is rather a symptom than a disease, and points to one of two 
 classes of causes: (1) reflex irritation, e.g., from gonorrhoea, prostatic dis- 
 ease, and injuries to penis ; (2) paralyses, e.g., from injuries to spinal cord. 
 
 The penis is liable to many other affections common to the ordinary 
 tissues, and these are frequently mistaken for specific affections ; e.g., I 
 have known one of the most able specialists in London to diagnose an in- 
 flamed lymphatic as a hard chancre. Phlebitis occurs occasionally, pro- 
 ducing the ordinary symptoms. 
 
 Penis, Injuries of. — Chief points in connection with these are that (1) 
 extensive contusion produces priapism, lasting for days ; (2) wounds 
 should be carefully adjusted, and united by sutures ; (3) bleeding is easily 
 arrested by cold and pressure ; (4) swelling of the penis in children should 
 suggest the possibility of a string tied round the organ having been hidden 
 by the swelling. 
 
 Perinaeum. — Chief affections are abscess and fistula. Hernia and a 
 misplaced testicle in the perinaeum occur very rarely. 
 
 Perineum, Abscess in the. —Commonly caused by a slight urinary extrav- 
 asation behind a stricture. Symptoms. — At first attention is attracted by 
 fever, perhaps rigors, and pain in the region of the bulb. A hard lump is 
 felt ; this increases and softens. Treatment. — Open early ; incise in the mid- 
 dle line. If a stricture coexist, it is good practice to divide it at the same 
 time (external urethrotomy). At all events the stricture, being the cause 
 of the abscess, must be treated. 
 
 Perineal Fistula. — A result of perineal abscess. Generally closes when 
 the original stricture of the urethra is cured. Perineal fistulas occasionally 
 have their origin in comparatively remote affections, e.g., cancer within the 
 pelvis. In order to cure a perineal fistula it may be necessary to (1) teach 
 the patient to catheterize himself four times' a day, or (2) to incise the fis- 
 tula freely, or (3) to cauterize it ; (4) it is to be remembered that the pres- 
 ence of a small calculus may prevent healing (Thompson). 
 
 Perineum, Injuries to. — Causes. — Blows received in climbing over rail- 
 
192 PHARYNX. 
 
 ings, etc., or by being thrown on the pommel of the saddle. Pressure of 
 child's head in parturition. The iD juries vary in seriousness from slight 
 bruises to injuries involving such important structures as the urethra, rec- 
 tum, and bladder. Parturition may result in — 
 
 Ruptured Perinceum. — Varies much in extent. The more extensive 
 ruptures often allow the walls of the vagina, rectum, or bladder, as well as 
 the uterus, to prolapse. The utmost annoyance may be caused by inabil- 
 ity to hold the faeces. Treatment. — Sutures should be put in at the time 
 when the injury occurs. Otherwise it is, except in trifling cases, advisable 
 to postpone the operation until the child can be weaned and the mother re- 
 stored to the best attainable health. Operation. — Scalpels with short and 
 with long handles, forceps long and short, strongly curved needles with 
 handles (e.g., Baker Browne's needle), sutures of silk, whip-cord, and silver 
 or catgut. ligature, artery forceps, etc. Handled sponges. Duck-bill 
 speculum ; retractors. Lithotomy position. Assistant holds duck-bill 
 speculum against anterior wall of vagina. Perinseum, etc., is shaved. 
 Square flaps of skin and mucous membrane are marked out on either 
 side of rupture, involving part of the vaginal surface of the recto-vaginal 
 septum, and widening somewhat toward the surface of the perinseum. 
 The flaps to be reflected thoroughly, not the slightest bit of mucous mem- 
 brane to be left. But the flaps need not be removed altogether : should 
 rather be left and sewn together over the vaginal edge of the wound. Pass 
 posterior sutures first. It should go through recto-vaginal septum, i.e., 
 should never appear in the rupture at all. Suture to enter and leave skin 
 at one inch from edge of wound. Fasten on two pieces of elastic catheter, 
 or else use button suture. When deep sutures are tightened, wound gapes 
 superficially. To remedy this add a few small silver sutures. Before su- 
 tures, are tightened, stop all hemorrhage. Iced water usually recom- 
 mended for this. I think hot water will be found to answer better (120° 
 to 130° Fahr.). The hemorrhage will be less if the mucous membrane 
 only, without any of the subjacent erectile tissue, be shaved off (T. Smith). 
 To lessen tension, the superficial fibres of the sphincter ani may be divided 
 laterally ; or lateral incisions may be made a short distance outside the ex- 
 ternal ends of the sutures. Bowels should have been well opened before, 
 and should, after the operation, be kept closed by liq. opii, TTL x., bis die, for 
 a fortnight. For ten days draw off urine thrice a day with a catheter ; 
 and for a week or two afterward patient should urinate on her hands and 
 knees. Pay attention to the diet. Keep the wound and vagina clean. 
 After washing with any antiseptic lotion, dry carefully and gently. 
 
 Periostitis. — Vide Bone. 
 
 Phagedaena. — Vide Ulcebs and Syphilis. 
 
 Pharynx. — Its chief affections are inflammation, abscess, tumors, 
 epithelioma, syphilitic disease, ulceration, wounds, and presence of foreign 
 bodies. 
 
PROSTATE. 193 
 
 Congenital Discontinuity of Pharynx and (Esophagus. — A complete 
 monograph on this, by Hott of Bromley, is in " Pathological Transactions 
 for 1876." 
 
 Acute Diffuse Pharyngitis. — Highly dangerous. Usually spreads from 
 fauces. Dyspnoea, dysphagia. Great swelling, internal (and often also 
 external). Progress rapid. Termination. — Usually death, in a few days, 
 either suddenly or with signs of sinking. Pathology. — Inflammation of 
 cellular tissue of pharynx and of oesophagus ; great oedema ; often suppura- 
 tion. Treatment. — Supporting, stimulating. Enemata. Quinine. Laryn- 
 gotomy to avert danger of suffocation. 
 
 Post-Pharyngeal Abscess. — Cause. — Often caries of cervical vertebrae. 
 Most dangerous in children : because then may not be diagnosed till it has 
 produced suffocation. May open externally in neck. Treatment. — Puncture 
 with an abscess knife having its blade, except near the point, protected by 
 lint. Finger may be used as a director. 
 
 Ulcers of Pharynx, usually syphilitic in adults and sometimes strumous 
 in children. Treatment. — See Treatment of Syphilis and Scrofula. 
 
 Dilatations and Pouches of Pharynx occur. Food is apt to lodge in 
 them. Diagnose by the history given by the patient. Regurgitation some- 
 times occurs, or patient may be able to empty the pouch by external pres- 
 sure. Secondary laryngitis may occur. 
 
 Pharynx, Foreign Bodies in. — Vide (Esophagus. 
 
 Phimosis. — Vide Penis. 
 
 Prostate. — Chief Affections. — Inflammation, acute and chronic ; ab- 
 scess, periprostatic abscess ; hypertrophy ; simple tumors ; atrophy ; tu- 
 bercle ; cysts ; malignant disease. 
 
 Prostate, Acute Inflammation of. — Causes. — Gonorrhoea, cystitis, strong 
 injections, cauterization, mechanical injuries, e.g., from sounds. Catching 
 cold, alcoholic excesses, and sexual excitement will determine an attack if 
 some other influence pre-exist, such as gonorrhoea, gout, or rheumatism. 
 Symptoms. — Local pain extending into loins and back, weight, and fulness. 
 Frequent and painful micturition, especially painful at the close of the act. 
 Pain becomes shooting and throbbing. Anal and perineal tenderness and 
 fulness. Defecation painful. Micturition often difficult or impossible. 
 Fever. Pus in urine when abscess bursts. Per anum the prostate can be 
 felt enlarged. Piles may be induced. Treatment. — Rest in bed. An aperi- 
 ent to commence with. Antimony. Acetate of potash in full doses. Ten 
 to twenty leeches to perinseum and round anus. Hot hip-bath. Poultices 
 to perinseum. Retention usually relieved by hot baths and liq. opii. Or 
 a soft catheter may be passed. Prostate remains for a long time afterward 
 enlarged and hard, obstructing flow of urine. 
 
 Prostate, Chronic Inflammation of. — Usually a sequel of acute. Gener- 
 ally, but not always, enlargement of the gland. Obstruction to passage of 
 urine. Anal and perineal pain. Gleety discharge. Sometimes nocturnal 
 13 
 
194 PROSTATE. 
 
 emissions. Pain in sexual intercourse. Irritable bladder. Treatment.-* 
 Rest. Regular and unstimulating diet. Tonics and stomachics. Iron, 
 with a mild aperient. Counter-irritation to perinseum. For the noctur- 
 nal emissions, make three or four applications of a solution of nitrate of 
 silver (gr. x.-xxx. to § j.) to the prostatic part of the urethra. As Sir H. 
 Thompson says, " To be successful an efficient instrument is absolutely 
 necessary, as well as care in injecting the fluid at the right spot." For en- 
 largement of prostate left by acute inflammation give a prolonged course 
 of pot. iod. and pot. bromid. ; sea-bathing and tonics. 
 
 Prostatic Abscess. — 1. Acute. — When prostatitis leads to abscess the 
 acute symptoms persist for more than a week or two, pain and tenderness 
 increase, rigors probably occur, and the prostatic swelling may throb. 
 Fluctuation may be felt sooner or later, perhaps per rectum. Abscess tends 
 to open into urethra, more rarely into rectum. Either termination is of 
 good prognosis. In exceptional cases, abscesses recur again and again. 
 Treatment. — Incise early in the median line of the perinseum. Foment and 
 poultice. " "When the suppuration is due to stricture, and probably ex- 
 travasation, the propriety of dividing the stricture and laying open the 
 perinseum down to the prostate cannot be questioned" (Bryant). 2. 
 Chronic Prostatic Abscess. — Either a sequel of acute abscess or the direct 
 result of old stricture of urethra. "Whole prostate may be destroyed. Con- 
 dition always serious. Chronic cystitis, progressive emaciation. Treat- 
 ment. — Rest, highly tonic and soothing regimen, fresh air. Sometimes 
 perineal incision is indicated. 
 
 Prostate, Hypertrophy of. — A senile affection. Never occurs before 
 fifty, usually over sixty. But, of old men, it attacks no greater proportion 
 than one-half. Affects every constituent of the prostate, but chiefly the 
 muscular and fibrous elements. Enlargement may be general or limited. 
 In the latter case, an outgrowth sometimes occurs from the centre of the 
 gland backward toward the bladder, improperly called the " enlarged third 
 lobe." Either lateral lobe may be disproportionately hypertrophied. Iso- 
 lated, almost independent, tumors (myomata) are very common in the sub- 
 stance of hypertrophied prostates. They contain very little glandular sub- 
 stance, and that ill-developed. Effect on the Urethra. — Prostatic part of 
 urethra is lengthened, and its antero-posterior diameter increased, while its 
 transverse diameter is lessened. Its direction is altered in a manner which 
 varies according to the part of the gland which is enlarged. The urethra 
 takes an abnormal curve whose concavity corresponds to the lateral lobe 
 most enlarged. So also the vesico-urethral orifice takes a crescentic form 
 with the concavity toward the enlarged lobe. When the " third lobe " is 
 enlarged, the urethra is bent suddenly upward in front of it. Occasional 
 outgrowth of median portion of prostate, overlapping vesico-urethral ori- 
 fice as a valve, which obstructs the flow of urine. Size of enlarged prostate 
 often very considerably increased. Diameter of over four inches and 
 
PROSTATE. 195 
 
 weight twelve ounces known. A weight of even one ounce signifies hyper- 
 trophy. Consistence varies. Symptoms. — (In earliest stage nil.) Diminu- 
 tion of force with which urine is ejected. Frequent desire to micturate ; 
 micturition is, as it were, incomplete. Uneasiness and weight about peri- 
 naeum and neck of bladder. Tenesmus. Hemorrhoids tend to develop. 
 Sometimes flattened stools. After a time, chronic cystitis. Sometimes 
 urethral discharge, or frequent erections of penis. Urinary obstruction 
 increases ; bladder overflows at night. Bladder-dulness tends to ascend 
 higher and higher in abdomen. General health gets worse. Accidental 
 circumstances, e.g., slight excesses, bring on attacks of retention. Small 
 hemorrhages. Urinary changes similar to those of chronic cystitis. Neu- 
 tral or alkaline reaction. Mucus. Phosphatic masses, soft and white. 
 Muco-pus. Diagnosis is usually determined by examination with the left 
 forefinger in the rectum. Information may be thus acquired concerning 
 the size, shape, and consistence of the prostate, and concerning the pres- 
 ence, absence, or position of fluctuation. Such examination is assisted by 
 simultaneously manipulating a catheter in the urethra. " If the catheter 
 has passed easily, say for nine or ten inches, and still no urine flows ; and 
 if, in addition, while following its course, the handle has become more than 
 usually depressed, there will be little doubt in respect of the existence of 
 prostatic enlargement" (Thompson). Of course, with a healthy urethra, 
 urine should flow through a catheter entered six and a half to eight inches. 
 When the catheter is deflected laterally in passing, the side toward which 
 the handle turns is probably the more enlarged. An examination should 
 be made with a short-beaked sound, such as that pictured in Holmes's 
 "System," vol. iv., p. 926 • or one of those described and illustrated by 
 Teevan in Lancet, vol., i. 1880. With this a possible calculus should be 
 searched for. Stricture of urethra contrasts with prostatic obstruction in 
 that (1) it occurs anteriorly to prostatic urethra, (2) it appears before 
 middle life, (3) the stream of urine is more diminished in volume (in pros- 
 tatic obstruction it is rather force than volume which is lessened). Other 
 conditions from which prostatic enlargement has to be distinguished 
 (though it may coexist with them) are vesical calculus, tumor of the bladder, 
 atony of the bladder, paralysis of the bladder. Compare with the symptoms 
 of these given under Diseases of the Bladder. Treatment. — A catheter 
 should be passed twice a day, oftener where urination is extremely feeble. 
 Patient should learn to catheterize himself. Elastic instruments preferable. 
 Silver prostatic catheters are either made with a large curve or else with a 
 short beak. Great irritability of the bladder, disturbing sleep, may re- 
 quire a vulcanized india-rubber catheter to be tied in all night. Treat co- 
 incidently such complications as catarrh of the bladder (quod vide). At- 
 tend to the general health and regulate the habits. Clothe lower limbs 
 warmly. Operations on diseased prostate are by most surgeons avoided. 
 Prostate, Atrophy op. — Unusual and unimportant. 
 
196 PSORIASIS. 
 
 Prostate, Malignant Disease of. — Encephaloid is the form which affects 
 this gland. Occurs only in childhood and at advancing age. Progress 
 very rapid in children. The symptoms are the usual ones of cancer, 
 added to those of prostatic obstruction, including, especially, severe pain, 
 occasional hemorrhages, and cachexia. Lymphatic glands of lumbar, and 
 sometimes of iliac region, enlarge. Urinary deposit may exhibit cancer 
 cells when examined. Treatment — If catheterism cannot be avoided, be 
 as gentle as possible. Kelieve pain by anodynes, etc. Treat hemorrhage 
 on general principles. Support the general strength. Perhaps Chian tur- 
 pentine, which Clay appears to have found useful in carcinoma uteri, might, 
 be fairly tried here. 
 
 Prostate, Tubercle of. — Very rare. Always secondary. Symptoms 
 probably raise a suspicion of calculus ; but no stone being found, and 
 coincidence of symptoms of tubercle elsewhere, correct the diagnosis. 
 Avoid instrumental interference ; protect from other sources of irritation ; 
 and treat the tubercle and its results, e.g., abscess, on general principles. 
 
 Prostate, Cysts of. — Small cysts sometimes occur. Often numerous ; 
 often contain small concretions. Probably dilatations of gland-tubules. 
 No known symptoms of consequence ; therefore no treatment. 1 
 
 Psoas Abscess. — See Spine, Caries of ; also Abscess, Chronic 
 
 Psoriasis. — A " squamous " disease of the skin, always chronic, often 
 recurrent — especially in spring and autumn — often syphilitic, sometimes 
 hereditary. The sufferers are, for the most part, in. perfect health, ex- 
 cept when syphilitic. Infants and very old people are almost exempt. 
 Psoriasis is a superficial dermatitis, without subepidermic effusion, i.e., 
 without causing vesicles. It forms red spots or patches, covered with 
 white, shining (epidermal) scales. The classification of psoriasis into 
 many varieties is of little more than nominal importance, e.g., psoriasis 
 guttata, psoriasis diffusa, psoriasis circinnata (formerly " lepra vulgaris "), 
 psoriasis nummularis, etc., psoriasis palpebrarum, psoriasis scrotalis, 
 psoriasis palmaris, psoriasis plantaris, etc. Diagnosis of Syphilitic from 
 Common Psoriasis. — Syphilitic is (1) generally darker in color ; (2) rarely 
 affects knees and elbows ; (3) is frequently palmar and plantar — the latter 
 is always syphilitic ; (4) may lead to painful fissures, and even ulcers. Non- 
 specific psoriasis has for its favorite seats the extensor sides of the knee 
 and elbow, because there the skin is coarse and dry. Of course, the his- 
 tory may be inquired into. Treatment. — Vigorous external treatment, and 
 arsenic internally. Begin with two Turkish baths or several warm 
 baths, using plenty of soap. Locally, prefer ung. picis. Olive oil, in con- 
 junction with repeated baths, may suffice. Crocker recommends thymol 
 ointment (gr. x.-xxx. tojj.). Ung. acidi chrysophanici (gr. xx. to Jj-) 
 
 1 The above account of diseases of the prostate is chiefly condensed from the 
 writings of Sir Henry Thompson. 
 
PYJEMIA. 197 
 
 (liable to stain linen). Begin with three minims of liq. arsenicalis three 
 times a day, and gradually increase to six minims. Note. — Arsenic at first 
 appears to aggravate the disease. Give it after meals. Other interna] 
 remedies are tinct. cantharidis and iodide of potassium (gr. x. doses). 
 
 For syphilitic psoriasis, rely mainly on ordinary antisyphilitics. 
 
 Pyaemia. — A disease characterized by remittent fever and the forma- 
 tion of multiple collections of pus in various parts of the body. It is a 
 near ally of septicaemia and of ordinary surgical fever ; but the scattered 
 abscesses are characteristic. Causes. — The immediate cause is granted to 
 be the absorption of pus or of septic material into the blood. It is still 
 disputed whether pus, in order to produce pyaemia, must be putrefying ; 
 and it is still uncertain whether the immediate cause of pyaemia can be ab- 
 sorbed through the mucous membranes, or whether it can enter only 
 through an open wound. Advocates of the germ theory suppose that al- 
 most every case of pyaemia is due to the entrance of microscopic germs 
 into open wounds, and produce strong experimental proof of that belief ; 
 but how those germs cause the multiple abscesses is not so clear. The 
 immediate cause of each scattered abscess ("metastatic" abscesses, they 
 are often called) is venous thrombosis and embolism ; but what is the 
 exact way in which the thrombosis is brought about ? 1 Some of the ab- 
 scesses near the original wound are merely terminations of lymphatic 
 inflammations, a track of inflamed lymphatics being sometimes traceable 
 to them from the wound. Cases of pyaemia sometimes occur, apparently 
 spontaneous in origin, and are called "idiopathic pyaemia." It must be 
 remembered that their idiopathic nature rests on negative evidence only. 
 
 Conditions predisposing to pycemia are (1) bad ventilation and foul air; 
 (2) accumulation of many wounds in one ward ; (3) neglect of having sick- 
 rooms thoroughly and periodically cleansed ; (4) dirty and careless dress- 
 ing and nursing ; (5) unnecessarily meddling with and disturbing injuries ; 
 (6) bad drainage ; (7) other analogous conditions. A second set of causes 
 belong more personally to the patient. They include (1) drunken habits, 
 (2) old age, (3) weak constitution, (4) unmanageableness and restlessness. 
 Many slight cases of feverishness have been converted into acute blood- 
 poisoning by severe exercise, e.g., ascending a mountain. "You will find 
 in every day's practice that fatigue has a larger share in the promotion or 
 permission of disease than any other single causal condition you can 
 name " (Paget). " After wounds, children are singularly free from pyaemia " 
 (Paget). Pathology. — The nature of the changes in the blood is unknown. 
 Localities attacked are (1) joints, (2) viscera, (3) serous membranes, (4) 
 mucous membranes, (5) skin ; and to these may be added the veins, lym- 
 phatics, and cellular tissue throughout the rest of the body. In the viscera 
 are found low inflammations and metastatic abscesses. The affected joints 
 
 1 See note on Microscopic Organizations in Appendix. 
 
198 EANULA. 
 
 and serous cavities are inflamed and filled with pus. External to the joints 
 are oedema and flushes of redness. The affected mucous membranes are 
 inflamed, and may give vent to great discharge. This, in the case of the 
 gastro-intestinal caDal, causes diarrhoea and even vomiting. When the 
 skin is affected, blood-poisoning usually shows itself as erysipelas (quod 
 vide), or as pustular inflammation. Veins become the seat of thrombosis, 
 with or without precedent inflammation. Jaundice and suppression of 
 urine sometimes occur in the course of pyaemia. Symptoms and Course. — 
 1. Of acute pyaemia. Kigors and feeling of illness. Perhaps purging and 
 vomiting, with or without jaundiced hue of skin. High temperature. 
 Rapid and frequent pulse. Erysipelatous inflammation of neighborhood 
 of wound. Tender and inflamed glands. Acute pneumonia or pleurisy. 
 Finally, " the patient — flushed, anxious, restless, even delirious — is in a 
 hopeless condition, with prostration and rapid sinking." 1 Duration: 
 about five or six days. 2. Subacute or chronic pyaemia. A typical case 
 presents, successively, the following symptoms : Wound dry and inflamed, 
 its edges swollen. This local inflammation spreads. Pain and tenderness ; 
 burrowing of pus ; fever ; rigors ; abscess forms near the wound ; neigh- 
 boring joint swells ; other abscesses form. Large lymphatics and glands 
 may inflame and suppurate. Fever continues ; temperature rises and falls 
 irregularly, high rises usually coincident with rigors. Distant joints swelL 
 Progressive emaciation ; yellow skin ; no sleep ; no appetite ; despondency. 
 Cough ; pain in chest (indicating pleurisy or metastatic pneumonia). Tongue 
 furred and dry. Bed-sores. Occasional delirium. Eyes dull. Finally, utter 
 prostration and death. Duration of subacute pyaemia, two to four weeks ; 
 of chronic, one to five months. Prognosis. — Of acute cases, practically 
 hopeless. Chronic and mild cases may recover, especially if prime cause 
 can be removed. Paget relates a case which lasted three years and finally 
 recovered. Treatment. — Chiefly prophylactic. It includes the whole art of 
 treating wounds properly (quod vide). Cleanliness, quietness, etc. Anti- 
 septic treatment. Hospitals properly situated, arranged, and ventilated ; 
 wards periodically cleansed and disinfected ; clean bedding ; obedient and 
 sensible nurses. When pyaemia is actually developed, plenty of fresh air, 
 diligent nursing, feeding with milk, eggs, etc. ; cooling drinks ; quinine (5- 
 15 grains for a dose) ; morphia at night ; hyposulphite of soda (gr. xx. 
 every two hours) ; warm baths and wrapping in blankets to produce copious 
 diaphoresis. In chronic pyaemia amputation may be indicated. Liq. 
 potassae ( 3 j. ter die) to remove pyaemic deposits (Paget). The commonest 
 surgical causes of pyaemia are compound fractures. 
 
 Ranula. — A cystic tumor occurring in two situations, (1) close by 
 fraenum linguae, (2) between mylohyoid muscle and mucous membrane. 
 The latter form of ranula bulges externally between chin and hyoid bone. 
 
 1 Callender in Holmes's System. 
 
DISEASES OF. 199 
 
 Contents : glairy, mucous fluid. But the second form may contain matter 
 of a cheesy consistency. Causes. — Eanulas are probably "retention cysts," 
 but not caused by obstruction of Warton's duct (Morrant Baker). Treat- 
 ment. — Open in the mouth, and cut away a part of the cyst-wall. Empty, 
 and if the fluid re-collects, repeat the operation, in addition cauterizing the 
 interior of the cyst. 
 
 Rectum, Diseases of (for those of Anus, vide Anus). — Stricture, can- 
 cer, polypus, malformation, hemorrhoids (vide Hemorrhoids). 
 
 Rectum, Stricture of. — Two kinds, viz., Simple and Cancerous. For 
 latter, vide Cancer of Rectum. Simple Stricture.— Causes. — (1) Contrac- 
 tion of simple inflammatory deposit in the walls of the rectum ; (2) syphilis ; 
 (3) cicatricial contraction after operative procedures ; (4) or after slough- 
 ing caused by pressure during parturition ; (5) or after strumous, dysen- 
 teric, or other ulceration. The chronic inflammation which leads to stric- 
 ture may be caused by the impaction of foreign bodies or by the constant 
 irritation of hard faeces. Pathology. — The seat of a simple stricture is 
 marked by a fibrous deposit, which may extend wholly or partially around 
 the bowel. When slight, it lies usually in the submucous tissue ; but often 
 the whole thickness of the rectum is affected. The usual seat is from one 
 inch to one inch and a half above the anus. Bowel above stricture dilated 
 and hypertrophied. Secondary abscesses and nstulse often form, as in case 
 of stricture of urethra. Signs. — (1) Constipation, (2) burning pain on 
 passing a stool, (3) straining at stool, (4) blood or mucus in stools, (5) 
 patulous anus, (6) "tape-like" motions, (7) detection of a stricture by dig- 
 ital examination or by a bougie. The 2d, 3d, 4th, and 5th signs mark 
 the ulcerative stage ; the 6th sign is not thoroughly reliable. Examine very 
 gently, especially if using a bougie. Roughness may do fatal damage. Do 
 not mistake for stricture obstruction caused by mucous folds or by the 
 pressure of pelvic tumors. Sooner or later the constipation ends in com- 
 plete obstruction, which may come on with great suddenness. In advanced 
 cases the general health breaks down under the influences of pain, dys- 
 pepsia, and anxiety. Treatment. — The prime agents are (1) dilatation by 
 bougies, (2) incision. The latter is suited only for traumatic strictures 
 close to the anus. Accessory mean's are, rest in bed, warm water enemata, 
 regulated diet, morphia suppositories and hip-baths. Oil the bougies well, 
 pass them every other day, gradually increasing the size. Patients, when 
 cured, should continue to pass bougies or wax candles for themselves, either 
 weekly or bi-weekly, or even daily, as may be found necessary. When 
 complete obstruction occurs try rest, warm hip-baths, warm oily enemata 
 and purgatives. The surgeon should not be in a hurry to operate, for these 
 cases may relieve themselves after weeks of obstruction. The last resource 
 is colotomy. When the stricture is high up, give the enemata through the 
 long tube. 
 
 Rectum, Cancer of. — Usually scirrhus. Pathology.— Originates in pro- 
 
200 RHEUMATISM. 
 
 liferation of the glands of the mucous membrane. These "grow in the 
 shape of tortuous and branched tubes ; the calibre of the gland is often 
 maintained ; and they fill with mucus, and the cylinder cells may maintain 
 this form and become very large " (Billroth). The infiltration and indura- 
 tion tend to surround the rectum with a hard ring. "Leaf -like prolifera- 
 tions commence close above the sphincter ani." Ulceration. "Inguinal 
 and retroperitoneal glands affected rarely and late." Ulceration may lay 
 open bladder, urethra, vagina, peritoneum, hip-joint, etc. Symptoms. — At 
 first, discharge of bloody mucus, and either constipation or diarrhoea. De- 
 fecation becomes more and more painful. Hemorrhage becomes more 
 serious. Digital examination usually reveals the hard, nodular ring, and 
 perhaps ulceration. Diagnosis. — At first from hemorrhoids, a little later 
 from simple stricture. Usually settled by digital examination. Treatment. 
 — 1, Palliative ; 2, radical. 1. Palliative. Anodynes, e.g., morphia sup- 
 positories ; afterward, morphia subcutaneously or by the mouth. Some- 
 times gentle aperients, warm water enemata. Enemataof cupri sulph. and 
 opium or of zinci chlor. (gr. j.-ij. to | j. aquae) may check foul discharges. 
 Obstruction or extreme pain in defecation may demand colotomy. 2. 
 Badical. Excision of rectum for cancer has usually been condemned on ac- 
 count of the risk of dangerous hemorrhage, and of opening the peritoneal 
 cavity. But there are good reasons for taking an opposite view, e.g., the 
 neighboring glands are not secondarily affected at an early stage. Subject 
 fully discussed by W. H. Cripps ("Cancer of the Rectum"). 
 
 Rectum, Polypus of. — Usually occurs in children, is adenomatous in 
 structure, apt to signify its presence by occasional hemorrhages, and may 
 be snipped off with scissors. In exceptional cases a ligature may be con- 
 sidered necessary. 
 
 Rectum, Ma lformations of. — Vide Anus, Imperforate. 
 
 Rectum, Injuries of. — Causes. — May be classed as follows : (1) falls on 
 sharp-pointed objects, e.g., spikes ; (2) sharp bodies swallowed, e.g., fish- 
 bones ; (3) objects wilfully inserted ; (4) obstetric processes ; (5) surgical 
 operations on neighboring parts. The first class usually recover thor- 
 oughly, unless fatal through complication with injury to more serious 
 parts, such as the peritoneum. The causes of the 2d and 3d class re- 
 quire immediate removal with the aid of fingers, forceps, speculum, plenty 
 of oil, etc. The 3d and 4th class of cases are apt to produce troublesome 
 fistulae. They should be treated with as little delay as possible. Vide 
 Vaginal Fistula. 
 
 Rheumatism. — A name applied almost indiscriminately by the public 
 to painful non-traumatic affections of the joints and muscles, more espe- 
 cially when chronic. The form called " rheumatic gout " chiefly concerns 
 the surgeon. He terms it chronic rheumatic (or rheumatoid) arthritis. 
 Causes. — Predisposing influences are mal-nutrition, poverty, approach of 
 old age, male sex. Exciting cause usually unknown. Sometimes injury, 
 
RHEUMATISM. 201 
 
 or disordered menstruation. Symptoms. — Pain in the affected joint, ag- 
 gravated by wet or cold weather and by exercise. Stiffness. Wasting of 
 muscles which act on the joint, e.g., of glutei and hamstrings in chronic 
 rheumatic arthritis of hip. Dry crepitation when the joint is moved. 
 Eventually, more or less enlargement of the bones of the articulation. 
 Thickening of the ligaments. Stiffness may proceed to anchylosis. When 
 the hip is affected shortening takes place sooner or later from absorption of 
 head of thigh-bone. Pelvis becomes oblique ; foot is either everted or in- 
 verted. When the temporomaxillary joint suffers, dislocation of one or 
 both sides of jaw forward may result from destruction of eminentia articu- 
 laris. Prognosis. — Progress of disease usually not uniform, but effected by 
 recurrent attacks with intervals of comparative comfort. But, unfortu- 
 nately, the joints do not return to the normal state in these intervals. Ke- 
 covery almost impossible. No direct danger to life. Billroth says : 
 " When you have such a patient to treat, arm yourself with patience, and 
 be not surprised if he consults first one and then another physician, and 
 finally all the quacks about, and lastly, blames you for the origin and ex- 
 tent of his disease." Diagnosis. — From (1) scrofulous arthritis, (2) gout, 
 (3) dislocation from injury. Compare with symptoms as given elsewhere. 
 Particularly consider history and course of disease, as well as age and cir- 
 cumstances of patient. 1 Pathology. — Begins by a fibrillous degeneration 
 of the cartilages. "In some places it becomes nodular, then rough on the 
 surface, may be pulled into filaments, and when the disease is far ad- 
 vanced it is altogether absent in places, leaving the bone exposed, quite 
 smooth, and polished " (Billroth). Cartilage-cavities enlarged and con- 
 taining increased numbers of new cartilage-cells. The bone, devoid of 
 cartilage, compact, and polished by friction, is termed "eburnated." 
 "Stalactitic" formation of osteophytes in immediate neighborhood of above 
 changes. Bone being absorbed in one place and formed in another, situa- 
 tion of a joint may shift considerably. Synovial membrane thickened, 
 slightly vascular, tufts elongated. Separate ossifications near the joint 
 (additamentary bones). New bone always compact. Muscles of affected 
 joint tend to contract. Joints tend toward a state popularly described 
 as " drawn up ; " witness rheumatic fingers of old people. Treatment. — 
 Meant rather to arrest or to palliate than to cure the disease. Improve the 
 diet. Remove from wet and cold localities. Clothe in flannel. Frictions 
 with stimulating liniments. " Shampooing." Douching with alternately 
 very hot and cold water. India-rubber bandages. Combinations of warm 
 stomachics, diaphoretics and mild purgatives, e.g., rhubarb, ginger, sul- 
 phur, mezereon, sassafras, cream of tartar, etc. Iodide of potassium, es- 
 pecially when pain is worse at night. Chloral and pot. bromid. when pain 
 is very severe. Actaga racemosa (15 to 30 minims of tincture three times a 
 
 1 See, in Appendix, Charcot's Joint Disease. 
 
202 RICKETS. 
 
 day). Kesidence at certain watering-places, e.g., Buxton, Harrogate, and 
 Aix-la-Chapelle. Leather or even plaster-of-Paris supports useful in some 
 cases of rheumatic knee-joint. Treat menorrhagia, if present. 
 
 Rhinoscopy. — Examination of nares by aid of the laryngeal mirror 
 turned upward in pharynx. Difficult. Natural Causes of Difficulty. — 1, 
 Irritability of fauces, and of posterior wall of pharynx ; 2, enlarged ton- 
 sils and uvula ; 3, insufficient distance between uvula and posterior wall 
 of pharynx. Bides. — Same as those for Laryngoscopy (quod vide), up to 
 Kule 6. Rule 7. Allow patient's tongue to remain at rest and untouched in 
 the mouth. 8. Hold mirror like a pen and with the reflecting surface up- 
 ward. 9. Let its shank rest lightly on the dorsum of the tongue ; but be 
 very careful not to touch the base of the tongue. Shift the mirror slightly 
 to right or left of uvula, according to which side it is desired to examine. 
 10. Direct patient to exhale quietly and continuously by the nostrils. 
 
 Rickets. — Rachitis. A disease of early childhood, manifested chiefly 
 by abnormal softness of the bones and consequent deformity, and by back- 
 ward development of the teeth. Causes. — Improper feeding in infancy, 
 especially giving young infants farinaceous food to supplement a scanty 
 supply of milk. Other bad hygienic conditions probably assist. Signs. — 
 At first the little patient often has diarrhoea. He shrinks from being 
 touched ; for movement is painful. Head perspires. Kicking off bed- 
 clothes at night. Backward dentition. Laryngismus stridulus. Emacia- 
 tion. The above symptoms are entirely or partially absent in older chil- 
 dren. Disease usually commences in second year. The infant ceases to 
 walk when disease is at its height. Deformity of chest (pigeon-breast) 
 now takes place. Bow-legs, knock-knees, curvature of spine (lateral and 
 antero-posterior), as well as, though more rarely, pelvic deformities, occur 
 when the patient walks about again. " Beading " of junctions of ribs with 
 costal cartilages. Enlargement of wrists, knees, and ankles. Fontanelles 
 remain open. Head grows too fast, face too slow ; hence projecting brows. 
 Large bellies ; 1 frequently enlargements of liver and spleen. Bronchitis. 
 The subjects of rickets in childhood will not, in later life, attain normal 
 height. Pathology. — Mineral constituents of bone not deposited in normal 
 amount ; but animal portions grow normally. Hence the bones soften, 
 lacunae enlarge, periosteum and epiphyseal cartilages proliferate ; and, as 
 ossification does not keep pace with this, long bones are apt to bend be- 
 neath the weight of the body, especially at the junction of their epiphyses 
 with their shafts. For similar reasons the growing brain forces apart the 
 cranial bones and keeps open the fontanelles. These changes near the 
 epiphyses account for the beaded ribs, the enlarged wrists, and the de- 
 formed knees and shins. Also general thickening, with partial thinning of 
 cranial bones. When the rachitis disappears, leaving a bent long bone, 
 
 1 An early sign of great value (Clement Lucas). 
 
SALIVARY CALCULUS. 203 
 
 the concavity of the curved bone is eventually strengthened by deposit of 
 a ridge of compact bone. Rachitic pelves are usually flattened antero- 
 posteriorly. Femora curve forward. Tibiae and fibulae usually bend for- 
 ward and outward (chiefly at junction of lower epiphyses). Spine affected 
 with general posterior curvature in early infancy, with lumbar lordosis in 
 early childhood, and occasionally with lateral curvature. Thorax — " pigeon- 
 breasted." Diagnosis. — Quite easy, except in early stage. Prognosis. — 
 Sometimes fatal to very weakly infants. Recovery usual, but rarely with- 
 out residual deformity. Treatment. — Correct diet. Plenty of milk. Suffi- 
 cient animal food. Cod-liver oil. Syrup of phosphates of iron and lime. 
 Parrish's chemical food. Vinum ferri. Cold sponging and dry rubbing. 
 Fresh air. Splints and other mechanical contrivances to correct de- 
 formities. In severe cases, osteotomy, or forcible straightening of limbs 
 under chloroform. Keep a young rickety child off its feet as much as pos- 
 sible without depriving it of fresh air and exercise. Sleep on a mattress. 
 
 Sacro-iliae Disease. — Causes. — Either struma or injury, or both 
 together. Symptoms. — Local pain and tenderness. Pain during defeca- 
 tion, sometimes also during micturition. Peculiar posture (vide figures in 
 Sayre's " Orthopaedic Surgery," p. 333). Patient bends his body over from 
 the affected side, " for the purpose of removing pressure from the diseased 
 structures by bringing the weight of the limb to bear upon the ilium." 
 Hence obliquity of the pelvis and apparent lengthening of limb on side of 
 disease. When abscess forms, it may appear either over the articulation, 
 or in the buttock, loin, groin, or even rectum. Diagnosis. — From neural- 
 gia, sciatica, and Pott's disease, but, above all, from hip disease. In sacro- 
 iliac disease, if the pelvis be firmly fixed, the hip-joint can be moved nor- 
 mally and painlessly. In sufficiently advanced cases, the pelvis can be seen 
 to be deformed ; and when abscess has opened, a probe will often reach 
 dead bone. Sayre's vertebrated probe may be useful. When pelvis is 
 not fixed, either lateral compression of trochanters or abduction of thigh 
 causes pain. Prognosis bad. Treatment. — Rest, extension and counter- 
 extension. Sayre puts a thick-soled shoe on the foot of sound side so that 
 the affected limb swings free of the ground when the patient moves out of 
 doors on crutches. Before suppuration takes place, use counter-irritation, 
 especially the actual cautery. Dead bone, if detected by probe, should be 
 removed if possible. Cod-liver oil, iron. High, dry, and healthy locali- 
 ties. 
 
 Salivary Calculus. — A concretion sometimes obstructs a salivary 
 duct Slit up the duct, if necessary, and remove it. May cause swelling 
 of gland. Ducts usually affected are :the sublingual or submaxillary. 
 
 Salivary Fistula (1) from obstructed duct. Treatment. — Establish an 
 opening into the mouth by passing a. i#e ton right through the fistula into 
 the mouth and tying its two ends together. Part of the cheek is thus, of 
 course, enclosed in the loop. When an opening into the mouth is thus 
 
204 SCROFULA. 
 
 kept open for ten days, endeavor to close the external opening by cauteri- 
 zation, unless it close spontaneously. (2) Salivary fistula from abscess in a 
 gland is difficult to cure. Try cauterization. 
 
 Sareocele. — See Testicle. 
 
 Sarcoma. — See Tumors. 
 
 Scalp, Injuries of. — Vide Head. 
 
 Sciatica. — Neuralgia of great or of lesser sciatic nerve. Causes. — (1) 
 Catching cold ; (2) pressure of hardened faeces in rectum or of pelvic tu- 
 mors ; (3) peripheral irritations, e.g., inflamed corns ; (4) many cases are of 
 quite obscure origin. Always bear in mind that sciatic neuralgia may be 
 only a sign of some more serious disorder. Diagnose from hip and from 
 sacro-iliac disease. Treatment. — Vide Neuralgia. In obstinate cases try 
 cautery (Corrigan's button), or even "nerve-stretching." Purgatives, qui- 
 nine. Iodide of potassium. Morphia injections. Blisters. Electricity. 
 For Pathology, etc., of Sciatica vide Neuralgia. 
 
 Scrofula. — Definition. — A diathesis rather than a disease. Its charac- 
 teristics are neatly given by Billroth as follows: "Exists chiefly during 
 childhood, though more advanced ages are not free from it." 1 " Persons 
 with this diathesis, especially children, are greatly disposed to chronic in- 
 flammatory swellings of the lymphatic glands, even after inconsiderable 
 irritations, to certain inflammations of the skin (eczema, impetigo), espe- 
 cially of the face and head, to catarrhal inflammations of the mucous mem- 
 branes, especially of the conjunctiva, more rarely of the intestinal canal 
 and respiratory organs, to chronic inflammations of the periosteum, and of 
 the synovial membranes of the joints." Formerly the condition called 
 "tuberculosis" was unanimously included in the term scrofula. Majority 
 of modern pathologists differentiate the two, while acknowledging the fre- 
 quent origin of the former from the products of chronic inflammations 
 induced by the latter. Causes. — Inheritance. Unfavorable conditions of 
 life (?), e.g., low, damp dwelling, want of light, insufficient food, mental 
 depression. Attacks of acute infectious fever, especially measles. Pathol- 
 ogy and Symptoms. — See under head of Glands, Chronic Disease of ; Ul- 
 cers, Scrofulous ; Joints, Chronic Disease of ; Ophthalmia, Strumous, etc. 
 Chronic inflammations, the result of scrofula, are indolent and slow to dis- 
 perse. They tend greatly to suppuration and caseous degeneration. Cer- 
 tain general appearances of the person are described as scrofulous types, 
 especially two, viz.: (1) thick lips, muddy skin, coarse features, pot belly, 
 flabby muscles, often with tendency to fatness ; (2) fair, thin, clear skin, 
 long eyelashes, fine hair, pearly teeth, bright, refined, "delicate" look. 
 These so-called typical appearances are of very doubtful diagnostic value. 
 Dyspepsia very common. Diagnosis. — The great question is, " What justi- 
 fies the surgeon in terming a certain patient ' scrofulous ? ' " The answer 
 
 1 Bead Paget on Senile Scrofula, in his Clinical Lectures. 
 
SCROTUM, DISEASES OF. 205 
 
 usually depends greatly on the surgeon's individuality. By some authorities 
 such a thing as scrofula is hardly admitted to exist ; all the appearances 
 associated with its name being referred to local or special causes. Usually, 
 any such morbid manifestations as have been catalogued above, if the 
 known exciting cause is trivial, or if no cause at all be known, are regarded 
 as scrofulous ; and especially if more than one such affection attack the 
 same individual, and if he present the peculiarities of personal appearance 
 mentioned above. Prognosis. — Under treatment, with moderately favor- 
 able conditions, the individual manifestations usually disappear, often 
 leaving ugly scars. But the diathesis almost always remains. It may lie 
 latent throughout a vigorous manhood, and reappear in a decrepit old age. 
 Danger of tuberculosis supervening : said to be greatest in fair, delicate, 
 or " sanguine " type of the scrofulous. Treatment. — Hygienic and medical, 
 general and local. Hygienic requires the various conditions usually con- 
 sidered " strengthening," fresh air, good food, dry lodging, daylight, cheer- 
 ful occupation, flannel clothing, moderate exercise. Cleanliness of head 
 and skin. Strict attention to each trivial ailment. Medical treatment is 
 (1) antidyspeptic, and (2) tonic and nutritive. Tongue, stomach, and 
 bowels must be attended to on general principles. Gregory's powder and 
 hydr. c. cret. often useful, especially in children. Sodae bicarb, (grs. x.- 
 xv.) ter die in inf. calurubse just before meals. Cod-liver oil is the remedy. 
 Give it after meals, 3 j. bis die, increased gradually up to 3 j. ter die. Occa- 
 sionally suspend its administration if it disagree with stomach. Small 
 doses of nitric acid and strychnine useful adjuncts (Williams quoted by 
 Savory). Iron, ammonio-tartrate, citrate, fresh carbonate, vihum ferri 
 (iodide of iron, in fat, flabby children). Iodides sometimes mischievous 
 if fever be present. Mineral acids. Quinine, tinct. cinchonge co. Pan- 
 creatic emulsion. Change to a new climate, which, whether warm or tem- 
 perate, should certainly be dry ; English watering-places, Margate, etc. ; 
 Madeira, sea voyage. Local treatment is given under special heads. In 
 old age, " iron, cod-liver oil, sea air, etc., of little potency. Best, warmth, 
 and good food more important" (Paget). 
 
 Scrotum. — Wounds heal very readily. Bruises often produce hcemato- 
 cele, quod vide. 
 
 Scrotum, Diseases of. — The scrotum, consisting as it does chiefly of 
 skin and cellular tissue, is liable to the ordinary cutaneous diseases. More- 
 over, inside its serous lining are found hydroceles, hematoceles, hernias, 
 and diseases of the testicle. Certain affections of the scrotum present spe- 
 cial features worthy of note. The chief of these are (1) inflammation, (2) 
 elephantiasis, (3) epithelioma. 
 
 Scrotum, Inflammation of, is remarkable for the amount of oedema 
 which accompanies it, for its usually diffuse character (a kind of erysipe- 
 las), and for its frequently ending in partial sloughings. Its usual causes 
 are extravasation of urine, or continued irritation of some trivial local af- 
 
206 SEPTICEMIA. 
 
 fection. Prognosis in every way good, except in bad cases of extravasation. 
 Treatment. — Vide Erysipelas, and Urine, Extravasation of. 
 
 Scrotum, Elephantiasis of. — A cellulo-cutaneous hypertrophy, with more 
 or less oily infiltration. Very rare except in the East and West Indies, in 
 Egypt, and in South America. Prime cause unknown. Exciting cause, 
 occasionally some local irritation. The tumor may even attain a weight 
 equal to that of all the rest of the patient, trunk and limbs inclusive. Sur- 
 face sometimes smooth, sometimes tuberculated. Prognosis. — Steady 
 growth. Perhaps eventually death from supervening ulceration. Treat- 
 ment. — Excision. If under forty-two pounds in weight, try to dissect out 
 and save testicles and penis. Danger of great hemorrhage. 
 
 Scrotum, Epithelioma of (Chimney-sweep's Cancer). — Chiefly attacks 
 chimney-sweeps. Commences as a wart or tubercle " oftenest near the 
 lower and fore part" of scrotum (Humphry). Structure that of epithe- 
 lioma elsewhere. Treatment. — Excise. Decidedly enlarged glands in groin 
 should be excised too. Very little tendency to affect the system, but great 
 tendency to recurrence. Irritation of soot has been known to produce 
 epithelioma on hand of a gardener. 
 
 Scurvy. — Believed to be a blood disease. Causes. — Salt meats. "Want 
 of fresh meat and fresh vegetables. Subsidiary causes are severe cold, and 
 all depressing influences. " In former Arctic expeditions scurvy occurred 
 in men who indulged to excess in alcohol, and who had not been exposed 
 to the deteriorating conditions that existed during sledge-travelling." 1 
 Morbid Anatomy. — Extravasations all over the body, beneath skin, in se- 
 rous cavities, in viscera, and in intermuscular spaces. Extreme emacia- 
 tion. Ulcerations. Symptoms and Course. — Premonitory signs, great 
 lassitude, pains in joints. Then appear sore mouth, petechia?, and, by 
 and by, ulcers and blood-tumors. Hemorrhages of various kinds, internal 
 and external ; progressive exhaustion. Prognosis. — Fatal, unless the causes 
 be removed. Proper treatment rescues very bad cases indeed. Treatment. 
 — Vegetables. Fresh meat. Lime-juice. Best attainable hygienic condi- 
 tions. Treat local manifestations on general surgical principles. Owing 
 to impossibility of melting lime-juice on sledge excursions in polar regions, 
 concentrated lime-juice lozenges have been devised. 
 
 Septicaemia. — A disease in which the blood is poisoned by septic 
 matter. In this respect it does not differ from pyaemia, and many if not 
 all cases of surgical fever. Bryant even writes, " Surgical, suppurative, or 
 traumatic fever ; septicaemia, ichoraemia, puerperal fever, and pyaemia, may 
 all be considered as so many different names for, and manifestations of, 
 one condition, blood-poisoning." In practice, however, " surgical fever," 
 " septicaemia," and "pyaemia " are not considered as different names for one 
 
 1 Report of Committee on Scurvy, in Sir George Nares' expedition, quoted by Mr. 
 H. Leach. 
 
SHOCK. 207 
 
 condition, though it is difficult to define the limits of each. I have most 
 often heard surgeons apply the term septicaemia to acute cases in which 
 the nervous and digestive organs were the seat of prominent symptoms, 
 while there was an absence of clear signs of secondary abscess. Compare 
 with pyaemia. Causes. — Vide Pyaemia. Signs. — Apathetic state ; rarely 
 excitement. Tongue very dry. Speech feeble. No appetite. Either 
 perspiration or dryness of skin. Symptoms often bear considerable re- 
 semblance to those of typhus. Urine scanty. Temperature, at first high, 
 tends to fall as death approaches. Occasional extreme rapidity of rise. 1 
 Bed-sores form ; urine and faeces are passed in bed. Finally collapse and 
 death. The elevation of temperature is often slight, especially in weak, 
 old people. Chronic blood-poisoning is more likely to take one of the 
 forms of pyaemia or the form of hectic fever. Pathology. — Condition of 
 the blood not at all characteristic. " If we have not seen the patient dur- 
 ing life, we shall often examine the dead body in vain for some palpable 
 cause of death" (Billroth). Spleen often enlarged and softened, rarely 
 normal. Liver congested and very friable. "In the heart the blood is 
 lumpy, half-clotted, tarry, and rarely firmly coagulated, buffy ; in most 
 cases the lungs are normal. Where the course of the affection ' has been 
 very long (a fortnight or more) the disease shows itself mostly by exten- 
 sive suppuration of the cellular tissue ' (near the wound), ' with more or 
 less extensive gangrene of the skin'" (Billroth). 8 Prognosis and Treat- 
 ment. — Vide Pyemia. 
 
 Shock.— Causes. — Injuries, especially if very painful, or attended with 
 hemorrhage ; or if in certain localities, e.g., abdominal viscera, testicles, 
 and the larger joints. Mental emotions. When an injury is foreseen and 
 expected, shock is more severe than when the recipient is excited and care- 
 less. Children less liable than adults. But acute pain readily causes col- 
 lapse in a few hours in children (H. Marsh). Signs. — Pallor, coldness, 
 weakness, even amounting to utter prostration. Consciousness may or 
 may not be seriously affected. The mind may be clear, and yet the limbs 
 but little sensitive to pain. Temperature actually sinks 2°, 3°, or 4°, or 
 more in severe cases. Pulse thread-like. Respiration sighing. Nausea, 
 vomiting. In certain cases the patient is noisy and delirious. Generally 
 he is either quiet or wanders slightly in his mind. Course. — Death may 
 result almost instantaneously, even when the prime injury is apparently 
 trifling. This is most common in injuries to the abdominal viscera. But 
 reaction usually occurs in a few hours, and is frequently excessive, passing 
 into fever. And, again, shock may endure for many hours, and at last 
 prove fatal. Pathology. —It is certain that paralysis of the vaso-motor 
 
 1 From 102.6 to 107 in ten minutes in a case under Mr. Bickersteth (British Medi- 
 cal Journal, 1879). 
 
 8 See Microscopic Organisms, in Appendix. 
 
208 sinus. 
 
 nerves, probably inhibitory, is an essential part of shock ; but it is not so 
 certain whether it is universal or local. Golz showed that when a frog is 
 struck on the abdomen, its heart ceases to beat, and at the same time the 
 portal system is vastly distended with blood. He supposes the former 
 phenomenon to be the effect of the latter, and the two together to account 
 for the features of shock ; but Moullin argues, and with reason, that, in 
 shock, there is primarily a far more general inhibition of the vaso-motor 
 system. Diagnosis from syncope, the result of hemorrhage. — When the 
 hemorrhage is internal, this diagnosis may be impossible at first ; but in 
 the case of hemorrhage, when reaction takes place, the pallor of the gums 
 and conjunctivae persists. Prognosis depends on the amount, on the per- 
 sistence, and on the attendant complications of the attack. A particularly 
 dangerous condition is that termed "prostration with excitement," in 
 which " the languor or stupor of collapse is succeeded by restlessness, 
 jactitation, tremor, and twitchings of the muscles, precordial anxiety, 
 often but not always delirium of various degrees" (Savory). Treatment. — 
 Warmth, hot water bottle to feet, flanks, and epigastrium, warm affusion 
 to head. Horizontal position. Frictions. Stimulants : brandy, ammonia. 
 Do not pour fluids down a patient unable to swallow. Galvanism to prse- 
 cordia. Treat hemorrhage if present. Eemember that collapse in some 
 cases of internal hemorrhage is useful, by giving time for nature to close 
 the bleeding vessels. In such cases the treatment had better be limited 
 to horizontal posture, strict quiet, external warmth, and such action as the 
 bleeding may demand. Transfusion. When reaction has commenced, 
 food must be given, e.g., small quantities, frequently repeated, of brandy 
 and egg mixture, milk, and strong soup. With regard to operating during 
 shock, the surgeon seldom hesitates now, relying upon the stimulating 
 powers of ether and the relief from pain and discomfort which follows 
 the removal of a mangled limb. But every care must be taken to prevent 
 hemorrhage, which is very badly borne by a collapsed patient. 
 
 Sinus. — An abnormal passage whose length decidedly exceeds its di- 
 ameter, and which is not a healthy, healing wound. Paget, in describing 
 sinus and fistula together, says they include three classes, viz. : (1) long, 
 narrow, suppurating canals ; (2) canals giving exit to unnatural secretions 
 {e.g., gastric fistula, biliary fistula) ; (3) abnormal apertures between mu- 
 cous cavities {e.g., vesico-vaginal fistula). He goes on to say that " if a dis- 
 tinction is to be made between the terms," " sinus " should be applied ex- 
 clusively to those of the first form, in which the canal has but one opening. 
 To thus limit the term " sinus," would be to differ from many surgeons 
 (vide, e.g., Pott's chirurgical works, p. 590, where " sinus " means either 
 blind or complete fistula). Causes. — Usually (1) abscess, sometimes (2) 
 wound, (3) ulceration, (4) sloughing. In addition to these, one or other of 
 the following secondary causes almost essential, viz. : (1) presence of 
 dead bone, or of foreign body, (2) some mechanical obstruction to the free 
 
SPERMATORRHEA. 209 
 
 discharge of pus, (3) the occasional passage of secretions or excretions 
 into the sinus, (4) presence of diseased glands (strumous or otherwise). 
 Passage of sinus among muscles is a cause which may be classed with (2). 
 Treatment. — Find out and treat cause. Sayre's vertebrated probe useful 
 when track is sinuous. Remove dead bone, etc. Slit up, if situation of 
 sinus permits. Injections of iodine, tannic acid, Condy, etc. Antiseptic 
 bougies. Pressure. Drainage by passing a tube nearly to the bottom of 
 the sinus. This can be combined with injection. Withdraw slightly each 
 day. Cautery, especially galvanic or benzoline cautery. If the sinus pass 
 among muscles, and cannot be slit up, the attachments of these muscles 
 should be fixed by bandages, etc. 
 
 Skin, Diseases of. — See Eczema, Ecthyma, Psoriasis, Corns, Warts, 
 Elephantiasis, Scabies, etc., etc. ; only the commonest forms are noticed 
 in this work. 
 
 Skin, Transplantation of. — (1) Minute pieces of epidermis, which should 
 include the youngest layers, namely, those next the time skin, are shaved 
 or cut off and placed upon the surface of a healing ulcer, in order that 
 they may there form nuclei whence cicatrization may spread. (2) Skin is 
 sometimes only partially severed from its connections, and then, with the 
 circulation still active within it, transferred to the raw surface of another 
 part. In this way, e.g., gaps in the skin of the chest may be filled in from 
 that of the arm. Of course the arm has to be bound to the bosom until 
 the skin has formed adhesions in its new site. (3) Pieces of skin, even of 
 considerable size, thoroughly cleaned free of subcutaneous tissue, have 
 been successfully transplanted without any pedicle being left attached to 
 them (vide papers by Wolff of Glasgow). In the first (far the common- 
 est) method it is enough to place a small piece of gutta-percha tissue over 
 each transplanted fragment, and to cover with water-dressing. 
 
 Skull, Injuries of. — See Head. 
 
 Sloughing. — See Gangrene. 
 
 Snake-bites. — See Bites of Snakes. 
 
 Snuffles. — See Syphilis, Congenital. (In Appendix.) 
 
 Spectacles. — See Eyes. (In Appendix.) 
 
 Spermatic Cord. — Frequently affected secondarily to the testicle, e.g., 
 by cancer. Subject independently to hydrocele (quod vide), hematocele, 
 lipoma, neuralgia, etc. 
 
 Spermatorrhoea. — An abnormal discharge of semen. A chronic dis- 
 order. Nocturnal emissions, if not oftener than once a fortnight, scarcely 
 considered abnormal. Cause. — Almost always masturbation. Symptoms. 
 — Niemeyer describes four classes of cases : (1) persons who have un- 
 natural emissions simply because they continue to masturbate. To their 
 doctor they describe such symptoms as " nervousness," lassitude, palpita- 
 tion, various exaggerated pains about the genitalia, etc. They readily con- 
 fess that they have practised self-abuse, but pretend they have given it up. 
 
210 SPINE, DISEASES OF. 
 
 (2) Robust-looking persons who have really given up their bad habits and 
 recovered their general health, but who are sexual hypochondriacs for some 
 other reason. (3) Weakly, anaemic persons, who have never masturbated, 
 and in whom ordinary and not frequent wet-dreams produce dulness and 
 lassitude. (4) True cases of spermatorrhoea, in which exhaustion, etc., are 
 really produced by too frequent seminal losses. Their symptoms are as 
 follow : sadness, dislike to work, lassitude, inattention, cowardice, trem- 
 blings, noises in the head, dizziness, neuralgic pain in back of head, etc. 
 Resemblance to hysteria. In these cases especially, semen often flows 
 away with the urine or during defecation. But note, the latter symptom 
 is not uncommon in healthy men. Distinguish between mere mucus and 
 semen by the microscope, which in the latter case should discover sper- 
 matozoa. Pathology of the last form (time spermatorrhoea). — Probably a 
 state of chronic congestion and relaxation about the prostatic part of the 
 urethra and the openings of the seminal ducts, added to an undue irrita- 
 bility of the nervous system ; in fact, a condition similar to the hysteria 
 caused in women by ulceration of the os uteri. Prognosis. — Cure difficult 
 in many cases, (1) because patient will not refrain from bad habits, either 
 of self-abuse, of alcohol- drinking, of excessive meat-eating, of lying in bed 
 in the morning, or of sedentary employment without proper outdoor ex- 
 ercise ; (2) because of chronic nature of ailment. Treatment. — Insist upon 
 total abstinence from the vices just enumerated. The difficulty of stopping 
 masturbation is well known. It seems to me that the most rational indi- 
 cation is to be derived from its being essentially a secret vice, practised 
 chiefly or entirely in bed. A patient who eventually lost his reason 
 through it, even when the habit was inveterate, always ceased from it so 
 long as his attendant slept in the same bed with him. The sex of the bed- 
 fellow does not affect the result, therefore marriage may be advisable. 
 Occasional intercourse with lewd women, which has been recommended 
 even by physicians, is of somewhat doubtful value, and of course morally 
 objectionable. Cold hip-baths in the morning. Patient should get up and 
 empty his bladder as soon as ever he awakes in the morning, even if he 
 gets into bed again. Hard mattress. No supper ; no tea in evening. At- 
 tend to digestion. Revalenta Arabica, or fish and milk diet may be useful. 
 Keep bowels open. Blisters to perinseum. When varicocele or relaxed 
 genitalia coexist, patient should wear my suspensory bandage, made by 
 Arnold, of West Smithfield. If improvement be not satisfactory, cauterize 
 prostatic part of urethra with Lallemand's " porte-caustique." Repeat 
 three or four times if necessary. Drugs given are (1) belladonna, gr. £ of 
 extract, + zinci sulph., gr. iiss., ter die ; (2) bromide of potassium. Phos- 
 phorus, quinia, strychnia, iron, and cantharides are given when sperma- 
 torrhoea is associated with impotence. 
 
 Spine, Diseases of. — Term " spinal disease " sometimes restricted to 
 caries. Angular curvature is, of course, always described with caries. Be- 
 
211 
 
 sides the above, there are lateral and anteroposterior curvatures, hyster- 
 ical and rheumatic affections, and spina bifida. 
 
 Angular Curvature ; Pott's Curvature of the Spine ; Cartes of the 
 Spune. — These three terms are not quite synonymous, but they are con- 
 stantly used as such. Caries precedes and causes the curvature. Causes. — 
 Scrofulous constitution — male sex in children, female sex in young adults, 
 rare in more advanced life. Often a history of a fall or blow. 1 Whooping- 
 cough. Pathology. — Commences either as simple caries, or as tuberculous 
 disease of the vertebral bodies, or as inflammatory softening of the inter- 
 vertebral cartilages. As the destructive process proceeds, two striking ef- 
 fects almost always result, viz. : (1) a posterior angular projection of the 
 corresponding spinous processes ; (2) less frequently, formation of abscess. 
 As many as six or eight vertebral bodies have been known to break down : 
 usually only two or three are involved. Laminae, spines, and articular pro- 
 cesses escape ; but there is a great tendency for them to anchylose together. 
 Collapse of the spine anteriorly at the seat of caries causes the posterior 
 angular projection. Compensatory curvatures in other regions of the spine. 
 Curvature in lumbar disease occasionally lateral as well as antero-posterior. 
 Middle and lower dorsal regions commonest seats of caries. Spinal cord 
 is (1) so small as compared with diameter of spinal canal, and (2) so well 
 protected by its membranes, that it is usually unaffected ; but in many 
 cases paraplegia, usually motor and partial, and often temporary, occurs. 
 The immediate cause is probably inflammatory effusion, or else pressure 
 from a sudden rapid increase of the deformity. Even aorta may be com- 
 pressed between the diseased vertebrae as the latter fall together. 2 Abscess 
 usually " psoas" in disease of dorsal or lumbar vertebrae. Frequently lum- 
 bar. In cervical caries, abscess usually presents toward side of neck, 
 sometimes in pharynx (retro-pharyngeal abscess). But the pus may bur- 
 row in various directions, e.g., into pelvis, buttocks, abdominal wall above 
 Poupart's ligament, and from the neck into the thorax. Psoas abscess 
 passes down in the sheath of the psoas muscle, forming a swelling first in 
 the inguinal region of the abdomen, and next in the thigh beneath Pou- 
 part's ligament, toward the outer rather than the inner side of Scarpa's 
 triangle. It may extend downward much farther, and occasionally turns 
 outward or inward. Sometimes it is double, i.e., passes down the sheaths 
 of both psoas muscles. Lumbar abscess perforates the quadratus lum- 
 borum, and presents in the loins immediately external to the erector spinae. 
 Spinal abscess may (1) be absorbed, or, (2) after a more or less chronic 
 
 1 See a paper by Mr. "Willett in St. Bartholomew's Hospital Reports, voL siv., 
 p. 325. Out of 60 cases, the assigned cause was a blow or fall in 21 cases, previous 
 illness in 5, and cause unknown in the remaining 34 ; 14 were strumous subjects; that 
 is, were sickly, delicate persons of strumous aspect. 
 
 2 See Goodhart, Pathological Transactions, 1878. 
 
212 SPINE, DISEASES OF. 
 
 course, burst, or (3) be opened by the surgeon. When opened, unless 
 antiseptic precautions be taken, hectic fever supervenes. When anchylosis 
 takes place, even the laminae and spinous processes of adjacent vertebrae 
 unite. Symptoms. — In children, the first sign observed is generally a 
 prominence of one or more vertebral spines ; but if the lumbar region be 
 affected, no prominence may be discovered till after the appearance of ab- 
 scess, or signs of general or local weakness and pain. Adults usually re- 
 mark pain and weakness before deformity. The erector spinas, rigid at first, 
 soon atrophies. Deformity varies in extent from the slightest degree up to 
 a huge "hump." Compensatory curves in the lumbar and cervical regions 
 make the chin project and the head sink down beneath the shoulders. To 
 take weight off spine, patient supports himself with his hands on his knees. 
 When picking up an article from the floor, he squats down, keeping the 
 affected part of his back rigid. If the atlo-axial- joint be affected, he turns 
 his body to the right or left instead of rotating his head. Pain may be 
 absent. In acute cases pain and tenderness are excessive. Often more 
 pain is felt in the side or abdomen than in the spine. Paraplegia may 
 come on, or temporary want of control over the sphincters. Incapacity for 
 and dislike to active exercise : health suffers in consequence. When ab- 
 scess opens and chronic septicaemia results, health may break down rapidly, 
 or abscess may dwindle to a comparatively unimportant sinus. Diagnosis. 
 — Usually easy. Difficult (1) at commencement, (2) when it occurs in hys- 
 terical females. A lateral curvature often results from caries of the lum- 
 bar vertebrae ; but, in this case, there is no rotation, as in true lateral curva- 
 ture, and there are probably collateral signs of caries, e.g., abscess. Some 
 persons attach importance to eliciting pain by concussing the top of the 
 •head, or by running a hot sponge down spine. Stiffness of spine an early 
 sign. Prognosis. — Favorable as regards life when proper treatment is 
 adopted. Prospect of undoing angle of curvature hopeless. Paraplegia 
 is frequently recovered from. Treatment. — Three classes — (1) rest in bed, 
 (2) movable supports, (3) fixed supports. Also general treatment. Kest 
 in bed essential in the worst cases, e.g., those complicated by paraplegia 
 and abscess ; but it is itself injurious, by taking away the benefits of fresh 
 air and exercise, and even when in bed the spine should be securely fixed. 
 Spinal supports are of various kinds. If an apparatus be applied, it should 
 be frequently examined and adjusted. Fixed apparatus, plaster-of-Paris, 
 poro-plastic, leather, paraffin, etc. To Sayre is chiefly due credit of demon- 
 strating their value. He uses bandages with plaster-of-Paris, applying 
 them from below the anterior superior iliac spines up to the armpits, 
 while the patient is suspended by a collar beneath the chin and loops in 
 the axillae, his toes only touching the ground. The bandages are made of 
 crinoline. Pads of cotton-wool over epigastrium, female breasts, and 
 prominent spines. Tight-fitting jersey next skin. Patient lies horizontally 
 for an hour after application of jacket (longer if convenient). Similar ap- 
 
SPINE, DISEASES OF. 213 
 
 paratus applied with patient in supine position (Walker), 1 or suspended 
 from the armpits and hips in prone position (Willett), or in hammock. 
 (Davy). 2 Patient's complaints as to pain, etc., should be attended to, lest 
 a sore form from pressure over projecting spines. The suspending rope 
 should be held by hand, as grown-up people sometimes faint, and require 
 instantly lowering to the horizontal, and little children might get hanged 
 if hooked up and left. Case should be cut up at least once in three or four 
 months ; six months minimum of treatment. With a Sayre's case, exercise 
 and play become enjoyable in cases where walking had previously been im- 
 possible. In case of pain near the prominent spine, cut a trap-door in the^ 
 case. When the cervical region is affected, the head should either be sus- 
 pended from a jury-mast, or supported by a leather collar, well moulded to 
 the chin, occiput, and base of the neck. Use the jury-mast also in upper 
 dorsal cases. Constitutional treatment is conducted on general principles. 
 Cod-liver oil, Parrish's food, sea-side, fresh air, sufficient diet, repose, etc 
 Abscess. — Its opening should be delayed as long as possible ; and then 
 strict antiseptic treatment should be carried out. 
 
 Spine, Latekal Cukvatuke of. — In practice the lateral curvatures which 
 sometimes result from empyema or from lumbar caries are not included 
 under this head. Causes. — Muscular weakness and excessive sitting or 
 standing in a lounging position about the age of puberty. Female sex 
 much more than male. Inequality in length of lower extremities. Hickets. 
 Kachitis adolescentium. (See Knock-knee.) Pathology. — Always a primary 
 and secondary, sometimes a third and fourth curve. Lumbar curve has 
 its convexity to the left nine times out of ten. Lumbar and dorsal curves 
 together form a line like the italic S. Simultaneous rotation of vertebrae, 
 so that in each curve the bodies of the vertebras which form it are turned 
 toward its convexity. Hence the actual extent of lateral curvature of the 
 bodies is greater than the apparent amount of curvature noticeable by 
 merely examining the spines. Hence, also, the transverse processes on the 
 side toward the convexity are twisted backward, while those on the side 
 of the concavity turn forward. Thorax is rotated forward and com- 
 pressed on the concave side, and rotated backward and dilated on the 
 convex side of the dorsal curve. Waist sinks in on concave side of lum- 
 bar curve and disappears on the opposite side, where its place is taken by 
 a depression half-way up the thorax. Thus in an ordinary case of lateral 
 curvature we should notice, (1) in the middle line, the row of spinous pro- 
 cesses curved with the lumbar convexity to the left and the dorsal to the 
 right ; transverse processes prominent on the convexities, sunk in on the 
 concavities ; (2) on the left side, the waist bulging, a spurious waist caused 
 by a depression in the thorax, and the thorax itself prominent anteriorly, 
 
 1 See British Medical Journal, December, 1878. 
 
 2 See St. Bartholomew's Hospital Reports, vol. xiv. 
 
214 SPINE, DISEASES OF. 
 
 flattened posteriorly, and compressed throughout ; (3) on the right side 
 the shoulder prominent ("growing out"), the thorax dilated and forming 
 a large swelling posteriorly, the waist sunk in, and the hip prominent. In 
 bad cases the last rib on this side impinges on the iliac crest. It is ex- 
 tremely likely that the immediate cause of lateral curvature is a softened 
 state of the bones due to an affection of the epiphyseal cartilages, like that 
 which causes knock-knee. The curvatures become confirmed by the bones 
 themselves altering in shape, atrophying where the pressure is increased, 
 hypertrophying where the pressure is. taken off. Signs are essentially the 
 naked-eye appearances which result from the changes just described. 
 Diagnosis. — See Angular Curvature. To distinguish structural from tem- 
 porary lateral curvature, make the patient bow down low. In the former 
 case the curve in the back persists. Prognosis. — Difficulty of cure very 
 great. Severe cases of any duration very nearly hopeless. Even commenc- 
 ing cases require most vigilant management. Treatment. — Various plans. 
 Almost all endeavor to combine extension, exercise, and localized pressure. 
 Many forms of spinal support. Sayre's plaster case. Gymnastic exercises, 
 especially swinging by the hands. Standing and sitting are to be avoided. 
 Eest should be taken in the horizontal position. Attend to general health. 
 Tonics ; fresh air. Treat menstrual irregularities. Of course, search 
 should be made after any possible exciting cause, and its removal effected 
 if possible. Friction to restore tone to spinal muscles. According to my 
 experience, Sayre's treatment at least prevents bad curvatures from getting 
 worse, greatly improves moderate ones, and even cures incipient cases ; 
 but daily extension by collar and pulleys is essential. * 
 
 Spine, Antero-Posterior Curvatures. — Lordosis, Kyphosis. Sometimes 
 arise from causes precisely analogous to those of lateral curvature. Fre- 
 quently secondary to hip disease. In lordosis the concavity is posterior, 
 in kyphosis it is anterior. Treatment. — Drilling, careful exercise, with in- 
 tervals of abundant horizontal repose. Attention to posture. Treat rickets 
 if present. In these cases, Sayre's plaster corset combined with daily ex- 
 tension should be employed for a considerable time, then left off gradually, 
 the intervals of wearing it being occupied in judicious exercises, frictions, 
 careful attention to carriage, and abundance of horizontal rest. 
 
 Spine, Hysterical. — Sometimes simulates spinal caries in young women. 
 Spasms, paralysis, difficult micturition, local tenderness. But " tenderness 
 is excessive and superficial, so that the patient flinches, and complains 
 more when the skin is pinched than when the vertebrae are pressed." 2 
 There is never found the stiffness characteristic of spinal caries. No pro- 
 portionate general wasting. Probably weak circulation and uterine or 
 ovarian disorder. Treatment. — See Hysteria. 
 
 1 I speak confidently on this subject, for I have now taken a part in the application 
 of nearly seven hundred plaster jackets. 
 
 2 See Savory, in Holmes's System, vol. i., p. 381. 
 
SPINE, INJURIES OF. 215 
 
 Spina Bifida. — Causes. — Defective development and non-union of verte- 
 bral laminae and spines, usually in lumbar region. Excess of cerebro-spinal 
 fluid in fetal life, according to Lowne. Pathology. — Perhaps primarily a 
 local inflammatory dropsy of spinal meninges. At all events, these mem- 
 branes bulge through defect in spinal canal. Spinal cord or spinal nerves 
 often in the tumor (when present, always in middle line, though often widely 
 spread). Dura mater and arachnoid blend with skin. Symptoms. — A fluc- 
 tuating tumor in median line behind, usually in lumbar region, sessile or pe- 
 dunculated, often translucent, springing from the bones ; may be partially 
 reducible by pressure — such pressure may cause spasms or convulsions. 
 May swell when child cries. Skin thickened and rough or thin and bluish 
 red. Diagnosis. — It is usually easy to see that a true spina bifida is one. 
 It is not always easy to be certain that a cyst closely connected with the 
 bones is not one. Compare each case with the signs just detailed. Prog- 
 nosis. — Grave. More hopeful when the neck of tumor is very narrow. 
 Treatment. — (1) Palliative, (2) radical. Palliative : a leaden shield, well 
 padded and accurately fitting. Eadical : three forms, viz., (1) injection 
 with iodine, (2) pressure, (3) excision. Operation very dangerous ; and 
 surgeon should be content with palliative measures, unless tumor is getting 
 steadily worse or on point of bursting. Pedunculated tumors offer best 
 prospect of success from injection. An endeavor should be made to isolate 
 sac from general cavity of spinal membranes during injection. Sometimes 
 long-continued pressure, e.g., by Dupuytren's enterotome, will effect this 
 isolation permanently, and thus cure the case. To inject iodine, a part of 
 the fluid should first be drawn off, and then two drops of pure tincture of 
 iodine injected (see Holmes's "System," vol. v., p. 806). Kepeated as- 
 piration may be tried without injection. Morton of Glasgow has been 
 very successful with the following injection : iodi., gr. x.; pot. iod., gr. xxx.; 
 glycerini, 3 j. About 3 ss. to 3 ij. is injected through a medium-sized 
 cannula. Repeat if necessary. Avoid unnecessary escape of spinal fluid. 
 
 Spine, Injuries of, include dislocation, fracture, and sprain. With 
 these should be studied concussion, traumatic compression, and traumatic 
 inflammation of the spinal cord and its membranes. 
 
 Spine, Dislocations of. — Causes. — Usually indirect violence, e.g., the 
 back being violently bent forward by a soft body falling on the head of a 
 person stooping. Occasionally direct violence, or even (in atlo-axial region) 
 destruction of the ligaments by disease. Usual Situation.— Lower cervical 
 region. Direction. — Upper vertebra is almost always displaced forward. 
 Signs. — Mostly "rational" and indirect. The most important depend on 
 injury to the cord : paralysis of parts supplied by nerves given off below 
 seat of injury. Perhaps local pain and tenderness. Shock: collapse at 
 first. In some cases manifest deformity. Variations in Symptoms accord- 
 ing to Seat of Injury. — (1) Dislocation in lower lumbar region. As a rule, 
 merely partial paralysis of lower limbs or pelvic organs from partial in' 
 
216 SPINE, INJURIES OF. 
 
 juries to cauda equina ; (2) upper lumbar region — paralysis of lower limbs 
 and sphincters ; (3) lower dorsal — paralysis of abdominal wall also ; (4) 
 upper dorsal — impaired breathing from paralysis of intercostals ; (5) lower 
 cervical — paralysis of every part below neck except diaphragm, respiration 
 entirely diaphragmatic ; (6) above third cervical vertebra, i.e., above origin 
 of phrenic nerve — instant death. Of course the higher lesions include all 
 the paralytic effects of the lower. Priapism. Later symptoms : alkalinity 
 of urine and catarrh of urinary organs ; bed-sores. These last-mentioned 
 complications cause death eventually. But, in cervical dislocations, death 
 results from obstruction of the lungs by frothy secretion. Diagnosis. — 
 From (1) fracture, hardly possible. From (2) mere concussion, by sudden 
 onset and by nature of cause ; also by deformity when there is any. Prog- 
 nosis. — Its badness varies directly with the height of the vertebra displaced. 
 High cervical dislocations perish usually in from two to three days, dorsal 
 in two or three weeks. But dorsal may recover, lower dorsal frequently. 
 Lumbar offer hopes even of complete cure. Treatment. — Best on back. 
 Gentle examination and nursing. Gentle extension. Withdraw urine 
 twice daily ; wash out bladder if urine become alkaline (see Bladder, 
 Catarrh of). Attend to bowels with enemas. The nursing is of vital im- 
 portance. Smooth, clean sheets, gentle change of position, dryness, daily 
 examination of sacral and trochanteric prominences. Good food. Trephin- 
 ing is for the most part condemned. In certain cases of injury to the spine, 
 especially if in lumbar region, it would be justifiable to apply a plaster-of- 
 Paris corset during extension. Sayre has published a case of this sort. 
 
 Spine, Fracture of. — Almost everything written above of dislocations 
 is applicable to fractures. In practice it is very seldom that any distinc- 
 tion is or can be made during patient's life. Seat. — More frequent in the 
 cervical region, but common enough in the dorsal. 
 
 Concussion of the Spine. — A term applied to a variety of traumatic 
 affections which can easily be differentiated post mortem, and sometimes 
 more or less easily diagnosed during life. They concur in having one 
 common cause, and in tending, so far as the worst cases of each kind go, 
 toward similar, if not identical, terminations. The common cause is in- 
 jury to the cord without fracture or dislocation of the spine. The worst 
 termination is disorganization of the cord with consequent paralysis. 
 Fortunately most cases stop short of this. Conditions included in the 
 term " Concussion of the Spine." — 1. Mere concussion. 2. Compression 
 from hemorrhage or effusion. 3. Laceration. 4. Inflammation. Causes. 
 — Injury, direct or indirect, to the spinal column. Especially common in 
 railway accidents. Blows, falls. Pathology. — Amount of visible injury in 
 the cord varies from slightest swelling or ecchymosis to considerable con- 
 tusions, lacerations, ecchymoses, effusions, and hemorrhages. Membranes 
 of cord suffer also. Ligaments of spinal column sometimes sprained or 
 torn. At a later stage are found softenings and thickenings, and, still 
 
SPRAINS. 217 
 
 later, atrophy or disintegration. Signs. — The most serious symptoms 
 arise much more from secondary inflammation than from the injury itself. 
 Concussion may be localized or diffused. When the injury is localized to 
 one part of the cord, either (1) the rational symptoms are confined chiefly 
 to paralysis or irritation of the nerves arising from that part, or (2) the 
 local mischief is severe enough to damage the functions of all the cord be- 
 low seat of injury. But the smallest local injury may serve as the starting- 
 point for the gravest general disease. In diffused or general concussion 
 the signs are often remarkably vague and insidious. Earliest are lassitude, 
 irritability, "inaptitude," sleeplessness. Then come pains and numbness 
 in various parts. Next, fixed pain in the back and rigidity of the spine 
 announce definitely the presence of spinous or intra-spinous inflammation. 
 Then uncertain gait, general clumsiness, disorders of sight, hearing, taste, 
 or smell, mental confusion, paralysis. Diagnosis. — (1) From fracture or 
 dislocation of spine (see Dislocation of Spine) . The symptoms are usually 
 less decided, less sudden, and less severe. (2) From malingering. Some- 
 times very difficult. Attach greatest weight to objective symptoms, but 
 notice if any of these vary when patient is off his guard. Cross-examine 
 about subjective symptoms ; but gross exaggeration is not uncommon even 
 when real concussion is present, so the detection of one falsehood proves 
 little. Test by galvanism. Muscles really paralyzed do not contract 
 properly under galvanism. Extensor muscles usually most affected. Prog- 
 nosis. — When symptoms last long and are extensive, recovery is very un- 
 likely. Treatment. — The most trivial case deserves complete rest in hori- 
 zontal posture till the symptoms have entirely passed away. Prone 
 position preferable. Moderate or low diet. No stimulants. Calomel, gr. 
 v.-x. When local pain or tenderness is present, dry cupping. Ice-bags. 
 Pot. bromid. and chloral hydrat., gr. xx.-xxx., at night. Later stages ; 
 Mercury, e.g., liq. hydrarg. perchlor., 3 j. t. d. s.; or pot. iod. Counter- 
 irritation over spine, blisters, etc. Still later, when active disease in the 
 spine seems to have passed away while its effects remain, employ strychnia, 
 tonics, exercise — passive or active — shampooing, galvanism. 1 
 
 Spinal Cord, Traumatic Inflammation of, and Splnal Cord, Compression 
 of, are noticed as secondary phenomena occurring in the course of a case 
 of Concussion of the Spine (see above). 
 
 Sprains. — A class of injuries in which the soft parts of and about 
 joints are stretched or torn. Causes. — Usually a sudden wrench or twist 
 
 1 I would venture to suggest that in the case of many patients, especially those 
 with trivial concussion, who will not keep the prone position, e.g.^ fractious children, 
 and in the case of other patients convalescing, a plaster-of-Paris jacket would be use- 
 ful. Certainly nothing does so much good to the very common injuries of the joints 
 of the limbs to which children are subject ; and many cases of so-called " spinal con- 
 cussion" must be primarily sprains of inter- vertebral ligaments, while other cases 
 would benefit from thorough local rest. 
 
218 SPRAINS. 
 
 occurring when the patient is unprepared to bring his muscular power to 
 the assistance of his ligaments. Sprains not unfrequently accompanied 
 by fracture, the tendons or ligaments in such cases being stronger than 
 the bony processes to which they are attached. Complete rupture of a 
 tendon is commonly described as an accident distinct from a sprain (see 
 Tendons, Injuries of). Most sprains of severity involve laceration of the 
 capsular ligament. Blood is rarely effused into the joint in any quantity, 
 but subcutaneous ecchymosis is very common. Serous effusion into joint- 
 cavity, and inflammatory swelling of surrounding soft parts, take place. 
 Pain, often excruciating, heat, and tenderness — usually best marked at cer- 
 tain points. Diagnosis is to be made from fracture by negative evidence. 
 Trust as much as you safely can to your eye, and to the history of the 
 case. Prolonged physical search for crepitus to be much condemned. 
 Treatment. — Methods apparently diametrically opposed succeed with these 
 injuries. In the great majority of cases nature is thoroughly competent to 
 cure sprains unassisted. Many people "walk them off," as they say. 
 Sprained thumbs habitually get what is really no treatment at all ; yet, 
 common and severe as they are, how rarely any permanent harm comes 
 from them ! On the other hand, almost all the surgical authorities, 
 alarmed by the number of joint diseases and the like which are attributed 
 (truly, no doubt) to neglected sprains, warn us to fix sprains with wooden 
 or iron splints for weeks. There may be some doubt about the amount of 
 harm to be really attributed to treating sprains by motion ; but there can 
 be no question whatever about the mischief done by the abuse of rest. 
 Bone-setters depend for their living upon the orthodox and blind worship 
 of splints. A treatment which will be found very successful (see the writ- 
 ings of Hood, Cowling, Pilcher, and the traditional practices of thousands 
 of the laity) is to supply the place of the torn ligaments by applying care- 
 fully and thoughtfully bandages outside the joint, to limit effusion and in- 
 flammation by the pressure of such bandages, and to secure elasticity, 
 and thus permit a certain amount of movement, by means of plenty of good 
 cotton-wool, or else by using india-rubber bandage, which probably fulfils 
 all the above indications better. This india-rubber bandage, if properly ap- 
 plied, gives great relief in cases of flat-foot, the pain of which arises partly 
 from a kind of chronic spraining of ligaments and tendons. When the 
 sprain is severe, complete rest for a few days may be desirable, and se- 
 vere exercise should certainly never be allowed till it is quite well. The 
 mobile treatment prescribes, or rather permits, only gentle, regulated, 
 limited movements ; and what it chiefly condemns is the continual and re- 
 peated resort to splints. 1 Under such a treatment it sometimes happens 
 
 1 Billroth. Sir James Paget says: "In deciding upon resorting to manipulation 
 in old cases, I believe you will be safe if you will take the temperature of the part 
 for your guidance." Rest is counterindicated when the joint is cold. 
 
SYPHILIS. 219 
 
 that each fresh walking experiment reveals a worse and worse state of 
 things ; the patient goes to the bone-setter, submits to a little violence, 
 courageously defies his doctor's warnings, walks about, and gets well. 
 When the treatment above sketched fails, as it will sometimes, then is the 
 time for putting on a plaster-of-Paris case. The perfect recovery of old 
 sprains is often prevented by the presence of adhesions in or about the 
 joint. Break down these by free movements. If inflammatory reaction is 
 feared, fix up the limb for a few days and apply an ice-bag. 
 
 Sterility. — In males, usually a consequence of impotence, quod vide. 
 But there are probably cases in which men perfectly virile are yet sterile. 
 No rules can be given for the treatment ; but if the surgeon should be 
 consulted on such a case, he should inquire carefully into it, and possibly 
 he may do good — even if it be only by finding that the patient is not really 
 sterile at all. 
 
 Sternum. — Liable to necrosis from syphilis, from struma, or from in- 
 jury. This may lead to abscess and perforation, and occasionally to 
 mediastinal abscess. Treatment. — Apply general principles, for which see 
 Bone, Neceosis of, and Syphilis, etc. 
 
 Synovitis. — See Joints. 
 
 Syphilis.— Former extended application of the term so as to include 
 all venereal diseases, even gonorrhoea. In modem language usually re- 
 stricted to the constitutional disease, and to such primary sores as are fol- 
 lowed by infection of the system. But it is considered natural and con- 
 venient by most writers to place together, for descriptive purposes, the 
 soft non-infecting chancre and the "hard" or "Hunterian" chancre with 
 its consequences. The same plan will be followed here. 
 
 Venereal Diseases. — 1, Gonorrhoea (see separate notice) ; 2, soft sore 
 (false syphilis) ; 3, syphilis proper. 
 
 Soft Sore, soft chancre, simple chancre, chancroid. Causes. — Inocula- 
 tion from another soft chancre. According to Hutchinson's views, it is 
 non-specific in origin, and arises merely from inoculation with pus, the 
 result of ordinary suppuration at a certain stage. Contracted not only 
 through impure sexual intercourse, but occasionally also by accoucheurs, 
 midwives, etc., accidentally. Bassereau, "by the aid of repeated confront- 
 ation of the patients infected with those who had given them the disease, 
 succeeded in proving that" soft chancre "resulted from a chancre of the 
 same kind." Belative Frequency (as compared with hard chancre). — Four 
 to one (8,045 to 1,955). Objective Characters (period of incubation, nil). — 
 Successively, redness, slight swelling, vesicular pustule, ecthymatoid pus- 
 tule, ulcer. Ulcer is rounded, clean-punched, spreading, rather deep, with 
 a floor, uneven, dirty-looking, purulent, and with abundant highly conta- 
 gious secretion. Any hardness of base is rare ; but such as there is, is 
 that of ordinary inflammatory thickening. Course is progressive, tendency 
 destructive for three or four weeks ; then natural termination is in cicatri- 
 
220 SYPHILIS. 
 
 zation, with depressed white soft scar. Complications. — 1, Inflammation ; 
 2, gangrene ; 3, phagedena ; 4, phimosis. In consequence of the liability 
 to these, a classification has been made of soft chancres into 1, simple ; 2, 
 phagedenic ; 3, gangrenous or sloughing. The phagedenic is character- 
 ized by unusually rapid, obstinate, destructive ulceration. Its form is 
 irregular, edges livid, surrounded by copper-colored areola ; secretion thin, 
 very offensive. Occurs in broken-down subjects. Gangrenous chancre is 
 usually a consequence of phimosis with inflammation. The prepuce is 
 the part which usually sloughs. Great hemorrhage may occur. Usual 
 Positions of Chancre in Women. — Just inside fourchette or labia minora. 
 Sometimes on cervix or os uteri. Diagnosis. — From herpes, by the latter 
 being, at most, an excoriation. From Hunterian chancre, by absence of 
 characteristic induration, by state of inguinal glands, by more active char- 
 acter of ulceration, and by ulcers appearing immediately after exposure to 
 contagion. Prognosis. — Soft chancre has been said to occasionally lead to 
 constitutional syphilis. The advocates of dualism {i.e., the great mass of 
 modern authority) deny it. Bubo (suppurating) attends or follows soft 
 chancre occasionally, especially if chancre affect frenulum, or be irritated. 
 Treatment. — 1. Of simple chancre : Restrict walking exercise. Low or 
 moderate diet, cleanliness, wash with hot water twice daily, each time 
 dressing with lint and lotio nigra (calomel, 3 j-; aque calcis, \ iv.), or blue 
 wash (cupri sulph., gr. j.; aqua, § j.), or with iodoform (contraindicated if 
 the sore be inflamed). If seen in first week cauterize with any caustic 
 (argent, nit., acid, nit., acid, carbol. fort, etc.). In later stage, when indo- 
 lent, stimulation with ung. hyd. oxid. rubri, or a touch of argent, nit. may 
 do good. For painful erection at night, use morphia suppositories. When 
 phimosis is present, try frequent hot injections beneath prepuce, rest, and 
 elevation. Avoid operation if possible. 2. Phagedenic chancre requires 
 generous diet, regulation of digestive and other systems, opium inter- 
 nally, and local caustic and antiseptic applications (carbolic oil, i.-x. Acid. 
 nitric, dil., 3 j- ; aque, § iv.). Some sores can only bear non-irritant 
 lotions, such as lead and opium. Change of air often seems to act won- 
 derfully. 
 
 Bubo. — See separate notice in alphabetical order. In addition to the 
 notes given there, it may be stated that the bubo consequent on a soft 
 chancre is itself a chancre of the gland affected. Matter from the interior 
 of this suppurating gland will, when inoculated, excite a true soft chancre. 
 
 Syphilis (true syphilis) is either acquired or hereditary. 
 
 Acquired Syphilis. — Ordinary true syphilis. Causes. — Always conta- 
 gion ; almost always direct contagion, e.g., impure sexual intercourse, 
 kissing, nursing (i.e., suckling), unnatural offences, and sometimes, unfor- 
 tunately, the performance of obstetric duties. The blood and other con- 
 stituent fluids of a syphilitic patient are capable of syphilizing by inocula- 
 tion. But excretions of such a patient are innocuous. It is even stated, 
 
SYPHILIS. 221 
 
 but not proved, that vaccine lymph can only transmit syphilitic poison 
 when mixed with blood. 
 
 Pathology and Semeiology. — In the progress of syphilis there are four 
 periods, viz. : 1, Incubation ; 2, local eruption or primary lesion ; 3, 
 general eruption, or secondary syphilis ; 4, gummy products, or tertiary 
 syphilis. " Well-marked differences separate each of these periods; in 
 the first it is the complete absence of local manifestations ; in the second, 
 the presence of a single unique modification of the tissues at the point of 
 deposition of the contagious matter. Numerous but superficial lesions, 
 which generally leave no appreciable trace of their passage, characterize the 
 third (i.e., secondary) period ; while the fourth is distinguished by changes 
 more deep-seated, and usually followed by cicatrices. Moreover, inocula- 
 ble and hereditary in the second and third periods, syphilis does not ap- 
 pear to be contagious either in the first or in the last " (Lancereaux). 
 
 Period of Incubation. — Three to five weeks. 1 
 
 Local Eruption (Primary Syphilis) ; Hunterian or Hard Chancre ; In- 
 fecting Chancre. — Microscopically examined, every hard chancre evidently 
 owes its hardness to cellular infiltration and consecutive formation of new 
 fibrous tissue, and the ulceration is partly due to " granulo-fatty metamor- 
 phosis " of the infiltration and the infiltrated tissue. 
 
 Three kinds of hard chancre : 1, dry papuli ; 2, chancriform or chan- 
 crous erosion ; 3, ordinary Hunterian chancre. 
 
 Dry Papuli. — Very rare. " A papular protuberance, usually having the 
 form of a patch, one or more centimetres in extent, of a dark or brownish 
 red color, round or oval, firm and elastic, and sometimes covered with 
 whitish scales, which give it a certain analogy with the syphilitic papules 
 of the next " (i.e., secondary) " period." 
 
 Chancrous or Chancriform Erosion ; Parchment-like Chancre of Ricord. 
 — Usually occurs just behind corona glandis. When pinched up be- 
 neath the finger, it feels like a thin, hard wafer, or piece of parchment. 
 Two such chancres out of three leave no permanent duration behind 
 them. 
 
 Ordinary Hunterian chancre not only has a hard base, but is surrounded 
 by an elevated, hard, callous border, so that it is deeper in the middle 
 than at the periphery. When the result of inoculation, its successive ap- 
 pearances have been observed to be as follows : red spot, red or dirty yel- 
 low papule, covering of grayish scales, scales accumulated to a crust, finally 
 a cup-shaped ulcer. Fully developed, its surface is indolent, glossy, larda- 
 ceous, and its secretion scanty, thin, degenerate, not pus, and not rein- 
 oculable on the same subject. Usually heals after about six weeks. The 
 
 1 In vaccino- syphilis the vaccine scar begins to show syphilitic signs, e.g., inflam- 
 mation and induration, about a month after inoculation, in the meantime the pustulo 
 having followed quite a normal healing course. 
 
222 SYPHILIS. 
 
 characteristic hardness feels like half a split pea, and does not usually en* 
 tirely disappear in less than four months ; it may be permanent. 
 
 Seat of hard chancre is, in females, usually external genitals, rarely 
 vagina, sometimes uterine neck or os, sometimes quite other regions of 
 the body. 
 
 Indolent Bubo ; Tkue Syphilitic Bubo. — Glands affected always multi- 
 ple, usually numerous. Surrounding cellular tissue not affected, each 
 gland is consequently distinguishable. Characters, — hardness, smooth- 
 ness, oval or round shape, enlargement not great. Sometimes one gland 
 much larger than rest. Never suppurates except under circumstances of 
 special irritation. Appears coincidently with induration of chancre, and 
 considerably outlasts it. 
 
 Subsequent Induration of other Lymphatic Glands, especially in nape 
 of neck, axilla, and groin of opposite side, very frequent. This may last 
 for years, and is valuable to assist in diagnosing a case where history of 
 syphilis is not easy to get. 
 
 Secondary Syphilis ; Period of General Eruption. — Often ushered in 
 by feverishness, gastric disturbance, dizziness, pains in joints, lassitude. 
 These symptoms have before now led to a false diagnosis of intermittent 
 fever, typhoid, neuralgia, or rheumatism. The parts chiefly affected by 
 secondary syphilis are — 1, skin ; 2, mucous membrane ; 3, glands ; 4, iris 
 and neighboring parts of eye. 
 
 Skin Syphilides ; Syphilitic Exanthemata. — Varieties : 1, erythematous 
 syphilide ; 2, papular syphilide ; 3, pustular syphilide ; 4, vesicular sy- 
 philide ; 5, squamous, and, 6, pigmentary syphilide. General diagnostic 
 peculiarities of syphilides : 1, copper color ; 2, pigmentary stains left be- 
 hind ; 3, indistinctness of type (e.g., in the same subject are seen transi- 
 tional forms between roseola and psoriasis, and few or no patches which 
 are distinctly either one or the other) ; 4, situation (e.g., syphilitic pso- 
 riasis is not confined to the knees and elbows, as is so often the case with 
 simple psoriasis) ; 5, shape of groups of eruption, usually circular or 
 crescentic ; 6, absence of itching ; 7, unusual thickness of crusts and 
 scabs. 
 
 Erythematous Syphilide ; Syphilitic Roseola. — Hose- colored spots, or red 
 and slightly raised patches. Generally commences on trunk. Course slow. 
 In diagnosing from non-syphilitic erythemas consider the history of the 
 patient and the state of the glands. Prognosis. — Usually disappears under 
 a month's mercurial treatment. Said to augur rather a mild attack of 
 syphilis. 
 
 Papular Syphilide. — Coppery-red papules, chiefly on trunk, but also on 
 limbs, forehead, and hairy scalp. Leaves no permanent scar. 
 
 Pustular Syphilide ; Syphilitic Impetigo. — Appears at a later stage than 
 the preceding syphilides, but not so late as syphilitic rupia, which indeed 
 is a tertiary affection. The pustules suppurate, scab, and leave scars. It 
 
SYPHILIS. 223 
 
 lasts for several months, and might at first be mistaken for small-pox, and, 
 later on, for common acne. 
 
 Vesicular Syphilide. — Extremely rare. 
 
 Squamous Syjihilides ; Syphilitic Psoriasis. — Spots rarely large, color 
 coppery, scales thin. Fissures. Frequently palmar and plantar in situa- 
 tion. Palmar psoriasis characterized by "slightly prominent, rounded 
 spots, of a coppery color, covered with hard grayish confluent scales, which 
 in some cases take the form of cracked patches, and give rise to chaps and 
 fissures, which are often painful." Characteristic brown border at edges 
 of patches. 
 
 Pigmentary Syphilide. — Grayish or coffee-with-milk colored patches, 
 size of sixpence, chiefly on neck, face, and abdomen. 
 
 Alopecia. — " Primary " or " consecutive." By " primary " is meant the 
 alopecia which occurs independently of any visible anatomical lesion during 
 the secondary period of syphilis. " Consecutive is the alopecia which 
 attends various local tertiary syphilitic affections. Very common indeed, 
 especially in women. Not confined to crown of head like senile alopecia. 
 Affects scalp irregularly. When of long duration, indicates a severe 
 syphilis. 
 
 Nails ; Onychia. — "Usually moist and ulcerative ; sometimes dry, and 
 coexistent with psoriasis elsewhere. Affects toes more than fingers. Part 
 primarily affected is, of course, the matrix. Pain of ulcerative form of- 
 ten considerable. Psoriasis of the nail makes it horny, thickened, and 
 fissured. 
 
 Mucous Membranes. — Especially of mouth, throat, nose, larynx, and 
 rectum. Secondary affections of these are either (1) erythemas, (2) 
 superficial ulcerations, or (3) condylomata. Type, syphilitic sore-throat 
 (secondary). Red patches, more or less irregular, on pharynx, soft palate, 
 and often at same time on mucous membrane of cheeks. These may 
 be attended or followed by small superficial ulcers, surrounded by a dark 
 red margin, covered with yellowish material, and tender, readily smarting. 
 Must not be confounded with mercurial stomatitis and angina. The latter 
 produce swelled gums and the odor of salivation. The throat, in the male 
 sex, is the commonest seat of condylomata. 
 
 Condylomata ; Mucous Tubercles. — Chief seats : Vulva, pharynx, palate, 
 mouth, anus, buttocks, glans penis, prepuce, scrotum, and intervals be- 
 tween toes. Structure : sarcomatous, or soft connective tissue. Prognosis. — 
 They indicate a very mild form of syphilis. 
 
 Secondary Visceral Affections. — Of liver, nervous system, etc. (See 
 medical works.) Secondary affections of the joints occur rarely, and may 
 be diagnosed by the history. Secondary thickenings of the muscles and of 
 the periosteum are very uncommon. 
 
 Iritis, when syphilitic, may be distinguished from rheumatic iritis by 
 a consideration of the following table (from Lancereaux, after Desmarres) : 
 
224 
 
 SYPHILIS. 
 
 Syphilitic Iritis. 
 No acute symptoms. 
 Slow development of the disease. 
 Yellowish green discoloration of the iris, 
 
 dimness of the cornea and aqueous 
 
 humor. 
 Perikeratic circle little distinct. 
 Synechise and pupillary exudations. 
 Punctated keratitis in the last period. 
 Condylomata of iris. 
 Very little photophob 
 No watering of eyes. 
 General dulness of eyes. 
 
 Rheumatic Iritis. 
 Always acute symptoms. 
 Rapid development. 
 Neither discoloration nor dimness. 
 
 Circle very distinct 
 Rarely synechiae. 
 Never punctated keratitis. 
 Never condylomata. 
 Photophobia intense. 
 Watering of eyes abundant. 
 Unusual brightness of eyes. 
 
 Course and prognosis of syphilitic iritis depend greatly upon whether 
 the affection develops early or late during the secondary period. In the 
 latter case, adhesions usually form between iris and capsule of lens, which 
 keep up an irritation apt to lead to choroiditis, retinitis, and permanent 
 impairment of vision. 
 
 Period of Gummy Products ; Tertiary Syphilis. — In the preceding para- 
 graphs, "we saw the morbid localizations of syphilis limited chiefly to the 
 skin, to some of the mucous membranes, and to a small number of the 
 organs," e.g., the eye ; "from this time syphilis extends its manifestations 
 beyond these limits, and we find it everywhere where a web of connective 
 tissue exists, that is to say, in all parts of the body." "It is no longer sim- 
 ple hyperemias with or without exudation, inflammations slight and of 
 short duration, but profound changes, essentially slow in their evolution, 
 and marked by chronic inflammations. Sometimes extensive and dis- 
 seminated in a single organ, they are rather comparable to the chronic 
 phlegmasia^ ; sometimes more limited and circumscribed, these changes 
 appear in the form of nodules or tubercles, and it is then that the name of 
 Gummy Tumors is more particularly reserved for them." These two an- 
 atomico-pathological varieties, differing only in form, have the same start- 
 ing-point and the same structure. Tertiary syphilis is usually separated 
 by a distinct interval of time (sometimes many years) from secondary syphi- 
 lis. And its own manifestations, in some cases, show a tendency to appear 
 in a certain order, viz. : firstly, deep-seated lesions of the skin ; secondly, 
 affection of the subcutaneous cellular tissue, muscles, and bones ; thirdly, 
 disease of the viscera. The peculiarities of tertiary syphilis of the special 
 organs and parts are described under the corresponding headings, e.g., 
 Bone, Tongue, Larynx, Kectum, Testicle, Ulcers, etc. It may be stated 
 here that tertiary syphilis attacks the skin as rupia and ecthyma ; and that 
 the great cachexia often observed at this stage is sometimes due to diseases 
 of the abdominal absorbent glands. Structure of a Gumma. — Primarily, 
 granulation-tissue, with a delicate stroma of fibres and a few blood-vessels. 
 Afterward, partly degenerates into a granular detritus. Its naked-eye 
 
SYPHILIS. 225 
 
 appearance has been well compared to boiled cod-fish, but it sometimes 
 really resembles a solution of gum. 
 
 Prognosis. — Certainly is affected for evil by bad nourishment, want of 
 cleanliness, changeable climate, damp, darkness, very early age, and origin- 
 ally feeble constitution. Some cases are manifestly bad, others as plainly 
 benignant from the first. Indications may be drawn from the character of 
 the prime lesion. Very indurated and, still more, phagedenic chancres 
 are of evil omen. " The first syphilide," according to Diday, "is the most 
 valuable sign to rely upon." With a trivial roseola, not showing any ten- 
 dency to become papular, spontaneous cure is almost certain. Papular, 
 squamous, pustular, and vesicular syphilides indicate probability of a 
 worse attack of syphilis. " Syphilis once, syphilis ever," is the teaching of 
 an influential body of pathologists who have yet to prove their thesis. 
 Numberless instances have been observed of syphilitic patients who during 
 the remainder of a long lifetime have enjoyed sound health, and begot 
 families of vigorous, apparently untainted children. 
 
 Treatment. — Public prophylaxis. Eegistration and periodical inspection 
 of prostitutes. In some Continental towns, males who visit immoral houses 
 are also inspected. Private hygiene : none thoroughly effective except 
 morality. Cleanliness, etc. Carbolic soap. Oil of eucalyptus. History 
 of treatment of syphilis may be divided into three main periods : the first, 
 when mercury was almost all in all, being rivalled only by guaicum, sarsa- 
 parilla, and other vegetable diaphoretics ; the second period, when the 
 still powerful school of anti-mercurialists had its origin in the experience 
 of the British army surgeons during the Peninsular War ; and the third 
 and present period, in which nine surgeons out of ten give mercury with 
 discretion, both as to amount and time, and frequently substitute for it 
 iodide of potassium. Practically convenient to notice treatment of primary, 
 secondary, and tertiary syphilis independently. 
 
 Primary Syphilis. — Sigmund's statistics tend to prove that cauteriza- 
 tion of the spot inoculated is very successful in averting, if only it be ef- 
 fected early in the period of incubation (before any chancre has appeared). 1 
 Mercury unable to prevent secondaries, but useful to hasten the absorp- 
 tion of a very indurated chancre, which is slow to disappear. Locally, 
 cleanliness and lotio nigra, or calomel ointment one part + simple oint- 
 ment four parts, applied three times a day. For treatment of phagedena, 
 see Soft Chancre. 
 
 Treatment of Secondary Syphilis. — General and local. — General : Mer- 
 cury in small doses, e.g., hydrarg. c. creta, gr. iij., bis die; calomel, gr. ij., 
 with opii, gr. ss., ter die ; hydrargyri iodidi virid. , gr. ij., ter die ; pil. hy- 
 drargyri, gr. v., opii, gr. ss., bis die ; liq. hydrarg. perchlor., 3 j., ter die. Mer- 
 
 1 Sir James Paget and Mr. Hutchinson are in favor of trial of cauterization in 
 early stage of hard chancre. 
 15 
 
226 TARSUS, DISEASE OF. 
 
 curia linunction, ung. hydrargyri, 3 ss.- 3 j. rubbed into skin of inner side 
 of thighs, arms, and of belly alternately, every evening ; calomel ointment, 
 which is cleaner, may be substituted. The peroxide of mercury dissolved 
 in olive oil is another "elegant" preparation for external use. Fumiga- 
 tion. — Apparatus required: spirit lamp, common tin plate, small tin for 
 boiling water, tripod to support tin plate over spirit lamp, cane- or wood- 
 bottomed chair, and blanket. Calomel, gr. xx., to be placed on plate dry. 
 Tin of boiling water to be put on plate beside the calomel ; lamp lighted ; 
 patient sits on chair with blanket round him. Lamp to be blown out in 
 ten minutes, but patient sits a quarter of an hour longer, and then gets 
 into bed without drying his skin. Repeat every night or every other 
 night. Iodide of potassium often given in secondary syphilis. Dose v.- 
 xv. grains, best combined with some alkali. Iodide of potassium and liq. 
 hydrarg. perchlor. sometimes prescribed in same mixture, especially in 
 scrofulous subjects. Red or periodide of mercury results. Mercury usu- 
 ally given cautiously till the gums become slightly touched, and then 
 stopped. When giving pot. iod; the signs of iodism should be watched 
 for — to guard against them, not to produce them. They are catarrh of 
 the mucous membrane of the nose, frontal sinuses, eyes, etc., great ner- 
 vous depression, and sometimes a rash. Locally, many secondary affec- 
 tions require no treatment, e.g., roseola and most squamous syphilides. 
 For sore throat, gargarisma nigra ; for mucous tubercles, calomel + zinci 
 oxidi aa sequales partes, occasionally argent, nit ; for ulcers, ung. hydrarg. 
 oxid. rubri, or calomel ointment, or lotio nigra, or purely non-specific 
 treatment. For intra-anal and rectal affections, cleanliness and mercurial 
 suppositories. 
 
 Vaccino-syphtlts and Hereditary Syphilis. — See Appendix. 
 
 Talipes. — See Club-foot. 
 
 Tarsus, Disease of, usually begins in the bones. — Diagnosis. — From 
 disease of the ankle-joint by the swelling being below the malleoli in affec- 
 tion of the astragalo-calcaneal joint, and by the motion of the ankle-joint 
 being comparatively free ; of course disease of anterior part of tarsus is 
 easy to distinguish from ankle-joint disease. Diagnosis of exact tarsal 
 joints and bones affected very important from its bearing on treatment. 
 When the swelling, tenderness, etc., are on the outer side of the foot, 
 whether affecting os calcis or cuboid, or both, if disease be inveterate, 
 excision is decidedly indicated. But when disease affects scaphoido-cunei- 
 form joints, and centre of tarsus, the necessity of amputation is to be 
 feared. Excise for disease of astragalus, or astragalo-calcaneal joint. Dis- 
 ease of os calcis usually confined to bone, not reaching any joint for some 
 time. It should be gouged out. Exact diagnosis is easiest when there 
 are sinuses through which dead bone can be felt. Sulphuric acid, slightly 
 dilute (1 in 3), well adapted for dissolving dead bone in some of these 
 cases. In early stages, rest, pressure, etc., combined with out-door exer- 
 
TESTICLE. 227 
 
 cise, indicated. A high heel should be placed on the sound foot, a plaster- 
 of-Paris bandage on the diseased one, and the patient sent about on 
 crutches. ( Vide Bone, Scrofula, etc.) 
 
 Tendons, Ruptured, should be treated like ruptured muscles. Best 
 in relaxed position for a fortnight. Afterward careful and gradual mo- 
 tion for weeks before attempting free use. 
 
 Tendons, Cut, can often be advantageously united by suture. 
 
 Tendons, Syphilitic Gummata of, occur. 
 
 Testicle. — Abscess ; Absence ; Atrophy ; Cancer ; Cystic Disease ; De- 
 velopment Imperfect ; Enchondroma ; Fibrous and Fibro-cystic Tumor ; 
 Hernia Testis ; Inflammation (Orchitis and Epididymitis) ; Injuries ; Mal- 
 position^ — Inversion, Testicle in Perinaeum, Testicle in Groin below Pou- 
 part's Ligament, Retained Testicle in Abdomen, in Inguinal Canal ; Neural- 
 gia ; Scrofulous Testicle ; Syphilitic Testicle. 
 
 Testicle, Abscess of. — Causes. — Generally chronic or subacute orchitis 
 of syphilitic or scrofulous origin. Occasional Results. — Hernia testis, trou- 
 blesome sinuses, and recurrent inflammations. Treatment. — Apply general 
 principles. Do not open too early. 
 
 Testicle, Absence of. — An extremely rare condition, except in cases of 
 general abnormality of the genital organs. Curling quotes trustworthy 
 case from the practice of Page, of Carlisle. 
 
 Testicle, Atrophy of. — Causes. — 1, the contraction of lymph effused in 
 the course of any variety of orchitis ; 2, similar contraction the result of 
 hematocele, and even of hydrocele ; 3, excesses, sexual or alcoholic ; 4, 
 varicocele ; 5, operations for varicocele, especially those in which the sper- 
 matic artery is injured ; 6, elephantiasis scroti ; 7, injuries of the head ; 
 8, injuries of the spine ; 9, blows on the back of the neck ; 10, old age. 
 Treatment. — Remove the cause if possible ; use means to excite the arterial 
 circulation in the part, and to support the veins. Attend to general health. 
 In some cases rest, in others exercise of the genital organs will be indi- 
 cated. Prognosis depends on cause and persistence. In genuine cases, 
 bad. 
 
 Testicle, Cancer of. — Almost always encephaloid. Pathology. — Begins 
 usually in the body of the testis. At first the tubular structure of the tes- 
 ticle is spread around the cancerous mass, not mixed with it. Cancerous 
 mass is soft and pulpy, generally whitish in color ; cystic, cartilaginous and 
 fibrous masses occasionally interspersed. Growth usually rapid. Very 
 little tendency to ulcerate through skin. Great tendency to infection of 
 lumbar glands. Secondary formations occur in lungs and elsewhere. In- 
 guinal glands sometimes affected. Signs. — A solid enlargement of the 
 testicle, progressing rapidly, without inflammation, is almost always cancer. 
 Testicle smooth and firm, till localized softening occurs. Pain, dulL 
 Special testicular sensation no longer evolved by pressure. Cord not af- 
 fected early. General health perfectly good at first. Diagnosis. — The first 
 
228. TESTICLE. 
 
 thing is to make sure that the enlargement is solid. A trocar will settle 
 this in doubtful cases. (Vide Hydrocele.) Next, a diagnosis has to be 
 made from orchitis, syphilitic, scrofulous, or simple. History, concomi- 
 tant symptoms, and the effect of mercury, pot. iod., oleum morrhuse, etc., 
 help to decide this. " The diagnosis from cystic disease may be based 
 partly upon the rate of growth, but especially upon the information elicited 
 by the trocar." (Humphry.) Prognosis. — Usually fatal in one and a half 
 to two years. Many cases of removal without recurrence have been re- 
 corded. Treatment— Unless the disease has spread to the abdomen, re- 
 move the testicle. 
 
 Testicle, Cystic Disease of. — Pathology. — A tumor, consisting of multi- 
 tudinous cysts of any size up to that of a walnut, with thin walls, lined by 
 tesselated epithelium, and containing fluid varying in consistence from that 
 of serum to an almost gelatinous thickness. At least three views as to the 
 origin of the cysts, viz. : (1) dilatation of tubuli seminiferi, (2) dilatation 
 of tubules of rete testis, (3) a fibrous or fibro-cartilaginous tumor in the 
 testicle, with more or less of cyst-formation in the tumor. The cysts are 
 sometimes "proliferating," containing fibrous or cartilaginous masses. 
 Symptoms and Diagnosis. — Negative symptoms, such as absence of pain, of 
 thickening of the cord, of inflammation, and of constitutional disease, to- 
 gether with positive symptoms, such as smoothness, oval or spherical form, 
 and slow growth, generally reduce the final diagnosis to a distinction from 
 hydrocele or haematocele. Cystic disease is heavier than hydrocele, fluc- 
 tuates less, and is non-transparent. Moreover the testicular sensation usu- 
 ally remains and is diffuse owing to the granular substance being present 
 on every side of the tumor. In hydrocele and hematocele, this sensation 
 is, of course, confined to the seat of the testicle. A good sized trocar is 
 usually employed to settle the question. Treatment. — Castration. But if 
 a patient has only one testicle, a less radical operation may be considered. 
 
 Note. — Cystic disease is sometimes associated not only with enchon- 
 droma, but with recurrent sarcoma and with soft carcinoma. 
 
 Testicle, Imperfect Development of, may occur, affecting either the 
 body of the gland or the epididymis, or both. So also part of or even all 
 the vas deferens may be absent, the testicle being present and even full- 
 sized. Such cases may be virile, though necessarily sterile. Another 
 form of imperfect development will be noticed under heading Malposition. 
 
 Testicle, Enchondroma of. — Usually associated with cystic disease, 
 sometimes with soft cancer, the small masses of cartilage growing into the 
 cysts. ? as to whether growths commence in lymphatics or in tubuli of the 
 gland. Appearances, naked-eye and microscopic, much like those of hya- 
 line cartilage. 1 Diagnosis. — Characteristic weight and hardness. Treat- 
 ment. — Excision. 
 
 1 Mr. Savory once observed of a section of a lovely specimen, " like pearls, only 
 more precions." 
 
TESTICLE. 229 
 
 Testicle, Fibrous and Fibro-cellular Tumors of.— Very rare. Kefer, if 
 necessary, to Curling or Humphry. 
 
 Hernia Testis. — The condition in which, as a result usually of abscess, 
 but sometimes of wound, the whole or a part of the tubular part of the 
 gland escapes through an aperture in the tunica albuginea, and through a 
 corresponding opening in the scrotum. Any form of chronic orchitis may 
 lead to hernia testis. The projection looks like a mass of granulations. 
 Both the tubuli and the margins of the opening through which they pro- 
 trude are thickened by fibrous deposits. Treatment— Cleanliness, rest, 
 unguent, hydrargyri oxidi rubri or ung. hydrarg. nitrat. locally, or strap- 
 ping, combined with appropriate general treatment, usually cause the skin 
 to cicatrize over. In more obstinate cases, try incision of constricting 
 edge of tunica albuginea (Pagan, of Glasgow), or, after slitting up all si- 
 nuses, the edge of the skin wound may be freshened and brought together 
 over the protrusion (Syme). Anything like paring off protrusion rarely 
 necessary and usually mischievous. 
 
 Testicle, Inflammation of (Orchitis and Epididymitis.) — Varieties. — 1, 
 Acute ; 2, Chronic. A list of sub-varieties might be made out, founded on 
 the etiology, e.g., gonorrhceal, traumatic, syphilitic, scrofulous, metastatic, 
 etc. ( Vide Strumous Testicle and Syphilitic Testicle.) 
 
 Acute Orchitis (Inflammation of the body of the testicle). — Causes. — 
 Blows, wounds, metastasis (mumps), and rheumatism. Symptoms. — Or- 
 dinary signs of inflammation, viz., pain, tenderness, heat, redness, swelling. 
 Effusion into tunica vaginalis. When accompanying mumps, it begins 
 about fifth or sixth day. Treatment. — Kest, suspensory bandage, cold lo- 
 tions, aperients, antimony (antim. potass, tart., gr. j., aqua? fervent., J 
 viii.; § j. 4 tis hortis). Leeches : they should be placed over the cord (Hum- 
 phry). Puncture of tunica vaginalis, or even of testicle, with a sharp, nar- 
 row-bladed knife. 
 
 Acute Epididymitis. — Frequently, though not quite accurately, termed 
 "acute orchitis." Causes. — Mostly gonorrhoea. Any urethral irritation, 
 e.g., stricture, catheterization, lithotomy, impacted calculus. Blows. 
 Rheumatism, gout. Epididymitis may supervene during any stage of a 
 gonorrhoea. Symptoms. — Tenderness, pain, swelling, and hardness of epi- 
 didymis. Effusion into tunica vaginalis. Skin reddened and tender. Con- 
 stitutional disturbance, fever, sickness. Resolution usually commences 
 within a fortnight, but thickening may persist for months. Treatment. 
 (See Acute Orchitis.) — Worth while to persist with treatment in or to re- 
 move the residual thickening, as the latter, if left, may interfere with func- 
 tion of testicle. Suspensory bandage, moderation in all things, and, ex- 
 perimentally, pot. iod. internally. 
 
 Chronic Orchitis. — Causes. — (1) acute orchitis ; (2) syphilis ; (3) struma ; 
 (4) injuries. Acute inflammation in the testicle, as elsewhere, sometimes 
 subsides into chronic. Most cases of chronic orchitis are syphilitic and 
 
230 
 
 TESTICLE. 
 
 very indolent. (See Strumous Testicle and Syphilitic Testicle.) The 
 treatment for syphilitic is adapted also for non-specific, chronic orchitis. 
 
 Testicle, Injuries of. — Blows cause intense shock. Mobility of testi- 
 cle and strength of tunica vaginalis greatly protect testicle. Extravasa- 
 tion into cord may extend up to kidney, or even higher. Chronic, 
 and, more rarely, acute orchitis may supervene. This orchitis may hope- 
 lessly damage organ. Treatment.— Apply general priDciples. Testi- 
 cles bear incised wounds well. Kecovery from self-mutilation usually 
 rapid. 
 
 Testicle, Inversion of. — When testicle lies in front of, instead of at 
 back of, scrotum, it is liable to be injured in tapping a hydrocele. 
 
 Testicle, Other Forms of Malposition of, are known as : 1, retained 
 testicle ; 2, descent of testicle into perineum ; 3, descent of testicle into 
 groin. The testicle in the perinaeuni is liable to injury, especially during 
 riding. Operations to restore it to the scrotum have been performed by 
 Adams and by Annandale. An undescended testicle may remain above 
 the internal abdominal ring, or may enter the inguinal canal. Size and 
 maturity of gland then sometimes imperfect ; but impotence not neces- 
 sary, and perhaps not usual, even when both glands are retained. Liabil- 
 ity to certain accidents, e.g., (1) inflammation, which may be confounded 
 with strangulated hernia or with bubo ; (2) attacks of severe pain owing 
 to testicles being suddenly "trapped" between abdominal facias ; (3) en- 
 cysted hydrocele ; (4) complication with congenital hernia frequent. Ex- 
 cessively troublesome testicles in inguinal canal have been excised. Treat- 
 ment. — When a hernia adherent to testicle threatens to descend with it, 
 both had better be kept in abdomen by a truss. When a non-adher- 
 ent congenital hernia exists, apply a truss above testicle and below her- 
 nia ; or, if testicle is still in abdomen, dispense with truss for a while 
 in the hope that it may descend. Be in no hurry to operate upon a 
 hydrocele of the testicle in the inguinal canal. Bemember that tunica 
 vaginalis cavity usually in these cases communicates with that of perito- 
 neum. 
 
 Testicle, Neuralgia of (with which may be associated " irritability," or 
 "hyperesthesia," or tenderness of the testicle ; although this condition may 
 exist separately). Causes and Pathology. — (1) reflex ; (2) the obscure state 
 of the nerves and vessels of a part commonly associated with neuralgia 
 elsewhere, and manifested chiefly by signs of congestion ; (3) in some 
 rare cases, the presence of coarse organic disease, e.g., chronic abscess 
 (vide specimen in Hunterian Museum) ; (4) malaria. Beflex neuralgia re- 
 sults from stone in the bladder or kidney, from varicocele, indigestion, etc. 
 The age most subject is the period of puberty and the next ten years. The 
 exciting cause, frequently, undue excitement of the genital organs. Prog- 
 nosis. — Time almost invariably works a spontaneous cure, both of the in- 
 dividual attack and of the disposition to it. Bemove the cause. Treat 
 
TESTICLE. 231 
 
 varicocele, indigestion, etc. Suspensory bandage, 1 cold bath, moderation in 
 diet and in exercise of gland, etc. Quinine for intermittent cases. Hy- 
 podermic injection of morphia (quarter grain). Horizontal position, or 
 elevation of pelvis and lower extremities. 
 
 Strumous Testicle. — Causes. {Vide Scrofula.) Pathology. — A deposit 
 of tuberculous matter takes place within the convoluted tubes of the epi- 
 didymis. This matter is probably at first mainly a collection of epithelial 
 cells. Subsequent change into a cheesy or into a calcareous mass. In 
 the meantime chronic inflammation tends to destroy the walls of the tubes, 
 and to connect the tubercle into one mass. Color of tubercle, white or 
 yellowish white. Disease usually begins in epididymis, but when it com- 
 mences in the body of the gland, small, scattered gray tubercles first ap- 
 pear. These enlarge, and coalesce in parts of the gland. The ordinary 
 processes of chronic inflammation occur around the deposits. These usu- 
 ally result in formation of abscesses and sinuses. Vas deferens usually 
 thickened. Both testicles often affected. Coincident disease of lungs 
 frequent, and of kidney, prostate, vesiculse seminales, etc., occasional. Signs. 
 — Epididymis and sometimes body of gland enlarge slowly ; very little 
 pain, except when an abscess is ripening. Formation of abscesses. Thick- 
 ening of vas deferens. Scrofulous appearance of patient. Sometimes co- 
 incident disease of lungs, etc. Any ordinary affection of testicle may be 
 the commencement of strumous disease in a strumous person. Prognosis. 
 — With suitable treatment, many cases make a satisfactory recovery, the 
 tubercle degenerating and becoming encapsuled, or discharged. Treatment. 
 (Vide Scrofula.) — Suspensory bandage, cold sponging in indolent cases, 
 iodine externally. Lay open and clean obstinate sinuses. Only in thor- 
 oughly hopeless cases, such as resist treatment and obviously undermine 
 the health, is excision justifiable. ( Vide Hernia Testis. ) 
 
 Testicle, Syphilitic. — A tertiary manifestation. Pathology. — (Com- 
 pare with Strumous Testicle. See above.) Generally confined to body of 
 gland, epididymis and cord remaining healthy. Deposit of lymph in areo- 
 lar tissue between the tubules, sometimes in nodules. Different lobules 
 affected in different degrees usually. Lymph-nodules upon tunica albu- 
 ginea. Disease sometimes spreads to tubuli. Tendency to fibrous 
 degeneration, eventual contraction, and even atrophy of the affected 
 gland. Both testicles often attacked, usually one after the other. Liability 
 to abscess and hernia testis. Symptoms. — Enlargement, usually slow. 
 Amount of pain depends directly on rapidity of progress. Frequently 
 neither pain nor tenderness. Stony hardness. Knotty feel (not always). 
 Epididymis not usually distinguishable from rest of gland. Hydrocele 
 often coexists. History of syphilis : perhaps other collateral symptoms, 
 e.g., nodes. Diagnosis. — Compare symptoms, as given above, of strumous 
 
 1 See Varicocele. 
 
232 TETANUS. 
 
 testicle. Chronic orchitis caused by injury, or by stricture, can scarcely 
 be distinguished from syphilitic, except by the history and general symp- 
 toms. But it requires similar treatment. Prognosis. — Danger of atrophy. 
 Liability to relapse. Quite under control of antisyphilitic remedies. 
 Treatment. — Support by strapping may be employed, unless suppuration 
 be progressing. Suspensory bandage. Iodine or mercurial ointment 
 locally when pressure is not advisable. Open abscesses early. Give iodide 
 of potassium internally, or order mercurial inunctions. (See Syphilis.) 
 
 Tetanus. — Causes. — 1, wound ; 2, catching cold ; 3, race ; 4, male 
 sex. Wounds in which nerves are lacerated or left in contact with sharp 
 spiculge of bones or with foreign bodies, and wounds of the hand or foot, 
 are said to be especially liable. Tetanus is a more common complication 
 of compound fractures than of surgical operations. Exposure to cold or 
 sudden change of temperature rarely acts without a pre-existing wound. 
 Negro race is very subject. Pathology. — Richardson, Billroth, and others 
 teach that it is a zymotic disease, i.e., a poisoning of the blood through the 
 absorption of septic material, which septic material is formed by decom- 
 position in the wound. Brown-Sequard and many others regard tetanus 
 as an affection of the spinal cord which has spread from some irritated 
 sensory nerve or nerves in the wound, when there is one. In favor of 
 the latter theory may be cited cases in which the spasm has been con- 
 fined to the injured side of the body, or even to the injured limb itself. 
 Often no post-mortem appearances have been seen in the cord ; sometimes 
 softening of the central gray matter. It has been truly observed that 
 great changes ought not to be expected, because " it would be quite im- 
 possible for motor impulses to originate from a spinal marrow reduced to a 
 mass of debris." Coats (see " Med. Chi. Trans.," vol. lxi.) observed changes in 
 medulla oblongata like those in cord, and even a morbid condition of the 
 motor regions of the convolutions. There was an accumulation of leuco- 
 cytes round the vessels of the medulla, of the cord, and of the kidneys, which 
 in his opinion supported the theory of a poison circulating in the blood. 
 Symptoms and Course. — Typical case : A man with compound fracture 
 of forearm, about three or four days after the accident complains of pain 
 in the part, and is rather feverish. The next morning his neck is stiff and 
 his jaw also : he thinks he has caught rheumatism in that region. Within 
 twenty-four hours short spasms of the back occur when the patient is 
 momentarily exposed or fed, or otherwise excited. The spasms rapidly 
 affect also the abdomen and the extremities ; and now, instead of being 
 merely transitory, as at first, they never wholly pass away, the abdomen 
 feels hard like a board, the back is arched (opisthotonos), the hands are 
 clenched, the face marked by the risus sardonicus, and the jaw much more 
 fixed than before. Skin bathed in perspiration. Temperature raised to 
 about 100°. Bowels constipated. Respiration impeded by stiffness of 
 respiratory muscles (chest feels " as if in a vice "), intellect quite clear, no 
 
TETANUS. 
 
 233 
 
 sleep ; pain in the muscles, becoming intense when the spasms are aggra- 
 vated. Slight noises, draughts, and other trifling irritants cause the 
 tetanic spasms to be suddenly trebled in force. During one such par- 
 oxysm, patient dies asphyxiated. Or he lingers on for a few days or a 
 week, and perishes of gradual asphyxia (carbonic-acid poisoning) or of ex- 
 haustion. Such is the course of acute tetanus, and traumatic tetanus is 
 usually acute. But the disease is sometimes chronic, especially if it be 
 idiopathic. Then all the symptoms are less severe, the patient is able to 
 take a fair amount of nourishment, and gets some sleep. His breathing is 
 not seriously interfered with, and he has considerable chance of recovery. 
 There are intermediate grades of severity of every shade. Expression of 
 face called risus sardonicus arises from contemporary spasm of all the 
 muscles of the face ; dilators, compressors, levators, depressors, altogether. 
 Thus every line is deepened and every feature fixed by its muscles, just 
 as a ship's mast is by its stays. This expression may persist long after 
 otherwise perfect recovery. Sometimes the trunk is arched forward (em- 
 prosthotonos) or sideways (pleurosthotonos). 
 
 Tetanus Neonatorum is attributed to the wound caused by dividing the 
 umbilical cord. It is first observed by the mother or nurse, in consequence 
 of the lock-jaw preventing entrance of finger or nipple into mouth. Course 
 presents nothing peculiar. Almost always fatal. 
 
 Diagnosis of tetanus from (1) strychnia-poisoning, (2) hydrophobia, 
 (3) hysteria, (4) rheumatism. — Strychnia-poisoning is much more rapid, 
 both in its onset and in its advance to a fatal result. The paroxysms of 
 spasm are interrupted by periods of complete relaxation. Hence there is 
 no continuous lock-jaw. Death almost always takes place within two 
 hours, at latest. In tetanus, the most rapid death on record was after four 
 hours' duration. Hydrophobia. See following table (abbreviated and 
 slightly modified from Poland) : 
 
 Tetanus. 
 
 1. Spasms continued (tonic). 
 
 2. Cause — wound, or exposure to cold. 
 
 3. Appears generally soon after injury. 
 
 
 4. Risus sardonicus. 
 
 6. Frequently gastric pain, but no vomit- 
 ing. 
 
 Hydrophobia. 
 
 1. Intervals of complete relaxation (spasms 
 
 clonic). 
 
 2. Bite of a rabid animal. 
 
 3. Period of incubation usually a month or 
 
 more. 
 
 4. Countenance expressive of excitement, 
 
 fearful distress and peculiar restless- 
 ness; occasionally frightfully con- 
 vulsed ; eyes bright and glistening, 
 but at times suffused. 
 
 5. Thirst ; often aversion to fluids ; dis- 
 
 charge of viscid saliva. 
 
 6. Vomiting and gastric pains. 
 
 7. Mind becomes delirious. 
 
 8. No authentic case of recovery. 
 
 9. Intolerant sensibility of surface and or- 
 
 gans of sense. 
 
234 toes. 
 
 Prognosis. — Acute traumatic tetanus almost always fatal. Subacute 
 traumatic tetanus often recovers, especially if it does not appear till some 
 time after the wound, and progresses slowly. The prognosis is favorable 
 according to the duration of the disease. Thus, a tetanus which has en- 
 dured three weeks is extremely likely to recover. Idiopathic and chronic 
 tetanus have a favorable prognosis. The longest duration of any recorded 
 fatal case has been thirty-nine days. Treatment. — Remove every source of 
 excitement, keep the room dark and silent, lay down thick carpets, protect 
 from draughts by screens. Cover the patient with light, warm clothing, 
 so as to encourage copious diaphoresis. Examine the wound very carefully, 
 if one exists. Remove any foreign body or splinter. If a nerve is believed 
 to be irritated, a portion of its course may be excised. Those who regard 
 tetanus as a septic poisoning would be justified in taking measures to make 
 the wound antiseptic. Amputation has been done. Many drugs have been 
 tried, chiefly anodynes and antispasmodics. Most surgeons now choose 
 between chloral, morphia subcutaneously, opium internally, and Calabar 
 bean. Curare. Chloroform. Quinine. Ice-bags to spine. Of Calabar 
 bean, Garrod writes : "In tetanus, enough must be given to produce the 
 physiological symptoms of the drug. One-third gr. of the extract, rubbed 
 up with 10-15 mimims of water, and neutralized with a little carbonate of 
 soda, may be injected every two or three hours subcutaneously, where 
 swallowing causes pharyngeal spasm. If given by the stomach, 1 gr. of the 
 extract rubbed up with a little weak spirit. According to Frazer, Calabar 
 bean should be given at the very onset of the attack, for the contraction of 
 muscles begets a substance which excites muscular contraction. When 
 Calabar bean is given, its action should be carefully watched, lest the res- 
 piratory muscles become paralyzed by it. Rational indications, derived 
 from the post-mortem evidences of hyperemia, etc., of spinal cord, are 
 to give belladonna, and to employ every available means of diminishing 
 spinal congestion (Fitzgibbon, Dublin Medical Journal, March, 1877). And 
 also, I think, if the wound be not too large, to swab it thoroughly with 
 pure carbolic acid. The patient should be patiently and frequently fed 
 with milk and the strongest beef-tea. Tracheotomy has been recom- 
 mended when there is a tendency to laryngeal spasm. 
 
 Thorax. — See Chest. 
 
 Thrombosis. — See Veins. 
 
 Thumb may be bifid, or it may be double. 
 
 Thumb, Dislocation of. — See Dislocations. 
 
 Thyroid. — See Beonchocele. 
 
 Toes may be hypertrophied, be webbed, bifid, or supernumerary. 
 
 Hammer-toe. — A condition in which the last phalanx is bent perpen- 
 dicularly downward. If necessary, divide subcutaneously, opposite sec- 
 ond phalanx, the corresponding digital offset of plantar fascia. Doubtful 
 whether its origin be a nervous contracture or the pressure of tight boots. 
 
TONGUE, DISEASES OP. ^35 
 
 Tongue, Diseases of. — With a view to facilitating diagnosis (a rather 
 difficult task to the student of tongue diseases), I shall adhere to the fol- 
 lowing analytical classification, which starts from the most palpable feature 
 of each disease. I. Superficial ulcerations — simple ; syphilitic primary, 
 secondary. II. Deep ulcerations — 1, simple ; 2, syphilitic ; 3, malignant. 
 TTT . Localized swellings — abscess, innocent tumor (very rare), nsevus, gum- 
 mata, malignant. IV. General swelling — acute inflammation, congenital 
 enlargement, general enlargement secondary to other diseases of tongue 
 or of digestive tract. V. Non-ulcerative superficial affections — psoriasis, 
 ichthyosis, papilloma. 
 
 Tongue, Simple Superficial Ulcerations of. — Cause. — Indigestion ; irri- 
 tation of sharp-edged teeth. Occasionally aphthous inflammation. Diag- 
 nosis. — No induration, or at least no marked degree of it. Ulcers some- 
 times multiple. Tongue frequently red and glazed. Corresponding sharp 
 edge of tooth may be detected. Signs of indigestion. Pain frequently. 
 Absence of syphilitic history and of collateral symptoms. Treatment. — 
 File sharp teeth. Touch ulcer with silver nitrate. Purgatives. Sodse 
 bicarb., with infus. calumbse, before meals. The more superficial the ul- 
 ceration, the more likely is chlorate of potash to be highly useful. 
 
 Tongue, Superficial Syphtutic Ulceration of (Secondary or Tertiary). 
 — Diagnosis. — Similar ulcerations on sides of mouth or fauces. Perhaps 
 psoriasis also present. No such marked induration as is common in can- 
 cer. History and patient's aspect may be syphilitic. Treatment. — Anti- 
 syphilitic. Locally, gargarisma nigra, hydrarg. c. creta, inhaling calomel 
 fumes (5 grains nightly). Internally, either pot. iod. or hydrarg. perchlor. 
 For obstinate syphilitic ulcer of tongue, Berkeley Hill recommends a pill 
 of iodoform, gr. .}, ext. gentian, gr. 1£, three times a day. 
 
 Primary Ulcer (Chancre) of Tongue is not unknown. 
 
 Tongue, Simple Deep Ulceration of. — Very rare. Diagnose from cancer 
 and syphilis chiefly by negative signs, especially absence of induration. 
 Tends to heal, unless phagedenic. Treatment. — Vide Simple Superficial 
 Ulceration. 
 
 Tongue, Deep Syphilitic Ulcerations of (Tertiary). — Causes. — Gumma- 
 tous abscess or (rarely) spread of superficial ulcer. Appearance. — A deep 
 ulcer or fissure, with abrupt edges, usually toward the centre of the tongue, 
 sometimes at the edge, and often with a history of previous tumor or swell- 
 ing (gumma). Speaking of gummata of the tongue, Morrant Baker says : 
 " They are usually, but by no means always, multiple ; they rarely or 
 never lead to fixation of the tongue, or to salivation, or to very much pain ; 
 and they are very tolerant of pressure." In these respects they contrast 
 with cancer. Treatment. — Antisyphilitic, especially pot. iod. (gr. x., ter 
 .die). 
 
 Tongue, Malignant Ulceration of (Epithelioma). — Causes as obscure as 
 those of cancer elsewhere. Chronic irritation of sharp teeth doubtless an 
 
236 TONGUE, DISEASES OF. 
 
 occasional factor. Clay-pipes. Most frequent in males and in late middle 
 age. Commences as a fissure (rarely as a wart). Syphilitic disease said to 
 sometimes pass into epithelioma. Diagnosis. — Distinguish from syphilitic 
 ulceration by (1) hardness of base and edges ; (2) absence of collateral 
 signs of syphilis ; (3) position — cancer usually begins at side of tongue, 
 deep syphilitic ulcer generally lies near septum ; (4) pain is greater in 
 cancer ; (5) glands are affected earlier and more extensively, and eventu- 
 ally form a huge, hard mass in cancer ; (6) fixation of tongue from can- 
 cerous infiltration ; (7) salivation. Unfortunately, in the very cases in 
 which diagnosis is most difficult and most important, the above signs may 
 not be well marked. Hence the surgeon sometimes has to try antisyph- 
 ilitic remedies merely because he does not know whether he has to deal 
 with cancer or syphilis. Tenderness — intolerance of firm pressure distin- 
 guishes cancer, and the characteristic hardness is of the same nature as 
 that of scirrhus mammse, i.e., not like inflammatory induration. Progno- 
 sis. — Without operation, hopeless. With operation, varies from some 
 hope of non-recurrence when a small cancer and a wide margin of appar- 
 ently healthy tissue is excised, to the certainty of recurrence when the 
 conditions are reversed. Treatment. — If diagnosis be doubtful, try large 
 doses of pot. iod. (grs. x.-xx., ter die). Draw bad teeth. Forbid smok- 
 ing. Regulate diet. Question of removal depends upon extent of disease. 
 If removal of whole tongue wiil not suffice to take away all the disease, 
 treatment must be palliative. Removal by (1) knife, (2) ecraseur, (3) gal- 
 vanic cautery, (4) ligature, (5) Richardson's scissors. Prefer knife for 
 comparatively limited operations ; ecraseur most popular in extensive 
 ones. Remove disease of anterior part of tongue, and in suitable cases 
 even more extensive disease, by operating entirely through mouth. In 
 some instances the whole tongue could be thus removed if Sir James Pa- 
 get's advice be followed — to pass scissors into the mouth and divide the 
 muscles which attach the tongue to the jaw, before pulling forward the 
 tongue. In such an operation the galvanic ecraseur, very deliberately 
 used, would be safest, for severe hemorrhage would here be embarrassing. 
 Various plans have been devised for giving the operator more room to 
 work in, especially (1) Nunneley's, who passes the ecraseur chain through 
 a wound in the mylo-hyoid space, and prevents it from slipping forward 
 by means of hare-lip pins piercing the base of the tongue well behind the 
 disease. (2) Sedillot's, who divides the symphysis of the jaw (in a >- 
 shaped manner to facilitate correct apposition after the operation). Of 
 course the lower lip is divided also. Sedillot's incisions, combined with 
 the ecraseur, form the plan probably most frequently used for extensive 
 cases. An interdental splint might be useful in after-treatment of divided 
 jaw. (See Lyons : "St. Bartholomew's Hospital Reports," 1878.) (3) Sub- 
 mental operation (Regnoli's). Broad arrow-shaped incision in mylo-hyoid 
 space, through which tongue is dragged previous to removal Protect fa- 
 
TONGUE, DISEASES OF. 237 
 
 cial arteries, and secure Unguals as soon as divided. (4) T. Smith's. In- 
 cision of cheek from corner of mouth outward. (5) Whitehead, of Man- 
 chester, cuts through base of tongue from before backward slowly with 
 scissors, looking out for the lingual arteries. [Lancet, 1880.) In all 
 operations on the tongue, a stout whip-cord ligature through middle of an- 
 terior third, metal retractors, and a simple gag, are required. Also pre- 
 pare for hemorrhage. Use Clover's or Mills' method of anaesthesia through 
 a tube. {Lancet, voL i., 1879.) Prognosis. — Quite good for small opera- 
 tions. Grave for larger ones. Speech returns perfectly in former ; dis- 
 tinct, but sadly modified, in latter. After-treatment. — Feed through 
 oesophageal tube and by enemas for a few days. Use simple gargles to 
 cleanse mouth. For distressing salivation — alum and pyrethrum gargles. 
 A particularly lengthy, complete, and clear account of operations on tongue 
 is to be found in Erichsen. 
 
 Tongue, Abscess. — Very uncommon. Causes. — Obstruction of mucous 
 glands? Syphilitic gummata? Foreign body. Make an exploratory 
 puncture to clear up diagnosis. 
 
 Tongue, Innocent Tumors of. — Very rare. Cysts beneath the tongue 
 are common. {Vide Eanula.) 
 
 Tongue, N^vus of. — Rare. Treatment. — Like that of . naevus elsewhere. 
 But if it cause no unpleasant effects, and do not grow, let it alone. 
 
 Tongue, Gummata of. — Seldom seen before stage of ulceration. Vide 
 Deep Syphilitic Ulcer of Tongue (above) . 
 
 Tongue, Malignant Tumor of. — Vide Malignant Ulceration of Tongue 
 (above). 
 
 Tongue, Acute Inflammation of (Acute Glossitis). — Rare. Causes. — 
 Mercurial salivation, iodism, injury, unknown influences. Symptoms. — 
 Swelling, often enormous. Pain. Salivation. Danger of suffocation. 
 Treatment. — Treat cause. Astringent gargles. Deep, longitudinal, dorsal 
 incisions in severe cases. As lower surface of tongue is more extensile 
 than upper, the former tends to present upward. Bear this in mind while 
 incising (Wormald and Holmes Coote). Support strength. 
 
 Tongue, Congenital Enlargement of (Macroglossia). — Very rare. Treat- 
 ment. — Remove V-shaped piece from anterior part of tongue, and bring 
 flaps together. Use ecraseur. Remember that children bear hemorrhage 
 badly. Slight enlargement of tongue is a common sign of constitutional 
 disorder. Treat the cause. 
 
 Tongue, Psoriasis of. — Sometimes, but not always, syphilitic. "Whitish 
 and dry-looking patches on the tongue, with shallow fissures. Under the 
 microscope, the epithelial layer is found slightly thickened, but the papillae 
 smaller than normal. The condition should be compared and contrasted 
 with that in " chronic superficial glossitis " (Fairlie Clarke), in which, ac- 
 cording to Butlin, the papillae are absent, the surface almost as smooth to 
 the microscope as to the naked eye, the epidermis thinned, but the sub- 
 
23 S TONSILS, CHRONIC ENLARGEMENT OF. 
 
 epithelial tissue thickened and infiltrated with cells (" Medico- Chiruigical 
 Transactions," vol lxi.). 
 
 Tonsillitis, Acute (Quinsy). — Causes. — Predisposing are chronic 
 enlargement and depressing influences, e.g., dark, damp residences, defec- 
 tive drainage. Exciting cause, usually catching cold. Signs. — Pain on 
 swallowing, at first slight, but gradually increasing in some cases till the 
 act of deglutition inflicts a pain like the stab of a knife. Swelling both 
 internally and externally. The swelling may become so diffuse that the 
 jaws may be scarcely separable. When suppuration takes place, pain usu- 
 ally strikes into ear and becomes throbbing. Fluctuation develops. Foul 
 tongue (owing to oral catarrh) ; offensive breath ; fever — temperature may 
 rise to 104°— and slight delirium for one or two nights not infrequent. 
 Diagnosis. — Seldom presents difficulty, except when the mouth will not 
 open. Then, upon looking carefully at the patient, it will be seen that the 
 swelling, however diffuse, has its centre below and beneath the angle of the 
 jaw, is not chiefly in front of and below the ear as in mumps, or over the 
 jaw as in diffuse inflammation commencing near the gums and teeth. 
 Moreover, the voice is generally characteristically guttural, and the history 
 clear of an acute course commencing in the throat. It is to be remem- 
 bered that inflammation of the tonsils may be only part of a more serious 
 disease, e.g., scarlatina or diphtheria. Prognosis. — Tonsillitis usually affects 
 those accustomed to it, and who generally know how, by a little care, to 
 check it. But it frequently goes on to suppuration ; and in exceptional 
 cases, when very diffuse, causes death by exhaustion or by suffocation. 
 Treatment. — Prophylactic, the same as that for catarrhs in general. In ad- 
 dition, do not wear low shirts and collars, especially as regards the night- 
 dress. Wear a light wrapper round the throat when out at night ; avoid 
 hot, smothering comforters. Early retirement to bed, with a narrow piece 
 of flannel round neck, will often cut short a sore-throat. Gargling, some- 
 times good, is often more irritating than useful. Best gargles are those of 
 capsicum, of guaiacum, and of chlorate of potash. Give mist, guaiaci. or 
 pot. chlor. ad libitum, internally. When swelling is very great, especially 
 if fluctuation can be felt, puncture tonsil. Use a bistoury wrapped in lint, 
 except toward the point, or a gum-lancet, and direct its edge and point 
 somewhat inward {i.e., toward median plane of body and away from great 
 vessels). If mouth cannot be opened, patient must simply rest in bed, 
 with a high pillow, in a rather warm, thoroughly dry room, using deriva- 
 tives, such as hot mustard and water to feet, inhaling the steam of hot 
 water, with a little creosote dropped in it. Hot fomentations may be ap- 
 plied externally, or leeches beneath the angle of the jaw. Do not forget 
 that leech-bites leave scars. 
 
 Tonsils, Chronic Enlargement of. — Common in scrofulous chil- 
 dren, especially in cold, damp climates. Pathology. — An hypertrophy of 
 both glandular and fibro-cellular constituents of tonsil, the result of chronic 
 
INDICATIONS FOR. 239 
 
 inflammation. Signs. — Visible enlargement of tonsil. Peculiar throaty 
 voice. Occasionally difficulty of breathing. Mouth usually kept open ; char- 
 acteristic expression of face. Deafness. Extra liability to acute and sub- 
 acute tonsillitis. Prognosis. — Considerable enlargement, if coming on be- 
 fore puberty, will often greatly diminish as adult life is approached, but 
 it seldom disappears spontaneously and entirely. Treatment. — For severe 
 cases of long standing, excision. Other cases should be treated as pharyn- 
 gitis, quod vide. Excision of Tonsil may be effected with a bistoury and 
 vulsellum forceps. In using tonsil-guillotine, take care to apply it with 
 the spear or hooks toward the median line and the ring next the tonsil. 
 Pass the guillotine into the pharynx horizontally, and rotate it to the per- 
 pendicular as you place it over the tonsil. In many cases the tonsil can be 
 pushed into the guillotine by the forefinger of the left hand placed outside 
 the neck. 
 
 Torticollis.— See Neck (Wey-). 
 
 Trachea, Foreign Bodies in. — See Larynx, Foreign Bodies in. 
 
 Tracheotomy, Indications for. — 1. Foreign bodies in trachea or 
 bronchi or pharynx. 2. Scalds of glottis in children. 3. Very advanced 
 and extensive disease of larynx. 4. Croup. 5. Diphtheria in children. 
 6. As a preliminary step in extensive operations on and about the jaws and 
 throat. In such cases the anaesthetic is usually administered through a 
 tube in the tracheal opening. At the same time the glottis may be shut 
 off from the lungs by using Trendelenburg's " trachea- tampon," thus pre- 
 venting any blood from passing down the trachea. Operation. — Two chief 
 varieties, viz., (1) high and (2) low, respectively above and below isthmus 
 of thyroid ; latter not usually either necessary or desirable. Instruments. — 
 Scalpel, dissecting forceps, artery forceps, bull-dog forceps, metal retrac- 
 tors, blunt hook, sharp tracheotomy hook, cannulas (Fuller's bivalve pref- 
 erable at first ; Baker's rubber tubes may be substituted after a few days). 
 Lawson recommends the bivalve cannula without the inner tube. Dur- 
 ham's " lobster-tail " cannula less irritating than ordinary metal tube. H. 
 A. Martin, of Boston, U. S., does not use tubes at all. (See Dublin Medical 
 Journal, September, 1878.) Tape to tie cannula in place. Sponges, liga- 
 tures, gauze, feather, kettle, curtains, etc., the latter for after-treatment. 
 Patient lies on his back ; surgeon stands on right side. Pillow beneath 
 neck, head back. Get best light possible. Determine exact median line 
 by seeing and feeling. Feel lower border of cricoid cartilage. Incise skin 
 from this point downward two inches. Avoiding anterior jugulars, cut in 
 middle line carefully down to trachea. When thyroid isthmus is recog- 
 nized, it may, if necessary, be hooked down or even divided. When trachea 
 is reached, it can easily be distinctly felt. Now insert sharp hook into 
 trachea, always keeping to median line. Slightly raise trachea with this 
 hook. It thus becomes defined, and can be incised with confidence. 
 Tracheal opening to be perpendicular, and of size proportional to the pa- 
 
240 TUBERCLE. 
 
 tient's and to that of the cannula to be used. Always keep to the median 
 line, and take care that the parts are not displaced laterally by the retrac- 
 tors. In opening trachea, turn edge of knife upward. After-treatment. — 
 Usual practice is to surround bed with curtains, to conduct steam of a 
 kettle by a tube to within the curtains, and to keep the room at a tem- 
 perature of about 70° Fahr. But some surgeons (e.g., Lawson) are less 
 particular about these points, preferring abundance of fresh air. Over the 
 tracheal wound place a sponge or a fold of gauze. From time to time, 
 when the patient coughs, assist with a feather to clear away mucus or 
 false membrane. Twice a day, or oftener if necessary, remove inner tube 
 and clean it. Surgeon may occasionally remove and clean outer tube with 
 advantage. This must frequently be done if inner tube is not used. Sup- 
 port strength with abundant liquid food, milk, beef-tea, etc. Of course, 
 when cannula has to be kept in any time, it does not prevent return to 
 solid food. Insensitiveness of glottis generally supervenes, and allows 
 part of food to trickle into larynx. Complications. — (1) Hemorrhage, (2) 
 bronchitis and pneumonia, (3) erysipelas. 
 
 Trephining". — Indications for the operation are given under Head, In- 
 juries of. The operation is occasionally done for cases of epilepsy, in 
 which the surgeon thinks he recognizes signs of localized mischief. And 
 it is likely enough that the labors of Fender, Fritz, Hitzig, Duret, and 
 others, together with the development of antiseptic surgery, may lead to 
 further co-operation between the physician and the surgeon in the treat- 
 ment of cerebral diseases. Operation. — Scalpel, dissecting forceps, artery 
 forceps, trephine, elevator, piece of quill, sponges, antiseptic dressings, 
 spray, etc. Unless bone is already exposed by a scalp-wound, reflect soft 
 tissues sufficiently by Y-shaped incision. Adjust trephine so that the pin 
 shall project very slightly beyond the teeth. If there be a fracture, place 
 the pin on a firm edge of bone. In working trephine, take care to press 
 evenly on all sides, lest dura mater be reached on one side before other 
 side of trephine is half through. As dura mater is approached, saw very 
 gently, and frequently probe with the piece of quill. As soon as this de- 
 tects dura mater on one side, tilt trephine toward other side. When loose 
 enough, remove disc of bone with elevator. Dangers : (1) of wounding 
 dura mater : to be avoided by precautions mentioned above ; (2) of wound- 
 ing a sinus or large arterial branch : to be avoided partly by some precau- 
 tions, but chiefly by bearing in mind anatomical landmarks. 
 
 Trochanter, Injuries of. (Vide Fractures of Femur.) — Prolonged 
 weakness, and sometimes permanent atrophy, occasionally produced by 
 falls upon the great trochanter, even without fracture. 
 
 Tubercle. — A term applied to three substances, which are sometimes, 
 but not always, merely three forms of the same substance, viz., (1) " mil- 
 iary tubercles " — small, round, transparent or semi-transparent millet-seed- 
 like nodules, the most usual seats of which are the substance of the lungs 
 
TUMOES. 241 
 
 and the surface of serous membranes ; (2) " cheesy " or " crude " tubercle 
 — dry, opaque, cheesy masses, tending either to soften into purulent, curdy, 
 creamy fluid, or to change to (3) a cretaceous mass. Forms 2 and 3 
 may be results of the metamorphosis of form 1. But they may also be 
 due merely to changes in ordinary inflammatory products. I say " ordi- 
 nary," because it is believed by many that even tubercle is sometimes a 
 product of inflammation. That the presence in the system of cheesy 
 masses, the result of inflammation, predisposes in some way to the forma- 
 tion of miliary tubercle, is pretty generally allowed. (See Scrofula for 
 treatment, etc.) 
 
 Tumors. — Definition. — Word "tumor" not always used in same sense. 
 
 (1) Surgeons sometimes use it loosely, as if synonymous with "swelling of 
 undetermined nature," as, e.g., in such a speech as this, " Examine this tu- 
 mor and tell me whether you think it is an aneurism or a new growth." 
 
 (2) The usual meaning of " tumor " is an abnormal swelling in the tissues, 
 which cannot be clearly regarded as mere inflammatory new formation, or 
 as aneurismal dilatation of a single vessel. The margins of this definition 
 are necessarily uncertain., because the limits of the process of inflammation 
 are not quite known. Causes. — There can be no question but that tumors 
 do frequently arise from continued local irritation, but to what extent he- 
 reditary predisposition acts as a predisponent is not yet settled. The very 
 common idea that cancerous tumors are almost as hereditary as Roman 
 noses is certainly wrong. That heredity plays no part in their production 
 is equally incredible. Why, it plays an unquestionable part in the produc- 
 tion of wooden legs, because the martial spirit which has exposed his in- 
 ferior members to shot and shell is often " bequeathed from bleeding sire to 
 son." It would appear from the clinical observations of Sir James Paget, 
 confirmed by the microscopic ones of Mr. Butlin, that the processes of in- 
 flammatory new formation, of ordinary cellular infiltration, may pass, by a 
 gradual commingling, into the process of cancerous infiltration with new 
 cells genetically sprung from epithelium. Often also cancer is seen to at- 
 tack localities which have long been the seat of syphilitic, of eczematous, 
 or of some other chronic fissure or ulceration. It is possible that new 
 growths may arise from irritation in a quite distant part. They can be re- 
 moved in that way. I have seen a recurrent tumor' over the scapula, which 
 had shrunk gradually to one-eighth its former size during the progress of 
 phthisis and fistula in ano. Such new growths as elephantiasis and bron- 
 chocele proceed from endemic, perhaps miasmatic influences. It is not 
 impossible that malignant tumors are contagious, though there are no clin- 
 ical proofs of it. Considering how slow most cancers are to infect the suf- 
 ferer's own system (since early removal often effects a perfect cure), the 
 absence of such proofs is not surprising. Certain localities and certain 
 ages are specially subject to certain tumors : e.g., lower lip of middle-aged 
 to epithelioma. Sex generally acts in a manner easily explained. For ex- 
 
 16 
 
242 TUMORS. 
 
 ample, it is not difficult to see why men alone should have epithelioma 
 scroti, women alone fibroid of the uterus, and women almost the monopoly 
 of tumors of the breast. Classification. — Fatty tumor ; fibrous tumor ; car- 
 tilaginous tumor ; osseous tumor ; myoma ; neuroma ; vascular tumors ; 
 sarcoma ; lymphoma, including glioma ; recurrent fibroid ; fibro-cellular 
 tumor ; myxoma, etc. ; papilloma ; adenoma ; cystic tumors ; carcinoma. * 
 The carcinomata, with most sarcomata and certain lymphomata, are often 
 classed together as malignant, the rest being termed innocent. Malignancy 
 means simply endowed with a tendency to infect the system. In diagnos- 
 ing a tumor, the most important question to answer is that of innocent or 
 malignant ? In some cases this is the only practical question. 
 
 Fatty Tumors, Lipomata. — Two varieties, viz. : 1, Circumscribed ; 2, 
 Continuous. The common fatty tumor belongs to the former variety. 
 Best example of continuous lipoma is excessive double chin. Cause. — 
 Usually unknown. Sometimes follows local irritation. Barely appears in 
 children or very old people. Continuous lipoma generally begins about 
 age of forty. Female sex most liable. Anatomy. — Common fatty tissue 
 surrounded by a fibrous capsule and divided into lobes by fibrous parti- 
 tions. Sometimes outlying lobes project into the adjacent parts. Fibres 
 connect the capsule with the skin and cause the latter to dimple. Signs. — 
 Lipomata are soft, elastic, "pillowy," movable, but causing the skin to 
 dimple as they move. Normally without pain or tenderness, except a lit- 
 tle aching from mere weight, and, in a few cases, a little pain, apparently 
 neuralgic. Almost always single. Occasionally multiple. Bulk ud lim- 
 ited, even up to 50 lbs. avoirdupois. Multiple fatty tumors rarely grow 
 to more than one inch in diameter. Growth slow. Their loose con- 
 nections often permit fatty tumors to shift their positions under the 
 influence of gravity. They are liable to cystic, cretaceous, and ulcerative 
 degenerations. Seat. — Chiefly trunk and adjacent parts of limbs. Diagnosis. 
 — When there is no cutaneous dimpling and they are unusually firm, they 
 may be mistaken for cysts, or for fibrous or sarcomatous tumors, but the 
 mistake is of no consequence. Treatment. — Let the continuous lipoma 
 alone, unless restricted diet and judicious exercise will benefit it. Or give 
 liq. potass., TTj, x., ter die, for a long time. Other single fatty tumors 
 should be excised. Cut straight down upon the tumor, or into it if you 
 like, and then dissect or tear it away from its connections. In dressing 
 the wound, attend to drainage and proper adjustment of pressure and 
 support. Multiple fatty tumors should be let alone as a rule. Lipomata 
 are occasionally pendulous : these should simply be cut off. 
 
 Fibrous Tumors. Fibromata. — Anatomy. — Fibrous tissue variously ar- 
 ranged, sometimes in interlacing bundles, sometimes in concentric circles. 
 Arrangement of fibres may or may hot be visible to the naked eye. Section 
 
 1 Paget adds : Neuralgic, Pulsating, Floating, and Phantom. 
 
TUMORS. 243 
 
 whitish or pale red in color. Consistence generally firm and elastic, 
 sometimes quite soft. Mucous softening, serous infiltration, calcification, 
 even true ossification not rare. Large cysts may form. Sarcomatous tissue 
 (round or spindle cells) frequently mixed with the fibres — "fibro-sarco- 
 mata." Vascularity usually low. Seats. — Usually uterus, bones, nerves, 
 cellular tissue near joints, sheaths of tendons, testicles, and ear-lobules. 
 Characters. — Rounded or modelled to surrounding parts, smooth, non- 
 lobed, firm, resistant, elastic, generally hard, occasionally soft. Of course 
 degeneration alters their physical properties. Growth slow. Size unlimited. 
 Pain absent. Commence in middle life. Those connected with nerves or 
 bones sometimes commence in the young (after puberty). Number : 
 periosteal fibromata usually solitary ; but uterine and neuromatous fibroids, 
 especially the latter, are more often multiple. Diagnosis. — "Consistence, 
 locality, age, mode of attachment and form of the tumor almost always 
 lead to its correct recognition." Treatment. — Remove thoroughly. Uterine 
 fibroids require special consideration, and are neither to be rashly inter- 
 fered with nor supinely let alone. Recurrence. — Pure fibroma probably 
 only recurs when excision has been incomplete. But fibro-sarcomata may 
 infect the system. 
 
 Cartilaginous Tumor — Enchondroma. — Anatomy. — Resembles some- 
 times hyaline and sometimes fibro -cartilage. But pathological differs from 
 normal cartilage in three respects, viz., (1) it is traversed by "capsular-like" 
 communicating connective-tissue meshes ; (2) these meshes are usually 
 vascular, while normal cartilage has no vessels ; (3) the intercellular sub- 
 stance may be gelatinous or friable. The section cuts gristly and is bluish 
 or yellowish white, or the tumor may be softened or degenerated. Locality. 
 — Chiefly the bones : metacarpals and phalanges of hand ; femur, pelvis, 
 etc.; parotids, testicles, ovaries, breasts, other glands. Frequently mixed 
 with other tumors. Age. — Youth. "The younger the age at which a tu- 
 mor of bone begins, the more it is likely to be cartilaginous, if its general 
 characters agree therewith " (Paget). Characters. — Hard, nodular, incom- 
 pressible, or perhaps very slightly compressible, with a very quick elastic 
 recoil. Rarely soft, but even then very elastic. Rate of growth not charac- 
 teristic. Size variable. Coincident ossification often occurs and alters char- 
 acter of tumor. Diagnosis. — Consider carefully locality, age, and rate of 
 growth. Prognosis. — Purely cartilaginous tumors are as innocent and non- 
 recurrent as any class of tumors. Treatment. — See Enchondroma of Bones^ 
 or Parotid Gland, and of Testicle. 
 
 Osseous Tumors ; Osteomata. — See Exostoses. 
 
 Myoma. — A tumor consisting of muscle-cells or fibres. Pure myomata 
 are unknown ; but muscular elements, both striped and unstriped, occa- 
 sionally are found in fibromata. 
 
 Neuroma. — The surgeon often applies this term to any tumor situated 
 on a nerve ; the strict pathologist confines it to a tumor consisting mainly 
 
244 TUMORS. 
 
 of nerve-filaments or substance. The latter, so-called " true neuromata," 
 are very rare, most tumors growing on nerves being fibromata, or fibro- 
 sarcomata. Usually multiple, often recurrent. Excision without injury 
 to nerve itself rarely possible. As a rule best let alone. A traumatic neu* 
 roma is the bulbous end of a divided nerve. When painful, excise. 
 
 Vascular Tumors — Angiomata — NiEvi — Erectile Tumors. — Definition. — 
 Tumors composed almost exclusively of vessels held together by a slighl 
 amount of connective tissue. Varieties. — Three : (1) capillary, including 
 common nsevi and "port-wine stains;" (2) venous, or cavernous angio- 
 mata ; (3) arterial, or pulsating, erectile tumors ; with which may bt 
 placed " aneurism by anastomosis." Etiology. — Many are congenital (es- 
 pecially the first kind). The others usually commence in early childhood^ 
 excepting aneurism by anastomosis, which often develops in young people, 
 after injuries. Anatomy. — (1) Capillary angioma consists of a mass of di- 
 lated capillaries, arranged in lobuli, each of which corresponds to the 
 blood-supply of a single hair or cutaneous gland. The whole mass is of 
 any size from a pin's head to a sixpence or a penny, or a much larger space, 
 and of varying though usually trifling thickness. Color from deep red 
 to slaty blue. But sometimes the skin itself is not involved, and it then 
 may be of normal color. Kedness disappears under pressure, so also does 
 part of thickness of tumor when there is any perceptible thickness. Cap- 
 sule, more or less denned. (2) Cavernous angioma consists of an assem- 
 blage of spaces filled with blood and resembling dilated veins, or, more 
 accurately, the corpus cavernosum penis. In some of the spaces, chalky 
 * vein stones " may be found. (3) Aneurism by anastomosis, or cirsoid 
 aneurism, is a convolution of dilated and elongated arteries. Signs. — 
 Port-wine stains and ordinary nsevi are easily recognized by their color, 
 and their congenital or early origin. All purely vascular tumors are more 
 or less. soft and compressible. The venous ones dilate during forced ex- 
 piration. The arterial pulsate. Seats. — Mostly subcutaneous tissue of 
 scalp, face, and trunk. Venous tumors not unfrequently occur more 
 deeply, especially in orbit, tongue, inter-muscular spaces, and even in the 
 liver. Degeneration, especially cystic, may occur. Number of nsevi in an 
 infant often multiple. Diagnosis. — Barely presents any difficulty except in 
 the deeper venous and capillary tumors. These may be confounded with 
 lipomata or cysts ; but the possibility of partially or wholly emptying them, 
 and the effect on them of forcible expiration, will often settle the question. 
 Prognosis. — If let alone, they will occasionally progress till they cause de- 
 formity, weakness, and the absorption even of important parts. But they 
 frequently remain stationary, or may even retrograde. Treatment. — 1. By 
 injection of tinct. ferri perchlor.; dangerous, especially in nsevi of head and 
 neck. 2. By galvano-caustic, benzoline cautery, bulbous nagvus cautery, 
 small sticks of lunar caustic driven into tumor. 3. By nitric acid (best for 
 small and superficial nsevi). 4. By ligature: various modes, subcutaneous 
 
TUMOES. 245 
 
 and otherwise. 5. By compression. 6. By excision. Before excision, the 
 base of the nasvus may be surrounded by an elastic ligature, which should 
 be tightened after pressing the blood out. 1 Thus the operation is rendered 
 bloodless. Naevi, being encapsuled, may be excised exactly like any solid 
 tumor. Balmanno Squire treats port- wine stain by systematic scratchings 
 and cross-scratchings with a hot cautery-needle. Excision is probably the 
 best treatment for aneurism by anastomosis. 
 
 Sarcomata. — This most interesting group of tumors, whose association 
 and nomenclature are mainly due to Virchow, includes the fibrocellular, 
 the mucous tumor, and the myeloid tumor of English practical surgery ; and 
 the group, on the whole, nearly corresponds to Paget's recurrent fibroid. 
 Therapeutic study and pathological study of these tumors have been, un- 
 fortunately, very independent of one another ; consequently, the varieties 
 of sarcoma have two quite different nomenclatures, one clinical and some- 
 what old-fashioned, the other scientific and chiefly German. The student 
 has no right to resent this, unless he thinks that science and art should 
 always be manacled together, and one never suffered to advance without 
 the other. First, let us notice chief points in the anatomy of sarcomata, 
 and in doing so, employ a strict pathological classification (after Billroth), 
 viz., into (1) granulation sarcoma ; (2) spindle-celled sarcoma ; (3) giant- 
 celled sarcoma ; (4) stellate sarcoma ; (5) alveolar sarcoma ; (6) pigmented 
 sarcoma. 
 
 Granulation Sarcoma, Round-celled Sarcoma (including Glioma), consists 
 of corpuscles like those of lymph. Intercellular substance is homogeneous, 
 striated, or reticulate, varying widely in amount. 
 
 Spindle-celled Sarcoma. — Cells acutely spindle-shaped. Intercellular 
 absent or scanty, homogeneous or fibrous. Most recurrent sarcomata 
 contain this tissue ; but every spindle-celled sarcoma does not recur. 
 
 Giant-celled Sarcoma — Myeloid Tumor. — In addition to the structural 
 elements of one of the other varieties of sarcoma, these tumors contain 
 large cells with many nuclei, and often with many offshoots. 
 
 Net-celled Sarcoma — Mucous Sarcoma. — This is not exactly the same thing 
 as myxoma. Myxomata are sarcomata of various kinds, but agreeing 
 in having a gelatinous appearance. Net-celled sarcoma contain stellate 
 cells with long processes and gelatinous intercellular substance. 
 
 Alveolar Sarcoma-— -Very rare ; great resemblance to carcinoma, but the 
 cells are not so easily detached from the meshwork in which they lie. 
 The cells are large, and usually lie each in a space to itself, " imbedded in 
 a fibrous, or more rarely homogeneous, slightly developed intercellular 
 substance of exquisite areolar type " (Billroth). 
 
 Pigmentary Sarcoma — Melanotic Sarcoma — Melanoma. — Pigment may oc- 
 cur in any variety of sarcoma. The pigment almost always lies in the 
 
 1 W. H. Brown of Leeds. 
 
246 TUMORS. 
 
 cells. All the cells mentioned above as occurring in the different varieties 
 of sarcoma are related genetically to corpuscles of the connective tissues 
 (areolar tissue, bone, etc.). Consequently, the cells of a sarcoma are 
 united by processes to the intercellular substance. In these two peculiari- 
 ties, sarcoma is distinguished from carcinoma, the cells of which lie free in 
 the alveoli of the cancer, and are genetically related, not to connective 
 tissue, but to epithelial cells. 
 
 Naked-eye Appearances of Sarcomata. — These do not correspond very 
 exactly to varieties in the kind of cell found under the microscope. In 
 fact, several forms, e.g., spindle-cell, round-cell, and giant-cell, are often 
 found in the same tumor. Some sarcomata and fibrosarcomata are firm 
 and tense, more or less lobed. On section, they are seen to be intersected 
 with white fibrous bands ; and, from the pale yellowish color of the 
 section, an inexperienced observer might readily suppose them to be 
 chiefly fat. They are very succulent and juicy when freshly cut. These 
 are the fibrocellular tumors. 1 Other sarcomata, especially the "net-celled," 
 are of loose, gelatinous appearance, even so much so as to trickle away on 
 section, like the vitreous humor of the eye. These are the myxomata. 
 Others resemble lean " flesh," and, on section, are seen to be blotched with 
 red, though in the main gray, or yellow and shining. Such often contain 
 giant-cells. Finally, tumors which will recur, or have already recurred, 
 are very often soft, and, with each recurrence, tend to get more and more 
 encephaloid or more and more gelatinous. Sarcomata are liable to cystic, 
 calcareous, osseous, and mucous degenerations. 
 
 Symptoms of Sarcomata. — Distinct, encapsulated ' tumors. Usually 
 rounded and smooth, often lobulated. Consistence varies from great 
 firmness to the softness of jelly. When connected with bone, they fre- 
 quently ossify. Cicatricial shrinkage very rare (this contrasts with carci- 
 noma). Partial mucous softening and cystic degeneration frequently 
 modify the consistence of a sarcoma. Ulceration occurs early in the course 
 of superficial sarcomata, but is not usually very destructive. The tumor 
 may then fungate. 
 
 The chief points for the diagnosis of sarcoma are thus concisely given by 
 Billroth : "Sarcomata develop with peculiar frequency after precedent local 
 irritations, especially after injuries. Cicatrices, also, are not unfrequently 
 the seat of these tumors*; black sarcomata may come from irritated moles. 
 Skin, muscles, nerves, bone, periosteum, and, more rarely, glands (among 
 these the mamma most frequently), are the seats of these tumors. Sarco- 
 mata are rarest in children, rare between ten and twenty years, most fre- 
 quent in middle life, and rarer again in old age. According to my obser- 
 vation, men and women are affected with equal frequency. If these 
 tumors be not located in or on nerve-trunks, they are usually painless till 
 
 1 See p. 247. 
 
TUMORS. 247 
 
 they break out. If the sarcoma be in the subcutaneous cellular tissue or 
 in the breast, it may be felt as an encapsulated movable tumor. The 
 growth is sometimes rapid, sometimes slow ; the consistence varies, so that 
 it can scarcely be used as a point in diagnosis." 
 
 Topography of Sarcoma. — Glioma is connected with the neuroglia of one 
 or other of the nervous parts. It occurs in the eyeball, or attached to one 
 of the cerebral nerves, and is peculiarly a disease of childhood. Myeloid 
 tumors occur in medullary cavity of long bones, but more frequently in 
 lower jaw. When commencing inside a bone, they dilate it to a mere shell 
 at the part affected. In those of the lower extremity, an aneurismal mur- 
 mur may often be heard. Intraosseous sarcomata contain giant-cells, and 
 are almost always solitary and innocent. But sarcomata which grow from 
 periosteum are malignant, and generally more or less ossified : sometimes 
 they are myxomata. Those sarcomata which originate in muscular inter- 
 spaces, in fasciae and in the skin, are almost always spindle-celled and re- 
 current, but (at all events, in the first place) not infectious. The typical 
 recurrent fibroid is to be found among these. 
 
 In glands, a mixture of adenoma and sarcoma is more common than 
 pure sarcoma. Cysts often form, and into these sarcomatous tissue may 
 grow (proliferous cysts). Thus are formed serocystic sarcomata. Of the 
 glands, the female breast and the salivary glands are most liable to sarco- 
 mata. 
 
 Fibrocellular Tumors are sometimes myxosarcomata and sometimes 
 merely fibromata of an unusually soft and cedematous nature. Or they 
 may be a combination of both. 
 
 Course and Prognosis of Sarcomata. — Some (e.g., most myeloid tumors) 
 are solitary, perfectly innocent ; recurrence, when it takes place, being 
 probably due to imperfect removal. Others are not less infectious and 
 malignant than encephaloid carcinoma. 1. Those which grow rapidly are 
 soft, and the softer the tumor the worse the prognosis. 2. The more sim- 
 ple and less differentiated the character of the microscopic elements of a 
 sarcoma, the more dangerous it is. Recurrent fibroids, with each recur- 
 rence, are apt to become softer in consistence and more " embryonic " in 
 microscopic structure. It is strikingly characteristic of sarcoma that it in- 
 fects the system through the blood-vessels and not through the lymphatics 
 (except in some rare cases quite late in the course of the sarcoma). Con- 
 trast this with carcinoma. Different sarcomata present every intermedi- 
 ate grade of infectiousness. Interval between recurrence very variable. 
 Death eventually occurs, in malignant cases, either from the disease re- 
 curring in a part where operation is impossible, or from infection (often 
 embolic) of internal organs. Number of secondary sarcomata unlimited. 
 Their favorite internal sites are peritoneum, pleura, and lungs. 
 
 Treatment. — Depends to a certain extent on locality ; but, as a general 
 rule, prompt excision is indicated. In the case of mammary, subcutaneous, 
 
248 TUMORS. 
 
 intramuscular, and osteal or periosteal sarcoma, there need be no hesita- 
 tion ; but adenosarcomata of the salivary glands in elderly people are 
 prone to extremely quick recurrence. Excision must be thorough, and in- 
 clude every offset. Caution. — Small sarcomata are occasionally overlooked 
 when lying near larger ones. Esmarch claims for pot. iod. in large doses 
 a curative power over recurrent fibroid. 
 
 Lymphoma. — (1) Idiopathic disease of the lymphatic glands, or (2) a 
 tumor resembling a mass of lymphatic cells with a stroma of adenoid tissue 
 but not situated in the site of any normal lymphatic gland. As, micro- 
 scopically, almost all affections of lymphatic glands are indistinguishable, 
 and as so-called " lymphomata " present every grade, from innocency up to 
 intense malignancy, it is obvious that milder cases cannot be separated 
 from mere secondary glandular inflammations or from scrofula. Indeed 
 lymphomata, as a class, have been termed "scrofulous sarcoma." But 
 surgeons are generally agreed in setting apart from other glandular dis- 
 eases, cases like the following : (1) One or more glands, in the neck usually, 
 enlarge and resist treatment. Obstinate anaemia comes on. Suffocation 
 by mechanical pressure may cause death ; or the progressive anaemia — 
 frequently with leucocythemia — proves fatal. Occasionally the disease is 
 arrested by antiscrofulous treatment or even spontaneously. Various glands 
 in other parts of the body often enlarge also. (2) Glands enlarge quickly 
 to soft "medullary tumors," the lymph-corpuscles simultaneously infiltrat- 
 ing the neighboring tissues. Anaemia and marasmus come on and advance 
 rapidly to a fatal result. Excision is followed by recurrence. Systemic 
 infection may take place. Prognosis is almost hopeless. Anatomy of 
 lymphoma. — All the cellular elements of the gland are multiplied and en- 
 larged; "the structure of the gland is gradually lost entirely ; the whole 
 organ becomes a mass of lymph-cells, although a fine network is generally 
 preserved." "The blood-vessels are preserved and their walls greatly 
 thickened." Treatment.— At first try antistrumous remedies, cod-liver oil, 
 iron, etc. Iodine injections, electrolysis, and compression appear to suc- 
 ceed occasionally, but rarely. Excision may be performed when the glands 
 are distinct and are causing local trouble. Billroth treats malignant 
 lymphoma successfully with arsenic — liquor arsenicali, tinct. ferri, aa T\[. v., 
 bis die. Increase by one drop every second or third day till symptoms of 
 poisoning appeal*. Then diminish by one drop every second day. See 
 Allgemeine medicinische Central-Zeitung, May 16, 1877. 
 
 Papillomata. — Include warts and horny excrescences. Papillomata are 
 formed of hypertrophied cutaneous papillae, covered by hypertrophied 
 epidermis. Warts usually show each papilla, with its thickened epidermal 
 covering, distinct to the naked eye. The ordinary wart is too well known 
 to need description, but there is a disease described by Mr. Erasmus 
 Wilson as verruca confluens, in which a considerable area of skin becomes 
 the seat of a warty growth. Syphilitic and gonorrhoea! condylomata are 
 
TUMORS. 249 
 
 more like hypertrophied granulation tissue than like true papillomata. 
 Causes. — Unknown. Much more common before than after puberty. Ir- 
 ritating fluids, such as the hands of the post-mortem clerk are exposed to, 
 often cause a warty state of the skin. Treatment. — Shave off the non-vascu- 
 lar summit and apply some caustic. Nitrate of silver, strong nitric acid, 
 glacial acetic acid, acid nitrate of mercury. Milder applications may suf- 
 fice, e.g., strong tinct. ferri perchlor. For gonorrhoea! warts, try powdered 
 sulphate of copper, and for syphilitic, calomel, with oxide of zinc. Dr. 
 Verco has observed a severe crop of common warts disappear rapidly du- 
 ring a sea-voyage. Horny excrescences in man are epidermal in structure 
 with a papillomatous base. Treatment. — Shave off and thoroughly cauterize 
 base or excise base. Some radical operation quite necessary, or they grow 
 again, and may become starting-point of epithelioma. 
 
 Adenomata. — Partial Glandular Hypertrophy. — Tumors containing some 
 proportion of glandular structure. This is usually mixed with some other 
 tissue, and the relative proportions vary much. Thus are produced adeno- 
 fibroma, adenosarcoma, etc. Microscopically, they are characterized by the 
 presence of tissue resembling tubular, and sometimes racemose glands. 
 By great dilatation of the tubules, cysts may be formed. In shape the tu- 
 mors are usually round or oval, and lobed ; but their other physical char- 
 acteristics depend greatly upon the kind of tissue which accompanies the 
 adenomatous — e.g., an adenomyxoma would be very soft, an adenochon- 
 droma usually very hard. Any innocent, smooth, round, lobed, and elas- 
 tic tumor situated in the breast, or in the parotid, is very likely to be, at 
 all events partially, adenomatous. Billroth says that he considers true 
 adenoma of the breast to be very rare, the glandular tissue found in mam- 
 mary sarcomata being merely part of the original acini of the organ. 
 Nasal, uterine, and rectal polypi are often partial adenomata ; solid or 
 semi-solid bronchoceles are adenomata. Treatment. — Pedunculated adeno- 
 mata can be removed by polypus-forceps, by ligature, by ecraseur, or by 
 scissors, or by combinations of ligature and scissors. See Polypus of Nose, 
 of Kectum, and of Ear. For treatment of thyroid and mammary adeno- 
 mata, see Bronchocele and Breast respectively. It may be shortly stated 
 that excision is the usual treatment, but that no tumors are so frequently 
 cured spontaneously, or without operation, as adenomata. 
 
 Cystic Tumors — Cystomata — Cysts. — Definition. — " A tumor formed by a 
 sac filled with fluid or pulp." Varieties. — The names of cysts have been 
 given on principles nearly as various as those on which human beings 
 have been named. Thus we have : I (1) Simple and (2) compound cysts. 
 K (1) Extravasation ; (2) exudation ; and (3) retention cysts. III. (1) 
 Serous ; (2) synovial ; (3) mucous ; (4) blood ; (5) sebaceous ; (6) pro- 
 liferous cysts. IV. Congenital cysts. The four classifications being based 
 respectively on number, on mode of origin, on contents, and on period of 
 origin. (Proliferous cysts are those which contain growths within them. 
 
250 TUMORS. 
 
 They are practically identical with " compound cysts." All other cysts are 
 " simple.") Causes. — Extravasation cysts are due to extravasation of blood. 
 They are usually traumatic. See Hematoma. Exudation cysts, at least 
 such as are ordinarily regarded as tumors, are of unknown origin, except 
 such as arise from local irritation. Ketention cysts are due to obstruction 
 of the orifice of some gland causing dilatation behind it. It ought to be 
 noted that the class exudation cysts is by Virchow considered to include 
 such serous dropsies as hydrocele, ganglion, and hydrarthrosis ; while 
 "retention cysts" include even dropsy of the gall-bladder, dilatation of 
 the Fallopian tubes, and so on. We shall now consider the anatomy, diag- 
 nosis, prognosis, and treatment of each variety of cyst separately. 
 
 Seeous Cysts. — Seats. — Most commonly in or near glands, kidneys, thy- 
 roid, breast, sublingual, etc. When in the neck they are called "hydro- 
 cele of neck." They may occur almost anywhere and in any tissue. Con- 
 tents. — Fluid usually thin, but sometimes honey-like, usually yellow and 
 clear, but may be dark even to blackness. Walls of connective tissue lined 
 with tesselated epithelium. Number, various. Growth is usually slow. 
 Diagnosis. — Not difficult when the fluid is thin and the cyst not tensely 
 filled ; but a very tense cyst may be mistaken for a solid growth. The 
 practised touch usually suffices to distinguish the fluctuation of a cyst 
 from the elasticity of an adenoma, a fibrocellular, or other soft solid 
 tumor. The latter are more likely to be lobed, and possess various special 
 characters described above. Abscesses may be recognized by the history, 
 and by considering locality, age, pain, etc. It is not often very important to 
 make a diagnosis before puncturing. Treatment. — Puncture with trochar 
 and canula, followed by pressure. Iodine injections. See Bkonchocele. 
 Drainage : in large cysts, antiseptic precautions to be taken. Cauterizing 
 interior. Free incision. Excision. Multiple cyst may require excision 
 of a whole affected gland. When the cyst is not complicated with some 
 recurrent, solid growth, and when operations on it are performed with due 
 care, prognosis is most favorable. 
 
 Mucous Cysts. — Type, ranula, q. v. 
 
 Blood-Cysts — Sanguineous Cysts. — Are either serous cysts into which 
 hemorrhage has occurred, or else hsematomata. Treat on the same prin- 
 ciples as serous cysts, and haematocele of the tunica vaginalis. Blood- 
 cysts frequently occur in malignant tumors, in which they are, of course, 
 of quite secondary importance. 
 
 Cutaneous Cysts. — Under this head may be considered sebaceous con- 
 genital cutaneous cysts. 
 
 Sebaceous Cysts are of two kinds, one of which shows the punctiform 
 vestige of the orifice of the follicle by whose obstruction the cyst has been 
 produced, whilst the other does not. The vestige above mentioned is a 
 dark point which can usually be found. Locality. —Anywhere, but espe- 
 cially head and face. Walls usually soft connective tissue. Contents. — 
 
TUMOBS. 251 
 
 White, pulpy epidermal matter, mixed with crystals of cholesterine, often 
 offensively smelling. Color occasionally brownish, and consistence some- 
 times very soft. Shape round, smooth, often changeable by pressure. 
 Growth slow. Age of first appearance, before middle age ; but the sur- 
 geon is not usually consulted about them at first. They have to be diag- 
 nosed from chronic abscess and other soft innocent tumors. Note the 
 characters mentioned above. Locality, history, absence of elasticity, and 
 presence of the black point are important. 
 
 Congenital Cutaneous Cysts. — Locality. — In or near orbit, often deep- 
 seated. May extend through aperture in bone, even into cranial cavity. 
 Walls very thin. Contents usually turbid, oily fluid. Size small (half an 
 inch). Diagnosis. — From nasvus, lipoma, and from serous cyst. Congenital 
 cutaneous (dermoid) cysts occur also in other parts of face and neck, but al- 
 ways in the lines of the branchial clefts. Hence their possible origin from 
 the accidental enclosure of dermal tissue when these clefts closed (Verneuil. 
 See Wagstaffe, "Pathological Transactions," 1879). Congenital dermoid 
 cysts of the head sometimes perforate the cranium, and then may be con- 
 founded with meningocele or encephalocele. This is not so serious a mis- 
 take as the converse. See Meningocele. Treatment of the Cutaneous Cyst. — 
 1. Dilate the black punctiform opening with a probe, and squeeze out 
 contents. Kepeatedly squeeze out if they reform till the sac has time to 
 obliterate itself. 2. Cauterize (to the size of a sixpence) with potash or 
 strong nitric acid. Afterward pull cyst out through the opening. 3. In- 
 cise skin over tumor, seize with forceps, and dissect out. Operation easy 
 unless inflammation has taken place. 
 
 Compound Cysts — Proliferous Cysts. — Definition. — Cystic tumors con- 
 taining growths. When these growths are themselves cystic, the tumor is 
 called a cystigerous cyst. But the growths are usually solid. Excellent ex- 
 amples of cystigerous cysts are furnished by many ovarian tumors. 
 
 Note. — Many cysts clustered together do not in themselves constitute 
 a compound, but a multiple cystic tumor. 
 
 Anatomy of Proliferous Cysts. — The solid intra-cystic growths appear 
 to grow from one point in the wall of the containing cyst. They gradually 
 fill up the containing cyst, displacing the fluid which previously occupied 
 it. Sometimes cysts and their contents cohere altogether, so that only the 
 appearance of a section indicates that the tumor has ever been cystic at all. 
 The nature of the intra-cystic growth is usually sarcomatous or adenosar- 
 comatous. Their physical characters are as various as possible, flat or ar- 
 borescent, soft or hard, pale or dark red. And they may be themselves 
 cystigerous. Diagnosis. — Locality almost always some gland — breast, 
 thyroid, etc. Their general characters resemble so closely those of ade- 
 noma and fibrocellular tumor, that unless palpation discovers evidence of 
 fluid in some parts, and of solid in others, diagnosis will probably be im- 
 possible. Skin quite healthy unless the tumor fungates. Age — most com- 
 
252 ULCERATION. 
 
 monly between thirty and forty. The chief -practical indication is to dis- 
 tinguish them from cancer. This is done on the general principles by 
 which other innocent tumors are thus distinguished. Prognosis. — Usually 
 favorable. Prospect of recurrence if the whole tumor be not removed, or 
 if the solid part of the tumor be soft and sarcomatous. Treatment. — 
 Thorough excision. 
 
 Carcinomatous Tumors. — See Cancer. 
 
 Ulceration. — One of the " terminations " of inflammation. The de- 
 struction of a part by gradual molecular disintegration, distinguished from 
 gangrene by the fact that in the latter process the dead particles cohere 
 together after their death, and from masses visible to the naked eye, 
 whereas in ulceration the disintegrated tissue falls away in granules or 
 pieces of microscopic size, or else is absolutely liquefied. The liquid in 
 which the particles flow away is called " discharge " or " ichor," and varies 
 with the character of the ulceration. Chief Varieties of Discharge. — 1. Thin 
 and serous, containing granules, debris, and sometimes a little diffused 
 blood (sanguinolent), or a little pus (purulent). 2. Foul, quickly decom- 
 posing, sometimes containing shreds of gangrenous tissue. 3. Laudable 
 pus, which consists almost entirely of serum crowded with pus -corpuscles, 
 which are leucocytes escaped from the blood-vessels. Its creamy appear- 
 ance well known. Contagious discharge may assume any of the above ap- 
 pearances. The first kind flows from spreading ulcers, the second from 
 still more active ulcerations (phagedaena), the third from healthy, healing 
 ulcers. 
 
 Classification of Ulcers (Paget's). — I. (Type) Simple or healthy ul- 
 cer.* 1 II. Varieties depending on constitutional causes (eleven) : 1, in- 
 flammatory ; * 2, eczematous ; * 3, cold ; 4, senile ; (* 5, strumous ; * 6, 
 scorbutic ; * 7, gouty ; * 8, syphilitic — strictly constitutional ;) 9, lupous ; 
 * 10, rodent ; 11, cancerous. HE. Varieties depending on local conditions 
 (eight) : 1, varicose ulcer ; 2, ©edematous ; * 3, exuberant ; 4, hemorrha- 
 gic ; * 5, neuralgic or irritable ; * 6, inflamed ; * 7, chronic or callous ; * 8, 
 phagedenic and sloughing. It is customary in describing an ulcer to 
 notice its (1) locality, (2) shape, (3) size, (4) base, (5) border, and (6) se- 
 cretion. 
 
 Simple or Healthy Ulcer. — Arises from loss of substance due to accident 
 or to some pre-existing, but now past, diseased condition. Locality, num- 
 ber, shape, and size — very variable. Base — covered with small red granu- 
 lations, not painful and not readily bleeding, neither raised nor much 
 sunk below level of surrounding skin. Border — outer circle of thin white 
 new epidermis, inner circle of still thinner (and therefore) blue epidermis. 
 
 1 The thirteen varieties marked with an asterisk are the most important to remem- 
 ber. The rest are, so to speak, subsidiary either to other ulcers or to altogether 
 special diseases. 
 
ULCERATION. 253 
 
 Pus, if present, laudable. Treatment. — Merely protective, e.g., simple 
 ointment on lint, and avoidance of irritation. Process of Healing. — Identi- 
 cal with that of superficial wound with loss of substance. 
 
 Inflammatory Ulcer. — Locality : usually lower part of shin. Shape, 
 irregular. Size : usually less than an inch. Base : without granulations, 
 raw and sloughy. Edges, abrupt. Discharge thin, acrid, often blood- 
 tinged. Surrounding skin inflamed, cedematous. Causes. — General 
 causes of inflammation, especially constant local irritation, bad diet, old 
 age, and drink. Treatment. — Best, elevation, water-dressing, poultices, 
 warm lead-lotion, followed in twenty-four hours by Martin's elastic band- 
 age. Or the bandage may be applied without any preparatory treatment.' 
 
 EczEMATOus Ulcer. — Resembles the last-mentioned (inflammatory) in 
 character, but appears in the middle of a patch of eczematous skin, in the 
 vesicle of which it has often originated. Sometimes its immediate cause 
 is a slight injury. Treatment. — Treat surrounding eczema, e.g., with zinc 
 ointment. But the sore itself must be managed as an inflammatory ulcer. 
 Martin's bandage. Danger of causing internal disease by curing eczema- 
 tous ulcer (?). 
 
 Cold Ulcer. — Resembles chilblains, and occurs on fingers and toes of 
 people with feeble circulation and cold, congested extremities, especially 
 young women with deranged sexual function. Aloes, iron, warm gloves, 
 thick boots, free exercise in open air. Dry lint. Stimulating lotions, e.g., 
 zinci sulph. (gr. iij.- § j.). 
 
 Senile Ulcers. — Kind of inflammatory ulcer, occurring in withered old 
 people. Nearly related to senile gangrene, with which it may be combined. 
 Vide Senile Gangrene. Locally : resin ointment and Peruvian balsam. 
 
 Strumous Ulcers. — Locality : neck, groin, knee, ankle, elbow, wrist, 
 and sometimes elsewhere. Often multiple. Shape : oval when single. 
 Size : small singly, but often very large by coalescence of several. Edges 
 undermined. Base soft, granulations large, readily bleeding, cedematous. 
 Discharge, thin, greenish pus. Treatment. — That of scrofula. Locally : 
 stimulant. Ung. hydrarg. oxid. rubri, unguentum plumbi, lotio iodi 
 (tinct. iodi c. aquae), on strips of lint. Iodoform. 
 
 Scorbutic Ulcers occur in the course of scurvy, and are covered with 
 crusts of the characteristic blood-clot deposit of scurvy: Indolent and 
 livid. Vide Scurvy. 
 
 Gouty Ulcers. — Superficial, indolent, occur in gouty parts, especially 
 over gouty deposits. Discharge itself leaves a chalky precipitate. Treat- 
 merit. — Water dressing. In absence of inflammation, sol. argent, nit. (gr. 
 v., aquae, § j.) may be used. 
 
 Syphilitic Ulcers. — Primary syphilitic ulcers (i.e., chancres) may occur 
 on lips, hands, etc. For their characteristics vide Syphilis. Secondary 
 
 1 The case must then be carefully watched, for there is a danger of erysipelas. 
 Iodoform is a valuable application to any ulcer not actually inflamed. 
 
254 
 
 ULCERATION. 
 
 eruptions rarely ulcerate : they are known by their concomitants. Terti- 
 ary are almost all the cutaneous ulcers named syphilitic. Commence in 
 two ways : 1, cutaneously (usually in rupia) ; 2, subcutaneously (a gumma 
 ulcerating outward) . The two varieties agree in occurring anywhere, in 
 having abrupt edges, in often being surrounded by a red areola, in being 
 associated with a syphilitic history (perhaps merely congenital), and- in 
 benefiting by antisyphilitic treatment, especially iodide of potassium ; but 
 they differ considerably. 1. That which begins superficially has for its fa- 
 vorite locality the trunk. Shape : annular, crescentic, or circular. Size : 
 various. Base : level, crimson. Granulations : small or absent. Dis- 
 charge concretes into scabs, often rupial in character. Not generally 
 simultaneous with any other syphilitic manifestation. One of the earliest 
 tertiary manifestations. 2. Deep tertiary syphilitic ulcers are caused by a 
 gumma finding its way outward through ulceration of the skin. Locality : 
 anywhere — usually Hmbs near the large joints. Shape : rounded. Size : 
 about an inch ; usually multiple. Edges : abrupt. Base : excavated, often 
 covered with " gummy deposit " sloughed. They have to be diagnosed 
 from strumous ulcers. The latter have a pink surrounding area, the for- 
 mer usually a dusky red one. Treatment of tertiary syphilitic ulcer. — 
 Locally : stimulant mercurial ointments, e.g., ung. hyd. oxid. rubri, or 
 ■ung. hyd. nitric-oxid. or lotio nigra ; iodide of potassium, gr. v.-x. ter die. 
 Small doses of liq. hydrarg. perchlor., etc. Vide Syphilis. 
 
 Lupous Ulcers, Bodent Ulcers, and Ulcerating Epithelioma may be 
 usefully contrasted as follows : 
 
 Lupous Ulcer. 
 
 Locality: most frequent- 
 ly face, especially tip or 
 alae of nose, upper lip, 
 cheek. Female external 
 genitals. Anterior, infe- 
 rior part of nasal septum. 
 Pharynx. 
 
 Borders : abrupt, irreg- 
 ular, sometimes slightly 
 elevated or thickened, 
 very rarely undermined. 
 
 Base : more or less level. 
 Granulations nearly ab- 
 sent, or else coarse and 
 dusky. 
 
 Often scabbed over. 
 
 Preceded by pink, firm, 
 flattened tubercles. 
 
 Rodent Ulcer. 
 
 Most frequently, cheeks, 
 
 I eyelids, upper lip, nose, 
 
 scalp. Also vulva, vagina, 
 
 areola of breast, near anus, 
 
 etc. 
 
 Abrupt ; perhaps with low 
 tubercles near, never under- 
 i mined, not everted; tough, 
 hard. 
 
 Smooth, dull reddish yel- 
 | low, looking half -dry a ad 
 glossy, void of granulations. 
 Base feels tough and hard, 
 as if bounded by a layer of 
 indurated tissue half a line 
 to a line in thickness. 
 
 Very little discharge in- 
 deed. 
 
 Commences in some tu- 
 bercular or scaly spot of 
 long duration. 
 
 Ulcerating Epithelioma of the 
 Skin. 
 
 Great majority occur on 
 lower lip, lower eyelid. 
 Other places where skin and 
 mucous membrane join, e.g., 
 anus, vulva, prepuce. Also 
 scrotum, back of hand, and 
 any other part of skin. 
 
 Generally raised, everted, 
 hard, nodular, warty. 
 
 Uneven, concave, hard, 
 nodular, warty, fissured. 
 Coarse granulations. Base 
 and surrounding parts hard, 
 thickened and infiltrated 
 with cancer. 
 
 Often scabbed over when 
 small. 
 
 Begins in many ways— 
 tubercles, warts, ulcers, fis- 
 sures, cicatrices, etc. 
 
ULCERATION. 255 
 
 The course of each is destructive to every neighboring tissue. Progress 
 usually slow, always sure. Lupus is often associated with scrofulous consti- 
 tution. Kodent ulcer more frequently coexists with perfect general health. 
 The same may be said of epithelioma, but epithelioma is, of all the three, 
 most usually painful and productive of cachexia. Epithelioma alone in- 
 volves, secondarily, the glands ; and the infection may spread to the en- 
 tire system. This is what constitutes its truly cancerous nature. Kodent 
 ulcer would only be described as semi-malignant. The last sentence is 
 meant to be understood in a purely clinical sense. Pathologically, " ro- 
 dent ulcer " is as truly carcinomatous as epithelioma, according to Bill- 
 roth. 1 Lupus is pathologically allied to tubercle, quod vide. Treatment. — 
 Lupus : use Volkmann's erosion treatment, i.e., scrape the disease away 
 with some spoon-shaped instrument. Antiscrofulous remedies, cod-liver 
 oil, etc. Eodent ulcer : thorough destruction with cautery or caustic. 
 Benzoline cautery. Among caustics, arsenic is very convenient, but un- 
 safe except in case of very small sores ; nitric acid acts rather superficially ; 
 Vienna paste and chloride of zinc paste are the best deep caustics. For 
 treatment of cancerous ulcers, vide Cancer. Esmarch and Billroth have 
 had encouraging results from large doses of arsenic internally in cancer 
 cases. Seasoning by analogy, the power of arsenic over psoriasis (super- 
 ficial epithelial hypertrophy) suggests a possible power over cancer (inter- 
 stitial epithelial hypertrophy). Lupus often returns. Bodent ulcer, if 
 completely extirpated, rarely returns. Prognosis after operation for epithe- 
 lioma depends on whether or not time has been given for glandular infection. 
 
 For other cancerous ulcers see Cancer. 
 
 Section UX — Varieties of Ulcer depending on Local Conditions.— They 
 do not need a full description, as each term owes its existence to some 
 single important condition grafted on one or other of the ulcers already 
 described. The nature of this characteristic, together with causation, 
 diagnosis, and treatment, have to be considered. 
 
 Varicose Ulcer.— Its characteristic is, that it owes either its origin or 
 continuance mainly to the existence of varicose veins. Two direct modes 
 of origin : (1) in suppuration over a thickened varix ; (2) in eczema caused 
 by obstructed cutaneous circulation. Form assumed by varicose ulcer is 
 that of inflammatory, of eczematous, or of chronic ulcer, q.v. The treat- 
 ment is acording to the particular nature of the individual ulcers. But, 
 always, either rest and elevation or else pressure. Martin's bandage. Give 
 iron internally. 
 
 The terms cedematous, exuberant, and hemorrhagic refer to the state of 
 an ulcer's granulations, and almost explain themselves. (Edematous gran- 
 ulations are usually connected with diseased bone. Exuberant granula- 
 
 1 Paget inclines to the same view. But Thin says that rodent ulcer is an adenoma 
 of the sweat-glands. Pathological Transactions, 1879. 
 
256 URETHRA, STRICTURE OF. 
 
 tions have to be diagnosed, by their softness, from cancer. An ulcer may 
 be hemorrhagic from (1) vicarious menstruation, (2) small and diseased 
 varicose veins, (3) scurvy, (4) hemorrhagic diathesis, (5) phagedena, (6) 
 malignant disease, (7) mere accidental injury or congestion. In the case 
 of cedematous and hemorrhagic ulcers it is necessary to treat the cause. 
 Pressure and caustics will destroy cedematous or exuberant granulations. 
 The popular name for the latter is " proud flesh." 
 
 Neuralgic or Irritable Ulcers. — Usually more or less inflamed, or sub- 
 ject to constant irritation, e.g., fissures round anus or mouth. If soothing 
 ointments, cleanliness, and local rest will not cure them, a touch of solid 
 caustic may. Carbolic lotion is an excellent local sedative. See Anus, 
 Fissure of. 
 
 Inflamed Ulcer. — Recognized by the presence of the four classical 
 signs of inflammation in the borders of the ulcer. Surface of ulcer also 
 changes, becomes " angry-looking," dusky, swollen, perhaps sloughy. 
 Treatment. — Eest, elevation, weak carbolic or lead lotion. Purgatives. 
 Occasionally, poultices are convenient. 
 
 Chronic, Indolent, or Callous Ulcers. — Seat : almost always the leg. 
 Border thick, hardened, brawny, abrupt, covered with thick, old, opaque 
 epidermis, and devoid of any delicate, new epidermis such as surrounds a 
 healing ulcer. Base, sunken, pale, or dusky, without granulations, usually 
 insensitive. Secretion, thin, offensive. Various kinds of ulcers attain this 
 condition through neglect or continued irritation, combined with feeble 
 local circulation. Treatment. — Above all, pressure. Martin's bandage. 
 Baynton's dressing (strapping with adhesive plaster). Covering ulcer and 
 its borders with a blister. See Syme's " Essays." Yery few cases of un- 
 complicated chronic ulcer can now justify amputation. 
 
 Phagedenic and Sloughing Ulcer. — See Gangrene and Syphilis. 
 
 Urethra, Stricture of. — Classification: (1) spasmodic, (2) inflamma- 
 tory, (3) organic. Organic are — A. Of neoplastic origin : (1) annular, (2) 
 indurated annular, (3) diffuse or tortuous, (4) bridle, (5) caruncle, (6) 
 traumatic ; B. Of heteroplastic origin : epithelioma, etc. 
 
 Causes. — Of Spasmodic Stricture : almost always an organic predis- 
 posing cause, situated within the urethra. Dyspepsia or gouty diathesis 
 with consequent acid state of the urine. Irritating diuretics, e.g., can- 
 tharides. Some foreign body, e.g., passage of a bougie or of a minute 
 calculus. Some disorder of the central nervous system. Of Inflammatory 
 Stricture: exercise, excitement, alcoholic or other excess during course 
 of a gonorrhoea. Of Organic Stricture: the great majority arise from 
 gonorrhoea, especially chronic gonorrhoea or gleet. Some follow non- 
 specific urethritis. Vide causes of urethritis. Traumatic strictures follow 
 rupture of the urethra. Hot climates. Abuse of alcoholic drinks, espe- 
 cially malt liquors. Neglect of proper treatment in gonorrhoea. Caustics. 
 Syphilitic ulceration of meatus. 
 
URETHRA, STRICTURE OF. 257 
 
 -Position. — Spasmodic stricture occurs in various parts of the urethra. 
 Inflammatory stricture is due to acute inflammation of the prostatic part. 
 Of organic strictures, two-thirds are in the bulbous part of the urethra, i.e., 
 in the posterior inch of the spongy part (Thompson). This is denied by 
 Otis, who says that strictures are most common in the penile part of the 
 urethra. For confirmatory observations, seeLockwood, " St. Bartholomew's 
 Hospital Reports," 1879. 
 
 Sigyis. — Earliest symptom is usually a slight gleet (almost all obsti- 
 nate gleets are said to be caused by stricture). Sometimes retention is the 
 first sign of all. Altered size and shape of stream — small, twisted, spirt- 
 ing, forked, or even divided. A few drops of urine trickle away after 
 micturition has apparently been completed. Commencement of the act of 
 urination difficult and slow, act itself prolonged. Advanced Symptoms. — 
 Constant desire to make water. Night's rest broken. Straining. Sense 
 of heat, soreness, and smarting about neck of bladder, " greatly aggravated 
 by an excess of acid in the urine, by cold, or imprudence of any kind tell- 
 ing on the parts." Pain in pubic region, in perinseum, back, and loins. 
 Pain during coition. Semen may recoil back into bladder. In some stric- 
 ture cases a discharge like that of gonorrhoea may follw sexual inter- 
 course. Anus shows effects of straining — prolapsus, and hemorrhoids. 
 In a few cases, almost the only marked symptom is the liability to attacks 
 of retention. 
 
 Urine tends to become alkaline and ammoniacal, 
 COH 4 N 2 + H 2 0=C0 2 + 2NH 3 
 urea -f- water = carbonic acid + ammonia, is the reaction which represents 
 transformation of urea into carbonate of ammonia. This ammonia irritates 
 the bladder, causing cystitis. The urine contains also triple phosphates in 
 abundance, as well as pus and mucus, owing to the cystitis. Occasional 
 hematuria, from rupture of vessels near stricture during erection of penis. 
 
 Complications. — 1. Dilatation of -urinary passages' and organs posterior 
 to stricture — prostatic part of urethra, bladder, ureters, kidneys. 2. 
 Atony and absorption of same structures ; kidney may suffer great atrophy 
 of its substance. 3. Inflammations and suppurations of the same parts, 
 especially of bladder and kidneys. 4. Incontinence of urine. 5. Rupture 
 of the urethra or bladder, and extravasation of urine. 6. Chronic absceSvS 
 and fistula. 7. Constitutional effects. For most of the above complica- 
 tions, see notices elsewhere, e.g., Bladder, Diseases of, Kidney, Urlne, etc. 
 
 Constitutional Effects.— Loss of strength. Impaired digestion. Thin- 
 ness. Careworn look. Irritability. Despondency. Pains in back and 
 loins. Feverishness of intermittent character. Urethral fever may be ex- 
 cited by the passage of a bougie, especially if the instrument be compara- 
 tively large. When there is organic kidney disease, catheterism almost al- 
 ways causes severe rigors. Then death may also ensue suddenly, perhaps 
 from poisoning by urea. 
 17 
 
258 URETHRA, STRICTURE OF. 
 
 Diagnosis is usually settled by passing instruments. History of case 
 may help to demonstrate nature and cause of the stricture. Act of mictu* 
 rition should be observed. 
 
 Prognosis. — Very good if stricture be treated early. Serious, if neglect 
 has allowed kidney disease to supervene. 
 
 Treatment. — The immediate treatment of strictures (whether inflam- 
 matory, spasmodic, or organic) in which there is retention of urine will be 
 considered under the head Ukine, Eetention of. Treatment of strictures 
 in which there is no urgent retention. Varieties may be classed as fol- 
 lows: (1) dilatation, (2) rupture, (3) urethrotomy. These three classes 
 include at least eight methods, viz. : (1) intermittent dilatation, (2) con- 
 tinuous dilatation, (3) vital dilatation, (4) rupture, (5) dilatation from 
 behind — Jordan's operation, (6) internal urethrotomy, (7) external ure- 
 throtomy, (8) perineal section. 1 1. Dilatation. — Instruments : silver, gum- 
 elastic (English), or French catheters or bougies. The soft French in- 
 struments are preferred to silver ones by the majority of people accustomed 
 to both. Sir Henry Thompson strongly recommends them. The English 
 gum-elastic has the advantage that it can be moulded to any curve in warm 
 water, and stiffened in the new curve by plunging it into cold water. 
 Silver catheters permit their points to be directed with greater precision 
 than soft ones. The advantage of using a catheter instead of a bougie, is 
 only that the former instrument, by giving passage to urine, tells you 
 when it has entered the bladder. French instruments usually taper near 
 the end, but have the end itself nobbed to prevent catching in the urethral 
 lacunae. Hence the name " bougie ct boule." The French sizes No. 3 to 
 No. 21 correspond nearly to our No. 1 to No. 12 : the number of each size 
 of the former scale representing the number of millimetres in its circum- 
 ference. Catgut and whalebone bougies are also used for very narrow 
 strictures. 
 
 Rules for Ordinary Catheterism. — 1. Patient may stand upright with 
 his back against the wall ; but as he may faint, it is safer for him to lie 
 down on his back. 2. Stand on patient's right if he is lying down. Sit 
 in front of him if he is upright. In difficult cases bring the patient to the 
 foot of the bed, and stand between his legs. 3. See that your catheter is 
 clean and not blocked up. 4. Warm it slightly. 5. Oil it well. 6. Steady 
 the penis with your left finger and thumb, and, holding the instrument 
 lightly between the thumb and two fingers of your right hand, pass its 
 point five inches down the urethra, that is as far as it will easily go while 
 the instrument is in its present position (that is to say, with its handle 
 parallel to the patient's left groin). 7. Bring the handle up to the middle 
 line of the abdomen, keeping the point of the catheter well down the ure- 
 
 1 To these should be added dilatation by Wakley's tubes, which glide one over 
 the other, and the smallest over a small silver catheter. 
 
URETHRA, STRICTURE OE. 259 
 
 
 thra. 8. Lightly depress the handle, at the same time pushing the point 
 onward round the sub-pubic curve into the bladder, employing only the 
 slightest degree of force with the lightest hand possible. By " depress 
 the handle " is meant " bring it downward, from the linea alba toward the 
 interval between the thighs." When in the bladder, the catheter should 
 be parallel with the thighs, or nearly so. Difficulties : (1) point may en- 
 tangle in lacunse in roof of urethra, or in a false passage ; (2) or may be 
 obstructed by the anterior layer of the triangular ligament, through which 
 the urethra passes about six inches from the meatus ; (3) or by spasm ; (4) 
 or by an elevation near prostate or neck of bladder. At first keep the point 
 on the floor of the urethra. Always be patient and gentle. Force can do 
 no good, and may cause much harm, especially false passages, hemor- 
 rhage, and pain. Gum-elastic catheter : be very careful to preserve its' 
 curve. When you have got the point well down the urethra, depress the 
 handle rather suddenly, but still with a light hand. French soft instru- 
 ments : simply push them gently on into the bladder. Indications for 
 treatment of stricture : (1) to restore normal size of urethra (or to dilate 
 as much as is consistent with safety and comfort) ; (2) to maintain the 
 ground gained. At the first examination of a case of supposed stricture— 
 1. Pass, or try to pass, a medium-sized instrument. If it passes very 
 easily, try a larger and a larger, till you find the largest which passes with- 
 out much pain. Note the size and position of the stricture. 2. If it will 
 not pass, let the patient make water, if he can. The size of the stream 
 will usually be a little larger than the diameter of the stricture. 3. If he 
 cannot make any stream of water, carefully examine hypogastrium, to see 
 if bladder be distended. A finger in the rectum to palpate base of blad- 
 der may assist in this examination. 4. If you have seen a stream of water, 
 take an instrument a little smaller than that stream, and try to pass it. 5. 
 But if there is no stream of urine, or if the instrument advised in last 
 paragraph (4) have failed, try the smallest soft French catheter you pos- 
 sess. 6. If this fails, try your finest bougie or catgut or Thompson's 
 probe-pointed catheter, or Maissonneuve's conducting bougie (if you pos- 
 sess them). Each instrument should have a fair and patient trial. Use 
 plenty of good sweet oil. Sir H. Thompson directs it to be injected into 
 the urethra. Another plan is to inject it in steadily at the very same 
 time that you are gently pushing on your fine bougie. The stream of oil, 
 entering the stricture, may carry the point of the bougie with it. 7. If 
 the stricture resist all this, put the patient to bed, and if there is no im- 
 mediate retention, reserve him to be treated as a difficult case. In the 
 meantime, tincture of opium, hot baths, and rest in bed may bring his 
 stricture to a state of easy permeability. 
 
 Dilatation, according to the ordinary plan, is thus managed. An instru- 
 ment as large as the patient can comfortably endure is passed the first 
 day. Then, at intervals of about two days, more or less according to the 
 
260 URETHRA, STRICTURE OF. 
 
 patient's urethral sensibility, a larger and a larger size are passed, till N©. 
 14- (English) is reached. Modern opinion is opposed to resting content 
 with No. 12. If any attempt is made to hurry the steps of this treatment, 
 the severest rigors and urethral fever may result. Some cases show sim- 
 ilar serious symptoms if the surgeon tries to dilate beyond even No. 7 or 8. 
 Such cases often get on very well with that calibre of urethra, and require 
 no further treatment. Each instrument should be taken out as soon as it 
 is passed. After ten minutes' horizontal rest, the patient may go about 
 his business again, provided no unpleasant symptoms ensue. 
 
 Continuous Dilatation. — The instrument is not withdrawn for forty- 
 eight hours, and then only to have a larger size substituted for it. This is 
 an especially good plan (a) when the instrument has been introduced with 
 difficulty ; (b) when false passages exist ; (c) if ordinary dilatation is in- 
 effective ; (d) if each introduction of the instrument induces pain or rigors. 
 Of course the bed must be kept during the treatment (i.e., for a week or 
 two). The catheter or bougie, when in, can be fixed by tapes or strap- 
 ping (vide works on bandaging, etc.), or by tying it with thread to the 
 hair of the pubes, a direction which some critic of Smith's and Walsham's 
 operative surgery has termed unpractical. Practical or unpractical, I have 
 myself constantly practised it. A cradle keeps the bed-clothes off the hips, 
 etc. Liq. opii sed. V{ xx., or morphia suppositories will relieve severe 
 pain. Some patients cannot endure the treatment at all. Orchitis is a 
 possible complication. Diarrhoea may require chalk mixture. Hemor- 
 rhage may occur. Slight purulent discharge accompanies the treatment. 
 
 " Vital " Dilatation. 1 — "When instrument will not pass through stricture, 
 and there is yet no retention, pass a bougie down to stricture and leave it. 
 Perhaps in a day or two it will pass. 
 
 Rupture by Holt's Dilators. — Mr. Holt passes an instrument consisting 
 of two parallel blades, and then forcibly driving a tube down between 
 them, ruptures the stricture. Give ether. Use sufficient force. Pass a 
 No. 10 catheter immediately. Remove it at once, and pass it again at 
 intervals of two days in first week, then once a week, then once a fort- 
 night, lastly once a month. This plan has a great deal in its favor. See 
 Mr. Holt's book. 
 
 Dilatation from Behind. — In certain cases, impermeable from the front, 
 Mr. Furneaux Jordan has plunged a bistoury into the membranous part 
 of the urethra, from the rectum, adjacent to which the membranous urethra 
 lies. This is done by placing the patient in the lithotomy position, feeling 
 for the anterior border of the prostate, and cutting exactly in the median 
 line. Then a fine bougie is insinuated from behind forward, through the 
 wound. 
 
 Internal Urethrotomy. — Various forms of urethrotome. Some cut from 
 
 .. . , l Dupuytren, Lemons Orales. 
 
URETHRA, STRICTURE OF. 261: 
 
 behind forward, others from before backward, in almost all cases with a 
 guide previously passed through stricture. Division from behind forward 
 preferred. Suitable cases are those strictures which either cannot be 
 dilated beyond a small calibre, or which rapidly recontract after dilatation. 
 Operation (with Civiale's urethrotome) : Ascertain position of stricture by 
 means of bulb at end of instrument. Pass the urethrotome so far down the 
 urethra that when the blade is projected the incision shall commence 
 about £ inch beyond the stricture. Pull out the instrument, incising the 
 urethra for about 1^ inch altogether. There is no danger in a long incision, 
 but real danger in incising very deeply. Proper depth about ^ inch. As 
 a rule, pass no instrument for forty-eight hours. Then pass a sound at 
 intervals, which should gradually increase, commencing at every other day. 
 Always press its curve well down into site of incision. Internal urethrot- 
 omy is relatively best, and absolutely excellent in the penile portion of 
 the urethra. Mortality, 10 in 1,192 (Teevan). 
 
 External Urethrotomy. — Suitable cases are those in which "large, mime-- 
 rous, or obstinate perineal fistulae coexist with old or obstinate strictures. 
 When other treatment has failed, and the fistulse refuse to heal, even 
 although the patient has withdrawn for some weeks his urine entirely by 
 catheter, no proceeding perhaps offers so good a chance of cure as this. 
 It is for such cases I reserve it now." 1 Operation. — Pass Syme's staff. 
 Lithotomy position. Best light obtainable. Operator sits. Incise in line 
 of raphe, two inches. Feel for staff with left forefinger. Take staff in left 
 hand, and straight bistoury in right. With right hand supine, cut through 
 stricture along groove of staff from behind forward. Withdraw staff one- 
 fourth inch, and extend incision that distance further forward. Shoulder 
 of staff will now easily pass on through site of divided stricture if the division 
 has been thorough. Thompson passes a concave, curved director through 
 the wound and toward the bladder, with the aid of which a catheter (not 
 smaller than No. 10) is afterward guided into the bladder. If catheter is 
 obstructed on its passage, stricture requires more complete division, which 
 should be done there and then. Morphia suppository. India-rubber tub-, 
 ing to catheter. Withdraw catheter after forty-eight hours. Pass No. 12. 
 bougie at intervals, first of four days, then one week, then a fortnight, and 
 so on. If any difficulty in passing this be experienced before wound heals, 
 pass a grooved staff, and, with a tenotomy knife in the wound, divide the 
 obstruction. 
 
 Rules for Managing a Stricture Impermeable to Ordinary Means. — It is 
 assumed that there is no urgent retention. 1. Kest in bed without instru- 
 mental disturbance for three days or more. 2. Low diet, purgative, alkaline 
 medicines, demulcent drinks. 3. Plenty of bed-clothing. 4. Opium, twenty 
 drops of tincture ; and 5, hot bath, 100°, rapid drying with towel, half an 
 
 1 Thompson on Stricture, p. 241. 
 
262 URETHRA, STRICTURE OF. 
 
 hour before surgeon's attempts to pass an instrument. 6. During cathe- 
 terism, expose only the genital organs. Cover trunk and arms with blan- 
 kets. 7. Give ether. 8. Commence with the very finest soft French bougie 
 you possess. If you have not a filiform one, snip off the bulb of a " bougie 
 ct boule." 9. While an assistant is in the very act of injecting oil into the 
 urethra, glide your bougie, by the side of the nozzle of the syringe, down 
 to, and if possible through, the stricture. 10. If that fails, try a catgut ; 
 but, if there are false passages, pass a No. 6 gum-elastic down to the stric- 
 ture, and glide your filiform bougie down by its side. 11. As a rule, a 
 perfectly new filiform bougie answers best, but occasionally the surgeon 
 finds an individual one of particular merit, which he treasures up and uses 
 again and again. 12. As the orifice of the stricture is not always in the 
 axis of the urethra, the instrument should be conducted carefully first 
 along one side of that passage, then on the other, then along the roof, then 
 along the floor. The soft instruments can only be used in this way when 
 the stricture is very near the meatus. Deeper strictures, when eccentric 
 in position, require the silver catheter. (Thompson's probe-pointed cathe- 
 ter should be employed). 13. When an instrument has been passed at 
 last, but with great difficulty, it should be left in a considerable time, say 
 forty-eight hours, careful note being made of the particular manoeuvre 
 which proved successful. Instead of withdrawing it to make room for a 
 larger size, a Wakley's tube can, with advantage, be passed over it. Wak- 
 ley's tubes are of various sizes, and glide over the originally introduced 
 catheter, which acts to them as a guide. 14. Whatever method is tried 
 should have a fair trial. Fickleness is very likely to result in failure. 15. 
 The attempts, if necessary, may be renewed on a future day. Suppose, 
 however, one of those rare cases of genuine impermeability. The stricture 
 may be near the meatus. Of course there will be false passages. In such 
 a case I saw Mr. Furneaux Jordan pass a very sharp, fine -pointed bistoury 
 into the glans where the meatus ought to have been (the meatus was itself 
 occluded, and the last quarter or half inch of the urethra too), and fortu- 
 nately or skilfully hit the urethra beyond. No trace of a meatus had re- 
 mained, the surface of the glans being merely cicatricial tissue. If the 
 impermeable stricture be in the penile part of the urethra, but not near 
 the meatus, divide it subcutaneously, that is, pass a grooved director down 
 to the stricture. Feel the size and position of the stricture with the finger 
 and thumb, from the outside. Then, observing your landmarks carefully, 
 and having the penis well and steadily held up on your director, pass a 
 sharp tenotome through the skin opposite the end of the director. Next, 
 without enlarging the skin-wound, and cutting always in the middle line, 
 divide the stricture. When the tenotome has once reached the urethra on 
 the proximal side of the stricture, the division can be accurately and thor- 
 oughly completed on a grooved staff. For genuine impermeable stricture 
 in the bulbous part of the urethra, perineal section must be done, or the 
 
URINE. 203 
 
 bladder may be punctured, after which catheterization may be possible, 
 owing to the repose which the stricture thus gets from pressure a tergo. 
 For treatment of Betention, see Retention of Urine. 
 
 Perineal Section. — This operation resembles external urethrotomy, but 
 differs from it in that the stricture, being impermeable, is not divided on a 
 staff, but is carefully dissected through. The surgeon requires an excel- 
 lent light. He should use all his knowledge of anatomy, constantly refer 
 to the landmarks which are visible or palpable, and will do well to make 
 the starting-point of his dissection the juncture of the distal part of the 
 urethra with the stricture, a point which can be fixed by the end of a staff 
 passed down to it. Work throughout in the exact median plane of the body. 
 The details of this operation have been admirably worked out by Wheel- 
 house, of Leeds. He uses a staff with a button-like end. Urethra is opened 
 a quarter of an inch in front of stricture, the orifice of the latter being then 
 searched for with the probe. See British Medical Journal, June 24, 1876. 
 
 Accidents of Stricture are perineal abscess, perineal fistula, penile or 
 ante -scrotal fistula, retention of urine, each of which is noticed in its al- 
 phabetical place. 
 
 False Passage is a common effect of rough catheterism. Treatment. — If 
 there is retention, the bladder may be reached sometimes by passing first 
 one middle-sized instrument, then a fine catheter beside it. Otherwise, it 
 is best to suspend attempts at passing instruments till the false passage 
 has had time to heaL An instrument in a false passage moves freely, one 
 in a stricture is gripped more or less tightly. Macleod, of Glasgow, rec- 
 ommends a course of quinine during the treatment of stricture. It is not 
 unreasonable to think that it might act as a prophylactic against septicae- 
 mia. 
 
 Urine. — Normal urine is clear, pale amber-colored, of specific gravity 
 not greater than 1030, and acid in reaction. It does not respond to the 
 tests either for albumen or for sugar, and it does not deposit urates as it 
 cools. From thirty to fifty ounces are usually passed in the twenty-four 
 hours. 
 
 The chief urinary deposits are urates, phosphates, and oxalates, casts of 
 the renal tubuli, mucus, and pus. Blood may be diffused in the urine, or 
 even be passed per urethram, almost unmixed with urine. Grape sugar may 
 be present in solution. Epithelium, bile-acids, bile -pigment, spermatozoa ; 
 certain constituents of the food may also be found, e.g., in the strong-smell- 
 ing urine passed after eating asparagus. The acidity of healthy urine 
 probably due to pre'sence of acid sodium phosphate. When a free acid is 
 present, " the reaction to test-paper is far stronger, and the liquid deposits 
 on standing, little, red, hard crystals of uric acid ; but this is no longer a 
 normal secretion" (Fownes' "Chemistry," eleventh edition). Alkalinity 
 of healthy urine very rare, and then due to neutral potash or soda salts 
 of vegetable acids (e.g. y tartrates, citrates, and acetates) taken into the 
 
264 URINE. 
 
 stomach. Alkalinity in retention cases is due to fermentation, -which 
 forms ammonium carbonate from urea. 1 
 
 Urates usually red, but vary from pale yellow to purplish. Readily 
 dissolved by heat. 
 
 Phosphates may be thrown down from neutral urine by boiling, but 
 dissolve instantly when a drop of nitric acid is added. Contrast with al- 
 bumen. Phosphates are most abundant in the alkaline, mucopurulent 
 urine of chronic cystitis. 
 
 Oxalate of Lime is recognized, under the miscroscope, by its dumb- 
 bell and octahedral crystals. 
 
 Benal Casts, found often in albuminous urine. Basis usually fibrin. 
 May be waxy or fatty. May contain blood or pus-corpuscles or epithelial 
 cells. 
 
 Mucus may occasionally come from the prostatic urethra, and conse- 
 quently be only accidentally mixed with the urine. Patient then generally 
 passes it toward end of act of micturition, But mucus and pus, existing 
 together, are usually accompanied also by phosphates and an alkaline re- 
 action. Urine reacts also to tests for albumen. 
 
 Pus, unmixed with mucus, if diffused, is probably from kidney ; if not 
 diffused, is from an abscess opening into bladder or urethra. 
 
 Blood in the urine may come from kidney, ureter, bladder, or urethra. 
 Very unlikely to come from ureter, even in case of injury to abdomen. If 
 renal, blood is diffused, producing "smoky" urine ; if vesical, less likely 
 to be entirely diffused, almost sure to pass partly pure ; if urethral, is likely 
 to pass quite independently of urine, sometimes without micturition, some- 
 times immediately after micturition. Bloody urine is necessarily albumi- 
 nous. Sham hematuria sometimes produced with coloring matters by 
 impostors. 
 
 Grape Sugar increases specific gravity of urine, imparts a sweet odor, 
 and increases flow of urine (diabetes). Trommer's test : add a few drops 
 of solution of cupric sulphate to urine, then add excess of liq. potassse, 
 lastly boil; a red precipitate (cuprous oxide) is quickly thrown down. 
 Pavy's test-pellets are handy. 
 
 Bile-pigment — In cases of jaundice, sufficient bilirubin may exist in 
 urine to answer to Gmelin's test. " Treated with oxidizing agents, such as 
 nitric acid yellow with nitrous acid, it displays a succession of colors in 
 order of the spectrum. The yellowish golden red becomes green, this a 
 greenish blue, then blue, next violet, afterward a dirty red, and finally a 
 pale yellow " ("Foster's Physiology"). 
 
 Epithelium and Spermatozoa, as well as casts and crystals, are discovered 
 by the microscope. 
 
 For the value of the above deposits, etc., see the sections treating on 
 
 1 In addition to what follows, concerning urinary deposits, see Calculus. 
 
URINE. 265 
 
 Diseases and Injuries of Bladder and Urethra, Abdominal Injuries, Impo- 
 tence, Calculus. 
 
 Urine, Retention of. — A term applied only to acute stoppage of the 
 urethra, and never to mere habitual difficulty in urination. Varieties. — (1) 
 Retention from organic stricture, (2) from inflammation, (3) from spasm, 
 (4) from internal obstruction, e.g., by calculus, (5) from external pressure, 
 e.g., by abscess, (6) from enlarged prostate, (7) from hysteria, (8) from op- 
 erations on pelvic or even on distant regions. Causes. — Partly indicated 
 in the last sentence. But the exciting cause of retention, whether purely 
 spasmodic, or arising in the course of organic stricture, or of gonorrhoea 
 (inflammatory retention), is usually drink or exposure to cold. Besides 
 gonorrhoea, various drugs, e.g., cantharides, ergot, and even quinine, will 
 sometimes temporarily close the urethra (by spasm or inflammatory effu- 
 sion or by both ?). The predominance of certain causes depends greatly 
 on the age. In children the least rare are impaction of a calculus or a for- 
 eign body, a string tied around penis, an injury to the perinseum, abscess, 
 phimosis, and adherent prepuce. In adults the most common are alcohol 
 and cold during organic stricture or gonorrhoea. Rarely too strong ure- 
 thral injections. In old age the chief cause is prostatic hypertrophy. 
 Symptoms. — An adult in his senses of course knows that he cannot pass 
 his urine properly. But adults when delirious, or prostrate, or insensible, 
 and children when young, may present no direct or striking sign of reten- 
 tion unless it be looked for. The bladder usually rises in the abdomen, mak- 
 ing dull successively the hypogastric and even the umbilical regions. But 
 in old cases of stricture, the bladder may be organically so contracted that 
 it would rupture before distending enough even to rise out of the pelvis. 
 Diagnosis. — The most dangerous mistake is that of taking a case of reten- 
 tion with overflow for one of pure incontinence. Always catheterize if 
 there be the slightest doubt. In suppression of urine the bladder is 
 nearly or quite empty, and the symptoms belong rather to the kidneys and 
 nervous system (e.g., lumbar pain and afterward coma), than to the blad- 
 der and urethra. Prognosis. — If unrelieved, great danger of rupture of 
 urethra, extravasation of urine, urinary abscess and fistula, or even gan- 
 grenous cellulitis and death. But this does not apply to hysterical reten- 
 tion ; nature usually remedies that herself after a time. Treatment. — Hot 
 bath (104°), liq. opii, TT[ xx., then bed and warm blankets. Catheterize 
 at once (except in hysterical cases). For spasmodic stricture use a No. 5 
 soft French catheter warmed by friction and well oiled. For organic 
 stricture try the same instrument. If it does not pass at once adopt the 
 measures detailed on pp. 262 and 263. If they fail to lead you to the blad- 
 der, and if his retention be complete or nearly so, the patient must not 
 be left unrelieved. Aspiration above the pubes is perhaps the safest and 
 best means of affording immediate relief. Other methods are (1) supra- 
 pubic puncture with a small trochar and canula, directed backward and 
 
266 VAGINA. 
 
 downward, (2) puncture per rectum, (3) opening the urethra behind the 
 stricture, (4) "perineal section" proper, i.e., without a guide. If the sur- 
 geon never hopes to open the urethra satisfactorily again, he had better 
 perhaps adopt plan 1. If he knows the stricture to be of that class for 
 which Syme recommended external urethrotomy, and if he have confi- 
 dence in his own skill, he is justified in attempting to cure both retention 
 and stricture by plan 4. In other cases his choice undoubtedly is practi- 
 cally confined to aspiration and puncturing per rectum. When retention 
 is caused by impaction of a calculus or foreign body, the obstruction must 
 be withdrawn if possible ; but if it cannot be extracted per urethram, it 
 had better be pushed back into the bladder, and reserved for further treat- 
 ment, e.g., crushing by lithotrite, or extraction through a median perineal 
 incision. 
 
 Uvula, Clefc. — Slightest grade of cleft palate. Pare edges and unite 
 with fine sutures. 
 
 Uvula, Relaxed. — Usually part of a general condition of pharyngeal 
 catarrh. Often causes troublesome cough. Astringent gargles. Touch 
 with silver nitrate. Tonics. Stomachics. Attack cause, e.g., over-indul- 
 gence of any kind. Or seize the extremity with forceps and cut it of£ 
 
 Vagina, Imperforate. — Usually a mere adhesion of opposite vaginal 
 walls, easily torn open, and prevented from readhering by oiled cotton- 
 wool. Not to be confounded with a very serious malformation, viz., Im- 
 perforate Hymen. This latter condition causes retention of the menstrual 
 fluid till long after puberty. The treatment is to open by incision. Dan- 
 ger of resultant inflammation spreading to peritoneum. (Open with anti- 
 septic precautions). Vagina may be a mere cul-de-sac, associated with ar- 
 rested development of uterus and ovaries. To diagnose the latter condition, 
 examine (1) with catheter in bladder and finger in rectum, (2) with specu- 
 lum. Nothing can be done. 
 
 Absence of Vagina occurs in rare instances. 
 
 Vaginal Fistula. — (1) Vesico-vaginal, (2) urethro-vaginal, (3) recto- 
 vaginal. Causes. — Laceration or sloughing, the result of difficult labor, 
 or, more rarely, of accident. Syphilis. (Fistulas from cancer are so irre- 
 mediable as to be best not considered here.) Symptoms. — Incontinence 
 of urine or of faeces. But the latter may not occur unless the rent is very 
 large or the faeces fluid. Flatus may escape and little or no faeces. Seat 
 and extent of fistula must always be determined by combined digital 
 and specular examination. Catheter often useful. Treatment. — Purely 
 operative. Cautery may be tried in very trivial cases. Instruments. — 
 Duck-bill speculum, long straight and long angular knives, long forceps, tu- 
 bular needles, with Startin's handle, wire-twister, long curved scissors, long 
 soft india-rubber catheter, silver wire, silk, handled sponges, etc. Chief 
 points of operation are ten: (1) Health good. (2) Rectum empty. (3) Po- 
 sition — lithotomy. (4) Nates held widely apart by assistant. (5) Duck-bill 
 
VAGINA. 267 
 
 speculum. Operator will occasionally hold this himself, but usually hand 
 it to an assistant. (6) Drag the fistula toward the vaginal orifice. This 
 may be done in various ways, e.g., with a blunt hook, or by one of the su- 
 tures. (7) Thoroughly pare the edges on the vaginal side ; (8) but do not 
 meddle with vesical mucous membrane. (9) Sutures must not enter blad- 
 der, nor be pulled too tight. (10) Sutures should enter and leave about 
 half an inch from edges of wound. As soon as operation is done, place, 
 secure, and leave flexible catheter in bladder. This should be cleaned 
 twice daily. Patient now lies on her side. Unless untoward symptoms 
 arise, leave sutures in ten days. 
 
 Operation for recto-vaginal fistula is precisely similar. Keep bowels 
 confined for ten days. " Whether or not the sphincter ani should be di- 
 vided will depend on the degree of tension which is present when the 
 parts are brought together. It is not a slight measure and should not be 
 heedlessly resorted to " (Hutchinson in Holmes's " System "). Wash out 
 vagina daily with a syphon. In operations about the vagina, remember the 
 erectile tissue which lies immediately beneath the mucous membrane, and, 
 therefore, remove the latter with delicacy, to avoid hemorrhage. Such 
 hemorrhage I have seen instantly controlled by hot- water injections (temp. 
 120°-130° Fahr.). 
 
 Vagina, Foreign Bodies in, generally pessaries or sponges, may cause a 
 false diagnosis of metritis, leucorrhcea, or even cancer, patient forgetting 
 their presence. Sometimes they have to be removed piecemeal. Pessa- 
 ries have for years remained unsuspected in the vagina, causing foul dis- 
 charge, etc. 
 
 Vagina, Infantile Tumors of. — Very rare. See T. Holmes in his " Sys- 
 tem," vol. v., p. 851. 
 
 Vagina, Lacerations of. — Usually the result of parturition, occasionally 
 caused by broken chamber-utensils or by assaults, etc. ; in rare instances, 
 even by bridal intercourse. Treatment. — Trivial cases require only rest, 
 silver nitrate, etc. ; medium cases require sutures, and, if neglected at first, 
 eventually operation for recto- or vesico-vaginal fistula. Severe cases may 
 cause collapse and rapid death. Complete circular rupture of vagina, with 
 expulsion of uterus, has been known during parturition ! And this, also, 
 without violent instrumental interference. 
 
 Vaginal Prolapsus, 
 
 Vaginal Tumors of Adults, and 
 
 Vaginal Discharges, non-Gonorrhosal, are apt to be so intimately con- 
 nected with uterine affections that they are most fully treated in Gyneco- 
 logical works. 
 
 Non-specific Vaginitis of Children may cause evil suspicion ; but the 
 affection should always be presumed to be innocent, unless there is col- 
 lateral evidence to the contrary. Cause. — In some cases the passage of 
 thread-worms from rectum to vagina, and local irritation. Struma? 
 
268 varix. 
 
 Treatment. — Local cleanliness, dryness, and mild astringents. Attend to 
 general health. 
 
 Varicocele. — Sometimes no less than seven causes of varicocele are 
 given ! And all these exist in every healthy individual, old or young, yet 
 varicocele is almost unknown in young children and old people. Quite suf- 
 ficient causes are to be found in the lax nature of the scrotum, and in the 
 amount of violent congestion to which the spermatic veins are subject in 
 many young adults. The left side is oftenest affected. Several reasons 
 have been given, e.g., rectangular juncture of left spermatic vein with re- 
 nal, and relation of former vein to sigmoid flexure of colon. Neither of 
 these reasons will bear strict criticism. The left side of the scrotum is 
 almost always larger than the right, and therefore laxer, as the left testicle 
 is no larger than the right. The veins are enlarged, lengthened, and 
 thickened. The enlarged veins coil around the cord and against the 
 testicle in such a way as to feel " like a bag of worms." Increase on 
 standing. Decrease on lying down. Impulse (slight) on coughing. Often 
 aching pain and tenderness. Depression of spirits. Treatment. — I beg 
 to recommend the suspensory bandage which I have myself contrived. 
 If properly fitted, it removes the venous congestion as soon as applied, 
 and will often substitute for low spirits and aching pain a feeling of 
 brightness and of being well braced up. Other local apparatus are 
 Wormald's ring, the common suspensory bandage (generally inefficient), 
 Morgan's (of Dublin) suspender ; an inguinal truss (which is said to "sus- 
 tain " the column of blood above, though it manifestly must equally ob- 
 struct the flow of blood from below). Cold douching. Attention to the 
 digestive system and bowels. Correction of evil habits. Operations for 
 varicocele are not unpopular with some, who, by good luck, have had no 
 shocking accident from embolism. Operation is justifiable when a patient 
 finds it urgently desirable to pass into the public service without delay, or 
 When a varicocele causes severe symptoms and will not yield to milder 
 measures. Atrophy of the testicle said to be caused by varicocele. Many 
 of the effects attributed to varicocele in certain cases are quite as much 
 due to genital irritation of which the varicocele is itself a result. Opera- 
 tions. — Two kinds and many varieties. Both subcutaneous, in one the 
 veins are merely constricted, in the other they are constricted at two points 
 and divided intermediately. The vas deferens (easily recognized by its 
 cord-like feel) must be slipped well out of the way : the spermatic artery 
 lies close to it. Lee's operation is probably as good as any. In it the 
 veins are constricted in two places by needles beneath them and figure-of- 
 8 ligatures over them. As these ligatures are not subcutaneous, they must 
 not be tight. A tenotomy knife divides the veins intermediately. On the 
 6th day, remove needles. Bed for three weeks : then suspensory bandage. 
 
 Varix. — Dilatation of veins. Causes. — Mechanical obstruction (e.g., 
 varix of saphena from pressure of pregnant womb on external iliac vein). 
 
veins. 269 
 
 Occupations in which there is much standing, e.g., those of laundress and 
 shopworn an. Such influences as the above act chiefly on persons with an 
 individual or a family predisposition, and on certain localities, namely 
 saphenous and spermatic veins, and their radicles. It is said that the deep 
 veins of the legs are nearly as often affected as the superficial. Frequently 
 the minute cutaneous venous radicles are alone affected. This often occurs 
 in the face, and is frequently hereditary. Pathology. —Hypertrophy as 
 well as dilatation of the venous coats, of the muscular as well as the fibrous 
 elements. Dilatation sometimes regular, sometimes saccular. Extent 
 varies from a small part of one vein to nearly all the veins of one or both 
 lower extremities. As the valves do not grow proportionally, they soon 
 become insufficient. Thickening of connective tissue round the veins. 
 This may increase to general thickening of whole limb. (Edema from 
 .difficulty of circulation through the dilated veins with inefficient valves. 
 (Edema leads to eczema : eczema to " varicose " ulceration. Occasional burst- 
 ing and hemorrhage. This may lead to ulceration. Coagulation in certain 
 parts of the vein, generally near valves, "phlebolites." Symptoms. — No per- 
 son who has seen one varicose vein can fail to recognize another ; but when 
 such a vein is surrounded by brawny tissue it may escape the sight : it can 
 then be felt as a soft, subcutaneous "channel." Color varies from flesh- 
 color to purple ; usually bluish gray. Aching pain after long standing. 
 Varix of spermatic vein may cause neuralgia and mental depression. See 
 Varicocele, above. Varicose veins, when inflamed, become hot, tender, etc. 
 Prognosis. — Easy to alleviate. Almost impossible to cure without opera- 
 tion — which is rarely justifiable (or entirely effectual when disease is ex- 
 tensive). Treatment. — Support by pressure of (1) elastic bandages, (2) 
 elastic stockings, (3) common bandages — preferably starched, (4) strong 
 lace-up stockings. Avoid standing or long sitting with legs dependent. 
 Regular but moderate walking with legs well bandaged. Attend to bowels 
 and general health. Iron. Horizontal rest in middle of day for an hour or 
 two. Bathing in cold water after exercise. Elastic stockings should fit well, 
 and are somewhat expensive, since they do not wear so long as bandages. 
 Operations. — A proceeding similar to one or other of those described above 
 under head of varicocele, is applied to as many parts of a varicose vein as 
 may be required to obliterate it, e.g., the vein may be compressed in 
 several places between needles passed beneath it and strips of india-rubber 
 stretched over it (outside the skin), and subcutaneously divided between 
 the points of acupressure (Lee). Caustics and injection of a drop or two 
 of perchloride of iron have been used and recommended, the latter as an 
 adjunct to acupressure (Bryant). Operation of excision of varicose vein 
 with antiseptic precautions (spray, etc.) is much practised at Guy's Hos- 
 pital by Howse and others. It is neatly described by Dunn in "St. Bar- 
 tholomew's Hospital Reports," 1879. 
 
 Veins, Inflammation of. — A subject which in most surgical works is 
 
270 VEINS. 
 
 considered as if inseparable from Thrombosis. The separation is really 
 difficult; but the mixture generally plunges the cautious student into 
 doubt and confusion as to what he is really reading about. Let it be pre- 
 mised that (1) inflammation of a vein is apt to lead to thrombosis in it, but 
 does not necessarily do so ; (2) that it is sometimes impossible to diagnose 
 whether a given case is phlebitis with or phlebitis without thrombosis ; (3) 
 that thrombosis is almost sure, unless quickly resolved, to lead to changes 
 in the vein obstructed ; (4) that many cases called phlebitis are really 
 cases of periphlebitis, i.e., of inflammation of the cellular tissue around 
 the vein ; (5) that the concurrence of thrombosis is generally the most 
 serious part of a case of phlebitis. Hence in treating any case of phlebitis 
 or periphlebitis, the idea of thrombosis and of its possible consequences 
 — e.g., solid oedema and pyaemia — never leaves the surgeon's mind. 
 
 Phlebitis. — Causes. — Injury, e.g., phlebitis of saphena following a dog- 
 bite, thrombosis or embolism, gout, obscure influences, possibly presence 
 of irritating materials in the blood. Varicose veins particularly liable. 
 Paget, classifying phlebitis according to its causes, gives eight kinds, viz. : 
 (1) from injury, (2) from exhaustion, (3) from propinquity of inflamed or 
 otherwise diseased parts, (4) rheumatic, (5) pya?mial, (6) puerperal, (7) 
 gouty, (8) from poisoning by foul drains. Some of these causes are quali- 
 fied in the original lecture. See Paget's " Clinical Lectures." Symptoms. 
 — Redness, hard swelling, tenderness, more or less pain in the course of 
 a vein or of part of a vein. Swelling sometimes knotty, knots said to cor- 
 respond to seat of valves. (Edema in parts whence the vein should drain 
 blood. Sometimes visible enlargement of collateral veins. If suppuration 
 occurs, there is local softening and general rise of temperature. Perhaps 
 a rigor. Diagnosis has chiefly to be made from lymphangitis. It depends 
 on the situation of the redness, etc., and on the width of the band of in- 
 flammation (greater in phlebitis). Glands also more likely to be enlarged 
 in lymphangitis. Pathology. — Inflammation of the vein itself is almost al- 
 ways preceded by thrombosis ; and, when not preceded by thrombosis, it is 
 probably secondary to periphlebitis. The experiments of modern pathol- 
 ogists, e.g., Lee and Callender, certainly prove that the older pathologists 
 were accustomed to mistake mere thrombosis for an exudation of lymph 
 from the wall of the vessel, but, to my mind, considering the anatomy of 
 the veins, and arguing analogically, they are not numerous and severe 
 enough to prove that exudation of lymph never takes place ; and they most 
 assuredly do not justify the dismissal of true phlebitis from our nosology. 
 But any thickening of the outer or of the middle coats, or roughness of the 
 inner coat of an inflamed vein, is so rarely found, independently of throm- 
 bosis, and is, in itself, of such small importance, that the most interesting 
 pathological features associated with phlebitis must be sought for under 
 the head of venous thrombosis. Prognosis. — Vide Venous Thrombosis. 
 Treatment. — Rest. Elevation, gentle and even pressure. If a common 
 
VEINS. 271 
 
 roller be used, place a layer of cotton-wool beneath for the sake of elas- 
 ticity. Regulate bowels. Moderate or low diet. If abscess threatens, it 
 may be poulticed, fomented with hot water, and opened early. Extensive 
 cases of solid oedema from venous obstruction are rarely entirely cured, 
 some thickening remaining. As ammonia readily enters the blood and, 
 when there, retards coagulation, there is a rational indication for giving it 
 in cases of phlebitis. I believe Dr. Richardson has demonstrated its value 
 in cases of thrombosis. The carbonate in large doses would be the best 
 form to administer. 
 
 Concerning gouty phlebitis, Paget says it is " either associated with or- 
 dinary gouty inflammation in the foot or joints, or occurs, with little or no 
 evident provocation, in persons of marked gouty constitution or with gouty 
 inheritance. Not rarely it has peculiar marks, especially in its symmetry, 
 apparent metastases, and frequent recurrences." Treatment. — Employ 
 same means as in managing gout affecting other external parts, especially 
 rest and elevation. When vein affected is large, rest should continue a 
 month from date of last marked attack of pain, to lessen risk of embolism. 
 
 Venous Thrombosis. — Formation of a clot in a living vein. Causes. — (1) 
 Injury to a vein, e.g., a wound. This may act either by causing a rough- 
 ness or projection into the calibre of the vein, or by obstructing the flow 
 of blood altogether. (2) Constriction. This is probably the way in which 
 inflammation external to the vein usually acts : the immediate effect is to 
 slow the blood-current. (3) Dilatation, by retarding the flow of blood, 
 will produce thrombosis, e.g., occasionally in varicose veins. (4) Another 
 cause analogous in mode of action to the last two is constitutional debil- 
 ity, " marasmic thrombosis." (5) The entrance of an irritant or of septic 
 poison into the blood. (6) Thrombosis in one vein may be merely the re- 
 sult of extension into it of a clot from a neighboring vein, e.g., in certain 
 cases of "white leg," obstruction of external iliac has spread up from uter- 
 ine veins through internal iliac. (7) Gout. 
 
 Pathology. — When first formed, clot usually small, rarely large. In- 
 creases by laminar deposits. Usually fills the vein : rarely leaves a chan- 
 nel beside it, i.e., between it and the wall of the vein. Sometimes spiral 
 in shape. Soon adheres to vein-wall. (In all above respects, it contrasts 
 with post-mortem clots.) In time, come (1) changes in the clot, (2) 
 changes in the vein itself, (3) changes in the peri-venous tissues. To 
 these may be added (4) changes in the parts formerly drained by the vein. 
 The clot may either (1) disintegrate and pass into the circulation, or (2) 
 organize into a fibrous band united with the vein, or (3) that part of it 
 first formed may melt into a puriform fluid — differing from true pus in 
 containing granular debris and not corpuscles. In this case the portion of 
 clot last formed almost invariably remains to shut off the liquefied part 
 from the circulation, or (4) the white corpuscles which wander into the clot 
 may, instead of converting it into a fibrous mass (as in case 2), be the 
 
272 WHITLOW. 
 
 agents in forming true pus within the vein, or (5) a portion or the whole 
 of the thrombus may be washed away, thus becoming an embolus. When 
 suppuration occurs in the course of a thrombosis it must be understood 
 that the pus is usually in the first instance outside the vein. The ctfurse 
 taken by the vein and its contained thrombus is almost always identical 
 with the changes taking place in the cellular tissue around the vein. Diag- 
 nosis. — See Vein, Inflammation of. But thrombosis may be recognized by 
 the hard cord-like feel of the vein affected, before inflammatory change has 
 commenced, and by the oedema. Prognosis. — Varies most widely accord- 
 ing to the extent and position of the clot, according to its first cause {e.g., 
 whether the mere ligature of a vein, or the entrance of putrid fluid into 
 it), and according to the course the case takes while under observation. 
 The danger of embolism exists to a slight extent in almost every case, 
 and of pyaemia in such as show a tendency to local suppurations or as arise 
 in the course of wounds. Treatment. — See Veins, Inflammation of. 
 
 Warts. — See Papillomata (under head of Tumors). 
 
 Whitlow. — Erysipelatous inflammation of finger. Varies in extent 
 from trivial but painful blush beside nail, to diffuse suppuration spreading 
 up forearm and destroying tendons, phalanges, and even wrist-joint. 
 Causes. — Local punctures, cuts and scratches, poisonous or otherwise. 
 Predisposing causes are same as those of erysipelas, quod vide, e.g., low 
 state of health, diseased kidneys, epidemic and endemic influences. Pathol- 
 ogy. — A cellulitis, at first, usually, of cellular tissue around ungmal pha- 
 lanx, but tending to spread to sheaths of tendons, to skin and subcutane- 
 ous tissues of back of hand, and even, as above stated, to phalangeal, and in 
 the worst cases to metacarpal and still larger joints. May subside. Usually 
 suppurates. Local and general effects precisely similar to those of cellu- 
 litis elsewhere. If a phalangeal joint be affected, or a tendon slough, 
 there will probably be a stiff and contracted finger afterward. Symptoms* 
 — Local redness, heat, throbbing, pain, tenderness, and swelling. Eeverish- 
 ness in slight cases, prostration in severe ones. Increased swelling and 
 oedema when pus has formed. As incision is generally made early, and 
 the part is exquisitely tender, fluctuation need not necessarily be felt for.- 
 Diagnosis. — Effects of a foreign body in the finger or hand may be mis- 
 taken for a simple whitlow. Prognosis. — Usually good as regards life, 
 even in extensive cases extending up forearm. Bad or good locally accord- 
 ing to extent to which tendons and joints are affected. Treatment. — Rest, 
 local and general. Elevation and flexion ; carry hand in sling just be- 
 neath chin. Pressure on brachial artery : patient can be taught to make 
 it with the thumb of his sound hand. Poultices : frequent hot fomenta- 
 tions. After forty-eight hours, if symptoms are unrelieved, make two 
 longitudinal incisions, one on each side of palmar surface of finger (of 
 course, excepting those slight cases where this part remains unaffected). 
 Give a purgative, e.g., calomel, gr. x., afterward iron (tinct. ferri perchlor., 
 
wounds. 273 
 
 "TT[ xv„ ter d. s.). Kegulate diet according to patient's condition and con- 
 stitution. As a rule avoid meat. Appetite is generally bad. Phalanges 
 may have to be excised or fingers amputated, in consequence of ill effects 
 of old whitlow. During convalescence, if contraction threatens, place 
 finger on a splint. Stiffness of hand may persist for a very long time, and 
 be eventually removed by passive exercise, frictions, etc. 
 
 Wounds. — Classification. — (1) Incised, (2) lacerated, (3) contused, (4) 
 punctured, (5) poisoned. Wounds are also either open or "subcutaneous." 
 1. Simple Incised. — Its characters are clean edges, freedom from bruise or 
 laceration and from poisonous matters, at least when first inflicted. 2. 
 Lacerated. — Its edges are usually irregular, and frequently more or less 
 contused. Comparatively small tendency to bleed. 3. Contused. — Has 
 bruised edges; is usually also "lacerated." 4 Punctured. — E.g., a bayo- 
 net stab, generally narrow and deep. When caused by gunshot, its walls 
 are bruised. 5. Poisoned wounds are such as snake -bites and dissection- 
 wounds. In subcutaneous wounds the aperture in the skin is small com- 
 pared to the incision beneath it, e.g., in " tenotomy." 
 
 Pathology. — Process of repair, etc. (compare with Inflammation, quod 
 vide). — When a simple incised wound is inflicted, nature first checks 
 hemorrhage by closing the ends of the divided vessels in the same man- 
 ner described under Hemorrhage, i.e., by coagulation and contraction. At 
 the same time there is usually a thin clot formed between the two surfaces 
 of the wound. In consequence of the blood being unable to find its way 
 through the divided vessels, there is congestion of the vessels about the 
 wound ; and the congestion of the neighboring parts, caused by the blood 
 pressing through the nearest uninjured channels, is called "collateral flux- 
 ion." In this way is produced the narrow line of redness around a fresh 
 wound. The course of events after this is determined by whether the 
 wound is to heal by the first intention (primary union), or by granulation. 
 First Intention. — There is a great accumulation of white corpuscles, both 
 inside and outside the blood-vessels near the wound. These leucocytes 
 permeate the clot, if there be one, cause its liquefaction and absorption, 
 and take its place. At the same time, the edges of the wound are them- 
 selves to some extent dissolved and replaced in the same manner. The 
 leucocytes pass gradually through an oval into a spindle shape. These 
 spindle- cells form, partly of themselves and partly of the intercellular 
 liquid substance in which they lie, fibres of connective tissue, thus tying 
 the two sides of the wound together. At the same time, new capillaries 
 are formed, which bridge across the wound, allow blood once more to flow 
 in its old course, and thus relieve the collateral fluxion. At this stage the 
 scar grows redder, and its surrounding edges paler. The new capillaries 
 are developed in two ways : (1) by loops which grow out from the vessels 
 divided by the wound ; (2) by certain rows of spindle-cells which develop 
 into capillaries. At a later stage, the new fibrous " cicatricial " tissue con- 
 18 
 
274 wounds. 
 
 tracts, becomes " drier," i.e., less succulent, and, in contracting, obliterates 
 many of the new capillaries. The cicatrix becomes, therefore, smaller and 
 paler. Of course, after healing by the first intention, it is merely linear 
 at first ; but in a short time it may defy detection altogether. So rapidly 
 does this disappearance take place in some cases that pathologists have 
 described what they call "immediate union" or "primary adhesion," 
 meaning, presumably, a perfectly simple cohesion like that of one piece of 
 melted sealing-wax with another, and without further interstitial changes. 
 Granulation. — The process of healing when raw surfaces cannot be 
 brought into apposition, and unfortunately also in some cases where they 
 can. The microscopic anatomy of this process differs from that of " pri- 
 mary union," in that (1) the accumulation of leucocytes forms, on the sur- 
 faces of the wound, small elevations called granulations ; (2) much of the 
 waste tissues and superfluous corpuscles, which would be absorbed or 
 profitably used in healing by the first intention, are, in the case of healing 
 by granulation, cast off as pus ; (3) the new capillaries Cannot extend from 
 one edge of the wound to the other, because they are too much separated 
 either by distance or by some other obstruction, e.g., a foreign body or 
 excessive clot ; (4) a much larger production of epidermis is required to 
 cover the surface of the wound. The resulting scar is larger, coarser, and 
 much more prone to mischievous contraction. The new epidermis is de- 
 veloped from the most superficial layer of corpuscles in the granulations ; 
 but it appears concentrically from the epidermis at the edge of the wound, 
 or else spreads from islets of old epidermis left by nature or placed by 
 art on the area of the wound. (See Skin-Gratting.) Pus-corpuscles are 
 identical with leucocytes, but often contain several nuclei, indicating a 
 tendency to multiply by division. Connective tissue, epidermis, epithe- 
 lium, bone, and even nerve are reproduced perfectly (the last only to a 
 limited extent) . Muscles are only repaired by development of connective 
 tissue. Lacerated and even contused wounds usually fail to heal by the 
 first intention. The latter, especially, are liable to slough at the edges, 
 and both tend to suppurate freely. Much depends on the conditions of 
 each case, e.g., on situation of wound, on state of patient's viscera, and on 
 treatment. Punctured wounds usually heal by first intention, except 
 when also contused, as they are in gunshot wounds. Five methods of 
 healing have been recognized, viz.: (1) primary adhesion ; (2) first inten- 
 tion (or primary union) ; (3) granulation (or second intention) ; (4) union 
 of two opposed surfaces, each covered with granulations (third intention) ; 
 (5) scabbing. Method 4 combines, in succession, the processes of 3 and 
 2 ; 5 is probably similar to 3 ; only, such waste-products as there are, dry 
 up into a scab, being of very small amount. 
 
 Healing by Organization of Clot is exactly similar in nature to healing by 
 the first intention, in which, indeed, a thin clot generally does exist and 
 becomes .organized. A curious phenomenon is, that if any clot project 
 
wounds. 275 
 
 beyond the level of the general surface, the new epidermis cuts off the 
 projecting part, healing only over the remainder. Organization of clot is 
 beautifully seen after antiseptic osteotomy, and is well described by Mc- 
 Ewen in his book on that subject. Lister rightly holds that the frequency 
 of this process under antiseptic treatment is a strong proof of the sound- 
 ness of his doctrines. 
 
 Consequences of a wound are (1) pain, (2) hemorrhage, (3) displace- 
 ment, (4) loss of function, (5) shock. Pain of dividing skin, tense fascia, 
 and bone comparatively great. (See Hemorrhage for separate notice.; 
 Wounds by laceration, crushing, and cauterization usually cause little, 
 often no hemorrhage. Displacement is usually a consequence of retraction. 
 Not only muscles, but mere fibrous structures retract, by virtue of their 
 elastic constituents. Loss of function varies in extent from stiffness, the 
 result of tenderness, up to death. (See separate notice for Shock.) Re- 
 traction is greatest in the direction of the length of a limb, and in the 
 muscles as compared with the skin, etc. Amount of pain varies with 
 character, and even with occupation of patient. Of course, loss of function 
 and displacement may amount to permanent paralysis and deformities. It 
 is when the surgeon is about to inflict wounds (i.e., operate) that he has 
 most to consider the above-mentioned " consequences." In treating ac- 
 cidental wounds, the " consequences " are generally only too manifest. 
 
 Prognosis depends on (1) locality, (2) extent, (3) health of patient, 
 especially state of kidneys and lungs, (4) age, (5) habits, (6) surroundings, 
 
 (7) character, i.e., whether incised or lacerated or poisoned or otherwise, 
 
 (8) treatment There are also other conditions less generally active, e.g., 
 race, which also may be secondary to such influences as habits. That wiry 
 countrymen are much more hopeful subjects than fat, flabby townsmen, is 
 an example of the action of " habits " and " health." Wounds of the up- 
 per do better than those of the lower extremity, especially as age advances. 
 Generally, youth is a great advantage ; but infants bear hemorrhage 
 badly. There is no more unfavorable habit than habitual drinking. 
 
 Treatment. — Indications are : (1) to check hemorrhage, (2) to remove 
 shock, if very severe, (3) to remove foreign bodies and to cleanse, (4) to 
 adjust, (5) to dress, (6) splints, position, etc. (1 and 2 vide Hemorrhage 
 and Shock.) 3. Use of hot water, cold water, sponges, camel's hair brushes, 
 forceps, fingers, etc., according to peculiarities of each case. Gentleness 
 is imperatively required. 4. In adjusting, avoid tension. Arrangement of 
 joints, etc., so as to relax parts divided : e.g., after accidental division of 
 tendo Achillis, foot should be extended and leg flexed. 5. Dressings : 
 prime objects are, firstly, to keep the divided parts in proper position ; 
 secondly, to prevent local and general complications which may interfere 
 with healing and even endanger life. First object is fulfilled by use of 
 sutures, strapping, pads, splints and position ; of course, all this array of 
 means is not used in every case. Second object requires precautions to be 
 
276 wounds. 
 
 taken against (1) exposure to draughts of cold air, (2) painful movements 
 and positions, (3) septic influences. Changes of dressing should be quickly 
 effected, and windows and doors closed during the process. Pain is pre- 
 vented by careful adjustment of dressing, of splints, of position (especially 
 by elevation and flexion), by use of swing-cradles, of cushions, etc. Opiates 
 sometimes desirable, especially morphia subcutaneously. Septic influences : 
 their avoidance can probably be thoroughly secured in only one way, viz., 
 by preventing the access of living germs to the wound. But much good 
 may be done by removing, as fast as they collect, all discharges which can 
 form a nidus for these germs. The former end is most surely secured 
 by the antiseptic system rigorously applied. The latter aim can be more 
 or less successfully attained by several means. Lister's antiseptic sys- 
 tem, though indirectly (e.g., by expediting cure) economical, is directly 
 expensive, especially when the surgeon does not habitually employ it, and 
 in the case of very large operation-wounds, e.g., amputations of the thigh. 
 In these cases immense quantities of expensive dressings have to be 
 changed, often daily, because of the great discharge. As, also, no antisep- 
 tic system can provide against all the dangers of wounds, it is not sur- 
 prising that a surgeon, after losing a case or two dressed with thorough 
 antiseptic precautions, should be disposed to return to more familar 
 methods, upon which, in past times, his fortune may have smiled more 
 favorably. In the case of moderate-sized wounds, Lister's antiseptic system 
 is simply perfect, and almost proof against ordinary carelessness, ignorance, 
 and stupidity. On the other hand, "open treatment " and oakum dress- 
 ings are free from the objections which may be urged against Lister's an- 
 tiseptic system, in the case of great amputations. They are very cheap 
 and simple. They doubtless both act by gaining the second end above 
 mentioned, viz., the removal of discharge from the wound as fast as it 
 forms, and, consequently, by depriving the septic germs of material to 
 work upon. 
 
 Pasteur's experiments prove germs to be too universal for the oakum 
 dressings to act otherwise, as no precautions, such as the carbolic spray, 
 are usually taken whilst changing them. Oakum dressings have these 
 superiorities over open treatment, they protect the wound from cold 
 draughts, they destroy offensive smells, keeping the general air of the 
 ward pure, and they actively drain the wound by their power of capillary 
 attraction. What I saw when house-surgeon under Gamgee at Birming- 
 ham, convinced me that no system of wound-dressing could be complete 
 without some provision for gentle and elastic compression. This, Gamgee 
 used to secure with cotton-wool ; but as soon as Martin's bandages became 
 known in England, I took to completely covering with them most of my 
 operation-wounds which were dressed antiseptically, and some which were 
 not. I have never seen a stump which healed more rapidly, or looked 
 better when healed, than one which had no dressing whatever but a rub- 
 
wounds. 277 
 
 ber bandage over it, and a pad of oakum to drain into. But in this par- 
 ticular instance it was not practicable to dress antiseptically. The mode of 
 dressing used lately by Esmarch, with a success perhaps unparalleled, not 
 only as regards general results, but as regards individual cases, may be 
 described as an instance of the successful combination of antisepticism 
 with gentle compression. Next the wound are placed pads soaked in iodo- 
 form and absolute alcohol (ten per cent.), then an iodoformed bandage, 
 then a large pillow of jute and gauze, then a moist bandage, and lastly an 
 elastic bandage. Even after amputation of the thigh, this dressing seldom 
 needs a single renewal. Healing takes place by the first intention, not 
 even a hole for the drainage-tube being left ; for Esmarch uses absorbable 
 tubes of decalcified bone. It is most important before applying such 
 dressings to check all oozing of blood. Eecurrent hemorrhage need 
 scarcely be feared at all. The under-bandages should be put on as 
 lightly as possible, and the elastic bandage should be applied with great 
 care and gentleness. Iodoform, insufilated, makes a capital dressing for 
 many wounds, e.g., lithotomy, perinseal section, operations near the mouth, 
 anus, urethra, and the like. Other modes of local treatment, compara- 
 tively rarely employed, are cotton-wool dressing, irrigation, and immer- 
 sion. Poultices of linseed, or of bread, are still in common use, and are 
 certainly soft, moist, hot, and comfortable, and therefore possibly act fa- 
 vorably on any local inflammations that may be near the wound. Oakum 
 (including the kinds termed " tenax," " stipium," etc.) is applied like a 
 poultice. Like every other antiseptic substance, it is somewhat irritating ; 
 therefore a narrow strip of protective should be placed next the edges of 
 the wound. The not uncommon practice of using lint soaked in carbolized 
 oil as a protective is unreasonable ; for the lint obstructs the absorptive 
 power of the oakum, whilst the carbolic acid is as irritating as the tar in 
 the oakum.- Earely should the wound, excepting when fresh, be syringed 
 or washed — it cannot be kept too dry. ( Vide Antiseptic Treatment.) Eead 
 Gamgee on the "Treatment of Wounds," an authority on oakum and cot- 
 ton-wool dressings, but unjust to Lister and his methods. Without anti- 
 septic treatment, grand statistical results have been obtained by various 
 surgeons ; but, considering how many things affect the success of surgical 
 practice, e.g., experience, observation, judgment, resource, manual dexter- 
 ity, pluck, and, perhaps above all, patience and enthusiasm, not to men- 
 tion endemic and epidemic influences, it is certain that mere statistics 
 prove little for or against any system of dressing wounds, unless those sta- 
 tistics extend over long periods of time, different localities, and immense 
 numbers of cases. And, even then, they should not be permitted to over- 
 rule other evidence such as presents itself to the surgeon who, in London 
 at all events, watches any small series of wounds in detail, of which some 
 are treated antiseptically and others not. For, even the statistics of an 
 honest observer have not really the force of mathematical certainty. Be- 
 
278 W0UND8. 
 
 hind them is always the human heart, whose truth is often noble, but never 
 mathematical. 
 
 These remarks are not uncalled for. Repeatedly, of late, have the stu- 
 dent and practitioner been invited to deprive themselves and their patients 
 of the safeguards offered by modern science, on the strength of compari- 
 son between the statistics of two places only. Such a comparison no more 
 furnishes an argument against Listerism than the security of those Aca- 
 dian farmers, who had n neither locks to their doors nor bars to their win- 
 dows," condemns the use of the Metropolitan Police. 
 
 Drainage. — A necessity for all wounds where there is likelihood of sup- 
 puration or serous discharge. Effected by drainage-tubes of rubber, of 
 decalcified bone (or, less frequently, of twisted wire), by strands of cat- 
 gut or horse-hair, or by strips of gutta-percha. Desirable to consider how 
 to favor drainage in arranging direction of cuts and position of wound. A 
 drainage-tube is a foreign body which may itself cause pain and irritation. 
 As a rule, it should be gently removed, squeezed, and washed every dress- 
 ing. It is useless to try to squirt carbolic lotion through seven or eight 
 inches of a drainage-tube riddled with holes and lying in a wound. Before 
 removing to clean, tie a piece of silk to it. Leave this in the wound, to 
 afterward use as guide for replacement. Be very gentle. 
 
 Very rarely do any severe wounds of the soft parts alone require am- 
 putation. But they may also do so when (1) even recovery would only be 
 with so much deformity or loss of function that the part would be worse 
 than useless ; or (2) when the injury is so extensive and serious that gan- 
 grene and death are threatened. Injuries complicated with division of 
 large arteries, with much contusion, and in the lower extremities of adult, 
 and, much more, of aged people, are of this nature. No verbal rules can 
 do instead of experience in deciding in such cases. Here even the master- 
 surgeon steers with perplexity between Scylla and Charybdis. 
 
APPENDIX 
 
 Microscopic Organism (Vegetable), 
 
 in which they have been found : 
 
 -Table of the chief diseases 
 
 Disease. 
 
 Favus. 
 
 Tinea tonsurans. 
 
 Sycosis. 
 
 Pityriasis versicolor. 
 
 Thrush. 
 
 Concretions in the mouth, salivary 
 ducts, and urinary bladder (including all 
 carbonate of lime calculi). 
 
 Caries of the teeth. 
 
 Malignant pustule. Anthrax (of ani- 
 mals). 
 
 Malarious affections. 
 Typhoid. 
 Typhus. 
 Leprosy. 
 
 The Septic processes : septicaemia, 
 pyaemia, progressive suppurations, hospital 
 gangrene, diphtheria, puerperal fever. 
 
 Mycosis septica (Orth) — a disease of 
 new- born infants. 
 
 Mycosis of the navel. 
 
 Acute exanthemata : variola-vaccina, 
 scarlatina, measles. 
 
 Inflammatory processes : endocarditis, 
 certain " rheumatic" or "fibroid" affec- 
 tions of the liver and kidney, which " lead 
 more especially to formation of connective 
 tissue, and not to suppuration." 
 
 Croupous pneumonia : erysipelas (al- 
 lied to croupous pneumonia — Klebs). 
 
 " Certain puerperal processes." 
 
 Mumps. 
 
 Tuberculosis. 
 Syphilis. 
 
 Glanders. 
 
 Organism. 
 
 Achorion Schonleinii. 
 Trichophyton tonsurans. 
 Microsporon mentagrophytes. 
 Microsporon furfurans. 
 Oidium albicans. 
 
 Leptothrix. 
 
 Leptothrix. 
 
 Bacillus anthracis. 
 
 Bacillus malariae. 
 Bacillus typhi abdominalis. 
 Bacillus typhi exanthematici. 
 Bacillus leprosus. 
 
 Cocco-bacteria 
 rina"). 
 
 Cocco-bacteria. 
 
 Cocco-bacteria. 
 
 Cocco-bacteria 
 
 of Klebs) 
 
 Cocco-bacteria (genus 
 
 (genus — "microspo 
 
 (genus — ' ' monadina " 
 monadina "). 
 
 Cocco-bacteria (genus — "monadina"). 
 
 Cocco-bacteria (genus — "monadina "). 
 Cocco-bacteria (genus — " monadina "). 
 
 Cocco-bacteria (genus — " monadina "). 
 Cocco-bacteria (variety, " helicomonas " 
 of Klebs). 
 
 Cocco-bacteria (variety, ' ' helicomonas") 
 
 Some of the diseases in which, though not hitherto observed, it is highly 
 probable that microscopic organisms will be found are cholera, yellow fever, 
 and madura-foot. 
 
280 MICROSCOPIC ORGANISM. 
 
 Methods of Studying these Organisms. — High power usually required. 
 Many micrococci look small even when magnified 700 diameters. Most, 
 but not all, resist the action of acids and alkalies, while animal tissues do 
 not. Staining fluids : hematoxylin and aniline dyes, especially the latter. 
 Special illumination apparatus : Abbe's. 1 Examination may be made of 
 either (1) the diseased animal tissues, (2) the soil, water, or air in which 
 some of the organisms unquestionably flourish, (3) cultivation-fluids and 
 solids, or of (4) the tissues of animals artificially inoculated. When culti- 
 vation-fluids are used or animals inoculated, conclusiveness may be given 
 to the experiments by separating the microscopic organisms from the 
 liquids in which they he. This is done in two ways — (1) Chauveau's, who 
 used the sediment deposited by vaccine ; (2) filtration through porous clay 
 (Klebs); or through gypsum (Pasteur). Further, though individual ani- 
 mals have very similar susceptibilities to these organisms, yet different 
 species are often very unequal in this respect. Thus the living animal 
 body can be sometimes used as a filter, to separate even one kind of minute 
 organism from another (Koch), and it is, of course, easy to separate any 
 organism which infects the body generally from one which infects only 
 locally. 
 
 Botanical Position. — The microscopic organisms, not animal, which are 
 found in animal bodies in infective diseases all belong to the sub-class 
 Thallogenae. In the order hyphomycetae are achorion, trichophyton, and 
 o'idium. In the order algae is leptothrix. In the order schizomycetae may 
 be distinguished two widely different forms, viz., bacilli and cocco-bacteria. 
 The bacilli have been respectively named after the diseases in which they 
 occur. (See above.) Cocco-bacteria are divided again into microsporina 
 and monadina. 
 
 Morphology. —In bodies so minute there cannot be great variety in 
 shape. The chief forms are delicate rods and granules. The former are 
 sometimes jointed, and the latter are frequently arranged in a chain-like 
 series. When a number of bacilli are joined end to end a thread-like ap- 
 pearance results. Masses of organisms occur termed zooglcea. The size 
 varies somewhat according to the species. 
 
 Parts they Inhabit. — Chiefly the blood-vessels. But those which are the 
 probable causes of local diseases are found only locally. The contents 
 and, still more, the walls of abscesses. Ogston says they are always to be 
 found in acute abscesses. Pyaemic deposits. The small metastatic de- 
 posits of pyaemia, puerperal fever, etc., consist of bacteria ; and the dis- 
 covery of this (by Eindfleisch) was "the first communication regarding the 
 occurrence of bacteria in the organs of those who have died of traumatic 
 infective diseases " (Koch). Granulations. Joint-surfaces. Serous mem- 
 branes. Diphtheritic exudations. Pus. Renal glomeruli and tubuli. In- 
 
 1 Made by Zeiss. 
 
MICROSCOPIC ORGANISM. 281 
 
 deed, every organ or tissue where the blood can penetrate appears to be 
 liable to invasion by some septic organism or another. The monadina 
 are actively movable, and penetrate the cells, causing considerable swell- 
 ing of them. 
 
 HOW DO THE ORGANISMS ENTER THE BODY, AND WHENCE DO THEY COME ? — 
 
 They do not exist normally in the healthy body. The best observers, those 
 who have added most positive information to our knowledge of minute 
 anatomy, have been quite unable to find them herein. The same class are 
 practically unanimous in rejecting the idea of spontaneous generation. 
 Many of the organisms enter seldom or never except through wounds or 
 slight abrasions, scratches or punctures. Others readily cling to and 
 grow into the cells of mucous membranes. Possibly some may have the 
 power of piercing skin, or at all events the skin of a person not in perfect 
 health. The organisms sometimes pass from one animal to another by 
 contact with secretions or excretions, or, in a few instances perhaps, 
 through the air. Some of the organisms exist constantly in certain locali- 
 ties in the air, the water, or the soil. Some cling to certain buildings, 
 perhaps to the walls, floors, ceilings, or furniture. 
 
 Do the Microscopic Organisms cause the Diseases, or are they merely acci- 
 dental concomitants, il parasites of the diseases" so to speak? — To answer the 
 first part of this question positively in the affirmative, it would be necessary 
 to demonstrate that (1) the organisms exist in every case of each disease ; 
 (2) that they exist also in sufficient numbers and in the proper localities to 
 cause the phenomena of the disease ; (3) that when transferred success- 
 fully and purely from one animal body to another of the same species they 
 reproduce the disease. Moreover, it would be very desirable to show that 
 the organisms of different diseases have themselves different morphologi- 
 cal peculiarities. The difficulties of fulfilling all these requirements are im- 
 mense ; but they have been overcome in the case of a sufficient number of 
 distinct diseases to encourage^ hope that ultimate success will attend the 
 investigation of the others. Finally, it should be noticed that Koch, hav- 
 ing produced pyaemia in mice, found that the micrococci adhered to the 
 red corpuscles, and that the red corpuscles thus affected tended to crowd 
 together in the capillaries. The ultimate result of this was thrombosis. 
 This, perhaps, explains the occurrence of " metastatic " abscesses in 
 pyaemia. 
 
 Many substances are fatal to every kind of bacteria. Such are carbolic 
 acid, oil of eucalyptus, salicylic acid, and iodoform. There are strong- 
 reasons for believing that certain substances are especially destructive to 
 particular species, e.g., quinine to bacillus malarise. Koch says that 
 "Eidam came to the conclusion that different forms of bacteria require 
 different conditions of nutriment, and that they behave differently toward 
 physical and chemical influences." But it is not too much to hope that the 
 marvellous resources of organic chemistry may soon prove to us that in 
 
282 OSTEOTOMY. 
 
 science, as in law, there is "no wrong without a remedy." The discoveries 
 of Pasteur, Chauveau, and Toussaint suggest the possibility of applying 
 the principle of inoculation as a prophylactic against many, if not all, spe- 
 cific organisms. Pasteur has shown that by the action of heat and oxygen, 
 organisms, deadly to certain animals, may be so modified that, while pre- 
 serving the power of infection, they can infect only mildly, and yet protect 
 the inoculated animal against future infection by more active organisms 
 of the same species. 
 
 In constructing the above, unfortunately, very imperfect account of 
 the present state of knowledge concerning a subject of absorbing interest 
 and vast importance, I have been chiefly indebted to Koch, on the "Etiol- 
 ogy of Traumatic Infective Diseases," translated for the New Sydenham 
 Society by Cheyne, and to the addresses of Pasteur and Klebs at the In- 
 ternational Congress, 1881. In these may be found the names of the 
 numerous workers who have discovered what is at present known of the 
 subject. 
 
 Charcot's Joint Disease. — Preceded by the "lightning pains," char- 
 acteristic of tabes dorsalis or locomotor ataxy. The limb near the affected 
 joint sometimes swells quickly and extensively, after some time returning 
 again to its normal size. Spontaneous dislocations. Fractures caused by 
 gentle movements. Accompanying signs of locomotor ataxy, e.g., more or 
 less inco-ordination of movements and loss of muscular sense. "The 
 very rapid and extreme wearing away of the articular extremities of the 
 bones is the principal character which, from an anatomico-pathological 
 point of view, distinguishes the arthropathies of ataxia from common 
 rheumatic arthritis (arthrite seche)." There is also little or no formation 
 of osteophytes. Excellent model and specimens in St. Thomas's Hospital 
 Museum. 
 
 Osteotomy. — A term now practically confined to the division of bone 
 for deformity, with, at most, the removal of ^ wedge-shaped piece. 
 
 Instruments. — Saws, osteotomes, and chisels. Saws are very narrow, 
 and either blades or chains. Osteotomes resemble chisels, but they are 
 bevelled on both surfaces, while the chisel proper is bevelled only on one. 
 The temper of the steel and angle of the bevel are of high importance in 
 the case of osteotomes and chisels. Improper instruments would easily 
 cause fatal results, or, at all events, splintering of bone, great shock, per- 
 haps failure to obtain the object aimed at, and occasionally a piece of the 
 chisel left in the bone. A proper osteotome can be driven by a mallet 
 through the femur of an ox without splintering the latter or damaging 
 itself. Never use a hammer. Osteotomes are used for simple division. 
 Chisels are entirely unfit for this purpose, except in the case of very small 
 bones, and should be reserved for removing wedge-shaped pieces. Place 
 limb on a sand-pillow (moistened just before operation and covered with 
 waterproof ). 
 
OSTEOTOMY. 283 
 
 Management of the Saw. — Adams' is commonly used. It has a shank 
 and is usually pointed. The soft structures are incised with a long tenot- 
 omy-knife down to the bone, and the periosteum is cut with the same 
 knife. The orifice of the incision is usually only half an inch long, or 
 even less. The knife being withdrawn, the saw is passed into the tunnel 
 just prepared for it and its cutting edge turned to the bone. The saw is 
 generally withdrawn when two-thirds of the bone are divided, then the 
 remainder is broken. 
 
 Use of the Osteotome. — Insert a scalpel right down to the bone at the 
 place to be divided. Wait two or three seconds, to give the muscles pen- 
 etrated time to quiet, then complete incision. Size of incision should at 
 first be large enough to admit finger. As operator gains experience he 
 will venture safely to dispense with this and pass in the osteotome alone. 
 Incise in line with the bone to be divided. Rotate osteotome when it 
 reaches the bone. Do this lightly so as not to damage the periosteum. 
 Hold handle of osteotome firmly in left hand, with ulnar border of that 
 hand against the skin of the limb. The direction and management of the 
 instrument vary with the site of operation. As a rule cut away from 
 large arteries and divide the hardest part of the bone first. When remov- 
 ing the osteotome, keep the thumb and first two fingers closed upon it, 
 and gradually work it out by alternate contractions and relaxations of the 
 other fingers. When two-thirds of the bone are divided the rest can usu- 
 ally be broken. 
 
 In using the chisel turn the bevelled side toward the wedge. If the 
 wedge is to be thick, cut a thin wedge first and chip away other pieces 
 from each side of the gap. 
 
 Never use either osteotome or chisel as a lever to break bone. Keep 
 saws, osteotomes, and chisels bright and free from rust, or they clean them- 
 selves in the bone. Check all hemorrhage before dressing. When both 
 limbs are osteotomized, the first wound can be compressed with an anti- 
 septic sponge and gauze bandage while the other is being operated on. 
 Operate strictly antiseptically. Cut away any projecting cellular tissue, 
 as it delays cicatrization. Use no drainage-tube unless some accidental 
 circumstance occurring during the operation leads you to expect sup- 
 puration. Healing usually takes place by organization of blood-clot 
 (see Wounds), but by granulation where cellular tissue is exposed uncov- 
 ered by blood. 
 
 After-treatment. — Take temperature morning and evening. A tempera- 
 ture of 101° demands inquiry. It may arise from some quite accidental 
 complication independent of the operation, or from a tight bandage, or 
 from an accidental sore-throat, or trivial ailment. If it cannot be thus ac- 
 counted for, expose and examine the wound. After osteotomy of the 
 lower limbs, unless the divided bone is supported in a firm plaster case, 
 some contrivance is useful to facilitate defecation, e.g., a mattress with a 
 
284 OSTEOTOMY. 
 
 movable central piece, or my stretcher. Immediately after the bone has 
 been divided it should at once be put into the position ultimately re- 
 quired. After osteotomy of the limbs, attend during the first twenty-four 
 and forty-eight hours very carefully to the state of the toes or fingers, as 
 the case may be. They should be free from numbness and obstructed 
 circulation. Permeation of discharge should be looked for from day to 
 day, though it seldom occurs after the first two days. So long as it is 
 absent the dressing does not need removal. 
 
 Genu-valgum, Osteotomy for. — Place of Incision for McEwen's Opera- 
 tion. — On the inner side of the limb, at a point where the two following 
 lines bisect one another : a line drawn a finger's breadth above the level 
 of the upper border of the external condyle, and a line drawn parallel to 
 and half-an-inch in front of the tendon of the adductor magnus. Manage- 
 ment of Osteotome. — To begin with, place it against posterior part of inner 
 border of femur and cut from behind, forward and outward, away from 
 femoral artery. Kemember that, just above the condyles, the outer bor- 
 der of the femur is thicker than the inner. 
 
 Place of Incision in Chiene's Operation. — "An incision two to three 
 inches in length is made over the tubercle" (that of the adductor magnus) 
 "and is carried upward for a sufficient distance." 
 
 The Wedge. — " The long axis of the wedge runs downward and out- 
 ward toward the notch between the condyles." 
 
 Grasp the tibia at its lower extremity, and by pressure inward bend the 
 neck of the bone attaching the condyle to the femur. (See Edinburgh 
 Medical Journal, 1878.) 
 
 Ogston's Operation for Genu-valgum. — If the genu-valgum be severe, 
 operate with the knee bent, otherwise with the knee extended. A tenot- 
 omy-knife is inserted at a point as far back as the level of the internal con- 
 dyloid ridge, and about four inches above the most prominent point of the 
 internal condyle. It is passed downward, outward, and forward, to the 
 notch between the two condyles, until the point can be felt projecting in 
 front of that notch. Before withdrawing it, the periosteum and cartilage 
 are incised. An Adams' saw is now passed in, and the internal condyle 
 sawn two-thirds off Now, extending the limb (if it has been flexed hither- 
 to), and using the tibia as a lever, with the operator's knee as a fulcrum, 
 the limb should be bent inward till the internal condyle cracks off and 
 slips upward. "With splints and pads place and keep the limb straight till 
 union has taken place. Commence passive motion about the end of the , 
 third week. Of course, use strict antiseptic treatment. (See Edinburgh 
 Medical Journal, March, 1877.) 
 
 Dressings, etc., of Osteotomies for Genu-valgum. — See general remarks 
 above. Well and judiciously padded box-splints are commonly used. But ? 
 as few or no changes of dressing are usually required, the limb can be 
 once for all fixed in a moulded case of plaster-of-Paris or similar material 
 
OVARIES. (BY MR. DORAN.) 285 
 
 Osteotomy for Ankylosis of Hip in a Bad Position. — If there be a good 
 neck to the femur, in other words, if the great trochanter appear to be set 
 far enough away from the os innominatum, divide the neck of the femur. 
 Otherwise operate below the great trochanter. 
 
 Division of Neck of Femur with an Osteotome. — Bisect a line between 
 the ant. sup. spine of ilium and the ant. sup. angle of the great trochanter. 
 At the point thus found pass in a sharp-pointed steel director backward, 
 inward, and a little downward till it stops at the neck of the femur. Along 
 this director pass a scalpel down to the bone ; first cut toward the tro- 
 chanter, then, rotating the director and reinserting the scalpel, cut toward 
 the ant. sup. spine. The incision should just admit the forefinger. Do 
 not withdraw the director till the osteotome is inserted. Botate osteotome 
 so as to bring it across the neck of the femur, cut nearly through and 
 break the rest. 
 
 Division of Neck of Femur with Saw (Adams' operation). — W. Adams 
 passes in a long tenotomy knife " a little above the top of the great tro- 
 chanter," and straight down to the neck of the femur. He divides the mus- 
 cles and " opens the capsular ligament freely." A narrow-bladed saw is 
 passed into the wound and across the front of the neck of the femur, with 
 its flat side against the bone. It is now turned on edge and the division 
 accomplished. 
 
 Extension by weight, and without any splint, after osteotomy of the 
 neck of the femur, is to be preferred. Sometimes a second weight pulling 
 outward from the upper third of the thigh adds to comfort. When it is 
 used a felt splint should be moulded to the inner side of the thigh to 
 distribute the pressure. Keep the foot perpendicular, or even a little in- 
 verted. 
 
 Removal of Wedge of Bone foe Curvature of Tibl\. — Use a chisel. 
 Make a single incision, the loose skin will permit this to be moved up and 
 down. The wedge need not go more than three-fourths through the bone. 
 Supposing it to be made at the apex of the angle of curvature, its upper 
 surface should be at right angles to the border of the tibia above, and its 
 lower surface at right angles to the border of the tibia below. When ad- 
 justing the bony surfaces avoid nipping muscle. The fibula can either be 
 broken or divided through a separate incision of the soft parts. See gen- 
 eral directions above. 
 
 Every commencing osteotomist should study McEwen's book. 
 
 Ovaries. 1 — Chief affections : inflammation, acute and chronic ; cystic 
 disease ; solid tumors. 
 
 Ovary, Acute Inflammation of. — Causes. — Gonorrhoea, sexual excesses, 
 exposure to cold, etc. Symptoms. — Severe pains in one or both iliac 
 
 1 Contributed by Mr. Alban Doran, Assistant Surgeon to the Samaritan Hos- 
 pital 
 
286 OVARIES. (BY MR. DORAN.) 
 
 fossa?, radiating to loins. By pressing the left hand on the iliac fossa, and 
 introducing two fingers of the light hand into the vagina, pressing up- 
 ward, the ovary may be felt between the right and left-hand finger — it 
 will be distinctly swollen, and very tender. Treatment. — Absolute rest 
 Leeches and poulticing to iliac fossa. 
 
 Ovary, Chronic Inflammation of. — Very insidious, and often begins 
 gradually ; not always preceded by acute symptoms, may end in cirrhotic 
 changes ; and is sometimes associated with persistent dysmenorrhcea so 
 intolerable that both ovaries, when thus affected, have been of late years 
 frequently removed, without always relieving the symptoms. Fixed pain 
 in iliac fossae, and detection of swollen ovary the chief signs of the dis- 
 ease, local complications infinite. Treatment. — Blisters, rest during period ; 
 observe closely the condition of surrounding viscera, and treat accord- 
 ingly. 
 
 Ovary, Cystic Disease of. — Pathology not yet absolutely settled. Cysts 
 that are evidently developed from enlargement and non-rupture of the 
 Graafian vesicles seldom appear to form a large tumor. Commonest form 
 is the multUocular cyst, originating in morbid changes in the stroma and 
 its vessels, and containing glairy fluid more or less colored ; contents may 
 be partly solid. Another type is the parovarian cyst, unilocular or nearly 
 so, and containing clear, watery, transparent fluid. A third is multilocular, 
 and contains exuberant papillary growths in its cavities. This also holds 
 clear fluid, and like the second kind, is believed to be developed from ves- 
 tigial relics of the Wolffian body. Lastly come dermoid cysts, containing 
 hair, sebaceous matter, teeth, bone, and walls lined with skin, bearing 
 complete glandular structures. 
 
 Symptoms. — Gradual distention of abdomen ; a prominent fluctuating 
 tumor occupies the hypogastric, umbilical, and often epigastric regions of 
 the abdomen, extending more or less into the flanks. May bulge into 
 Douglas's pouch, where it can be felt from the vagina, or may draw uterus 
 high up ; then it cannot be detected by vaginal examination. 
 
 Diagnosis. — From ascites: as the patient lies supine, the bulging and 
 dulness is in the front of the abdomen in cystic ovarian disease, in the 
 flanks in ascites ; in the latter resonance is altered by change of position, 
 but not in the case of ovarian cyst. From cystic kidney : in this disease 
 the dulness is very marked in one flank, and seldom extends far across the 
 median line to the opposite side of the abdomen. It may push the colon 
 forward, which may be detected, as a cord, or a tube resonant on percus- 
 sion, in front of it. From hydatid cysts : when in the liver, there is reso- 
 nance in the lower part of the abdomen, but abnornal dulness to the right 
 side above ; the fluctuating cysts project from the solid liver. When in 
 the great omentum, the abdomen becomes distended, but not prominent 
 anteriorly ; the small fluctuating cysts can be detected separately, feeling 
 on palpation like potatoes in a sack. In all cases of hydatid disease tap- 
 
OVARIES. (BY MR. DORAN.) 287 
 
 ping will procure the characteristic fluid. From fibro -cystic uterine tumors : 
 chiefly by introducing the sound into the uterus. If it move very inti- 
 mately with the tumor, that growth may be uterine, or else an ovarian cyst 
 with very close connections with the uterus. The diagnosis from soft solid 
 growths must depend on careful palpation. 
 
 Complications. — Inflammation of the cyst- wall, indicated by sudden at- 
 tacks of abdominal pain, and generally causing adhesions to abdominal 
 walls, omentum, or viscera. Suppuration of cyst, indicated by rigors. 
 Strangulation of cyst by twisting on its own pedicle, so as to obstruct its 
 nutrient vessels. If partial, this may cause diminution in size of cyst from 
 atrophy ; if complete, the cyst will slough, with fatal results if not relieved. 
 Rupture of cyst, from violence or from degeneration of its walls ; the tumor 
 gets suddenly smaller and less denned, with more or less severe abdominal 
 symptoms. 
 
 Treatment. — If the patient be very weak, and suffer from extreme dis- 
 tention, the tumor may be tapped, and the operation deferred for a few 
 weeks. It is always right to operate, and as early as possible, except 
 in cases of cysts that appear to contain solid malignant growths, and are 
 at the same time suspected of being intimately adherent to other struc- 
 tures. 
 
 Ovariotomy. — Place the patient on her back, with shoulders slightly 
 elevated. Make an incision a few inches long over the linea alba, begin- 
 ning about an inch below the umbilicus. Bleeding vessels are best secured 
 till the end of the operation by self-holding forceps, which check hemor- 
 rhage permanently. When the peritoneum is divided and the cyst ex- 
 posed, plunge the special trochar into the tumor, withdrawing fluid con- 
 tents through canula into a pail or other receptacle under the table. 
 Break down solid contents of cyst with hand introduced into the tumor. 
 If there be adhesions to parietal peritoneum, break them down with hand, 
 and secure any bleeding vessels ; adherent omentum must be cut away 
 and the vessels secured ; pelvic and visceral adhesions require great care 
 in separation. Then place two or three clean sponges into pelvic cavity 
 and above tumor. Raise the flaccid tumor out of the wound ; the pedicle 
 must then be transfixed (avoiding large veins) by a stout needle armed with 
 two stout silk threads. The ends of each thread on one side of the pedicle 
 must be crossed over each other, then tie the free ends round the opposite 
 Bides of the pedicle. If the outer border of the pedicle be very tense, 
 secure the ovarian vessels separately, else they will slip. The pedicle, if 
 very broad, may require a second transfixion, the threads must then be 
 crossed again on one side as before. Next cut the tumor away and drop 
 the pedicle. Search for the other ovary, and remove it, if it be distinctly 
 cystic. Then take out the sponges, and see if they show that there has 
 been fresh hemorrhage from separated adhesions ; use fresh sponges to 
 mop up any cystic fluid or clots that may have escaped into the cavity of 
 
288 HEREDITAKY SYPHILIS. 
 
 the peritoneum. Remove all forceps and sponges, count them, sew up 
 abdominal wound with silk thread or silkworm gut threaded to a needle 
 at each end, introducing the needles from the peritoneal side, and avoid- 
 ing the recti muscles. Some operators use the cautery instead of the 
 ligature for securing the pedicle ; the clamp is almost entirely discarded. 
 Lister's precautions valuable in this operation. In cases of strong ad- 
 hesions, with exudation from peritoneum after they have been separated, 
 pass a glass drainage-tube into Douglas's pouch through the abdominal 
 wound. 
 
 Ovaey, Solid Tumoes of the. — Fibroma or fibromyoma sometimes ob- 
 served in the ovary, Its occurrence there can be understood now that the 
 strong resemblance of the spindle-cells in the stroma to uterine tissue is 
 well recognized. Sarcomata and carcinomata from solid tumors distin- 
 guished from uterine growth by their being free from the uterus, as the 
 sound will detect. They are nearly always accompanied by ascites : the 
 health rapidly deteriorates. Treatment. — Fibromata and even malignant 
 tumors may be removed by ovariotomy. Abdominal wound must be 
 large, often extending above umbilicus ; the pedicle is generally very thick 
 and vascular. Never operate on malignant growths when there is much 
 ascites with large cells in the fluid, cedema of the abdominal walls, evi- 
 dence of strong adhesions, or marked cachexia. 
 
 Scarlatina not unfrequently complicates the after-course of operations 
 on children. It appears to differ little from ordinary scarlatina, provided 
 only nature or antiseptic treatment guards the little patient from coinci- 
 dent septicaemia. If anything, it is less dangerous than ordinary scarla- 
 tina. The subject has been extensively treated of late years in the journals 
 and hospital reports, and at the Societies, 1 by Messrs. Marsh, Howse, 
 Owen, etc. 
 
 Hereditary Syphilis (Congenital Syphilis). — In hereditary syphilis 
 the foetus either (1) dies early in utero, abortion taking place, or (2) is 
 born alive prematurely, or (3) is born dead at full term, or (4) is born ap- 
 parently healthy, the disease manifesting itself afterward. The more recent 
 the syphilis in the parents, the greater the danger to the infant. In the 
 case of syphilis of the placenta the fetal portion is much more commonly 
 affected than the maternal. Gummata are found therein in the form of 
 yellowish white tubercles. Hennig showed their intimate relation to the 
 vessels. The obliteration of the vessels, if extreme, interferes with aera- 
 tion of the fetal blood, thus producing death of the foetus (Frankel, quoted 
 by Baumler). Infants with congenital syphilis are generally in appearance 
 old, small, and shrivelled. They have snuffles, i.e., nasal catarrh, and erup- 
 tions. These, usually papular or roseolar, are sometimes bullae, but rarely 
 pustular, and very rarely vesicular. Bullae (pemphigus neonatorum syphi- 
 
 1 Also at the International Congress, London, 1881. 
 
VACCINO-SYPHILIS. 289 
 
 iticus) occur especially on palms and soles. This is a point in diagnosis. 
 Mucous tubercles at corners of mouth and eyes, in flexure of limbs, on neck 
 and behind ears. Characteristic eruptions are very copper-colored. Stoma- 
 titis. Mucous tubercles in mouth, throat, and larynx. Iritis sometimes, 
 especially about fifth month. Deafness occasionally. Osteochondritis. — 
 Important diagnostically, because it is often the only pathognomonic symp- 
 tom. It is caused by syphilis exclusively. Affects chiefly epiphyses of long 
 bones — femur, tibia, humerus, etc., clavicle, sternum, ribs. Epiphyseal 
 cartilages swell, and can be felt projecting as would a ring round the bone. 
 The swelling is usually smooth. Little or no pain or interference with 
 movement. Occasionally causes ulceration and necrosis. Is commonly 
 symmetrical. Leaves no ill effects if resolution takes place quickly. Other- 
 wise may permanently affect growth of limb. Period of its occurrence, 
 usually at birth or during first month. For a very full account read Bum- 
 sted and Taylor. But Wegner, of Berlin, first described it. Spleen is en- 
 larged in at least fifty per cent, of cases, and often accompanied by hyper- 
 trophy of liver (Gee). Later Effects. — About period of second dentition, or 
 about puberty (in girls especially), appear interstitial keratitis, serpiginous 
 ulcerations, eruptions almost rupial in character, ulcerations of throat and 
 hard palate, nodes, affections of viscera ; and certain nervous affections, 
 especially epilepsy, chorea, and even paralyses (Hughlings Jackson). The 
 characteristic signs present at this period, besides the manifestations just 
 mentioned, are certain relics of infantile syphilis, viz., flattened nose, pro- 
 jecting forehead, dull-colored skin, lines about the corners of the mouth, 
 and "Hutchinson's teeth." The peculiarities of the last are due to stomatitis 
 in infancy ; therefore, if the syphilitic infant escape stomatitis, it will es- 
 cape teeth deformity. The upper front permanent teeth are the most pecu- 
 liar, the central incisors especially. These converge toward each other, are 
 dirty looking, imperfectly covered with enamel, often small and short, and 
 are either notched or pegged on their cutting edges. Prognosis. — Depends 
 mainly on the severity of the symptoms. The worst cases usually die. 
 But most infants and adolescents (especially the former) with inherited 
 syphilis are strikingly amenable to treatment. Treatment is to be con- 
 ducted on exactly the same principles as that of acquired syphilis, q.v. 
 Children readily take hyd. c. creta, or respond to mercurial inunction. Al- 
 ways add iodide of potassium when bone is affected, and in the later mani- 
 festations. 
 
 Vaccino-Syphilis. — The chief practical points connected with this 
 subject are that (1) the child from whom the lymph is taken should not 
 be less than four months old ; (2) the lymph first drawn from the pustule 
 should be used ; (3) it should be clear, entirely free from any perceptible 
 admixture of pus or blood ; and, of course, (4) the appearance and history 
 of the child and its parents should be unimpeachable. But Keber, of 
 Dantzig, has shown that even clear vaccine lymph contains pus and blood- 
 19 
 
290 TOOTHACHE, 
 
 corpuscles, and in a small proportion of infants (5 in 158, Diday) congeni- 
 tal syphilis does not show itself till later even than the fourth month. 
 Lymph from the calf is much less likely (according to some certain) to be 
 free from any taint of syphilis. When syphilis is communicated by vac- 
 cination the pock runs its normal course, and no sign of specific infection 
 appears till about the twenty-eighth day. Refer to Hutchinson's " Illus- 
 trations of Clinical Surgery," fasc. vL ; and to Hugh Thompson, Glasgow 
 Medical Journal, 1879. 
 
 Toothache l is a pain arising from a lesion, either within or about 
 the region of a tooth. Causes. — Caries ; irritation of the pulp ; acute and 
 chronic inflammations of the tooth-pulp ; acute and chronic periodontitis ; 
 exostosis and necrosis. Symptoms. — When toothache arises from caries, 
 the pain is of a dull aching character, and is treated by the application of 
 creosote, morphia, mastiche, and various anodynes, which are inserted 
 into the cavity of the affected tooth, and then in a few days the carious 
 matter excavated, and metallic fillings placed in the tooth. In irritation of 
 the pulp the pain is the same as in the above affection, but is more pro- 
 longed, and is treated in the same manner. Toothache from acute inflam- 
 mation of the pulp is recognized by the pain, which is at first confined to 
 the affected tooth, being of a dull aching character, which soon becomes 
 more intense and lancinating, and appears to spread over entire side of 
 head and face. Disease is almost always accompanied by caries, and may 
 run on to suppuration and gangrene of the pulp. Treatment. — In children 
 the extraction of the offending tooth is generally called for ; but, in 
 adults, either application of arsenious acid, ■£$ of a grain, may be used to 
 hasten the destruction of the diseased pulp, or the constant and renewed 
 applications of carbolic acid on pellets of cotton-wool may attain the de- 
 sired end. The tooth may then be afterward filled. 
 
 Chronic Inflammation is generally the sequel of acute inflammation of 
 the tooth-pulp, and, if the occurrence is frequent, the tooth had better be 
 extracted. The pain is of a dull and gnawing kind. 
 
 Acute Periodontitis may arise from a blow, or be the sequel of acute 
 inflammation of the pulp, or may arise from constitutional causes, such as 
 rheumatism or scrofula. Pain commences with a feeling of uneasiness, 
 which increases to an aching, combined with great tenderness on pressure. 
 The tooth is felt long, neighboring teeth become involved, and the inflam- 
 mation spreads to the palate and cheek, which is swollen and cedematous. 
 Suppuration takes place, pus is formed, and an abscess may burst at any 
 point, either external or internal to the dental arch. Treatment. — If the 
 tooth is far involved in caries, extraction of the offender is the best remedy. 
 When it is desirable that the tooth should be retained, applications of 
 
 1 Contributed by Mr. L Lyons, Assistant Dental Surgeon to St. Bartholomew's 
 Hospital. 
 
TUBERCULOSIS. 291 
 
 poultices or poppy fomentations are of great benefit, but must be applied 
 inside the mouth only, and about the region of the affected tooth ; or local 
 bleeding by leeches, and free incisions, and the prescribing of such consti- 
 tutional remedies as may be indicated. 
 
 Chronic Periosteal Inflammation is generally the sequel of the above 
 disease. The character of pain is the same but more modified, and the 
 treatment is nearly always extraction of the tooth, 
 
 Dental Exostosis is an outgrowth of osseous tissue from the surface of 
 the cementum of the fang. The usual cause of it is chronic periodontitis. 
 The pain is of a neuralgic character. Extraction is the only available 
 remedy. 
 
 Necrosis arises when the fang of a tooth becomes denuded of its perios- 
 teum, and its most frequent cause is acute periodontitis. 
 
 Tuberculosis. — An excellent account, by Klein, of the present state 
 of knowledge concerning the infectious nature of tuberculosis is to be 
 found in the Practitioner for August, 1881. The chief practical points 
 are that (1) the possibility of infecting cattle, pigs, and sheep by feeding 
 with the meat, and even with the milk, of tuberculous animals has been 
 proved ; that (2) the materies morbi is present in gray or caseous tubercle, 
 and is not present in caseous matter which has not been derived from real 
 tubercle originally. The first point is made more important by the evi- 
 dence offered by Creighton of the transmissibility of bovine tuberculosis 
 to man by means of milk. All this lends probability to statements which 
 have over and over again been made of the infectiousness of phthisis. 
 Klebs and Schuller have observed that micrococci are constant in human 
 tubercular matter. 
 
NOTES ON OPHTHALMIC SURGERY, 
 
 BY HENRY JUIiEE, F.R.C.S., 
 
 SENIOB ASSISTANT STTRGEON, ROYAL WESTMINSTER OPHTHALMIC HOSPITAL ; BBMONSTBATOB OF ANAT- 
 OMY, ST. MABY'S HOSPITAL; CLINICAL A8SISTANT, BOYAL OPHTHALMIC HOSPITAL, MOOBFIKLDS. 
 
 Cataract — Central, Cortical, Lamellar, Capsular, Traumatic, Secondary. Opera- 
 tions. Spectacles. 
 
 Choroid — Hyperaemia, Choroiditis, Sclerotico-Choroiditis Posterior, Tubercle, Tu- 
 mors, Bone Formation, Coloboma, Rupture. 
 
 Ciliary Region — Sympathetic Irritation, Sympathetic Ophthalmitis. 
 
 Conjunctiva — Ophthalmia, Neonatorum, Gonorrhoea^ Mucopurulent, Diphtheritic, 
 Granular. Xerophthalmia. Pinguecala. Pterygium. 
 
 Cornea — Local Keratitis, Ulceration, Hypopion, Onyx, Syphilitic Keratitis, Punctate 
 Keratitis, Arcus Senilis, Pannus, Periotomy, Conical Cornea, Wounds. 
 
 Eyelids — Blepharitis, Stye, Tarsal Tumor, Warts, Rodent Ulcer, Syphilitic Ulcer, 
 Lupus, Naevus, Ptosis, Trichiasis, Symblepharon, Entropion, Ectropion. 
 
 Glaucoma — Acute, Chronic, Secondary. 
 
 Iris — Iritis, Iridectomy, Iridotomy, Iridodesis, Prolapse, Coredialysis, Congenital 
 Irideremia, Coloboma, Mydriasis, Myosis. 
 
 Lachrymal Apparatus — Mucocele, Stricture of Nasal Duct, Fistula of Lachrymal 
 Sac. Lachrymal Gland, Diseases of, Excision of. 
 
 Optic Nerve — Optic Neuritis, Atrophy. 
 
 Retina— Retinitis, Syphilitic, Albuminuric, Apoplectic, Pigmented. Detachment. 
 Glioma. 
 
 Refraction — Emmetropia, Ametropia, Presbyopia, Myopia, Hypermetropia, Astig- 
 matism. 
 
 Strabismus — Internal, External, Operation. 
 
 Cataract is an opacity of the crystalline lens. Various classifications 
 are used. The following is perhaps the best : (1) Central ; (2) Cortical ; 
 (3) Lamellar ; (4) Capsular ; (5) Traumatic ; (6) Secondary. 
 
 1. Central or Nuclear. — Opacity begins at the centre and shades off 
 toward circumference. It mostly occurs in old people, when it is hard at 
 the centre and of amber color. When occurring before the age of thirty- 
 five it is softer and whiter. 
 
 2. Cortical or Radlvting. — Opacity begins at the surface of lens as 
 triangular or pyramidal streaks pointing toward centre. When advanced 
 they involve whole structure of lens. 
 
CATARACT. 293 
 
 3. Lamellar or Zonular. — Opacity consists of a shell-like layer depos- 
 ited within the substance of the lens at a variable distance from its sur- 
 face. It occurs in very young subjects (1 to 3 months), and is sometimes 
 congenital ; the subjects of it frequently suffer from infantile convulsions. 
 
 4. Capsular. — (a) Pyramidal; (b) Posterior Polar, (a) Pyramidal. — 
 Occurs as a very white well-defined opacity on front part of lens just 
 beneath the capsule. It is generally caused by ulcer of cornea follow- 
 ing purulent ophthalmia, and, consequently, is generally associated with 
 opacity of cornea, (b) Posterior Polar. — Begins at posterior part of chief 
 axis of lens and radiates ; generally associated with disease of choroid and 
 vitreous. 
 
 5. Traumatic. — Follows wound of the lens capsule by which the aque- 
 ous humor is admitted to the lens substance, causing swelling, opacity, and 
 final absorption of this, and leaving only a chalk-like deposit upon the re- 
 maining capsule. 
 
 6. Secondary Cataract is so called when it is the result of some other 
 local disease, as glaucoma, irido-cyclitis, etc., or of some general disease, 
 as diabetes mellitus. 
 
 Any combination of the above forms would be called a mixed cataract. 
 The degree of hardness of a cataract depends chiefly upon the age of the 
 patient, all cataracts occurring before the age of thirty-five being " soft." 
 
 Diagnosis. — Gradual failure of sight without local inflammatory symp- 
 toms is a subjective indication of cataract. A grayish appearance of the 
 pupil is often observed in old people, which is not due to cataract, the lens 
 being transparent. When the presence of cataract is suspected the pu- 
 pil should be dilated by atropine and examined. (1) By daylight, dif- 
 fused rays condensed upon the pupil with a convex lens. (2) By gaslight 
 in a similar way. These will give a white, amber-like, or brownish ap- 
 pearance of lens. (3) By the ophthalmoscope, when the opacity of lens 
 will appear as dark patches, streaks, or a central nucleus ; the red cho- 
 roidal reflex will only be observed inversely as the amount of opacity. In 
 lamellar cataract, a well-defined shell of opacity appears, surrounded by a 
 clear (cortical) layer of lens substance, through which the bright red cho- 
 roidal reflex is observed. When any portion of the lens substance remains 
 clear, note should be made as to the state of the vitreous, optic disc, ret- 
 ina, and choroid, with a view to probable fitness for future operatioo. 
 Opacities of cornea will also appear as dark patches with ophthalmoscope, 
 and may be seen by superficial examination. Opacities of vitreous appear 
 as moving bodies, and are distinguished by their continuing to move after 
 the patient's eye has suddenly come to rest. 
 
 Treatment. — In early stages of nuclear cataract the sight may often be 
 improved by moderate dilatation of the pupil by atropine. Use atropine 
 drops, gr. iv. ad § j., once or twice a week. Dark spectacles may be worn 
 to favor dilatation of the pupil. In lamellar cataract patient can often 
 
294 CATARACT. 
 
 see fairly welL When vision is seriously impaired and the margin oi 
 translucency is wide, make an artificial pupil by iridectomy ; when the 
 margin is narrow, perform the operation of solution, or of extraction. In 
 forms other than lamellar, sight can be restored only by one of the follow- 
 ing methods of operating on the lens : (1) Extraction ; (2) Needle opera- 
 tion ; (3) Suction. (1) Extraction. — Various methods are in use at the pres- 
 ent time, but all have the following common points : (1) An incision in 
 the cornea or at the junction of the cornea and sclerotic, or in the sclerotic 
 just beyond the cornea, sufficiently large to allow exit of lens. The inci- 
 sion is usually made with Von Graefe's straight knife. (2) Iridectomy is 
 very frequently performed, either as a second stage of the operation or 
 two or three weeks previously. This is done to lessen the danger of iri- 
 tis, which more frequently follows the older operation in which iridectomy 
 was not performed. (3) The capsule is freely ruptured by a sharp-pointed 
 instrument introduced through the corneal wound. (4) The lens is re- 
 moved through the torn capsule, either by pressure and manipulation out- 
 side the eye or by means of a scoop passed behind the lens. The chief 
 types of operation for extraction are : (1) Graefe's Modified Linear or Periph- 
 eral Linear. — Here the incision is made with a long, narrow knife, slightly 
 beyond the sclero-corneal junction, involving conjunctiva and forming a 
 small arc of a circle larger than the cornea, the plane of incision forms a 
 large angle with that of the iris. Iridectomy follows the incision. (2) 
 The incision has nearly the same curve as the above, but is not carried 
 so far toward sclerotic, being mostly in the cornea. Iridectomy is not 
 usually performed here. (3) Flap Operation (old). — Incision just within 
 margin of cornea, and concentric with it, equal to half its circumference, 
 and parallel to plane of iris. Beer's triangular knife. No iridectomy. 
 Disadvantages of modified linear operation : Frequent hemorrhage into 
 anterior chamber. Greater risk of loss of vitreous. Eisk of irritability 
 from prolapse of iris into corners of wound, and of sympathetic ophthal- 
 mitis in the other eye. Disadvantages of the old flap operation : The 
 large flap is liable to gape or fall forward, causing sloughing. Frequent 
 prolapse of iris. Frequent severe iritis. After-treatment for either of 
 these methods. — Keep the patient in bed for a week. Apply a piece of 
 soft linen to the closed eyelids, and a pad of cotton wool over this to both 
 eyes, and secure by a four-tailed bandage. Keep the room nearly dark. 
 Remove dressing, and gently cleanse the lids with warm water twice daily, 
 just separating their edges to allow escape of tears that may be retained. 
 Use one drop of atropine solution daily after the third day to prevent iritic 
 adhesion. During the first few hours there will be some soreness, and the 
 first dressing a little blood-stained ; after this there should be no pain, and 
 only a little mucous discharge. If doing well there will be slight conges- 
 tion, but no chemosis, edges of wound united, and pupil black. Discon- 
 tinue bandage after eight or ten days, and order a large shade. 
 
CATARACT. 295 
 
 2. Needle Operation for Solution.— (1) Dilate pupil by atropine. (2) 
 Give anaesthetic unless the patient is old enough to control himself well. 
 (3) Hold lids open by stop-speculum, and use fixation forceps to steady 
 globe. (4) Direct a fine cataract needle to a point just within the margin 
 of the cornea, plunge freely and obliquely through into anterior chamber, 
 and carry point to centre of pupil. (5) Dip point of needle back through 
 the capsule into superficial layers of lens at centre, make a few gentle to 
 and fro movements, so as to break up its substance, then steadily withdraw 
 the needle. After-treatment.— Dilate the pupil with atropine (gr. iv. ad 
 
 I j.) three times daily. Bandage the eye lightly, and employ dark room 
 for several days. In case of iritis apply leeches to region of eye, and ice 
 or evaporating lotions to lids. The result varies with the amount of the 
 opacity of the lens. In cases of complete cataract no marked change will 
 be observed for some weeks after operation. In partial cataract the rup- 
 tured portion of the lens will become opaque and swollen in a few days, 
 and in seven weeks the lens will be smaller. After six to eight weeks, if 
 the eye be perfectly quiescent, and not otherwise, the operation may be 
 repeated, and the needle used more freely. A third or fourth operation 
 may be required. 
 
 3. Suction Operation. — Only applicable to soft cataract, and requires 
 great skill in its performance, to avoid danger of iritis, or cyclitis. (1) 
 Dilate pupil with atropine. (2) Make oblique opening in cornea with a 
 broad-cutting needle between its centre and its margin, and lacerate cap- 
 sule freely. (3) Withdraw needle and pass nozzle of syringe through 
 wound, and dip into lacerated lens-substance. In lamellar cataract, and 
 some other cases, it is necessary to allow an interval of three days between 
 the needle operation and the suction, in order that the lens may be soft- 
 ened by the admission of the aqueous. (4) Use very gentle suction, and 
 remove if possible the whole of lens-substance at one sitting. After-treat- 
 ment is the same as for needle operation (but in the case of waiting, careful 
 watch must be made, and suction performed at once if inflammation be set 
 up by the rapid swelling of the lens). 
 
 When to Perform Extraction.— The more complete the opacity of the 
 lens, the more easily is it shelled out of its capsule, whilst in immature 
 cataract some of the transparent lens-substance is apt to remain ; this 
 will become opaque and may interfere with result of operation. The 
 signs of this " ripe " condition are : (1) No shadow of iris thrown upon 
 lens within the pupillary area ; (2) no choroidal reflex with ophthalmo- 
 scope ; (3) patient is able to distinguish light from darkness, but is un- 
 able to count fingers when held up before the eyes. When one eye only 
 is affected, or when one is less affected than the other, extraction should 
 be deferred until the better eye is no longer useful, unless for special 
 reasons. WTien both cataracts are mature, only one should be operated on 
 at a time, with an interval of a few months. When there is no percep- 
 
296 CHOEOID. 
 
 tion of light do not operate, as cataract alone is not sufficient to prevent 
 this. 
 
 Occasional Results of Extraction. — 1. Sloughing of cornea, very rare 
 since flap operation was abandoned. 2. Suppurative inflammation extend- 
 ing from wound to the whole cornea, iris, and vitreous, variable in degree, 
 but, when established, generally going on to suppurative panophthalmitis, 
 or to severe plastic irido-cyclitis with corneal opacity and contraction of 
 eyeball. 3. Iritis of a plastic nature which deposits a membrane in pupil- 
 lary area. 4. Prolapse of iris into the wound, either at the time of opera- 
 tion or afterward. 
 
 Conditions of Sight after Operation. — Results are good when, with the 
 aid of proper spectacles, patient can read any of Snellen's test types from 
 No. 1 to No. 14 at 22 centimetres (8 inches), and from No. 6 to No. 24 at 
 6 metres (20 feet). The operation renders the eye very hypermetropic for 
 want of the lens. Very strong convex glasses are required to compensate 
 for its absence. Glasses should not be worn for three months after opera- 
 tion, and then not continuously at first. Two pairs of spectacles are needed, 
 one pair making the eye emmetropic and giving clear vision for distant 
 objects (about + 12 dioptres), the other pair stronger, to render the eye 
 myopic, so that the patient is able to read, etc., at about 8 or 10 inches 
 (about -f 16 dioptres). 
 
 Choroid. — Diseases. — 1, Hypercemia ; 2, Choroiditis ; 3, Sclerotico- 
 choroiditis Posterior ; 4, Tubercle ; 5, Tumors ; 6, Bone Formation ; 7, Colo- 
 boma ; 8, Rupture. 
 
 Choroiditis may be (1) Syphilitic, (2) Simple, (3) Suppurative. 
 
 Syphilitic Choroiditis is the most common. It is characterized by the 
 presence of numerous distinct patches scattered about fundus, but most 
 abundant toward periphery ; they are at first of a yellowish red appear- 
 ance, which soon changes to yellowish white or glistening white, accord- 
 ing to the extent of choroidal atrophy. The patches are more or less pig- 
 mented. Vision is affected in proportion to the extent of the disease. 
 Usually no pain. Generally a history of acquired or inherited syphilis. 
 Treatment. — Mercury combined with iodide of potassium. Rest of eyes 
 by means of dark room. Artificial leech or dry cupping to temples. In 
 the early stage mercury does great good, and in old cases where failure of 
 sight is increasing it should be given. Prognosis, guarded. 
 
 Simple Choroiditis. — In this form the patches of atrophy are similarly 
 distributed but are confluent (compare with syphilitic form). Or, large 
 areas of incomplete atrophy are interspersed with separate patches, or 
 there may be a widespread superficial atrophy with pigmentation. The 
 field of vision is here also affected in proportion to bhe change. 
 
 Suppurative Choroiditis is acute, and occurs in conjunction with similar 
 inflammation of neighboring parts (panophthalmitis). 
 
 Sclerotico-choroiditis Posterior is limited to the regions of the optio 
 
 *k 
 
CILIARY REGION. 297 
 
 disc and yellow spot, which present many varieties of localized change. It 
 is common in myopic eyes, and the appearances thus produced are known 
 as "posterior staphyloma," "myopic crescent," etc. 
 
 Tubercle of Choroid appears in the form of small circular, circum- 
 scribed spots (0.3 to 2.5 mm.), situated chiefly in the region of optic disc. 
 
 Tumors. — 1, Sarcoma ; 2, Carcinoma. 
 
 Bone Formation sometimes occurs on the inner surface of choroid of 
 eyes which have been long destroyed ; it varies in thickness from a mere 
 film to a dense osseous cup. 
 
 Rupture of Choroid may occur from a blow on the globe and may 
 exist with or without rupture of other coats. Hemorrhage at once occurs, 
 and blood may be effused (1) between choroid and retina ; (2) between 
 choroid and sclerotic ; (3) into vitreous. 
 
 Ciliary Region. — Sympathetic Irritation and Sympathetic Ophthalmi- 
 tis. — In sympathetic irritation the changes in the sympathizing eye are 
 chiefly functional. In sympathetic ophthalmitis they are of a destructive 
 inflammatory kind. 
 
 Pathology. — The exact mode of transmission from the exciting to the 
 sympathizing eye is not well known. Very interesting facts are known. 
 
 1. The change commences in the region of the ciliary body and iris of 
 the exciting eye, and its effects are mostly seen in the corresponding part 
 of the sympathizing eye. This region is richly supplied by branches of 
 ciliary nerves (fifth, sympathetic, and third). 
 
 2. In exciting eye inflammatory changes are always found, and in some 
 cases have been found to extend to the ciliary nerves. It is considered 
 probable that the disease passes along the ciliary nerves, probably as neu- 
 ritis, to some nerve-centre, and thence to the other eye. 
 
 3. The optic nerve is considered to have no part in the transmission of 
 the inflammation ; but the space between the dural and pial sheaths of the 
 optic nerve is a probable channel of communication. 
 
 Symptoms in Sympathizing Eye. — 1. Irritation. — Eye extremely weak 
 and irritable ; patient may be able to read No. 1 of Snellen's type, but soon 
 becomes tired, because the power of prolonged accommodation fails. Eye 
 sometimes reddened, may be watery ; neuralgic pains common. Iris not 
 affected. No plastic exudation nor disorganizing changes take place. Liable 
 to recur. Excision of exciting eye at once cures the disease. 
 
 2. Ophthalmitis. — Begins from one to three months, or more, after 
 affection of exciting eye. May be ushered in by irritation. May be well 
 marked from the first, or may commence in a manner so insidious as to 
 escape notice. It consists chiefly of irido-cyclitis or irido-choroiditis, the 
 iritis evincing a tendency to the formation of tough and extensive syne- 
 chia. There is a zone of ciliary congestion. Thickening and muddy ap- 
 pearance of iris. Tendency to formation of dots of opacity (keratitis 
 punctata) on the posterior layer of the cornea. The vitreous, when the 
 
298 CONJUNCTIVA. 
 
 condition of the pupil allows it to be seen, presents floating opacities. 
 There may be neuro-retinitis. Tension of globe often increased. In the 
 mildest forms of the disease there may be only slight serous iritis. In se- 
 vere cases the eye either shrinks or may become glaucomatous with bulging 
 of the sclerotic, total posterior synechia, secondary cataract. 
 
 Treatment. — 1. When there is, as yet, neither sympathetic irritation nor 
 sympathetic ophthalmitis, the injured eye must be watched as to the seat 
 of its inflammation, and, if this is found to threaten the iris and ciliary re- 
 gion, precaution must be taken to do all that is possible to subdue it. 
 Atropine should be applied. Patient kept in dark room for long period ; 
 eye bandaged. Mild mercurials and iodide of potassium internally. 
 
 2. If irritation is set up, the foregoing remedies to be applied to both 
 eyes, and if the exciting eye is past hope of recovery it should be excised at 
 once. 
 
 3. If ophthalmitis is established and exciting eye quite blind it should 
 be excised at once ; but if any useful sight remains it should be saved, as 
 it may prove the better eye in the end. 
 
 In the latter case do all you can to save both the exciting and the sym- 
 pathizing eye. (1) Use atropine drops every few hours ; (2) rest the eyes 
 by exclusion of light ; (3) apply leeches, blisters, warm fomentations, etc. ; 
 (4) give mercurials. 
 
 Do not perform any operation on the eye until inflammation has sub- 
 sided. 
 
 Conjunctiva. — Ophthalmia. — This term is applied to all forms of con- 
 junctivitis. Chief forms are — 1, Purulent; 2, Jluco-purulent ; 3, Membra- 
 nous; 4, Granular. 
 
 Purulent Ophthalmia is generally due to contact with pus from the 
 urethra or vagina, which may be gonorrhceal or otherwise. The quality of 
 the infecting discharge greatly influences the nature of the ophthalmia. 
 "When caused by gonorrhoea the course is very violent. When occurring in 
 newly bom children it is called O. neonatorum. 
 
 Symptoms. — In from twelve to forty-eight hours after infection there 
 are itching and slight injection of the conjunctiva, these soon become in- 
 tense ; then chemosis, tense swelling of the lids, great pain and discharge, 
 at first serous, then turbid, then uniformly purulent. If untreated the 
 discharge ceases in about six weeks, leaving the palpebral conjunctiva 
 thickened, relaxed, and more or less granular. Cicatricial changes follow. 
 The cornea is in danger from two chief causes, viz.: (1) strangulation of 
 the vessels from pressure, and (2) the influence of the discharge. If with- 
 in the first few days the cornea be hazy and dull, it may partly or entirely 
 slough. In milder cases transparent ulcers may appear and sometimes 
 cause perforation. In many cases no corneal opacity occurs. 
 
 Treatment. — When one eye only is affected, carefully protect the other 
 by a watch-glass strapped on. Frequently and thoroughly remove the 
 
conjunctiva. 299 
 
 discharge by free douching with water. Use astringent or caustic lotions 
 or drops every hour in severe cases, e.g., lotio aluminis, gr. x. ad 3 j.; lo- 
 tio zinci, gr. x. ad 3 j.; lotio hydrarg. perchlor., gr. $ ad § j.; lotio argent, 
 nit., gr. ij. ad 3 j. Apply simple ointment to the eyelids to prevent adhesion. 
 Evert the lids and brush a strong solution of nitrate of silver (gr. x. or xx. 
 ad 1 j.) freely over the conjunctiva once daily, and well wash off immedi- 
 ately afterward either with water or with solution of common salt. Repeat 
 less frequently as the discharge diminishes. In cases where the lids are 
 so swollen that nothing can be applied to their conjunctival surfaces, the 
 outer canthus can be divided, or Mr. Critchett's method of dividing the 
 upper lid by a vertical incision can be adopted. 
 
 Treatment should be continued as long as any discharge or granula- 
 tions remain on the lids, for fear of a relapse which is apt to occur. 
 
 Muco-purulent Ophthalmia (Catarrhal Ophthalmia). — Very common, 
 very contagious, mostly attacks both eyes, differs in severity in members of 
 the same household, who are generally attacked at the same time. Symp- 
 toms. — Congestion of conjunctiva, with patches of ecchymosis. Gritty 
 pain, sometimes severe. Spasm of lids. Free muco-purulent discharge. 
 Lids somewhat swollen and red, never tense. The cornea seldom suffers. 
 Spontaneous recovery takes place in about two weeks. Treatment. — Any 
 mild astringent lotion or drops will cut the malady short. An outbreak 
 of this malady in a crowded community is serious. Very common in pau- 
 per schools. 
 
 Membranous Ophthalmia (Diphtheritic Ophthalmia). — Very rare in this 
 country, and must not be confused with muco-purulent or purulent oph- 
 thalmia, in which there is often a distinct layer of inspissated pus beneath 
 the lids. In membranous ophthalmia the whole thickness of the conjunc- 
 tiva is occupied by a solid exudation, which is called " diphtheritic " by 
 some surgeons. It may appear in patches, or may cover all the whole in- 
 side of the lids. 
 
 Granular Ophthalmia. — Very common. Symptoms. — Firstly, appear- 
 ance as of small granules like sago-grains on the inner surface of the lower 
 lid, due to inflamed lymphatic follicles. These extend to upper lid ; then 
 progressive changes in the palpebral conjunctiva in which it becomes thick- 
 ened, vascular, and roughened by granular elevations. New tissue is 
 formed in the deep parts of the conjunctiva, which afterward is partly ab- 
 sorbed, and partly undergoes cicatricial contraction. Causes. — Feeble 
 health. Prolonged residence in badly-ventilated dwellings. Treatment. 
 — Generally tedious. Evert the eyelids and apply a solution of nitrate of 
 silver (gr. xx. ad 3 j.) with camel's-hair brush, once, twice, or thrice a week; 
 or apply the mitigated nitrate of silver stick ; in each case wash the lids 
 with water before inverting them. Solid sulphate of copper may be used 
 instead of these. Glycerine of tannin applied daily is beneficial. Results. — 
 (1) Haziness of cornea ; (2) Pannus (see cornea) ; (3) Entropion, Trichiasis. 
 
300 CORNEA. 
 
 Xerophthalmia (Xerosis, Cuticlar Conjunctiva) is a condition of exces* 
 sive dryness of the ocular and palpebral conjunctivae. 
 
 Pterygium is a triangular patch of thickened conjunctiva, generally 
 placed opposite the palpebral fissure, its apex pointing to or encroaching 
 upon the cornea. Rare in this country. Treatment. — Dissect up from 
 apex and transplant it into a cleft below the cornea. This is said to be 
 more effectual than excision or ligature. 
 
 Pinguecula, a harmless patch of yellowish white thickened conjunctiva 
 situated near margin of cornea. 
 Lupus may occur on conjunctiva. 
 
 Warts are sometimes seen on the ocular and palpebral conjunctiva? ; 
 they are cauliflower excrescences. To be snipped off with scissors. 
 Epithelioma and Sarcoma may occur on the conjunctiva. 
 Cornea. — Inflammation of the cornea may be circumscribed or diffused, 
 may involve its proper layers, or may be confined to its anterior or poste- 
 rior epithelial layer. It may be local, leading generally to suppuration or 
 ulceration, or it may arise from constitutional disease, as inherited syphilis. 
 It may exist with other inflammations, as in kerato-iritis, cyclo-iritis. 
 
 Local Keratitis (Corneitis). — Symptoms. — Commences with a more or 
 less perfect zone of pinkish-red vessels around the margin of the cornea. 
 Photophobia more or less severe. Cornea becomes hazy, and has a steamy 
 or ground-glass appearance. Generally there is lachrymation, and fre- 
 quently pain in and around the eye. Pathology.— The intercellular sub- 
 stance becomes opaque from infiltration with leucocytes, which are sup- 
 posed to have emigrated from the surrounding vessels. The cells of the 
 corneal tissue proper also undergo proliferation into small corpuscles, 
 greatly resembling leucocytes. The disease often has a tendency toward 
 recovery, but more frequently leads to suppuration and ulceration. 
 
 Ulceration of Cornea is preceded by inflammatory infiltration, and the 
 inflamed part breaks down at the centre, forming an ulcer with more 
 or less infiltrated base and edges. Symptoms. — Photophobia, congestion 
 more or less, consisting of a circular zone of vessels beneath the conjunc- 
 tiva at periphery of cornea, and sometimes also of conjunctival vessels. 
 Pain sometimes acute, 
 
 Ulcers may be (1) small and central, with infiltration of base and edges. 
 These generally heal quickly, but leave a hazy (nebula) or an opaque spot 
 (leucoma). 
 
 2. Small and central, without much infiltration. These heal slowly and 
 with loss of tissue, perhaps without opacity, but give & facetted appearance 
 to the cornea. 
 
 3. Phlyctenular ulcers (Herpes corneae). 
 
 4. Serpiginous ulcers. 
 
 5. Acute suppurating ulcer following abscess or otherwise. Treatment. 
 — First secure rest, either by bandaging the affected eye, and so reducing 
 
CORNEA. 301 
 
 friction against eyelids, or by shading both eyes. Soothe local pain by 
 atropine drops. In suppurating cases apply hot fomentations to lids ; if 
 abscess is defined, open by valvular incision. When indolent, stimulate 
 ulcer by astringent drops, ointment of yellow oxide of mercury, calomel 
 powder, eserine drops (gr. iij. ad. § j.), etc. 
 
 Counter-irritants to temple, as seton or blister. Constitutional treat- 
 ment. 
 
 Hypopion signifies a collection of pus or purolymph in the lowest part 
 of the anterior chamber. The pus is derived (1) from the rupture of an 
 abscess through the posterior layer of the cornea ; (2) from suppuration of 
 the epitheloid layer covering Descemets' membrane ; (3) from surface of iris. 
 
 Onyx is a term applied to that condition in which pus is observed be- 
 tween the layers of the cornea at its lower part. 
 
 SYPHrLmc Kekatitis (Interstitial K. Parenchymatous K.). — Symptoms. 
 — The visible changes of the cornea are usually preceded for a few days by 
 some ciliary congestion and lachrymation ; then there is cloudiness in one 
 or more patches, and after a few weeks a ground-glass appearance. Fre- 
 quently accompanied by iritis and posterior synechia. Blood-vessels often 
 appear in the layers of the cornea, extending from the ciliary vessels ; they 
 are thickly set in patches (salmon patches) of a reddish pink color, and of 
 various shapes ; they may extend all over the cornea, except, perhaps, to 
 the immediate centre. The disease is always symmetrical (contrast with 
 local keratitis), but second eye is usually attacked a few weeks after the 
 first. Age generally between six and fifteen. Often accompanied by in- 
 flammation of the ciliary region and iris, which may give rise to secondary 
 glaucoma, to stretching and elongation of the globe in the ciliary zone, or 
 to softening of the eyeball ; but, as a rule, the cornea throughout its whole 
 structure undergoes a chronic inflammation, showing no tendency either 
 to suppuration or ulceration, the inflammatory products being partially or 
 entirely absorbed after several months. Cause. — Inherited syphilis. Other 
 signs of inherited syphilis are usually present. (See Congenital Syphilis.) 
 
 If no other signs are shown in the patient, a history of infantile syphilis 
 can generally be ascertained, either in the patient or his brothers and 
 sisters ; or a history of acquired syphilis in the parents may be traced. A 
 few cases have been seen in which this disease has occurred as the result of 
 acquired syphilis. 
 
 Treatment. — A long but mild course of mercury. Mercurial inunction, 
 gray powder, blue pill, etc. Iodide of potassium may be combined with 
 these. Keep a strict watch against salivation. If the patient be anaemic 
 or strumous, give iodide of iron, bark, quinine, etc. Keep the eyes shaded. 
 Use atropine drops daily, as iritis may occur without being detected 
 through the opaque cornea. When inflammation has subsided, apply 
 calomel powder or ointment of yellow oxide of mercury to the cornea 
 daily, in order to promote the absorption of the opacity. 
 
302 EYELIDS. 
 
 Keratitis Punctata is characterized by the presence of small dots of 
 opacity on the posterior elastic lamina of the cornea. They are generally 
 arranged in the form of a triangle, having its apex at the centre, and its 
 base toward the lower margin of the cornea. This condition is generally 
 secondary to some form of inflammation of iris. It is frequently seen in 
 sympathetic ophthalmitis. 
 
 Arcus senilis is caused by fatty degeneration of the corneal tissue just 
 within its margin. 
 
 Pannus is the result of friction from a granular condition of the upper 
 lid, trichiasis, etc. It is characterized by haziness of the cornea, with 
 vascularity, the vessels being continuous with those of the conjunctiva, and 
 the anterior layers of the cornea more or less infiltrated with plastic mat- 
 ter. Treatment. — 1. Try to cure the granular lids. 2. The operation of 
 syndectomy or peritomy — that is, the removal of a zone of conjunctival and 
 sub-conjunctival tissue from around the cornea — is strongly recommended 
 by Mr. Critchett in old intractable cases of pannus. 3. Very severe and 
 universal pannus is best treated by inoculation with pus from purulent 
 ophthalmia, or even from gonorrhceal discharge. It is a severe remedy, 
 and may be followed by sloughing of cornea. It should never be resorted 
 to if there is any portion of the cornea transparent. 
 
 Conical Cornea is caused by a bulging forward of the central part of 
 the cornea forming a blunt conical curve, which gives rise to irregular 
 astigmatism and myopia. In advanced cases the protrusion of the cornea 
 is very evident, and the apex of the cone may become nebulous. In some 
 cases vision may be improved by concave glasses in combination with a 
 screen having a narrow slit or small hole in it. In advanced cases opera- 
 tion is needed : (1) Graefe's. Shave off apex without entering anterior 
 chamber, then apply mitigated nitrate of silver stick to the raw surface to 
 cause ulceration and cicatrization. (2) Cut off apex with a cataract knife, 
 enter anterior chamber, leave wound to unite by itself or use sutures ; use 
 atropine drops. 
 
 Wounds of Cornea. — When penetrating, if iris is prolapsed push it back 
 with a blunt instrument, and order atropine drops ; if iris not protruding, 
 order atropine drops. If only abraded, still order atropine drops. Close 
 the eye with a bandage to prevent friction. 
 
 Eyelids. — Blepharitis, Stye, Tarsal Tumors, Warty Growths, Molluscum 
 Contagiosum, Ulcers, Rodent Ulcer, Ptosis, Ectropion, Entropion, Symble- 
 pharon. 
 
 Blepharitis (tinea tarsi, ophthalmia tarsi, sycosis tarsi) is an inflam- 
 matory condition of the edges of the eyelid, which commonly attacks the 
 glands and the follicles of the eyelashes. It varies in degree from mere 
 congestion, with a sticky exudation, to chronic or subacute inflammation, 
 with thickening of the tissues, excoriations, and even pustules. Treatment. 
 — (1) Keep the eyelids clean and free from scabs by bathing twice daily 
 
EYELIDS. 303 
 
 with warm water or warm alkaline lotion. (2) Apply dilute nitrate of 
 mercury ointment twice daily ; in severe cases pull out the lashes with 
 epilation forceps, and apply nitrate of silver to the edges of the lids. 
 
 Stye (hordelum) is a small furun cuius at the margin of the lid, often 
 very painful. Successive crops very common. Treatment. — Foment with 
 warm water, apply bread-and-water poultice ; puncture with a sharp lancet 
 as soon as pointing has commenced. 
 
 Tarsal Tumor (meibomian cyst, chalazion), a chronic hypertrophy of a 
 meibomian gland, occurs as a small hard nodule from 1-4 mm. in diameter 
 in upper or lower lids ; one or more may appear at the same time. The 
 skin is freely movable over the tumor, which is hard, and not painful. If 
 left alone it generally causes thinning of the conjunctival tissue, or it may 
 point through the surface. Treatment. —Evert the lid and remove by in- 
 cision from the conjunctival surface. When it points outward it is better 
 to remove through the skin by incision parallel to margin of eyelid. When 
 thus thoroughly removed it does not recur. When only incised it may 
 remain for some time. 
 
 Warty Growths occasionally appear on edges of lid. Remove freely 
 with scissors. 
 
 Molluscum Contagiosum often appears in region of eyelids. Consists of 
 one or more hemispherical elevations of from one to six mm. in diameter, 
 containing sebaceous material. Treatment. — Divide each little tumor by 
 vertical incision, and squeeze out the contents by means of the thumb- 
 nails applied to the bases of each. 
 
 Rodent Ulcer (epithelial cancer, rodent cancer) begins as a slight eleva- 
 tion near margin of eyelid ; this is followed by a shallow ulcer with slightly 
 indurated edges, and generally a brownish incrustation. Mostly occurs 
 in persons over forty. Progresses slowly. Seldom cicatrizes. Attacks 
 all surrounding tissues. Neighboring glands not enlarged. Treatment. — 
 Remove all the diseased structure with the knife, or with the thermal 
 cautery, as early as possible. In severe cases apply chloride of zinc paste 
 in addition, after removal with the knife. 
 
 Syphilitic Ulcers are more acute, more punched out in appearance, 
 have less indurated margins, and are more amenable to treatment than 
 rodent ulcer. 
 
 Lupus generally occurs in younger subjects, and in other parts of the 
 face. It is less indurated and more inflamed than rodent ulcer. 
 
 N^vus, often congenital, occasionally occurs on the eyelids, may be con- 
 fined to the skin, or may involve subcutaneous tissue. Treatment. — 1. By 
 electrolysis. 2. By subcutaneous ligature. 3. By galvano-puncture. 
 
 Ptosis is partial or complete closure of the upper eyelid. Causes, 
 various. May be congenital and due to non-development of the levator 
 palpebral superioris muscle. May be due to paralysis of the third nerve, 
 which supplies that muscle. May be the result of injury to that muscle. 
 
304 GLAUCOMA. 
 
 Treatment varies with cause. Graefe's operation ; make incision through 
 skin three lines above the margin of upper lid, and extending through its 
 whole length, and expose the orbicularis palpebrarum muscle ; seize the 
 muscle with forceps, excise a portion about five lines in width. In bringing 
 edges of skin together pass the suture through the cut edges of the muscle. 
 
 Trichiasis, ingrowing of the eyelashes, causing irritation of the globe. 
 Frequently caused by contraction of the tissues after granular lids and 
 after the application of caustics to inside of lids. Treatment. — If only a 
 few lashes are turning in, these may be removed with epilation forceps. 
 If many exist, then excision of the hair-bulbs should be performed as fol- 
 lows : Fix the lid by means of compressorium forceps. Make two incisions 
 along the margin of the lid, one on each side of the row of eyelashes. Cut 
 deeply, unite the incisions at each end, and remove the piece with scissors. 
 Sutures not required. 
 
 Symblephaeon is union of the palpebral and ocular conjunctivae or of 
 the margins of the eyelids. Caused generally by burns, as with molten 
 lead, or caustic, as quicklime. Treatment. — 1. When the edges of only the 
 lids are united, or when a probe can be passed beneath the united con- 
 junctivae ; (a) simply divide adhesions with knife, and keep the parts 
 separated by means of oiled lint ; (b) pass a strong silk ligature beneath 
 the bands, and tie tightly, allowing the ligature to come away by itself. 2. 
 When no probe can be passed beneath the adhesions, the results of opera- 
 tion are less satisfactory. Separate the parts by incision, and then dissect 
 up the conjunctiva on both sides, and endeavor to bring the flaps thus 
 formed over the raw surface by means of very fine silk sutures ; still keep 
 the ocular and palpebral portions apart by oiled lint. 
 
 Entropion. — Inversion of the eyelids, generally caused by cicatrices 
 after caustics such as lime or nitrate of silver, or after injury. Treatment. 
 — When very severe, and the conjunctiva is much contracted, remove the 
 whole row of eyelashes as recommended for trichiasis. When less severe, 
 perform Streatfeild's operation of grooving the cartilage. 
 
 Ectropion. — Eversion of the eyelid ; may be partial or entire. Causes. 
 —Contraction after injury or inflammation of the parts of the eyelid which 
 are external to the tarsal cartilage ; or contraction of cicatrices of the face 
 following burns, lupus, etc. Treatment. — Try to prevent the progress of 
 eversion by skin-grafting on to wounds of face. When permanently estab- 
 lished try a plastic operation. 
 
 Glaucoma is so called from the occasional greenish appearance of the 
 pupillary area. The pathognomonic symptom in all cases of glaucoma is 
 increased hardness or " tension " of the eyeball. 
 
 Classification. — 1, Acute; 2, chronic ; 3, secondary. 
 
 Acute Glaucoma. — Early Symptoms. — Increased tension. Rapidly in- 
 creasing presbyopia. Periodic dimness of sight. Halos or " rainbows n 
 around the candle or other lights. Diminution of the field of vision. 
 
iris. 305 
 
 Later Symptoms. — Acute pain. Congestion of conjunctiva, and of ciliary 
 region. Dilated and sluggish pupil. Rapid impairment of vision. Ten- 
 sion of globe much above normal, T + 1 to T + 3 or T + 4. There may 
 be turbidity of the vitreous obscuring the fundus, otherwise the oph- 
 thalmoscope reveals — 1, cupping of the whole of optic discs, the edges 
 being abrupt ; 2, probably pulsation of the retinal vessels ; 3, tortuosity 
 of the veins ; 4, small hemorrhages occasionally. 
 
 Chronic Glaucoma presents the same symptoms as the acute form, but 
 in a modified degree. The tension of the globe is above normal, T + -J to 
 T + 1 or T + 2, but the increase of tension is less rapid. The pain is 
 much less, and may be absent altogether. 
 
 Secondary Glaucoma is so called when occurring as a result or com- 
 plication of some other disease or injury of the eye, as iridochoroiditis, 
 needle operation, etc. It is a very grave symptom. 
 
 Pathology. — What is the cause of the increased tension? Theory 1. 
 Active contraction of the sclerotic. 2. Excess of fluids of eye from in- 
 creased supply of blood. 3. Defective removal of fluids from eye. 
 
 The region of the ciliary body is generally found to have undergone 
 great changes. It becomes shrunken to half its natural size, its muscular 
 fibres are atrophied and sclerosed. The base of the iris is found to be 
 closely applied to the marginal part of the cornea. The ciliary arteries are 
 enlarged. The changes are supposed to impede the escape of fluid from 
 the anterior chamber, and perhaps from the vitreous also. The glaucoma 
 cup is caused by pressure from within. The lamina cribrosa which forms 
 the floor of the optic disc, being the weakest part of the capsule of the eye, 
 slowly yields, becomes depressed and hollowed out, causing atrophy. 
 
 Treatment for Acute Glaucoma. — Perform iridectomy without delay. 
 (1) Make incision partly in cornea and partly in sclerotic. (2) Make wound 
 large enough to allow of exit of one-fifth of iris. (3) Remove iris quite up 
 to its ciliary attachment. 
 
 Apply leeches to eye, and warmth : give purgatives and derivatives 
 internally. 
 
 In Chronic Glaucoma. — First try action of eserine drops, with local de- 
 pletion, and calomel and opium internally. If tension continues to increase 
 perform iridectomy as in acute cases. 
 
 Sclerotomy, by similar incision to that of the scleral iridectomy, but 
 without removing a portion of iris, is sometimes practised. Trephining 
 the sclerotic behind the ciliary region has also been introduced, but these 
 are both less efficient than iridectomy. 
 
 Iris.— Iritis. — Causes. — Syphilis. Rheumatism. Inflamed or ulcerated 
 cornea. Injuries as in operation for cataract. 
 
 Symptoms. — (1) Change in color ; (2) change in mobility ; (3) change 
 in vascularity ; (4) pain ; (5) impairment of vision ; (6) photophobia and 
 lachrymation. 
 20 
 
306 iris. 
 
 (1) Change in color is due to congestion, and to effusion of lymph and 
 serum into the texture of iris, as well as, in part, to turbidity of aqueous. 
 It looks blurred and "muddy." 
 
 (2) Change in mobility is indicated by the pupil not responding actively 
 to light, but becoming sluggish or quite inactive. The iris becomes more 
 or less adherent by its posterior surface to the capsule of lens, constituting 
 partial or complete posterior synechia ; when partial the pupillary margin 
 becomes jagged under atropine ; when complete, the pupil cannot be dilated 
 by mydriatics. When exudation of a layer of lymph takes place into the 
 pupillary area the condition is termed " occlusion." 
 
 When margin of pupil is adherent to lens capsule by its whole circum- 
 ference the condition is termed "exclusion." 
 
 (3) Increase of vascularity in the ciliary zone, around the margin of the 
 cornea, generally occurs early, and the conjunctival vessels are generally 
 congested. 
 
 (4) Pain of a neuralgic character in and around the eye, variable in 
 degree. 
 
 (5) Impairment of vision is always more or less marked, may be owing 
 to turbidity of aqueous, exudation of lymph on capsule in the pupillary 
 area, impairment of accommodation by extension of inflammation to the 
 ciliary body. 
 
 (6) Photophobia and lachrymation may or may not be present. 
 
 In Syphilitic Iritis, which only occurs in secondary syphilis, there is ten- 
 dency to effusion of lymph, and formation of nodules in the structure of 
 the iris. It seldom relapses ; it is often symmetrical ; pain not generally 
 severe. 
 
 In Rheumatic Iritis there is little tendency to effusion of lymph, nodules 
 never formed, generally unsyrametrical, although both eyes may suffer in 
 turns ; frequently relapses at intervals of months or years ; congestion and 
 pain often severe ; sight not much affected. 
 
 Treatment. — (1) Use atropine drops (atropise sulph., gr. ij. ad. § j.) 
 three times daily to prevent adhesions, or to break down those which may 
 have recently formed, also to relieve pain and congestion. 
 
 (2) If pain and congestion be severe apply leeches to temple, malar 
 eminence, or septum nasi; repeat if necessary; apply blister to temple; 
 avoid stimulants. 
 
 (3) For syphilitic iritis employ the treatment proper for secondary 
 syphilis. For rheumatic iritis give alkalies, iodide of potassium, colchi- 
 cum. 
 
 (4) Rest the eyes ; all eye work to be discontinued ; order a shade for 
 both eyes ; darken the room, or bandage the affected eye with a pad of 
 cotton-wool, especially in rheumatic cases. 
 
 (5) Iridectomy should be performed (1) in those cases in which judi- 
 cious local and internal treatment have been tried for several weeks with- 
 
LACHRYMAL APPARATUS. 307 
 
 out benefit ; (2) where adhesions exist and attacks are recurrent ; (3) when 
 there is complete exclusion of the pupil. 
 
 Operation of Iridectomy. — (1) Separate lids by a spring-stop speculum. 
 (2) With lance-shaped knife incise sclerotic one line from corneal margin, 
 and let the point enter anterior chamber just in front of iris, keeping 
 point well forward to avoid wounding the lens. (3) Introduce iris forceps 
 through wound, and seize iris near pupillary margin ; draw this out through 
 wound and cut off with fine scissors. 
 
 Artificial Pupil is mostly made by (1) iridectomy ; but for cases in 
 which this is unsuitable one of the following methods may be adopted : 
 (2) by using a broad needle and hook ; (3) by iridodesis, or ligature of iris 
 (Critchett's operation) ; (4) by division of iris with Wecker's scissors intro- 
 duced into anterior chamber (iridotomy). 
 
 Prolapse of Iris generally follows penetrating and incised wounds of 
 cornea. Treatment. — (1) By removal of prolapsed portion with fine scis' 
 sors. (2) By compress applied externally over closed lids. (3) By fre 
 quent puncturings of the prolapsed iris with a fine needle. In either of 
 these methods a soothing treatment should be adopted. Atropine drops 
 three times daily ; bathing with belladonna lotion. After some days a 
 shade should be worn, and the eyes carefully watched. 
 
 Goredialysis is a partial detachment of the iris from its ciliary border, 
 forming a second pupil. It is generally caused by a sharp blow. Congeni- 
 tal irideremia (absence of iris) is occasionally seen. 
 
 Goloboma of the Iris (congenital cleft) appears like a very regular result 
 of iridectomy downward, or downward and inward ; usually symmetrical ; 
 variable in degree ; generally associated with a corresponding defect in 
 the choroid. 
 
 Mydriasis (dilatation of the pupil) is a derangement which may be 
 caused by disease or by the action of mydriatic drugs, e.g., glaucomatous 
 tension of the globe, diseases of choroid or retina, optic atrophy, paralysis 
 of third nerve. Mydriatics, sulphate of atropia, extract of belladonna, sul- 
 phate of duboisine, sulphate of daturine, etc. 
 
 Myosis (contraction of pupil) may be caused by spasmodic action of the 
 circular fibres of iris, loss of power of radiating fibres of iris, hyperesthesia 
 of retina, affection of spino-sympathetic filaments which supply the radiat- 
 ing fibres of iris, myotic drugs, e.g., Calabar bean, sulphate of eserine, ni- 
 trate of pilocarpine. 
 
 Lachrymal Apparatus. — Overflow of tears (lachrymation, epiphora, 
 stillicidium) is caused by excessive secretion, or by some defect in the 
 lachrymal apparatus which prevents the escape of the tears. This defect 
 may exist (1) at the punctal achrymalia, which may be displaced or ob- 
 structed; (2) in the canaliculi, which may be obstructed by stricture near 
 the sac or by foreign body ; (3) in the lachrymal sac or nasal duct. 
 
 Inflammation of the Lachrymal Sac is very common ; generally caused 
 
308 OPTIC NERVE. 
 
 by stricture of the nasal duct. Symptoms. — Laclirymation, presence of a 
 tumor (mucocele) at the inner canthus, which may often be emptied by 
 pressure with the finger, the contents passing upward through canaliculi, 
 or downward through nasal duct. The contents of the sac vary according 
 to the character of the inflammation. At first it consists of viscid mucus, 
 which may remain a long time, or may become semi-purulent; in more 
 acute inflammation there is abundant suppuration with swelling of sur- 
 rounding parts, and pointing either through the skin, when a lachrymal 
 fistula is established, or through the conjunctiva near the caruncle. Treat- 
 ment. — 1. Slit up the canaliculus, and so give free exit to contents of sac. 
 This may be done upon Critchett's director, or by passing a Weber's canal- 
 iculus knife, or by a pair of delicate scissors. 2. Endeavor to cure the 
 stricture of the nasal duct by passing a lachrymal probe every third day 
 until lachrymation ceases. Various kinds of lachrymal probes are used, as 
 Bowman's, Couper's, Weber's. 
 
 Fistula of lachrymal sac frequently occurs in acute inflammation — a 
 small tortuous sinus between the sac and the skin, from which a contin- 
 uous oozing of the tears on to the cheek takes place. Treatment. — (1) 
 Cure the stricture and restore the mucous membrane to a healthy condi- 
 tion. (2) If necessaiy, pare the edges of fistulous opening, and bring to- 
 gether by fine suture. 
 
 Lachrymal Gland. — Hypertrophy, acute and chronic inflammation, ab- 
 scess, fistula, cysts, sarcoma. Removal sometimes required for disease or 
 for obstinate cases of lachrymation. Operation. — Make incision below 
 upper and outer third of the orbital ridge through skin and the fascia : 
 feel for gland with finger, seize with hooked forceps, draw forward, sever 
 with knife, do not close wound till hemorrhage has ceased. 
 
 Optic Nerve. — Diseases : Neuritis ; Atrophy. 
 
 Optic Neuritis may extend from the brain to the retina (descending) ; 
 may commence at the optic disc (papillitis) and thence pass along the 
 nerve (ascending). When the disc is affected there may be (a) simple con- 
 gestion ; (b) congestion with swelling, which renders the outline of the 
 disc more or less obscure. Causes. — Cerebral tumor, meningitis, syphilis, 
 albuminuria, lead-poison, wound of cornea, hypermetropia. The sight is 
 affected in proportion to the change in the optic nerve fibres. There may 
 be lessened acuteness of vision, limitation of field of vision, altered color 
 perception. Treatment. — Endeavor to find the cause of the malady and 
 treat this. Rest the eyes. In cases where syphilis is a known cause, give 
 a prolonged but mild course of mercury and iodide of potassium. When 
 syphilis is the probable cause, give iodide, and in the early stage give mer- 
 cury also. In strumous cases, pursue tonic treatment. 
 
 Atrophy of Optic Nerve may commence without any visible inflamma- 
 tion of disc (primary), or may follow as a result of papillitis. The optic 
 disc varies in appearance from slight pallor to bluish-white. The vessels 
 
RETINA. 309 
 
 may be of normal size, or may be much atrophied. Treatment. — Give qui- 
 nine and iron internally. Phosphorus, nitrate of silver and strychnine are 
 each sometimes employed. Try the interrupted voltaic current. 
 
 Retina. — The healthy human retina is so transparent during life that 
 it is hardly seen with the ophthalmoscope. The vessels of the retina are 
 seen radiating from the optic disc. Inflammatory and other deposits in 
 the retina are also seen when present. The chief diseases of the retina 
 are, Hyperemia, Ketinitis, Detachment, Embolism of the Central Artery, 
 G-lioma, Cysts. 
 
 Hyperemia. — Generally caused by overwork, especially if patient be 
 ametropic. Fundus looks too red, and optic disc has a pinkish, flushed 
 appearance. Treatment. — Functional rest, local depletion by leeches or 
 blister if necessary. Correction of ametropia by use of spectacles. 
 
 KETrNiTis. — (a) Syphilitic; (b) albuminuric ; (c) apoplectic; (d) pig- 
 mented. 
 
 Syphilitic Eettnitis. — One of the many secondary symptoms of syphilis 
 — generally occurring between six and eighteen months after infection — 
 occurs in inherited as well as in acquired syphilis. Ophthalmoscope shows 
 a grayish white haze around optic disc, patches of yellowish white exuda- 
 tion over the fundus, generally more or less choroiditis, generally more or 
 less turbidity of vitreous. Treatment. — Functional rest of eyes, general 
 treatment for secondary syphilis. 
 
 Albuminuric Ketinitis (Nephritic K.) may come on gradually with the 
 advance of kidney disease ; may be dependent on uraemia and occur in the 
 later stages of kidney disease. May be caused by temporary albuminuria, 
 as in that which occasionally occurs during pregnancy. In early stage 
 sight may be unaffected. Ophthalmoscope shows a dull gray haze in cen- 
 tral region of retina due to oedema, generally a few small patches of hemor- 
 rhage scattered over fundus. Optic disc may be also swollen. In ad- 
 vanced stage sight greatly affected in one or both eyes. Central region 
 occupied by numerous dots, spots, or patches of an opaque white substance 
 grouped around the yellow spot. Hemorrhages are frequent, and usually 
 have a striated appearance. Optic nerve sometimes inflamed (neuroreti- 
 nitis). Prognosis must be guarded. Treat disease of kidneys. Best and 
 protect eyes by cobalt-blue glasses. 
 
 Retinitis Apoplectica. — From sudden hemorrhage from a retinal vessel, 
 from disease of vessels, or of heart. 
 
 Retinitis Pigmentosa. — Characterized by a peculiar deposit of dark pig- 
 ment — varying in pattern — usually commences at the periphery of the 
 fundus, and gradually approaches the centre. Optic disc of a pale yellow 
 color. Often associated with posterior polar cataract. Often occurs in 
 several members of the same family. Prognosis bad. May remain station- 
 ary. May go on from bad to worse. 
 
 Detachment of Retina may be partial or entire. Causes : (a) elonga- 
 
310 REFRACTION. 
 
 Hon of coats of eyeball as in extreme myopia ; (b) diminution of vitreous; 
 (c) hemorrhage or serous exudation between retina and choroid ; (d) tu- 
 mors of choroid. Symptoms. — By direct examination the detached portion 
 appears as a bluish-gray film bounded by a sharp line. The vessels traced 
 from disc give a sudden bend at the line of detachment. The detached 
 portion is seen to be pushed forward, and the vessels upon it are tortuous, 
 small, and of dark color. The field of vision is limited. Prognosis is un- 
 favorable. 
 
 Glioma, a small round-celled growth proceeding from the granular 
 layers of the retina, occurring generally in very young children. It is seen 
 as a glistening white substance at the bottom of the eye, and if allowed to 
 remain, it rapidly spreads along optic nerve to the brain, and to the sur- 
 rounding structures within the orbit. Secondary deposits may occur. 
 Treatment. — Early excision of globe. 
 
 Refraction of the eye signifies the influence exercised by the trans- 
 parent media upon rays of light entering it. 
 
 Emmetkopia signifies normal refraction. 
 
 Ametropia signifies abnormal refraction, and may be divided into (1) 
 myopia; (2) hypermetropia ; (3) astigmatism. 
 
 Emmetropia is that condition of refraction in which rays from distant 
 objects, and which are practically parallel, come to a focus upon the retina 
 when the eye is at rest, that is, when accommodation is relaxed. The Em- 
 metropic eye cannot see near objects without increasing the convexity of 
 the crystalline lens, because the rays from near objects are divergent, and 
 would therefore focus behind the retina. This change of shape in the lens 
 is effected by the ciliary muscle, and is called accommodation. 
 
 The farthest distance of distinct vision in any state of refraction is 
 called the far-point, the shortest distance of distinct vision is the near-point. 
 The near-point and the far-point are found by means of test types. Those 
 of Snellen and Jaeger are in common use. The distance between the near- 
 point and the far-point is called the range or amplitude of accommodation. 
 It is the distance over which the eye has command by means of its accom* 
 modation. 
 
 Accommodation, as we have seen, depends upon the contractility of the 
 ciliary muscle, and upon the elasticity of the crystalline lens. Now, as age 
 advances, the ciliary muscle gradually loses its contractility, and the lens 
 its elasticity. So that in emmetropia the near-point gradually recedes 
 from the eye. This recession commences at about the age of ten. Thus 
 at the age of ten years the amplitude of accommodation is equal to a lens 
 of 14 D, and the distance of the near-point from the eye is 7 centimetres ; 
 at fifteen years the distance is 8 ctm. ; at twenty years it is 10 ctm. ; at 
 thirty years it is 14 ctm. ; at forty years it is 22 ctm. ; at fifty years it is 
 40.5 cm. 
 
 The emmetropic eye, therefore, can read No. 6 of Snellen's test types 
 
EEFRACTIOISr. 311 
 
 at the distance of six metres without the aid of either convex or concave 
 lenses (V=f) at all ages. It can read No. 1 of Snellen's test-types for 
 reading as near as 7 centimetres up to the tenth year of age, but after that 
 time there is a gradual recession of this near-point. At the age of forty 
 years the near-point is 22 ctm. 
 
 Presbyopia (Old Sight) is that condition in which the near-point has so 
 far receded as to cause discomfort in reading and fine work. This distance 
 is about 22 ctm. (8 inches). In the normal eye this distance (see Emmetbo- 
 pia) is reached at about forty years, so that after that age all fine work, 
 such as reading, needlework, etc., must be held at more than 22 ctm. from 
 the eye. This inconvenience is easily overcome by prescribing convex 
 lenses to be worn for reading and fine work. The following table will 
 show the strength of the lens required by the normal eye at different ages, 
 to correct for presbyopia : 
 
 Strength of Spherical Convex 
 Age. Lens in Dioptres. 
 
 40 
 
 45 1 
 
 50 2 
 
 55 3 
 
 60 4 
 
 65 4.5 
 
 70 5.5 
 
 75 6 
 
 80 7 
 
 In hypermetropia presbyopia comes on earlier than in emmetropia, be- 
 cause the hypermetropia has to be neutralized before any accommodation 
 is available for near vision. Thus, suppose a hypermetrope of 2 dioptres, 
 what strength of lens would be required to correct his near vision at the age 
 of fifty ? He will require first 2 D to correct the hypermetropia, and, by the 
 above table, we see that 2 D would be the strength required if he were em- 
 metropic. Therefore, 2 + 2= 4D, or let x be the amount of hypermetropia 
 expressed in dioptres, and x l the strength of lens required according to 
 age, then xT> + x x ~D will be the strength of the spectacles required for 
 near vision. In myopia presbyopia comes on later than in emmetropia, 
 because for the same amount of accommodation the near-point is always 
 nearer than in the normal eye. In very high degrees of myopia (over 4.5 
 dioptres) the patient will never become so presbyopic as to require convex 
 glasses ior near vision, because in a state of repose the eyes are adapted 
 for a shorter distance than 22 ctm. He may, however, require concave 
 glasses for near as well as for distant vision (see Myopia). Suppose a myope 
 of 3 D, sixty years old, what spectacles would he require ? We see by the 
 
312 REFRACTION. 
 
 table that, if emmetropic, lie would require 4 D, and we know that he has 
 myopia =-3D. Therefore +4-3=-(-lD will be the strength of spec- 
 tacles required for near vision. 
 
 Myopia (Short Sight) is that condition of refraction in which parallel 
 rays come to a focus in front of the retina, the eye being at rest. Symp- 
 toms. — Patient cannot see distant objects clearly, and if told to read small 
 print (No. 1 of Snellen's test types) will hold it within the distance of his 
 far-point from the eye. Vision improved by concave spherical lenses, 
 made worse by convex lenses. Retinoscopy reveals a shadow which passes 
 in the same direction as the reflected light. Ophthalmoscopy. — 1. By di- 
 rect examination with mirror alone, image of vessels of fundus seen at dis- 
 tance from eye, and moves in the opposite direction to the observer's head 
 when the latter is moved from side to side. 2. By indirect examination, 
 the optic disc appears smaller than in emmetropia, and appears to increase 
 in size on withdrawing the lens used. 3. By direct examination, when the 
 instrument is held close to the patient's eye the retinal vessels, optic disc, 
 and other details of the fundus cannot be clearly seen without the inter- 
 vention of a concave lens, the strength of the lens required for this pur- 
 pose being a measure of the degree of myopia. In many cases a crescentic 
 patch of yellowish white appearance {myopic crescent) is seen on the outer 
 side of the optic disc ; this is caused by atrophy of the choroid. In high 
 degrees of myopia other patches of choroidal atrophy are often seen. 
 Choroidal hemorrhages and hemorrhages into vitreous occasionally oc- 
 cur. Causes. — Too great length of globe. Too great curvature of cornea. 
 Too high refractive power of media of eye. Hereditary tendency. Pro- 
 longed use of eyes in looking at close objects. Treatment. — Having ascer- 
 tained accurately the degree of myopia, order spectacles to be worn. 1. 
 To give clear vision of object at a distance (No. 6 to 60 Snellen's at 6 me- 
 tres). 2. To enable the patient to read small print (No. 1 Snellen) at the 
 same distance as an emmetrope. In all cases of myopia below 6 or 7 diop- 
 tres, where the accommodation is good, the glasses which exactly correct 
 the myopia should be used for near and for distant vision. They should 
 be worn constantly. In most cases where the myopia is higher than 7 D, 
 and in all cases where the accommodation is feeble, two kinds of spectacles 
 must be worn : one pair for distance, equal in strength to the degree of 
 myopia, another pair for near vision of lower power. The required strength 
 of these is found in the following manner (Donders) : From the lens which 
 exactly neutralizes the myopia deduct the strength of a lens whose focal length 
 is equal to the distance at which we wish the patient to ivork. Thus, suppose 
 a myope of 10 D wishing to read No. 1 Snellen at 40 ctm. From 10 D 
 deduct the lens whose focal length is 40 ctm., viz., 2.50 D ; then' —10 + 
 2.50=— 7.50 D, and —7.50 D is the strength of spectacle required. In 
 prescribing for patients over forty, proper allowance must be made for 
 presbyopia (see Presbyopia). 
 
REFRACTION". 313 
 
 Hypermetropia is that condition of refraction in which parallel rays 
 come to a focus behind the retina — the eye being at rest. 
 
 Causes. — 1. Most commonly the axis of the eye is too short. 2. The 
 curvature of the cornea or of the surface of the lens may be insufficient. 
 3. The refractive index of the media may be too low. The disease is fre- 
 quently hereditary. 
 
 Symptoms. — Since rays from a distant object (parallel rays) come to a 
 focus behind the retina, it follows that rays from a near object (divergent 
 rays) will be focussed still further behind the retina, and therefore a hyper- 
 metrope is unable to see anything clearly, either distant or near, without 
 using accommodation. If therefore the hypermetropia be slight, and the 
 accommodation powerful, there will be no inconvenience, either for near 
 or distant vision. But if the accommodation is failing, as it always does 
 from age, and as it frequently does from disease, the patient cannot see 
 near objects for long together without aching pains or sense of fatigue in 
 the eyes, combined with dimness of vision. In high degrees of hyperme- 
 tropia the greater part of the accommodation is required for distant vision, 
 and the patient is never able to see near objects clearly. The symptoms 
 therefore vary with the degree, and become more manifest as age advances. 
 Hypermetropia is frequently an indirect cause of squint (see Strabismus). 
 The objective symptoms are as follows : 
 
 1. Eeratoscopy reveals a shadow which passes in the opposite direction 
 to that of the reflected light. 
 
 2. Ophthalmoscopy. — Direct method at a good distance from the eye 
 shows the image of vessels of fundus, and this image moves in the same 
 direction as the observer's head when the latter is moved from side to side. 
 
 Indirect method shows size of disc to diminish on withdrawing the lens 
 from patient's eye. 
 
 Direct method. — When oblique mirror is used close to the patient's eye, 
 and the accommodation both of patient and observer relaxed, no clear de- 
 tail of fundus can be made out without the aid of a convex lens. The 
 strength of the lens thus required to mate quite clear the detail of fundus 
 gives an exact estimate of the degree of hypermetropia. 
 
 3. By means of Test-types and Test-glasses.— See if patient can read Nos. 
 6 to 100 Snellen at 6 metres. Then, if he can read the same as well or 
 better with a convex glass, the highest glass with which he gets the best 
 vision is a measure of his manifest hypermetropia. In children, and in all 
 cases where spasm of the ciliary muscle is suspected, it is necessary to 
 paralyze the accommodation by atropine drops, in order to obtain the latent 
 as well as the manifest, that is, the total hypermetropia. 
 
 Treatment. — Having found the degree of hypermetropia, order specta- 
 cles to be worn as follows : 1. In children and young adults order the con- 
 stant use of glasses both for near and distant vision ; the strength of these 
 should be equal to all the manifest hypermetropia plus half the latent. 
 
314 REFRACTION. 
 
 Patient may complain of inconvenience, but should persevere. 2. In per- 
 sons over forty years of age order glasses as directed under Presbyopia 
 (see Presbyopia). 
 
 Astigmatism is Regular or Irregular. 
 
 Regular Astigmatism is that condition in which the refraction is differ- 
 ent in different meridians of the same eye ; the two principal meridians 
 being always at right angles to each other. 
 
 Irregular Astigmatism is that condition in which there are different de- 
 grees of refraction in different parts of the various meridians. Regular 
 Astigmatism may exist in live different forms. 
 
 1. Simple Myopic. — One meridian emmetropic, and the other myopic. 
 
 2. Simple Hypermetropic. — One meridian emmetropic, the other hyper- 
 metropic. 
 
 3. Compound Myopic. — Both meridians myopic, one more than the 
 other. 
 
 •£. Compound Hypermetropic. — Both meridians hypermetropic, one 
 more than the other. 
 
 5. Mixed. — One meridian myopic, the other hypermetropic. 
 
 Causes. — Chiefly unequal curvature of cornea, perhaps irregularity of 
 lens also. Symptoms vary with the bind and the degree of astigmatism. 
 The lower forms often pass unheeded until rather late in life. The higher 
 forms cause such fatigue and distress that the eyes are disqualified from 
 prolonged exertion. Astigmatism must always be suspected when by test- 
 ing with spherical lenses the patient cannot be made to read Nos. 6 or 9 
 Snellen at 6 metres (the fundus being otherwise healthy). "When astigma- 
 tism is suspected, proceed to examine each eye carefully as follows : 
 
 1. Retinoscopy. — The intensity, direction, and velocity of shadow will 
 indicate the hind of error in each meridian. 
 
 2. Ophthalmoscopy. — By indirect examination the optic disc appears 
 oval instead of circular, and by withdrawing the mirror used away from 
 the patient's eye the disc appears to change its shape. By direct examina- 
 tion, the mirror being held close to patient's eye, the vessels of the different 
 meridians may be seen with lenses of different powers, the difference be- 
 tween the powers of the lenses thus used being an exact measure of the 
 degree of astigmatism. 
 
 3. Place patient at distance of six metres from Snellen's test-types, and 
 with spherical lenses correct the ametropia as far as possible. Then rotate 
 in front of the correcting lens a stenopaic slit ;• by this means the two prin- 
 cipal meridians will be found, and must be corrected seriatim. The differ- 
 ence of power between the lenses which correct these two meridians is an 
 exact measure of the degree of astigmatism. The same object may be ef- 
 fected by the use of cylindrical glasses without the slit 
 
 4. An excellent instrument for finding the two meridians is Tweedy's 
 Optometer (see Lancet, October 28, 1876). 
 
STRABISMUS. 315 
 
 Whatever means be employed in diagnosis, cylindrical lenses should 
 be prescribed which fully correct the astigmatism. The patient may not 
 be able to see very much at first, but by the continued use of spectacles the 
 vision will generally improve. 
 
 Strabismus (Squint). — The visual line is the axial line joining the 
 centre of the object observed, with the centre of its image on the yellow 
 spot of the retina. Deviation of the eye from the visual line, so that the 
 image does not fall on the yellow spot, but on some other part of the retina, 
 is called squint. This deviation may produce double vision — diplopia — 
 when the image formed by the squinting is usually fainter than that of the 
 other eye, and is called the false image. When the false image appears 
 on the same side of the true image as the deviating eye, the diplopia is 
 termed homonymous, when on the opposite side the diplopia is crossed. 
 The greater the deviation of the eye the fainter the image appears, as it 
 falls more upon the periphery of the fundus. Patients learn to disregard 
 the false image, and so to use one eye at a time or one eye only. Causes 
 of Squint. — (a) Ametropia; (b) affection of ocular muscles, as over-action, 
 weakness, paralysis ; (c) disuse of eye. Chief kinds are internal and ex- 
 ternal. 
 
 Internal Strabismus (Convergent). — Yery common, generally caused by 
 hypermetropia. In hypermetropia the patient is obliged to use accommo- 
 dation in order to see even distant objects. Now accommodation is always 
 accompanied by convergence, and when a near object has to be seen, the 
 accommodation and, consequently, the convergence used, are so great that 
 the eyes deviate internal to the visual line, so that the image does not fall 
 upon the yellow spot, and is therefore not distinct. Patient then fixes one 
 eye upon the object, i.e., causes it to move in the direction of the visual 
 line whilst the other eye still deviates. The amount of deviation is meas- 
 ured by the distance between two vertical lines, one bisecting the pupil, 
 the other bisecting the eyelids. Diag7iosis. — In well-marked cases let pa- 
 tient look steadily at the tip of index finger placed about a foot in front of 
 eyes, then screen each eye successively, and watch the eye thus screened. 
 The squinting eye makes a decided movement toward the visual line when 
 the working eye is covered, but the working remains quite stationary when 
 the sqiiinting is screened. In less marked cases the diagnosis is more 
 difficult. Take patient into dark room and direct him to look steadily at 
 lighted candle at distance of ten feet without moving his head. Place a 
 piece of red glass in front of one eye, then if diplopia be present the image 
 of this eye will be red and that of the other eye of normal color. The 
 distance of these images apart and their relative position gives the charac- 
 ter of the deviation — homonymous diplopia indicating convergent, and 
 crossed diplopia indicating divergent strabismus. Treatment. — 1. If the 
 patient be hypermetropic, if squint be slight and of recent date, and if 
 vision be good in both eyes, try the effect of well-fitting convex spectacles 
 
316 STRABISMUS. 
 
 for one or two months. 2. Perform tenotomy of the internal rectus of one 
 or both eyes. Both eyes generally require to be operated on. Operation. 
 — Separate lids by stop-speculum, let assistant turn eye outward by for* 
 ceps, with toothed forceps pinch fold of conjunctiva between cornea and 
 caruncle, with squint-scissors cut through this and through the capsule of 
 Tenon, pass squint-hook beneath the tendon from below and cut it through 
 between hook and globe, pass in the squint-hook a second time to be quite 
 sure that the tendon is divided ; suture for conjunctival wound is not gen- 
 erally used. 
 
 External Strabismus (Divergent) is the result of weakness of the inter- 
 nal rectus ; commonest in myopia ; occasionally occurs in hypermetropia ; 
 sometimes occurs in a blind eye ; may follow tenotomy of internal rectus 
 where too much subconjunctival tissue has been divided ; common in par- 
 tial or complete paralysis of the third nerve. Diagnosis, the same as for 
 internal strabismus. Treatment. — If resulting from paralysis, try and find 
 the cause of paralysis and treat this ; if not from paralysis, perform tenot- 
 omy of the external rectus, and if necessary also, at the same sitting, per- 
 form the operation for readjustment or advancement of the internal rectus. 
 This is done in various ways, and consists of separation of the muscle from 
 its insertion into sclerotic, and bringing it further forward on sclerotic by 
 means of sutures passed through the muscle and attached to conjunctiva 
 close to cornea. 
 
 List of Works Consulted in the Foregoing Notes. 
 
 Wecker and Landolt— u Traite Coinplet d'Ophthalmologie," 1879. 
 
 Wecker — " Chirurgie Oculaire." 
 
 Donders — " Anomalies of Accommodation and Refraction." 
 
 Pagenstecher and GTeath — "Atlas of the Pathological Anatomy of the Eyeball.' 
 
 Graefe and Saemisch — " Handbuch der Augenheilkunde." 
 
 Soelberg Wells — " Diseases of the Eye." 
 
 Nettleship — " Diseases of the Eye." 
 
 Lawson — " Diseases and Injuries of the Eye." 
 
 Brudenell Carter — " Diseases of the Eye. 
 
 Gowers — " Medical Ophthalmoscopy." 
 
 Streatfeild — Chapter on " Ophthalmic Surgery " in Erichsen's " Surgery." 
 
INDEX OF NAMES. 
 
 {See also end of " Notes on Ophthalmic Surgery.") 
 
 Abbe, 280 
 
 Abrath, 102 
 
 Adams, 115, 230, 283, 285 
 
 Allarton, 172 
 
 Alibert, 56 
 
 Allingham, 60 
 
 Amussat, 60 
 
 Anel, 15 
 
 Annandale, 230 
 
 Antyllus, 15, 17 
 
 Arnott, 42 
 
 Ayres, 29 
 
 Bakek, Mokrant, 14, 37, 42, 199, 235 
 
 Barker, A., 21 
 
 Barwell, 59, 116, 158, 190 
 
 Bassereau, 219 
 
 Baumler, 288 
 
 Beck, Marcus, 160, 161 
 
 Bellocq, 76 
 
 Bernard, 1 
 
 Bickersteth, 207 
 
 Bigelow, 32, 170, 174, 175 
 
 Billroth, 37, 38, 54, 98, 100, 109, 112, 144, 
 
 153, 200, 201, 204, 207, 218, 232 
 Birkett, 130, 189 
 Bloxarn, 64 
 Brandeis, 183 
 Brasdor, 15, 17 
 Brodie, 28, 35 
 Brou, 103 
 Brown, G-., 57 
 Brown -Sequard, 232 
 Browne, Baker, 192 
 Browne, Lennox, 169, 183 
 
 Brunei, 169 
 
 Bryant, 22, 51, 92, 111, 120, 135, 185, 194 
 
 206, 269 
 Buchanan, 172 
 Bumstead, 289 
 Burdon- Sanderson, 145 
 Busch, 162 
 Busk, 28 
 Butcher, 78 
 Butlin, 39, 237 
 
 Cadge, 170 
 
 Calender, 72, 94, 187, 198, 270 
 
 Callisen, 60 
 
 Card en, 10 
 
 Carte, 15 
 
 Cassells, 183 
 
 Chapman, 147 
 
 Charcot, 178, 201, 282 
 
 Chauveau, 280, 282 
 
 Cheyne, Watson, 104, 282 
 
 Chiene, 102, 162, 284 
 
 Chopart, 7 
 
 Civiale, 173, 175 
 
 Clarke, Bruce, 95 
 
 Clarke, Fairlie, 237 
 
 Clay, 196 
 
 Cline, 87, 91, 97 
 
 Clover, 9, 12, 32, 173, 175, 237 
 
 Coats, 232 
 
 Cock, 71 
 
 Cohnheim, 145 
 
 Colles, 72, 95 
 
 Collins, 119 
 
 Cooper, Sir Astley, 43 
 
318 
 
 INDEX. 
 
 Cooper, T., 102 
 Coote, Holmes, 237 
 Corrigan, 28, 204 
 Cowling, 218 
 Coxeter, 107 
 Creighton, 291 
 Cripps, 19 
 Crocker, 197 
 Croft, 78 
 Curling, 227, 229 
 
 D'Ancona, 45 
 Davy, 8, 111, 213 
 Delahaye, 167 
 De Lignorolles, 8 
 Delore, 162 
 Desmarres, 224 
 De Wilde, 106 
 Diday, 225, 290 
 Dieulafoy, 188 
 Dolbeau, 173 
 Donovan, 74 
 Doran, 285 
 Dreschfeld, 142 
 Druitt, 49 
 Duchenne, 178, 179 
 Dunn, 269 
 Dupuytren, 65, 215 
 Duret, 73, 240 
 
 Eade, 33 
 
 Eidam, 281 
 
 Erb, 179, 182 
 
 Erichsen, 35, 92, 124, 189, 190, 237 
 
 Esmarch (including u the bandage"), 6, 
 
 16, 37, 38, 54, 78, 80, 151, 277 
 Evans, 84 
 
 Fauvel, 167 
 Ferguson, 187 
 Ferrier, 73, 240 
 Fitzgibbon, 234 
 Flower, 71 
 Foster, Michael, 264 
 Frankel, 288 
 Frazer, 234 
 Fritz, 240 
 Fuller, 239 
 
 Gamgee, 120, 185, 276, 277 
 
 Garrod, 234 
 
 Garson, 133 
 
 Gee, 289 
 
 Gmelin, 264 
 
 Golz, 208 
 
 Goodhart, 133, 211 
 
 Gordon, 89, 95 
 
 Gritti, 10, 171 
 
 Gross, 29 
 
 Guthrie, 25 
 
 Hainsby, 116 
 
 Halford, 28 
 
 Hall, Marshall, 25 
 
 Hamilton, 79 
 
 Hancock, 8 
 
 Hart, 16 
 
 Hasse, 139 
 
 Hawkins, Cassar, 61 
 
 Henle, 182 
 
 Hennig, 288 
 
 Hey, 7, 35, 37 
 
 Hill, Berkeley, 235 
 
 Hilton, 3 
 
 Hitzig, 240 
 
 Holmes, 14, 17, 29, 34, 56, 63, 66, 105, 
 
 116, 177, 215, 267 
 Hood, 218 
 Howard, 25 
 Howse, 269, 288 
 Humphry, 98, 191, 206, 228, 229 
 Hunter, 15, 219, 220 
 Hutchinson, J., 147, 219, 225. 267, 289, 
 
 290 
 Hyde, 12 
 
 Ilott, 193 
 
 Jackson, Hughlings, 289 
 Jordan, Furneaux, 39, 150, 190 
 
 Keber, 289 
 
 Klebs, 279, 280, 282, 291 
 
 Klein, 291 
 
 Koch, 280-282 
 
 Lallemand, 141, 210 
 Lancereaux, 221, 223 
 
INDEX. 
 
 319 
 
 Langenbeck, 151, 185 
 
 Langton, ISO 
 
 Lawson, 239, 240 
 
 Leach, K, 206 
 
 Lecompte, 106 
 
 Lee, 269, 270 
 
 Lees, 179 
 
 Legg, 109 
 
 Lewis, 136 
 
 Lisfranc, 8 
 
 Lister, 6, 7, 8, 9, 18, 80, 88, 98, 111, 276, 
 
 277 
 Liston, 87, 90, 91 
 Littre, 60 
 
 Longmore, 106, 107 
 Louis, 73 
 Lowne, 215 
 Lucas, Clement, 202 
 Lyons, 93, 236, 290 
 
 Macewen, 162, 166, 284, 285 
 
 Mclntyre, 87, 97 
 
 Malgaigne, 64, 94 
 
 Marsh, H., 153, 207, 288 
 
 Marshall, 40 
 
 Martin, 158, 239 
 
 Mikulicz, 162 
 
 Mills, 152, 237 
 
 Milton, 44, 102 
 
 Montgomery, 143 
 
 Morgan, 268 
 
 Morton, 215 
 
 MouUin, 208 
 
 Murray, 17 
 
 Nares, Sir G-eorge, 206 
 
 Neale, 189 
 
 Nelaton, 8, 68, 95, 106 
 
 Niemeyer, 49, 139, 165, 178, 182, 209 
 
 Nunneley, 236 
 
 Ogston, 60, 162, 280, 284 
 Orth, 279 
 Osborne, 137 
 Otis, 170 
 Owen, 288 
 
 Packard, 80 
 Pagan, 229 
 
 Page (Carlisle), 227 
 
 Paget, Sir J., 3, 31, 37, 38, 55, 84, 98, 139, 
 
 141, 159, 160, 175, 197, 198, 204, 205, 
 
 208, 218, 225, 236, 270, 271 
 Partridge, 191 
 Pasteur, 276, 280, 282 
 Pavy, 264 
 Peitavy, 75 
 Petit, 111 
 Pilcher, 95, 218 
 Pirogoff, 6, 8 
 Pirrie, 4 
 Poland, 233 
 Pollock, 148, 187 
 Porter, 109 
 Pott, 39, 40, 65, 91, 122, 137, 203, 208 ; 
 
 211 
 
 Reeves, 162 
 Regnoli, 236 
 Reid, W., 15 
 Rendle, 12 
 Reynolds, 178 
 Richardson, 232, 236, 271 
 Ricord, 221 
 Rindfleisch, 32, 280 
 Ringer, 164 
 Rivington, 17 
 Rizzoli. 151 
 Robbins, 12 
 Roosa, 183 
 
 Salter, 80, 87, 158 
 
 Sansom, 55 
 
 Savory, 139, 205, 208, 214, 228 
 
 Sayre, 18, 26, 78, 135, 158, 190, 203, 209, 
 
 212, 214, 216 
 Sequard, Brown-, 232 
 Scarpa, 59 
 Schoenlein, 279 
 Schrotter, 166 
 Schiiller, 291 
 Scott, 156, 158 
 Sedillot, 236 
 Sibley, 52 
 Sigmund, 225 
 Signorini, 111 
 Simon, 143 
 Simpson, Sir J. , 4 
 Sims, Marion, 57 
 
320 
 
 INDEX. 
 
 Sinkler, 178 
 
 Skey, 71 
 
 Smith, Alder, 133 
 
 Smith, H., 114 
 
 Smith, N. R.,172 
 
 Smith, T., 7, 33, 116, 180, 187, 192, 237 
 
 Smyth, 24 
 
 Spence, 6, 10, 94 
 
 Square, 160 
 
 Stanley, 39, 82 
 
 Startin, 187 
 
 Staton, 101 
 
 Sylvester, 25 
 
 Syme, 3, 7, 17, 229 
 
 Taylor, 289 
 
 Teale, 5, 6, 10 
 
 Teale, T. P., 159 
 
 Teevan, 29, 172, 195 
 
 Thomas, W., 75 
 
 Thomas (Liverpool), 135 
 
 Thompson, Sir H., 26, 28, 49, 102, 170, 
 
 191, 194, 195, 196 
 Thompson, Hugh, 290 
 Tiemann, 107 
 Toussaint, 282 
 Trendelenburg, 152, 166, 239 
 
 Trommer, 264 
 Trousseau, 138, 178 
 Tufnell, 16 
 
 Vanzetti, 57 
 Vermale, 10 
 Verneuil, 101 
 
 Wagstafpe, 44 
 Wakley, 258 
 
 Walker (Peterborough), 213 
 Walsham, 34, 39, 52 
 Wardrop, 17 
 Watson, P. H., 15 k 80 
 Weeks, 25, 26 
 Wagner, 289 
 Wheelhouse, 29, 263 
 White, P. P., 29 
 Whitehead. 237 
 Wilders, 102 
 Willett, 17, 84, 210, 213 
 Williams, C. J. B. , 205 
 Wolfe (Glasgow), 209 
 Wood, John, 29, 126, 190 
 Wormald, 237, 268