^1 LIBRARY \sg] A iJ uwvensmr CAUfORNU m THE SURGICAL DISEASES OF CHILDREN THE SURGICAL DISEASES OF CHILDREN AND THEIR TREATMENT BY MODERN METHODS BY D'ARCY POWER M.A., M.B. Oxon., F.R.C.S Eng. DEMONSTRATOR OF OPERATIVE SURGERY AT ST. BARTHOLOMEW'S HOSPITAL ; SURGEON TO THE VICTORIA HOSPITAL FOR CHILDREN, CHELSEA ; EXAMINER IN THE UNIVERSITY OF DURHAM ; MEMBER OF THE CONJOINT EXAMINING BOARD OF THE ROYAL COLLEGE OF PHYSICIANS (LOND.) AND OF SURGEONS (ENG.) WITH ILLUSTRATIONS PHILADELPHIA BLAKISTON, SON & CO I012 WALNUT STREET 1898 TO HOWARD MARSH, F.R.C.S. Eng. CONSULTING SURGEON TO THE CHILDREN'S HOSPITAL IN Great Ormond Street Cbis motk is BeMcatefr BY a former pupil The Author. Apuiv eifaonpreTi' /j.a\\ov 7] vucav kcu'wj. PREFACE Little excuse appears to be needed for the present work. The surgery of childhood is singularly wanting in text- books. There are but a few in German, still fewer in French. In English, only the works of Mr. Holmes and Mr. Owen are devoted to pure surgery. Messrs. Ashby and Wright's excellent treatise, and Keating's Cyclo- paedia of the Diseases of Children, combine medicine with surgery. Some excuse is perhaps necessary for the fact that the work is written by a single individual, and not by that system of collaboration which is now fashionable in medical literature. I believe, however, that the loss in detail is more than balanced by the gain in harmony, for conflicting statements are less likely to be made when a book is written by one person. I have endeavoured to state briefly and yet clearly the various methods connected with the treatment of the surgical diseases of children, which have proved them- Vlll PREFACE selves the most successful in my hands. The work has been made as practical as possible, and only so much pathology has been introduced as is necessary to show why the modern treatment differs from that formerly employed. My position as a surgeon to the Victoria Hospital for Children, has given me ample opportunity of performing the more common operations ; whilst as a teacher of operative surgery and tutor in surgery at the largest metropolitan school of medicine, I have been obliged to acquaint myself with the most recent surgical work both at home and abroad. The necessity of keeping the book within a reasonable compass has led to an apparent neglect of the orthopaedic side of children's surgery. I have the less regret for this omission as there are already several excellent treatises upon this subject, and Mr. Walsham promises us a still more complete one, of which a part is to appear in the near future. I have not hesitated to make very free use of the papers of Dr. Macewen, Mr. Howse, Mr. Clutton, Mr. Ballance, Dr. Brothers, Dr. Aldibert, Dr. Byerson Fowler, Dr. Felizet and others, for these writers are past-masters in the subjects of which they treat, and my own limited experience is as nothing when compared with theirs. The collection of TMses for the Faris M.D., which is being PREFACE IX augmented daily at the Library of the British Medical Association, has afforded me invaluable assistance, for each contains an excellent bibliography in addition to the original work which is often important. I have appended a list of papers chiefly remarkable for the excellence of the bibliography which they contain, or for their historical interest. It does not pretend to be more than a guide to those who wish to pursue each subject more thoroughly than can be done in a text-book, but to make it useful I have been at considerable trouble to verify my references, and so to adopt a rule which is more often honoured in the breach than in the observance. It is my pleasant duty to thank most cordially those gentlemen who have kindly assisted me. My father and Mr. W. H. C. Staveley have done me good service in read- ing the proofs ; Prof. Reid, Dr. Colcott Fox, Mr. B^ant, Mr. Jonathan Hutchinson, jun., Mr. Battle and Mr. Lock- wood have lent me blocks, whilst the Staff of St. Bartholo- mew's and of the Westminster Hospitals have permitted me to make drawings of specimens in their museums. Dr. Sims Woodhead and Dr. Kanthack have been good enough to revise what I had written upon some of the more recent bacteriological work in connection with diphtheria and with actinomycosis. Dr. Lewis Jones has also laid X PREFACE me under an obligation by reading through the pages on the electrolysis of nssvi. I am further indebted to Mr. Lewis, Messrs. Cassell, Messrs. Down, the publishers of Testut's Anatomie and of Hoffa's Lehrbuch, for the readiness with which they acceded to my request for clichtis of the various figures which are borrowed from their works. To each and all of these gentlemen I offer my heartfelt thanks.. 26, Bloomsbury Square, W.C. Mai-chy 1895j CONTENTS PAGE CHAPTER I. General Surgical Considerations 1 CHAPTER II. Non-Infective Gangrene 10 CHAPTER III. Non-Tuberculous Infective Diseases 16 CHAPTER IV, Surgical Tuberculosis 51 CHAPTER V. Tuberculous Disease of Bone ...... 62 CHAPTER VI. Tuberculous Diseases of Joints and Bursas ... 97 CHAPTER VII. Tumours and Syphilitic Disease of Bone .... 146 CHAPTER VIII. Injuries of Bones — Fractures and Separated Epiphyses. 158 xi Xll CONTENTS PACiR CHAPTER IX. Conditions leading to Alterations that require Surgi- cal Interference in Bones and Muscles — Anterior Poliomyelitis — Scurvy — Rickets — Scoliosis, and Torticollis 193 CHAPTER X. Non-Tuberculous Forms of Arthritis 225 CHAPTER XI. Acquired Dislocations and Congenital Displacements of Joints 235 CHAPTER XII. Surgical Affections of the Lips, Mouth, Tongue, and (Esophagus 253 CHAPTER XIII. Surgical Diseases of the Tonsils, Pharynx, and Nose . 273 CHAPTER XIV. Deformities and Diseases of the Ear .... 290 CHAPTER XV. Disease of the Temporal Bone and the Cerebral In- flammations ARISING FROM IT 303 CHAPTER XVI. Intracranial Disease and its Surgical Treatment . . 313 CHAPTER XVII. Surgical Diseases of the Air Passages .... 332 CONTENTS Xlll CHAPTER XVI II. Surgical Affections of the Abdomen and its Contents . 375 CHAPTER XIX. Heknia and its Treatment . . . . . . . 401 CHAPTER XX. Diseases and Malformations of the Rectum . . . 422 CHAPTER XXI. Diseases and Injuries of the Kidney 432 CHAPTER XXII. Diseases of the Bladder ....... 447 CHAPTER XXIII. Surgical Affections of the Urethra ... . 458 CHAPTER XXIV. Surgical Affections of the Testicle' 475 CHAPTER XXV. Diseases of Bloodvessels and N^evi 490 CHAPTER XXVI. Burns and their Treatment — Skin-Grafting . . . 501 CHAPTER XXVII. Some Malfoemations and Congenital Deformities . . 507 LIST OF ILLUSTRATIONS FI8. PAGE 1. Diagram of Horrocks' method of transfusion . . .6 2. From a photograph showing how free may be the move- ment in children's joints even after prolonged drainage 36 3. Femur showing an unusual form of periostitis . . 38 4. Transverse sections through the bone depicted in fig. 3 . 39 5. Diagram showing the ordinary arrangement of the sheaths of the flexor tendons in the forearm and hand 45 B. Diagram to show an abnormal arrangement of the same tendon sheaths ....... 46 7. Diagram to show another abnormal arrangement of the tendon sheaths in the forearm . . . .47 8'. Diagram of a child with spinal caries . . . .78 9. Diagram of a child with ricketty curvature of the spine 79 10. Diagram to show the method of applying a plaster-of- Paris case for the treatment of spinal caries . . 83 11. Taylor's brace for use in cases of spinal caries . . 85 12. Dunn's modification of Barker's flushing scoop . . 89 13. Diagram of a large psoas abscess . . . . .91 14. Diagram of a double psoas abscess . . . . .92 Coloured plate showing the relationship of the synovial membranes to the epiphyses in the shoulder, elbow, hip, knee, and ankle 96 LIST OF ILLUSTRATIONS XV 136 201 209 213 215 223 244 fig. PAGE 15. The treatment of tuberculosis of the hip by extension . 117 16. Thomas' knee-splint in use 128 17. Howse's splint, with a swing cradle, for use after excision of the knee 18. Bones of the pelvis and lower extremity, showing the changes which occur in infantile scurvy 19. Outside splint, with pelvic band, for use in the slighter forms of knock-knee ....... 20. Diagram of plaster case for leg 21. 22. Ricketty deformity of the tibia before and after the operation of osteotomy ....... 23. Lorenz's head-swing, for use in cases of wryneck 24, 25. Diagrams of the anatomical structures at a meta- carpo-phalangeal articulation, before and after dis- location of the joint 26, 27. Single and double congenital displacement of the hip 247 28. Nipple, with flexible metal shield, for the use of infants with cleft palate 258 29. Diagrams showing Prof. Rose's method of inserting sutures in the operation for cleft palate 30. Matthieu's tonsil guillotine 31. Two forms of Gottstein's curette 32. Dalby's. artificial nail .... 33. The cranio-cerebral topography in the adult 34. The cranio-cerebral topography in a child 35. Skull of a child, showing the points at which the lateral sinus may be trephined and the lateral ventricles may be explored . . 36. Intubation instruments .... 37. Diagram of the method of intubation 38. Method of feeding after intubation . 39. Trendelenburg's tampon tracheotomy tube 40. Rubber tube for draining the chest in empyema 41. Fowler's modification of Trendelenburg's operating table 42. Diagram of a case of exomphalos 261 275 283 284 326 327 328 340 342 345 34! I 371 391 403 XVI LIST OF ILLUSTRATIONS FIG. PAGE 43-45. Diagrams of the lower part of the abdomen to show the changes which take place in the position of the external abdominal ring as the child grows. . 405-407 46-49. Normal and abnormal conditions of the external abdominal ring 408, 409 50. Processus vaginalis at the eighth month of intra- uterine life 410 51. Macewen's hernia needle 420 52. Instruments used for litholapaxy 450 53. 54. Diagrams showing Felizet's method of forming a new frsenum during the operation of circumcision . 464 55. Bladder and kidneys, showing the effects of an untreated phimosis 467 50. Torsion of the spermatic cord 482 57, 58. A child with cystic lymphangioma, before and after operation 498, 499 59. Pelvic cyst, showing its relations to the rectum . . 516 60. Child with congenital overgrowth of the feet and secondary hypertz-ophy of the legs .... 520 THE SURGICAL DISEASES OF CHILDREN CHAPTER I GENERAL SURGICAL CONSIDERATIONS The surgical diseases of childhood only need a special study in young children; for as the age of the patient increases, he comes more and more under the hand of the general surgeon. The children's surgeon requires some special qualifications if he is to be successful in the practice of his art. He must he rather more observant than the surgeon who deals chiefly with adults, for much can be learnt from an attentive study of the little patient, who is as yet unable to express his feelings or his symptoms. He must be very gentle in all his manipula- tions, for the tissues are but fragile and the sensations are very acute. He must be sympathetic, and must possess the power of winning a child's affections, and that quickly ; for when such confidence is once obtained, the child will permit many liberties to be taken with it which would otherwise be impossible. Above all, the children's surgeon must be possessed of as keen an eye and as unerring a hand as a skilful operator for cataract, since most of his operations have to be done in a limited space and upon 15 2 THE SURGICAL DISEASES OF CHILDREN the most delicate structures. In fine, the children's sur- geon should be the antithesis of the late Poet Laureate's ideal, " big voice, big chest, big merciless hands." There are a few points which render surgical practice amongst children different from that which obtains amongst adults. The difficulties of diagnosis are usually greater, for a young child is unable to localise its sensa- tions or to give expression to its feelings, and more time has therefore to be spent in ascertaining the nature of a difficult case. A lack of observation or a want of care often leads to lamentable results : a fracture may be over- looked, the bellyache of spinal caries may be incorrectly interpreted, the pain and fever of acute infective osteo- myelitis may be attributed to any but the right cause. Children, on the other hand, have less control over their feelings, and by their instinctive actions often give a clue to the nature of their illness. Too much attention can hardly be paid to the attitude of a sick child ; his cry, his gestures, and often his very expression afford the most valuable information to those who can read them aright. The diagnosis of an injury is rendered more easy by the readiness with which a child can be stripped and examined from head to foot. Its difficulty is increased, on the other hand, by the fact that young children are often very fat, and that many of the bony points which are so useful in adults as landmarks are as yet undeveloped. It is almost superfluous to say that in examining a child the most superficial methods should first be employed, and then as the child's confidence is gained those which are more terrifying or painful. The exercise of a little discre- tion will often enable a careful surgeon to probe a wound or to examine the naso-pharynx without the use of any anaesthetic, and with comparatively little discomfort to the patient or to himself. GKNERAL SURGICAL CONSIDERATIONS 3 Rest and the conservation of parts are two golden rules in the treatment of the surgical diseases of childhood. Nowhere is the brilliant surgeon more completely out of place than in the operating theatre and wards of a hospital for children. The whole tendency of modern sur- gery is towards the performance of atypical rather than of formal operations, for the best results are obtained by put- ting the tissues in a position to cure themselves. Yet rest and the conservation of parts may do harm if carried to an extreme, as is too often seen in joint disease, in the treatment of tuberculous glands, and in insufficiently bold operations upon harelip. When an operation has been decided upon, it will generally be found that better results are obtained if the child be removed from its accustomed surroundings and is placed in the charge of those who have special experience in nursing sick children. Only in very exceptional cases can a mother be trusted to nurse her own child after a serious operation, and in many instances the recovery of a spoilt and fractious child is seriously retarded by the presence of those who love it best. It is therefore acting in the best interests of the child, to recommend that it should be placed a few days before a capital operation in a surgical home, or in the charge of an experienced children's nurse. It is also well to delay an operation of any magnitude, if it be possible, until the expiration of the incubation periods of the exan- themata from which the child has not yet suffered, and until it has recovered from its home-sickness. Children as a rule bear general anaesthetics excellently for a short time, but they soon become collapsed, so that no operation should be unduly prolonged ; and I do not remember to have seen a case in which it appeared to be inadvisable to give chloroform. Local anaesthetics are useless in young children. When chloroform has to be 4 THE SURGICAL DISEASES OF CHILDREN given, care should be taken, in addition to the ordinary precautions, that the child is not faint from hunger. It is therefore a rule in my practice, when the operation is done at nine or ten in the morning, to order the patient to take a good-sized teacupful of warm milk at seven o'clock. The chloroform should not be given too quickly, for the child often cries and makes such deep inspirations as to render it difficult to regulate the amount of vapour passing into the lungs. It is perfectly possible, and it is often well, to administer chloroform to a sleeping child ; for many of the smaller operations, such as squint and others in which no dressings are required, may thus be performed absolutely without the knowledge of the patient. Children bear hunger, cold, pain and loss of blood very badly, so that these are the main points to guard against in operating upon them. It has long been our custom at the Victoria Hospital for Children to prevent loss of heat in infants during the performance of an operation by plac- ing them upon a water bed half filled with water at 100° F., and wrapping up all exposed parts in a thick layer of absorbent wool, kept in place by light bandages. After the removal of a child to its cot, hot water bottles or hot bricks will be sufficient to maintain its heat, the nurses being warned against placing them in such a way as to allow the child to be burnt or blistered. Loss of blood during operations upon the limbs is usually prevented by the application of an Esmarch's bandage ; though there are some cases, as in excision of the knee or elbow, where the subsequent oozing of blood prevents this method being of service. It is most useful during the removal of sequestra, and the cavity should be thoroughly packed with gauze before the tubing is relaxed. Haemorrhage is arrested in other cases by the use of pressure forceps, which may be employed with much greater freedom and certainty in GENERAL SURGICAL CONSIDERATIONS 5 children than in adults, owing to the greater contractility of the arterial walls. Care must alwa} T s be taken com- pletely to arrest bleeding before the wound is closed. This is important, because operation wounds in children much more often heal by first intention than they do in adults, and it should be the endeavour of the surgeon to obtain so gratifying a result in every case, for when this is done the scars after a few years are as inconspicuous as those seen after a successful operation for the cure of a harelip. Transfusion in cases of collapse from the loss of blood is often instrumental in saving a child's life. A saline solution is generally used, for the theory of its beneficial effect is that it acts by maintaining the blood-pressure, and so enabling the heart to beat under the least disad- vantageous conditions until fresh blood can be produced, and in sufficient quantity to make up for that which was lost. Landerer says that salt solutions are useless in animals when the loss of blood exceeds 4| per cent, of the body weight. He employs a solution consisting of common salt 5iss., white sugar 5viss., dissolved in li pints of dis- tilled water, to which one or two drops of caustic soda have been added. Kronecker's formula is somewhat simpler. It is l.V pints of water, to which 110 grains of common salt and 1 grain of sodium carbonate have been added. The solution in either case must be hardly alkaline, and it must be introduced at the temperature of the body. A teaspoonful of common salt in a pint of water is sufficiently near a 06 per cent, saline solution for ordinary purposes when, as usually happens, the operation of transfusion has to be hurriedly performed. The method recommended by Dr. Horrocks, as seen in fig. 1, is simple and effective. One of the veins at the bend of the elbow is exposed, and this is no easy operation 6 THE SURGICAL DISEASES OF CHILDREN in a bloodless child. It may therefore be necessary to lay bare one of the vense comites of the brachial artery, and to pass the cannla into it instead of into one of the superficial veins. The solution is allowed to flow into the proximal portion of the vein through a glass canula connected by Fig. 1.— Diagram of Horrocks' method of transfusion. an india-rubber tube with a small glass funnel held three or four inches above the arm. The india-rubber tube should be provided with a clip to allow the air to be expelled and the tube to be kept full of the saline solution. The fluid is then allowed to flow into the vein until the pulse shows that a marked improvement has taken place in GENERAL SURGICAL CONSIDERATIONS 7 the circulation. There need be no fear of introducing too large a quantity, but half a pint to a pint is generally sufficient. The canula is removed, the vein is ligatured, and the wound is closed and dressed in the ordinary manner. Nearly all the forms of lower life flourish luxuriantly in and upon children, so that their convalescence after an operation is often retarded or arrested by one of the exanthemata. So prone are children to support microbic life that the vast number of surgical diseases are clue to one or other of the protophytes which have effected a lodgment in their tissues or organs. They have the power of destro} T ing many of these micro-organisms if their bodies be placed under favourable conditions, and even the most prolonged suppuration they often bear well and recover from. They should never, however, be left to fight for themselves in such cases, for the surgeon should make every endeavour to remove the cause of the suppuration as soon as possible. An effort, too, should always be made to abolish any pain from which a child may be suffering, for if this can be done he will often play and sleep as well as when he is in perfect health. Unlike adults, children look neither before nor after, they live for and in the hour, and so long as they are free from pain they are careless of slight inconveniences. Over and over again I have seen a child upon whom an hour before I had performed an osteotomy, or whose tendons I had divided, eating a hearty meal, and talking and laughing as if nothing had hap- pened. The indications given by the thermometer are of much less clinical value than in adults. A passing digestive disturbance, pain, sleeplessness, and such physical causes as terror or a fit of temper, are sufficient to raise a child's temperature in a manner which is appalling to those who 8 THE SURGTCAL DISEASES OF CHILDREN are not forewarned of its slight importance. Sudden and transient elevations of temperature are not unusual in cases of tuberculous arthritis in which the inflammation is apparently local. We do not know the cause of these sudden feverish attacks, but they are of bad import and are possibly associated with dissemination of the disease, though for weeks afterwards there may be no evidence of any generalisation having taken place. A transient rise of temperature may be, and usually is, of small diagnostic importance ; but a permanent rise or a hectic temperature has the same value in children as in adults, and its cause should be as carefully ascertained and treated. A tem- perature which is only slightly above normal does not necessarily imply that everything is going on well after an operation in a child, for extensive suppuration may be coincident with quite a low body temperature ; perhaps because, as the young tissues are more elastic, the tension is less marked, and there is less septic absorption. The treatment after operations in children is not usually attended with any difficulty, for a sick child almost in- stinctively keeps a seriously injured part at rest. They are usually very amenable to moral persuasion in less severe cases, and they are so conservative that when once they have been taught to lie still they will often continue to do so for an indefinite length of time. Children so frequently suffer from poisonous symptoms after the use of carbolic solutions and of iodoform that I have ceased to use them for some time past, and I have contented myself with freshly boiled water to flush wounds and sinuses. I have also made use of camphorated naph- thol for packing cavities, and a solution of one and a half or two volumes per cent, in water of hydrogen peroxide for dressing suppurating tracts. Camphorated naphthol, invented by Desesquelle of the Lariboisiere Hospital in GENERAL SURGICAL CONSIDERATIONS 9 Paris, is a colourless liquid, obtained by pounding sepa- rately one part by weight of /3-naphthol and two parts by weight of camphor. The two powders are mixed, warmed gently and filtered. Camphorated naphthol is insoluble in water, but it is readily soluble in oil, alcohol, ether and chloroform, It must be used with some care, as poisonous symptoms have been produced by leaving an ounce and a half in a cavity. I have never seen any ill-effects follow the use of two to four drachms, but often great benefit. It produces a copious fluid discharge and the wound heals kindly, but the tendency for the discharge to dry renders it necessary to paint the margins of the wound with oil to prevent the sticking of the dressings. Dressings of cyanide gauze, or of gauze which has been sterilised by heat without the addition of any antiseptic, are less irritating than the ordinary forms of medicated dressings, and are therefore better suited to the delicate skins of children. The dressings should always be as light as possible, and they should not be applied with too tight or too heavy a bandage. There is a little tendency to fall into these errors of bandaging owing to the absence of well-defined bony points in children, for the surgeon feels as if the bandage were insecurely applied. It is often very difficult in young children to keep the dressings clean and sweet when they are applied to the thighs and pelvis, and this forms a special difficulty in the treatment of hernia by the radical operation and in many cases of fracture and wounds of the thigh. It must be counteracted by the judicious application of waterproof over the dressings, by varnishing the plaster-of-Paris splints with ordinary spirit or finishing varnish, and by much extra vigilance upon the part of the nurse. CHAPTER II NON-INFECTIVE GANGRENE etiology. — Non-infective gangrene is occasionally met with in children and, as in the adult, its cause is either local or general. The local causes are interference with the blood supply from pressure upon the vessels after fracture, the pressure being exerted by the ends of the bones themselves or by a badly applied bandage. It may occur as the result of a severe crush or compound fracture which has led to rupture or obliteration of the vessels or to injury of the large nerves. It occasionally follows too long an application of an Esmarch's bandage to the limbs of weakly children. Gangrene, due to constitutional causes, occurs in Raynaud's disease, sometimes in the later stages of typhoid fever, and in the diabetes of children about the age of puberty. It is especially liable to occur in the ill-nourished and in hospital practice, where even trivial wounds occurring in children from the lowest neigh- bourhoods frequently slough. Pathology. — The pathological conditions are the same as in adults. The tissues die as a result of interference with the blood supply, and are cast off by a process of ulceration at the expense of the living tissues along a well-marked line of demarcation. Symptoms. — The symptoms are more or less marked pain, oedema, alteration in the colour of the skin, variations 10 NON-INFECTIVE GANGRENE I I in the pulse, temperature and general condition of the patient. Treatment. — The treatment varies with the particular form of gangrene, and is given in detail in the subsequent sections. Traumatic Gangrene. This is rare in children, but it is somewhat more frequent after fractures than after other injuries. It is characterised by the painless course which it runs. It is therefore advisable to see the patient frequently for the first few da} T s after a splint has been applied, to enable the surgeon to assure himself that undue swelling is not leading to this calamity. The gangrene which results from the prolonged applica- tion of an Esmarch's bandage is not often seen. It is preceded by an acute oedema of the part. The mortifica- tion is trivial and, as a rule, affects the edges of the wound. It is, however, an unpleasant complication, and its possible occurrence should be borne in mind when the surgeon undertakes prolonged operations upon bloodless limbs in delicate children who have a weak circulation. Raynaud's Disease. etiology. — Spontaneous gangrene of the extremities, which is either symmetrical or asymmetrical and which arises independently of obvious vascular obstruction, occa- sionally occurs in children, and somewhat more frequently in girls than in boys. The predisposing and exciting causes of the condition are quite unknown, but in a certain proportion of cases it seems to be associated with paroxysmal attacks of hemoglobinuria and with peri- pheral neuritis. The severity of the affection varies greatly ; in some cases it is merely a tendency of the I 2 THE SURGICAL DISEASES OF CHILDREN extremities of the tips of the ears, of the nose, or of cer- tain circumscribed cntaneons areas, to become numb and bloodless — the syncopic form — whenever the peripheral arterioles are contracted, either locally from the application of cold or reflexly by the dilation of the arterioles in other parts. More severe lesions are present in other instances ; the extremities or other parts of the body become gangren- ous, sometimes superficially, and sometimes the deeper tissues are involved as in the case (p. 13) related below. The symmetry of the gangrenous patches is sometimes very remarkable ; but it is not an essential condition, for the gangrene is often unilateral. The gangrene is either of the dry or of the moist form. Symptoms. — The symptoms are often ill-defined, and the patients are not seen until the gangrenous condition is well established. The affected part becomes of a lilac colour — the asphyxia! form — and the patient complains of tingling, which in a few days may become a severe pain. The tissues adjacent to the affected part are often a little cedematous and hypersemic. The heart is normal, and the pulse never ceases to be perceptible in the arteries of the affected limbs, though it may be increased in frequency and diminished in strength. Progress. — The gangrene generally follows a continuous course, either acute or chronic, but the symptoms may be intermittent. Dr. Raynaud states in his original thesis that its duration is never less than twenty days, and never more than ten months ; but these two terms are excep- tional, and the ordinary duration is three or four months. The Diagnosis is not difficult. The incipient gangrene must be distinguished from chilblains and frostbite, whilst the pain must not be mistaken for that due to rheumatism or neuralgia. It must also be distinguished from gangrene due to other causes. NON-INFECTIVE GANGRENE I 3 The Prognosis is not wholly good, for although many children affected with symmetrical gangrene recover, a certain proportion die. The Treatment in the earliest and simplest forms con- sists in stimulating the local circulation either by sham- pooing or by the use of the constant current. Dr. Barlow 1 states that he has obtained good results by plunging the extremity of the limb which is the subject of local asphyxia into a large basin containing salt and water : " Place one pole of a constant current battery on the upper part of the limb, and the other in the basin, thus converting the salt and water into an electrode. Employ as many elements ns the patient can comfortably bear; make and break at frequent intervals so as to get repeated but moderate con- tractions of the limbs. In a typical paroxysmal case, if two limbs be similarly affected, it will be found that the limb which is subjected to the above treatment will more rapidly recover than the one which is simply kept warm." This method of treatment should be adopted both in the acute and in the chronic cases. During the painful periods an icebag may be applied to the part, or if this fails to give relief, warm applications may be tried. Amputation is required for aesthetic purposes when the gangrene has affected the deeper tissues of the fingers and toes ; but it should not be adopted until there is a well-defined line of demarcation. The following case which recently came under my care will serve to illustrate the general characters of the affec- tion. A girl, aged 56 months, but looking much younger, was brought to me in March, 1893, suffering from gangrene of both feet. She had been much troubled in the winter of 1890 with chilblains, and in November, 1892, her feet and legs became livid in the evening, but were of the natural colour during the day. The toes became black and 14 THE SURGICAL DISEASES OF CHILDREN shrivelled in December, 1892. The fingers had always been natural. The child had never walked or crawled, but there was no paralysis, and the want of power appeared to depend upon simple weakness. The father was subject to chilblains, but there was no family history of phthisis, diabetes, or heart disease. She occasionally passed large quantities of urine. The pulse, when I first saw the patient, was 144, regular and of high tension. The radial arteries were thickened, they were tortuous, and were more easily felt than usual. Pulsation could be detected in the dorsalis pedis artery of each foot, and in both posterior tibial arteries. The skin of the body was natural, the finger-nails were cracked and the finger-tips beneath the nails were blue. The heart and lungs were normal. The eyes were natural, and there was no retinal haemorrhage. All the toes on both feet were shrivelled and black, and the gangrene extended to the metatarso-phalangeal joints. There was a small patch of black skin about half an inch in diameter on the inner side of the left heel, and at a corre- sponding point upon the right heel the skin appeared to be redder than natural. The patient was ordered a generous diet, with half an ounce of brandy every twenty-four hours. One-minim doses of tincture of opium with aromatic spirits of ammonia were given every three hours. A line of de- marcation began to be formed five days after I first saw her, and nearly three months after the beginning of the mortifi- cation. The line of demarcation was formed along each series of metatarso-phalangeal joints, and at the same time the slough on the left heel separated, leaving a small super- ficial ulcer, whilst the red patch on the right heel com- pletely disappeared. Four days later, on March 18th, the phalanges of the little toe on the left foot were completely separated. Chloroform was administered on April 6th, and the remaining phalanges on both feet were removed. NON-INFECTIVE GANGRENE I 5 The patient made an uninterruptedly good recovery, except that on April 16th a small black spot was noticed about the junction of the upper with the middle third of the anterior surface of the right tibia. The child was again ordered to take one-minim doses of laudanum, and the spot disappeared in a few days. The urine was repeatedly tested whilst she was under treatment. It was generally neutral or feebly alkaline, and it was at all times free from sugar, blood and hsemoglobin. It contained crystals of triple phosphate, and on one occasion there was a trace of albumin. A year later, the child was fat and well. She had passed through the winter without any return of her old symptoms. Typhoidal Gangrene. My friend and colleague, Dr. Dawtrey Drewitt, 2 * has recently published a short but complete account of gangrene of the limbs following typhoid fever. He thinks that gangrene in this disease is more frequent in children than in adults, because the young heart is able to hold out to the end in cases of typhoid, where older hearts would fail, and though grey and bloodless are still able to contract on the half dried up and clotting blood- stream. The facts, that in typhoid fever the gangrene occurs late in the disease, and is generally preceded by a sudden pain in the limb, whilst the artery becomes big with thrombus, points, Dr. Drewitt considers, to an embolic origin. He therefore recommends that cardiac stimulants as well as an abundance of fluid food should be given in the later stages of typhoid fever to counter- act any tendency to the formation of emboli. * The Nos. throughout refer to the Bibliographical Appendix. CHAPTER III NON-TUBERCULOUS INFECTIVE DISEASES SAPBJEMIA. The simplest form of septic disease is that which arises from a suppurating wound. The child is constipated, his temperature rises two or three degrees, he is flushed, drowsy, and has a bad appetite. The neighbouring lym- phatic glands become tender, enlarged, and may suppurate. Free vent is to be given to the pus if it has been confined. The wound should be well cleansed and dressed antisepti- cally, the bowels are to be relieved, and in a clay or two all signs of the fever will have disappeared. SEPTICAEMIA. More serious manifestations sometimes present them- selves after an operation. Symptoms of a typhoidal character arise, and the child passes through an attack of true septicsemia, often associated with a rash. This rash is an erythema of infective origin, and is often seen around the seat of puncture after the inoculation of the various antitoxins. It is not uncommon during conva- lescence from diphtheria and typhoid fever. It appears first near the joints or upon the buttocks, somewhat less frequently upon the belly, and still more rarely on the neck. The rash varies considerably in extent, it is fugi- tive, and has a great tendency to become petechial. It is often symmetrical, but it does not spread. Its appear- ance is attended by constitutional symptoms of greater or less severity. The temperature rises, falls, and rises again, the pulse-rate is increased, the patient vomits, and has it; NOX-TUliERCULOUS INFECTIVE DISEASES 1 7 diarrhoea. The urine is scant}-, and may contain albu- min. These symptoms are truly septicaemic. There is no doubt that they are caused by an inflammation which is secondary to the disease from which the child is convales- cent, and that they are due to septic organisms lurking in the various mucous membranes of the body. The attack may be complicated by pneumonia, bronchitis, or pericar- ditis. It does not usually cause death in an uncomplicated form. The Treatment consists in removing the local cause of infection as soon as possible, clearing out the contents of the bowels with Rochelle salts or a calomel purge, and, if necessary, rendering the alimentary tract aseptic by the ad- ministration of small doses of /3-naphthol. Quinine should be given, with brandy and plenty of milk. The prophylactic treatment is to render the mouth and pharynx aseptic during convalescence from pneumonia, diphtheria, typhoid fever and other diseases which are likely to lead to the harbouring of micrococci. This can be done by the use of gargles, sprays and tooth brushes. PYAEMIA. etiology. — Pyaemia is one of the worst forms of septic disease, but like septicaemia it is not very common in children. It is met with in new-born infants, associ- ated with a similar puerperal condition in the mother, or the child may become affected independently from its filthy surroundings. Pyaemia in older children is perhaps most often associated with neglected osteomyelitis, with mastoid abscess, causing purulent infection of the lateral sinus, or as a sequel of diphtheria and erysipelas. I have seen it follow excision of joints and compound comminuted fractures, when children have been run over by tramcars. Symptoms. — The pysemic symptoms are the same as c 1 8 THE SURGICAL DISEASES OF CHILDREN those met with in acUilts. Extreme prostration, irregular temperature, repeated rigors, sweating, and greatly en- feebled cardiac action are the chief points. The abscesses found in the joints are not necessarily accompanied by increased febrile disturbance at the time they are formed, though a fresh abscess is often found within a few hours of a rigor. Course. — Pyaemia in children runs a rapid and fatal course, characterised by the formation of abscesses in dif- ferent parts, and frequently by gangrene of the skin. It is chronic in a few cases, and may then cause secondary dislocations of one or many joints, as a result of the sup- purative arthritis which characterises the disease. Treatment. — The only treatment consists in the free administration of quinine and stimulants, the early opening of secondary abscesses, and the thorough cleansing of any wound. Ligature of the vein carrying blood away from the affected part is sometimes of service ; but this treat- ment is considered in greater detail under the heading of infective thrombosis of the lateral sinus. ERYSIPELAS. etiology. — Erysipelas occurs even in new-born chil- dren, for in Lebedeff s case the streptococcus erysipelatosus was found in the skin of a child who died ten minutes after its birth from a mother who was herself suffering from erysipelas. It most commonly attacks the navel and genital organs, though it may also start from abra- sions, ulcers and eczematous conditions of skin in other parts. It is not very uncommon after vaccination, or after chickenpox. Young children are especially liable to attack, and they bear erysipelas badly, for they often die rapidly with diarrhoea and bronchitis, or if they recover from the immediate effects they succumb to the NON-TUBERCULOUS INFECTIVE DISEASES 1 9 inflammatory and gangrenous conditions of the skin which form such common sequelae. Indeed, it is said that children under one year old who are attacked by erysipelas, die, and } r et they only suffer from the cutaneous form. Erysipelas is very rare in older children, and they usually bear it much better. The Symptoms are the same as in adults. There is a well-marked initial rigor, with vomiting, delirium, increase of temperature to 104-105° F., and erratic erythema with the formation of bullse. Treatment. — The treatment consists in the administra- tion of half -drachm doses of Epsom salts, and as soon as the bowels have been well opened, a mixture containing tinct. ferri perchlor. m] xx. and glycerine 5 i- in each ounce of water should be given three times a day for a child of six to eight years. Alcohol, best given in the form of brandy or whisky, is nearly always required as a stimu- lant. The inflamed part should be dressed with lead lotion, or it may be powdered with oxide of zinc. CELLULITIS. etiology. — Acute cellulitis is rare in children, but the more chronic forms associated with infective disease are by no means uncommon. They are usually associated with diphtheria, for the relief of which tracheotomy has been performed, leading to cellulitis of the neck and septic osteomyelitis, causing cellulitis of the limbs ; but cellulitis may also occur in the course of an attack of chickenpox, scarlet fever, or measles. Symptoms. — Primary cellulitis is an acute inflam- mation, and runs a very virulent course. It attacks the submaxillary or, more rarely, the ischio-rectal region in children who have been weakened by some debilitating disease, or who from some other cause are in a bad state of 20 THE SURGICAL DISEASES OF CHILDREN health. In the submaxillary form the lymphatic glands at the angle of the jaw become enlarged, but they do not suppurate, and a brawny oedema very soon affects the neck, from the chin to the sternum, either ou one or both sides. The mouth and pharynx often remain unaffected, but the tongue may become swollen, owing, Mr. R. W. Parker 3 thinks, to the pressure of inflammatory products upon the lingual vein. The disease reaches its height in two or three days, and is characterised by the usual symptoms of septic infection, rendered more acute by the fact that the inflammatory products are pent up under a very dense fascia. There is a difficulty in swallowing in some cases, but in many dysphagia is by no means a prominent sign. An abscess forms when no treatment is employed, and it opens either by the side of the tongue, or ex- ternally at the margin of the jaw. The patients recover in a few cases, but in too many instances they die of septicaemia, and in a very short time. A similar condi- tion occurs in adults, and was first clearly described by Dr. Ludwig, of Stuttgart (Mcdicinisches Correspondenz- blatt, Bd. 6, 1836, p. 21), after whom it has received its modern name of Angina Ludovici. : ^ It was, however, known to Aretseus and to Paulus iEgineta, for both writers describe it. The Treatment consists in early and free incisions carried through the deep fascia, and with as little loss of blood as possible. The incisions should be made before gangrene of the cellular tissue has occurred, and when only blood-stained serum exudes. Some effective means of drainage must be adopted, and wounds must be dressed antiseptically. It is then probable that the disease will run a simple suppurative course. Quinine, brandy, and a sufficient supply of easily digested food are impera- tively demanded. NON-TUBERCULOUS INFECTIVE DISEASES 2 1 FURUNCULOSIS. This is a very common disease in the badly nourished children of large towns. The boils appear in crops upon the trunk more often than upon the extremities, and they are often so close together as to lead to a diffuse suppura- tion. They may be so numerous and are accompanied by so much constitutional disturbance as to put the life of the patient in jeopardy. The Treatment consists in feeding the child well and regularly, and administering J-grain doses of calcium iodide or sulphide three times a day. Yeast, too, in doses of one or two teaspoonfuls three times a day, may also ba used with advantage in some cases. It is given quite empirically, for we have no idea of the manner in which it acts. Poultices should not be applied to the abscesses, but the skin over them should be carefully and gently washed with soap and water ; and it should then be incised, and dressed with gauze soaked in a 40 per cent, solution of carbolic acid or a 1 in 2000 solution of perchloride mercury. PHAGEDENA AND SEPTIC GANGRENE. Dr. Gee explains phagedena to be a rapid ulceration, the tissues being destroyed particle by particle, and being cast off in like manner. In gangrene the dead tissues remain in situ until the patient dies, or are cast off in masses called sloughs. This distinction is a real one, and is of practical value. Both phagedsena and gangrene occur amongst children, and their cause is either local or consti- tutional. The best known form of phagedsena is noma, including cancrum oris, though it occasionally assumes a gangrenous form. Noma and cancrum oris occur in children, between the ages of three and six years, who have been weakened by an attack of scarlet fever, measles, typhoid, or less frequently, 2 2 THE SURGICAL DISEASES OF CHILDREN in the very debilitated without any such predisposing cause. As the terms are used in this country, noma is usually restricted to an acute inflammatory condition, rapidly passing into phagedena, and affecting the vulva or penis, and more rarely the anus, whilst cancrum oris is a similar condition affecting the mouth. There is no reason, how- ever, why noma should not be used to the exclusion of cancrum oris. Course.— The affection begins insidiously on the mucous surface of the part attacked, the skin remaining white. The deeper tissues soon become infiltrated, and a small, hard and round spot can be detected. Examination of the mucous membrane will reveal a painless patch, covered with a yellow secretion. This patch rapidly spreads, and the whole of the infiltrated tissues are destroyed. The disease, as we see it in London, runs an acute— gangren- ous — an d a less acute — phagedsenic — course, the slower form being the more usual. I have only seen it amongst the poorest and most neglected children. Treatment.— The course of the disease must be arrested, if possible, or death will take place in eight to twenty-one days from pneumonia, bleeding, or starvation. The readiest means of stopping the inflammatory process is to put the patient under chloroform, scrape away the foul and softened area, and then thoroughly swab it over with fuming nitric acid, or acid nitrate of mercury, taking care that none of the caustic passes beyond the diseased tissue, and that all excess is wiped away. Very great deformity sometimes results from the destruction of the tissues if the patient recovers, but in the acute cases all remedies are too often useless. Fresh air, good food, alcohol, small doses of opium, and local applications of chlorate of potash, will assist the patient's convalescence as soon as the sloughing process is arrested. The affection is no doubt due to NON-TUBERCULOUS INFECTIVE DISEASES 23 micro-organisms, but no specific form has yet been iso- lated. GANGRENE OF THE FAUCES AND SOFT PALATE. This may be erysipelatous, but it is sometimes idio- pathic, and it then occurs as an insidious and very fatal form of disease in young adults. Symptoms. — It commences as an acute inflammation of the tonsils, with the ordinary symptoms of pain, fever, dysphagia, and constipation. The inflammation rapidly passes on to gangrene, involving the soft palate and the fauces, leading to the formation of an extensive slough. The symptoms are not unduly severe, and there is but little pain, so that the surgeon is apt to be thrown off his guard, until the stinking discharge and a sharp haemor- rhage from the mouth or nose warn him of the true nature of the case. Treatment. — The few cases I have seen have run a rapid and fatal course, in spite of all that could be done for them. The condition must be distinguished from an allied form of phagedgenic ulceration of the fauces, which is not uncommon after the exanthemata, and notably after scarlet fever, diphtheria, and typhoid. This secondary form is less likely to kill, for it is amenable to treatment internally by quinine and tonics, locally by chlorate of potash spray. The anterior pillars of the fauces are found after recovery to be perforated, the per- forations sometimes being single and sometimes double. *e> GANGRENOUS EMPHYSEMA. Pathology. — Malignant oedema is a very severe form of gangrenous inflammation produced by the inoculation of a bacillus capable of spontaneous movement. It is smaller than the anthrax bacillus and, during sporulation, it en- 24 THE SURGICAL DISEASES OF CHILDREN larges at one end and forms an oval, brilliant and blnish spore. It is essentially an anaerobic organism, and it lives in the earth, only occasionally migrating to animal tissues. etiology. — The disease is due to the direct inoculation of the bacillus into the cellular tissue of the body. Symptoms. — The incubation period is from a few hours to six days after a more or less severe injury, marked by malaise, and often associated with pain around the wound, and sometimes with so much bronzing of the skin as to lead Velpeau to give it the name of erysipele bronze. Dr. Roswell Park, in his recent Mutter Lectures, says that the invasion period is characterised by a rapid elevation of temperature which continues with but trifling remissions until death. The tongue becomes dry and covered with a thick and foul fur. The patient soon loses consciousness or becomes apathetic, complaining only of pain and burning thirst. Incontinence of urine and fasces, frequent and superficial breathing, and dilatation of the pupil are the precursors of death, which may occur from fifteen to thirty hours after the onset of the acute symptoms. The inflammation spreads rapidly from the wound, and leads to a speedy destruction of the tissues with the forma- tion of gas. A dirty, reddish-brown skin, mottled with blue, whose veins are filled with stagnant blood, covers the affected areas. The underlying tissues are sodden with fluid, and distended with the gaseous products of decom- position. They yield a fine crepitus, due to subcutaneous emphysema. A thin and foul-smelling secretion flows from the wound. Diagnosis. — Gangrenous emphysema is not always malignant oedema. It might be mistaken for quarter-evil, and a closely similar condition has been met with after typhoid fever. NON-TUBERCULOUS INFECTIVE DISEASES 25 Prognosis. — The prognosis is serious, but not neces- sarily fatal. Treatment. — The treatment consists in making free in- cisions, with as little loss of blood as possible, and the most thorough disinfection of the wounds. The strength of the patient must be supported by every possible means. . ACUTE RETROPHARYNGEAL ABSCESS. etiology. — Retro-pharyngeal abscess, 4 due to inflam- mation of the deeply seated lymphatic glands in the neck, which receive the lymphatics of the tonsil, soft palate and pharynx, is not very infrequent in children. It often occurs insidiously and from no very apparent cause, though a cross-examination of the parents may elicit a his- b try of otitis, nasal catarrh, teething, or other chronic inflam- mation of the tissues near the pharynx. The abscess is associated with the presence of several forms of strepto- coccus usually found in the larynx. It is due in other cases to the burrowing of an abscess in the neck from inflammation of the middle ear, or more rarely to scarlet fever, measles, or direct injury. A more chronic and otherwise widely different form is secondary to tuberculous or other disease of the cervical vertebrse (p. 81), when the pus accumulates beneath the deep fascia and the anterior common ligament ; whereas in the acute cases it is situated in the cellular tissue, between the pharynx and the fascia covering the prevertebral muscles. Symptoms. — The onset of the disease is singularly in- sidious ; the child is obviously ill, but there is nothing to account for it until, as the pharyngeal swelling increases, deglutition and respiration become impaired. Tho voice is said to be low and quacking like a duck ; but. this was not noticeable in any of my cases. The child usually keeps 26 THE SURGICAL DISEASES OF CHILDREN its head in a fixed position, either bent towards the un- affected side when the abscess is unilateral, or inclined forwards when the swelling is median or bilateral. Diagnosis. — The diagnosis is readily made by an exam- ination of the inside of the mouth, when a swelling usually placed to one side of the middle line will be seen bulging the pharynx forwards. The swelling feels soft, fluctuation can be obtained, and its upward and downward limits are easily felt, though in some cases it may pouch downwards like a psoas abscess (fig. 14), one pouch being connected with another by a narrow channel. When the collection of pus is considerable it may point in the neck, pushing the large vessels in front of it, and giving rise to a pulsat- ing tumour which might conceivably be mistaken for an aneurism. The urgent dyspnoea often accompanying these abscesses makes it necessary to distinguish them from croup, bronchitis and oedema of the glottis. Simple exami- nation of the throat will establish the presence of an abscess, whilst even slight external pressure upon the larynx markedly increases the dyspnoea and the pain. The voice is less affected than in croup or diphtheria. Course. — The duration of the disease is from two to four weeks, though it sometimes runs an acute course and opens spontaneously, or it may become chronic, as in cases of cervical caries, when it may extend downwards into the mediastinum or pleural cavity ; but the abscess should never be allowed to open itself, as it has been known to cause instant death by discharging its contents into the air- passages during sleep, or from haemorrhage by ulcerating into the large blood-vessels of the neck. Broncho-pneu- monia and oedema of the glottis are the most frequent complications in ordinary cases. Treatment. — The treatment consists in opening the abscess through the neck, either by Chiene's incision along NON-TUBERCULOUS INFECTIVE DISEASES 2 J the posterior border of the sterno-mastoid,or by Burckhardt's incision along the anterior border of the muscle. I prefer the former method. A one-inch incision is commenced an inch below the mastoid process and immediately behind the posterior border of the stemo-mastoid. The knife is laid aside as soon as the deep fascia has been divided, and the abscess is opened with a blunt-pointed director, one finger being kept in the mouth touching the back wall of the pharynx. The abscess is readily emptied by pressure exercised through the pharynx ; but care must be taken to empty any pouches which may extend downwards. The proof of having done this successfully is the marked im- provement taking place in the respiration. The abscess cavity is well washed out and a drainage-tube is inserted, — for I have not yet ventured to scrape and try to obtain union by first intention, — the ordinary dressings are applied, and the child in uncomplicated cases usually does well. It sometimes happens that the dyspnoea is so urgent that it is necessary to perform tracheotomy, and when this is requisite, the low operation is said to be preferable to the high. The after-treatment consists in keeping the child in bed with its head fixed until the wound has healed, and in giving plenty of good food. The older operation of opening the abscess, by an incision carried through its whole extent in the pharynx, would not, I think, give such satisfactory results, though it is still recommended by some surgeons, as the bleeding and the discharge of pus in a patient whose respiration is already greatly impeded, renders it dangerous, quite apart from the fact that after such an operation the abscess cannot be kept aseptic. It is possible, however, that cases might arise in which such a method of opening would be more advisable than that of incising through the neck. Aspira- tion in these cases should not be attempted. 28 THE SURGICAL DISEASES OF CHILDREN ACTINOMYCOSIS. ^Etiology. — Actinomycosis is a rare disease sometimes affecting children, for I saw Dr. Douglas Powell's 5 patient, a boy of nine. It is due to the invasion of the tissues by a fungus, sometimes derived by inoculation from cattle, but more often perhaps from infected grain. The exact method of introduction is doubtful, but it probably gains entrance by the respiratory passages, and in a few rare instances by the mouth, through carious teeth. Pathology. — The actinomyces fungus has a character- istic appearance which 'allies it to streptothrix. It consists of a mycelium associated with a considerable quantity of inflammatory granulation tissue. The mycelium is sur- rounded by a fringe of clubs arranged radially, which has led to its name of " ray fungus." Only the most typical specimens terminate in these clubs or cocci, whose significance is still unknown. The younger nodules in man rarely show the club-shaped extremities, whilst the older nodules often lose their central mycelial mass and become crescentic in shape. The growth spreads by con- tinuity from tissue to tissue, it sets up local irritation, leads to extensive suppuration, and may cause pyaemie symptoms. Symptoms. — The symptoms are those of a chronic abscess affecting the skin, mucous membranes, bones or viscera, especially the lungs and liver. It appears on the skin in the form of numerous globular masses which are soft and spongy and have an indurated erythematous base. Dr. Pringle's case, occurring in a' boy of thirteen years, presented large, sarcomatous-looking growths, ulcerating at various points, situated upon hard, brown and deeply undermined skin. From the ulcerating points pus exuded, mixed with characteristic yellow granules which were recognised under the microscope as colonies of actinomyces. NON-TUBERCULOUS INFECTIVE DISEASES 29 Diagnosis.— It is found that the abscess either consists of caseating substance, or of a semi-fluid, brain-like mate- rial mixed with blood. It is therefore most likely to be mistaken for a chronic tuberculous abscess, for a sarcoma, or for an empyema. The pus, however, is gritty, and close examination reveals that the grittiness is due to minute nodules just visible to the naked eye and readily seen as rounded masses under a low power of the microscope, con- sisting of colonies of the ray fungus. In cases of suspected actinomycosis, Gram's method of staining, applied to a coverglass px*eparation of the colonies obtained from the pus, will easily demonstrate the typical masses of branch- ing mycelium. The clubs may be shown, if they are present, by first staining a crushed nodule with hsema- toxylin, and then with acid fuchsin. They will be found scattered over the field of the microscope, and not arranged in definite circles. Prognosis. — The disease runs a very chronic course, as it may last for months or even for years ; when it sets up a pleurisy, the effusion may be absorbed. Treatment. — The treatment consists in attacking the individual nodules, thoroughly removing them, and by afterwards applying chloride of zinc in solution. INFECTIVE OSTEITIS. Inflammatory diseases of bone have long been known in association with the exanthemata. The inflammation is an osteomyelitis, but the stress of the disease may fall, either upon the deeper layers of the periosteum and lead to its separation or to its increased functional activit}', or it may fall upon the bone itself, leading to sclerosis, local or general, suppuration, or to its rarefaction. Pathology 30 THE SURGICAL DISEASES OF CHILDREN does not yet tell us why these changes take place. It may be that they are associated with the infective micro- organisms themselves ; it may be that they are due to the poisonous products of their activity ; it is more likely that they result from the action of separate organisms and that the exanthematous germs merely prepare the way before them. The inflammation takes place in those parts of the bone tissues which are the most vascular, and in which the most elaborate developmental changes are going on. They are therefore most often seen in the neighbourhood of the epiphyses and in the jaws. Acute osteomyelitis for the present must be looked upon as a mere clinical term, which in the course of a few years we shall be able to replace by a series of groups capable of being distinguished one from another, and perhaps capable of individual treatment. The question at present is one of transcendental pathology, and though it is of the greatest interest, it need not longer detain us. Acute Osteomyelitis. Pathology. — In only a few instances has pathological work borne such good fruit as that connected with the causation of acute osteomyelitis, which in its later stages was known as " acute necrosis." Our knowledge of this most serious affection is now founded upon so firm a basis of facts, acquired by experimental methods, that its modern treatment is no longer empirical. The first great advance in our knowledge was the recognition of the important fact that osteomyelitis was an infective disease due to a micrococcus. The second, that there was no specific micrococcus producing it, but that a variety of different forms might give rise to that group of clinical signs and symptoms which in the aggregate is called acute osteo- myelitis or acute septic osteitis. The third great step in NON-TUBERCULOUS INFECTIVE DISEASES 3 I advance was made on the discovery that the micrococci were not necessarily introduced directly into the bone, but that they often gain access through some other portal. This discovery at once coreelated experimental work with clinical experience, for it had been long known that the worst cases of this disease occurred after the exanthemata, the exciting cause often being the most trivial injury. etiology. — It is therefore obvious that in septic osteo- myelitis, as in all other infective diseases, there must be a proper soil for the growth of the organism, and this is known as the predisposition to the disease. There must be the organism itself, which in this case is circulating through the blood, and so far as can be ascertained, is daily being absorbed by the various mucous membranes which for some reason have failed to perform their protec- tive functions. Lastly, there must be a place of least resistance where the organisms which have thus gained access to the body may settle and multiply. All these factors are found in cases of acute osteomyelitis. The child is nearly always in a debilitated condition, as it has recently passed through an attack of measles, scarlet fever, influenza, whooping cough or pneumonia, all diseases associated with the presence of specific micro-organisms. Exciting Causes. — A slight injury to one of the bones, or the mere application of cold to a limb, may set up sufficient vascular disturbance to fit the part to act as a nidus for the organism, and the disease is started. The excellent scientific work which has been done by the Lyons School of Medicine has shown how complex are the changes which take place at the epiphyseal line of a growing bone ; 80 that we have no difficulty in understanding why the micro-organism, in cases of acute osteomyelitis, usually shows so great a preference for this part of the bone, that many surgeons have proposed, but unadvisedly, to call the 32 THE SURGICAL DISEASES OF CHILDREN disease by the name of epiphysitis. The developmental processes lead to the formation of many new blood-vessels, some of which are still cul-de-sacs ; so that the micro- organisms remaining in the stagnant blood-stream are able to exercise their full powers for evil, by leading to an emigration of leucocytes. The disease, as it is well known, occurs in children — boys usually — from the time of birth until the union of the epiphyses has taken place ; but it is less frequent in the later than in the earlier years of child- hood. It most often attacks the lower end of the femur and upper end of the tibia, more frequently bones which are subcutaneous than those which are well covered (though the flat cranial bones are an exception to this rale, for they are rarely affected). Bones which grow rapidly are more liable to be attacked than those which grow slowly. It is therefore most frequent in the femur and tibia, and it is least often seen in the lower jaw and clavicle. Varieties. — Septic osteomyelitis is met with in two forms : circumscribed when its effects are limited to the immediate neighbourhood of the part in which it starts, and diffuse when large tracts of tissue are involved. The worst possible results ensue from the diffuse form. Mr. Pick has recently pointed out that in children under one year, acute osteomyelitis is usually an inflammation of the young growing bone beneath the epiphyseal line, and as the epiphysis is cartilaginous and thin, the neighbour- ing joint is very frequently directly involved in the in- flammation ; whilst in older children, the epiphysis being less cartilaginous and thicker, the joint may escape, for the abscess may open externally. In these older children, if the joint does become involved it is by a different process, for the inflammatory products do not pass directly through the epiphysis, as in the previous case, but the whole limb being in a condition of cellulitis the inflammation tracks NON-TUBERCULOUS INFECTIVE DISEASES $$ round by the periosteum, and then enters at the periphery of the articulation, instead of through its centre. The Symptoms of acute osteomyelitis are those of a more or less severe attack of septicaemia, but they differ somewhat with the age of the child, though in the worst forms death may take place before any coarse bone lesion is found. In very young children, in whom pain is neither felt acutely nor localised definitely, the symp- toms are ill-defined. The child is noticed to be ailing, and refuses its food. It is fretful, and screams when it is dressed or moved. Careful and prolonged observation will show that one limb is kept motionless, and if this part be examined, pain can be elicited by even moderate pressure, the tender spot being situated near one of the epiphyses. If these symptoms pass unnoticed, or are allowed to go untreated, the joint often becomes suddenly and acutely inflamed, for an abscess bursts into it, and the child is then brought to the surgeon for treatment. The disease sometimes runs a less severe coiirse, the epiphyses remain enlarged, but no acute abscess is formed. In other cases, again, the abscess tracks upwards or downwards into the soft tissues, and the joint escapes the full force of the disease ; but these cases are less frequent in very young children. Acute osteomyelitis runs its most typical course in children over two years of age, though it is commonly seen between the ages of nine and fifteen years. It begins suddenly in a delicate or debilitated child with a convul- sion, or more rarely a rigour, vomiting, diarrhoea, or severe headache. The child only complains of pain near a joint if it be questioned, for it is often too ill to do so spontaneously. Its temperature rises rapidly to 105° or 106° F., with morn- ing remissions to 102° F., and he often becomes delirious. He now presents all the symptoms of acute septic poisoning. D 34 THE SURGICAL DISEASES OF CHILDREN His tongue is dry, lie has diarrhoea, he sweats profusely, his spleen is enlarged, his urine contains albumin, and he often has a little bronchitis. The tacttis eruditus will alone detect the bone lesion during the first two days of the illness, and even that sometimes fails ; but in the later stages, when the time for cure has passed, it is obvious that the bone, and perhaps the joint, is extensively diseased. A diffuse abscess, filled with purulent and blood-stained fluid, has formed, and a sequestrum of greater or less extent must be the result. The Differential Diagnosis is of the very greatest im- portance, for there are few diseases in which so much can be done in the early stages, and so little in the later ones. There are few diseases, too, in which a mistaken diagnosis is more common. The acuteness of the onset usually leads the practitioner to think of the acute diseases with which he meets more frequently than acute osteomyelitis. He therefore attributes the attack to acute rheumatism, to cellulitis, to the onset of one of the exanthemata, to tuber- culous peritonitis or meningitis, to typhoid fever, or even to scurvy, and in this way much precious time is lost. It should be a matter of routine to examine the limbs in all cases of acute illness occurring in growing children, and a moment's examination will eliminate everything except articular rheumatism. Mr. Edmund Owen has recently drawn attention to the fact that in the early stages acute osteomyelitis near the knee may be distinguished from rheumatism by gently moving the limb, and observing that the joint is normal, and that the inflammation affects the deeper tissues above or below it ; whilst in the later stages, before an abscess has formed, there is a tender swelling of the ends of the bone, which is felt most readily by putting a finger and thumb upon either side of the bone and com- paring it with the corresponding part on the opposite side. NON-TUBERCULOUS INFECTIVE DISEASES 35 The confusion of rheumatism with septic disease is no doubt due to the pernicious habit acquired by English practitioners of calling infective arthritis in all its forms rheumatism, instead of speaking in precise pathological language of gonorrhoea! arthritis, scarlatinal arthritis, and other similar forms. The Prognosis of acute osteomyelitis, unless it be seen in its very earliest stages, is always grave. Death of the affected bone, to a greater or less extent, is the rule ; the joint may become involved, or the infective process may spread throughout the body, so that the patient dies with pysemic symptoms. If he escapes the immediate risks of the acute stage, he may succumb to the remote effects of a long-continued suppuration, in the endeavour to cast off large pieces or even the whole shaft of bone which has died. Recent improvements in surgery, by timely operation, have materially lessened the number of deaths due to diarrhoea, lardaceous disease and exhaustion. Operative Treatment must be adopted in every case as soon as the disease is recognised, and, if possible, before an abscess has been formed. The limb should be rendered blood- less by elevation and the application of a rubber bandage. One or more incisions should be made at once through any tender swelling right down upon the bone, and under no circumstances should the incision be deferred until fluctua- tion can be detected. Good will have been done to the patient even though nothing but blood escapes, for tension will have been abolished. The wound in these cases must not be closed, it should be packed with aseptic gauze and allowed to granulate. A thorough examination on either side of the epiphyseal line should be made by means of a probe if pus be found. Any opening in it should be enlarged with a gouge or burr, and the cavity into which it leads should be thoroughly scraped to remove all granu- 36 THE SURGICAL DISEASES OF CHILDREN lation tissue. Care must be taken in doing this that the joint be not opened, and that the compact tissue is not Fig. 2.— Photograph of a child who had a large drainage-tube passing from A through her shoulder-joint for twenty-eight days. It shows the free movement which often occurs in children's joints, even after prolonged suppuration. unduly encroached upon. The cavity thus cleaned should be swabbed out with a 1 in 15 solution of zinc chloride, thoroughly irrigated with a saturated solution of boric NON-TUBERCULOUS INFECTIVE DISEASES T>7 acid, and packed with gauze, no attempt being made to close the wound. Attention should be directed to the shaft of the bone, if the epiphysis appears to be unaffected and there is no pus beneath the periosteum. The guarded use of a drill, gouge, or trephine, will sometimes reveal the presence of suppuration within the bone. The compact tissue in these cases should be gotiged away, and the same treatment employed as has been recommended for the epiphysis. The joint in cases of secondary arthritis should be laid open, thoroughly washed out, and freely drained. It should be dressed antiseptically, and fixed immovably in the position which is the most likely to give a useful limb in case there is subsequent anchylosis. The reparative power in children is so great, however, that the recovery with a useful joint is not to be despaired of even in what appears to be the least hopeful case at the time of the operation. The following instance shows how useful a limb may be obtained after the most severe treatment of a joint. It also shows that free and prolonged drainage of a joint does not of necessity lead to its anchylosis. The details were briefly as follows : — E. M., aged 4J, fell upon the back of a chair, striking her left axilla, on February 12, 1894. She complained of pain in the shoulder, and a week later a large abscess was found in the armpit. The abscess was incised, three ounces of pus were let out, and its cavity was scraped. As it was connected with the shoulder- joint, a counter- incision was made over the head of the humerus. The upper part of the shaft of the bone was felt to be bare, and a drainage-tube was passed through the joint from one opening to the other. The joint and the cavity of the abscess were then irrigated with boric lotion, and a dress- ing of cyanide gauze was applied. The tube was retained 3% THE SURGICAL DISEASES OF CHILDREN in the wound from February 12 to March 11, and four days later the child was sent to her friends. She came to see me on August 27, 1894, and I had her photographed. Fig. 3.— The right femur of a child. The lower half of the shaft is greatly enlarged, as a result of suppurative periostitis of an unusual character. [From a drawing in the Museum of St. Bartholomew's Hospital.] She has absolutely free movement of her shoulder in every direction, and the left arm appears to be in every respect as useful as the other (see fig. 2). NON-TUBERCULOUS INFECTIVE DISEASES The remarkable changes which sometimes result from a stripping off of the periosteum are well seen in the annexed drawings (see figs. 3 and 4) from a specimen in the Museum of St. Bartholomew's Hospital. The bone is ex- panded in its lower half, and the sections show the original shaft lying in the centre of a cavity with bony walls. The space between the bony shaft and the inner edge of the wall of this cavity measures five-eighths of an inch, and Fig. i.— Transverse sections through the enlarged portion of the femur represented in fig. 3. The increase in the size of the shaft is seen to be due to a thick ring of new bone, separated from the shaft by a considerable space. [From Specimen No. 39 (b) in the Museum of St. Bartholomew's Hospital.^ a few irregular fibrous bands extend across it. It con- tained pus when it was first opened. This peculiar appearance seems to be due to the fact that the periosteum was separated from the shaft by an acute inflammation which involved it without destroying its functions. The intervening space became filled with pus, and the inner la}^er of the periosteum formed a layer of bone round it. The child, aged one year, had only been ill a month before he died of bronchitis complicated by laryngitis. He had never been strong or healthy, but he had no symptoms of 4-0 THE SURGICAL DISEASES OF CHILDREN scurvy or rickets. The legs were swollen and oedematous. The lower part of each thigh was greatly swollen, but there was no effusion into the joints. The outer side of the right femur fluctuated, and pus was let out through an incision made seventeen days before death. NON-SUPPURATIVE OSTEOMYELITIS. An analogous condition is sometimes met with in older children, in whom the osteomyelitis runs a sub-acute course. It is associated with the presence of the staphylo- coccus pyogenes albus, and is known under the name of periostitis albuminosa. The inflammation usually com- mences near the epiphyses of one of the long bones, and leads to the formation of a swelling, which is tender, and contains a serous fluid with mucus and fat. This form can be distinguished from the ordinary osteomyelitis, by its slow course, by the slight constitutional symptoms to which it gives rise, and by the small extent to which the bone is involved. The treatment consists in cutting down upon the swelling and scraping away its contents. It seems to be the result of an attenuated virus. Typhoidal Osteomyelitis. A still rarer form of osteomyelitis is now beginning to be recognised as one of the sequelse of typhoid fever. ^Etiology. — The inflammation is rarely purulent, and it seems to be always associated with the presence of typhoid bacilli, which disappear if suppuration occurs. Symptoms. — Severe pain is felt in the affected part usually during the second or third week of convalescence from typhoid fever. The pain is worse at night, and when the part is dependent. It most often affects the lower limbs and the vertebral column. A doughy ox- elastic tumour after a time develops at the seat of the NON-TUBERCULOUS INFECTIVE DISEASES 4 1 pain. The temperature is raised, and it may be of the hectic type. There may be considerable wasting. Course. — The swelling may be absorbed, leaving a tem- porary periostitis. Its contents may caseate, and it may then open spontaneously. In some cases it liquefies, when the surface of the bone may become affected, or a sequestrum may be produced. Treatment. — The treatment consists in cutting down upon the swelling before it has undergone secondary changes. Its contents should be removed with a sharp spoon, and an attempt should be made to get union by first intention. Sequelae of Suppurative Osteomyelitis. — Necrosis does not often take place, even in the most acute forms of septic osteomyelitis, for some days after the onset of the symptoms. Dr. Macewen points out that the bone dies as a whole when the periosteum is raised from the shaft and the nutrient vessels either become occluded by thrombosis or embolism, or are ruptured. Superficial necrosis, on the other hand, occurs when the periosteal blood supply is cut off from the portions of the shaft of the bone, whilst the nutrient arteries remain intact. When the bone has been exposed in a case of osteomyelitis it is often found to be white and bare, and if the nutrient arteries are intact it gradually becomes covered with granulations, but if they are blocked the bones remain white. The signs denoting the presence of a sequestrum are often obscure, especially if it lies deeply in the bone, for it is then likely to be mistaken for a new growth in the bone. There is usually no difficulty in detecting dead bone when it lies loose at the bottom of a sinus whose orifice is guarded by a mass of granulation tissue. Its presence can only be guessed at when there is no sinus, in cases where after an attack of osteomyelitis the bone is enlarged, thickened and pain- 42 THE SURGICAL DISEASES OF CHILDREN ful, for chronic osteitis may produce a similar condition. A cautious surgeon will therefore hesitate to perform an operation for the removal of a sequestrum unless he has clear evidence of its presence, or unless the suppuration is so extensive as to threaten the advent of lardaceous disease. It is sometimes necessary to remove the dead bone as soon as possible when the whole diaphysis has perished, especially if it be the radius, ulna, or fibula ; but caution must be exercised in the case of the tibia, femur, and humerus. It sometimes happens, if the bone be too early removed, that the osteogenetic properties of the periosteum are not sufficiently developed to form an entire new shaft, even with the assistance of the epiphyses, and an insecure limb results. When this happens, means must be taken to stimulate the inner layer of the periosteum by the introduction of foreign bodies, which will remain aseptic. It is generally wise to allow an interval of two months to elapse in the upper extremity, and three months in the lower, before attempting to remove an extensive seques- trum, and in the meantime free drainage must be allowed, and the limb should be kept at rest upon a splint. Treatment of Sequestra.— A sequestrum is removed either as a whole or piecemeal as soon as it is felt to be loose. The child is ansesthetissd for this purpose, its limb is rendered bloodless by means of an Esmarch's bandage, and the sinus is enlarged, the cloaca is then explored and gouged away until the sequestrum can be withdrawn with a pair of strong forceps. The gouge has often to be supple- mented by cutting forceps, Hey's saw, or a trephine. The cavity in which the sequestrum lay is thoroughly scraped until pink bone is reached and until blood oozes from the Haversian canals. The diseased skin and the granulation tissue at the orifice of the sinus is also scraped away, and all the parts are swabbed with a solution of chloride of NON-TUBERCULOUS INFECTIVE DISEASES 43 zinc (15 grains to the ounce), and afterwards flushed with warm boric lotion. The cavity is then packed with dry gauze, or in very young children the gauze is moistened with camphorated naphthol, and the wound is allowed to granulate from the bottom : a process which takes several weeks. The secretions must not be allowed to collect in the wound, and repeated dressings are therefore necessary. In children it is only necessary to amputate the limb in very exceptional cases. Rarefaction and Sclerosis of Bone. Sinuses discharging a thin pus, unhealthy scars showing a constant tendency to break down upon slight provocation, and residual abscesses are very frequent sequelse of an attack of osteomyelitis. So frequent and so well known are these sequelae that the tragedian made Philoctetes suffer from such an issue in that play which, though it is not the greatest of its author's creations, has yet an abiding interest for the surgeon, for it depicts a case of infective osteomyelitis terminating in sclerosis as it was presented to an Athenian audience 2,400 years ago. The treatment in all cases consists in cutting down upon the inflamed spot, and drilling the bone towards the epiphysis in those cases where there is much pain apparently associated with circumscribed collections of pus. The bone must be tre- phined if pus is found, and the abscess is then treated in the same way as the sequestrum cavity. The carious bone is gouged away if a discharging sinus remains, and the wound is allowed to heal under antiseptic dressings. WHITLOW. The term whitlow is clinical rather than scientific, and it is employed loosely to denote any infective inflammation affecting the tissues of the fingers. It is one of the most 44 THE SURGICAL DISEASES OF CHILDREN troublesome and painful of the minor affections to which children are liable. Varieties and etiology.— (1) In its simplest form it is a localised inflammation of the skin of the finger, the result of direct inoculation after a slight injury. (2) The superficial or subcutaneous whitlow is generally found about the nail and the finger-tips of children who are thoroughly out of health, or in those who have recently suffered from one of the exanthemata. It is often associated with eczematous patches upon other parts of the body. (3) A whitlow may run the ordinary course of a case of infective osteomyelitis, terminating in the death of one of the phalanges, usually the terminal one, though either of the others may be affected. It follows a slight blow or sprain, or it may be produced by a punctured wound. (4) The most severe form of whitlow is that known as the thecal abscess. It is formed inside the sheath of the flexor profundus digitorum tendons. It is an infective inflammation, originating like the other forms in a very slight puncture or in a poisoned wound. (5) Painless whitlow is a rare form occurring in syringo- myelia. It is of trophic origin, and was first described by Morvan. It is said to run a chronic and painless course, and may lead to complete destruction of the terminal phalanx. Symptoms.— The symptoms in the slightest cases are local pain, followed in the course of a few hours by redden- ing of the skin without any great swelling. The subcutaneous whitlow causes much pain, with localised tenderness and inflammation. The finger-tip is not much swollen, but a blister is formed upon it usually of considerable size, and often produced upon more than one phalanx. The blisters are opaque, and contain a purulent fluid. NON-TUBERCULOUS INFECTIVE DISEASES 45 Diagrams showing the usual and the commoner forms of irregular arrangement of tendon sheaths in the hand (from Testufs Anatomie Humaine). A S R Fig. 5. — Diagram showing the ordinary arrangement of sheaths of the flexor tendons of the forearm (from Testut's Traiti a" Anutomie Humaine). A, radius ; B, ulna ; /., //., III., IV., V., indicate the thumb with the index, middle, ring, and little fingers respectively; 1, the external carpo-phalangeal synovial mem- brane continued downwards as 1' the phalangeal synovial membrane of the thumb; U. the internal carpo-phalangeal synovial membrane continued down- wards as 2' the phalangeal synovial membranes of the little finger; 3, 4, 6, the three phalangeal synovial membranes of the second, third and fourth fingers; 6, the tendon of the flexor longus pollicis; 7, 7, the tendons of the flexor pro- fundus digiiornm ; 8, median nerve. The dotted lines represent the position of the anterior annular ligament. 46 THE SURGICAL DISEASES OF CHILDR EN Fig. 0.— Diagram showing an abnormal arrangement of the sheaths of the flexor tendons in the forearm (from Testut's Anatomis). The references are the same as in the preceding figure. The two carpo-phalangeal synovial sheaihs have coalesced at the wrist. The whitlow caused by osteomyelitis is attended by much throbbing pain in the terminal phalanx, with great consti- tutional disturbance. Pus is quickly formed, and slowly makes its way to the surface unless it is let out by a timely incision. The phalanx dies as a whole, but the tendon sheath is not as a rule involved. Sinuses are NON-TUBERCULOUS INFECTIVE DISEASES 47 Fio. 7. — Diagram showing another abnormal arrangement of the sheaths of the flexor tendons in the forearm (from Testut's Anatomie). The references are the same as in fig. 5. There is a separate synovial sheath in this form for the carpal portion of the long flexor of the index finger 7'. The phalangeal portion of the sheath, however, 3', remains distinct. formed in cases which have been left untreated, and through these sinuses the necrosed bone may readily be removed. The inflammation, in cases of thecal abscess, runs a very acute and severe course. It may lead to much constitu- tional disturbance, and it may terminate in sloughing of 48 THE SURGICAL DISEASES OF CHILDREN the tendons affected. The diagrams (figs. 5, 6 and 7) copied from Testut's Anatomie show the usual and the two un- usual forms of the arrangement of these important sheaths in the hand and the forearm. When they are inflamed the abscess is likely to extend through the hand, especially if the thumb or little finger is involved, as in these digits the synovial sheaths are in direct connection with the synovial membrane beneath the annular ligament at the wrist. Dr. von Rosthorn, however, has shown that in new-born children each of the fingers possesses a separate phalangeal synovial sheath which does not communicate with the carpal sac. In early childhood the tendon sheaths of the thumb and little finger gradually extend backwards until they coalesce with the carpal sheaths to form the adult condition represented in fig. 5. Treatment. — Whitlows are always evidence of greatly impaired health, and when they are recurrent, as is fre- quently the case in children, I think that they imply bad hygienic surroundings, or that they indicate a strumoixs condition which is especially liable to pass on into tubercle if the necessary bacillus is forthcoming. The general health should therefore be attended to in every case, and the defective hygienic surroundings should be remedied. Quinine should be given for a day or two, and the child should then be placed upon a course of carbonate of iron in some agreeable form. The simplest cases may be treated by compresses of absorbent wool soaked in a 1 in 20 solution of carbolic acid. The fluid in a subcutaneous whitlow should be let out by incising the cuticle, which is an absolutely painless proceeding, and by afterwards fomenting the inflamed part with a solution of boric acid containing 20 grains to the ounce. NON-TUBERCULOUS INFECTIVE DISEASES 49 When the inflammation is produced by osteomyelitis, and there is much pain and swelling, an early incision carried along either side of the affected phalanx through the condensed cellular tissue, until the point of the knife touches the bone, relieves the pain, and at the same time renders necrosis less likely to occur. So long as the in- flammation persists, the affected hand should be soaked for an hour or more once or twice a day in an arm-bath or basin containing a solution of corrosive sublimate of the strength of 1 in 2000 at a temperature of 100° F. The hand must be dressed antiseptically in the intervals, and suspended in a sling. The epiphyseal end of the phalanx often escapes in these cases, so that a shortened but useful finger results. Thecal abscess I have only seen in boys after twelve years old. Mr. Morrant Baker points out that a thecal abscess can be distinguished from the whitlow due to osteomyelitis by the early impairment of voluntary move- ment in the distal phalanx. He recommends that, in order to estimate the movement of the tendon within its sheath, the second phalanx of the finger should first be fixed by the surgeon, who places his thumb on the front of the second phalanx and the end of one of his fingers of the same hand on the back of the first phalanx. The patient is now told to bend his finger, and the surgeon will then be able to recognise, both by sight and by touch, the range of movement, if any, still possessed by the tendon. If the terminal phalanx remains motionless, the presumption is that by some means the profundus tendon is tethered. It often happens, on the other hand, that the patient can bend the tip of this finger under these conditions, even when the finger has been long and exten- sively inflamed ; and when this happens, we are to give a favourable prognosis, for we are taught thereby that E 50 THE SURGICAL DISEASES OF CHILDREN the inflammation has been in the deeper tissues lying beneath the tendon sheath. A stiff finger, however, often follows npon this form of whitlow. The Treatment consists in making a small incision into the sheath of the tendon opposite the head of the metacarpal bone, for this is the lowest point reached by the synovial membrane, except in the thumb and little finger. When the inflammation extends up the arm, along the synovial sheaths upon the inner and outer side, the whole hand becomes acutely inflamed, and the swelling and puffi- ness are especially marked upon its back. Unless very active measures are taken, abscesses form and burrow amongst the tendons of the forearm, and the patient goes in serious danger of his life. Free incisions must be made in these cases into the palm of the hand, along the metacarpal bones anterior to the superficial arch. The scalpel must only be used to divide the skin and fascia, the deeper tissues being sepa- rated with a director until the abscess is laid open. A counter-opening must also be made above the annular ligament, between the tendons of the flexor carpi radialis and the palmaris longus, and a drainage-tube should be passed under the annular ligament between the two open- ings. The hand and arm, as in the previous forms, should be kept for two or three hours a day in an arm-bath con- taining a solution of 1 in 1000 perchloride of mercury, at a temperature of 100° ¥ n antiseptic dressings being applied between the immersions. Stimulants, quinine, and good food are imperatively necessary. Patient and prolonged attempts at passive movement must afterwards be carried out. CHAPTER IV SUEGICAL TUBERCULOSIS etiology. — Tuberculous disease occurs so frequently and is so fatal in childhood, that it has been estimated that it kills one-third of the children who annually die in hospitals. Tubercle in adults is often localised, and is very frequently pulmonary ; in children it is much more often generalised. My friend, Dr. Walter Carr, indeed finds, as a result of extended observations in the post-mortem room attached to the Victoria Hospital for Children, that the primary focus of tubercle occurred in the lymphatic glands in 72 - 5 per cent, of cases in which the children died of this disease, and of these no less than 65 - 8 per cent, commenced in the glands of the thorax or abdomen. He points out, however, that these statistics do not fairly represent the cases of tubercle starting in joints and bone, for such cases do not usually die in hospitals. The bacilli doubtless gain access by small local lesions directly to the lymphatics, and so to the gland, the organisms being originally obtained either from inhalation or from the ingestion of contaminated milk, as Dr. Woodhead has suggested. When once they have obtained a local habi- tation, they readily spread through the lymphatic system in persons who present them with a congenial soil. The varying receptive power offered by different persons is no doubt always due to heredity, but the tendency can be diminished by hygienic means, even in the most sus- ceptible. 51 52 THE SURGICAL DISEASES OK CHILDREN Pathology. — The tubercle bacillus, by the irritation it produces, gives rise to an aggregation of leucocytes ; which, undergoing slight modifications, are known as miliary tubercles. If tubercle bacilli, and tubercle bacilli only, are present, the cells grow and fuse, finally undergoing changes in the direction of the formation of fibrous tissue. If, on the other hand, the ordinary septic bacilli are mixed with the tubercle bacilli, as most often happens, suppura- tion takes place, and the various forms of tuberculous abscess result. It is, therefore, of the utmost importance that all wounds in connection with tuberculous tissues be kept thoroughly free from contamination with septic micro-organisms, for only by such care can the surgeon benefit the patient upon whom he operates. Drainage- tubes are therefore inadmissible, except under special circumstances. Tuberculous disease, so far as it is interesting to the surgeon, affects the lymphatic glands, the bones, the joints, and bursse, the pleura, the peritoneum, the kidney, the testis and the skin. Tuberculous disease of the brain, leading to the formation of caseating masses or to a sub- acute inflammation of its meninges, is of more doubtful interest to him ; as, although operations have been per- formed for the relief of cerebral tuberculosis, they have not yet been attended with sufficient success to warrant any recommendation of them for general use. Disease of the lymphatic glands is one of the most frequent of the primary manifestations of tubercle. No surgical measures are of service for the relief of the bron- chial and mesenteric glands which, as Dr. Carr's statistics show, are most commonly affected, for they are beyond the reach of operative treatment, but much can be done for the cure of those glands which are more superficially placed. SURGICAL TUBERCULOSIS 53 TUBERCULOUS LYMPHADENITIS. Varieties. — Tuberculous infection in the lymphatic glands manifests itself as it does in other parts in many ways. Sometimes there is a simple hyperplasia of the glandular substance, which does not necessarily involve the capsule, so that the individual glands remain separate and distinct ; in other cases they are matted together, and are embedded in such dense fibrous tissue that it is very difficult to remove them ; whilst in other cases, again, they suppurate and form either a diffuse abscess or a localised bag of pus. The tuberculous infection is often limited to the glands, when it is frequently the mildest form in which the patient can have the disease — no doubt, because the gland tissue has the power of destroying the infective material — -in other cases the tuberculous adenitis is secon- dary to, or is a part of, a generalised tuberculosis. Chil- dren under ten years of age are especially liable to this form of tuberculous disease, and in its primary form it is more often seen in the glands of the neck than in other parts. Prognosis. — The prognosis as regards life and dis- semination is good in the case of glands situated within the reach of surgery, but local infection of the skin often, occurs, leading to unsightly scars. Treatment. — The treatment of tuberculous glands is either palliative or operative. It should be remembered that enlarged glands in the necks of children are not always tuberculous, for they are often associated with local irri- tation. The removal of lice, eczematous inflammations, carious teeth, mastoid abscesses, chronic otitis media, and other local causes, will generally lead to a reduction in the size of the affected glands, and often to their com- 54 THE SURGICAL DISEASES OF CHILDREN plete recovery. Local remedies should also be tried in every case. The judicious application of iodine, or of an ointment containing mercury or potassium iodide, with the administration of one-drachm doses of cod-liver oil directly after food, and a quarter of a grain of grey pow- der before each meal, will be found most serviceable. The patient should, if possible, be sent to Margate or to Broad- stairs for a thorough course of fresh air. Operative means must be adopted when these measures have failed, or when, as often happens, the child is brought at too late a period for them to be tried. Few departments in surgery have undergone so rapid and radical a change as that appertaining to the removal of enlarged tuberculous glands. The palliative method was alone employed until 1885, when Dr. Clifford Allbutt and Mr. Pridgin Teale, who were then colleagues at the Leeds General Infirmary, pointed out that the proper treatment lay in the complete extirpation of the glands as soon as it was clear that con- stitutional measures were unavailing to prevent caseation, and that in no case should they be allowed to suppurate. Their practice and advice has been so largely followed, that the early removal of tuberculous glands is now the rule amongst all surgeons ; the only contra-indications being the extreme weakness of the patient, or the fact that the enlargement is part of a general tuberculosis. The glands most frequently requiring removal are those occurring in the neck, beneath and along the anterior border of the sterno-mastoid muscle ; the glands in the anterior fold of the axilla, and the superficial and deep glands in the groin. The indications for the removal of tuberculous glands are their size and their condition. When they are so large as to cause disfigurement, and when there is the slightest indication that they are about SURGICAL TUBERCULOSIS 55 to suppurate, they should be extirpated without delay. The incision, in the case of the neck, must be planned so as to lead to the smallest amount of disfigurement, and advantage should therefore be taken of natural lines and creases. Operation. — The incision should be linear, and of suf- ficient size to enable the surgeon to see clearly what he is doing ; for glands are nearly always more deeply situated than they appear to be before the operation is commenced, and serious injury may be done to the arteries, veins, and nerves of the neck, unless great care be taken. Lastly, every effort should be made to obtain union by first inten- tion. This can usually be effected if asepsis be ensured, and care be taken not to infect the skin and tissues by opening the capsule of the gland. The incision should be carried on until the capsule is reached, the knife should then be laid aside, and the gland freed with a blunt - pointed steel director. It should be raised between the finger and thumb as soon as possible, as the capsule is liable to be injured and the wound infected if it be seized with a vulsellum. The gland can often be pulled out quite easily, but in many cases it will be found that the capsule has become adherent to the surrounding tissues, owing to the chronic inflammatory processes to which it- has been subjected. It is then absolutely necessary to cut through the adhesions, but the division must be done with the greatest care and deliberation ; for even large nerves like the hypoglossal and the spinal accessory may be divided; whilst haemorrhage from injury to the vessels is not infrequent. All bleeding points must be arrested at once, either by ligatures or by the use of pressure force] »s, as it is of the greatest importance that the wound should be kept bloodless, that the surgeon may see what he is doing at every stage of the operation. 56 THE SURGICAL DISEASES OF CHILDREN Several glands can generally be removed through a single well-planned incision, especially if there be a skilful assistant who knows how to make each in turn prominent. It is, however, better to make two or three incisions rather than to endeavour to dissect blindly or extensively. The sterno-mastoid itself sometimes requires division, but this is not a serious proceeding, as in such cases it has become thin and atrophied from the pressure of the glands beneath it. Its cut ends must afterwards be sutured. The greatest gentleness of manipulation is required when the glands are caseating, and if they have already suppurated, but with care they may be moved unrup- tured. It too often happens that the abscess has become diffuse before the patient is seen by the surgeon. It is then necessary to lay it open, remove the pus, and look carefully for the remains, or for the capsule of the gland. The abscess is often superficial, whilst the gland is situated deeply beneath the cervical fascia. The sinus leading from the abscess to the gland must be cautiously enlarged, and all the caseating material must be carefully scraped away with a sharp spoon, the cavity being afterwards swabbed out with a solution of 1 in 15 zinc chloride, or with a solu- tion of camphorated naphthol, and afterwards well flushed with a boric lotion. Several cases of poisoning have oc- curred after the use of camphorated naphthol, so that it is better not to leave any large quantity of the solution in the abscess cavity. The same treatment must be adopted when the skin is undermined, and is riddled with fistulous tracts. It is often advisable in these cases to cut away the skin clear of the disease, as there is less chance of subsequent infection than after scraping. The skin- wound, in either case, should be brought together with point sutures of horsehair, taking care that the edges are in exact apposition. It is then dressed with sterile or cyanide SURGICAL TUBERCULOSIS 5 7 gauze, and usually heals by first intention, if care be taken to keep the head at rest. Many surgeons prefer to dust the wound with iodoform, boric acid, or nitrate of bis- nmth ; but I find that such applications are unnecessary, as the repair takes place equally well without them. The sutures should be removed as soon as possible, and usually on the third or fourth day, when, if there is no discharge, the dressing is changed for a layer of gauze, kept in place by collodion. Tuberculosis of the various Mucous Membranes. This form of tuberculosis is rather frequent in children. The tubercle appears either in the form of circular ulcers, each with a well-defined outline, or as masses of granulation tissue. They may be seen in the septum nasi, in the mouth, on the tonsils, and in the pharynx. The local manifestation should always be removed early and completely, unless it forms part of a general tuberculosis ; or unless it be situated in a part like the pharynx, where an operation can only be palliative, and for such a place the electro-cautery may be employed. (See also chap, xiii.) Tuberculous Disease of the Tendon Sheaths. This is fairly common in childhood. It may begin in the sheaths themselves, or it may be secondary to bone or joint lesions. The inflammatory process either gives rise to the formation of nvnch granulation tissue, or it may in rarer cases produce a cystic distension of the tendon sheaths. The extensors of the fingers are more often affected than the flexors. Prognosis. — The prognosis is good so long as suppura- tion does not take place ; though the secondary forms are unsatisfactory, owing to the unhealthy state of the sur- rounding parts. 58 THE SURGICAL DISEASES OF CHILDREN Treatment. — A clean sweep should be made of the whole of the affected tissue by careful scraping, under the strictest antiseptic precautions. Primary Tuberculous Infection of the Skin. The skin is sometimes the primary seat of tubercle, and of this a good example recently came under my notice. A healthy student, who had no tuberculous relations, scratched his knuckles whilst making a post-mortem ex- amination of a tuberculous heifer, and the sore place never healed properly.- Four months later, when he applied to me for advice, there were three small circular patches, each surrounded with an inflamed zone, lying immediately over the right extensor indicis tendon. The centre of each patch was a scab. The growths were removed, and were subjected to microscopical examination. They consisted of granulation tissue, containing giant cells, but no tubercle bacilli were detected. A year later the patient was in perfect health. Such cases are not very uncommon, and when there is reason to suspect their tuberculous character, excision is the best mode of treat- ment. In most cases, tuberculous inflammation of the skin is secondary,, and the result of direct extension from other and deeper tissues, as from a case of tuberculous lympha- denitis. The sores produced in such cases are puckered, blue, and often very unsightly. They often show a great tendency to break down. LUPUS, etiology. — Lupus, is defined by Professor Leloir as a slightly virulent form of tuberculosis of the integuments. The elementary lesion is. a tubercle, reddish brown in colour, soft in consistence, developing slowly, and destroy- ing the tissues either by interstitial absorption, by ulcera- tion, or by sclerosis. SURGICAL TUBERCULOSIS 59 Pathology. — Lupus may attack any part of the skin or the mucous membrane adjacent to it. It generally begins in infancy, and may produce a partial or general infection of the S3 r stem. The primary lesion is either nodular or diffuse. Its tuberculous character has been demonstrated by the production of general tuberculosis in animals who have been inoculated with lupus ; and there appears reason to suppose that lupus in a child is often the result of direct inoculation from an external source, though it may sometimes be the result of auto-infection. It is characterised microscopically by the large number of giant cells contained in the growth. The cells caseate rather less rapidly than in an ordinary tuberculous nodule, and the infiltrated area is somewhat more vascular. The tubercle bacilli are very few in number.. Course. — The affection may continue throughout life, and often causes lasting deformity. It attacks, by pre- ference, the nose and cheeks, and it often begins sym- metrically upon either side of the face, the two patches afterwards extending and becoming connected across the nose. It may also affect the pinna of the ear, and more rarely the skin in the neighbourhood of the joints, whose movements it may seriously hamper by ulceration and cicatrisation of the skin. It hardly ever attacks the genital organs either in girls or boys. I have seen it spread from the upper lip to the gums and tongue, causing extensive ulceration. Diagnosis. — It has to be distinguished from some forms of eczema and from cutaneous syphilides. Its chronic course will distinguish it from either unless, as often happens in hospital practice, syphilis and tubercle are coexistent. Treatment. — Lupus, at any rate, in children is no longer the bugbear that it was to the older surgeons. 60 THE SURGICAL DISEASES OF CHILDREN Scraping and skin-grafting have enabled us to do some- thing towards its cure, though there are frequent relapses, and scarring is unavoidable. The treatment I usually adopt is one which was, I believe, originally introduced by Mr. Arbuthnot Lane, and it often yields excellent results. The patch of lupus and the surrounding skin is -disinfected as far as possible overnight, and is protected with a gauze dressing. An anaesthetic is given on the morrow, and the whole of the diseased area is scraped away with a sharp spoon, especial care being taken to destroy every part of the sinuous edge and all outlying patches. The diseased area is readily recognised by the readiness with which it breaks down under the scoop, whilst the healthy tissue grates and shows no tendency to be removed. The bleed- ing is stopped by pressure, and precipitated sulphur is sprinkled over the whole of the raw surface, which is then dressed with dry cyanide gauze. The sulphur produces a superficial and very complete slough, which separates on the fourth or fifth day, leaving a healthy granulating surface. It should then be dressed daily with boracic ointment, the wound being bathed with a solution of boric acid. Skin-grafting by a modification of Thiersch's method (q. v.) is adopted as soon as the wound is clean ; for routine purposes, this is a week after the scraping. The grafts are usually taken from the anterior aspect of the thigh. The part is disinfected and an antiseptic dressing is applied on the day preceding the operation. The patient is anaesthetised, and the wound, as well as the skin of the thigh, is washed with a solution of perchloride of mercury, 1 in 2000. The skin-grafts are shaved off with a broad razor, moistened with a - 6 per cent, solution of common salt. The grafts should be as long and broad as possible, and they should be sufficiently numerous to cover SURGICAL TUBERCULOSIS 6 I the whole of the wound. They are best obtained by flexing the leg and thigh, and by then stretching the skin with the thumb and forefinger of the left hand. The razor is made to cut through the tops of the cutaneous papillae, so that a slight oozing of blood marks its course. The mistakes most frequently made are not to cut with suf- ficient boldness, so that the grafts are too small and too thin, for they will then only consist of squamous cells ; on the other hand, an operator whose hand is heavy or whose sight is bad, cuts too deeply, so that his grafts have an under surface of fibrous tissue or fat, often covered with a layer of blood, which clots. Grafts which are properly cut have a slimy feel and are pale in colour. They have a great tendency to curl up, so that it is better to float them from the razor straight on to the wound. They should be fitted together by means of a probe, in such a way that their edges slightly overlap. A piece of green protective, moistened with a sterilised salt solution, is then placed over the wound, gauze dressings are applied, and the part is not dressed for a week. It will usually be found that most of the grafts have taken, whilst the parts which remain uncovered are rapidly healed by the sur- rounding epithelium. The thigh is dressed with antiseptic dressings in the ordinary manner. Many surgeons have followed the plan introduced by Mr. AVatson Cheyne, of dissecting out lupus patches, making an incision through the healthy skin, and remov- ing the subcutaneous fat over the infected area. The bleeding is staunched and the wound is immediately covered with skin-grafts. CHAPTER V TUBERCULOUS DISEASE OF BONE ^Etiology. — Tuberculous osteitis 7 is one of the commonest bone diseases seen in children. It affects all the bones, long and short, cylindrical and flat, cartilaginous and membranous. It is frequently a mixed infection, but in some cases, and especially in the phalanges and meta- carpal bones, the inflammation may be due to the tubercle bacillus alone, without any intermixture of septic organ- isms. Tuberculous osteitis seems to occur spontaneously in many cases, for it is often impossible to obtain a history of any exciting cause, but it usually follows an injury. Pathology. — The tuberculous deposit is found typically in the cancellous tissue, but it may occur deeply in the substance of the compact bone, beneath the cartilages or sub-periosteally. The labours of Lannelongue, Oilier, and other members of the great French school of scientific surgery, have proved that tuberculous disease of bone very often begins in the long bones as a localised deposit in the neighbourhood of the epiphyseal line. Anatomical Characters. — The deposit of tubercle, as it is seen in its earliest condition, consists of minute nodules lying in the cancellous tissue. These nodules rapidly undergo caseation, and coalesce, in some cases leading to very little damage, but usually causing absorption of the bone, by setting up a process of rarefying osteitis. The 62 TUBERCULOUS DISEASE OF BONE 63 caseated products sometimes undergo absorption, they may become converted into fat, but much more frequently sup- puration occurs, and the bone becomes carious. In the long bones, the process of suppuration may be very chronic, and does not give rise to many symptoms, so that a chronic abscess of bone may result ; in other cases the suppuration may be much more acute, and may lead to the destruction of a fragment of bone which then lies in an abscess, the condition being known as '" caries necrotica." Necrosis, however, is not a common result of tuberculous osteitis in children ; and it only occurs in cases of mixed infection. The disease ends either in destruction of the bone, and its replacement by scar tissue of a fibrous type, or in condensation of the bone, owing to the continued irritation to which it has been subjected. This sclerosis is often so complete that such a bone as the tibia may con- sist entirely of compact tissue ; in such cases it is often longer than its fellow and much more curved. Symptoms and Course.— The symptoms of tubercu- lous inflammation of bone vary greatly. It occurs in the simplest form, in tuberculous inflammation of the fingers or toes (p. 70) and in the bones of the carpus and tarsus. The pain in these cases is only slight and of a pricking character, worse at night, and when the part is subjected to pressure or when it is moved. The bone is often expanded, and its interior is converted into a mass of softened tissue, which leaves a mere shell of compact tissue when it has been removed. The skin, at first unaffected, afterwards may become involved in a true tuberculous inflammation. These symptoms subside in the simplest cases, and a slow but spontaneous cure may result. A mixed infection, however, is much more fre- quent : an abscess forms whicli opens externally, leaving a fungating sinus, along which the disintegrated portions 64 THE SURGICAL DISEASES OF CHILDREN of bone pass for long periods of time. The sinuses may eventually close, and a depressed and puckered scar re- mains to show where they were. In the worst forms, sequestra may be produced, or many bones may become involved in the carious process. The skin and surround- ing tissues become widely involved, the joints are impli- cated ; and unless amputation be performed, there is dan- ger of death from lardaceous disease ; or if the bone lesion be part of a general tuberculosis, from cerebral meningitis. Diagnosis. — The diagnosis is usually easy, but where there is a deposit of tubercle deeply seated in one of the long bones it is extremely difficult to recognise, and it is then likely to be mistaken for chronic osteomyelitis, or for a sarcomatous growth within the bone. Verneuil says that tuberculous osteitis can be distinguished from a sarcoma by the greater pain attending the malignant growth, and by the fact that the temperature of the affected limb is two or three degrees higher than its fellow ; whilst in tuberculous osteitis such a difference in the heat of the two limbs does not occur. The differential diagnosis has to be made between a new growth and inflammatory swelling of bone, and this can best be done, as Mr. Howard Marsh has very ably pointed out, by paying attention to the following points. Osteitis is more common in children than a new growth. An injury is more likely to lead to an inflammation of bone than to a sarcoma. A uniform swelling of the bone is more likely to be inflammatory than a lobed, nodular or irregular one. Sarcomata in children are often very soft, whilst the inflammatory swellings are densely hard. The rate of growth affords very little information, for in both forms of swelling it may be slow or rapid. The condition of the skin overlying the tumour is not a much more trustworthy guide than the rate of the growth, whilst the body tern- TUBERCULOUS DISEASE OF BONE 65 perature in inflammatory conditions is generally subject to greater variations than in sarcoma. The symptoms, how- ever, are often so similar in the two conditions that it is impossible to make an accurate diagnosis, though usually they are so distinct as to render a mistake impossible. Prognosis. — No general rule can be laid down in re- gard to the prognosis, for so much depends upon the posi- tion as well as upon the extent of the disease. Each case therefore has to be considered upon its merits. Treatment. — The first treatment to be adopted in every case of tuberculous osteitis consists in rest of the affected part, with an improvement of the patient's health by sending him to the seaside, and preferably to some bracing place, as well as by the administration of cod- liver oil. The tubercle bacillus has so uncertain a tenure of life that in many cases the disease can be cured by these means. Physiological rest is best secured by the application of a plaster-of-Paris splint or by a Thomas' splint. Operative interference is called for when the local symptoms do not speedily subside under this treatment ; and when pyogenic, as well as tubercle bacilli, are present, this can hardly be expected. The surgeon then endeavours to remove the tuberculous foci as completely as possible. An Esmarch's bandage is therefore applied, the bone is ex- posed, all the unhealthy tissue is scraped away, the cavity is treated with zinc chloride, washed, and an endeavour is made to obtain union by first intention. I used to fill the cavities with iodoform, camphorated naphthol, bismuth, boric acid, or other disinfectant ; but as time goes on I find myself less inclined to use any antiseptic in these cases, and to trust entirely to aseptic methods when the disease has once been removed completely, for I am sure that the best results are obtained by their means. When there has F 66 THE SURGICAL DISEASES OF CHILDREN been prolonged suppuration, however, and union by first intention is impossible, the ordinary antiseptic solutions must be employed. Amputation is sometimes necessary in cases of tuberculous osteitis which have been neglected. It is especially useful in the foot, where the whole of the tarsal bones are often so extensively diseased as to render it the only available method of treatment. TUBERCULOUS DISEASE OE THE LONG BONES. (1) Epiphyses. Tuberculous disease affects either the epiphyses or the shafts of the long bones. The epiphyses are rather more frequently implicated, and the disease assumes the form of an osteomyelitis, leading either to f ungation, to necrosis, or to infiltration of the affected tissues. The fungating form often leads to implication of the joint, and is described more fully at page 98. The necrosing variety leads to the formation of an abscess in the head of the bone, which can be distinguished from that due to septic osteomyelitis by the fact that it is less frequently surrounded by a layer of dense bone, though it has a much better defined pyogenic membrane. The sequestra vary, for they are sometimes small and caseating, sometimes larger and wedge-shaped. These cuneiform masses can be produced artificially by in- jecting tuberculous substances into the nutrient artery of the bone, and it therefore appears as if they had an embolic origin. The infiltrating form of tuberculous osteomyelitis is the least common and the most unsatisfactory to treat, for it progresses steadily, and is often associated with extensive suppuration. Course. — The disease runs a very chronic course, and may terminate in a chronic abscess near the head of the bone, which may remain for years, and may then open to TUBERCULOUS DISEASE OF BONE 6j the exterior or into the joint ; in other cases rapid funga- tion may take place, and with similar results. The surrounding tissues often become involved in the tuber- culous process, and a complicated system of sinuses is developed, which lasts for years if it is left without treatment. Symptoms. — The symptoms are generally very obscure when the tubercular deposit takes place deeply in the epiphyseal line, and it is often only discovered accidentally on making a section of the bone, after death, or after it has been removed for some other reason. It is more easy to recognise when it occurs in the superficial than when it is in the more deeply seated bones, and more easy when it suppurates than when it is encysted. The symptoms upon which alone any reliance can be placed are pain, swelling, local tenderness, redness when the skin is be- coming involved, and atrophy of the muscles, due some think to disuse, whilst others hold that it is a result of nervous disturbances in the affected part (see also pp. 74 and 114). Prognosis. — The prognosis upon the whole is not so serious as it was forty years ago, when constitutional measures were relied upon to the exclusion of all other means except amputation. The disease is always tedious and often dangerous, but with care and repeated atypical operations good results are often obtained. Treatment. — The general treatment consists in remov- ing the cause, if possible, by improving the general tone of the tissues, and so enabling them to destroy the bacillus ; if this is not feasible, by injecting such sclerosing agents as zinc chloride (p. 102) to convert the inflammatory pro- ducts into fibrous tissue, or else cutting down upon the part and removing the products of tuberculous action, f< r when this is done the inflamed tissues are often found to 68 THE SURGICAL DISEASES OF CHILDREN be capable of preventing the further growth of the tubercle bacillus. It is essential, however, that the parts should be kept strictly aseptic. In tuberculous infection of the epiphyses, a thorough exploration of the epiphyseal line should be made as soon as there is evidence that the inflammatory focus has suppurated, for there is great danger lest the joint become involved either by the direct spread of inflammation or by sympathy. (2) Shafts. Tuberculous osteitis of the shafts of long bones is either primary or secondary when it results from extension from the epiphyseal line, and this is the more common form. The inflammation runs the same course, and presents the same obscure symptoms in its earlier stages as in the similar condition of the epiphyses. Necrosis, however, is somewhat more common, and in some cases the bones become the seat of a remarkable form of rarefying osteitis, which is more fully described at page 70, and leads to the formation of a condition known as spina ventosa. The sequestrum is sometimes situated between the laminae of the compact bone, and its presence is attended by sup- puration. The bone then slowly enlarges and becomes painful, and the condition is likely to be mistaken for a sarcoma ; in other cases condensation and sclerosis of the entire bone may take place. The disease is more often an osteomyelitis than a periostitis, though the periosteum is involved in the later stages. The general treatment is the same as in the epiphyseal infection. TUBERCULOUS DISEASE OF THE SHORT AND OF THE FLAT BONES. In the skull tuberculous disease sometimes affects the frontal and parietal bones, though the mastoid may be TUBERCULOUS DISEASE OF BONE 69 implicated secondarily from the middle ear (q.v.). An abscess pointing externally, ornecros is of the whole thick- ness of the bone, may be the first sign of the disease, as it is not usually characterised by any marked symptoms. The child may even die with symptoms of cerebral compression, when the tuberculous inflammation has been limited to the inner table of the skull, without any suspicion of the true cause of the condition. The treatment, when the disease is recognised, consists in opening the abscess, scraping away any fungating material, and causing it to heal as quickly as possible. The superior maxilla, the malar, and the lower jaw are the most common seats of tuberculous disease in the face. Caries is somewhat more common in these bones than necrosis, and the treatment consists in cutting down upon the affected part and clearing away the softened tissue with a sharp spoon and a rugine. The only complication likely to occur in the case of caries of the superior maxilla is a stillicidium lachrymarum from interference with the nasal duct. Tuberculous disease of the ribs, according to Schmalfuss and Fasbender, in children under fifteen years of age forms 125 per cent, of all recorded cases of caries of the ribs. The disease is either primary or it is secondary to an empyema of tuberculous origin, but in either case tuberculous periostitis is more common than a lesion of the bone itself. A chronic abscess is the great sign of the disease. It should be opened, and the diseased ribs should be resected. The sternum is occasionally the seat of tuberculous caries, leading to the formation of an abscess which may project into the mediastinum or to sinuses opening externally. The clavicle and the scapula are sometimes affected with tubercle, but the disease in these bones is more often JO THE SURGICAL DISEASES OF CHILDREN connected with disease of the shoulder and of the sterno- clavicular joints. The bones of the carpus and tarsus are frequently the seat of tuberculous deposits, but they are in the same way usually associated with tuberculous disease of the joints of which they respectively form a part (pp. Ill and 137). TUBERCULOUS DACTYLITIS. Inflammation of the phalanges of the fingers and toes, and of the metacarpal and metatarsal bones, often occurs as a form of simple tuberculous inflammation in children. It usually affects children during the second and third year, biit it may occur at any time between the first and the sixteenth year. The metacarpus is more often affected than the neighbouring phalanges, the metatarsus more often than the phalanges of the toes. Pathology and Morbid Anatomy. — The disease is essentially a tuberculous osteomyelitis, either commencing in the bones themselves, or less frequently, immediately beneath the periosteum. The affected part becomes en- larged, and the bone undergoes a process of rarefaction, which may either terminate in resolution, with or without deformity, or in fungation and suppuration, which may lead to necrosis. The bone is often so thinned and ex- panded as to leave only a perforated skeleton, thus afford- ing the most perfect examples of rarefaction. Symptoms. — The patient is often a typically tuberculous child, and the enlargement of the bone comes on as part of a general process. It is painless and uniform, and does not attain a maximum for many weeks. The skin and the overlying tendons are at first free, but they often become involved. The movements of the bone are impaired, the skin is first thin and then yields, so that a depressed sinus TUBERCULOUS DISEASE OF BONE 7 1 is left with granulations springing from it. A probe passed along the sinus reveals softened or, in rarer cases, dead bone. Diagnosis. — The diagnosis is not difficult, for the only condition for which it is likely to be mistaken is enchon- droma, syphilitic dactylitis, or the results of acute septic osteomyelitis. Enchondroma is harder, has no tendency to suppurate, and runs a more chronic course. Syphilitic dactylitis is much less common than the tuberculous form, occurs in a different type of child, is amenable to anti- syphilitic remedies, and is periosteal rather than endosteal in origin. Septic osteomyelitis runs a different course from the commencement. Prognosis. — The prognosis is good as regards the local indications, but it is bad as regards the general health of the child, since it usually occurs in connection with other manifestations of tubercle. Treatment. — The treatment, as is usual in tuberculous disease of bones, consists essentially in rest. The affected part is put upon a splint, after compression has been applied by means of strips of plaster, whilst the health of the child is improved as far as possible. When these means fail, and when fistulas have formed, the limb should be rendered bloodless, and the sinuses should be enlarged, so that the parts may be thoroughly scraped. Care must be taken to avoid injuring the tendons or their sheaths. The cavity is then dusted with iodoform, and is dressed antiseptically. The disease runs so chronic a course that there is always a little danger of leaving it alone until the mischief is too far advanced to enable operative mea- sures to be of any avail. The best results are obtained by operating as soon as it is clear that rest is useless. J 2 THE SURGICAL DISEASES OF CHILDREN POTT'S DISEASE OE THE SPINE. Pathology. — Pott's disease of the spine occurs at any age, and in both sexes. It is most frequent in the first decennium, and after the age of two years. It is due to tuberculous changes in the bodies of the vertebras, the changes usually commencing in the anterior parts of the body close to the lines of the epiphyses, though the posterior portions may also be affected. The tuberculous inflammation leads to rarefying osteitis, with subsequent absorption of more or less of the cancellous tissue, and the eventual fusion of those parts of the vertebral column which are brought into apposition by the curvature neces- sarily ensuing upon the disappearance of the front of the column. The progress of the disease is usually slow, often taking years to run its course ; caseation may then take place with sclerosis. If the infection is mixed, or if the disease runs an acute course, and only lasts months instead of years, necrosis may take place with the formation of extensive abscesses. etiology. — HofFa states that the tuberculous osteitis usually commences at that part of the spinal column which is most exposed, where movements make the greatest demand upon it, and where the weight of the body is chiefly incident. It is therefore most common, he says, in children in the cervical vertebras, and in later life in the lumbar region ; in the neck the upper verte- bras are more often diseased than the lower. It is most often seen, however, in the dorsal region in my expe- rience. Injury, as in all other surgical manifestations of tubercle, plays an important part in the local production of the disease, but it often follows an attack of scarlet fever, measles, whooping cough, or other disorder which TUBERCULOUS DISEASE OF BONE 73 lowers the vitality of the child, and there is no doubt that it sometimes arises without any known cause. The Symptoms vary according to the particular part of the spinal column affected ; as a rule, they are not well marked in the early stages, and they may pass completely unnoticed. The symptoms common to the disease in all parts of the spinal column are rigidity, the result of muscular spasm. The rigidity keeps the spine fixed so that the vertebral movements are very limited in every direction ; the child walks and moves stiffly, and turns his body with care. In stooping and in rising, the spine is spared at the expense of the limbs. The diagnosis of the disease in its earlier periods depends greatly upon this muscular rigidity, and the child cannot be considered cured until it has completely disappeared. Pain is an early symptom ; it varies greatly in intensity as well as in position. It is elicited by sudden movements of the segments of the spine upon each other, and the patient is therefore careful to keep his muscles in a state of tonic contraction. It is often worse at night, and it wakes the patient as soon as he has fallen asleep. More marked symptoms appear as the disease progresses. Some amount of lateral curvature may be observed in the vertebral column even before there is any projection of the spine, and this is best seen by viewing the spine as a whole against a dark background. Kyphosis sooner or later becomes apparent, and various compensatory changes then take place in the skeleton. The character of the curve depends upon the number of the vertebrae affected, being sharp when few, and round when many, are diseased. The child stumbles, and becomes more and more disinclined to walk. Chronic abscesses frequently form, more often when the seat of the disease is below than when it is above the level of the diaphragm, 74 THE SURGICAL DISEASES OF CHILDREN Nervous Symptoms. — The nervous disturbances asso- ciated with caries of the spine have recently been studied very carefully at home and abroad, for they have gained in importance owing to the surgical treatment which has been adopted for their relief. They are more common when the laminae and posterior parts of the bodies are affected, so that they are often present when there is but slight deformity. The symptoms are due in part to alterations in the nerve roots at the points where they leave the spinal canal, and in part to alterations in the spinal cord itself. They are sometimes due to tuberculous inflammation of the lymphatic tissues about the arteries of the cord ; some- times, but very rarely, to the kyphosis itself, which leads to compression of the cord ; sometimes, when the paraplegia comes on suddenly, it is due to fracture of the carious vertebrae, and still more rarely to the bursting of an abscess into the spinal canal, to haemorrhage into the canal, or to the presence of bony sequestra which, by their displacement, press upon the cord. Most frequently it is due to tuberculous granulation tissue filling up the vertebral canal, and causing by its pressure degenerative changes either in the nerves or in the spinal cord. The area of myelitis in these cases rarely exceeds an inch or an inch and a half in length, but the completeness of the com- pression is often seen by the readiness with which pulsation returns in the cord as soon as the granulation tissue has been removed in the course of a laminectomy. The various nerve symptoms resulting from compression in cases of spinal caries have been well grouped by Dr. Eskridge, of Denver, 8 from whose lectures the following account is condensed. The pressure upon and the consequent irritation of the nerve roots leads to an early loss of reflex movements in TUBERCULOUS DISEASE OF BONE 75 the parts supplied by the affected nerves, though in the very earliest stages there is often an exaggerated plantar reflex. The alterations in sensation are usually manifested sooner than the motor symptoms. There is a constant or an intermittent pain which is either dull and aching or sharp and neuralgic in character. It is felt radiating over the back of the head in disease of the upper cervical region, down the arms in the upper dorsal region, round the abdomen in the lower dorsal, and down one or both thighs, along the course of the sciatic nerves, in disease of the lumbo-sacral region. The pain is most often felt in the joints, and they become so extremely sensitive that the slightest touch upon the skin causes great suffering. The nerves are at first unaffected, but after a varying time they become the seat of a descending neuritis which renders them tender, and at the same time prevents them from conducting impulses, so that the patient presents patches of greater or less extent which are anaesthetic when touched, but are the seat of subjective pain. The motor changes come on later, and are characterised by gradual weakening and wasting of the muscles, which may lead to a case of spinal caries being mistaken for progressive muscular atrophy, if the wasting is a more prominent symptom than the bone lesions. The trophic disturbances usually come on later still, and when the disease occurs in the lower cervical and upper dorsal region there is irregularity of the pupil, with vaso- motor disturbances and sweating. Herpes zoster is only occasionally seen. When the cord is affected the disease is usually of long standing, and the paralysis is a more prominent and an earlier symptom than the sensory affections. The paralysis is generally bilateral : it may come on slowly, or its onset may be sudden. The bladder is rarely affected in the more j6 THE SURGICAL DISEASES OF CHILDREN chronic cases, but it is always affected when the paralysis appears suddenly. The anaesthesia may be complete in cases of severe compression ; but the sensory changes, as a rule, are less pronounced than the motor, and in the latest stages of the disease there are often marked ataxic symp- toms, even when the paralysis is passing off. The inter- costal muscles and the diaphragm are sometimes seriously affected when the spinal cord is compressed in the upper cervical region, so that death may occur directly from the effects of the pressure, or indirectly from any slight pul- monary affection. The reflexes are exaggerated, but bed- sores are not formed with undue readiness. When the lumbar enlargement is compressed, the bladder and rectum become paralysed, the knee-jerk is absent, and there is great wasting of the paralysed muscles. The compression due to tuberculous disease of the spinal column must be distinguished from ordinary myelitis due to inflammation caused by tumours in which the trophic disturbances are generally much better marked, from haemorrhage into the vertebral canal, and from syringo- myelia. The cord is compressed from within outwards in syringo-myelia, whilst in tuberculous disease the pressure is exercised from without inwards. The absence of tem- perature and pain senses, whilst the tactile sensations remain fairly good, the absence of symptoms due to disease of the bone, or to pressure upon the nerve roots, together with the prolonged duration of the disease, are sufficient to distinguish syringo-myelia from tuberculous compression. Prognosis. — The prognosis in cases of paraplegia due to pressure is fairly good. The pain remains for a long time, but the other sensory symptoms improve, whilst the disappearance of the paralysis is extremely gradual ; the appearance of cystitis and bedsores necessarily increases the gravity of the prognosis. The chances of complete TUBERCULOUS DISEASE OF BONE 77 recovery are greatest when the dorsal portion of the cord is compressed. The prognosis in these cases is more favourable when absolute paralysis develops rapidly after the appearance of symptoms indicating myelitis than when it appears more gradually, for it is then due to an inflammation of the cord which may subside, rather than to gradual changes within the canal which tend to remain permanent. The prognosis of spinal caries itself is grave, but by no means bad. Recovery may take place without sup- puration, but with anchylosis of one or more vertebrae ; or septic infection may lead the patient to the very brink of the grave, and leave him crippled for life. Hoffa gives a mortality of 27 cases in a series of 269, and says that the older the patient the worse is his chance of recovery. Even the paralytic symptoms tend to recover spontane- ously if the patient be put under favourable conditions. Myers has shown that 55 per cent, out of a total of 218 cases of paraplegia have completely recovered. The aver- age duration of the paraplegic symptoms, in connection with disease of the cervical spine, was twelve months ; in the upper dorsal region, nine and a half months ; in the lower dorsal, six months ; and in the lumbar, eight months. The Differential Diagnosis of Pott's disease is from rheumatic spine, hysteria, scoliosis, ricketty curvature, typhoidal spine, sacro-iliac and hip disease, torticollis, acute septic osteomyelitis, commencing in the vertebrae ; gummatous and sarcomatous infiltration of the bodies, and more rarely from actinomycosis leading to absorption of the vertebrae. It has been carefully considered by Mr. Robert Jones and Dr. Ridlon in the Provincial Medical Journal for 1802. Rheumatic inflammation in children runs a more acute 78 THE SURGICAL DISEASES OF CHILDREN course than tuberculous, the pain is more diffused and is not increased by pressure, and there is not the same worn facial expression. Hysteria is recognised by the absence of rigidity and by the character of the pain, light stimuli often being more effective in producing it than heavier ones. Lateral curvature does not cause rigidity until it has lasted for a long time ; the pain is less, the deformity Fig. 8. — Diagram of a child with spinal caries. It shows that the prominence does not disappear during extension of the vertebral column. [From Hoffa's " Lehrbuch der Orthojiadinchen Chirv/rgie."'] of the chest is asymmetrical, and the curve is rather a spiral condition of the vertebral column than a bending of the entire trunk as in Pott's disease. In ricketty curvature there is an absence of pain, evidence of rickets, and sometimes rigidity. The exact nature of the curve is sometimes to be proved by laying the child flat upon its stomach, and then raising it gently by the ankles so that the back becomes concave. An angular curvature remains, whilst ricketty and lateral TUBERCULOUS DISEASE OF BONE 79 curvatures usually disappear. The following diagrams (figs. 8 and 9) copied from Hoffa show this difference. The history is sufficient to recognise spinal curvature occurring after typhoid fever, which sometimes causes a chronic osteitis some months after the acute symptoms have passed away, and may leave a life-long deformity. Sacro-iliac and hip disease are both rather likely to be mistaken for disease of the lumbar spine, and conversely, Fig. 9. — Diagram of a child with ricketty curvature of the spine. It shows that the prominence disappears during extension of the vertebral column. [From Hoffa's " Lehrbuch."'] especially if a psoas abscess has caused some amount of flexion with fixation of the hip. A rectal examination may clear up a doubtful case of sacro-iliac disease, by demonstrating the presence of inflammatory symptoms in the neighbourhood of the joint ; whilst in cases in which it is doubtful whether the hip or spine is affected, a careful examination of the movements at the hip will show that in cases of lumbar caries with an abscess all its movements are free, except extension. A psoas abscess 8o THE SURGICAL DISEASES OF CHILDREN itself must not be mistaken for a perinephric or other form of chronic abdominal abscess. Wryneck is closely simulated by caries in the upper cervical region. In wryneck, however, the chin points away from the prominent sterno-mastoid muscle ; in caries it points towards that muscle if only one sterno-mastoid be prominent. The movements of the head are restricted in all directions in cervical caries ; in torticollis only in one direction — that which puts the shortened muscle on the stretch. Acute septic osteomyelitis originating in the vertebrae runs a much more acute course, and may affect a very much larger number of vertebrae than does caries. The constitutional symptoms are much more severe. Syphilitic disease of the spine sometimes occurs at two different points in the vertebras separated by one or more healthy vertebras, whilst such healthy intervals less often occur in tuberculous disease. It may co-exist with syphi- litic disease of other joints, and it is amenable to the ordinary anti-syphilitic remedies. It is impossible to distinguish sarcoma of the spine from spinal caries until the progress of the case or the pressure of the tumour clears up the doubt. Actinomycosis, aneurism of the dorsal aorta, and hydatids of the spine are so rare in England that they do not enter into the question of diagnosis in children. Characters of Spinal Caries in Different Regions of the Vertebral Column. It is essential for the proper examination of a case of spinal caries that the patient should be stripped. When cervical caries is suspected, Mr. Jones suggests that the patient should be examined by placing him face down- wards upon his parent's knees. If disease exists, the child TUBERCULOUS DISEASE OF BONE 8 1 will not let his head drop, even though the examination be prolonged, and if he be placed supine he will show no inclination to bend his head towards the sternum in the first act of rising. Pain may be felt in the chest, or running up the back of the neck and head, or down the arms in caries of the cervical spine. An abscess is not frequent, but when it is present it may point either behind the sterno-mastoid muscle or at the back of the pharynx. It differs ana- tomically from the retropharyngeal abscess due to sup- puration of the glands and connective tissue (p. 25) in the fact that it lies beneath the anterior common ligament. Dorsal caries is the commonest form of disease. In addition to the ordinary rigidity and difficulty in stooping, the respiration is interfered with, and the child pants. Lateral deviation of the vertebrae, with or without rota- tion, may precede the angular curvature in this region. An abscess is not very frequent when the upper dorsal vertebrae are affected; but when it appears, it points between the ribs, some little distance outside the spinous processes; a psoas abscess results from disease of the lower dorsal vertebrae. The pain is felt as a girdle pain or stomach-ache. Lumbar caries is less common than dorsal, but more common than cervical disease. The pain is felt along the front and inner sides of the thigh. One or both psoas muscles may become spasmodically contracted, so that the disease may be mistaken for hip disease, as flexion of the joint occurs before the appearance of any curvature. Mr. Jones gives the following directions for recognising flexion due to spinal disease : " The patient is placed prone upon a table, the pelvis is held firmly down with one hand, while with the other hand first one and then the other knee is lifted upwards. The freedom with which they can be 82 THE SURGICAL DISEASES OF CHILDREN raised, and the difference in extent of movement, or the extent to which each of them differs from the normal, must be noted. Then, with one hand upon the back, at about the tenth dorsal vertebra, and the other hand lifting up both knees at the same time, the rigidity of that part of the spine is noted. It is upon this rigidity that the diagnosis must depend. In healthy children the spine can be bent backward so far that the thighs are at nearly a right angle with the upper dorsal spine." Paraplegia is very uncommon in disease of the lumbar spine. Abscess is frequent ; it may pass into the psoas muscle, and open in the thigh ; or, if the disease is below the third lumbar vertebra, the pus may pass into the sheath of the psoas where it is continuous with the sacral end of the pelvic fascia, so that it tracks down to the pyriformis, and leaves the pelvis by the great sacro- sciatic foramen to point in the buttock. The abscess sometimes extends laterally, following the nerves, and pointing in the loin some inches from the spine. The chronic abscess appears at very variable periods in the disease, sometimes quite early, often soon after the ap- pearance of the spinal deformity, occasionally not until months later ; or, if it be a " residual " abscess, not until years after the patient has been cured. The abscess does not necessarily open, for it is no uncommon thing in making a post-mortem examination to find one psoas a mere shell of muscle containing caseating or even calcified material, associated with cured disease of the spine, resulting from simple tuberculous infection. The infection is more frequently mixed, and the abscess then runs an ordinary chronic course, pointing, in the case of a psoas, either externally or internally to the femoral sheath, or else tracking down the thigh for long distances. The projection of the spine is sometimes produced quickly TUBERCULOUS DISEASE OF BONE 83 and continues to alter its shape for a considerable period, whilst at other times it only forms slowly, and hardly undergoes any subsequent change. The amount of de- formity too varies greatly ; in some rare cases it is hardly perceptible, whilst in others it is so marked that Shaw quotes a case in which the unfortunate patient could only get about " on all-fours." Treatment. (1) Palliative. — The 'treatment in the earlier stages of the disease is essentially palliative, and exactly the same methods must be adopted for its relief as in other cases of tuberculous osteitis. Rest is there- fore a matter of the first importance, and it is essential that the weight of the body should be taken off the Fig. 10. — Diagram to show the method of applying a plaster-of-Paria case for the treatment of spinal caries. [From Hoffa's " Lehrlwsh."] spine. These indications are met if the patient can be kept absolutely rigid and flat in bed for long periods of time. Mere rest, indeed, will often relieve the pain and lessen the symptoms of paralysis, putting the patient in the fair way towards recovery ; but rest alone is in- sufficient in many cases where the spines of the vertebrae have already become prominent. A moderate amount of extension must then be maintained by moulding a convex splint of plaster-of-Paris, leather, gutta-percha, or in very small children, of poro-plastic felt, to the patient's trunk, as has been recommended by Reeves and Lorenz (fig. 10). A wicker-work tray is often sufficient for better-class patients. The splint should be moulded on to the spine 84 THE SURGICAL DISEASES OF CHILDREN whilst the child is upon its hands and knees and after the surgeon has gently placed the diseased vertebras in the position of least deformity. A jury-mast is necessary when the disease is above the eighth dorsal vertebra. A double Thomas may be employed in place of the moulded splint. When the pain has subsided, when the surgeon con- siders that there is no longer any tendency to the formation of an abscess, when the child has regained its colour and eats heartily, it need no longer be kept in bed. A rigid jacket made of light material should then be moulded to the spine whilst the vertebral column is in a state of gentle extension, and the patient should be encouraged to take gentle exercise. Whatever material is used for the jacket, it should be well and accurately adapted to the body, reaching from the great trochanters to the axillae, provided with shoulder straps, and, if neces- sary, with a jury-mast. A skilfully made plaster-jacket meets the requirements well, if care be taken to keep pressure off all bony points, including the spinal curvature, by pads of felt. As soon as possible the hot and uncom- fortable jacket should be replaced by a properly adjusted and light spinal support, which must be worn until the absence of all muscular rigidity in the spine allows it to be laid aside, for only then will complete consolidation have been effected. Some modification of Taylor's support (fig. 11) is often used for this purpose. It consists essentially of two steel uprights, one on either side of the spine, with a cross-piece, straps, and pads. (2) Operative.— Many cases, however, do not run so smooth a course. Abscesses form, the pain continues, the disease progresses, and symptoms of spinal meningitis followed by myelitis occur in spite of absolute physiolo- gical rest of the part. Mr. Arbuthnot Lane, Dr. Macewen TUBERCULOUS DISEASE OF BONE 35 and Mr. Thorburn in this country, Dr. Chipault and others abroad, have followed the anti-tuberculous treat- ment of spinal disease to its logical conclusion by cutting down upon the vertebral column, removing the laminae over the affected region, and scraping away the granula- tion tissue which gives rise in the majority of cases to the paraplegic symptoms. This treatment is especially useful when the disease is limited to the posterior part Fig. 11.— Taylor's brace for supporting the vertebral column in spinal caries after the plaster-jacket has been laid aside. of the vertebral column ; but it is not useful in every case of paraplegia occurring in the course of Pott's disease. (1) Indications for Operation.— Mr. Thorburn says that the indications for the operation of laminectomy are a steady increase in the symptoms, in spite of favourable con- ditions and treatment ; the presence of symptoms which directly threaten life, such as secondary chest troubles and intractable cystitis ; the persistence of paraplegic symptoms 86 THE SURGICAL DISEASES OF CHILDREN after the original pressure lesion has ceased to act, the symptoms being due to pressure caused by scar tissue ; and in caries of the posterior part of the spinal column, for in these cases the whole of the tuberculous tissue can easily be removed, and the condition of the patient can thus be materially ameliorated. The operation is also of service when severe pain is rapidly exhausting the patient. (2) Contra-Indications. — Prof. Macewen very properly holds that the operation of laminectomy should not be per- formed when active tuberculous changes are going on in other organs ; in cases of general meningitis, when fracture has followed as a resialt of caries ; and when the symptoms of paraplegia have suddenly manifested themselves. Laminectomy. The operation is a strictly logical one if our theories of the pathology of tubercle are correct, and it will probably be found serviceable in some cases. It should not be considered as a matter of frequent necessity, for many cases of paraplegia due to spinal caries, which appear suitable for laminectomy, undergo such marked improve- ment from rest, with the ordinary methods of treatment, that the operation becomes unnecessary. When it has to be performed, however, it should be done before advanced secondary changes have taken place in the cord, so that the surgeon ought not to wait too long. The theoretical objection attaches to it, that when the uninjured parts are removed by operation and the remaining parts are softened by disease, the use of the spinal column as a support is lost. This argument would be valid in the case of a skeleton ; but in the body, if the bone is removed sub-periosteally, the osseous tissue is soon replaced. The Technique of laminectomy is simple. The child is placed upon his left side, an incision is made over the TUBERCULOUS DISEASE OF BONE 87 projecting part of the spine, the soft parts are separated upon the two sides, and with them the periosteum covering the vertebras, until two or three laminae are thoroughly exposed. One lamina is then divided with a pair of strong cutting forceps, and is twisted out of place with sequestrum forceps. A sufficient number of laminae, generally two or three, and if necessary the vertebral spines and the laminae upon the opposite side, are removed, until the vertebral canal is clearly exposed to view. It is sometimes found to be filled with tuberculous granulation tissue, which must be carefully removed with a sharp spoon, the bleeding being arrested as far as possible, and care being taken that the blood does not pass down into the canal. The spinal cord lies along the anterior surface of the vertebral canal, and at some distance below its posterior arch. It is easily recognised as it lies in its membranes. The spinal cord with its sheath is gently drawn aside by large and broad retractors, until the posterior surface of the bodies of the diseased vertebrae are exposed. The granulation tissue is again scraped away as completely as possible, any abscesses which may be present are opened, the bones are swabbed with a solution of 1 in 15 zinc chloride, and the wound is afterwards well flushed with sterilised water at a tempera- ture of 105° F. The cord is allowed to fall back into place, and the surgeon should not consider that he has done his best for the patient until he sees pulsation in the cord, for he is then sure that every source of constriction has been removed. The soft parts and the skin are brought into accurate apposition, and every endeavour is made to obtain union by first intention, without the use of any drainage- tube. Sensation is restored throughout the body within a few days of the operation, whilst motor power returns more gradually. Fistulous tracts are liable to form at the seat of operation, and recurrence of the symptoms for which 88 THE SURGICAL DISEASES OF CHILDREN the operation was originally performed has taken place in some of the cases. The Treatment of Cold Abscesses. The large cold abscesses which so often occur in con- nection with tuberculous diseases of the vertebrge and of the hip have long been bugbears to surgeons, and in pre- antiseptic days those surgeons treated their patients best who left such abscesses alone. The abscesses are of two kinds — those containing pus, and those filled with caseous material. The ideal method of treatment for both forms is to dissect them out cleanly without pricking the membrane which surrounds them ; but they are often so extensive and so deeply seated that this can only be done in exceptional instances. Dissection is, however, practicable in the case of those caseating collections found in the thigh in connection with cured or stationary disease of the hip ; but if it be attempted there must be no hesitation and no mistake upon the part of the surgeon, for the operation must be carried through. If the mass be cleanly removed, the wound will heal by first intention, and good will have been done ; if, on the other hand, it be badly removed, and a part be left behind, extensive suppuration is almost sure to follow ; for if it be pricked and some of the caseating material be allowed to escape, the wound may become infected, and harm will have been done to the patient, for the scar may become the seat of a tuberculous dermatitis, and it must then be cut out. Failing the adoption of the ideal method, the surgeon resorts to the next plan, which has been strongly advocated by Mr. Barker, and which is now very generally adopted, with excellent results. The abscess or caseous collection is laid open at its most accessible part, and the contents are allowed to escape. The surgeon then introduces some TUBERCULOUS DISEASE OF BONE 8 9 form of " flushing-scoop " (fig. 12), which is a sharp spoon provided with a tubular stem, through which a constant stream of fluid can be passed into the hollow of the scoop. The instrument is attached to an irrigator containing a gallon or more of boric solution at a temperature of 105° P., and the irri- gator is attached to a pulley running in a block, and is raised and secured at a height of about five feet above the patient as he lies upon the operating table, so that a good head of water may be obtained for the flush- ing purposes. The scoop is then introduced into the abscess, and its walls are gently but systematically scraped, the fluid being allowed to pass through the scoop either con- tinuously or at intervals. The abscess cavity is thus distended, and its contents as they are loosened by the scoop are carried out of the wound by the reflux stream. The surgeon must exercise care and discretion in using the scoop, for if he is too rough very serious damage may be done to the parts. The hot solution serves two purposes besides that of removing the debris : it allows of the more ready removal of the contents of the cavity if it be caseous, and at the same time it staunches the bleeding. The cavity is squeezed dry as soon as the whole of the pyogenic membrane has been removed, or the drying is done by introducing pieces of absorbent wool freshly wrung out of a solution of boric acid. The wound is then closed with sutures of horsehair, and is dressed antiseptically. It is better not to use a drainage-tube. This treatment cannot H ft O O o m be c 90 THE SURGICAL DISEASES OF CHILDREN be carried out to its full exteut in many cases of psoas abscess ; indeed, it only gives the best results when the bone disease is quiescent and the abscess cavity is simple, and even then it may be necessary to repeat the operation. The annexed drawings (figs. 13 and 14) — copied from Hoffa— will show how complex these abscesses often are, and that no single operation would be sufficient to cure them. Palliative rather than curative measures must then be tried, or the abscess may be treated piecemeal. I usually open such an abscess, scraping and flushing it as far as it can be reached. A long probe is then passed upwards from the groin into the flank, and afterwards downwards into the thigh. It is made to project beneath the skin in both situations, and counter-openings are made. Drainage-tubes are passed from the counter- openings to the wound in the groin, and antiseptic dressings are applied ; but if it is possible the edges of the wounds should be pared and sutured after the abscess cavity has been rendered aseptic. Strict cleanliness is enforced, and little by little the drainage-tubes are shortened, so that the wound in the groin heals first. There is usually no difficulty in getting the wound in the femoral part of the abscess to close, for it is cut off from the source of infection ; but it is far different with the iliac part, which is still in connection with diseased bone, and so long as the disease progresses, so long will pus continue to be formed. The after-treatment will now depend upon the individual case ; if the abscess be comparatively simple, like that represented in fig. 13, the opening above the crest of the ilium may be enlarged, and valuable information as to the extent of the disease may be obtained by digital exploration, even to the extent of finding a sequestrum, which should be removed if it is possible. TUBERCULOUS DISEASE OF BONE 91 This method is inapplicable when the abscess forms a series of lagoons and canals, like that represented in fig. 14. Fig. 13. — A large psoas abscess dissected to show the relations it bears to the various anatomical structures in its neighbourhood. [From. Hoffa's " Lehrbuch."~\ Two courses are then open to the surgeon. He may cut down upon the diseased vertebrse if he feels pretty sure 92 THE SURGICAL DISEASES OF CHILDREN that the discharge is kept up by the presence of a seques- trum, and so remove the source of irritation ; or if he be less certain of his diagnosis, he may content himself with scraping the sinus and injecting it with an emulsion of iodoform or with camphorated naphthol. The treatment of psoas abscess in this stage is still unsatisfactory. Such Fig. 14.— Diagram of a double psoas abscess to show its loculated character. [From Hoffa's " Lehrbuch."] improvements, however, have recently been made in our methods of treating these conditions that we need have no fear that we have arrived at the end of our surgical resources, but we may feel assured that in due time a satisfactory cure will be found even for the last stage of a loculated psoas abscess. TUBERCULOUS DISEASE OF BONE 93 HYPERTROPHIC PULMONARY OSTEO- ARTHROPATHY.'' Under this very cumbersome title occur certain interest- ing cases of hypertrophy of the bones and joints. Pathology.— The hypertrophy may be due to a benign form of tuberculous affection, in which there is no tendency to break down or caseate, caused perhaps by toxines pro- duced during the inflammation. It occurs in children as well as in adults, but very rarely in females. Symptoms. — The hands and feet are always greatly and symmetrically enlarged, the increase in size involving also the lower part of the forearms and legs, implicating the bones more than the soft parts, and markedly affecting the terminal phalanges, over which the expanded nails are spread out with a transverse and longitudinal curve, so as to be very convex. The nails themselves are large, and bending over the ends of the fingers give them a great resemblance to the beak of a parrot ; they are usually striated longitudinally. Various long bones are often hypertrophied, especially at their ends, and effusion of fluid into the knees and other joints is not uncommon The disease in children may be limited to the phalanges. The skull remains unaffected. Scoliosis is common, and it is not rare to meet with kyphosis affecting the lower dorsal region. The disease is generally of insidious onset and long duration ; but it sometimes runs a rapid course, and in all or nearly all the cases is accompanied by some form of chronic bronchial, pulmonary, or pleural disease, es- pecially empyema. Diagnosis. — It has to be distinguished from acromegaly, osteitis deformans and myxcedema. There is no intrinsic danger to life, and the primary and causal condition not 94 THE SURGICAL DISEASES OF CHILDREN being of necessity fatal, the ultimate result cannot be observed. There is no tendency to acute inflammation or to suppuration of the affected bones or joints. Relief of the pulmonary condition appears to react beneficially upon the complication. EXPLANATION OF PLATE. Fig. 1. — A section through the right shoulder joint to show the relation of the synovial membrane to the upper epiphysis of the humerus. The synovial membrane on the inner side comes below the epiphyseal line, but it stops above at the anatomical neck, and is separated from the synovial sheath of the biceps. Fig. 2. — A vertical section through the elbow joint at the age of eighteen months, showing the lower epiphysis of the humerus, and the upper epiphysis of the ulna, and their relation to the synovial membrane of the elbow joint. (After a drawing made by Mr. Jno. Hutchinson, jun.) Fig. 3. — Section through the left hip joint to show the relation of the synovial membrane and capsular ligament to the articular surface and to the epiphyses. Fig. 4. — Section of the left knee to show the relation of the synovial membrane to the articular surface, and to the epiphyses of the femur and tibia. Fig. 5. — A section through the ankle joint to show the rela- tion of the synovial membranes to the epiphyses and to the astragalus. (All the figures are semi-diagrammatic.) 96 m I m I \ /• " L -■■■•'•'• Fig- S- DIONS OF Joints SHOWING THE RELATION ok the Synovial Membranes. CHAPTER VI TUBERCULOUS DISEASES OF JOINTS AND BURS^E Morbid Anatomy. — Tuberculous disease of the joints 7 is very frequent in children. It is most often local, but it may be part of a general tuberculosis. The inflammation commences either in the synovial membrane, or more often in the ossifying tissue of the head of the bone from which the joint becomes secondarily affected by its extension. The frequency with which the joints are affected by this process depends directly upon the anato- mical relations of the epiphyseal line to the capsule of the joint — relations which I have endeavoured to make clear in the semi-diagrammatic representations in the coloured plate. It will be seen that the line of the epiphysis in the hip and in the lower end of the humerus is always within the capsule. Tuberculous disease of these joints is there- fore frequent, as a result of inflammation of their epiphyses. The capsule is only partially attached to the line of the epiphysis in the shoulder and in the lower end of the femur, so that these joints may escape, although the epiphyseal lines are diseased. This is not often the case, however, as the union between the capsule and the epiphysis is extensive. The capsule of the knee is attached above the upper tibial epiphysis ; this joint often escapes, therefore, even when there has been a sharp 97 H 98 THE SURGICAL DISEASES OF CHILDREN attack of tuberculous inflammation, involving the upper epiphyseal line. In the ankle the line of the lower epiphy- sis of the tibia is external to the capsule, but the astraga- lus and the lower epiphysis of the fibula are within it. The disease, therefore, usually spreads upwards into the joint from the tarsus, as the lower end of the fibula is not often the seat of tuberculous inflammation. The appearances in the joint vary according to the character of the disease. When the inflammation com- mences in the synovial membrane, there may be a general thickening or, more rarely, a local hypertrophy of its tissue. Suppuration takes place in some cases, whilst in others the synovial membrane secretes a clear fluid, which distends its cavity and leads to the condition known as hydrops articuli ; indeed, all chronic effusions into the joints of children should be regarded with very grave suspicion, for they are nearly always tuberculous. Certain secondary changes take place both outside and within the joint. The thickened synovial fringes may caseate, or they may become oedematous, and grow over the articu- lar surfaces, leading to softening of the ligaments and destruction of the cartilages. The connective tissues surrounding the joint either undergo a gelatinous trans- formation or a fibroid thickening, and in this manner a typical white swelling is produced. Intra-articular or peri-articular abscesses form, and the joint is destroyed. The changes in the bone are of the same general charac- ter as those in the synovial membrane. A deposit of tubercle takes place at some part of the epiphyseal line. This either caseates, or fungates, or suppurates, until, in young children, the inflammation extends through the thin epiphysis and sets up an arthritis. The inflammatory products in older children may pass into the joint by less direct methods, usually round the edge of the capsule. In TUBERCULOUS DISEASES OF JOINTS AND BURS/E 99 a few cases the joint escapes, but its movements are seriously hampered by the osteophytes formed by the osteoplastic periostitis which the inflammation causes. The cartilages become destroyed, either piecemeal by a process of ulceration, or more rarely by actual necrosis. Granulations spring from the ends of the inflamed bone, and if the patient is under the best possible conditions, bony anchylosis takes place in a good position. Faulty position and fibrous anchylosis is very common in this form of joint disease, or the suppuration is so prolonged and extensive as to lead to death or to a necessity for amputation. Symptoms. — The individual symptoms will be found described under each joint. The general symptoms com- mon to all forms of tuberculous arthritis are rigidity, swelling, fluctuation, pain, flexion, shortening and dis- placement. The swelling is a constant symptom of joint disease, and it is seen more early in exposed joints, like the knee and elbow, than in those which are more deeply situated, like the hip and shoulder. The swelling is the result of effusion into the joint, of hypertrophy of the synovial membrane, or to oedema and caseation in the connective tissues outside the joint. The wasting of the muscles above and below the joint always makes it appear to be greater in the knee than it is in reality. This can easily be proved by taking comparative measurements round the two limbs at similar points above, over, and below the affected joint. The fluctuation varies greatly. It is best marked in cases of simple synovial disease, and it is least marked or absent when the swelling is due to extra-articular changes. The pain is often a characteristic symptom, for it occurs in severe attacks at the instant when the patient falls asleep, and is one cause of the " night-screaming " which IOO THE SURGICAL DISEASES OF CHILDREN accompanies many of the chronic inflammations in chil- dren's joints. The pain appears to be produced by the momentary approximation of the two ends of the inflamed bone, owing to the relaxation of the tonic contraction in which the child keeps its muscles so long as it is con- scious. It is therefore usually seen when the cartilages have ulcerated, and it can often be overcome by mechani- cally separating the inflamed surfaces of the joint with an extension apparatus, but not always, for it appears to be sometimes associated with the changes which precede the formation of an abscess. The pain may also be elicited by movement, and by pressure upon the part. Flexion is often an important symptom of joint disease, and it is associated with the rigidity of the muscles, which is one of the earliest and most persistent symptoms of a joint lesion. So long as rigidity lasts, so long is there progressive joint disease, and the child should not pass away from the surgeon's care until this symptom has disappeared. The pathology of the muscular rigidity is just beginning to be understood, and it appears to be due to reflex irritation originating in the inflamed articular surfaces, and is part of the general process leading to that atrophy of all the tissues which may result in a shortened limb, even when there has been no absorption or removal of the articular bone. The muscular changes may be so advanced as to lead to a marked fibroid change, rendering them useless. Shortening is partly due to the displacement which often accompanies disease of the joints, and partly to trophic disturbances. The displacement is usually only partial, as in the case of the hip and knee, but it is occasionally a true dislocation. Diagnosis. — The diagnosis of tuberculous arthritis in children is not difficult ; but if the case be seen early, and is at all doubtful, a careful examination should be made TUBERCULOUS DISEASES OF JOINTS AND BURS.E IOI under an anaesthetic to ascertain the exact power of move- ment which the joint possesses. Prognosis. — The tendency of tuberculous arthritis is towards destruction of the joint, with subsequent anchy- losis of the two surfaces either by bony or fibrous tissue, and often in a bad position. In many cases, however, the patient who is left to nature may die before this process is completed from the effects of the long-continued suppura- tion attendant upon a mixed tuberculous infection. The inflammatory changes lead to alterations in the growth and the functions of the affected parts, and the surgeon has to guard against these in treating such cases. Relapses and local recurrences are of very frequent occurrence in all cases of tuberculous arthritis. Treatment. — The recognition of tubercle as a locally infective disease has materially modified the treatment of the tuberculous disease of joints within the last ten years. There existed formerly only excision and amputation ; ex- cision dating back at least to the time of Paulus iEgineta, and amputation which is coeval with surgery. The treat- ment by rest must also have been employed from time immemorial. Increased knowledge has taught us that the tubercle bacillus causes lesions which have in themselves no tendency to suppurate, but rather to undergo caseous changes. The infection in many cases is not simple, but the tubercle bacillus has various septic micro-organisms mixed with it, and these are pus-producing. Still further investigation — but of this we are not so sure — tends to prove that the caseous masses in tubercle are in reality the dead and degenerate remains of the white corpuscles which have been destroyed in an endeavour to limit the spread and the multiplication of the bacilli, the destruction being brought about by the poisonous secretions, or toxins, manufactured for defensive purposes by the micro-organ- 102 THE SURGICAL DISEASES OF CHILDREN isms. The destruction of the bacilli is thought to be carried out by the great digestive powers with which the white blood corpuscles are endowed. If this be the cor- rect interpretation of the pathology of tubercle, the treat- ment of tuberculous disease by " Sderogeny " is founded upon the most secure and scientific principles. This method was introduced into surgery by Prof. Lannelongue in 1891. It consists in the injection into the tissues near the tuberculous foci of a solution of zinc chloride. The irritation produced by this reagent leads to an increase in the number, and an alteration in the character, of the white corpuscles in the tissues, which in turn react upon the tuberculous nodules, leading to their destruction. This, at any rate, is the theoretical explanation ; the point of surgical interest is that, after such injections, the tuber- culous foci sometimes undergo a retrograde process, and become converted into fibrous tissue, which may afterwards be dealt with, if it be necessary, in the ordinary manner. (1) Sderogeny. — The details of the operation in the case of the knee or shoulder are the following : — The patient is anaesthetised, as the injections are painful, and the part having been thoroughly cleansed in the usual manner, a drachm of zinc chloride solution, of the strength of 1 in 10, is taken up in an aseptic hypodermic syringe. The canula of the syringe is first wiped dry. This is important, as any of the solution remaining on its outside will destroy the skin and tissue in the track of the needle. It is then pushed through the skin and the tissues until its point touches the bone outside the synovial membrane. The point is withdrawn, and four minims of the solution are forced out into the peri-articular connective tissue. The injections are repeated at different points round the joint until about half a drachm of the solution has been used, care being taken in each case that none of the fluid enters TUBERCULOUS DISEASES OF JOINTS AND BURS.ii IO3 the cavity of the articulation, and also that the injections are made at the parts where the synovial membranes re- ceive their chief blood supply, i.e. at the reflection of the synovial membrane on to the bone and along the great ligaments of the joint. When the part to be injected lies superficially, the syringe should be directed obliquely to prevent any reflux of fluid. In no case must an injection be made directly under the skin, and it stands to reason that the large arteries and nerves are to be avoided. The parts should be firmly bandaged after the operation, to limit, as far as possible, the congestion and cedema ; and if there be much pain, a hypodermic injection of morphia must be given. There is usually a pretty sharp reaction, which subsides by the third or fourth day. The limb is put up in a plaster case, and in the most favour- able position, as soon as the inflammatory symptoms have subsided. The symptoms of sclerogeny — hardening, and retrogressive changes — are generally well marked in three weeks to two months after the operation, and from this time onwards the muscles should be regularly shampooed and galvanised. A single series of injections is alone necessary in a successful case ; but if the operation has to be repeated, an interval of at least three weeks should be allowed to elapse. Prof. Lannelongue claims that in suc- cessful cases the results are most satisfactory, whilst in the less successful ones the injections pave the way for further operations of a more radical nature. I am giving the method an extensive trial, but it is too soon to dogmatise upon it. Many other methods have been adopted to secure the same ends, with a greater or less amount of success. Thus a tincture of iodine, 2 per cent, solution of carbolic acid, a 1 in 4 emulsion of balsam of Peru made up with sweet almonds, a solution of iodoform in glycerine or olive oil, and the liqueur de Villate, consisting of equal parts of zinc sulphate 104 THE SURGICAL DISEASES OF CHILDREN and copper sulphate, with, a little Goulard extract and dilute acetic acid, have at different times been employed. The iodoform emulsion is made according to the following formula : — 1£> Iodoform 10 parts Glycerine 70 „ Water 10 „ Wash the powdered crystalline iodoform in a 1 in 2000 solution of corrosive sublimate, and then rub it up with enough spirit to prevent its becoming lumpy. Shake the iodoform and water together, and then add the glycerine. Prof. Senn injects the iodoform emulsion directly into the cavity of the joint after removing the synovial fluid or tuberculous pus, and washing out the cavity with a 3-5 per cent, solution of boric acid. He continues the injections at intervals of a week or two, until there is distinct evidence of diminished tuberculous inflammation. The improve- ment usually manifests itself after the third or fourth injection. I thought a few years ago that I obtained good results after the use of iodoform emulsions in the treat- ment of tuberculous abscesses ; but I believe now that the most satisfactory method is to scrape away all the tuber- culous material with a sharp spoon, and endeavour to obtain union by first intention. (2) Rest. — The treatment of tuberculous disease of joints by rest is frequently attended by excellent results in chil- dren, due no doubt, in part, to the fact that it allows the tissues time to deal effectively with the tubercle bacillus, and partly because it abolishes the reflex stimulus leading to trophic disturbance. This method of treatment is especi- ally satisfactory in cases where the synovial tissue is alone or chiefly affected. It is only of slight use where the bones are extensively diseased, and where there is much deformity, unless the deformity be due to fibrous bands TUBERCULOUS DISEASES OF JOINTS AND BURS.E IC5 which yield to extension. Good as the method is, however, it is liable to abuse if it be adopted too exclusively and for unsuitable cases. The worst cases of lardaceous disease which have recently come under my notice have been those in which the expectant treatment has been con- scientiously carried out in patients who had abscesses and sinuses which it was impossible to render aseptic. Acute abscesses must be opened as soon as possible in a child who has been treated for tuberculous arthritis by rest. The contents of the abscess must be evacuated, and an attempt made to obtain union by first intention ; for it should be clearly understood that many of the effects of tuberculous disease are due to the septic rather than to the tuberculous bacilli. Nature, too, in many cases does not give such good results as can be obtained in a shorter time by surgical treatment judiciously applied. Care, therefore, should be taken in the employment of this method. On the one hand, rest should be adopted as a routine proceeding in all cases of incipient joint disease in children ; on the other hand, if after its adoption there is not marked improvement, if the disease is progressive, if abscesses form which cannot be effectively dealt with, or if, after sufficient trial, relapses occur as often as the patient is allowed to get about, it should not be persisted in, but recourse should be had to the more radical measures of arthrectomy or excision. (3) Operation. — It is the duty of the surgeon to cut down upon the bone, and to remove any caseating masses when rest, sclerogeny, and the allied methods have failed. He must operate at once when he suspects that a tuberculous focus is present in the epiphyseal line. He is especially bound to do this when the disease affects the posterior part of the head of the humerus, the upper or lower epi- physes of the tibia, the popliteal surface of the femur, and 106 THE SURGICAL DISEASES OF CHILDREN the upper part of this bone, particularly when the great trochanter is alone involved. The operation should be per- formed upon a limb which has been rendered bloodless by the application of an Esmarch's bandage. The bone should be exposed, and should be gouged away in the neighbour- hood of the epiphysis. When the diseased tissue is ex- posed, it should be removed, and the cavity in which it lay should be swabbed out with a 1 in 15 solution of zinc chloride. It should be thoroughly flushed with boiled water, packed with gauze, and allowed to granulate. I have recently been trying the effect of packing such tuber- culous cavities and sinuses with camphorated naphthol, taking care never to introduce more than four drachms at a time, lest poisonous symptoms should result. The direc- tions for making the preparation will be found on page 8. The results are, I think, a little better than those obtained from packing with cyanide gauze. Sternoclavicular Joint. Frequency. — Inflammation of the sterno-clavicular joint 10 is one of the rarest forms of tuberculous arthritis. It may occur in young adults, but there is no case on record in which it has been seen in infants It is either primary, when it commences as a synovitis, or it is secondary to tuberculous caries of the clavicle. Symptoms. — Pain is the earliest symptom of the dis- ease, and it is of such a nature as to compel the patient to assume the position which is thought to be characteristic of a broken collar-bone. He supports his bent elbow in his hand to take off the weight of the arm, and inclines his head to the affected side to relax the tension of the muscles. Sooner or later, a swelling appears over the sterno-clavicular end of the joint, and it is a typical tumor albus. It is oval in shape, with its long axis lying parallel TUBERCULOUS DISEASES OF JOINTS AND BURS/E IO7 with the clavicle. The skin is distended over it, but it is unaltered in character, except that it is traversed by a few veins which are rather more conspicuous than usual. It feels doughy. The temperature is not warmer than the surrounding parts. Careful examination will show that it projects behind the articulation as well as in front of it, and in this stage it is likely to be mistaken for a sarcoma. It eventually suppurates, and leads to sinuses in the thoracic wall. The sternal end of the clavicle may be dis- placed, and in some rare cases the abscess has been known to point and open into the mediastinum or into the pleura, or it may even lead to ulceration of the great venous trunks lying in its immediate neighbourhood. The Treatment consists in cutting down upon the swell- ing, removing all the f ungating tissue, and sterilising the cavity as far as possible, so as to enable it to heal by healthy granulations. Tuberculous Disease of the Shoulder. Frequency and Course. — The shoulder is less fre- quently affected than the other large joints, for it only forms 25 per cent, of the total number of joint cases in children. The tubercle may be deposited in the syno- vial membrane, or rather more often in the cancellous tissue of the bones themselves, as " caries sicca " is not unusual in the head of the humerus. Suppuration takes place, and the abscess tracks downwards along the biceps tendon, or opens into the bursa beneath the deltoid. More rarely it appears in the axilla, or it may point behind in the supra-spinatus or infra-spinatus fossa. In some very interesting cases, known as caries sicca, the disease runs its whole course without marked symptoms and without suppuration, so that complete bony anchylosis of the shoulder may take place in a child who hardly appears to 108 THE SURGICAL DISEASES OF CHILDREN have been ill. A similar quiet anchylosis takes place in other joints, especially in the elbow, knee, and ankle. This form of anchylosis is usually attributed to tuberculous or rheumatic processes ; but we are quite ignorant of its true pathology, and it requires much more careful observa- tion thau has yet been bestowed upon it. The Symptoms in an ordinary case of tuberculous disease of the shoulder are loss of function in the joint, with internal rotation and adduction of the arm. Pain is not usually a very marked feature. The Prognosis is good, for a useful limb results in the majority of cases. Treatment. — Rest is best obtained by the application of a plaster-of-Paris bandage, after a pad has been put into the axilla to produce a certain amount of abduction. An atypical excision may sometimes be required when the sinuses are persistent, but such an operation is not of fre- quent occurrence. A formal excision of the joint is best performed with the arm extended and rotated outwards, through an incision carried just external to the coracoid process longitudinally downwards, so as to expose the long head of the biceps lying in the bicipital groove. The fibres of the deltoid are held back by broad retractors, and the capsule of the joint is laid open. Its cavity is thoroughly explored, and the diseased tissue is removed as far as may be necessary, either by scraping it away or by sawing through the head of the bone, either at the anato- mical neck, through the tuberosities, or at the surgical neck. The whole of the diseased tissue is removed with dissecting forceps and scissors, the cavity of the joint is swabbed out with a 1 in 15 solution of zinc chloride and flushed, and the sinuses are treated in a similar manner. The parts are then brought together, and every endeavour is made to obtain union by first intention. Passive move- TUBERCULOUS DISEASES OF JOINTS AND BURS/E IO9 ment should be commenced within the first fortnight, as a movable joint is required. The results in children are not so good as in adults. Elbow. Frequency. — Tuberculous disease of the elbow is very common, as it forms 50 per cent, of all cases of joint disease in children. It nearly always begins in the bones. Symptoms. — It commences insidiously, for the pain and functional disturbance are not marked symptoms until the disease is well advanced. The swelling is first noticed at the back of the joint, but it soon extends all round, and the typical oval tumour is developed, which has led to the use of the term " tumor albus " as a synonym for tuberculous arthritis. Pronation and supination are not materially affected, though complete extension soon becomes impos- sible. Secondary dislocations are rare, but anchylosis is not at all an infrequent result. Treatment. — Complete rest until all inflammatory symp- toms have passed away is the first treatment to be adopted in these cases. The elbow should be bent to a right angle and should be secured in a plaster-of-Paris case, or in a well- fitting leather splint applied along the back of the joint. An arthrectomy must be performed when sinuses form in spite of this treatment. Mr. Glutton has recently advo- cated and adopted this operation with great success. He prefers, however, to do it quite at an early period, and before suppuration has taken place ; for he aims at securing a movable joint without having recourse to passive move- ment. His method of operating is as follows : — Arthrectomy. — The skin is thoroughly cleansed with soft soap or liquor potassse. A transverse incision is made across the base of the olecranon, which is then divided with a saw. The olecranon is drawn upwards, and the HO THE SURGICAL DISEASES OF CHILDREN fascial expansion is divided until the joint can be so freely opened as to allow all its parts to be efficiently scraped. All the granulation tissue is then removed with forceps and scissors, special attention being paid to the various pockets in the synovial membrane. Pieces of loose cartilage are scraped away with a sharp spoon, and the soft and carious bone is gouged out, the whole of the exposed surface being repeatedly flushed with a solution of 1 in 5000 perchloride of mercury, at a temperature of 100° F. The most difficult part of the operation consists in clearing the part of the joint beneath the brachialis anticus. The olecranon is attached to the ulna, by means of a wire or an aseptic silk suture, as soon as the diseased tissues have been removed. The edges of the skin incision are brought together accurately with sutures, and an antiseptic dressing is applied, with the arm at a right angle. A narrow strip of plaster-of-Paris bandage is applied to the front of the arm, and in favourable cases the dressings are not removed for two or three weeks. When the temperature rises the wound must be dressed, and it may be necessary to separate its edges with a director to allow any retained secretion to escape. The plaster-of-Paris splint is applied to the back of the joint as soon as the wound has healed ; it is worn until all tenderness has disappeared— usually for two or three months— and the patient is then allowed to use the arm freely. In many cases Mr. Clutton has obtained excellent results ; in some, anchylosis has resulted ; in others, the persistence of suppuration has obliged him to have re- course to excision of the joint. Excision. — A formal excision is best performed by rendering the arm bloodless with an Esmarch's bandage, bending the elbow, and then carrying a vertical incision along the back of the joint and a little to the inner side TUBERCULOUS DISEASES OF JOINTS AND BURS/E I I I of the middle of the olecranon. The incision should mea- sure three inches in length, and the anconeus should be injured as little as possible in order to secure the power of extension. Care must also be taken to injure neither the triceps, its aponeurosis, nor the lateral ligaments. The condyles of the humerus are cleaned, and the bone is sawn through on a level with their base, whilst the heads of the radius and ulna are made to project, and are then sawn off together above the attachment of the brachialis anticus. The synovial membrane must be thoroughly removed, especially from the upper part of the olecranon fossa, where large masses of granulation tissue are apt to be overlooked. The wound is flushed, closed and dressed in the same manner as after an arthrectomy. The child is anaesthetised about the tenth day, and gentle passive movements of the elbow should then be commenced. They must be repeated daily by the surgeon, who fixes the arm and gently pronates and supinates the forearm. The results of excision of the elbow are satisfactory, though it is not often necessary to perform the operation. Wrist. Tuberculous disease of the wrist is rare in young children, but it becomes a little more frequent as age advances. Symptoms. — It is a chronic and very insidious affection, usually commencing in the bones themselves, and gene- rally involving the whole of the carpus. The wrist is full and smooth in outline both on the dorsal and palmar aspects. There is a little difficulty in extending it, and the hand is not used so freely as its fellow. Sinuses are formed sooner or later, and if these be probed there can be no doubt as to the presence of caseous and carious bone. The tendons and their sheatl s are often involved in the 112 THE SURGICAL DISEASES OF CHILDREN tuberculous process. I have occasionally seen cases in which the carpal bones have undergone necrosis, apparently due to the disease having begun as a tuberculous synovitis ; but such a form is much less common in children than tuberculous caries commencing in the bones themselves. Treatment. — The treatment in the early cases consists of rest both of the wrist and hand. Atypical excision must be performed in the later stages, and as much of the fungating tissue as possible should be removed by enlarg- ing the sinuses. A free application of zinc chloride should then be made. The results are not, as a rule, very satis- factory ; but Mr. Eve recently showed a case in which the patient could play the piano after undergoing an excision of the wrist. Sacroiliac Disease. Sacro-iliac disease n may be mistaken for tuberculous disease of the hip in its earlier stages, but it so rare in children that it need hardly be taken into account. The affection may be confined to the sacro-iliac joint, or it may be part of a general tuberculous infection. It runs a very slow course. Symptoms. — The patient limps, and the pain is often much more severe than in disease of the hip. The buttock atrophies early, and there is evidence of swelling over the joint. The pain is relieved when the patient is in bed, but it is increased by movement, by pressing the iliac bones inwards, and by deep pressure over the joint. Abscesses are formed which pass through the anterior ligament and open beneath the glutseus maximus into the psoas, or iliacus, or more rarely into the rectum. They sometimes track along the multifidus spinas, and point either in the lumbar region or directly over the joint. Diagnosis — The movements of the hip are free, and a TUBERCULOUS DISEASES OF JOINTS AND BURS/E I I 3 careful examination may reveal a little thickening or swelling over the affected joint. The surgeon should assure himself that the symptoms are not due to tuber- culous disease of the lumbar spine. Prognosis. — The prognosis is less favourable than in hip disease or lumbar caries. It is better when the posterior part of the articulation is affected than when the carious process involves the front of the joint, for it then extends to the sacrum, and leads to the formation of abscesses within the pelvis. Treatment. — The treatment consists in keeping the patient absolutely at rest in bed, with a weight and exten- sion apparatus (p. 117) upon the leg of the affected side, until the more acute symptoms have passed off. The pain can sometimes be relieved by the application of a Paquelin's cautery over the affected joint, but counter-irritation must not be applied when abscesses have formed. As soon as the acute symptoms have subsided, the patient should be allowed to go into the fresh air, after a double Thomas' splint has been applied ; but every night the splint should be taken off and the extension reapplied. The splint reaches from the axilla to just above the knee, and is pro- vided with a broad band passing round the body at the level of the sacro-iliac joint. It should have shoulder straps. A leather splint moulded to the pelvis may be employed in place of the Thomas' ; but in either case a boot and patten should be put upon the sound leg, and crutches should be used. Operative measures must be adopted as soon as there is evidence of suppuration. Hip. Frequency. — Tuberculous disease of the hip is said to form 37 per cent, of all the cases of joint disease in 1 I 14 THE SURGICAL DISEASES OF CHILDREN children. Riedel has recently shown that 84 per cent, of the cases begin in the bone, and that only 16 per cent, are synovial in origin. Course. — Sequestra are much more common in cases of hip disease than in any other joint. The infection is usually mixed so that cold abscesses are formed early, the capsule of the joint is destroyed, and displacement of the head of the femur is frequent, though true dislocation is rare (see p. 120). Remarkable trophic disturbances are seen in connection with the large muscles of the gluteal region. The exact cause of their wasting is a matter of dispute, though there is reason to suppose that it may be reflex in origin and that it is not due simply to disease or to flexion of the thigh. Symptoms. — The symptoms, as in other cases of tuber- culous arthritis, are ill-defined in the early stages. The first noticeable symptom is limping, either with or without pain. The limping is due to the abduction of the thigh, external rotation, and to the flexion in which it is main- tained by the tonic contraction of the surrounding muscles ; for if the child be ansesthetised during this stage the movements at the hip are found to be quite free. Pain felt either in the knee, or referred to the hip, with or with- out exacerbations at night, is a frequent symptom at this stage. The pain is usually, and I think correctly, assumed to be due to stimulation of one of the articular twigs of the obturator nerve, running along the ligamentum teres ; but some surgeons hold that it is an impression conducted along the centre of the bone from the inflamed medulla. The flexed and abducted position of the limb leads to certain compensatory changes to enable the patient to maintain his equilibrium. Lordosis and some amount of lateral curvature are the most marked, and as a result of these changes the limb on the affected side seems to be TUBERCULOUS DISEASES OF JOINTS AND BURS^ I I 5 longer than it is upon the sound side, so long as it is kept in a state of abduction, though if it be adducted it seems to be shorter. It is important, therefore, actually to mea- sure an affected limb, to ascertain that lengthening or shortening does not really exist, or else to observe that the two anterior superior spines of the ilium are not upon the same level. Swelling in the neighbourhood of the joint is an early symptom of the disease. It is often most obvious behind the greater trochanter, or it may be noticed that the pulsation in the femoral artery is more superficial and easier to feel in the groin on the affected side. A rectal examination, in some obscure cases where the disease has begun in the acetabulum, may reveal the presence of a painful swelling in the affected ilium. Differential Diagnosis. — The recognition of hip disease is not always easy, for it has to be distinguished from hysteria, from spinal caries, from simple neuralgia of the joint, as well as from sacro-iliac disease. Hysterical disease of the hip usually comes on suddenly after a slight injury. It lasts for very long periods of time without producing any of the objective symptoms characterising active disease. The pain is more violent than in tuberculous disease, and it may be elicited by light cutaneous stimuli, which would be quite ineffectual in true disease. The hysterical symptoms may cease as abruptly as they commenced. Osteomyelitis of the femur or aceta- bulum runs a more rapid course than tuberculous disease ; but all infective forms of inflammation, as well as that which is due to syphilis, have to be taken into account in making a diagnosis. Treatment. — Rest and extension will often cure a patient in the earlier stages of the disease, even when some amount of suppuration lias takeu place. Dr. Sayre says that patients who have been perfectly cured of hip Il6 THE SURGICAL DISEASES OF CHILDREN disease should be able to flex the thigh to an acute angle, and cross the foot over the opposite thigh. The crossing of the foot he considers a crucial test, for it is a very diffi- cult movement for a patient to execute if there is the least rigidity about the hip-joint. He says that if an imperfectly cured patient be watched as he puts on his boots and laces them, he will nearly always stand and put his foot out to one side ; whilst a person who has perfect freedom of move- ment at his hip, sits and crosses his foot over the opposite thigh. Treatment by Extension.— The method of applying extension is shown in fig. 15. It is as follows :— The leg is carefully washed and thoroughly dried. A piece of stout strapping, 2 inches in width and 28, 32, or 36 inches in length, is obtained and doubled ; into its centre is secured a square piece of wood called the stirrup. The strapping is warmed, and applied to either side of the leg, care being taken that it extends an inch or two above the knee (fig. 15b). The two longitudinal pieces of strapping are kept in place by winding a second piece of strapping over them and spirally up the leg. A light roller bandage, not shown in the figure, is placed over the strapping to keep it secure. A cord is then passed through the centre of the stirrup and is allowed to run over a pulley fixed to the bed, a weight of varying amount being attached to the end of the cord. This weight should be sufficient to overcome the starting pains at night in an ordinary case, and the limb must be extended at first in its faulty axis. It is usually two pounds for a child of two years old, and in- creases half a pound for each additional year. The foot of the bed may be raised upon two wooden blocks three or four inches in height. The cot is provided with a firm mattress, and the child is prevented from raising itself into a sitting position by a band of webbing, provided with TUBERCULOUS DISEASES OF JOINTS AND BURS.*: I I J loops to pass round its shoulders (fig. 15 d), the ends being secured under the bed (fig. 15 E). It is often necessary to Il8 THE SURGICAL DISEASES OF CHILDREN keep the pelvis level in a restless child by applying a long Liston's splint upon the sound side. The extension must be capable of alterations in height and in angle to enable the lordosis to be entirely overcome, and it should be a routine part of the surgeon's business to pass his hand under the lumbar spine of the patient, as often as he sees him, to assure himself that it is flat (fig. 15 c) upon the bed. The lordosis, which is at first extensive, can nearly always be overcome by continued extension, the hip being at first flexed to the full extent necessary to overcome the lumbar arch by the use of a graduated series of wedge - shaped pillows under the leg (fig. 15 a). The pulley should then be lowered daily, and gradually, until the two legs are absolutely parallel. The amount of lordosis is of great importance in the treatment of hip disease by extension, for it is a measure of the flexion of the hip ; but it is too often overlooked in a patient who has been confined to his bed for a long time, and the surgeon should therefore constantly assure himself that it does not exist, by passing his hand from time to time under the loins, and ascertaining that the body lies flat upon the bed. The leg must be raised if the loin is arched ; but when anchylosis is unavoidable, a slight amount of flexion at the hip may render the limb more serviceable than one which is absolutely straight. It is very important, too, in cases treated by prolonged rest with extension, that the limb should not be allowed to become adducted. The treatment by weight extension must be maintained for many weeks or months, until all symptoms of muscular rigidity have passed away, and until the joint has resumed its original freedom of movement. This takes place in a certain proportion of cases, and the result of the treatment is then perfect. TUBERCULOUS DISEASES OF JOINTS AND BURS/E I 1 9 Symptoms and Treatment of Abscesses. — Ab- scesses form in a large number of cases, even though the joint has been maintained at absolute rest, and this must of necessity take place in all cases where there is a mixed infection. The abscess is usually deeply situated near the joint, and it often requires great skill to detect its pre- sence at an early period, for the sense of deep fluctuation is often very obscure. An increase in " night screaming " when the pain is not relieved by increasing the weight of the extending force, is often one of the earliest symptoms of the formation of such an abscess. The pain in these cases is sometimes relieved by the administration of five-grain doses of sodium, or potassium bromide, with the local appli- cation of hot fomentations of boric acid or of belladonna. All abscesses must be opened and rendered aseptic as soon as they are recognised ; sequestra should be re- moved, and if they cannot be made to heal by first inten- tion they must be drained. The abscesses usually point either in Scarpa's triangle ; on the inner side of the thigh ; below the anterior superior spine, between the tensor fasciae femoris and the sartorius ; just above the insertion of the psoas muscle, or beneath the glutei behind. In some cases they pass into the pelvis and may open above Poupart's ligament, or they may even open into the rectum or bladder. They should never be allowed to attain any large size, or to open spontaneously, as they infect the various tissues with which they come into contact. Their contents vary greatly, from ordinary pus to a mass of mortar-like material, consisting of caseating products of the tuberculous inflammation. Sequelae. — Displacement of the femur upwards occurs in neglected cases, and sometimes in spite of every care. The leg then becomes shortened, inverted, and the tro- chanter on the affected side is placed above Nelaton's line. 120 THE SURGICAL DISEASES OF CHILDREN The shortening is partly dne to a change in position of the head, and partly due to trophic changes in the bone itself. A true dislocation sometimes takes place suddenly and quite early in the disease, but the displacement is more usually gradual, and is the result of the absorption of the head of the femur, and the enlargement of the acetabulum upwards and backwards. Mr. Holmes has shown that true dislocation, in which the head of the femur leaves the acetabulum, is a rare result of hip disease, and that the ordinary appearances are due to the head of the bone being drawn upwards by muscular action so as to bring the trochanter into a relatively higher position. The integrity or destruction of the capsule will determine the exact position of the bone. The displacement is disastrous, on account of the shortening which it produces, and it must be prevented as far as possible by careful extension, so that when anchylosis takes place the upper end of the femur may still bear a direct relation to the lower part of the altered acetabulum. The tendency to inversion and adduction of the thigh must also be overcome. Anchylosis in a good position is the best that can be hoped for in these cases ; but perfect movement in the hip may be obtained after the formation of abscesses, and even when sinuses have remained open for some time. Duration. — The affection usually takes months or years to run its course, but in a minority of cases the disease is acute, dislocation takes place early, there is very great pain, and death takes place from some other tuberculous lesion ; in fact, the disease of the hip is only part of a general tuberculosis. Treatment. (1) Palliative. — The treatment in the chronic forms is to keep the patient in a horizontal position until the muscular rigidity has become markedly lessened, or TUBERCULOUS DISEASES OF JOINTS AND BURS/E 12 1 until abscesses are no longer formed, and there is evidence that firm anchylosis has taken place. He is then ordered to wear a Thomas' hip-splint, a patten is put upon the boot of the sound leg, and he is taught to walk upon crutches until all symptoms of disease have passed away. He should be examined, however, from time to time to see that the disease is quiescent. As soon as the disease is cured, the patient is provided with a boot whose sole is thick enough to make up for the shortening of the affected leg ; or, when it is important to conceal the deformity as much as possible, an O'Connor extension apparatus may be employed on great occasions, for its permanent use is inadvisable. It is surprising to notice how little discom- fort is experienced by a young patient, even when one hip is completely anchylosed. (2) Operative Treatment : Primary. — Excision of the hip is performed when the disease progresses in spite of adequate treatment by rest, when sequestra are present within the capsule, and when there is reason to suppose that the head of the bone is dead, though this is more often the result of acute osteomyelitis than of tuberculous disease. The operation is generally done somewhat earlier than in similar disease of other joints ; and, ideally, it should be performed whilst the disease is confined to the joint, and has not yet invaded the surrounding parts. It has the great disadvantage that the upper epiphysis of the femur lies within the capsule of the joint, and must therefore be removed, so that shortening of necessity follows the operation. The patient is prepared in the usual manner for excision of a joint, and any large abscesses having been thoroughly scraped and cleansed, an incision is carried downwards and a little inwards, commencing just below the anterior superior spine of the ilium, and terminating three inches 122 THE SURGICAL DISEASES OF CHILDREN lower down, so that it passes between the tensor fasciae femoris on the outer side, and the outer border of the sartorius upon the inner side. This incision is carried straight down to the bone, and in many cases it will be found possible to utilise the sinus communicating with the abscess, which usually lies beneath the sartorius and the tensor fasciae femoris, to enable the surgeon to reach the joint. The soft parts are retracted, and a finger is intro- duced to feel the capsule and to ascertain the condition of the joint. Sequestra are removed with forceps, or if the head is so carious and ulcerated that it be deemed unwise to leave it, the great trochanter is sawn through obliquely downwards and forwards with a narrow-bladed saw, and it is removed. Mr. Pollard prefers to saw through the neck of the bone only, and he takes care not to divide more of the Y-ligament than is absolutely necessary ; for it is one of the chief agents in limiting the subsequent displacement of the femur upwards. It is sometimes even necessary to saw through the femur below the trochanter ; but this is only done in cases of very extensive disease of the neck of the femur. After the head of the bone has been removed, the acetabulum is carefully examined with the finger to ascer- tain what carious patches it may contain ; and these, with as much of the fungating tissue as can be reached, are removed with a flushing scoop. The cavity is then swabbed out with a solution of zinc chloride, thoroughly irrigated with sterilised water at the temperature of the body, dried, and as soon as the bleeding has been com- pletely arrested, the wound is sewn up without any drainage-tube. Antiseptic dressings are applied, and the requisite rigidity of the joint is obtained by means of a plaster-of-Paris case, shaped like a pair of women's drawers, or by a double Thomas' splint, so modified as to maintain the limb in slight abduction. TUBERCULOUS DISEASES OF JOINTS AND BURS/E I 23 Mr. Barker, who has done much to perfect the technique of the operation in England, points out that the best re- sults are obtained when union occurs by first intention, and this can only be ensured when the operation is performed before the sinuses have formed. If, however, sinuses are present at the time of the operation, they must be thoroughly scraped and rendered as aseptic as possible. They may sometimes be utilised as the lines of incision when they are of considerable size. The hip does not lend itself readily to arthrectomy; but atypical operations, or operations which are not carried out upon the formal lines described in text-books, are often necessary. These operations are performed to re- lieve symptoms as they arise, by removing such sequestra and pieces of diseased bone or tissue as may from time to time be discovered. Secondary operations are required nearly as often after excision of the hip as after excision of the knee. Indeed, it very rarely happens in either joint that a single operation is sufficient to secure the absolute removal of all the diseased tissue. Secondary Operations. — Operative measures are re- quired when anchylosis of the hip has taken place in a faulty position. Flexion and adduction of the joint lead to the most serious interference with its functions. Teno- tomy and myotomy must be performed if the contraction be of muscular origin. The sartorius, tensor fasciae feino- ris, glutseus medius, rectus and ilio-psoas muscles most often require division. The adductors, too, may be divided, taking care not to injure the femoral vessels. Forcible straightening under an anaesthetic, after all the active symptoms of the disease have passed away, is suf- ficient to overcome a fibrous anchylosis ; but the method must be used with care, as great and permanent injury may be done to the joint. 124 THE SURGICAL DISEASES OF CHILDREN A sub-trochanteric osteotomy must be performed when there is bony anchylosis. An incision is made just below the great trochanter, and upon its outer aspect. An Adams' saw is passed along the knife, which is then with- drawn, and the bone is sawn from without inwards until its division can be completed by fracturing the compact tissue on its inner aspect. The section must be made at right angles to the long axis of the femur, and without any reference to the pelvis. It is generally necessary to divide some of the tendons surrounding the hip before the joint can be completely straightened. The wounds are dressed antiseptically, and heal by first intention. The limb is put up in its corrected position, and a long Liston's splint or plaster-of-Paris drawers are applied for a month, care being taken during the whole time that the leg and thigh are maintained in slight abduction. Amputation at the hip-joint still has to be performed occasionally to save the life of a patient suffering from morbus coxae. It is required when excision has failed ; when profuse suppuration threatens life ; when lardaceous disease manifests itself in the form of diarrhoea and albuminuria ; when there is evidence of progressive tuber- culous disease in other organs ; in some very acute cases, attended with extreme pain, and when there is evidence that the disease has extended from the acetabulum into the pelvis. The thigh is readily and almost bloodlessly removed by Furneaux-Jordan's method. A simple circular incision is made down to the bone at the apex of Scarpa's triangle (digital compression of the femoral artery being made by an assistant), the femur is sawn through, and the main arteries are picked up and tied as quickly as possible. A straight incision down to the bone is then made along the outer side of the thigh, commencing at the top of the TUBERCULOUS DISEASES OF JOINTS AND BURS^l I 25 great trochanter, and terminating at the cut end of the stump. The soft tissues, including the periosteum, are then stripped off the femur, and the head of the bone is disar- ticulated. This part of the operation is perfectly easy in a child, for the softened tissues are easily stripped off, and the head of the bone has often disappeared, either wholly or in part. The periosteum, acetabulum, and the sinuses are examined, if the condition of the patient permits, and all the granulation tissue is removed with a sharp spoon. The muscles retract so much into the acetabulum that it is unnecessary to form any skin-flap, for the edges of the wound come together nicely. A drainage-tube is inserted, sutures are introduced, and a good sound stump usually results. When it is important to lose as little blood as possible, the outer incision should be made first, the head of the femur disarticulated, the soft parts freed from the bone ; the circular incision dividing the femoral artery then completes the operation. Double Disease of the Hip. Tuberculous disease of both hips is not of very frequent occurrence. Dr. Ridlon, who has had opportunities of observing such cases, says that it rarely begins simul- taneously in both joints. The second hip may become affected whilst the patient is confined to bed, so that it is clearly not due to injury. The joint first affected is often the last to recover, so that the disease runs a more rapid course in the joint secondarily affected. Treatment.— The treatment does not differ from that of the ordinary form of morbus coxae. The patient is put to bed with a weight and extension until the acute symptoms have passed away. He is then allowed to go about in a well-fitting double Thomas' splint. The result is not un- favourable ; complete recovery may take place, but double 126 THE SURGICAL DISEASES OF CHILDREN anchylosis, with more or less adduction, is the commoner result. Knee. Frequency.— Tuberculous disease of the knee ranks next in frequency to morbus coxse, for it occurs in 307 per cent, of all the joint diseases in children. Pathology. — The disease commences more frequently as a synovitis than in other cases, though foci of inflamma- tion in the bone are by no means uncommon, either in the ends of the bone, within the capsule of the joint, or in those parts which are extra-articular. The tuberculous synovitis assumes two forms in the knee — one, a simple and chronic form leading to hydrops articuli, which is rare, and the other a fungating variety, which is common. The infiltration usually begins at the point where the synovial membrane blends with the periosteum, or with the articular cartilage. The synovial membrane and its fringes become thickened, and the inflammatory products either caseate or suppurate. Large abscesses are thus formed in the joint, or its cavity may be so much obliter- ated by the tuberculous thickening as to allow of the formation of local abscesses. When the bones are pri- marily involved, and in very chronic cases, radical changes take place in the condyles of the femur and in the head of the tibia. Flexion results with backward displacement and external rotation of the tibia, giving rise to the characteristic " triple displacement." Symptoms. — The disease commences in children between three and six years of age, though I have under my care at the present time a well-marked case of white swelling of the knee in a child aged eleven months. It is usually attributed to an injury. The child limps, because his knee is bent ; but he does not, as a rule, complain of pain in TUBERCULOUS DISEASES OF JOINTS AND BURS.£ 12J the earlier stages. Examination shows that the joint is warmer than its fellow, and than the limb above and below it. The outlines of the joint, especially npon either side of the ligamentum patellse, are fuller than they should be, so that there is a diminution in the natural dimples. The limb above and below the joint is wasted. There is some fluctuation in the joint, but not much. In cases of hydrops articuli, however, fluid collects in the joint in considerable quantities, but its functions are hardly inter- fered with for years. In the ordinary pulpy degeneration of the synovial membrane, the outline of the knee soon becomes oval, and all evidence of the thickened synovial membrane is lost to sight, owing to the (edematous con- dition of the peri-articular connective tissues, though the increased resistance which it offers can still be felt. Anchylosis, with the limb in a state of triple displace- ment — flexion, external rotation and backward displace- ment of the tibia — takes place in simple infection, as well as when the joint has suppurated. Diagnosis. — Tuberculous disease of the knee may be mistaken for rheumatic or syphilitic arthritis, or for osteo- myelitis ; and, conversely, an ossifying sarcoma of the lower end of the femur may be mistaken for a case of tuberculous disease, though the infiltration of the glands in the groin will soon render the true nature of the case conspicuous. Gonorrhoeal arthritis also occurs in children, but it is very rare, and there is evidence of a purulent discharge either from the eyes or the genitals. Treatment. (1) Palliative. — The treatment of tuber- culous inflammation of the knee consists in keeping the joint extended and at rest, indications which are best met by the application of a plaster-of-Paris case, by a Thomas' knee-splint, or by a properly moulded leather splint. Thomas' splint (fig. 16), with extension, is ap- 128 THE SURGICAL DISEASES OF CHILDREN plied in the following manner : — A splint is selected which reaches from the groin to four inches below the instep. The oblique ring at the top of the splint is slipped up the thigh until it lies comfortably in the groin, the child being recumbent. An extension apparatus, similar to that used in the treatment of hip disease, is then applied to the leg. Four strips of strapping, two inches wide, and long enough to go twice round the thickest part of the limb, are then Fig. 16.— Back view of a boy wearing a Thomas' knee-splint applied in the manner described in the text. cut — two for the thigh, and two for the leg. One end of the first piece of strapping is secured round the upper part of the thigh, and is passed from without inwards round the outside of the splint. The second strip is secured round the lower part of the thigh in an opposite direction, for it is passed round the borders of the splint from within out- wards, so that the thigh is slung and fixed immovably TUBERCULOUS DISEASES OF JOINTS AND BURS.E I 29 between the two parallel borders of the splint. The thigh being fixed, the knee is straightened, and the ex- tension is maintained by tying tapes from the stirrup to either side of the splint below the cross-bar. The leg is then fixed in a manner similar to the thigh, by passing two strips of strapping in opposite directions. A roller bandage — not shown in the figure — is finally applied from the foot, which should be kept at right angles, as high as the middle of the thigh. The patient is then provided with a patten for the sound foot, and is allowed to go about upon crutches. Anchylosis with the knee straight may sometimes be obtained by these means. (2) Operative Treatment. — In cases of hydrops articuli, the synovial fluid may be let out and the operation of sclerogeny (p. 102) may be performed ; or a drachm or two of camphorated napb.tb.ol may be introduced through the aspirating syringe, the joint being afterwards kept at rest. Radical measures must be adopted, and either arth- rectomy or excision must be performed when suppuration has taken place, and simple incision and drainage have failed to cure ; for it is important in these cases to secure bony anchylosis of the joint as rapidly as possible. Arthrectomy or Erasion of joints is a term which has been adopted to denote the operation of removing all the diseased structures from a tuberculous joint. It is em- ployed for those cases in which the stress of the disease has fallen upon the synovial membranes, and in the extra- articular forms of disease, the bones and epiphyses being only slightly affected. Its success depends, to a very large extent, upon minute attention to details. It should be the aim of the surgeon to remove every particle of diseased t issue — though, scientifically, this is not an absolute neces- sity, for we know that here, as in other tuberculous lesions, if the bulk of the disease be removed, the innam- K 130 THE SURGICAL DISEASES OF CHILDREN matory processes thereby set up are able to destroy the slight manifestations of tubercle. The operation was introduced into this country by Mr. Wright, of Manchester, in 1881, and its adoption has been ably advocated by Mr. Edmund Owen and by Mr. Clutton. The operation is specially adapted for the knee, and in a less degree for the ankle. It has the great advantage over excision, that in its most successful form it leaves a joint the movements of which are but little if at all impaired, whilst the limb is in no degree shortened. Its great dis- advantages lie in the frequent relapses, necessitating re- peated operations, and in the very prolonged convalescence. When the operation fails completely, the extensive sup- puration militates against the more radical measures of excision or amputation which have then to be adopted. The operation should be performed quite at an early stage of the disease, when it is obvious that rest will not be of any avail. The incisions are planned to expose the cavity of the joint to its fullest extent, yet to avoid its main ligaments and tendons as far as possible. The knee- joint may be opened either by an incision across the patella, or by division of the ligamentum patellae, the knee-cap being turned upwards. If any fistulous tracts exist, the incision may be carried through them. The synovial mem- brane and peri-articular tissues are first examined, all the pulpy granulation tissue is carefully removed from before backwards with a pair of forceps and scissors, particular care being taken to clear out all the pockets, and to follow the diseased tissue where it has insinuated itself between the ligaments and tendons. The semilunar cartilages and the crucial ligaments are next picked clean, or even re- moved entirely if they are greatly diseased ; otherwise, they should be left, though the synovial prolongations in their neighbourhood are carefully severed with blunt- TUBERCULOUS DISEASES OF JOINTS AND BURS.E I 3 I pointed scissors. The condyles of the femur are made to pro- ject, and the posterior part of the capsule is explored and cleaned as thoroughly as possible, a 1 in 10 solution of zinc chloride being applied to those parts which cannot other- wise be reached. The condition of the bones and articular cartilages next engages the attention of the operator. They are scraped and gouged until all ulcerated patches have been removed, and for this purpose a variety of gouges curved in different ways will be required. The articular surface of the patella is not to be overlooked. The bleeding points having been dealt with as they occur — since the bloodless method is not adopted in this operation — the whole of the joint cavity is again swabbed out with the solution of zinc chloride. It is afterwards well flushed with sterilised water ; for if the caustic be not thoroughly washed away, the after-pain will be greatly exaggerated. Provision is made for the most efficient drainage, if it is considered necessary ; though here, as in other cases, it is better to avoid the use of a drainage-tube if it be possible. The patella or the ligamentum patella?., and the lateral ligaments, if they have been divided, are carefully sutured with horsehair, and the wound is closed. An antiseptic gauze dressing, with plenty of absorbent wool over it, is applied to the knee. The limb is bandaged from the feet upwards, and is then fixed upon a straight back splint. The drainage-tube is removed as soon as practicable. In many instances the suppuration is very prolonged, in others granulations sprout, cloacae are formed, and a succession of secondary operations have to be done ; but in some of the cases I have seen, the patient has ultimately had per- fect use in the limb. All our efforts to prevent the spread of the disease sometimes prove futile, and excision, or even amputation, has to be performed in order to save the life of the patient. I32 THE SURGICAL DISEASES OF CHILDREN Excision of a joint consists in removing the whole of the articular surfaces for injury or disease, and allowing either bony or fibrous anchylosis to take place between the ends of the bones. In children's practice, excision is only done for tuberculous disease. The operation is per- formed by most surgeons at a later period in the disease than ar three tomy, but by its most thoroughgoing advo- cates it is carried out at a comparatively early period. Mr. Howse, 7 for instance, says that when a well-marked case of pulpy disease has lasted over six months, it is not worth while, in the interests of the patient, to attempt the conservation of the joint for a longer period ; but in saying this, he does not wish it to be understood that he would advise the excision of every joint which has been affected with tuberculous disease for six months. The advantages claimed for the operation are, that it affords a speedy and permanent cure of the disease, that a thoroughly service- able limb is left, and that the risk of tuberculous infection is proportionately lessened. Indications for Excision of the Knee.— Mr. Howse sums up the cases in which excision of the knee should be performed, under the following heads : — 1. In all cases in which the disease has advanced so far as to cause flaking of the articular cartilage, and grating in the movement of the joint, whether suppuration be evidently present or not. 2. Cases in which softening of the ligaments has ex- tended so far as to give rise to backward displacement of the tibia. 3. All cases of over six months' duration, in which there is reason to believe that the disease has started in an epiphyseal osteitis, which has given rise secondarily to changes in the cartilage. 4. Cases of extensive suppuration in the knee-joint. TUBERCULOUS DISEASES OF JOINTS AND BURS.E [33 All cases of this description which have started from pulpy mischief should be excised. In suppuration which is pygemic in its origin, incision should be first practised, and excision, only after evidence has been obtained of damage to the cartilages, or of such damage to the ligaments as to have caused displacement. 5. Cases in which the pulpy infiltration of the synovial membrane has advanced to any considerable degree over the articular cartilage. 6. Cases in which pulpy infiltration has extended be- yond the capsular ligament to the crucial ligaments and semilunar cartilages. Mr. Howse probably has had a larger experience in excision of the knee than any surgeon living, so that we may assume that these indications are the correct ones for excision of this joint. Amputation, on the other hand, must be performed in cases of joint mischief where there is lardaceous disease, where the lungs or viscera are affected, where the emaciation is very great, and where several joints are affected. Excision is not a very suitable operation when the joint disease is accom- panied by extensive osteitis or periostitis, or where the tuberculous deposits are chiefly peri-articular. The knee should be straightened as far as possible before the operation, by the judicious application of an extension apparatus and a moderate weight (fig. 15) for a week or ten days. The extension process is sometimes assisted by wrapping the whole limb in a mackintosh and then passing steam under it from a bronchitis kettle, so that the joint is put into an extemporised vapour bath. Chloroform must be given, and the adhesions must be gently broken down in all cases where an extension cannot be completed by the or Unary methods. There are many methods of excising the knee-joint. 134 TH E SURGICAL DISEASES OF CHILDREN The one I generally use consists in making a semilunar skin-flap upwards, by cutting across the flexed joint from the back of one condyle to the back of the other, the knife being carried over the front of the leg, just above the tubercle of the tibia. The skin-flap is carried upwards until the quadriceps tendon is exposed. This is divided, and the patella is turned downwards. The joint is then laid open by dividing the extrinsic and, if necessary, the intrinsic ligaments ; a very sparing use of the knife is sufficient, as the diseased tissues are very soft. The saw is then applied to the femur, and the bone is divided transversely, so as to remove the condyles to the bottom of the intercondyloid notch, care being taken not to encroach upon the epiphysis. The bone is sawn from before backwards, and it is very important that it should be cut exactly at right angles to the long axis of the femur. This can be ensured in two ways : one by holding the bone over the end of the operating table and sawing vertically towards the floor, the other by laying it at full length upon the table and sawing until a good groove is formed in the bone, and in the proper direction, when the knee is flexed and the sawing is completed. The head of the tibia is then freed by carrying a knife round it immediately below its articular surface, and in such a manner as to divide all the soft structures. The saw is applied to the head of the tibia, and as little of the bone is removed from before back- wards as possible. The patella is removed with this slice, for the ligamentum patellae was divided by the circular in- cision. The tibial epiphysis must not be removed ; but if the bone is found to be diseased beyond the point where it is sawn, it is often necessary to scoop away the cancellous tissue beyond the epiphyseal line. This may be done safely ; for so long as the circumference of the bone is not trenched upon, no harm results. TUBERCULOUS DISEASES OF JOINTS AND BURS.E I 35 The operator next examines the soft parts, treating them exactly in the same manner as in an arthrectomy (p. 130), and it is attention to this detail which has restored excision to that place in surgery which a few years ago it seemed in danger of losing. The more the caseating material and the pulpy synovial membrane is removed, the greater is the likelihood of obtaining a firm and bony anchylosis without relapses, and a subsequent malposition of the limb. Yet, practically, it is impossible to remove every fragment of the pulpy synovial membrane ; but this does not interfere with speedy and perfect repair, if only the bulk be taken away, for as I have already pointed out, there are strong reasons for believing that the normal inflammatory pro- cesses are able to deal effectively with small portions of tuberculous tissue, though they are unable to destroy it when it occurs in bulk. The diseased tissue is removed with dissecting forceps and a pair of blunt scissors curved upon the flat, and especial attention is paid to the various pockets and folds made by the synovial membrane. The whole of the joint is then swabbed with a solution of chloride of zinc (40 grains to the ounce), and is flushed with boiled water at a temperature of 105° F. The bleeding is stopped by ligatures and firm pressure. The periosteum is then divided at corresponding points on the inner and outer sides of the femur and tibia, and a drill is passed obliquely through the bones. Sutures of stout silver wire or aseptic silk are passed through the holes. A drainage-tube is then laid along the back of the joint, so that it projects upon either side, and the sutures in the bone are drawn tight, so that the two raw surfaces are kept in accurate apposition. The skin is united by point sutures, the main ones of silver and the secondary ones of horsehair. There is a very great divergence of opinion as to the utility of peeing the l> mes together after excision of I36 THE SURGICAL DISEASES OF CHILDREN the knee : many surgeons still considering that it is a iiseful if not an integral part of the operation, whilst many, and perhaps the majority, discard pegs altogether. The limb is then dressed antiseptically and is securely fixed in an ex- tended position, either in a plaster-of-Paris splint, which should include the hip, or in some form of excision splint. The splint employed by Mr. Howse (fig. 17) consists of two shallow troughs of sheet iron, tinned, and made so as to fit the shape of the leg and thigh. The foot-piece works in a slot, and the two troughs are connected at the back by knee G ' 17 -~ Howse ' 8 8 P lint " with a 8nin g cradle, for use after excision of the two strong bars of iron, made convex transversely so as to avoid cutting into the skin of the popliteal space. The bars are so arranged that the interval between the troughs, which corresponds to the excised joint, can be lengthened or shortened according to the case ; and this interval, even in the youngest children, should never be less than four inches. The splint also has a small pulley at the bottom beyond the footpiece, by which the splint is slung to a cradle as soon as the limb is secured. Mr. Howse employs a peculiar system of fixation which he considers very effective. It will be found to be described in detail in the TUBERCULOUS DISEASES OF JOINTS AND BURS.E I 37 Gay's Hospital Reports, vol. xlix., 1892. The first dress- ing is usually required at the end of forty-eight hours, and the subsequent ones at increasing intervals. Abscesses or sinuses which are formed during the healing period must be scraped with a sharp spoon, and swabbed out with a solution of zinc chloride or other caustic in the ordinary manner. It is of the utmost importance that the limb should be maintained absolutely immovable for at least three months after the operation ; and throughout this time the greatest care must be taken to maintain the leg exactly straight with the thigh, and to overcome the tendency which the thigh evinces to become rotated outwards, whilst the leg is kept by the splint and bandages in its normal position. Bony union must be obtained, or the operation is worse than useless ; and when the splint is removed and the patient is allowed to get about, he must still wear a leather splint moulded to his leg and thigh for a prolonged period, to prevent the gradual flexion which may mar the best immediate result. Ankle. Frequency and Pathology. — Tuberculous disease of ankle occurs in 1575 per cent, of cases, so that it is less frequent in children than similar affections of the hip, knee, and elbow. It more often begins in the bones than in the synovial membrane, and it very generally commences in the cancellous tissue which is so abundant in the tarsal bones, the ankle only being secondarily affected. The disease is always progressive, and the chronic form of hydrops articuli, which is common in adults, is practically unknown in children. Symptoms. — The symptoms are those which are com- mon to tuberculous disease in the joints. Swelling, specially I38 THE SURGICAL DISEASES OF CHILDREN marked upon either side of the tendo Achillis ; limping, although the child can still walk considerable distances ; limited joint movement, which is only noticeable at first in extreme flexion and extreme extension ; heat over the joint ; pain not usually well marked, and wasting of the leg- Diagnosis. — A diagnosis has to be made as to whether the disease affects the ankle, the transverse tarsal joint, or whether it is confined to the tendon sheaths outside the joint ; and this can only be done by a careful examination under chloroform. Course. — Suppuration, with the formation of sinuses and slow ulceration of the articular cartilages, frequently takes place. The symptoms are so ill-defined that the parents often do not understand the serious nature of the disease, and the child is therefore not brought for advice until the disease has made very serious progress. Treatment. (1) Palliative. — Few joint diseases yield more readily to rest, if it be taken in time. A well- applied plaster-of-Paris case for the ankle, with a Thomas' knee-splint (fig. 16) to keep the affected foot off the ground, will cure the patient, if at the same time he be put under good hygienic conditions. In some cases it is more advisable to apply a plaster case to the ankle, and to make the patient use a knee-rest, so that his foot does not come in contact with the ground. (2) Operative Treatment. — When the sinuses have formed, or when there is clear evidence that the tarsal bones are infiltrated with caseating tubercle, the diseased spots should be exposed, scraped, swabbed with zinc chloride, flushed, and packed with camphorated naphthol on gauze. Arthrectomy is required for the somewhat rarer cases in which the disease is essentially synovial in origin, and TUBERCULOUS DISEASES OF JOINTS AND BURS/E I 39 Mr. Clutton has obtained most excellent results from this method, using multiple incisions and utilising for this purpose the sinuses. Amputation is required in a few rare cases where the joint is disorganised, when there are extensive sinuses, and when the general condition of the child forbids the hope of recovery from any less severe measure. Syme's amputation is the best operation to perform, even if the disease involves the lower end of the tibia. After remov- ing the foot and sawing off the malleoli, all the granula- tion tissue should be scraped away ; the diseased centre of the tibia should also be removed, taking care to leave a ring of bone intact. The whole of the inflamed surfaces should be swabbed with a 1 in 15 solution of chloride of zinc, and after they have been well flushed, the flap should be attached with primary point sutures of silver wire and secondary sutures of horsehair. A drainage-tube may be laid in the posterior part of the wound, but it should be removed on the second or third day. Union by the first intention usually takes place even in the worst cases, the sinuses close at the same time, and only rarely present any recurrence of tuberculous disease. Tuberculous Inflammation of Burs.e. The large bursse in the neighbourhood of joints in chil- dren sometimes become affected with tuberculous inflam- mation, leading either to a passive serous effusion or to suppuration. There is no doubt as to the tuberculous nature of the lesion, as the scar left after laying open the bursa sometimes becomes the seat of a tuberculous inflam- mation which may render its removal necessary. ^Etiology. — The exciting cause is usually a slight injury, and I have more often seen the bursa over the great tro- chanter affected than that in other parts, no doubt because I4-0 THE SURGICAL DISEASES OF CHILDREN it is especially liable to injury in children, as they so often fall. There is every proof that during the early stages the inflammation is strictly limited to the bursa. The child does not limp or complain of pain, there is no rise of temperature, no muscular fixation of the neighbouring joint, and if an anaesthetic be given, the bone moves freely in its socket. The child's attendant usually discovers the swelling accidentally, and comes for advice about it. Diagnosis. — These passive enlargements of bursa? are often of very serious import, and are of great diagnostic value, for they are frequently the first indications of tuber- culous mischief occurring in a patient who otherwise appears sound. They must be distinguished from simple abscesses in bursa?, and from secondary infection of the bursse due to tuberculous arthritis, which is the more frequent cause of such a condition. The slighter consti- tutional disturbance will distinguish the tuberculous from the traumatic abscesses, whilst the early appearance of the swelling, the joint being still healthy, will distin- guish the primary from the secondary form of the disease. Prognosis. — The prognosis must be guarded, for tuberculous trouble thus starting in a bursa will spread rapidly to the neighbouring joint, unless care be taken to prevent it. Pathology.— The joint may be affected by extension along the lymphatics, or by the direct spread of tuber- culous inflammation from the bursa, as by the bursting of the abscess into its cavity ; but this does not happen if ordinary care be taken. The second method is more insidious, but at the same time the more frequent. The child is on the verge of tubercle, for the bacilli have estab- lished themselves in a single bursa, and have there caused a passive effusion. The tubercle bacilli have been able to effect this lodgment owing to the slight injury which the TUBERCULOUS DISEASES OF JOINTS AND BURS.-E I4I bursa sustained, for this led to a diminished resistance on the part of its tissues. The congestion produced in the neighbourhood by the inflammation of the bursa is suffi- cient to enable the tubercle bacilli to effect a further lodgment, and thus an arthritis is started. The followers of Metchnikoff's teaching would explain the sequence of events in a somewhat different manner. Thus, the con- gestion leads to increased multiplication of tubercle bacilli. Increased multiplication of bacilli means increased invasion of the affected tissues by the various forms of leucocytes attracted in virtue of their chemotactic properties. The destruction of the phagocytic and other leucocytes which then takes place gives rise to the caseating masses known as tubercle. These masses are destructive to the functions of the joint in which they are formed, and if they become septic, are even inimical to life itself. The following cases illustrate the main features of this form of bursal enlarge- ment : — Case 1. — A delicate and very intelligent girl, aged 8 years, was brought to me because she had a swelling on the outer side of her left thigh. She appeared to be quite healthy in every other respect, and she had been running about as usual, until her mother accidentally noticed the swelling about a week previously. There was an obscure history of the child having fallen out of bed six or eight weeks before the appearance of the swelling. The Bwelling was in the situation of the bursa over the great trochanter on the right side ; it was clearly a cold abscess, and the skin was absolutely healthy. The child was put to bed, her thigh was rendered aseptic, and the abscess was opened on the day after I first saw her. There was no doubt, when she had been anaesthetised, that her hip-joint was healthy. Six or eight ounces of pus escaped, and a Inge quantity of tuberculous material was scraped away 142 THE SURGICAL DISEASES OF CHILDREN with a sharp spoon. I introduced my finger and assured myself that the abscess was confined to the bursa, and that it did not in any way communicate with the joint. The cavity was then thoroughly flushed with a warm solution of boric acid, was closed with horsehair sutures, without a drainage-tube, and was dressed with antiseptic gauze. The dressings were left untouched for a week ; it was then found that the wound had healed, and that the swelling had disappeared, but that there was a little fulness beneath the scar. The sutures were removed, some clear serous fluid escaped through one of the suture holes, and the wound was again dressed with wet gauze. Three days later fluid had again collected beneath the line of incision to such an extent that the scar became stretched ; gentle pressure opened one of the suture holes which had become closed by a small scab, and permitted of the escape of about an ounce of very clear and yellow serous discharge. This continued to drain away for ten days and gradually ceased. Three weeks after the operation the child was sent home cured. Case 2. — A delicate girl, aged 4 years, who had suf- fered from superficial keratitis, was admitted under my care into the Victoria Hospital on June 4th. Her left but- tock was noticed to be swollen eight days previously. She walked well, but could not sit with comfort. It was found on examination that the left buttock distinctly fluctuated, and that the swelling extended from the crest of the ilium to three or four inches below the great trochanter. An incision was made into it, and eight ounces of shreddy pus were let out. It was clear, when a finger was put into the cavity, that the abscess had been formed in the multilocular bursa situated between the glutseus maximus and the great trochanter. The abscess wall was thoroughly scraped away, the cavity was washed out with boric lotion, and TUBERCULOUS DISEASES OF JOINTS AND BURSAL I43 the wound was closed with horsehair sutures. It healed by first intention, the child went home cured, and she has remained well ever since. Case 3. — A girl, aged 6 years, was admitted into the Victoria Hospital under the care of Mr. Pick. She began to halt on the left leg five weeks before admission. She had a large fluid swelling behind the left hip. The joint was freely movable, and did not appear to Mr. Pick to be in any way affected, as there was neither shortening, flexion, nor abduction of the limb. An incision behind the great trochanter allowed of the removal of much caseous material. The cavity which then remained extended be- neath the gluteus maximus as far as the finger could reach. It had no connection either with the hip-joint or with the bone. The wound remained open for some time, but the child was kept at rest and with an extension apparatus. She was discharged six weeks later in a plaster-of-Paris case, and with a patten on the sound foot. Case 4. — A girl, aged 1 year, was admitted to the hospital under my care, with a fluid swelling about the size of a hen's egg situated over the great trochanter. The movements of the hip were absolutely unimpaired, but the child was ill and had digestive troubles. An incision was made into the swelling, and three ounces of yellowish red pus were let out. It was again clear, when the finger was introduced into the cavity, that the abscess had been formed in the bursa. Three weeks later the wound had almost healed, but the thigh was flexed at the hip and there was much lordosis. An extending weight of a poiind was attached to the leg. Three days later the child's general and local condition had greatly improved. She had regained her appetite, the leg was straight, and she had no lordosis. Six weeks later her usual posture in bel was on her back kicking both legs freely in the air. 144 THE SURGICAL DISEASES OF CHILDREN She was therefore sent home as cured. It is obvious that this child just escaped an attack of tubercular arthritis. Case 5. — A boy, aged 4\- years, was admitted into the hospital, under the care of Mr. Waterhouse, on account of an enlarged patellar bursa. The knee appeared to be un- affected. The bursa was dissected out, and was found to be the seat of tubercular disease. Primary union of the wound took place at every part except where a small drainage-tube had been inserted, and there a sinus formed. The knee became affected with pulpy degeneration, and six weeks later it was found to need excision. On opening the joint for this purpose the synovial membrane was seen to be invaded everywhere by tubercular granulation tissue. There was no disease either of the cartilages or of the bones. A continuous tract of tubercular tissue, however, could be traced from the old scar at the side of the pre- patellar bursa to a spot in the synovial membrane of the knee, just above the patella, where the tubercular material had iindergone caseation. This case differs, therefore, from the preceding ones in the fact that the joint became affected by direct extension from a tubercular focus. Case 6. — I was asked to see a boy of 17, employed as a gardener in a small village, who had developed a painless fluid swelling in the situation of the bursa over the great trochanter. He evinced an unconquerable aversion to leaving home, or to any form of treatment by rest. He continued his occupation from the time I saw him in March until the end of July. His hip then became affected with acute arthritis, and in two months he was dead of general tuberculosis. It is evident from these cases that passive enlarge- ment of the bursse in children is of considerable importance both in diagnosis and in prognosis : in diagnosis, because effective treatment should be adopted at once; in pro£ >g- TUBERCULOUS DISEASES OF JOINTS AND BURS.E 1 45 nosis, because it is clear that unless great care be taken the worst results are to be apprehended. Treatment. — The treatment to be adopted is that given in the successful cases, and it follows directly from the pathology. If the passive effusion into the bursa be seen before suppuration has occurred, the fluid should be let out by means of an incision rather than by aspiration. Why, we know not, but we do know that in such passive effusions due to tubercle, and notably in tubercular peritonitis with simple effusion, a cure more often follows after a free incision than after a puncture, even though the wound heal by first intention. If suppuration has occurred, the abscess must be opened, scraped, thoroughly cleansed, and every effort must be made to get it to heal at once. Union by first intention is of vital importance in these cases, for if it can be secured the patient will in all probability escape further trouble. Suitable precautions are to be taken at the same time to secure physiological rest for the joint, whilst the general hygiene of the patient must be improved ; for it should never be forgotten that when the bursse are enlarged in this manner, the patient has already passed the threshold of tubercular disease. If the wound fail to heal by first intention, there is danger lest the slight increase of inflam- mation so produced may hasten the tubercular process, and thus the operation will have done more harm than good. It is perhaps better for this reason not to insert a drain- age-tube, but to close the wound in its whole extent. CHAPTER VII TUMOURS AND SYPHILITIC DISEASE OF BONE TUMOURS OF BONE. Innocent tumours of bone occur more frequently in children than sarcomata. They are chondromata, exostoses, and much more rarely lipomata and cysts. Chondromata. Chondromata spring either from the interior of short bones, like the phalanges, or they grow subperiosteally in the neighbourhood of the epiphyses of long bones. They may also grow from the bones of the skull ; but whatever may be their origin, they are innocent, though in some cases they may attain so large a size as to render the limb useless and necessitate amputation. They are recognised by their hardness and by their immobility. They grow slowly and are usually painless. Treatment. — No operation is needed in the case of enchondromata of the fingers, unless they are unsightly, cumbersome, or rapidly growing. They can often be extirpated, but occasionally more radical measures are necessary. They frequently undergo calcification, and they may suffer mucoid and fatty degeneration ; in some cases cysts are formed in them. 146 TUMOURS AND SYPHILITIC DISEASE OF BONE 1 47 Exostoses. Exostoses originate either from chondromata which have become ossified, or they are formed directly by the periosteum ; the latter are the rarer. They are usually situated near that epiphysis which grows most quickly. They may be single, or they may occur in very large numbers in different parts of the skeleton. The single exostoses growing near an epiphysis either originate outside the joint from the epiphyseal line, or much more rarely from just within its capsule, in which case they are en- closed in the synovial membrane, when they appear to originate from the articular cartilage itself. It is of great importance to remember the latter variety, as any attempt to remove such a tumour will involve opening the joint. There is usually no difficulty in recognising exostoses, al- though their typical appearance is sometimes masked by an adventitious bursa which is occasionally formed over them, and by the fact that in some cases they consist of two parts, one superimposed upon the other, and separated by a kind of false joint. Ivory exostoses are less frequently seen in children than in adults, but when they are met with they occur in similar situations. Exostoses are usually painless, even in parts subject to constant irritation, for they are protected by a cap of cartilage. Treatment. — Palliative means are generally sufficient for their treatment, though it may occasionally be neces- sary to remove them, as when they spring from the terminal phalanx of a toe. When they spring from the epiphyseal line, they may become attached to the diaphysis instead of to the epiphysis, and so may be carried upwards until they are found at some distance from the extremity. They are then likely to be mistaken for sarcomata. I48 THE SURGICAL DISEASES OF CHILDREN Parosteal Lipomata. Parosteal lipomata sometimes grow from or are inti- mately connected with the periosteum of long bones, to which they are attached by a very broad base. I showed an instance of such a growth at the Pathological Society of London, in 1888. It was taken from a boy, aged 9 years, who was admitted into St. Bartholomew's Hospital, under the care of Mr. Smith. He had a soft, painless, and elastic swelling extending over the upper third of the left thigh, and along its outer aspect. The skin was normal and freely movable over the tumour, but the superficial veins were slightly distended. The tumour weighed 15 ozs. after removal, and was divided into several lobes. In spite of this case being well impressed on my mind, I mistook the last example that I saw for a chronic abscess of the thigh. These tumours are always congenital, and may be mistaken for an abscess or for a sarcoma, the only certain means of diagnosis being an exploratory puncture with an aseptic grooved needle. They had better be removed when their size hampers the movement of the limb. Fibrous Epulis. Fibrous epulis is a hard and dense tumour, covered with healthy, congested, or ulcerated mucous membrane. It usually springs from the gums between two teeth or from the periodontal membrane, and it projects more upon the lingual than upon the buccal side of the alveolus. The tumour grows slowly, and I have only seen it in connection with the permanent dentition. The Treatment consists in extracting a tooth, and it sometimes happens that the epulis comes away with it ; if it does not, it must be removed, and if necessary, a part of the jaw must be taken away as well. The growths do not recur. TUMOURS AND SYPHILITIC DISEASE OF BONE 1 49 Cystic Tumours of Bone. Cystic tumours of bone are either simple, parasitic, or malignant (p. 150). Dentigerous Cysts occur either in the upper or lower jaw, and usually in connection with the permanent denti- tion. They form single tumours, which expand the bone as they grow, and are filled with a clear serous fluid. They may be due to errors of development in the tooth sac, to faulty position of the teeth, to normal persistence of a deciduous tooth which should be shed to make room for its successor, or to the presence in the jaw of super- numerary teeth. Treatment. — The cyst should be laid open without making any skin incision, as soon as its nature is recog- nised, and the tooth removed. The bones soon recover their natural shape and size. Parasitic Cysts are due either to hydatids or to actino- mycosis, but both are so rare in England that they do not require more than to be mentioned here. SARCOMATA. The malignant tumours of bone are either endosteal, of which the myeloid form is limited to children and to young adults, or it is periosteal, taking the form of round or spindle-celled growths, of which the ossifying sarcoma presents somewhat peculiar features. The jaws and the long bones are particularly obnoxious to the growth of sarcomata, but an infiltrating form of sarcoma is not very uncommon in the bones forming the vault of the skull. Some of these cases run an acute course, and become very widely disseminated. Nothing can be done for them, and they fortunately soon involve the brain, leading to uncon- I50 THE SURGICAL DISEASES OF CHILDREN sciousness. The sarcomatous growth, in one case which I saw, was of a sage-green colour (p. 446). Myeloid Sarcomata. Myeloid sarcomata are nearly always central in origin. They spring from the long bones near their articular ends, and they occur more often in young adults than in children. They grow slowly, and cause such expansion of the bone that it may become a mere shell, which eventu- ally gives way and allows the growth to infiltrate the surrounding tissues and to spread and disseminate like a periosteal sarcoma. Such endosteal sarcomata are usually cystic ; they may pulsate, they rarely affect the articular cartilages, and they lead, in some cases, to spontaneous fracture. The tumours they produce are usually of an ovoid or spheroidal shape, except when they grow sub- periosteally, and they are then irregular and lobed. Prognosis. — The prognosis is not so bad as for other sarcomata in children, recurrence is somewhat less likely to occur, and when it does occur the secondary growths are not necessarily of the myeloid type, for they may con- sist of any other form of sarcomatous tissue. The lymphatic glands are more often implicated in children than in adults. Treatment. — The treatment consists in excising the affected portion of the bone, or in the enucleation of the growth when it is limited and the case has been seen early. Amputation, however, should be performed if there is any reason to suppose that the surrounding parts are affected ; for when this has been done, there is the least likelihood of a recurrence. Blood Tumours.— Mr. Roughton has recently dealt with the blood tumours of bone. They are of great rarity, and he considers that they are sometimes angeiomata and TUMOURS AND SYPHILITIC DISEASE OF BONE I 5 1 sometimes angeio-sarcomata. He quotes a case in which such a tumour was clinically innocent, though microscopic examination showed that it contained myeloid cells. The case was that of a girl, aged 4 years, who hurt her leg by a fall ten months before she came under Mr. Roughton's care. A tumour slowly developed in the interior of the tibia, and gradually expanded the bone until eggshell crackling could easily be detected. There was neither pain, tenderness, redness, nor oedema ; the knee-joint was natural, and there was no enlargement of the lymphatic glands either generally or locally. The thigh was slightly wasted, probably from disuse. The contents of the tumour proved to be a dark red fluid, looking like altered blood and serum. The cavity was stuffed with lint, and eventually healed well. Malignant Epulis. The sarcomatous epulis grows from the periosteum of the alveolar border of the jaw — the upper more often than the lower — and from the first is of a much more livid colour than the fibrous epulis. The lividity is partly due to pig- ment granules, which are present both in the cells and in the stroma of its tissue. A malignant epulis usually contains numerous giant cells. It does not, however, run a very malignant course, and there is no recurrence if it is removed by resecting a piece of the jaw. Neither form of epulis should be mistaken for the mass of "proud flesh," which is sometimes seen in children's gums as a result of carious teeth, or after extraction ; for these growths are much softer, bleed more freely, and are clearly not covered with mucous membrane. Periosteal Sarcomata. The periosteal sarcomata spring from the deeper layers of 152 THE SURGICAL DISEASES OF CHILDREN the periosteum of any of the long bones. They are either round or spindle-celled, mixed or fibrous. ^Etiology. — They may occur at any time in childhood, and are seen even in infants. They can be traced a little more frequently to direct injuries in children than in adults ; otherwise, they run a similar course and must be treated upon the same lines. The tumours grow more rapidly and disseminate more freely than in older persons. Ossifying Sarcoma. — Sarcoma affects the long bones and the cranial bones in children. Diagnosis. — It is very likely to be mistaken for a tuberculous arthritis of the knee when it grows from the lower end of the femur ; or it may be looked upon as an osteitis, a chronic abscess of bone, or as a mass of peri- articular gummata. It may be distinguished, however, from all these conditions by its steady increase in size, and by the early enlargement of the lymphatic glands when the cylindrical bones are affected. Symptoms. — The tumour grows rapidly, so that the disease runs an acute course. The annexed case, which I narrated some years ago at the Pathological Society, illustrates the ordinary course of the affection. A girl, aged 13, noticed a slight pain and stiffness in her left knee immediately after a long country walk. The stiffness continued, in spite of treatment for three months ; but it was not severe, and the patient was able to do her ordinary school work. Her knee was observed to be swollen three months after the stiffness was first complained of, and it was treated for ttiberculous syno- vitis. The swelling increased rapidly, and an enlarged and densely hard gland appeared in the groin. Her thigh was amputated in the middle third, and a month later the enlarged gland was removed from the groin. It was then found to be so firmly attached posteriorly to the sheath of TUMOURS AND SYPHILITIC DISEASE OF BONE 1 53 the femoral vessels that an inch of the femoral vein had to be removed with it. A mass of new growth was detected in the pelvis, shortly after the removal of the gland, and a month before the death of the patient there were symptoms of a secondary deposit in the lungs. Treatment. — This case and others like it show that the only effective treatment is amputation of the limb as soon as the diagnosis is established, and, if possible, before the glands are affected and before dissemination has taken place. SYPHILITIC DISEASE OF BONE. Syphilis attacks the bones of children in several ways. Long Boxes. (1) Osteomyelitis is one of the very earliest symptoms of inherited syphilis. The long bones of children under a week old are sometimes found to be affected with a plastic osteomyelitis, chiefly affecting the periosteum, pro- ducing bony deposits, and leading to thickening of the epiphyseal lines. The epiphyseal lines themselves are affected primarily in children under three months old. Symptoms. — The symptoms are ill-defined, for the child does not appear to be in pain until his limbs are handled, he is lethargic, and he does not move about like a healthy baby. Examination of his limbs shows that there is a marked thickening at the line of the epiphysis in several of the long bones, and a diagnosis of rickets is therefore often made. In course of time, if he be left untreated, the enlargement increases, and one or more of the epiphyses separate, so that the limbs become quite helpless. Sup- puration occasionally takes place, the abscess usually bursting externally, though the joint is sometimes involved. If the child dies before suppuration has occurred, the 154 THE SURGICAL DISEASES OF CHILDREN thickening of the epiphyseal lines is found to be due to the formation of a semi-transparent gelatinous material, containing small yellow nodules of gummatous substance, and it has a great tendency to suppurate or to caseate. The degeneration is sometimes red instead of yellow. This condition has been carefully studied by Parrot, who has given it the name of chondro-osteitis. Diagnosis.— It has to be distinguished from rickets, scurvy, chronic septic osteomyelitis, and osteosarcoma, as well as from the earlier stages of tuberculous disease of the epiphyses. Prognosis. — Its prognosis, even in the worst cases, is most satisfactory. I have seen one or two cases, how- ever, in which such inflammation of the epiphysis led to permanent shortening of the bone. Osteomyelitis also occurs in older children. The radius and ulna and the tibia are most often affected, but the vertebrae and the phalanges do not always escape. This form of syphilitic spine and syphilitic dactylitis is likely to be mistaken for its more common tuberculous congener. Syphilis, however, affects the periosteum more than tubercle, and in the spine the syphilitic deposit takes place at more than one spot, with intervening healthy tissue, whilst in tubercle the lesion is rarely multiple. (2) Osteitis. — A chronic sclerosing osteitis sometimes affects the long bones, and leads to their thickening and bending. Necrosis takes place in other cases, associated with great rarefaction of the surrounding bones. Lastly, there is a true gummatous ulceration of the long bones, ' associated with a similar condition of the joints. This occurs in young adults, and is more fully described at page 231. (3) Decalcification. — A remarkable decalcification of the bones sometimes takes place in syphilitic children between TUMOURS AND SYPHILITIC DISEASE OF BONE I 55 the ages of five and six months. The decalcification is occasionally general, and it is then likely to be mistaken for rickets, and to be treated ineffectually. It may be confined to one or two bones, and it then seems to be the result of a local gummatous deposit, which may lead to that variety of spontaneous fracture which is occasionally seen in the ribs. Skull. The bones of the skull are affected by syphilis in a manner similar to the long bones, though less fre- quently. Hutchinson and Parrot first drew attention to the fact that, at variable periods within the first two j-ears of life, osteophytic growths appear on the outer surface of the cranial bones, and in definite positions, viz. on the frontals and parietals, at the boundaries of the anterior fontanelles, extending backwards parallel with the sagittal suture. These elevations are lens-shaped, and of a violet or red colour, porous in character, and grooved by vascular channels. They extend gradually, and bridging over the sutures may lead to synostosis of the skull, and so to a condition of microcephalus. Similar conditions are also met with in rickets, so that in difficult cases too much stress must not be laid upon Parrot's modes in making a diagnosis of syphilis. Doughy swellings, which may ulcerate or suppurate, sometimes appear on the heads of syphilitic children. They present the ordinary characters of soft nodes, and may do serious injury to the bones, for they may cause craniotabes, or that condition of the skull in which the bones yield and feel like parchment when pressure is made upon them. The process of ulceration commences on the outer side of the bone, is well defined, and of limited extent. It may be distinguished from the craniotabes of 156 THE SURGICAL DISEASES OF CHILDREN marasmus and rickets by the fact that it is not limited to the part of the skull which is most liable to pressure, for it may involve the parietals and the anterior part of the occipital bones. M. Parrot also describes an atrophic lesion of the skull, due to a gelatiniform transformation of the bony material, similar to that seen in the epiphyseal lines. A sclerosing process is sometimes seen in the skulls of young adults who have been the subjects of inherited syphilis, for the calvaria is very thick and dense, and the sutures are wholly absent. The syphilitic disease of the skeleton is characterised by its slow course and by its painlessness. Diagnosis. — It has to be distinguished from acute osteomyelitis, from tuberculous disease, and from sarcoma. The disease is sudden in onset in osteomyelitis ; it is attended with more fever, and the swellings suppurate more readily. It is often difficult to distinguish the bony lesions of syphilis from those produced by tubercle. The condition of the child, its snuffles, its muddy complexion, the rash about its anus, the peeling of the palms of its hands and the soles of its feet, and the mucous patches about its mouth and anus, will serve to complete the differential diagnosis in young children ; whilst in older ones the stunted growth, the peg-topped and crescentically notched permanent incisors, the deafness, and the intersti- tial keratitis will serve the same purpose. Sarcoma is only likely to be mistaken for syphilitic disease of bone in its earliest stages, for it runs a rapid course in children, and very soon involves the soft parts. Prognosis. — The prognosis of syphilitic disease in chil- dren is most satisfactory, even in the worst cases. Treatment. — One-grain doses of grey powder three times a day for a child of six or eight weeks old, with the TUMOURS AND SYPHILITIC DISEASE OF BONE 1 57 inunction of a 5 per cent, solution of oleate of mercury, or of blue ointment, soon work a marvellous change. The child in a very short time loses its marasmic condition, its pseudo-paralysis disappears, for the separated epiphyses reunite, sinuses and fistulse close, and the patient is rapidly restored to health. CHAPTER VIII INJURIES OF BONES FRACTURES AND SEPARATED EPIPHYSES. etiology. — Fractures in children present several inter- esting deviations from similar injuries in adults. Apart from those produced by direct or indirect violence, there are intra-uterine, congenital, ricketty, and spontaneous varieties. The ordinary traumatic fractures are most frequent in children under twelve, in the radius, humerus, clavicle, femur, and leg. The jaws, nose, fingers, and skull are less often broken, whilst the sternum, scapula, and pelvis are only damaged after the most extensive injuries. In addition to the injuries of bones usually met with in adults, children present two special forms — the " greenstick " fracture, and separation of the epiphyses. Symptoms. — The symptoms of fracture are the same as in adults, but are not usually so well marked. It should be remembered in making a diagnosis that the pain of a fracture in a child is often inconsiderable, whilst the crepitus may be much less distinct than it is in an older person, partly because the periosteum remains unruptured in a certain proportion of cases, and partly because the separation may not involve ossified tissues, if it has taken place near an epiphysis. The deformity, too, is often much less, because the fracture is not so oblique, and the muscles are weaker. Inattention to these points, and the difficulty of recognising " greenstick " fractures, 158 INJURIES OF BONES I 59 may lead inexperienced surgeons to overlook a fracture which is only too obvious as soon as callus has been pro- duced. Such errors in diagnosis react in two ways — upon the surgeon by lessening the parents' confidence in him, and upon the child by increasing the risk of an ununited fracture from want of restraining apparatus. Course. — Fractures in children heal with great rapidity, and, as a rule, with great certainty, owing to the activity of the formative processes which take place in their bones, and there is often an exuberant formation of callus. The subsequent modelling process is carried out so perfectly, that after a few months it is often impossible to ascertain the exact seat of the injury, even when a section of the bone is made. Sequelae. — The sequelae of fractures are few. I have seen non-union in various bones, the persistence of de- formity and shortening, chiefly after injury near the epiphyses, and crossed union in the bones of the forearm, owing to carelessness in the application of splints. Gan- grene may be produced by the application of too tight a bandage, but it is fortunately of very rare occurrence. Treatment. — The general treatment consists in imme- diate and perfect reduction, and this is especially necessary in separated epiphyses, so that an anaesthetic is often required, and the subsequent application of appropriate restraining apparatus. Nothing is better for this pur- pose than a well-fitting plaster-of-Paris splint or case. Non-union I believe to be nearly always due to imperfect fixation of the broken ends of the bone. Its prognosis is very unsatisfactory in children, for in spite of wiring, grafting pieces of bone or periosteum, local irritation, and other means, a useless limb too often results, and ampu- tation may have to be performed. A few successful cases of wiring are on record, and in ununited fracture of the l6o THE SURGICAL DISEASES OF CHILDREN clavicle, at any rate, a useful arm may exist in spite of non-union of the fragments. Spontaneous Fractures. " Spontaneous fractures " are those resulting from violence which would be insufficient to break a long bone under ordinary conditions. They are secondary to other diseases of bones, to muscular action, or, much less commonly, to trophic changes connected with diseases of the central nervous system. Sometimes, as in scurvy, they are due to constitutional causes, and some children and families seem to have peculiarly brittle bones without any other evidence of ill-health (see p. 161). It is also associated with phosphaturia, and it is met with in diabetes ; sarco- mata or other endosteal tumours lead to it. Spontaneous fracture of the tibia is sometimes the result of an osteitis caused by injury. I have seen a spontaneous fracture of the tibia in a child who had central necrosis of the femur, in which, after amputation of the thigh, the tibia and fibula, though physio- logically healthy, were reduced to a mere shell, and even the compact tissue was riddled with holes until it looked like lace-work, the changes being due to interference with the blood supply, resulting from the chronic inflammatory changes in the thigh. Spontaneous fracture is said to occur in some cases of infantile paralysis of long stand- ing, as a result of advanced degenerative changes taking place in the bone, and it is even less frequently met with in cases of hydrocephalus. Such cases of spontaneous frac- ture must not be confused with the spontaneoiis separation of the epiphyses which takes place shortly after birth, as a result of syphilis, or with the spontaneous fractures some- times connected with changes in the bone during the early stages of rickets. In syphilis and rickets the prognosis INJURIES OF BONES l6l of spontaneous fracture is good, for under the influence of appropriate treatment repair takes place, whereas in the other cases it is bad, and amputation will be required. Osteopsathyrosis. Spontaneous fractures occurring in scurvy must be dis- tinguished from spontaneous multiple fractures occurring in individuals who have an hereditary tendency to frac- ture. 12 Etiology. — We know very little of this remarkable condition, except that the bones repeatedly become broken as the result of very slight violence. Symptoms. — The symptoms are those of an ordinary fracture, except that there is less pain, with less swelling and bruising of the soft tissues. Diagnosis. — Osteopsathyrosis or fragilitas ossium must be distinguished from the other causes producing spontan- eous fracture which have been enumerated above. The number of fractures, the good health of the child, and the history of heredity, transmitted solely in the male or in the female line, are siimcient to make certain the diagnosis of true osteopsathyrosis. Prognosis. — The prognosis is good, for the fractures repair well under the ordinary methods of treatment. In a case in the St. Bartholomew's Hospital Museum, however, which was under the care of Mr. Langton, who has kindly given me leave to publish the details, the patient died with sarcoma at the age of thirty. At eleven years old he fractured the upper part of his right humerus whilst he was throwing a cricket ball ; the bone united. In 1874 he slipped and fell, fracturing his left humerus ; the bone united. In November, 1878, he fell whilst playing foot- ball, and again fractured his right humerus just above the condyles ; the bone united. In June, 1880, he broke M 1 62 THE SURGICAL DISEASES OF CHILDREN his right femur by a twist, owing to his left leg slipping under him : the bone broke as he stood ; it united partially, but not firmly, and there was much eversion. In spite of the non-union, and although there were three inches of shortening, the patient said that he could walk sixteen miles in a day, at the rate of three and a half miles an hour. His right heel slipped whilst coming downstairs in February, 1884, and to save himself from falling he swung round, grasping the banisters with both hands ; the left femur broke above the condyles as he was standing, but he did not fall. The union was satisfactory. The bone, however, began to bend at the seat of fracture two years later, and movement began three and a half years after the injury. In September, 1888, he noticed movement at the seats of fracture of the right humerus, owing, as he said, to excessive use. In April, 1889, a sarcoma formed in the right arm, which grew until November, 1889, when it was deemed advisable to remove the arm at the shoulder. Recurrence took place in the scar in February, 1890, and the patient died in June, 1890, from secondary deposits in the internal organs. Intra-uterine Fractures. There appears to be no doubt that injuries to the abdomen of a pregnant woman may cause one or more fractures in the foetus. Fractures so caused usually unite, sometimes in good position, sometimes with a greater or less amount of deformity ; occasionally they remain un- united. Such intra-uterine fractures are of course to be distinguished from true congenital fractures produced at the time of birth. Traumatic Separation of the Epiphyses. These accidents 13 are necessxrily confined to young per- sons, though different epiphyses are liable to separation at INJURIES OF BONES 1 63 different times. Some epiphyses, like that of the femur, are more often separated early in life ; whilst others, like the olecranon, are only separated comparatively late. The separation may be accurately through the epiphyseal line, as is usual in infants, or it may involve a portion of the shaft of the bone, as is not unusual when the injury occurs between the ages of twelve and sixteen. Separation of the epiphyses occurs most frequently at the lower end of the femur, next at the upper and lower ends of the humerus, at the lower end of the radius, and at the lower end of the tibia. The particular dangers of epiphy- seal separation lie in the fact that the joint either is or may be affected, for the capsule in many joints includes the epiphyses, as may be seen by referring to the coloured plate (p. 96). Some epiphyses are more liable to become displaced after they have been separated than others, for some are pulled aside by the muscles attached to them, whilst others have no such muscular attachments. Per- manent deformity or serious secondary injuries may there- fore be produced by such injuries, even when the greatest pains have been taken during the process of repair. The periosteum is often torn away from the shaft of the bone for a considerable distance by the separation of an epiphysis, so that periostitis in its various forms may result. Suppuration is by no means uncommon, even after a simple separation of an epiphysis, due, no doubt, to the tendency which septic micro-organisms show to settle in the neighbourhood of an injured epiphysis. Necrosis results from this sup- puration. Finally, if all goes well immediately after the accident, and the epiphysis unites firmly and in good posi- tion, premature ossification may take place, leaving a stunted and often atrophied limb. The diseases and injuries to which epiphyses are liable have been most exhaustively studied by Mr. Jonathan 164 THE SURGICAL DISEASES OF CHILDREN Hutchinson, jun., and by Mr. Tubby, whilst Mr. Sturrock has collected many interesting examples. Fractures of the Skull. .etiology.— Cranial fractures in young children are always the result of direct violence, and they present certain remarkable peculiarities which mark them off very clearly from similar injuries in adults. In the first place, fractures of the skull are uncommon in children, for the bones are so thin, homogeneous, and elastic that they readily yield to external violence, and bend rather than break. Extensive fissured fractures, therefore, do not occur with anything like the same frequency that they do in adults, and depressed fractures with splintering of the inner table are practically unknown, though Mr. Staveley reminds me that the Museum of St. Thomas' Hospital contains a typical example produced by the pecking of a hen. Their place is taken, however, by those cases in which a depressed piece of bone is driven beneath the neighbouring intact bony vault. Permanent depressions of large tracts of the parietal or frontal bones are not rare, and, on the other hand, I have seen a variety of green- stick fracture in the parietal bones marked by a convexity beneath the pericranium, following injuries received during birth. Secondly, as Mr. Rickman Godlee has shown, the bones are united by soft sutures, and as the fontanelles are not closed, the whole force of the injury falls upon the part struck. The dura mater is very firmly attached to the in- terior of a child's skull. It follows, therefore, from these two conditions that a fracture of the vault is nearly always attended by laceration of the dura mater, whilst severe injuries to the brain substance are much more frequent after such accidents in children than they are in adults. The INJURIES OF BONES 1 65 brain injuries are often overlooked, partly because they give rise to few and uncertain symptoms, — for a child's brain shows great power of adapting itself to altered conditions, — partly because such symptoms as do occur after a slight compound and fissured fracture do not manifest themselves until many days or weeks after the injury, and partly because the thinness of the bone and the yielding nature of the skull allow of extensive damage to the skull without laceration of the scalp. Cases of simple fissured fracture in children sometimes gape widely, perhaps because the freely movable bones allow of a considerable displacement of the fractured parts. Marchant has shown that in frac- tures of the skiill occurring in children under ten years of age, rupture of the middle meningeal artery much more frequently gives rise to external haemorrhage than to the ordinary intracranial haemorrhage. Hernia cerebri sometimes results from a compound frac- ture of the skull. It is a dangerous condition, as death often results from meningitis, or from inflammation of the cerebral substance. The tendency to it may be lessened by keeping the wound aseptic ; but if, unfortunately, a hernia should occur, the granulation tissue must be scraped away, the soft parts may then be refreshed, loosened, and brought together over the wound. The pericranium may be slightly detached, and shavings of fresh bone, obtained from some other part of the body, may be introduced into the aperture in the skull before the wound is closed. Traumatic Cephalhydrocele or Meningocele. A remarkable form of injury occurs in very young chil- dren, to which Dr. Conner has applied the name traumatic cephalhydrocele, though it is better known as traumatic meningocele. 11 1 66 THE SURGICAL DISEASES OF CHILDREN Symptoms. — The condition is characterised by a fluid swelling developing slowly at the seat of injury some weeks after a fall upon the head, usually in children under three years of age. The swelling in some cases pulsates, and it may have a respiratory rhythm. It is always in direct communication with the subarachnoid space, for if it is punctured cerebro-spinal fluid escapes, and probably in every case the opening in the skull is also connected with the ventricles of the brain. Pathology. — The exact pathology of these swellings is still a matter of doubt. They undoubtedly start from a simple fracture of the skull, associated with rupture of the dura mater. Mr. Clement Lucas believes that there has also been laceration of the brain substance, reaching to the cavity of the lateral ventricles. The substance of the brain softens, and there is an increased secretion of cerebro- spinal fluid owing to the irritation thus set up. The pres- sure from within and the yielding of the brain together contribute to" the escape of the fluid from the ventricles. A hernia of the cerebral meninges takes place, and this, by the constant pressure which it exercises, leads to absorp- tion of bone ; and as the tumour lies outside the skull, the absorption of the bone takes place from without inwards. Diagnosis. — The diagnosis is easily made if the history can be obtained correctly, or when clear cerebro-spinal fluid is drawn off through an aseptic puncture. The swelling may be mistaken for a hsematoma, but it may be distinguished by its tendency to remain stationary, or to increase in size, whilst a hsematoma diminishes. The prognosis is grave. Treatment. — The treatment varies in individual cases. Puncture may cure the tumour when the opening in the skull is small ; but when there is a free communication between the two sides of the cranial bone, it is unlikely INJURIES OF BONES 1 67 that much good will follow such an operation. It is note- worthy that most of the reported cures have taken place where no operative treatment has been adopted, whilst in many cases death from meningitis has followed tapping. The surgeon must therefore be absolutely sure of his asepsis before he punctures such a swelling. The tumours in many cases are stationary, and palliative treatment by the use of a gutta-percha shield is perhaps best, for in a certain proportion of cases the tumour has disappeared spontaneously. Fractures of the Skull in Young Adults. Fractures of the skull in older children whose skull has consolidated present no peculiarities. They follow the same course, and must be treated upon the same principles as those which govern similar injuries in adults. Nasal Bones. iEtiology. — I have seen several cases of broken nose in children resulting from falls upon the face, or in older boys from diving into shallow water in swimming baths, as well as from other forms of direct violence. The nature of the injury is often masked by the effusion of blood. It is of extreme importance, however, to recog- nise the fracture at once, for repair takes place by first in- tention, often leaving a marked deformity. A very careful examination under chloroform should therefore be made in all cases of suspected fracture, that is to say, when after an injury there is flattening and lateral deviation of the nose. Attention must be paid at the same time to the condition of the nasal cartilages and the septum nasi, as they are often displaced, either wholly or in part. Treatment. — There is usually but little tendency to displacement, so that it is sufficient to replace the frag- 1 68 THE SURGICAL DISEASES OF CHILDREN ments in the proper position. If it is difficult to maintain their position, however, or if the deformity recurs, Mason's treatment must be adopted. The fragments are elevated and replaced by means of a pair of dressing forceps, and a hare-lip pin is passed through them as far back as possible. Its ends are cut off so that they project for a short distance upon either side, and a piece of adhesive strapping or an india-rubber band is passed from one end to the other. The fragments are thus supported posteriorly as well as laterally. The needle should be withdrawn at the end of a week. Lower Jaw. Fractures of the lower jaw are very rare in children ; but Hamilton records instances and gives details of cases, as well as of one which would have been called a green- stick fracture if it had occurred in a long bone. Treatment. — A gutta-percha splint should be made for the chin, and it should be kept in place by a four-tailed bandage until the swelling has subsided. A mould of the alveolar border of the lower jaw should then be taken in wax. A Hammond's splint is then made by accurately adapting a piece of stout silver or platinum wire round the bases of the teeth in a cast made from the mould. The ends of the wire being soldered, the splint is transferred to the patient's mouth, and is kept in place by a thin silver wire run in and out between the teeth. Clavicle. A broken collar-bone is one of the commonest accidents which a surgeon is called upon to treat in infants and young adults, and it is the one most frequently over- looked. There is no danger of mistaking it when it is complete, and there is a clear history of an accident ; but when it is of the greenstick variety, when the periosteum INJURIES OF BONES 169 is intact, and when a careless nurse who has dropped her baby gives a purposely misleading history, the diagnosis is often most difficult. The pain is then often attributed to teething or other trivial causes, and close and prolonged observation will alone show that the injured arm is not used as readily as the opposite one. Treatment. — The treatment for an infant in arms con- sists in binding the arm to the side with a roller bandage, and dressing the child so that the injured arm is kept inside its clothes for a fortnight ; for an older child this is supplemented by keeping its arm in a sling for another week. This method should be adopted in every case in which a fracture is suspected, and in very young children it is a safe precaution to adopt whenever there has been an injury to the shoulder. The arm should be kept at rest for ten days in doubtful cases, as by that time the formation of callus will establish the diagnosis, whilst if there has only been a bruise the surgeon will have erred upon the right side. The only cases of ununited fracture of the clavicle I have seen were those in which the injury had been overlooked and the children had been allowed to go about without any restraining apparatus. Sayre's method of applying two pieces of stout strap- ping is as effectual for young adults as any other. One piece of strapping three inches wide is stitched loosely round the injured arm opposite the insertion of the del- toid. An assistant is directed to draw the arm down- wards and backwards to stretch the clavicular fibres of the pectoralis major, and whilst this is being done the surgeon carries the strip backwards round the body so that the sticky side adheres to the skin. He then stitches the end to the encircling band in the middle of the back. The assistant is next told to bring the elbow forwards and inwards so that the hand lies flat upon the I70 THE SURGICAL DISEASES OF CHILDREN opposite shoulder. The humerus is thus supposed to act as a lever, throwing the shoulder outwards and prevent- ing the two fragments of the clavicle overlapping ; but I greatly doubt whether its action is more than temporary. A second piece of strapping is carried obliquely across the sound shoulder, in such a way that the point of the elbow on the injured side is received into a slit made in the strapping, whilst the hand and forearm are also covered. A flannelette bandage may be applied over the whole to keep everything in place. The apparatus is left on until firm union has taken place, which is usually at the end of a fortnight or three weeks. The Epiphysis of the Clavicle. The sternal extremity is sometimes torn off in young persons. The Symptoms are undue prominence of the inner end of the bone, and the presence of a sharp bony extremity beneath the skin. Mr. Christopher Heath says that in a case which came under his notice in a boy, aged 14, the supra-sternal notch was quite distinct and equally defined on both sides ; the presence of a thin lamella of bone on the injured side could be clearly detected as it lay between the notch and the gap formed by the forward projection of the shaft of the clavicle. Diagnosis. — Separation of the epiphysis has to be dis- tinguished from fracture on the inner side of the rhomboid ligament, but the fracture is farther away from the joint. The Treatment consists in keeping the patient flat upon his back in bed for fourteen days. Humerus. Every variety of fracture occurs in the humerus in children ; but separation of the epiphyses and injuries to its lower extremity are of more especial interest. INJURIES OF BONES IJl Separation of the Upper Epiphyses. Separation of the epiphyses in the upper end of the humerus either includes the head of the bone, or it chiefly involves the greater tuberosity. Separation of the whole of the upper epiphysis takes place after the sixth year, for it is only then that the nuclei for the head unite with that of the greater tuber- osity to form a single mass. It is generally met with about puberty, and the separation results from direct violence to the shoulder. It is likely to be mistaken for a sub- coracoid or sub-clavicular dislocation. Careful examination will show that the head of the humerus lies in the glenoid cavity, whilst in some cases the upper end of the lower fragment can be felt beneath the skin ; in this case the projecting mass of bone may readily be mistaken for the head of the humerus. Symptoms. — The arm is helpless, and the upper end of the shaft projects abruptly beneath the coracoid process, so that the axis of the arm is altered and the elbow is directed a little outwards and backwards. There is abnormal mobility just below the shoulder- joint, — which is best demonstrated by abducting the humerus, — with rapid swelling about the shoulder and some shortening if the diaphysis is wholly displaced. There is muffled crepitus when the diaphysis is brought into contact with the separated epiphysis. The deformity can be reduced by extension and counter-extension, but it is immediately reproduced when the arm is left to itself. Prognosis. — The prognosis is not very good, for- as Mr. Hutchinson, jun., points out in his excellent essay on the diseases and injuries of the epiphyses, 13 there is sometimes great difficulty in maintaining the fragments in good position when the upper epiphysis of the humerus has 172 THE SURGICAL DISEASES OF CHILDREN been separated. This difficulty he attributes to the fact that there may be a longitudinal rent in the periosteum through which the upper end of the shaft projects, and this rent may have to be enlarged before the shaft can be replaced. Good union does not take place readily ; but in spite of this a useful arm results, though there may be some shortening from interference with the growth of the bone. Treatment. — Steady traction should be made upon the arm, and slight abduction, aided by a rotatory movement ; and if the reduction is once fairly effected, the epiphyseal line is so sinuous that the parts remain in fairly good apposition. Splints should be applied, and the shoulder treated as if for a fracture, by flexing the forearm, and bringing it forwards so that the fingers lie upon the opposite shoulder; this carries the elbow well across the chest, and the injured arm is then fixed securely with a broad flannel bandage. Some means of extension may be employed advantageously in older children. Separation of the Greater Tuberosity. The great tuberosity is usually torn off by direct violence, but sometimes it has been separated by muscular effort. The tubercle is drawn upwards and backwards towards the back of the acromion process, whilst the shaft of the bone is drawn upwards and inwards by the sub- scapularis, pectorales, latissimus dorsi, and anterior fibres of the deltoid. Symptoms. — These changes in position lead to a great widening of the shoulder and a marked prominence of the coracoid process on the injured side. The separated epiphysis can often be taken between the finger and thumb, and can be moved into its natural position ; and INJURIES OF BONES 173 if the arm be extended at the same time, the deformity can be temporarily overcome. Treatment. — The best results are obtained by putting the patient to bed, raising the arm above the head, and securing it in such a position that the greater tuberosity lies over its point of separation. The surgeon must in many cases content himself with applying a gutta-percha or leather cap moulded to the shoulder, and fitted with a pad on its inner surface, with the object of retaining the great tuberosity in position, when from any reason the child cannot be kept in bed. Shaft. Fractures of the .shaft of the humerus do not differ materially in their causes, symptoms, or treatment, from similar injuries in adults. There is not so great a risk of non-union since there is less displacement of the fragments, as the periosteum is often less torn than in adults. Good repair usually takes place in a fortnight under any method of fixation, but the injured arm should not be used for a month. An internal angular splint with an external straight splint or a piece of a " kettle-holder " (Gooch's) with a sling usually affords sufficient fixation, and I prefer it to a plaster-of-Paris splint, at any rate for the first fortnight. Elbow. Fractures in the region of the elbow u are very numerous and very complicated in children. They are usually the result of falls in young children, and of direct violence in older ones. Treatment. —Anchylosis is so common after these frac- tures in the immediate neighbourhood of the elbow that there is the greatest diversity of opinion in respect to 174 THE SURGICAL DISEASES OF CHILDREN their treatment. One school of surgeons advocates the arm being maintained in a state of flexion, whilst another holds with equal tenacity that extension yields the better results. I prefer the flexed position myself, and I always employ it in these cases. The method adopted by Prof. Busch, of Bonn, is a serviceable one. It consists in main- taining the limb at an angle of about 120° until the swelling has subsided ; the elbow is then bent to an acute angle for a week or ten days. It is carefully straightened under an anaesthetic upon the twentieth day until it has been extended to an angle of 180°, and the splint is again applied until the twenty-eighth day, when it is per- manently laid aside. A formal operation may have to be performed when anchylosis has taken place, if the adhesions cannot be broken down. The joint is exposed by an incision carried along its outer side, the callus is removed or the articular ends are divided with a chisel until the fragments can be replaced in their proper relationship to each other. The arm must then be fixed upon a rectangular splint, and the case treated as if an excision had been performed. Separation of the Lower Epiphysis of the Humerus. The lower epiphysis may be separated at any time up to the 13th or 14th year, though the separation is somewhat more frecpaent in children under four years of age. It ossifies from four nuclei ; that for the internal condyle forming a separate epiphysis from that of the articular surface and external condyle, and uniting with the shaft later. etiology. — The lower epiphysis may be torn off by forcible adduction or abduction, and it sometimes follows a fall upon the hand with the elbow bent. INJURIES OF BONES I 75 Mr. Jonathan Hutchinson, jun., says that in these cases there is more or less complete backward displacement of the epiphysis, with an abnormal projection backwards of the olecranon, more marked when the arm is extended than when it is bent. There is therefore an increase in the antero-posterior diameter of the affected elbow, rendered more marked by the rapid swelling within the joint, which is a usual concomitant of the injury. Voluntary movement is limited, but there is abnormal mobility just above the elbow, corresponding to a line drawn transversely at or just below the epicondyles. Diagnosis. — Separation of the lower epiphysis must not be mistaken for a backward dislocation of the radius and ulna, though it bears a superficial resemblance to it, as the lower fragment is tilted backwards beneath the triceps, whilst the upper fragment projects forwards. When the radius and ulna have been dislocated backwards, the lower end of the humerus can be felt to bear its articular sur- faces ; whilst after separation of the epiphysis the articular surfaces are carried backwards with the forearm, and only the naked end of the shaft of the humerus projects in front. This lower end sometimes presses upon the brachial artery, until it has caused gangrene, or there may be injury to the nerves. Treatment.— The patient should be put to bed, and his arm laid upon a Stromeyer's cushion with the elbow flexed. An evaporating lotion, consisting of equal parts of methylated spirit and lotio plumbi, should be applied until the swelling begins to subside. A plaster-of-Paris case may then be moulded to the arm, and it should be kept in position by means of a bandage and a sling for three weeks. The child may leave his bed after the tenth day. I76 THE SURGICAL DISEASES OF CHILDREN Supracondylar Fractures of the Humerus. iEtiology. — These injuries are rare in children, but when they occur they are produced by a fall from a height or by a blow or kick. They are often compound. Symptoms. — The line of fracture is nearly always oblique, so that the lower fragment projects backwards beneath the triceps, as in separation of the lower epiphysis. Gentle extension applied to the forearm reduces the de- formity, but it is reproduced as soon as the arm is left to itself. There is so much swelling attending both these injuries, and they are often so obscure, that no certain diagnosis can be made until the child is anaesthetised. Treatment. — Supracondylar fractures should be treated like a separation of the epiphysis, by placing the arm midway between pronation and supination, so that the thumb is uppermost. The elbow is bent and the arm is secured to a well-padded rectangular plaster-of-Paris splint applied along its inner side. Passive movement should be commenced upon the twentieth day, and the muscles of the arm should then be shampooed daily. T-Fracture. etiology. — The supracondylar fracture in children is sometimes complicated by a vertical fracture extending downwards through the lower fragment into the joint, thus forming the well-known T-fracture. Symptoms. — There is usually no difficulty in recog- nising this form of fracture. The elbow is swollen and shapeless, the joint is full of blood ; and if the child be anaesthetised, the fragments of bone can readily be moved upon each other. Prognosis. — The prognosis in these cases is of necessity grave, for the joint is seriously implicated ; but the repara- INJURIES OF BONES 1 77 tive power in children is so great that I have seen most useful arms follow even the worst injuries of this nature. Treatment. — The treatment consists in placing the child under chloroform, and remodelling the elbow until the fragments are in good position. This is done by forcibly extending the arm, and then pressing the upper end of the ulna downwards and forwards, whilst the forearm is being pronated and flexed to an acute angle with the upper arm. The arm may then be placed upon a Stromeyer's cushion, over which a mackintosh sheet has been laid. The cushion is supported upon a board projecting from the cot, or upon a low, flat table placed alongside it, so that the arm is extended from the body with the elbow bent to a right angle. An extension apparatus may be applied if there is any marked tendency to shortening. An evaporating lotion of Goulard extract and spirit or an ice-bag is applied to the elbow, and every means is taken to allay excessive inflammation. A well-padded angular splint should be applied to the flexed arm as soon as the swelling has somewhat subsided, and gentle passive movement com- bined with massage should be commenced on the twentieth day after the injury. The split condyles of the femur are generally displaced laterally. Dr. Dulles 14 has lately shown that if the forearm be fully flexed so that the hand touches the opposite shoulder, and if at the same time it be semi- pronated, the radius and ulna hold the corresponding points of the lower end of the humerus in tolerably good position. He therefore advocates that fractures of the elbow-joint should be treated in this position, and this may be done by means of flexible metal or felt splints care- fully moulded on to the arm. Fractures of the Epicondyles. Fractures of the epicondyles are not uncommon, for they N 178 THE SURGICAL DISEASES OF CHILDREN often occur as a complication of dislocations at the elbow ; fractures on the inner side of the joint being rather more frequent than those on the outer. Cause. — The accident is sometimes the result of direct violence, and sometimes it is due to indirect injury. Mr. Jonathan Hutchinson, jun., points out that separation of the inner epicondyle is nearly always a clean separation of the epiphysis on the inner side, and that it often unites by fibrous tissue alone, but without materially impairing the usefulness of the arm. The separated epitrochlea is drawn downwards towards the ulna, and by its pressure upon the nerve it may give rise to paralysis of the muscles supplied by the ulnar, with pain and limited movement of sufficient severity to warrant the removal of the frag- ment of bone. Treatment. — The limb may be kept for three weeks in a plaster-of-Paris splint moulded on to the fully flexed elbow. Intra-articular Fracture of the Capitellum. Fracture through the external condyle of the humerus is also of frequent occurrence in children, as a result of falls upon the elbow. Symptoms. — The detached fragment is usually displaced a little outwards, and carries the head of the radius with it, so that the distance between the two condyles is greater on the affected than on the sound side. Crepitus is most easily obtained by seizing the fractured condyle between the finger and thumb, and lightly moving it upon the humerus. Prognosis. — The prognosis must be guarded in these cases, for the simple fracture is often complicated by other injuries which may be overlooked at the time of the injury owing to the swelling which it causes. A good INJURIES OF BONES I / 9 instance of this occurred in a case which I saw with Mr. Pick about a year ago. A school-boy, aged 10, fell back- wards out of a window, a distance of fifteen feet, into a paved area, and sustained a severe injury to his elbow. The injury involved the joint, and when I saw him three months afterwards there was impaired movement, thicken- ing at the back of the external condyle, and inability to extend or fully to flex the forearm. A diagnosis was made that the external condyle had been fractured, and that there was now a forward dislocation of the radius. Mr. Pick reduced the dislocation under chloroform. The arm was fixed at a right angle in a plaster-of -Paris splint, and six weeks later the boy had good movement in the joint, which has since become perfect, for he tells me that he can now ride and drive without difficulty. The capitellum is very liable to remain as a loose body in the elbow-joint, and it may then lead to considerable impairment of move- ment and serious disorganisation of the elbow, though it does not undergo necrosis. Treatment. — The arm should be placed upon a rect- angular splint for a fortnight, when passive movement must be commenced, the splint being replaced after each stance until the end of the third week, when it may be laid aside. Mr. Hutchinson suggests that when the ex- ternal condyle fails to unite, it may be necessary to fix the detached fragment by a needle, or to peg it by some other means to the surface from which it has become detached, the needle being removed at the end of three or four weeks. Forearm. Separation of the Epiphysis of the Olecranon. The nucleus for the ossification of the olecranon appears l8o THE SURGICAL DISEASES OF CHILDREN at the tenth year, and the epiphysis unites with the shaft about the seventeenth year. ^Etiology. — This injury is generally the result of direct violence. Symptoms. — The symptoms are semiflexion with loss of power to extend the arm, great effusion into the elbow- joint, and a more or less marked gap at the back of the elbow. Prognosis. — The prognosis is not good ; fibrous union may result, or anchylosis may take place. Treatment. — The treatment is the same as for a frac- tured olecranon. The arm should be laid at rest upon a cushion for a week imtil the swelling has subsided, the patient being kept in bed. A pad is then placed above the separated epiphysis, and is secured with a strip of plaster in such a manner as to keep the two fragments in apposition, and a plaster-of-Paris splint is applied to the flexor aspect of the arm from the axilla to the wrist, to keep the arm fully extended. The plaster splint is left on for a fortnight, and upon the twenty-first day from the accident it is removed, and the arm is gently flexed to an angle of 100° to 120°. A fresh splint is applied, and at the end of a month or five weeks systematic passive move- ment of the joint with massage of the limb is commenced. Separation of the Upper Radial Epiphysis. Separation of the upper epiphysis of the radius is rare, but Mr. Mansell Moullin showed an example at the Patho- logical Society in 1888. It occurred in a boy of sixteen, whose arm was crushed by a machine. The more common injury, which is often diagnosed as a separation of the upper epiphysis, partakes more of the nature of a strain, and is perhaps due to a partial dis- INJURIES OF BONES l8l placement of the head of the radius, caused either by the head slipping downwards, or to the orbicular ligament slipping upwards. Its exact pathology, however, is un- known, but it is considered more in detail at page 242. The accident occurs in infants and in young children who have been held up or swung round by their hands. The forearm is painful ; it is held motionless, and is in- capable of being completely extended or supinated. Free movement of the arm is obtained by first bending the elbow, and then gently but completely supinating the arm. The arm should be bandaged to an angular splint for forty-eight hours, and an evaporating lotion should be applied to the elbow. Mr. Jonathan Hutchinson has pointed out that such accidents are very likely to be followed by disease of the elbow- joint in tuberculous chil- dren, just as the more severe forms of sprained elbow may form the starting-point of an acute infective arthritis. Shaft. Fractures of the shafts of the radius and ulna are not more numerous in children than they are in adults, nor do they differ much in their signs or in their treatment. The surgeon, however, has to be on his guard against over- looking those cases in which one or both bones are broken subperiosteally, or in which they are only bent or partially fractured, for such injuries are accompanied by the pro- duction of as much callus as though a complete fracture had taken place. Dr. Brossard has shown that subperio- steal fractures of the ulna are produced by indirect violence applied when the arm is adducted, for in this position the force is transmitted directly along the bone. It may also be produced by twisting the arm into a condition of ex- treme supination, for the posterior surfaces of the two bones are then brought into such intimate contact that 1 82 THE SURGICAL DISEASES OF CHILDREN the ulna is bent backwards. A similar twist into exag- gerated pronation may cause a spiral fracture of the radius. The fracture is a mere fissure, and it may be accompanied by an incomplete transverse fracture, or even by a tearing away of the lower epiphysis. Symptoms. — The symptoms most to be relied upon in these cases of incomplete fracture are pain and swelling limited to the seat of injury. They are extremely likely to be mistaken for simple bruising, as there is neither deformity nor undue movement of the bones. Treatment. — Any deformity in the bones must be ac- curately remedied. The surgeon must be careful to see that the radius and the ulna lie parallel to each other through- out any prolonged application of splints, and that the splints are sufficiently wide to prevent the bandage from pressing upon the sides of the arm and so squeezing the bones together, for crossed union takes place very readily, and little or nothing can be done for the relief of a patient who has two or three inches of callus in his interosseous space. The bandage over the splint may be starched, but a plaster-of-Paris splint had better not be applied. Three weeks is a sufficient length of time to keep the arm fixed. Separation of the Lower Epiphysis of the Radius. etiology. — The lower epiphysis of the radius is oc- casionally separated by falls upon the outstretched hand, and I think that, with the increase of bicycling, it is becoming rather more frequent in young adults. An injury which in adults would lead to a Colles' frac- ture, leads in young children to this accident, to a dislo- cation of the radius and ulna backwards at the elbow, or to a broken collar-bone. INJURIES OF BONES 1 83 Symptoms. — The symptoms of separation of the lower epiphysis resemble those of the fracture immediately above the articular surface of the radius, to which English sur- geons give the name of Colles. Pronation and supination of the arm are impossible ; the radial border of the forearm is shortened, and the styloid process of the ulna is unduly prominent. The line of separation sometimes involves part of the shaft of the bone, so that the crepitus may be more obvious than is usually the case in separation of an epiphysis. Diagnosis. — The deformity produced by separation of the lower radial epiphysis is almost identical with that occurring in Colles' fracture. It may be distinguished, however, by observing that the outline of the wrist is angular, whilst in fractures it is curved. The projection, too, upon the palmar surface is more obvious after epiphy- seal separation than after a fracture. Prognosis. — The lower radial epiphysis unites quickly, and the repair is usually so perfect, that after a few months it is difficult to identify the line of separation. The growth of the radius, however, may be arrested as a result of the injury sustained by the growing line. Treatment. — The deformity must first be reduced. A Carr's splint is then applied, the fingers being confined for the first week. The splint should be replaced by a plaster- of-Paris mitten at the end of three weeks, and this should be worn for a fortnight. Ribs. etiology. — Fractures of the ribs occur in children who have been run over, or have sustained other serious hv juries, but they are not very frequently observed. The thorax is so elastic that such fractures are only produced 184 THE SURGICAL DISEASES OF CHILDREN by considerable violence, and more than one rib is usually injured. The prognosis is therefore unsatisfactory, for the injury is often severe enough to have implicated the lungs, or even the heart ; and I have more than once seen a hsemo- thorax produced within a few hours after a child has been run over. Symptoms. — The symptoms vary greatly with the nature and extent of the injury, and are more dependent upon the complications than upon the broken ribs. The Treatment consists in keeping the child in bed, and treating the complications as they arise. There is a specimen in the Museum of St. Bartholomew's Hospital, in which the heads of the third, fourth, and fifth ribs are separated from their necks. The patient was a girl of two, who was run over by a dray. She died instantly, and the lung was found to have two large rents in its posterior border. I hesitate to call this injury a separation of the costal epiphyses, as the angular epi- physis for the head of a rib does not appear until the sixteenth year. Diagnosis. — Traumatic fractures of the ribs must not be mistaken for broken ribs resulting from rickets, or more rarely from localized gummatous deposits in cases of inherited syphilis. Such cases readily heal under appro- priate constitutional treatment, aided by strapping applied to one side of the chest in the ordinary manner. Femur. Fractures of the femur are of very common occurrence in children, and they may occur at any part of the bone. Upper End. — Very obscure injuries occur at the upper end of the femur, and they often lead to permanent lame- ness. These injuries were for many years supposed to be INJURIES OF BONES 1 85 associated with separation of the upper epiphysis. Several surgeons — Dr. Royal Whitman amongst the foremost — have recently brought forward good arguments to prove that in a certain proportion of these cases the neck of the femur itself is fractured, though there can be no doubt that the upper epiphysis is often separated. In some cases, too, the fracture is only partial, and causes a greenstick fracture, which leads to bending of the neck of the bone. The separation of the epiphysis is the result of a sudden wrench or sprain, whilst the fracture of the neck is pro- duced earlier in life, and by a less severe injury, as a fall or blow. Symptoms. — The symptoms in either case are shorten- ing of the limb, with elevation of the great trochanter above Nt'laton's line to the extent of three-quarters of an inch. There may be either external rotation of the thigh, or it may be inverted. There is usually pain on movement and some swelling about the joint, with inability to use the limb. Diagnosis. — These injuries may be mistaken for a dislocation of the hip, if a history of injury is forthcoming ; but if the child is only seen some time afterwards, the symptoms are often attributed to hip disease, or to the effects of infantile paralysis. The freely movable joint, the character of the deformity, and the absence of trophic disturbance, should enable the surgeon to suspect the nature of the injury even in the absence of any history as to its cause, but it is generally impossible to ascertain its exact nature. Prognosis. — The prognosis is not very good in young children, for the injury is frequently overlooked until the patient learns to walk. An ununited fracture may be the result of this neglect, or the fragments may unite in a faulty position. Permanent lameness is caused, but the 1 86 THE SURGICAL DISEASES OF CHILDREN limb is otherwise serviceable. Mr. Tubby has lately- shown that separation of the upper epiphysis of the femur is most common after the age of fourteen years ; that the prognosis of union is not better when it occurs at this age, but that, as in younger patients, a serviceable limb is usually obtained. Treatment. — The application of a plaster-of-Paris splint to the thigh and pelvis gives satisfactory results, if the child is seen soon after the injury. The splint should be put on whilst the child is anaesthetised, and extension should be maintained until the plaster has set. The splint should include the pelvis. A Thomas' splint, with exten- sion, is also a good method of fixing the limb in these cases ; but slight abduction of the thigh must be maintained, so that a useful limb may result in case anchylosis of the hip takes place. Separation of the Great Trochanter. The great trochanter is sometimes separated in patients under the age of seventeen years, and this form of injury must be distinguished from extra-capsular fracture of the neck of the femur, and from dorsal dislocation of the hip. Diagnosis. — The diagnosis is difficult, for there is no shortening of the limb after separation of this epiphysis, and the trochanter on the injured side describes the same arc when the thigh is rotated as it does on the sound side. There is usually local pain, with slight swelling. Treatment. — The treatment consists in the application of a Thomas' hip-splint. There seems to be a special liability to suppuration, and even to pyaemia, after this injury, so that too favourable a prognosis should not be given. The patient must be kept in bed until the surgeon has satisfied himself that sufficiently firm union has taken INJURIES OF BONES 1 87 place, to prevent movement setting up any inflammatory- processes at the seat of injury. Shaft of Femur. Fractures of the shaft of the femur are common in young children, and are produced by comparatively slight vio- lence. They are more frequent in the ricketty than in the healthy. Symptoms. — The thigh assumes such a characteristic position that the nature of the injury can hardly be mistaken ; but the absence of pain and the difficulty of obtaining crepitus sometimes cause the fracture to be overlooked. It is often nearly transverse, and there is generally very little overlapping of the fragments. It may be incomplete, and of the greenstick variety. Prognosis. — The prognosis is very good, for bony union without shortening is usually the result of every rational method of treatment. Treatment. — There are many ways of treating a broken thigh in childhood. The simplest is to put the patient upon a fracture bed, and to apply a Gooch's splint, i.e. a " kettle-holder," to the whole thigh, securing it in place by webbing straps. An extension of two or three pounds, or of so great a weight as is necessary to steady the limb, is applied to the leg, and this is usually reckoned as a pound for each year of the child's age. The method of applying extension is identical with that described at page 116, and seen in fig. 15. There is firm union in three weeks, but I prefer to keep the child in a plaster-of-Paris case for a fortnight after the splint has been removed. A plaster splint (p. 212), with extension, may often be ap- plied with advantage from the beginning. A long Liston's splint, applied along the uninjured side, should be used in both methods to compel the child to lie straight. 1 88 THE SURGICAL DISEASES OF CHILDREN Children who have incontinence of urine, very young children, and those who have both thighs broken, can often be treated satisfactorily without any splint, by keeping them flat upon their backs and rigging up an extension apparatus consisting of a weight and pulley so situated above the bed that the thighs are flexed to a right angle with the body. The method is not well adapted for private practice, however, and in little girls it sometimes leads to an attack of vaginitis. Restless children, who cannot be induced to lie straight and flat by any other means, are best secured in a Bryant's or in a double Thomas' splint. Dr. Elefson states that he has most successfully treated a fracture in the upper part of the thigh of a new-born child by the application of well-padded antero-posterior splints of plaster, the thigh being fixed in complete flexion upon the abdomen for fifteen days. Separation of the Lower Epiphysis of the Femur. This is not a very rare injury in young people. It is more frequent in boys than in girls, and it is most frequent about the age of sixteen years. etiology. — It occurs in its simplest form and without displacement as a result of traction during labour, and from wrenching the thigh during the operation of manual osteoklasia. A much more severe form results from acci- dents. The violence in these cases is always very great, and in thirteen out of twenty-six cases collected by Mr. Tubby it was produced by such a wrench as might be caused by getting the leg entangled in a revolving wheel. Pathology. — The epiphysis in the more severe cases is always considerably displaced. It may pass forwards, — which is most usual, — backwards, or sideways, the exact INJURIES OF BONES 1 89 direction appearing to vary with the nature of the injury producing it. When the epiphysis is displaced backwards into the ham, or when the end of the shaft passes back- wards and the epiphysis lies in front of it, there is a very real danger of pressure upon the main vessels and injury to the large nerves in the popliteal space. In such cases the large veins may become the seat of infective throm- bosis, gangrene results, and may lead to the death of the patient. Symptoms. — The pain varies in intensity according to the injury done to the nerves ; the knee is generally semi- flexed, and often much swollen. The foot is everted, and there may be an inch or two of shortening. The epiphysis can be felt in its new position, and there is undue lateral movement of the leg, including the knee-joint, with obscure crepitus in cases where there is but little dis- placement. Diagnosis. — The separation of the epiphysis must be distinguished from dislocation of the knee, and from supra- condyloid fracture of the femur. The downward and back- ward direction of the epiphyseal line usually allows the lower end of the shaft to project backwards into the popli- teal space, whilst the lower fragment is displaced forwards, and can readily be felt. Prognosis. — The prognosis in the simple cases is good, for perfect repair usually takes place. It is far otherwise in the varieties which have been the result of severe vio- lence, for the injury may then be compound, or the back- ward pressure may lead to gangrene from thrombosis, or to secondary haemorrhage from pressure and ulceration. Treatment. — The treatment in the simple cases consists in putting up the limb in a plaster-of-Paris splint, with the knee fully extended. The patient must be anaes- thetised when there is displacement, and the epiphysis I9O THE SURGICAL DISEASES OF CHILDREN must be accurately replaced. This is done by making extension and counter-extension upon the leg and thigh, whilst the surgeon manipulates the epiphysis. The leg is then carefully put up in two lateral plaster-of-Paris splints, taking care that the epiphysis does not become displaced. The splint should be kept on for a month, the surgeon being on his guard during the earlier period for the slightest symptoms of complications. The femoral vein may be ligatured when there is reason to suppose •that it is the seat of an infective thrombosis ; but in some cases, and especially if gangrene result, amputation is sometimes unavoidable. Excision may be required in un- complicated cases when it is impossible to replace the epiphysis. Patella. Fractures of the patella do not occur in young children, and in young adults they present no peculiarities by which to distinguish them from similar injuries in the full grown. Cause. — They are usually the result of direct violence or of muscular action. Bones of the Leg. Separation of the tubercle of the tibia may take the place of a fractured patella in a child, and is readily mis- taken for a broken knee-cap. Treatment. — The treatment for this injury consists in the application of a straight back-splint to the leg, which is then raised to an easy angle with the body, in order to relax the quadriceps muscle. The separated tubercle may be kept in place by a piece of strapping, and the leg must be kept at rest for six to eight weeks. INJURIES OF BONES 191 Shafts of Tibia and Fibula. Fractures of the tibia and fibula are tolerably frequent in children, but they are much less common than fractures of the thigh. They are often compound in children who have been run over ; but even the worst cases of compound fracture of the leg are usually amenable to conservative surgery, and it is only in the most exceptional cases that a primary amputation is necessary. The upper epiphyses of the tibia and fibula are occasionally separated by vio- lence, but fracture is most common in the middle and lower third of the bones. Treatment by plaster-of-Paris splints usually ensures good repair in three weeks ; but it should be borne in mind that non-union is more common in the tibia than in any other bone in a child, and the patient should therefore be kept in bed, and not allowed to sit with its legs dangling from a high chair. Lower Epiphysis of the Tibia. The lower epiphysis of the tibia is occasionally sepa- rated, either by direct traction during childbirth or by a sprain. The periosteum is not necessarily torn, and the accident may therefore escape notice. The ordinary treatment for a Pott's fracture should be adopted. In older children, separation of the lower epiphysis of the tibia is often compound, and is associated with a fracture of the fibula. Metacarpal Bones. Fractures of the metacarpus are very rare in children, except as a result of machine accidents in our manufac- turing towns. Mr. Jonathan Hutchinson, jun., has recently shown that many cases of supposed dislocation and fracture 192 THE SURGICAL DISEASES OF CHILDREN of the metacarpal bones are in reality separated epiphyses when the injury is situated at the phalangeal extremity. The treatment consists in the application of a well-padded Carr's splint to the forearm, and securing the fingers for a fortnight over the end of its transverse portion. Metatarsal Bones. Fractures of the metatarsal bones usually occur from the foot being run over. The pain and swelling are suf- ficient to confine the patient to his bed. The foot should be fixed in a plaster-of-Paris bandage as soon as the swelling has subsided. CHAPTER IX CONDITIONS LEADING TO ALTERATIONS THAT REQUIRE SURGICAL INTERFERENCE IN BONES AND MUSCLES ANTERIOR POLIOMYELITIS. Ixfaxtile paralysis in its acute stages usually comes under the notice of the physician, but a thorotigh know- ledge of its course and pathology is required by the surgeon, on account of the frequency with which he is called upon to treat its more remote effects. etiology and Pathology. — The cause of infantile paralysis is usually an acute and often well-localised inflam- mation in the multipolar nerve-cells of the anterior horn of the grey matter of the spinal cord, though there is some evidence to show that in a few cases of infantile paralysis the lesion is primarily in the brain, and more often on the right than upon the left side. The predisposing and exciting causes of the inflammation are quite unknown to us. It is most frequently seen in young children after the beginning of the teething period, but it may occur in young adults. The inflammatory process terminates in the disappearance, shrivelling, or pigmentation of the affected cells, and in alterations of the axis cylinders originating in them, leading to degenerative changes in the voluntary muscles supplied by them. The functions of the nerve-cells appear to be largely trophic, for after their 193 194 THE SURGICAL DISEASES OF CHILDREN disappearance the muscular fibres shrink in size, and the contractile siibstanee often disappears entirely, so that the fibrous elements alone remain. The bones, the tendons, and the ligaments also undergo similar atrophic changes, in part the result of trophic disturbances, but chiefly secondary to the muscular paralysis, for they are partly due to disuse, partly to the mechanical causes produced by the changes at the joints. Symptoms. — The onset is acute, and may be so sudden that, as in the case of Sir Walter Scott, a child who goes to sleep in apparent health has been known to awake paralysed. The temperature rises to 100° or 102° F., and there is sometimes a twitching of the affected limbs. Pain is not a prominent symptom, and the sphincters are not relaxed. The paralysis is at first more widely spread than it afterwards proves itself to be. The muscles which are permanently affected waste in the course of two or three- weeks, and cease to respond to the faradic current, though galvanism produces exaggerated contraction as compared with the sound side. This alteration in the excitability of the muscles is known as the reaction of degeneration. It is of great service in prognosis, since as a broad and general rule the muscles which give this reaction for a period of six to nine months after the onset of the disease, will remain permanently paralysed. Treatment. — The general treatment to be adopted in these cases, when the acute symptoms have passed away, is to keep the muscles in the best condition to resume their functions if their nerve supply is regained, and at the same time to regulate the vascular supply to the parts, and so to prevent, as far as possible, the chilblains and ulceration which form so troublesome a feature in limbs which have been paralysed for long periods of time. These indications for treatment are met by recommending the ARTHRODESIS 195 parents to bathe the child daily in a hot bath at a tempera- ture of 80° F. for ten to fifteen minutes, and afterwards to nib some lin. camph. co. into the affected part. The surgeon should himself shampoo the child two or three days a week. Ten-minute , applications of the galvanic current for very long periods of time afford the most satis- factory method of local treatment. The child must be carefully educated to this treatment by commencing with weak currents, and care must be taken not to fatigue the muscles. Large electrodes render the application less painful than small ones, and the positive pole should be applied over the affected part, as it is less painful than the negative one, which can be placed over the spine. A cur- rent of three milliamperes should be used first, and may be gradually strengthened after a few sittings to six. A dozen contractions of the muscles is sufficient at first. Care must also be taken throughout the treatment to obviate deformities, or to prevent their increase, by the use of splints or light steel supports, for if this be satisfac- torily effected it will save many troublesome operations. The various forms of talipes, stunted limbs, dislocations, contracted and flail joints are the most frequent results of infantile paralysis. Club-foot must be treated upon the ordinary principles by division of the tendons or by the subsequent application of supports. Carefully adjusted orthopaedic apparatus will prevent contraction of the joints, and may assist a patient who has a flail joint. Arthrodesis. lfi Arthrodesis is the operation performed to anchylose a joint in order to secure an orthopaedic result. It was first done by Albert, at Vienna, on July 20th, 1878, and it has since been repeatedly performed in London by Mr. Howse and Mr. Jacobson, and in Liverpool ly Mr. Robert Jones. I96 THE SURGICAL DISEASES OF CHILDREN It is of especial service in cases of infantile paralysis of long-standing, at the knee when the limb is flail-like, and at the ankle when there is so much varus that division of the tendons and the application of orthopaedic apparatus have failed to rectify the deformity. It has also been recommended for the treatment of similar paralytic con- ditions in the arm, and in cases where the paralysis has followed typhoid fever and variola, or has been due to neuritis ; and von Winiwarter has excised the wrist in a case of infantile paralysis affecting the arm. Those who have performed the operation most frequently speak of it in terms of high praise ; but no case has yet come under my care in which I have felt justified in departing from the ordinary rule of amputating through the thigh for the relief of this condition when the use of suitable apparatus has failed. The chilblains, the ulcerated condition of the skin, and the extreme degeneration of the muscles have always led me to think that the artificial production of an anchylosed joint would be of less service to the unfortu- nate patient than removal of the paralysed limb. I shall have no hesitation, however, in performing the operation as soon as a suitable case presents itself. In the knee the transverse incision dividing the liga- mentum patellse is usually adopted, whilst in the ankle the anterior incision from one malleolus to the other appears to be preferable to the external or internal lateral, or to the posterior incisions. The line of incision, in each instance, must be planned to meet the requirements of the case, care being taken to suture the various tendons and ligaments which have been divided when the operation is completed. The cartilage covering the articular sur- faces of the bones is gouged away, but there is no need to remove the synovial membrane. The joint is fixed in a plaster-of-Paris case for six weeks or two months after the SCURVY 197 operation until the anchylosis is complete, and as the joint is not diseased every effort should be made to secure union by first intention, and no drainage-tubes should be employed. In cases of flail-leg, both the knee and ankle joints may have to be abolished before a useful limb is obtained. SCURVY. 17 jEItiology. — Scurvy is a rare disease, occurring at any time after a child is four months old, and most often about the age of nine months. It appears to be the result of feeding children upon patent foods and artifici- ally sterilised milk. It is therefore a little more frequent in the children of well-to-do parents than of paupers. Symptoms. — Scurvy is likely to be mistaken for the subacute form of osteomyelitis, for the stress of the disease falls upon the bones. It is not an infective disease, how- ever, and it runs a widely different course. The onset is usually gradual ; the child loses its appetite, it is averse to moving, and lies quietly in its cot with its legs and thighs drawn up. Presently it becomes peevish, and any movement appears to produce the greatest pain. It is dusky and pallid, and it wastes rapidly. The gums may bleed or there may be passive haemorrhages from the nose or beneath the skin, and yet it is not a bleeder, for there is no hereditary history, and the joints are unaffected. Sooner or later one or more of the limbs becomes ex- quisitely tender, and the legs more often than the arms. Examination of the tender spots shows that in young children they are usually situated close to the epiphyses, but in older children they may be at any part of the bone. The swelling gradually increases in size and in extent, until the whole bone may be encased in a hard cylinder. This swelling may involve all the bones in I98 THE SURGICAL DISEASES OF CHILDREN both legs and thighs equally or unequally, or it may affect only a single bone. The scapulae, the bones of the skull, and more rarely the bones of the face, are affected in a similar manner. The skin is tense and shining, but it is generally pale, and does not feel unduly hot unless the affected bone is quite subcutaneous. There is a vary- ing amount of oedema. The disease usually lasts many weeks, and during this time the temperature is very erratic, though it rarely rises above 101°- 102° F. Mr. Holmes Spicer describes a sudden proptosis as a feature in some of these cases, though this symptom has not been marked in any of those which have come under my obser- vation ; whilst Dr. Wallis Ord has observed an extensive subcranial haemorrhage. The protrusion of the eyeball, which is accompanied by puffmess and very slight staining of the upper lid, soon becomes bilateral, the ocular con- junctiva either being a little ecchymosed or else quite free. Spontaneous fractures are peculiarly liable to occur. The fracture is either a separation of the epiphysis, or more rarely it is a true fracture through the shaft (fig. 18). It generally occurs without any marked symptoms, and the first sign of its presence is an everted and helpless limb. Dr. Barlow says that the sternum, with the adjacent costal cartilages and a small portion of the contiguous ribs, some- times appear to have sunk back bodily as a result of these changes ; but this condition I have never happened to see. Morbid Anatomy.— Many of the children affected with scurvy die, and the autopsy reveals the presence of exten- sive extravasations of blood beneath the periosteum of the affected bones, as well as an undue loosening of the periosteum throughout the skeleton. The swellings sub- side slowly when the child recovers, and the tenderness lessens. The power of voluntary movement is regained, and the broken bones repair. SCURVY 199 Diagnosis. — The disease lias to be distinguished from septic osteomyelitis, from rickets, from congenital syphilis, and from the cedematous condition into which marasmic children sometimes pass. Rheumatism, hip disease, sar- coma, and infantile paralysis can hardly be mistaken by the most careless observer for scurvy. The chronic nature of the disease and the absence of signs of septic infection distinguish scurvy from osteo- myelitis. The recurrent symptoms, such as the gradual onset in winter months, the cachexia and extreme ansemia, the marked languor, the sponginess of the gums and foul breath, the pain, the ecchymoses and the haematomata, will serve to distinguish scurvy from rickets, from rheumatism, and most other forms of disease. Treatment. — The effects of treatment are very re- markable, and the child often makes a speedy recovery, even from the worst conditions. The diet suitable to the age of the patient should be given, but in the ordinary quantity of milk one lightly boiled and mashed potato should be given in twenty-four hours, the number of potatoes being gradually increased if the child relishes the mixture. The juice of a quarter of a pound of lightly cooked steak may also be added to the milk. The judicious administration of a little raw meat-juice is also of the greatest advantage. This is best made by pouring two ounces of cold water upon a quarter of a pound of rump- steak. The beef must be finely scraped, and all the fat should be removed. The beef is soaked in the water for half an hour, or until it is white, and it is occasionally stirred with a fork. The extract is then strained off through a fine gravy strainer. Two or three teaspoonfuls are enough for a chill of six or seven months old. The juice of one orange should be administered after each meal, and the chill ought to be taken out daily into the open 200 THE SURGICAL DISEASES OF CHILDREN air as soon as the acute symptoms have passed away. A dessert-spoonful of cream may be given night and morn- ing, to be replaced by cod-liver oil as soon as the patient can assimilate it. The tenderness of the limbs is best alleviated by a wet compress. The bcal treatment adopted by my colleague, Mr. Picker- ing Pick, consists " in fixation and perfect rest of the affected limbs, for it must be borne in mind that the blood extravasation is the primary lesion, and that the subsequent fracture probably arises from some slight degree of violence acting on the weakened bone, and therefore every care must be taken by fixing the swollen limbs to prevent this accident taking place. Even after fracture has occurred, fixation is still necessary in order to keep the broken ends in apposition, and to promote union, which in cases that recover seems to take place readily and rapidly, and if attention be paid to position, without deformity. The affected limbs should be bandaged with soft flannelette bandages in such a manner as to fix them in a straight and extended position, and the child should be laid upon a soft pillow to which it can be fixed by a broad flannel bandage passed over the trunk, and on which it can be carried about, and even taken into the open air, with as little movement to its limbs as possible." Massage is useful, after the child has recovered, to counteract the wasting of the muscles and the stiffness of the joints. Dr. Colcott Pox has very kindly permitted me to copy the annexed figure (fig. 18), showing the appearances of the bones and periosteum in a case of infantile scurvy which came under his care when he was attached to the Victoria Hospital for Children. The specimen is in the Museum of the Westminster Hospital. The details of the case are published in the Pathological tiocittijs SCURVY 201 Fro. 18. — The bones of the pelvis and lower extremity, showing the changes wnich occur in infantile scurvy. [From Dr. Colcolt Fox's specimen in the Ifuseum of the Westminster H'>si>itaK] 202 THE SURGICAL DISEASES OF CHILDREN Transactions, vol. xxxviii. The patient was a boy, aged 11 months. He was quite helpless, and he screamed and ssemed to be in great distress when he was touched or when any one approached his bed. The somewhat limited physical examination which could be made, showed amongst other things that the carpal ends of the bones of his forearms and the head of the right humerus were enlarged, whilst the tibiae and fibulae were broken up as completely as if he had been run over. There were no haemorrhages into the skin. The temperature was normal when the child was first seen, but it gradually rose to 104-2° F. The post-mortem examination showed that the right humerus was fractured through the middle third, its upper epiphysis was widely separated by blood-clot, and the periosteum was completely stripped off the shaft in its whole length by an effusion of blood. The left humerus, the bones of the left forearm, and the scapulae were un- affected. Both ilia were unduly soft and yielding, the cancellous tissue of the right was blood-stained, and the periosteum was separated by haemorrhage. The crest of the left ilium was loosened. The periosteum of the right femur was completely stripped off by a layer of extra- vasated blood, and there was a rather irregular oblique fracture of the lower end of the shaft nearly on a level with the epiphyseal line, the ragged ends of the frag- ments being separated by clot. The right tibia was stripped of periosteum, had both epiphyses completely detached, with irregular splintering of the ends, and a comminuted fracture of the centre of the shaft. The right fibula was in a similar condition ; and with regard to the bones of the left extremity, the lesions corresponded exactly with those on the right side. The earliest indication of tenderness in the bones began RICKETS 20; J two mouths before the child was seen, though it had been ailiuc: for six mouths. o RICKETS. The deformities resulting from rickets are constantly- brought to the surgeou to be remedied, and from his point of view rickets connotes alterations in the bony and liga- mentous structures of the body. ^Etiology. — The cause of the disease is unknown, but it often occurs in children fed on patent foods and in those who are suckled for long periods of time by mothers who have been repeatedly pregnant at short intervals. It appears to be due to the failure of the system to assimi- late certain substances, either because they are absent from the child's food, or because when present the digestive tract does not absorb them, or the tissues refuse to make use of them. We do not yet know what these substances are ; some pathologists hold that the disease is due to the defective assimilation of fat, and others that the absorption of lime is wanting. The first symptoms of rickets gene- rally appear during the teething period ; they may appear for the first time in a girl at puberty. Symptoms. — The intestinal symptoms are usually the first to appear. The child has colic and a tumid belly ; it passes more water than usual, and the urine is loaded with phosphates. It sleeps badly, and is restless, often pre- ferring the nurse's arms to its cot. This no doubt is asso- ciated with the tendency to cranio-tabes, which is so marked a sign in many cases. Symptoms of an unstable nervous system also show themselves in convulsions, attacks of laryngismus strid- ulus or its modified form, when the child has " fits of hold- ing its breath." There is often great vascular dilation coupled with profuse sweating of the head during sleep, or 204 THE SURGICAL DISEASES OF CHILDREN as a result of excitement, and there is often bony as well as cutaneous hyperesthesia. The milk teeth are late in making their appearance, and if the child has begun to walk it ceases to do so — "goes off its feet," the mother will say ; why, we do not know ; perhaps it is the result of general debility ; perhaps, as Dr. Lee suggests, it is due to paresis from nerve starvation. This paresis is sometimes so marked that it may be mistaken for a case of pseudo- hypertrophic paralysis. Pathology. — Rickets produces characteristic changes in the bones and in the ligaments which are of great interest to the surgeon, for they lead to numerous changes requir- ing operative measures for their relief. The early bone changes are connected with an imperfect formation and consolidation of the bone, both in the shafts and at the epiphyses. The line of calcified cartilage at the epiphysis becomes much thicker than it should be, and as the bone increases in length, long lines of cartilage-cells with im- perfectly calcified capsules are left behind in the bone, and so appear to dip downwards from the wide epiphyseal line into the newly formed bone. The new bone is imperfectly formed, its tissue is loose and spongy, and a process of absorption takes place in it leading to the formation of spaces filled with abnormal marrow. The same changes take place beneath the periosteum of the shaft, and the bone has its constitution so radically altered that it be- comes soft and pliable, whilst at the same time the epiphyseal line is so much thickened as in itself to give rise to a deformity. Course. — These changes in the bone lead, after a longer or shorter period, to alterations in the skeleton which are liable to become permanent. The head becomes square, its crown depressed, and the fontanelle is not closed by the fifteenth or sixteenth month, as it should be in a healthy RICKETS 205 child. The face has the ill-developed appearance so often seen in the factory hands of our large towns ; the teeth are cut late, and appear at long intervals, they are often notched and soon become carious. They are mis- placed, for the jaws are malformed. The vertebral column becomes altered in shape, partly owing to changes in the bones, and partly owing to yielding of the ligaments, so that various forms of curvature are produced, often antero- posteriorly, sometimes laterally with concomitant altera- tions in the thorax. The spinal column may be curved both laterally and antero-posteriorly. The primary curve in the ricketty lateral curvature is more often to the left than to the right. The pelvis is so altered that there are important modifications in the length of its diameters, a change of great importance in the female. The long bones, including the clavicle, become bent in various directions, usually in that of their normal curves. They break as a result of any slight violence, they may become curiously twisted, or their epiphyses may separate. Alterations also take place at the knee-joint leading to one form of genu valgum, and in the spine causing lateral curvature. These conditions are more fully described on pages 207 and 216. Sooner or later, if the child survives the diarrhoea, and does not die from bronchial catarrh passing into bronchitis or with cerebral symptoms, progressive changes take the place of the retrogressive changes in the tissues. The bones, at first softer, now become harder than usual. Those which have been bent acquire a buttress along their cor- cave surfaces by the condensation of the newly formed inflammatory products, and the bone itself shares in the S3lerosis. The epiphyses unite, and leave dense .and stunted bones which are permanently deformed. The method by which these changes are brought about are as yet only 206 THE SURGICAL DISEASES OF CHILDREN imperfectly known. Their study would well repay any one who chose to devote himself to the subject. Diagnosis. — Rickets has to be distinguished from many forms of digestive and nervous disturbances, from tuber- culous, syphilitic, and scorbutic affections of the bones, and from simple marasmus. When it affects the spine, it is particularly likely to be mistaken for caries. The curva- ture in rickets is less persistent, and is abolished by exten- sion of the trunk (see fig. 9, p. 79). The muscular rigidity is less, and not so lasting ; the pain is less acute, and it does not occur in paroxysms ; but the child is peevish, and has not the intervals of comparative happiness which mark the course of Pott's disease. Treatment. — The treatment of rickets is constitutional for the improvement of the general health, and local for the cure of the deformities. The geuei'al treatment of rickets resalves itself into doses of rhubarb and soda for the purpose of improving the child's digestive powers. It should be fed at regular and stated intervals. Starchy foods, in the form of corn-flour and milk-puddings, are to be given in small quantities at a time. Fats in some cheap form, as margarine, suet, dripping, and frizzled bacon or sardine oil, are often palatable when the more expensive forms are not available or are not relished. The adminis- tration of small doses of cod-liver oil is advisable after each meal. It may be given in combination with minute proportions of phosphorus, either as phosphates or as the element itself, T ig of a grain being a full dose for a child of two years old. Neither drug should be persisted iu if it is found to increase the digestive disturbances to which the child is subject. Plenty of milk should be given, and cream diluted with water is often taken greedily. The child must be kept under the best hygienic conditions, and the patient is easily kept warm at night, KNOCK-KNEE 20J when he is apt to catch cold from throwing off the bed- clothes, by making him sleep in loose flannel pyjamas pro- vided with feet. He should be douched every morning in a tepid bath of salt water, if this proceeding is followed by a good reaction, and he should have plenty of fresh air and good food. Care must be taken to prevent any exaggera- tion in the tendency to curvature of the bones or spine by not allowing him to assume improper positions, and the child's legs may be strengthened by the judicious applica- tion of light and jointed steel supports passing into the sole of the boot and along the outside of the leg to a pelvic band (fig. 19). These supports are especially indicated in children from one to three years of age, for operative measures are not generally required until the bones have become consolidated in their faulty positions. The opera- tive treatment is considered in the next section. KNOCK-KNEE. 18 etiology. — Genii valgum, or knock-knee, is one of the commonest of a group of deformities caused by rickets, though the condition is acquired later in life as a result of various ligamentous and muscular changes. Ricketty knock-knee is bilateral, whilst the acquired form is gene- rally unilateral. The ricketty form is the result of changes taking place at the lower end of the femur, combined with some curving of the shaft of the femur or tibia. Sir George Humphrey has recently and ably defended the thesis that the condition is due to stunt- ing of the outer condyloid part of the femur, due to the fact that it is the weight-bearing portion of the bone. .Most pathologists attribute it to undue growth of the internal condyloid portion of the femur, and they are no doubt partially correct. The ligaments of the joint are scarcely altered. Knock-knee in older subjects is, with 208 THE SURGICAL DISEASES OF CHILDREN or without curvature of the lower part of the shaft of the femur, undoubtedly due to changes in the lateral and intrinsic ligaments of the knee, and at a later period in the muscles, the bones only becoming secondarily modified in very long-standing cases. Flat-foot is sometimes a predisposing cause. Symptoms. — Bilateral knock-knee is noticed in children who are manifestly ricketty soon after they have learnt to walk. The signs are more obvious than the symptoms. If the knees are made to touch each other when the child is lying down, it will be found that the ankles are widely separated, and the interval between the two internal malleoli is the measure of the deformity. The lateral movement in the knee is too free, owing to the stunted growth of the outer condyle, and there is an exaggeration in the normal movements of the joint. There is usually a well-marked projection of bone upon the inner side of the joint, partly due to the internal condyle of the femur, and partly to the upper end of the tibia. This prominence disappears when the knee is flexed. The patella is displaced outwards to a greater or less extent. Treatment. — The treatment of genu valgum and ricketty deformity of the legs by operative measures is of daily occurrence. It is not necessary, however, to adopt it in every case, for in young children the bones are often sufficiently pliable to enable the deformity to be gradually remedied by the application of suitable apparatus (see fig. 19), whilst with better-class patients a pony may be recommended for the boys to ride. In the later stages of rickets when the bones are dense, and in the very extreme cases of genu valgum, an operation is imperatively called for, and it is only wasted time to delay its performance. The operations in ordinary use are those of osteoklasia and osteotomy. OSTEOKLASIA 209 Osteoklasia is of two kinds, either by forcible straight- ening, 18 or by means of the osteoclast. Mr. R. W. Murray has performed the operation of forcible straightening no less than 311 times in 1893, and it was extensively per- formed by the late Mr. Walter Pye. It has been largely employed by the French and Italian surgeons. I have Fig. 19.— Outside splint with pelvic band and lateral attachments for use in the slighter forms of knock-Unee. adopted the treatment in a few cases, and always for children under 8 or 9 years of age whose bones seemed pliable, but I have never been able to acquire the knack of cracking the denser bones without using what I consider to be an undue amount of force, and I have therefore of late years given it up in favour of osteotomy. The technique of forcible straightening is easy to de- P 2IO THE SURGICAL DISEASES OF CHILDREN scribe, but there is a certain knack of breaking even the most compact bone, which is only acquired by practice and cannot be communicated by words. In an anterior curva- ture of the tibia the bone is fractured laterally, and it may be necessary to divide the tendo Achillis to enable the lower fragment to be brought into good position. In forcibly straightening a knock-knee, the thigh is grasped firmly about two inches above the patella, and the surgeon, using his index finger supported by his other fingers as a fulcrum, holds the thigh perfectly steady and gradually straightens the limb till the bone yields, the knee-joint being kept over-extended the whole time. The usual point of fracture it is stated almost invariably takes place where the lower end of the femur joins the shaft, and quite an inch above the epiphyseal line, so that there is no danger of injuring the epiphysis, and so of interfering with the subsequent growth of the limbs. Barbarin, however, has recently devoted his attention to the exact seat of rupture in cases of forcible osteoklasia, and he has demonstrated by the examination of specimens that in some cases the line of the epiphysis is actually involved. The leg and thigh should be put up in a plaster bandage for three weeks after the operation. Ricketty bones are sometimes broken by means of the osteoclast. I have often seen the method employed, but it has always seemed to me to be barbarous, and to be a con- fession of weakness on the part of the surgeon that he had not perfect trust in his ability to keep the wound aseptic. It is a method which might perhaps be recommended in private cases, where the sanitary conditions and surroundings were not all that could be desired ; but even in such cases it would be unsatisfactory, on account of the after-pain, which is greater than that occurring after forcible straightening or after osteotomy. OSTEOTOMY 2 I I Osteotomy is either linear or cuneiform. Linear osteo- tomy is performed for genu valgum, ordinary ricketty curvature, and at the neck of the femur in cases of anchylosis in bad position as a result of hip disease (see p. 124). Cuneiform osteotomy consists in removing a wedge from the tibia for the cure of ricketty bowed legs when the curvature is directed forwards. (1) Linear Osteotomy. — Some modification of Macewen's operation is usually performed for the cure of the more ad- vanced forms of knock-knee in children over five years of age. The limb is rendered aseptic in the usual manner, on the day before the operation, and is wrapped in a gauze dressing. An anaesthetic is given on the following day, the dressings are removed, and the skin of the knee and thigh are thoroughly washed with perchloride of mercury solution 1 in 1000. The leg is slightly flexed and laid upon its outer side on a wooden block covered with absorbent cotton wool freshly wrung out of the solution of per- chloride of mercury. The operator then feels for the well-defined inner border of the femur, and after making the skin tense with the finger and thumb of his left hand, enters his scalpel longitudinally about half an inch above the upper border of the internal condyle. The scalpel is carried on until it reaches the bone after the periosteum has been divided, and an incision is made of sufficient length to allow the osteotome to be entered. The scalpel is now transferred to the left hand without withdrawing it from the wound ; the osteotome, an instrument whose cutting edge is bevelled upon both sides and blunt laterally, is then taken up and is passed into the wound along the side of the scalpel, until its edge is felt to be in contact with the bone. The scalpel is immediately with- drawn and a pledget of lint soaked in the antiseptic lotion is held round the osteotome at its point of entrance to 212 THE SURGICAL DISEASES OF CHILDREN prevent the access of air to the wound. The osteotome is next turned transversely, so that its cutting edge lies across the bone at right angles to the shaft. Its head is then repeatedly struck with a wooden mallet, the osteotome being held firmly in the fingers of the left hand, whilst it is steadied by the extended thumb, until it is felt to have entered the bone for some distance. Bones vary greatly in their density, so that the force used must be regulated in accordance with the require- ments of the individual case. The surgeon soon learns to distinguish when he has passed through the compact tissue on the inner side of the bone, and has come to the can- cellous tissue in the centre. He should withdraw his osteotome as soon as he meets with the resistance offered by the compact tissue on the outer side. An endeavour is then made to fracture the bone by seizing the leg in one hand and the thigh in the other, keeping the pad of wool over the wound with one thumb. A sudden wrench is usually enough to complete the division. It should be the surgeon's object not to enter the osteotome more than once; but if the bone does not yield, it is better to replace the instrument than to use an unjustifiable amount of force in endeavouring to fracture the bone. It is not generally necessary to insert any sutures, as a half- inch skin incision is amply sufficient for the entrance of the osteotome, and I think it is better not to irrigate the wound. The wound is at once dressed with a pad of wet gauze, and the ordinary antiseptic dressings are applied. A flannelette bandage is then applied from the foot, up the leg and over the knee, and a plaster case is fitted from just above the ankle to the fork of the thighs. The case is usually made by cutting a piece of ordinary house flannel of two thicknesses and placing a layer of lint upon its inner side. The shape is represented in the diagram (fig. OSTEOTOMY 213 20), the side ab corresponding to the length of the limb, and ac, bd to its circumference at the thigh and ankle respectively, the piece below bd being the foot piece. The inner lining of lint is sufficiently large to allow of its being wrapped over the edges of the flannel. The flannel is saturated with plaster-of-Paris paste made by mixing one pound of freshly burnt plaster with one pint of water, the excess of plaster being wrung out of the case. The lining of lint is then put in, and the case is bandaged on Fig. 20. — Diagram of plaster case for use after osteotomy of the femur for genu valgum, or after a cuneiform osteotomy of the tibia. to the limb. The limb must be held firmly until the plaster has set, that is to say, until it gives a metallic ring upon being struck, and whilst it is setting the thigh must be pulled outwards whilst the leg is pushed inwards, so as to completely overcome the position of knock-knee. Much of the after-success of the operation depends upon the effectual performance of this simple manoeuvre. The dangers of the operation in children are not great ; and although I have performed it many dozen times, I 214 THE SURGICAL DISEASES OF CHILDREN have never yet got into serious trouble. Sometimes there is sharp arterial bleeding when the scalpel is entered, either because the incision has been made too high, or from the division of some branch of the anastomotica magna or superior internal articular branches ; the bone may be unduly vascular in other cases, so that subsequent oozing may require the dressing to be changed and firmer pressure to be applied. The popliteal artery is not likely to be injured if a narrow osteotome be used, and its edge be carried more towards the front than the back of the bone whilst the section is being made. The after-treatment is of the simplest : the child is kept flat upon its back in bed for three weeks without any change of dressing, unless it has been accidentally soiled, or unless the temperature rises. (2) Cuneiform Osteotomy has to be performed much less frequently than linear osteotomy, as it is only required in the most pronounced cases of anterior bowing of the leg, and when division of the tendo Achillis has been ineffectual in allowing the curvature to be overcome ; the result of the operation is, however, most satisfactory, as may be seen in the annexed drawings (figs. 21 and 22), made from photographs of the same patient. The operation is performed with the same antiseptic precau- tions as in the previous case. A two-inch incision is made immediately to the inner side of the shin at the point of its greatest convexity. The periosteum is divided, and is carefully separated from the inner and outer borders of the tibia, transverse incisions being made through it at the upper and lower margins of the wound. The periosteum, and with it the skin and tissues covering the shin, are then retracted upon either side. A bone chisel is applied with the flat side to the upper part of the tibia, and is made to divide the anterior and the inner surfaces of the OSTEOTOMY 215 bone by repeated blows upon its head with, a mallet until the medullary cavity is reacted. The bone is again cut at the lower border of the wound, and a wedge can then be extracted with a strong elevator. The remainder of the tibia and the fibula are then fractured forcibly, and the leg is brought into good position ; or, if this cannot be done, more bone is removed until the surgeon is satisfied Fig. 21.— Ricketty deformity of the tibia. Fig. 22.— Leas of the same patient after the performance of cuneiform osteotomy. [From a patient who was subjected to cuneiform osteotomy.] with the result. The wound is then thoroughly flushed with a 5 per cent, solution of boric acid, any sharp spiculse of bone are removed with cutting forceps, the edges of' the periosteum are brought together, but it is unnecessary to suture them, and the wound is closed with horsehair sutures. Antiseptic dressings are applied, and the leg is put into a plaster case (fig. 20) and is held straight until 2l6 THE SURGICAL DISEASES OF CHILDREN the plaster sets. The child is kept in bed for about three weeks. Union takes place by first intention if care has been taken to perform the operation subperiosteally, not to bruise the periosteum, and to keep the wound aseptic. The only complication likely to occur is a sharp haemor- rhage from the nutrient artery of the tibia ; this stops, however, as soon as the bone is completely fractured. SCOLIOSIS, OR LATERAL CURVATURE. etiology. — Lateral curvature is essentially a disease of young adult life, and is more common in girls than in boys. It is due to a variety of causes. In a few cases it is congenital, in others it is supposed to be the result of habit, but on inconclusive grounds. It is often a manifes- tation of rickets, but it is most frequently secondary to alterations in the long axis of the body, and so is com- pensatory to other conditions. Under this head come the paralytic form, lateral curvature associated with paralytic affections involving the muscles of one side of the back, that seen in tuberculous affections of the vertebrae, and of the hip, or after knock-knee, or in deformities of the pelvis and hip, in wryneck, and as a result of a cured empyema. Rickets is practically the only cause of lateral curvature during the first few years of a child's life ; and the primary curve in these cases is a little more common upon the left than upon the right side. Morbid Anatomy. — In a typical case of lateral curva- ture the spinal column presents a marked curvature to the right in the dorsal region, and a compensating curve to the left in the lower dorsal and lumbar region. The curve, however, varies as greatly in its position as it does in its extent, and the primary curve may be to the left, the secondary curve being upon the right. The vertebras LATERAL CURVATURE 2 I 7 themselves become greatly modified, for in the more severe cases their anterior surfaces face towards the convexity of the curve, whilst the spinous processes maintain their normal relations better, so that the curvature is much more marked anteriorly than posteriorly. There is con- siderable doubt as to the exact nature of the torsion in these cases, most pathologists maintaining that it is due to modifications in the vertebrae themselves, whilst some hold that it is due to a rotation of the vertebral column as a whole ; and others think that it is only an exaggeration of the tendency towards spiral growth which characterises so many animal and vegetable organisms. As a result of these changes, the transverse processes and the ribs on the convex side are separated from each other and are directed backwards, whilst upon the concave side of the curve they are crowded together and look forwards. The inter- vertebral fibro-cartilages undergo similar changes, or they become wedge-shaped, the thin edge of the wedge being directed towards the concavity of the curve, whilst the ligamenta subflava are shortened along the concavity. The anterior common ligament also undergoes considerable changes, but the posterior common ligament hardly changes at all, even in the most severe cases. The thorax also becomes modified, owing to the changes in the vertebral column, the net result being an increase in the size of its cavity upon the convex side and a con- traction upon the concave side. In severe cases a portion of the thoracic cavity actually lies behind the plane of the vertebral spines upon the convex side of the curve. Symptoms. — The first symptom to be noticed is that " the shoulder - blade grows out," or that the patient carries one shoulder, generally the right, higher than the other, or that his right hip is more prominent than his left. In some cases the right side of the chest seems to 2l8 THE SURGICAL DISEASES OF CHILDREN be more fully developed than the left. The subjective symptoms are ill-defined, and generally a sense of weak- ness is alone complained of, or there may be neuralgic pains due to pressure upon the spinal nerves at the inter- vertebral foramina. A thorough examination of the spine must be made in all suspected cases. It will then be found that the curvature can be classified into three groups. The first, in which there is a simple weakness of the back, and although there is a primary curve, no compensatory condition has yet been produced. In these cases the curvature readily disappears when the child lies flat, or when it is supported by placing the hands under the armpits, or when it is made to bend forwards. In the second stage the curvature is diminished when the patient's vertebral column is supported, but it does not entirely disappear. In the third stage the curvature is permanent, and compensatory changes have taken place. The third and worst form of scoliosis is often accompanied by symptoms due to the alterations in the thorax. The breathing is short, the patient may be subject to bronchitis and pneumonia, and there may be serious vascular dis- turbances culminating in dilatation of the right ventricle. Secondary changes in the abdominal and pelvic viscera are by no means infrequent. Diagnosis. — Scoliosis is more liable to be overlooked than to be mistaken for any other condition. Pott's disease and simple weakness of the spine are, however, occasionally assumed to be cases of scoliosis. Weakness of the spine practically presents the same changes as the first stage of lateral curvature, though the pathology is not identical, for in weak spines there is no rotation of the front of the vertebrae. The two conditions are dis- tinguished from the second stage of scoliosis by making the patient bend downwards with the knees straight and LATERAL CURVATURE 219 the arms outstretched until the finger-tips touch the floor. The scoliotic curve will remain, whilst the curvature of weakness disappears. In Pott's disease the curvature is rather a deviation of the entire body to one side than a sinuous condition of the vertebral column. The bending of the trunk is usually towards the right side, and it is more perceptible when the patient is looked at from before than from behind. Prognosis. — Scoliosis varies greatly in the course which it pursues. The curves usually develop slowly and almost imperceptibly ; sometimes, however, they attain their full development in the course of a few months, and sometimes they remain stationary. The process generally terminates with the cessation of bony growth, that is to say about the twenty-second to the twenty-fifth year. Treatment. — The treatment is either prophylactic or curative, and it should always be causal if possible. Pro- phylactic treatment consists in improving the general health, in correcting faulty or unilateral movements of the spine, and in strengthening as far as possible the ligaments and muscles of the vertebral column by shampooing, and gymnastics carried out under intelligent supervision. The patient should be made to rest in the painful forms of the disease. In the slighter forms she may be directed to lie flat upon her back upon the floor or upon a hard, firm couch for a certain length of time daily, the time to be spent in reading by holding her book above her. Ling's system of Swedish gymnastics may also be tried with good effect in these slighter cases, whilst in the more severe forms the patient should lie upon the affected side, which is supported in a sling consisting of a broad webbing bandage, so adjusted that the weight of the body may serve to straighten the curves. Mechanical means must be adopted if the curvature 2 20 THE SURGICAL DISEASES OF CHILDREN progresses in spite of these slighter measures. The appliances are manifold, and range from a simple diagonal bandage to the most complex and expensive jackets. The consideration of these forms of apparatus belongs strictly to orthopsedic surgery. The chief points to be borne in mind are that they should be as light and as simple as is compatible with utility, that they should not be employed to the exclusion of other methods, and that in every case the treatment should be carried out upon physiological principles, for lateral curvature is essentially an inter- ference with the normal processes of growth, and is not in itself a disease. Lorenz has recently advocated forcible straightening in advanced cases of lateral curvature, with the application of a plaster-of-Paris jacket which is capable of easy removal, and is appropriately padded, to obtain diagonal compression of the thorax. The jackets are put on with the body sufficiently extended to overcome the curvature. WRYNECK. Torticollis is that condition in which the head is held either permanently or intermittently in a condition of uni- lateral abduction, the chin being turned to the opposite side, and being at the same time a little elevated. The condition is congenital or acquired, primary ; or a symptom of some other affection. Congenital Wryneck. etiology. — The congenital form is due to congenital shortening of one sterno-mastoid muscle, perhaps con- nected with defective development of the cervical vertebrae, with errors of intra-uterine position, or as Mr. Grolding- Bird supposes, with a central brain lesion — acute polio- WRYNECK 22 1 encephalitis — akin to acute infantile paralysis. It is far more frequent upon the right than upon the left side, and may be associated with defective development of one side of the face. Diagnosis. — The wryneck in its slightest forma is often better recognised by looking at the patient's reflec- tion in a mirror than by direct observation. Treatment. — The treatment consists in dividing the sternal attachments of the shortened muscle, and the sub- sequent application of some form of elastic apparatus to keep the head straight. Acquired Wryneck. etiology. — Acquired wryneck may be the result of cicatrisation after extensive burns, or from the contraction of the fasciae beneath the skin as a result of various in- flammatory conditions. ' It is occasionally produced by primary contraction of the fasciae of the same character as Dupuytren's contraction of the palmar fascia, or it may be a purely muscular change connected either mainly with the sterno-mastoid itself, or less frequently with the platysma. The muscular contraction may be due to local causes affecting the muscle itself, or it may be due to nerve injury, to nerve irritation, or to inflammatory con- ditions of the parts near the muscle, as in cases of enlarged glands. Acquired wryneck due to muscular spasm is sometimes a sequel of typhoid, scarlet fever, diphtheria, or malaria. New growths in the sterno-mas- toid and injuries of the muscle may produce wryneck by leading to its fibrous degeneration. In other cases the wryneck may be due to paralytic changes in the muscle of the opposite side, or it may be a symptom of cervical caries ; but this form can be readily recognised by the fact that the chin points towards the affected sterno-mastoid, 222 THE SURGICAL DISEASES OF CHILDREN whilst in the other forms it points away from the muscle. The contraction of the trapezius, of the splenius, and of other muscles of the back of the neck sometimes produces various modifications of wryneck. The prognosis depends very much upon the cause. Treatment. — In the mildest forms of wryneck, some form of elastic apparatus is alone necessary, and Mr. Golding-Bird's method is a good and useful one. It consists of " a rubber door-spring attached above to a webbing head-band laced round the crown of the head and below to a stout hook sewn on to a pair of stays, tempor- arily worn for the purpose. The rubber spring has lengths of tape at its ends whereby it is fastened, and by means of which the tension can be regulated." The tension apparatus need only be worn during the day ; and if this be done for two or three months, a cure may be effected. In more severe cases, however, much more prolonged treatment is necessary. When the contraction of the sterno-mastoid is slight, and the wryneck is obviously due to it alone, division of its lower attachments affords excellent results, if care be taken to keep the head erect during the process of repair. The muscle is divided either by the open method or subcutaneously ; personally I prefer to perform the operation subcutaneously. The child is anaesthetised, its neck is exposed upon the affected side, and the two origins of the sterno-mastoid are separately divided from behind forwards, the knife being entered upon the inner side in each case, and the cut being made obliquely downwards towards the clavicle. The division of the muscle is very often followed by a rumpling of the deep fascia, which may lead an inex- perienced operator to suppose that he has not completely divided the muscle. He should not, however, be tempted WRYNECK 223 to enter his tenotome a second time, though many sur- geons recommend the complete division of the deep fascia in all cases where it is deemed expedient to resort to tenotomy for the cure of wryneck. Care must be taken Fig. 23.— Lorenz's head-swing for use in cases of wryneck. [From Hoffa's " Lel\.rbv.ch."~\ to ensure asepsis, and the two punctures are closed with cotton wool soaked in collodion. A bandage is put on, and the head is at once placed straight, or it is pulled a little over to the opposite side, 224 THE SURGICAL DISEASES OF CHILDREN and is secured in that position by means of a plaster case passing round the thorax and across the head at the forehead. This is left in position for eight to ten days before it is taken off, and by that time the wound will be healed. Some fixed support capable of regulation will be required, and it must be supplemented by the use of the head-swing (fig. 23), shampooing, and gymnastics. The cheapest form of head support is made by moulding two collars of poroplastic felt, one across the top of the shoulder to form a tippet, and a second over it round the neck in such a manner that its rounded edge takes a purchase beneath the jaw, and thus supports the neck in an erect position. If it be considered desirable, the sup- port can be made of leather, and the two collars may be connected together by a special spring to maintain con- stant traction in the required direction. This forms the essence of Weinberg's apparatus, but I do not find that it is very serviceable in effecting the purpose for which it is constructed. CHAPTER X NON-TUBERCULOUS FORMS OF ARTHRITIS TRAUMATIC ARTHRITIS. Simple traumatic arthritis, whether due to injury or to perforating wounds of the joints, presents the same symp- toms, runs the same course, and requires the same treat- ment as in adults. The prognosis, however, is rather better in children than in adults, and when suppuration occurs there should be no hesitation in laying the joint freely open and thoroughly draining it. HYDROPS ARTICULI. Hydrops articuli of a very chronic form sometimes oc- curs in the knees of children without any obvious cause. etiology. — The prolonged swelling sometimes leads to the protrusion of hernise of the synovial membrane, and is sometimes associated with dilatation of the deeply seated bursse. I believe that such cases are generally tubercu- lous in origin (p. 127), though in other cases they are perhaps associated with that group of symptoms known as osteo-arthritis (p. 227), for this disease is occasionally met with as a pathological curiosity about puberty. Treatment. — The fluid may be removed by an incision carried along the side of the joint if asepsis can be en- sured, when the joint shows symptoms of weakness, or when there are other pressure symptoms of importance. The wound should be sutured with horsehair, dressed antisep- 225 q 2 26 THE SURGICAL DISEASES OF CHILDREN tically, and the limb should afterwards be kept at rest by the application of a plaster-of-Paris splint until the wound has healed. SECONDARY INFECTIVE ARTHRITIS. 18 * etiology. — The exanthemata are often associated with joint trouble in children. Scarlet fever, typhoid, measles, mumps, diphtheria, and smallpox may all develop symp- toms of arthritis in their course. The inflammation may be a mere neuralgia of the joint, or it may be a true synovitis, either serous throughout, serous becoming suppurative, or suppurative from the beginning. The joints of the lower extremity are more often affected than the shoulder, elbow, or wrist. Spontaneous dislocation may occur as a result of the inflammatory conditions, and this is said to be of especial frequency in the hip. The exact time of the occurrence of the dislocation is often overlooked, as the deformity is masked by the synovial swelling. Where dysentery is common, similar joint affections have been observed in young people. Treatment. — The treatment consists in keeping the joint at rest and allaying inflammation by the ordinary measures. The joint must be laid open and drained if it suppurates ; means must be taken by extension to prevent spontaneous displacement or dislocation, and when it occurs, care must be taken not to overlook it. A secondary dis- location can sometimes be reduced ; but if this is impos- sible, attempts may be made either to form a new joint by employing passive movements, or means may be taken to ensure firm anchylosis according to the joint which is affected. An osteotomy may be required when the disloca- tion has been overlooked, for anchylosis in a faulty position often results, and the operation is usually associated with NON-TUBERCULOUS FORMS OF ARTHRITIS 2 27 a tenotomy to enable the limb to be brought down so as to lie parallel to its fellow. OSTEO-ARTHRITIS. A secondary infective arthritis occasionally assumes a chronic form in children, and leads to a condition which is known for the present as osteo-arthritis. It is seen more often after scarlet fever than after the other exanthemata. Many joints are affected, and the child is quickly crippled by the swelling and pain. The aetiology and pathology of this condition, like that of osteo-arthritis itself, require further study. Prognosis. — The prognosis is very bad ; such children do not recover when the symptoms are well marked, and, unfortunately for themselves and their attendants, do not soon die. Treatment. — The treatment can only consist of local applications to the affected joints for the purpose of allay- ing the pain. GONORRHEAL ARTHRITIS. 18 b Acute inflammation of a single joint is occasionally met with in infants who are suffering from purulent conjuncti- vitis, and in girls who are brought for the treatment of a purulent vaginitis. Pathology. — These inflammations of a single joint have been shown to occur in those cases in which the pus from the vagina and the conjunctiva contained Neisser's gonococcus. Symptoms. — Richardiere 18b and Deutschmann have each recorded cases in which one of the large joints be- came affected with an acute synovitis a fortnight after the appearance of a purulent discharge containing gonococci. The course and symptoms were similar in every respect to those occurring in the gonorrhceal arthritis of adults. 2 28 THE SURGICAL DISEASES OF CHILDREN Treatment. — The affected limb should be fixed upon a splint, evaporating lotions should be applied to the in- flamed joint, and the source of infection should be removed by curing the purulent discharge as quickly as possible. SYPHILITIC ARTHRITIS. Surgeons are so accustomed to see tuberculous inflam- mation in joints, that they are apt to overlook the various arthritic manifestations of syphilis. Varieties, (a) Commencing in the epiphyseal line. — Arthritis, secondary to syphilitic inflammation of the epiphyseal line, occasionally takes place, and it must be treated on the same lines as the succeeding form. (&) Commencing in the joint. — The joints in infants are sometimes affected by a syphilitic inflammation commenc- ing in the joint, which may be serous, but is more often purulent. It sometimes attacks only a single large joint, but two or three joints are generally affected. The cap- sule of the joint soon yields, and extensive diffuse abscesses are formed which may open spontaneously. Good evidence of inherited syphilis is usually available in such cases. The treatment consists in laying the joint open, draining it freely, and giving the child grey powder. Free move- ment is usually obtained in the joint when the child survives the process of suppuration. (c) Gummatous Arthritis. — Syphilitic arthritis also occurs in later childhood, either in the form of a gumma- tous infiltration of the bone and of the fibrous tissue out- side the joint, or as a gummatous synovitis. The disease in either case is extremely likely to be mistaken for tuber- culous arthritis ; but its rather more chronic course, the slight though marked evidence of syphilis in other parts of the body, and the smaller amount of pain, will generally serve to distinguish the syphilitic from the tuberculous NON-TUBERCULOUS FORMS OF ARTHRITIS 229 type of disease. The prognosis is good, except in those cases where the cartilages of several joints are extensively involved; for in these cases the patients die from the effects of the syphilis upon the nervous or digestive sys- tems. The following case illustrates very well the course run by a case of gummatous arthritis, as well as the treat- ment to be adopted for its cure : — A boy, aged 14, came under my care at the Victoria Hospital for Children on the last day of January, 1894, to be treated for an inflammation of the right knee. He had diphtheria in September, 1893, and about a month after- wards sores appeared upon his body. He was noticed to be walking lamely about the end of December. His younger brother has had one ankle-joint excised, presum- ably for tuberculous arthritis. The patient's complexion on admission was muddy, and scattered over his trunk, limbs, and scalp were patches of superficial ulceration covered with thick scales or with black and raised crusts. The voice was husky, but his teeth were healthy, and there was no evidence of keratitis, or of iritis, either present or remote. The glandulae concatenate on both sides of the neck were slightly enlarged. The right knee was affected with synovitis. It measured 12^- inches over the centre of the patella, whilst the left one only measured 10| inches in circumference at the same level. There was a little synovial fluid in the left knee. The synovial membrane in both joints appeared to be thickened, and this was especially marked at the sides. The patient occasionally had a little throbbing pain at nights, but unless the knee was moved he did not com- plain of pain, and he had never felt any starting pains at night. The boy was brought by his mother, who presented such obvious signs of tertiary syphilis that he was at once ordered 230 THE SURGICAL DISEASES OF CHILDREN one-grain doses of grey powder, and in ten days' time his complexion had cleared and his voice was less husky. There was also less synovial effusion in the right knee, whilst the left appeared to be healthy. This improvement continued until March 7th, when the patient was allowed to go home with his right knee in a plaster-of -Paris case. He returned on March 26th, complaining of much pain in both knees, with increased swelling. A plaster-of-Paris splint was again put upon each leg. He returned again on April 2nd, with increased swelling of both knees and some synovitis of both elbows, and he then confessed that he had not taken any powders for a fortnight. He was made to understand that medicine was necessary, and was ordered to continue the one-grain doses of grey powder three times a day. His elbows were less troublesome on April 9th, though his knees were still swollen. He was therefore given half -drachm doses of perchloride of mercury with five grains of potassium iodide three times a day, and a week later he reappeared, saying that his elbows were well, his knees better, and that he had not suffered any pain since he had been taking the new medicine. He in- creased in weight from 64^ lbs. to 71| lbs. between April 16th and April 30th, and has remained well and at work as an errand boy ever since. Mr. Clutton first drew attention to these interesting cases ; and though they are often associated with intersti- tial keratitis, this is not always the case, as is shown by the above instance, where the stress of the disease fell upon the skin and synovial membranes, and not upon the cornea and teeth. (d) Chondro- Arthritis. — The worst form of syphilitic arthritis is fortunately the rarest, for it does not respond to the ordinary antisyphilitic remedies, and it is practi- cally incurable. It is that form of inherited syphilis NON-TUBERCULOUS FORMS OF ARTHRITIS 23 [ which is seen as one of the later manifestations about puberty. The bones and joints are extensively affected by a rarefying osteitis, with a deposit of caseating material in the cancellous tissue. A similar process takes place in the articular cartilages, and leads to the formation of irregular grooves and pits. Symptoms. — The condition may be preceded by tran- sient attacks of synovitis, with evidence of chronic inflam- mation of the long bones. There are usually many other manifestations of syphilis, with evidence of marked intra- ocular lesions. Diagnosis. — These cases are very likely to be mistaken for cases of tuberculous disease of the bones and joints. They are to be distinguished, however, by their slower progress, by their slighter tendency to fungation, and by their association with other unmistakable signs of in- herited syphilis. Treatment. — These patients are often so completely permeated by syphilis that very little can be done for them. Mercurial vapour-baths, perhaps, afford them the best chance of recovery, with the inunction of 10 per cent, oleate of mercury at the affected joints. HEMORRHAGIC DISEASE. Two definite forms of haemorrhagic disease occur in chil- dren — the one peculiar to the individual, the other charac- teristic of the family to which he belongs. (1) Passive heemorrharjes are of no very unusual occur- rence in newly-born children ; but it is only recently that they have been scientifically studied by French and American surgeons. Dr. Townsend, of Boston, has collected a series of cases which show that such haemorrhages are most frequent from the stomach, navel, intestines, vaginrt, mouth, and nose. They also occur as bruises beneath the 232 THE SURGICAL DISEASES OF CHILDREN skin. They are usually seen within the first seven days of birth, the majority beginning on the second or third day. Prognosis. — The affection is a serious one. Half the cases which die are fatal within the first day, and the remainder within a week. Recovery takes place in the slighter and more favourable cases within nine days. The haemorrhage is associated with a marked rise of tem- perature. Its cause is at present unknown, but it is not associated with any injury to the child, and it is quite unconnected with haemophilia. Treatment. — Rest, careful feeding, warmth, and minute doses of alcoholic stimulants during the stage of collapse seem to give the best results. (2) Haemophilia differs from the previous condition in the fact that it is rarely seen before the end of the first year, that it occurs in families, and that in them it is more frequent amongst the males than the females ; whilst during the haemorrhage there is a local, and not a consti- tutional, rise of temperature. Members of bleeding fami- lies are always subjects of great anxiety to the surgeon in whose neighbourhood they happen to live ; and, in spite of all treatment, they usually continue to bleed until they either die or Nature herself arrests the haemorrhage. *&"■ HEMOPHILIC ARTHRITIS. 19 Symptoms. — Sudden swellings of the ankles, knees, and elbows often take place in children who are known to be " bleeders, ' : or to come of a haemorrhagic stock. A few years ago I had two brothers who came to me from time to time on account of painful swellings of their knees and ankles. The attacks came on spontaneously ; the skin over the affected joints was glazed, shiny, and hotter than NON-TUBERCULOUS FORMS OF ARTHRITIS 233 that covering the unaffected parts. There was a good deal of local tenderness, and there was sometimes ecchymosis. Movement in the ankles was impaired, but the knees were free. Pathology. — The joints in such cases are remarkably injured, owing, as some suppose, to the fact that the blood effused into them maintains its vitality for a long period of time, though this case is inadequate to explain the results. The cartilages become shaggy, and the ends of the bones are lipped and irregular in the manner once thought to be characteristic of osteo-arthritis, but which now appears to be common to all forms of very chronic joint irritation. A greater or less amount of anchylosis with deformity is a frequent result of these changes. The bleeding comes from the capillaries rather than from the large arteries, so that some surgeons hold that operations of urgency are not contra-indicated in haemophilia. Treatment. — The surgeon in all cases where haemo- philia is present should warn the child's parents that it is their duty to tell the patient the nature of his disease as soon as he is of an age to understand, for many dangers may thereby be avoided. No styptics should be used to the bleeding point, as they are always useless. Prof. A. E. Wright 19 states that the coagulation time of the blood can be shortened in cases of haemophilia by the administration of three to five-grain doses of calcium chloride three times a day ; and this general treatment may be supplemented by allowing the patient to inhale carbonic acid gas mixed with atmospheric air. The local treatment consists in casing the affected joint in a well-moulded splint of pla'ster- of-Paris, which can be easily removed. The splint should be applied until the heat and swelling have subsided, but as soon as possible gentle passive movement and shampoo- ing should be adopted. The result of repeated passive 234 THE SURGICAL DISEASES OF CHILDREN haemorrhages into the joints is so bad that Prof. Konig has recently advocated the puncture and subsequent wash- ing out of such joints with a 1 in 60 solution of carbolic acid — a method of treatment which I should be very loth to adopt. CHAPTER XI ACQUIRED DISLOCATIONS AND CONGENI- TAL DISPLACEMENTS IN JOINTS Dislocations from injury are unusual in children, partly on account of the elasticity of the capsules and ligaments of their joints, and partly owing to the want of rigidity possessed by the various elements entering into the con- struction of their skeletons. Secondary dislocations as a result of disease are also uncommon, though partial dis- placements are by no means rare. Congenital dislocations are occasionally met with. DISLOCATION OF THE SEPTUM NASI. Mr. Walsham says that dislocation of the anterior end of the septum nasi from the nasal spine is an exceedingly common result of injury. Symptoms. — It gives rise to an unsightly red promi- nence just within the nostril, and usually causes the tip of the nose to turn slightly to the opposite side. It may lead to considerable obstruction. Treatment. — The most satisfactory method of treat- ment, he says, is to shave away the superimposed mucous membrane and the underlying cartilage, layer by layer, till the patency of the nostril and the symmetry of the part is restored. 235 236 THE SURGICAL DISEASES OF CHILDREN LOWER JAW. Dislocations of the lower jaw are practically unknown in children, and they do not occur with great frequency in young adults. Subluxation of the jaw has been known since the time of Sir Astley Cooper. It usually occurs in young people, and is very prone to recur. It appears to be due to relaxa- tion of the capsule, ligaments, and muscles, but its exact pathology is unknown. The exciting causes appear to be yawning or biting upon some hard substance. Dr. Hamil- ton describes the symptoms in his own case as being a sudden arrest of the motions of the jaw with the mouth about half open, the arrest of motion being accompanied, or more usually preceded, by a sensation of slipping in one of the articulations. The chin is slightly inclined to the opposite side. The condyle may be felt somewhat advanced in its socket, and while it remains in this position the patient experiences some pain. The locking in his case was sometimes upon the right and sometimes upon the left side. Treatment. — The condyle can generally be made to fall into place by a voluntary lateral movement of the jaw, but occasionally it is necessary to press gently against the chin with the hand. Prognosis. — The annoyance may cease as the patient becomes older and stronger. ANCHYLOSIS OF THE JAWS. ao etiology and Varieties. — Anchylosis of the jaw is by no means infrequent in children. It is bony or fibrous, bilateral nearly as often as unilateral. Its movements are sometimes impeded as a result of cicatrices of the cheek, due to burns and various ulcerative processes. True bony anchylosis occurs after injury to the condyles, as a result DISLOCATIONS 237 of suppuration involving the glenoid cavity after measles, scarlet fever, or other infective disease, or from the open- ing of a cervical or retropharyngeal abscess into the joint. A curious spasmodic form is sometimes associated with dental caries, or from the irritation of retained wisdom teeth. Treatment. — The symptoms are obvious, for there is difficulty, or even absolute inability, to open the jaws, and any attempt at mastication may be accompanied by severe pain. The treatment is most unsatisfactory. The employment of wedges and the forcible opening of the mouth by gags are cruel and futile expedients, and should not be adopted except in the very simplest cases of fibrous anchylosis. A plastic operation after division of the bands of scar tissue affords some measure of relief when the impaired movement is due to cicatrices. Operative measures are alone beneficial in cases of bony anchylosis. Many forms of operation have been devised, each with the design of obtaining a false joint either on one or both sides of the jaw, as the occasion requires. The methods of Swain, Esmarch, Mears, and Bottini are said to yield the most satisfactory results. Mr. Swain advises that an incision about an inch and a half in length be made at the angle of the jaw, parallel with it, and taking the angle as the centre of the incision. The knife is car- ried down to the bone, the soft parts are retracted, and the periosteum, carrying with it the attachments of the masseter and the internal pterygoid muscles, is raised from the outer and inner surfaces of the angle. A narrow saw is then applied, and a wedge-shaped piece of bone is removed. This piece of bone should include the angle of the jaw, and the base of the wedge should measure about an inch. A similar operation may be at once performed 238 THE SURGICAL DISEASES OF CHILDREN upon the opposite side if the anchylosis is bilateral. The operation is not a difficult one ; there is no bleeding, no important structures are likely to be injured if it is per- formed subperiosteally, good movement is obtained, and the scar is not very perceptible. It is important that union by first intention should be obtained in these cases ; for if suppuration takes place, it is very likely that bony union will take place. Passive movement is begun upon the third day, and is repeated daily for a period of six to eight weeks. Dr. Mears suggests that the use of American chewing-gum is serviceable in these cases to maintain the movements of the jaw during the formation of the false joint. It is often difficult to decide which is the anchylosed side in cases of firm bony union ; but in cases of doubt there is a slight springing of the jaw, which is more noticeable upon the unaffected side ; it is best marked during mastication. The jaw in most cases is slightly displaced towards the affected side, owing to the absorption of bone and carti- lage, which occurs during the process of anchylosis. This displacement is easily detected by noticing the intervals between the incisors in the upper and lower jaws. SHOULDER. Primary dislocations of the shoulder are very infre- quent in children, and their place is taken by separation of the upper epiphysis of the humerus ; but dislocations at the elbow and of the fingers are by no means rare. The signs and symptoms of separated epiphysis have already been given (p. 171). ELBOW. Dislocation of the elbow in children is generally due to falls upon the hand with the palm downwards. The radius DISLOCATIONS 239 and ulna are usually displaced backwards, probably owing to the want of development of the coronoid process of the ulna ; though the radius may be dislocated alone, its head being driven forwards. o DISLOCATIONS OF RADIUS AND ULNA BACKWARDS. Symptoms. — The symptoms presented by a double dislo- cation of both bones backwards are that the elbow is slightly bent, and is so fixed that it can be moved somewhat more readily from side to side than in the ordinary direction ; the hand and arm are moderately pronated ; the lower end of the humerus projects forward, whilst the upper ends of the radius and idna can be felt posteriorly. It is important to know the relative positions of the olecranon and condyles in a normal elbow, as in no other way can a correct diagnosis be made of obscure injuries in this region. Holden, in his Landmarks, says that when the elbow is extended the highest part of the ole- cranon is never above a line joining the most prominent part of the external and internal condyles posteriorly, but it always lies in this line. With the elbow at right angles, the point of the olecranon is vertically below the line of the condyles. In extreme flexion, the point of the ole- cranon lies in front of the line of the condyles. In cases of backward dislocation the olecranon lies at a higher level than the internal condyle ; but the distance between the acromion and the external condyle of the humerus is iden- tical upon the two sides. An intelligent child will some- times complain of a referred pain felt along the inner side of its hand, owing to the stretching of the ulnar nerve over the projecting bone, and there may be numbness along the course of the median nerve. Diagnosis. — A diagnosis has to be made between a 24O THE SURGICAL DISEASES OF CHILDREN backward dislocation of a radius and ulna and fractures at or near the lower epiphysis of the humerus. This is often very difficult, unless the patient is seen directly after the injury, for swelling soon obliterates all the landmarks of the elbow. Flexion of the arm in a case of dislocation causes the olecranon to become more prominent, whilst in extension the prominence is diminished : the exact con- trary of this is observed in cases of fracture at the base of the condyles. Treatment. — Reduction can generally be effected with- out using much force, either, according to Sir Astley Cooper's method, by bending the elbow round the knee, so that the radius and ulna are pressed backwards until they are dis- entangled from the humerus, or by over-extending and then suddenly flexing the arm. The proof of complete reduction is the ability to flex the arm to a right angle. The sur- geon should not be satisfied until his patient can do this ; for, in a case of separated epiphysis, the deformity will reappear as soon as traction is taken off the arm ; and in cases of dislocation it sometimes happens that only one of the two bones is replaced in its normal position, unless the surgeon pays attention to the voluntary power possessed by the joint when he thinks reduction has been effected. The arm must afterwards be put upon a well-padded rectangular splint, and it should be slung with the points of the fingers directed upwards. The elbow should be covered with an evaporating lotion, and the splint should be removed at the end of a week or ten days, massage and gentle passive movements being then adopted. Prognosis. — The result is usually good, but anchylosis occurs rather more often after dislocations of the elbow than in other joints. Arthrotomy or excision of the joint must be performed in these unfortunate cases if other means fail. DISLOCATIONS 24 1 DISLOCATION OF RADIUS AND ULNA FORWARDS. Dislocation of the radius and ulna forwards is sometimes seen in children, but less frequently than the preceding form. It is said to be caused by a fall upon the elbow with the arm in a position of forced flexion. It is rather more frequent in children than in adults, and it is often associ- ated with detachment of the internal epicondyle. Symptoms. — The forearm is shortened and flexed upon the arm when the dislocation is complete, but the forearm is extended in the incomplete forms. Treatment. — Reduction is effected in the incomplete forms by extension, and in the complete form by flexion first and extension afterwards, the arm being treated in the same way as after dislocation of both bones backwards. DISLOCATION OF THE RADIUS. Dislocation of the radius forwards is usually associated with rupture of the orbicular ligament. It may be pro- duced by falls upon the elbow or upon the hand with the arm extended and pronated, or by a direct blow upon the posterior surface. The head of the bone can be felt in its new position, and the tendon of the biceps is relaxed, whilst the forearm is more or less pronated. Flexion beyond a right angle is impossible, as the radius strikes against the front of the humerus. The contraction of the biceps is the chief obstacle to reduction after the injury, and it tends to reproduce the displacement when the head of the radius has been put back into its normal position. Treatment. — Reduction is effected by first flexing the elbow, and then causing an assistant to extend the arm whilst the surgeon presses the head of the bone into posi- tion. The necessary manipulation is generally attended R 242 THE SURGICAL DISEASES OF CHILDREN with success, but the tendency to dislocation is so great that the elbow must be kept bent for at least three weeks. SUBLUXATION OF THE HEAD OF THE RADIUS. A remarkable accident sometimes occurs in children which is provisionally described as a subluxation of the head of the radius. It was known to Hippocrates and to Celsus, and was described by Fournier in 1671. Attention has recently been called to it by Mr. Jonathan Hutchinson, jun., and by Mr. Mansell Moullin in England, and by Dr. van Arsdale and Dr. van Santvoord in New York (p. 180). ^Etiology. — The injury always results from some cause which leads a child suddenly to bear its entire weight upon the arms whilst they are fully extended. It occurs in children under nine years of age, but it is most common under six. I have seen the accident result from a fit of temper when an obstinate nurse has jyulled in one direction and a still more obstinate child has pulled in the other. Symptoms. — The child immediately allows the hand to hang downwards, as if it were paralysed. He complains of pain in the wrist, and feels pain on attempting to lift, bend, or extend the forearm. There is no marked defor- mity of the arm or at the elbow, but the arm is pronated and slightly flexed. Pressure over the head of the radius always causes pain, and voluntary supination is impossible. Morbid Anatomy. — The cause of the condition is quite unknown, although many theories have been put forward to account for it. It is perhaps associated with a more or less complete displacement of the small and ill- developed head of the radius beneath the orbicular ligament. Diagnosis. — The symptoms are so characteristic that, DISLOCATIONS 243 coupled with a history of the injury, they are not likely to be mistaken for either a bruise or a sprain of the wrist or elbow. Prognosis. — The prognosis is good, for even if left un- treated a perfectly useful arm results. Treatment. — Extend the arm by pulling upon the hand, supinate it, and at the same time press downwards and backwards upon the head of the radius until it has descended to a level with the articulating surface of the humerus. The forearm is then flexed upon the arm, so that the hand passes outside the shoulder, the pressure upon the head of the radius being at the same time vigorously maintained. The arm should then be bandaged to a well-padded rectangular splint for three or four days. The supination appears to be the most important part of the manipulation, and the reduction of the injury is usually effected with a distinct snapping sound and sensation at the head of the radius. DISLOCATION OF THE PHALANGES. 21 Dislocations of the phalanges upon each other or at the metacarpophalangeal joint occur rather frequently in chil- dren, either from falls or direct injuries. They are simple and incomplete, when the phalanx has not left the head of the metacarpal, or they are simple and complete, the phalanx being displaced backwards. Complex forms of backward dislocation also occur in which the phalanx of the thumb is dislocated backwards, but the glenoid liga- ment with its sesamoid bone becomes turned upon itself, and is interposed between the articular surfaces of the metacarpal and the phalanx in such a manner as to render the dislocation irreducible. I am indebted to Mr. Battle for his kindness in lending me the figures 24 and 25 which show the normal and injured condition of structures at the 244 THE SURGICAL DISEASES OF CHILDREN metacarpophalangeal joint. Faraboeuf thinks that this accident is nearly always the result of ill-judged attempts to reduce the simple complete form. Treatment. — Mr. Battle, 21 who has paid much attention to these injuries, recommends that the displaced phalanx should be hyperextended and tilted up until its articular Fig. 21. Fig. 25. Diagrams of the anatomical structures at a metacarpophalangeal articula- tion, before and after dislocation of the joint. [From blocks kindly lent by MV. W. H. Battle.] Fig. 24. — Section through metacarpophalangeal joint (after Henle). M, head of the metacarpal bone ; P, base of the first phalanx ; a, tendon of the flexor profundus digitorum ; b, tendon of the flexor sublimis digitorum; c, glenoid ligament; d, dorsal ligament (absent, according to Gray); e, vaginal ligament ; /, interosseous ligament; g, tendon of extensor communis digitorum. Fig. 25. — Diagram to illustrate the position of the glenoid ligament, antero- posterior section. M, metacarpal bone ; P, phalanx ; c, glenoid ligament dis- placed and turned upon itself; d, ruptured dorsal ligament, occasionally present. surface projects anteriorly under the skin. The two fore- fingers should then be placed so as to keep it in position, and pressure should at the same time be made against the distal extremity of the metacarpal bone. Firm pressure of the surgeon's thumb against the base of the dislocated phalanx will then permit it to be pushed into place. The reduction is generally easy, and is accompanied by an audible click. In complex cases the base of the phalanx DISLOCATIONS 245 should be carried backwards along the dorsal surface of the metacarpal bone, whilst traction is made upon the thumb so as to pull .the ligament with its sesamoid bone more fully in front of the anterior margin of the articular surface of the phalanx before flexion. An anaesthetic must be given if this method fails, and the glenoid ligament must be divided subcutaneously. The tenotome is entered in the middle line and on the dorsum of the metacarpal, so as to avoid the sesamoid bone. If reposition cannot yet be effected, a lateral incision should be made along the joint, and the ligament or flexor tendon must then be replaced. After severe compound fractures, or when anchylosis of a joint has taken place as a result of an injury, the head of the metacarpal bone may be excised, passive movement being adopted at the earliest possible opportunity. DISLOCATION OF THE HIP. Traumatic dislocations of the hip are not of frequent occurrence in children. I have only seen one. The head of the bone lay on the dorsum ilii in a boy of eight years, and it was reduced without difficulty by manipula- tion. Hamilton records several instances in children from six months old and upwards. The mechanism of produc- tion, the varieties, the method of reduction, and the after- treatment are the same as in adults. DISPLACEMENTS IN JOINTS SECONDARY TO DISEASE. 22 Secondary displacements of the hip, shoulder, elbow, and knee are of frequent occurrence as a result of chronic or destructive inflammation of the joints, and in exceptional cases true dislocation may occur. One of the great objects in the surgical treatment of chronic arthritis is to prevent 246 THE SURGICAL DISEASES OF CHILDREN the occurrence of such accidents, or if displacement is inevitable, to minimise its evil results. Displacements of the shoulder and knee are often coexistent with paralysis of the limbs. They are caused by alterations in the muscles, ligaments, and capsule, owing to trophic changes, or they may be produced by alterations in the ends of the bones themselves. Treatment.— Arthrodesis (p. 195) may sometimes be satisfactorily performed for the relief of this condition ; but more usually some form of orthopsedic apparatus is employed to render the limb less cumbersome. CONGENITAL DISPLACEMENTS IN JOINTS. Congenital displacements have been described in the lower jaw, the ensiform cartilage of the sternum, at either end of the clavicle, at the upper end of the humerus, either back- wards or forwards at the wrist, at the fingers, and at the patella. The details of these congenital defects will be found in the works of R. Smith of Dublin, and of Jules Ouerin of Paris. Such displacements are rare ; they are treated by the use of suitable orthopaedic apparatus, and they may be dismissed without further remark. Con- genital displacement of the hip and knee stand on rather a different footing. Our knowledge of their pathology, causation, and treatment has been lately advanced, and they may therefore be considered in greater detail. Congenital Displacement of the Hip. 23 Morbid Anatomy— There is no longer any reasonable doubt that congenital displacement of the hip is due to a malformation of the acetabulum, due to developmental errors in its iliac segment. Secondary changes occur in the head of the femur, and it is never caused by injuries at birth, as was formerly maintained by nearly all sur- CONGENITAL DISPLACEMENTS 247 geons. The displacement is more often bilateral than unilateral, and in 88 per cent, of the cases it occurs in girls. Fig. 26. Fig. 27. Figs. 26, 27.— Single and double congenital displacement of the hip. The case of single displacement is copied by permission from Mr. Adams' work. Symptoms. — The defect is not usually discovered until the child begins to walk. Attention is then called to it 248 THE SURGICAL DISEASES OF CHILDREN by the peculiar gait which is acquired owing to the play of the head of the femur upon the dorsum ilii inside the elongated capsule. This leads to a rolling, waddling move- ment if the displacement is double, for at each step the body is inclined towards the limb upon which the weight is borne. The physical examination is best made by sit- ting behind the patient, who has been stripped. It will then be noticed that the buttocks are unduly wide, that the great trochanter is raised above Nelaton's line, and that the child presents the peculiar form of lordosis known as "saddle-back" (figs. 26, 27). Mr.Barwell 23 has recently shown that when the patient bends forward with the knees straight the trochanter on the affected side projects up- wards above all the other bony points of the pelvis in an absolutely unmistakable manner. A further examination may next be made in a recumbent position. It will then be found that the affected leg is shortened, but that the shortening can readily be overcome by pulling upon it, though, as soon as the extending force is taken off, the head again ascends and assumes its original position, which is usually above and behind the acetabulum. A slight jerk will often be felt as the femur passes over the sur- face of the ilium, as though it were moving along an irregular surface. Diagnosis. — Congenital displacement has to be dis- tinguished from the weak joint associated with infantile paralysis or unnoticed septic arthritis occurring in connec- tion with one of the exanthemata ; but, as a rule, there is not the least difficulty in recognising a congenital dis- placement if attention be paid to the history and to the symptoms. Prognosis. — The prognosis is at present very unsatis- factory, for no method of treatment has yet succeeded in giving a perfect limb, though all methods claim to improve CONGENITAL DISPLACEMENTS 249 a condition which in its slighter forms is only incon- venient. Treatment. — Many methods of treatment have been adopted. They may he divided into operative and ex- pectant. The most recent operative method is that carried ont by Lorenz. The limb being extended, he divides the adductors sub- cutaneously. Through the same incision the hamstrings are likewise detached from the tuberosity of the ischium. An incision between two and three inches long is then made from the anterior superior spine of the ilium vertically downwards. This enables the operator to divide the fascia lata, tensor fasciae femoris, the anterior edge of the gluteus medius and the sartorius in a transverse direction. Passing more deeply between the tensor fascise and the sartorius, he introduces a director under the tendon of the rectus femoris, which he divides immediately below the anterior inferior spine of the ilium. The anterior aspect of the capsule having been exposed, the joint is opened by a crucial incision. Extension is now relaxed, the thigh flexed and adducted, and the femur forced upwards so as to bring the head into contact with the acetabulum. At this stage of the operation it is im- portant to divide with a probe-pointed knife a few tense bands from the capsule which are inserted into the neck of the bone. When this is done, the acetabulum can be reached and even seen by separating the edges of the opening. The cotyloid cavity is now enlarged, care being taken to preserve the bony rim intact above and behindhand a little extension brings the head opposite the acetabulum, into which it readily glides. The operation is completed by closure of the external wound, except in its middle part, which remains open. Lastly, an apparatus is applied which maintains the thigh in a position of slight abduction. 25O THE SURGICAL DISEASES OF CHILDREN This, like all other operative measures, is only indicated for patients between the ages of 4 and 7 years of age, as a cutting operation is difficult and dangerous in older chil- dren. Division of the femur below the trochanter is serviceable for older children when there is extreme de- formity of the hip with adduction. Hoffa's operation may also be adopted in these cases. The head of the bone is sawn off at the intertrochanteric line in his operation, the posterior part of the capsule is cut away in order to allow of good apposition of the limb, which is then put up in a plaster case in an abducted position. When the displacement is unilateral and only slight in degree, it may be sufficient to conceal the shortening by the use of some form of high boot. Lannelongue's method of sclerogeny (p. 102) is sometimes serviceable when the range of movement is unduly extensive. The treatment of these cases by prolonged rest with extension has found many advocates, either in its simplest form, as has been advocated by Buckminster Brown and by Mr. William Adams (to whose kindness I am indebted for fig. 26), or in its abridged form by division of the tendons and by endeavouring to form a new acetabulum. The method of absolute recumbency for two or three years, followed by the use of instruments to secure the immobility of the hip for a further period of eighteen months, sometimes yield satisfactory results if it be adopted for children of two or three years old. Congenital Displacement of the Tibia. Congenital displacement of the knee is less frequent than a similar condition in the hip. Of the twenty-six recorded cases, Hoffa says that fifteen were double, and of the rest nine were on the left side and onlv two were on the right. Both sexes are equally affected, and there is no evidence of CONGENITAL DISPLACEMENTS 25 I any hereditary predisposition. The tibia is nearly always dislocated forwards, for only in a single instance did it lie behind the femur. There is no difficulty in recognising the condition, though it must not be mistaken for the back-knee, which results from defective growth at the epiphyseal lines, and is often connected with infantile para- lysis. Congenital absence of the patella has been noticed in a few cases of congenital dislocation of the knee. The prognosis is good when the affection is unilateral. Treatment. — The dislocation should be reduced and the leg should be fixed in a plaster case extending above the knee for a week. Massage and passive movement should then be commenced, the splint being removed daily until, at the end of a fortnight, it can be entirely laid aside. Passive Dislocations of the Fibula. 21 The upper end of the fibula is sometimes dislocated, either completely or incompletely, in children. The head of the bone is usually displaced outwai'ds, and although it is readily replaced, it is as readily dislocated again. The condition appears to be due to knock-knee, when it is only accidentally discovered, or it may result from in- jury. It may be due to congenital defects, to weakness of the ligaments, or to infantile paralysis of the quadriceps. The signs are obvious, the symptoms less well defined ; for the child walks easily, but is apt to stumble. The treatment must depend upon the cause. The knock- knee must be corrected, and it may be necessary to suture any ligaments which have been torn in cases following upon an injury to the knee. Congenital Displacement of the Patella. The knee-cap is sometimes displaced congenitally. It is 2^2 THE SURGICAL DISEASES OF CHILDREN always outwards, and is generally associated with knock- knee. Heredity appears to play a great part in its pro- duction. Its treatment is unsatisfactory, but an attempt may be made to remedy the defect resulting from the deformity by the application of a light outside iron splint with a pelvic band. Congenital Displacement of the Elbow. Congenital displacement of the elbow is very rare. Both bones may be dislocated backwards or forwards, or the radius alone may be displaced, though this is exceed- ingly rare. Excision, either of the joint or of the head of the radius, may be performed in very severe cases. Congenital Displacement of the Shoulder. Congenital displacement of the shoulder is of unusual occurrence, for most of the recorded cases have been met with in adults, and there is reason to suppose that they were of paralytic origin. The dislocation in the undoubted cases has either been of the subcoracoid or subacromial variety, whilst in one of Gruerin's cases the head of the humerus was displaced upwards and outwards. Graillard has seen a girl whose humerus was observed to be displaced a few days after birth. At sixteen years of age she was found to have developed an infraspinous dis- location, with fixation and much wasting of the shoulder. Treatment is ineffectual. CHAPTER XII SURGICAL AFFECTIONS OF THE LIPS, MOUTH, TONGUE, AND (ESOPHAGUS Harelip. Varieties. — Harelip is either partial or complete, single or double. It may or may not be associated with a cleft palate, and in cases of double harelip there may be marked alteration in the position and relation of the intermaxillary bones, and of the alse nasi. In some more rare cases the cleft is median, in others it is a cleft of the lower lip, and in yet others the cleft is lateral and extends into the cheek, constituting a condition of macrostoma. The recog- nition of harelip presents no difficulties, and the only questions that arise in connection with it are, when and how it shall be cured. Feeble children who are wasting daily in spite of their being able to suck, the surgeon will have nothing to do with ; syphilitic babies come into the same category, and so do those who have thrush, diarrhoea, or bronchitis. The operation in each case, however, may be performed as soon as the child's health is restored. Wasting babies are often rapidly improved by forced feeding. This is best effected by passing an inch and a half or two inches of india-rubber tubing to the back of the mouth and connecting the other end with a glass syringe. The syringe, filled with liquid food, is worked rhythmically to imitate the discharge of milk from the nipple. 254 THE SURGICAL DISEASES OF CHILDREN Time for Operating.— The best time for the operation is during the fourth month, for the child is then strong and well able to bear the loss of blood, whilst it is suffi- ciently far from the commencement of the teething period to prevent any anxiety on that score. When it is impos- sible for the child to get sufficient food owing to its inability to suck, and when it is otherwise healthy, it may be necessary to operate earlier ; but such cases are very rare, and much depends upon the nurse. Operation. — The mouth, gums, and nose must be thoroughly cleansed before the operation, by means of small pledgets of absorbent wool soaked in a saturated solution of boric acid. The child is then wrapped up in a sheet to prevent it raising its arms during the operation, and it is anaesthetised. The assistant stands upon the left side of the patient, and takes the lip upon either side of the cleft, between the finger and thumb of each hand, in such a manner as to compress the inferior coronary arteries and so to arrest the bleeding. The surgeon then everts the lip, and with a thin scalpel separates its outer portion very freely from the cheek by cutting through the mucous membrane until the sides of the cleft can readily be ap- proximated ; but if possible he leaves the central edge of the cleft and the frsenum of the lip untouched. A piece of sponge on a holder is then pressed between the cheek and the bone to arrest the haemorrhage, and a fresh supply of chloroform is administered to the patient. The operator then takes a pair of toothed forceps in his left hand, and with the scalpel in his right, he proceeds to pare the edges of the cleft upon both sides, taking care to pare the angle in a simple cleft, and to carry his incision well up into the nose in the complete form. The paring should be liberal, and must include the whole of the red surface of the lip. The edge should be completely cut HARELIP 255 away on the central border, but it should not be detached upon the cheek side, where it should be left as a flap. The edges of the cleft are approximated at once, so that the two borders of the lip are in exact apposition, and a suture of silver wire is passed through the whole thickness of both sides of the cleft, at the point where the two arteries have been cut, to arrest the haemorrhage. Horse- hair sutures are then put into the lip above and below the wire suture, so as to bring the edges into accurate contact. The flap attached to the outer side of the cleft is then brought over the lip upon the inner side, and for this purpose the free border of the lip upon this side has been freshened. It is secured by a horsehair suture. The notch which sometimes appears after the operation for harelip can in this way often be prevented from appearing. The lip is gently dried, and a piece of cyanide gauze shaped like the figure 00 is cemented over it with collodion, a piece of strapping being applied over the whole to keep it firm. The wound usually requires dressing on the third day, and it sometimes happens that union is so complete as to enable the sutures to be removed ; more often, however, they must be left in position from four to seven days, though it is better to remove them as soon as possible. Modifications. — The above is the simplest operation, but it is rarely performed in its naked simplicity, for no two cases of harelip are alike, and the surgeon is called upon to exercise his ingenuity as often in this operation as in any other plastic procedure. When the cleft is complete, the nose is often much flattened, and it must be dealt with before any operation is performed upon the lip. Mr. Thomas, of Birmingham, has recently introduced a slight modifica- tion in the treatment of these cases, which is often very useful. The first step in his operation consists in restoring the margin of the nostril, by freeing the outer edge of the 256 THE SURGICAL DISEASES OF CHILDREN ala nasi, and attaching the edge of its cartilage to the columna nasi. An interval is then allowed to elapse until union is complete, and the ordinary operation is then per- formed. The most troublesome cases of harelip are those in which the cleft is wide and has uneven margins, or those in which the premaxillse are displaced ; for a double harelip is not necessarily more difficult to close than a single one. The surgeon has to be guided to a certain extent by the necessities of each case, as no hard-and-fast rule can be laid down for the treatment of the premaxillse. The broad rule is that they must be saved as often as possible, when their retention does not militate against good union of the lip on the one hand, or against the prominence of the alse nasi on the other. It sometimes happens that if undue force be exerted to twist and maintain them in good position, the tip of the nose may be unduly flattened; whilst, on the other, if they be ruthlessly cut away on every occasion, an unsightly and square upper lip is produced. If the mass is attached to the tip of the nose, it had better be removed after its covering of mucous membrane has been turned downwards to enable it to be utilized at a later stage in the operation. Kronlein's suture should be employed when the tissue is deficient, when an undue strain is put upon it, or when from any cause union by first intention has failed, and it is necessary to obtain adhesion by granulation. A piece of stout silver wire is threaded through a pearl shirt- button which has been boiled to render it aseptic, its free end is passed with a needle through the cheek just beneath the malar bone, and then transversely across the gum to an exactly corresponding point beneath the opposite malar, where it is threaded to a second button and drawn suffi- ciently tight to keep the two borders of the cleft in good HARELIP 257 apposition. A useful tension suture is thus obtained, and if the silver wire is thick enough, it may be left in position without producing any suppuration until good union is obtained, and it only leaves two pinhole scars which are hardly noticeable. It is often a mistake to try and do too much at a single operation upon a harelip, for the child becomes collapsed, or unduly weakened by loss of blood, and the tissues do not then repair by first intention. It is better to perform two or three operations in severe cases, and except in the simplest forms, a secondary operation is very frequently required. After-Treatment. — The after-treatment consists in keeping the child quiet and in not permitting it to cry. It should be fed from a feeding-bottle which allows the fluid to be drawn up easily. Mr. Jacobson and Mr. Wright have both drawn attention to the urgent dysp- noea, even to asphyxia, which sometimes occurs after the operation for harelip. It is due apparently to a valvular action of the lower lip, preventing the entrance of air into the lungs of a child who has not yet learnt to breathe through its nose. The dyspnoea comes on suddenly, and the condition is a relapsing one. It is rare, fortunately, for it is so fatal that each of the three recorded cases died. No child, therefore, who has been operated upon for a harelip, should be left without the supervision of a nurse. She must be instructed to depress the lower lip, at inter- vals of ten minutes for an hour or two after the operation, to enable the child to obtain plenty of air by its mouth, if it presents symptoms of dyspnoea. She ought also to be shown how to maintain artificial respiration, and she must be told instantly to send for assistance if the child becomes livid. 258 THE SURGICAL DISEASES OF CHILDREN CLEFT PALATE. Varieties. — Congenital clefts of the palate may or may not be associated with harelip. Clefts of the hard palate are always associated with clefts of the soft palate ; but the soft palate is sometimes cleft, whilst the hard palate is normal. Cleft palate in the early life of a child causes trouble in deglutition, and in later life speech is altered. The earlier difficulties can be overcome by allowing the child to suck from a bottle with a very large nipple, or from one in which the nipple has attached to it a soft metal cover (fig. 28) serving as an obturator, or by careful feeding with a half-decked spoon. The later difficulties Fig. 28.— Nipple, with flexible metal shield, for the use of infants with cleft palate. are partially removed by repairing the defect before the child has learnt to talk. Time for Operation.— The operation should therefore be performed when the child is about three years of age ; but the harelip, if it be present, should be repaired at the ordinary time, as its closure appears to exercise some degree of traction upon the two inaxillse, and so prevents undue widening of the cleft, if it does not actually tend to close it. The Operation.— The tonsils, if they are unduly en- larged, should be removed before the operation is undertaken. The child otherwise needs but little preparatory treatment beyond the ordinary purge and the application of an anti- septic solution to the mouth and naso-pharynx. The CLEFT PALATE 259 patient is anaesthetised, and is so placed upon the operating table that his head hangs vertically over the end, in the manner recommended by Professor Rose, of Berlin. The table must be arranged to get the best possible light upon the mouth, for it is of the utmost importance that the surgeon should see quite clearly every part of its roof. A skilled anaesthetist is very necessary in cases of cleft palate ; for the ease of the operation, and often a great part of its success, will materially depend upon his abilities. A gag is introduced into the side of the mouth, and the simpler the pattern the better ; it is taken charge of by the assistant, who stands upon the left side of the patient, whilst the operator stands upon the right side. He then takes a narrow-bladed scalpel fixed into a long handle, and with it he makes an incision upon either side of the palate, external to the descending palatine artery, and reaching from the anterior angle to the posterior border of the cleft in the palate. The mucous membrane, with its glands and the periosteum, are then raised with a raspatory upon either side, and along the whole length of the incision, so that the two flaps hang loosely, and can readily be brought together along the middle line. This stage in the opera- tion is attended by much bleeding, and it is an important part of the assistant's duty to prevent the blood passing into the trachea ; for this purpose he is provided with numerous small pieces of surgically-clean sponge, mounted on holders. The whole depth of tissue down to the bone must be taken up in the flaps, and their thickness is often a matter of surprise. As soon as the flaps have been detached, a piece of sponge is held lightly against them in such a manner as to com- press them against the palate, whilst a fresh supply of chloroform is administered to the patient. The bleeding soon stops, and the surgeon then proceeds to pare the edges 260 THE SURGICAL DISEASES OF CHILDREN of the cleft. He seizes the extremity of one side of the uvula with a pair of long-handled forceps, and makes one side of the cleft tense. He then enters a sharp-pointed and thin knife, which may be double-edged if he prefer it, close to the margin of the cleft, and pares the whole of one side ; the other end of the uvula is then stretched, and the pro- ceeding is repeated upon the opposite side, especial care being taken to freshen the anterior angle of the cleft and the tips of the uvula. Professor W. Rose, of King's Col- lege, who has had very great experience in performing the operation, strongly recommends that the mucous membrane should be cut away in a single strip, so as to ensure its complete removal. It is enough to freshen the edge if the incision be made square, and in no case should it be bevelled. Every fragment of tissue in an operation for cleft palate is of importance, so that no more should be removed than is absolutely necessary. In simple cases, when the edges of the flap come to- gether readily in the middle line, the sutures may be inserted at once ; but if there is the least tension upon them, it is better to pass underneath the palate a pair of blunt-pointed scissors curved upon the fiat, and to cut transversely so as to divide the attachment of the palate to the posterior border of the palate bone. Professor W. Rose relieves the lateral tension by dividing the levator palati. " A narrow-bladed and probe-pointed bistoury is introduced through the lateral aperture in the palate upon either side, and is carried directly backwards through the soft palate." The tip of the uvula is first united by a horsehair suture introduced by a curved or rectangular needle fixed into a handle, and care must be taken to get- exact approximation of the two points, so that the uvula should not afterwards look bifid. The suture is tied in a reef knot, and is left long. Its ends are then seized in a CLEFT PALATE 26l pair of long dissecting forceps, and they are pulled back- wards towards the pharynx until the uvula is stretched ; a second horsehair suture is then introduced into the uvula and tied, and its ends are cut off. Three sutures are generally sufficient. The main sutures in the muco-periosteurn of the hard palate should be of silver wire (No. 30 or 32 gauge). They are introduced from behind forwards, one at the base of the cleft, a second about the middle, and the third an- Fig. 29. — Diagrams showing the old method of inserting sutures in the operation of cleft palate (the left-hand figure), and the method recommended by Professor W. Rose (the right-hand figure). [Copied by permission from Prof. Rose's work on Cleft Palate and Harelip.] teriorly. Personally, I always use Mr. Thomas Smith's tubular needle, but many surgeons employ angular needles fixed in a handle. The wire sutures should not be drawn together until the secondary sutures have been introduced. The secondary sutures are of horsehair, and Professor W. Rose has shown that much better results are obtained when they are introduced by needles, whose cutting edge is at right angles, instead of lying parallel to the edge of the cleft like those generally made, as will be seen in the annexed 262 THE SURGICAL DISEASES OF CHILDREN diagram (fig. 29). As soon as all the sutures are passed, the ends of the one in the uvula are cut short, the wire sutures are twisted up, the anterior one first, then the middle, and finally the posterior one. The horsehair sutures are then tied off, and in a nicely finished operation the united cleft should appear as a single line running straight fore and aft without any puckering. In tying the sutures, care should be taken that the edges of the wound do not become inverted. When it is doubtful whether the hard or the soft palate should be closed, it is better to operate upon the hard palate first ; but when it is possible, the whole palate should be closed by a single operation. The cleft is some- times so large that it is impossible to close it by the ordi- nary linear incision, and Mr. Davies Colley has recently recommended an operation by means of flaps for these cases. The cleft again may be so large that no operative measures will close it, and such cases must be sent to the dentist to be provided with some form of obturator. Dangers of the Operation. — No serious danger at- tends the actual operation for cleft palate, if the pharynx be kept clear of blood ; but serious haemorrhage from the descending palatine artery may occur as late as the ninth day, as in a case which I reported in the British Medical Journal for 1894. When this happens, the wound should be carefully explored in a good light, if ice and the ordinary measures fail to check the blood-flow, and an endeavour should be made to secure the bleeding point. Haemorrhage, both immediate and remote, is due to puncture or partial injury of one of the main trunks of the descending palatine artery ; and if it occurs at the time of the operation, the trunk must be completely divided, as the collateral circula- tion is so free that there is no risk of the flap sloughing. After-Treatment. — The after-treatment consists in CLEFT PALATE 263 keeping the patient very quiet, silent, and with his head low. Food should not be given for three hours after the operation, and only sparingly for twenty-four hours. Spoonfuls of warm milk and water may then be given at frequent intervals, with soups or jelly. Bread and milk may be given on the seventh day, but hard food should be withheld for at least a [fortnight. The sutures may be removed in a fortnight or three weeks, the silver sutures being removed last. After each meal the mouth should be gargled with a 1 in 40 solution of warm boric acid solution. Secondary Operations.— Some part of the cleft often remains unclosed, or, more rarely, the operation may be a total failure. When a small sinus alone exists, it should be left untouched for a time, as it occasionally closes spon- taneously during the process of cicatrisation. If it fails to close, it may be touched with the point of a Paquelin's cautery. When the unclosed part is larger, a repetition of the original operation may be required. EPITHELIOMA OF THE LIP. Epithelioma of the lip occurs in children as a patho- logical curiosity, with the same characters, running the same course, and requiring the same treatment as in adults. BANULA. Banula occurs either congenitally, as a cystic formation in connection with the glands of Nuhn, or due to blocking of one of the mucous follicles in the floor of the mouth. The tumour derives its name from a fancied resemblance to the guttural pouches in the frog. It is either placed laterally, or it may extend over the whole floor of the mouth. 264 THE SURGICAL DISEASES OF CHILDREN Diagnosis. — The ranula must be distinguished from a dermoid cyst in the same region. The mucous membrane in a ranula is so thin that the fluid can be seen beneath it, and is glairy ; whilst in a dermoid the covering is too thick to allow the more solid contents of the cyst to be visible. The diagnosis between a ranula and some forms of congenital cyst in the floor of the mouth can only be made by a microscopical examination of the wall, when the cyst, if it has been developed from the lower part of the thyreo-glossal duct, will be found to be lined with ciliated epithelium. Treatment. — A radical operation should be performed as far as possible by extirpating the cyst, for puncture and injection of iodine do not give very satisfactory results. If the entire cyst cannot be removed, the mucous mem- brane is fixed with a pair of forceps, and incised. A large opening is then made into the cyst wall by the removal of a portion of the mucous membrane. The ranula thus treated cicatrises, and quickly heals. THE TONGUE. Injuries, ulcers, and new growths are as common in the tongues of children as they are in adults. Injuries. Children sometimes fall with the tongue between the teeth, and so inflict serious injury upon it. Treatment. — It is necessary in such cases to put in one or two point-sutures of horsehair, and to keep the mouth washed out with an antiseptic solution. Repair readily takes place. Glossitis. The tongue may become inflamed spontaneously, and DISEASES OF THE TONGUE 265 either the whole of the organ or one side is involved. It does not suppurate, and the inflammation subsides under local treatment in the course of a few days. Some in- duration may be left. Abscess of Tongue. Abscesses of the tongue are not unusual ; they are uni- lateral, and may be so chronic as to lead to their being mistaken for some form of new growth. They are some- times tuberculous, but I think they are more often the result of injury. Treatment.— The treatment consists in laying them open, scraping out their contents, and suturing the mucous membrane to obtain union by first intention. Mucous Patches of Tongue. Mucous patches are often seen in young children who have inherited syphilis. They are situated upon the dorsum of the tongue, and at the corners of the mouth. Treatment. — They are quite amenable to treatment with grey powder, and local antiseptic applications of glycerine of borax. Ulcers of Tongue. Various forms of ulceration occur. The most common is the aphthous ulcer, either commencing as a patch in the ordinary way, or as a group of vesicles containing a clear fluid. Dyspeptic ulcers are less frequent. They have a small central slough, with sharp-cut edges and a bright red zone round them. Treatment.— Both forms may be cured by the applica- tion of the glycerine of borax, if proper attention be paid to diet. The more rebellious ulcers may be touched with a 1 in 10 solution of chromic acid. 266 THE SURGICAL DISEASES OF CHILDREN Tuberculous ulceration is seen in the later stages of laryngeal phthisis, but it is sometimes primary. The ulcer is usually extensive, and is most often situated far back upon the dorsum, though it may involve the whole of the mucous membrane. The edges are sharply defined, and the ulcerated surface may have a characteristic warty and papillomatous appearance from the presence of small yellow points. Treatment. — Palliative measures alone can be em- ployed unless the ulceration is primary, when the tongue may be scraped with a sharp spoon. Lupoid ulceration is very rare. It affects the anterior part of the tongue, and is generally the result of direct extension from the lips. Treatment. — It must be treated by scraping away the diseased tissue. MICROGLOSSIA. etiology. — Microglossia is a clinical term, embracing those pathological conditions which lead to enlargement of the tongue. The affection is usually congenital, and is most often produced by venous or lymphatic naevi, and in some cases by a combination of both forms. The en- largement is either unilateral, or it affects the whole tongue. It is often associated with epilepsy, idiocy, or other mental defects, and is occasionally found associated with endemic or sporadic cretinism, myxoedema, and acromegaly. Macroglossia is occasionally traced to an injury, or to chronic or acute irritation affecting the superficial parts of the tongue. The enlargement in these cases is probably associated with some interference with the lymphatic circulation (see also p. 497). True hypertrophy of the several tissues of the tongue also occurs ; but it is much less frequent than the older DISEASES OF THE TONGUE 267 writers thought, and is sometimes part of a unilateral enlargement of the head, or even of the whole side of the body. Tumours, either simple or, less frequently, malig- nant, may lead to a condition of macroglossia. Symptoms.— The symptoms are unmistakable. The mouth is always open, the tongue protrudes, and usually curves downwards from the tightness of the frsenum, lead- ing to depression and eversion of the lower lip. The free salivation accompanying this condition usually leads to excoriation of the lips. Treatment. — The treatment in those cases where the tongue protrudes to only a small extent consists in the application of judicious pressure ; in other cases it may be necessary to remove a portion, or even the whole tongue. Electrolysis is not an effective method of treatment. Papilloma and Soft Fibroma. Papillomata and soft fibromata are not very unusual in children. They are situated far back upon the dorsum of the tongue, in the cases I have seen ; but I do not doubt that they may occur at any part. They are readily removed with a pair of scissors. They occasionally grow again. Lipoma. Lipomata are so rare in the tongue as to be pathological curiosities. They grow in the substance of the organ. Adenoma. Adenomata or glandular tumours grow from the dorsum and back part of the tongue. They are occasionally cystic. It is thought that they may be accessory thyroid glands, for they are found to have a structure similar to that of the thyroid gland. Such tumours can sometimes be removed by a snare, but they usually have to be dis- sected out. 268 THE SURGICAL DISEASES OF CHILDREN Malignant Tumours. A few cases of sarcoma of the tongue are recorded as occurring in children, but they are excessively rare. The only treatment is to excise that portion of the organ in which they are growing. Dermoids and Congenital Cysts. Dermoids and congenital cysts of the tongue and neck are considered under the heading of congenital defects (p. 512). Anchyloglossa. Anchyloglossa, or tongue-tie, is a bugbear of many mothers, though it is not of very frequent occurrence. The fear is clearly a relic of the time when, as Alexander Read tells us, about 1634, it was necessary to make " some just animadversions upon the temerity of midwives, who always wear one of their nails of a great length, and being thus ready with an incision instrument in their hand, wherever they come to do their office, they cut the new-born child's tongue; and unless they did this, they believe the children could never speak." etiology. — It is a congenital defect caused by an undue breadth of the frsenum linguae, or else to the fact that the bridle extends too far forwards towards the alveolar border of the lower jaw. Symptoms. — The tip of the tongue is drawn down- wards, when an attempt is made to protrude it, and the deformity interferes with sucking. Treatment.— It is easily remedied by slightly snipping the frsenum with blunt-pointed scissors, care being taken not to operate upon " bleeders," and to keep the ends of the scissors well away from the ranine artery which runs along the base of the tongue. This is best done by putting WOUNDS OF THE MOUTH 269 the freenum upon the stretch with the fingers, and snipping towards the floor of the month, and as close to the jaw as possible, as if to remove the frsennm from the floor of the mouth and not from the tongue. WOUNDS OF THE MOUTH. Children, like adults, sometimes sustain penetrating wounds of the mouth and pharynx by falling whilst they are sucking a foreign body. A careful examination should always be made in such cases, for it may happen that a part of the foreign body gets impacted in the soft tissues, and is broken off so short that digital examination will alone reveal its presence. The body may remain for a long time undiscovered, and it may cause severe hsemor- rhage by the ulceration it eventually sets up. The following case is a good instance of such an acci- dent. A boy, aged two years, fell on his face whilst he was pretending to smoke a clay pipe. His father picked him up, and seeing the pipe sticking out of his mouth, drew it away, but did not notice at the time that its end was broken. There was a wound on the right side of the mouth, at the junction of the upper alveolar arch with the palate, which bled profusely and was considerably swollen. The child was taken to a hospital, where the wound was probed, but no foreign body was discovered. He could hardly eat anything for a week, and for some time afterwards had to live upon soft food. There was profuse salivation, and for a month the wound discharged pus. The mouth in the situation of the wound remained red and swollen for two years, but there was no suppura- tion after the first month. Two years later, a portion of pipe stem was noticed projecting a quarter of an inch beyond the site of the old wound. It was loose, and was easily removed with a pair of forceps. 27O THE SURGICAL DISEASES OF CHILDREN FOREIGN BODIES IN THE (ESOPHAGUS. Children who have swallowed various foreign bodies are constantly brought to the surgeon. In the majority of cases, the bodies pass smoothly through the oesophagus into the stomach, and are eventually cast out into the draught, though it sometimes happens that they are never seen again. In every case, however, a child who is reported to have swallowed a foreign body should be examined with the finger, and even if nothing can be felt, a probang should be passed as soon as possible, partly for the satisfaction of the surgeon, but chiefly to relieve the anxiety of the friends. The usual treatment when the body has passed into the stomach, consists in giving porridge and hasty- pudding for a day or two, and then a purge of castor oil. The foreign body sometimes becomes impacted in the oesophagus, and if it is smooth, like a coin or a marble, it may give rise at first to very few symptoms, though sooner or later the mucous membrane swells, the muscular coat yields, and the impacted body becomes enclosed in a pouch, from which it is impossible to remove it without having resort to cesophagotomy. Suppuration often occurs in such cases, the temperature rises, and the child dies with pneumonia. The early recognition of a body im- pacted in the oesophagus is therefore of the greatest importance. The diagnosis is often difficult when the body is smooth, but it becomes proportionately easier as the body is more irregular or ragged in outline. A halfpenny is just large enough to be firmly grasped by the oesophageal wall if it lies vertically. It is often situated flat along the posterior wall of the larynx, and it readily eludes recognition by lying just beyond the reach of the finger. The impaction FOREIGN BODIES IN THE OESOPHAGUS 27 I of foreign bodies in the lower part of the oesophagus is much less common, though I have seen a marble lying an inch above the cardiac orifice of the stomach cause death by ulceration in a girl of four years old. Treatment.— A bimanual examination of the gullet must be made in all doubtful cases of impaction, and Dr. Polikier of Warsaw reports two cases in which he has been able to remove such bodies in children by external manipulation of the oesophagus. Emetics are never ser- viceable in causing a child to eject an impacted foreign body, for the straining which they produce is likely to lead to rupture of the softened tissues. Endeavours must at once be made, and with discretion, to dislodge the body by means of a probang or other instrument. Forceps have never proved themselves of any use in my hands. (Esophagotomy must be employed when these measures are unsuccessful ; and it should be performed at once, for the surgeon should remember that the operation is not a particularly dangerous one if it be done early, and before the temperature has begun to rise ; while the child is almost certain to die if the body be left in position. The average mortality after opening the oesophagus to remove an impacted body is given by Fischer as 33 per cent. ; but this, of course, includes many cases in which the operation was performed as a last resource. The operation is performed in exactly the same manner as in adults, upon the left side, and through an incision corresponding to that used for tying the upper part of the common carotid. Care must be taken not to injure the recurrent laryngeal nerve where it lies between the oesophagus and trachea, and not to wound the inferior thyroid artery until preparations have been made to secure it. The oesophagus should be made to project into the wound by passing a sound, catheter, or oesophageal forceps, through the mouth. It 272 THE SURGICAL DISEASES OF CHILDREN should be opened with a scalpel, and the opening must be enlarged by a pair of blunt-pointed scissors. The foreign body must be gently removed with sequestrum forceps, and the wall of the oesophagus should be sewn up with Lembert's sutures if it is healthy and not softened by prolonged inflammation. The patient must be fed by the rectum for a few days, but as soon as possible a soft catheter should be passed into the stomach at meal-times. Some surgeons prefer to introduce the tube through the nose, and leave it in position for several days, only taking it out now and again to clean it. The tube causes less faucial irritation when it is passed through the nose than when it is introduced through the mouth. STRICTURE OF THE (ESOPHAGUS. Non-malignant strictures may occur at either end of the oesophagus in children : at the upper end, as a result of incomplete processes of development, at the point where the stomadseum joins the mesenteron, or more frequently from cicatricial stenosis caused by swallowing corrosive substances, or by scalds. A very rare form of stricture has been observed at the lower end of the oesophagus, due to simple hypertrophy of the muscular coat of the pylorus. CHAPTER XIII SURGICAL DISEASES OF THE TONSILS, PHARYNX, AND NOSE CHRONIC ENLARGEMENT OF THE TONSILS. Nothing in the whole range of children's disease more often presents itself for treatment than chronic enlarge- ment of the tonsils. The enlargement is most frequent between the ages of five and of twenty years of age, though it is not uncommon to see it in much younger children. It is by no means always associated with adenoid vegetations. The cause of the enlargement is unknown, but it is often associated with that debilitated condition which may pass with the assistance of a suit- able infective agent into tubercle. Varieties. — The enlargement assumes two distinct forms, the one truly hypertrophic, in which the organ is increased in size and studded with crypts. In these cases the lymphoid tissue is increased in quantity, and the vas- cular supply is correspondingly large, but there is only a slight increase in the connective tissue stroma of the gland. In the second form there is an overgrowth of the connective tissue elements, without a corresponding in- crease in the lymphoid tissue. In these cases the crypts are absent, the blood supply is diminished, and the tonsil often appears pale. The hypertrophied tonsils either in- crease in their lateral diameter, and project towards the 273 T 274 THE SURGICAL DISEASES OF CHILDREN uvula, or they grow antero-posteriorly, when they lie fiat in the fauces and may yet extend for some distance down the pharynx. Inflammatory adhesions sometimes bind down the tonsil to one or both pillars of the fauces. Both tonsils are usually enlarged, but it often happens that only one is affected. Symptoms. — The symptoms are not easily mistaken in an advanced stage. The patient is slightly deaf, though the deafness is more frequent when adenoids are present ; the character of his voice is so altered as to lead to the idea that he is talking with his mouth full, and there is an absence of nasal tone. The breath is foul, respiration and even deglutition may be impaired, and there may be many of the sequelae associated with adenoids. The deficient oxygen supply leads to anaemia, and pre- disposes the child to catch any infectious disease, at the same time rendering it less able to withstand the disease, so that it usually experiences the full force of an epidemic. A good instance of this recently came under my notice. Diphtheria attacked a family of four children ; the two eldest, who were girls, had enlarged tonsils, and were re- peatedly subject to tonsillitis. The third child, a boy, was healthy, and the fourth was a baby in arms. The two eldest children died, whilst the boy and the baby escaped. There is very great probability that if the enlarged tonsils in these cases had been removed before the attack, the two lives would have been spared. The deficient supply of oxygen is often a cause of nightmare in children ; to be distinguished, as Dr. Bosworth very shrewdly remarks, by the fact that the nightmare of indigestion only occurs once in a night, whilst that due to want of air may be repeated many times. The signs are equally obvious. The mouth is kept open, DISEASES OF THE TONSILS, PHARYNX, AND NOSE 275 as nasal respiration is often impossible. This leads, on the one hand, to drying of the fances and a reflex cough ; and, ou the other, to the stupid expression which is so well reproduced in many of Du Maimer's pictures of society life. Impairment of hearing is also a very frequent con- comitant of chronic hypertrophy of the tonsils. Diagnosis. — Inspection of the fauces will at once confirm the diagnosis. This is best effected by pressing the tongue down firmly but slowly, and at the same time drawing it forward until a good view of the tonsils is obtained. This is done with a spatula, and the double movement necessary is easily acquired after a little practice. The only error into which it is possible to fall is to mistake an acute inflammation, or a new growth, for chronic enlargement of the tonsil. Treatment. Palliative. — It is not necessary to perform tonsillotomy in every case of enlarged tonsils, but it is necessary to do so where they give rise to obvious signs of interference with the supply of air to the lungs, and when they are liable to recurrent at- tacks of inflammation. Only in very rare cases do they require removal a second time. Astringents should be employed where there is reason to sus- pect that the enlargement is due to chronic irritation, rather than to true hypertrophy. The astringents I have been accustomed to use are glycerin of tannic acid, a solu- 3 o © CO 276 THE SURGICAL DISEASES OF CHILDREN tion of nitrate of silver, four grains to the ounce, or a solution of sulphate of zinc, containing a drachm to the ounce. These solutions are painted over the tonsil night and morning by means of a camel-hair brush in a handle. Operative. — The proper treatment for most cases of chronic tonsillar enlargement is removal. This was re- cognised by Celsus, who says (Medicince lib. Septimus, xii. 2) : " Tonsillas an tern, quse post inflammationes induruerunt, dvriaSes autem a Grrsecis appellantur, cum sub levi tunica sint, oportet digito circumradere et evellere : si ne sic quidem resolvuntur, hamulo excipere, et scalpello excidere ; turn ulcus aceto eluere, et illinere vulnus medi- camento, quo sanguis supprimitur." This method of removing the tonsils with a bistoury, after it has been seized and drawn forwards in a vulsellum, is still used by many practitioners, though it has lately been super- seded by a tonsillotome. The particular form of tonsil- lotome employed is unimportant, for each surgeon uses the one with which he is most familiar. Heister's instru- ment, as modified by Matthieu (fig. 30), is very useful ; but care should be taken to see that the bevelled and not the flat side of the cutting blade is next to the fork. Many surgeons, however, prefer a simpler instrument ; but, whatever method is employed, as large a piece of the tonsil as possible should be removed. It has long been an accredited piece of folk-lore that there is a relationship between the tonsils and the genera- tive organs, and that if the tonsils be removed in children there will be a diminution or loss of the reproductive power after puberty. This hare has recently been started afresh in a half -joking way in America by Dr. Penrose (see the Medical Gazette, N.Y., 1881, viii. p. 92), and the fable has thus acquired a fresh lease of life, for I have several times been asked during the last few years whether there DISEASES OF THE TONSILS, PHARYNX, AND NOSE 277 was any truth in it. It is obviously false, and the con- verse is the more likely to prove true, owing to the impaired vitality produced by impeded respiration. The mouth in unhealthy children should be washed out before the operation with 1 per cent, solution of carbolic acid, night and morning, for a few days ; and if there is a purulent nasal catarrh, aristol may be insufflated into the nasal fossse three times a day. Dr. Caille has recently pointed out that it is well not to remove tonsils, if the operation can conveniently be postponed, during epidemics of diphtheria, for tonsillotomy in such cases is sometimes followed by an attack of diphtheria, due, no doubt, to the fact that bacilli which have been lying quiescent in the naso-pharynx thus gain access to an open wound. The patient is placed upright upon a stool at the time of the operation, and the surgeon sits exactly facing him, and upon a slightly higher level, with a spatula in his left hand and the tonsillotome in his right ; the nurse or assistant stands behind the patient, and steadies his head, whilst with her finger and thumb she presses on either side of the nesk, just behind and below the angle of the jaw, to make the tonsil somewhat more projecting. No gag is required. The tonsillotome is easily introduced if the child's confidence has been gained ; and it is much more satisfactory to do the operation in this way than to have recourse to force or to partial anaesthesia, though such means are sometimes unavoidable. The tonsillotome must be applied from below upwards, so as to include any portion of the gland which may be hanging down into the pharynx, and both tonsils should be removed at the same sitting. The pain is so trivial that I do not consider it necessary even to paint on cocain, since it is as trouble- some to do so in a child as to remove the tonsils them- selves. There may be rather sharp bleeding, and to prevent 278 THE SURGICAL DISEASES OF CHILDREN the blood passing down the pharynx, the head is pressed forwards as soon as the tonsillotome with the excised piece of tonsil has been withdrawn from the mouth. Tonsils may also be removed by the snare, by the galvano-cautery, and by the application of caustics, all methods which are less applicable to children than to adults. Broad, flat tonsils always require to be removed with scissors and forceps, for no form of guillotine will seize them. It sometimes happens that the tonsils are so soft that the guillotine cannot be used, for it merely tears through the tissue ; or the glandular substance may be so adherent to the pillars of the fauces that it cannot be re- moved in the ordinary manner. M. Ruault has recently suggested that the tonsil in such cases should be removed piecemeal with a pair of punch forceps, liniment of iodine being afterwards applied to the bleeding surface. I have never had occasion to resort to such a method. After-Treatment. — The after-treatment consists in giving the child bread and milk for forty-eight hours until the wound has healed, and, if necessary, applying a cold compress to the neck. Dangers attending the Operation. — The operation in the large majority of cases is a trivial one, and if the pillars of the fauces are not injured the bleeding very soon ceases. It occasionally happens, however, that dangerous haemorrhage 25 occurs either at the time of the operation, or some hours or days afterwards, and this possibility should always be borne in mind. The proper treatment for these cases is direct digital pressure upon the bleeding point, for it appears that styptics are usually without avail, and even ligature of the external and of the common carotid arteries has not arrested it. Mr. de Santi suggests that the method recommended by Mr. Treves for the arrest of bleeding in the neck might prove serviceable in these DISEASES OF THE TONSILS, PHARYNX, AND NOSE 279 cases. It consists in exposing the external carotid artery in the usual manner, and occluding it by tying a thick catgut ligature loosely round it. The circulation in the artery is arrested when the ligature is pulled upon, and is restored as soon as the traction is relaxed. The bleeding is generally arterial, and seems to come from a branch of the tonsillar artery ; but it is sometimes a general oozing, which only ceases when the loss of blood has provided a natural styptic. If the bleeding be slight but trouble- some, Sir Morell Mackenzie's formula may be used. It is, Acid, gallici J y ii. ; acid, tannici 3 vi. ; aq. 3 i. Misce. Sip and swallow half a teaspoonful at frequent intervals. ADENOID VEGETATIONS 25 (Syn. Post-Nasal Growths, Hypertrophy of the Pharyngeal Tonsil). Adenoids are nodules of lymphoid tissue grouped into masses, and covered with ciliated epithelium. They are formed by a simple overgrowth of the lymphoid tissue normally found in the vault of the pharynx, and are fre- quently associated with chronic enlargement of the tonsils. These overgrowths are equally common in boys and in girls. They may be found at birth, and they sometimes persist into early adult life ; but they are more frequently seen before than after ten years of age. Racial idiosyn- cracies are said to play a great part in their production. They were first recognised by Czermak in 1860 ; but Wilhelm Meyer, of Copenhagen, was the first to attach importance to them as factors in the causation of disease. ./Etiology.— The growths occur in those who are pre- disposed to colds, perhaps in tuberculous subjects, and in those whose nasal passages are narrowed from any cause, either congenital or acquired. Such narrowing leads to 280 THE SURGICAL DISEASES OF CHILDREN chronic hyperemia, and in course of time to overgrowth of the tissues. Damp and cold climates are also pre- disposing causes, whilst a syphilitic taint produces a somewhat similar overgrowth of pharyngeal lymphoid tissue, which can only be successfully treated by the use of mercury. The exciting causes of adenoid vegetations are those leading to chronic hypersemia of the parts, such as repeated and neglected nasal catarrh, diphtheria, whooping cough, the exanthemata, especially measles and scarlet fever. Symptoms. — The symptoms are snoring, a mucous discharge, altered speech, and, in time, a peculiar and characteristic aspect. The snoring is an early but not necessarily a constant symptom. It occurs, as Mr. C. A. Parker points out, because, during sleep, air enters the lungs through the nasal passages rather than through the mouth, as is usual when the patient is awake. He further shows that, although 86 per cent, of the cases of nasal ob- struction sleep with their mouths open, in 82 per cent, the respiration is entirely nasal, and in 16 per cent, it is partly nasal and partly buccal. Bad dreams, night terrors, and sometimes slight delirium may be the result of this deficient aeration of the blood, whilst its remote effects are said to be anaemia, stunted growth, impaired cerebral development, deformities of the chest, asthma, laryngismus stridulus, and even epilepsy. A muco-purulent discharge fills the nostrils and runs down the pharynx. The voice is characteristically altered, and the alteration is observed earlier in singing than in speaking. It is thick, and there is difficulty in pronounc- ing many of the consonants, thus B replaces P, D replaces T, and B is used for M ; a change due in part to the en- feeblement of the soft palate, and in part to the nasal DISEASES OF THE TONSILS, PHARYNX, AND NOSE 28 I obstruction, which no longer allows the vault of the pharynx to act as a sounding-board. The facial expression is characteristic in the later stages, for the patient has a dull and heavy look, with a sallow complexion. His lips are prominent, thick, and without expression, and his mouth is open. The nostrils are narrow, and each ala of the nose is indented at the junction of the superior and inferior lateral cartilages, whilst the bridge is broad, and is often crossed by a congested vein. The broad bridge and the narrow alas make the eyes appear unduly far apart. The patient is often hard of hearing, and, in advanced cases, the arch of the palate loses its rounded form and becomes more pointed. Chronic hypertrophy of the tonsils is usually associated with adenoid vegetations ; but it often happens that the growths occur independently of chronic tonsillitis. The pillars of the fauces, the soft palate, and the uvula are congested. The parts look dusky and flabby, and there is often impaired movement of the palate. The back of the pharynx is covered with muco-pus, and it is studded with large and pale granulations, increasing in size as they approach the naso-pharynx. The results of the obstruction act in two directions. In the early stages, as Dr. Scanes Spicer has shown, the presence of the adenoids leads to chronic congestion and hypertrophy of the post-nasal mucous membrane, with dilatation of the vein running across the roof of the nose ; whilst in the later stages, the obstruction may be so complete as to lead to pharyngitis sicca, for the air only passes through the inferior meatus of the nose, and so is insufficiently moistened. Diagnosis. — The diagnosis is readily made in all stages of the disease by digital examination of the naso-pharynx. The surgeon should stand behind and on the right side of the patient, who sits in a chair. He wraps a piece of lint 282 THE SURGICAL DISEASES OF CHILDREN round his left forefinger, or protects it with a shield of horn or celluloid, and employs it as a gag, whilst he intro- duces his right index into the mouth, passing it beyond the soft palate, and then bending it upwards to explore the naso-pharynx. The exploration must be done methodi- cally, and the growths are detected as masses of soft and velvety tissue, in the form of ridges, cushions or lobules at the upper part and sides of the posterior nares. A firm pad of thickened tissue, situated in the pharyngeal vault, a little to one side of the middle line, can often be felt when the growths have disappeared spontaneously. Pos- terior rhinoscopy, in experienced hands, gives good results, and it may readily be applied to tractable children. It is often a useful supplement to digital examination, unless the tonsils are enlarged, when it is a very difficult method to use. Bosworth's mode of detecting nasal obstruction may be used in doubtful cases. It consists in spraying sweet oil into one nostril. The heavy spray returns with almost equal force through the other nostril, if the nasal passages and naso-pharynx are quite clear, but not other- wise. Differential Diagnosis. — Adenoids are to be dis- tinguished from polypus of the nose, which is very rare in children ; from fibrous growths, which are harder than adenoid vegetations ; and from enlargement of the posterior ends of the inferior turbinated bones, which are easily recognised by digital examination. Retro - pharyngeal abscess is so painful, and runs such a rapid course, that it is not likely to be mistaken for post-nasal growths ; whilst a retro-pharyngeal sarcoma causes more bulging of the surrounding parts, especially of the soft palate, and leads to greater enlargement of the cervical glands. Sequelae. — Adenoids are a frequent cause of deafness, and of inflammation of the middle ear. They produce DISEASES OF THE TONSILS, PHARYNX, AND NOSE 283 hyperemia of the Eustachian tubes, and of the tympanic cavities, which leads to thickening of the mucous mem- brane lining the cavities of the ear, or to an increased activity of the glands, terminating in a suppurative in- flammation, with subsequent perforation of the tympanic membrane. The frequency of ear-trouble in these cases is explained in many ways, but every one agrees that it is associated with diminished air tension in the middle ear. Treatment. — The increased liability to disease to which children with adenoids are liable, renders it advis- Fig. 31.— Two forms of Gottstein's Curette, used in removing adenoids. able to remove the growths as soon as they cause the patient to breathe through his mouth. They do not recur after complete removal ; but it is not sufficient to scarify them, or merely to crush them. The child should be put under chloroform, so that the operation may be performed with deliberation, and it is of extreme importance that the anaesthesia should not be too deep. The patient should be able to cough refiexly throughout the operation, as there is then less risk of suffocation from blood entering the larynx. Every operator has his favourite position and method of removal. I am accustomed to have the head hanging over the end of the table, so that the blood does not run down the throat, although in this position there 284 THE SURGICAL DISEASES OF CHILDREN is increased venous engorgement of the head and neck ; but many surgeons prefer to have the patient lying upon his side, with his head level with the rest of his body. A gag being placed in the mouth, the growths are syste- matically removed, through the mouth and naso-pharynx, with some modification of Loewenberg's forceps, with Meyer's ring knife, Gottstein's curette (fig. 31), with Sir William Dalby's artificial finger-nail (fig. 32), or, less pre- ferably, with the finger-nail itself ; and it is often neces- sary to use a combination of these instruments before the growths can be completely extirpated. Many operators, however, choose to remove the growths with a sharp spoon Fig. 32.— Dalby's Artificial Nail, employed in removing adenoids. passed through the nares, and guided by a finger in the mouth. The nasal cavity is repeatedly swabbed out dur- ing the operation with wet absorbent wool. The bleeding is very free ; but it usually stops as soon as the gag is removed and the mouth is closed. The tonsils should be removed if it is necessary, and whilst the patient is still unconscious. The operation is not quite free from risk, as it some- times causes a sharp attack of suppurative inflammation in the middle ear two or three days afterwards. This may be due to the entrance of blood through the Eustachian tubes, and it is especially likely to occur in those cases of sub-acute otitis media which are characterised by thickening and retraction of the tympanic membrane, or by its perforation. Pneumonia occasionally results from DISEASES OF THE TONSILS, PHARYNX, AND NOSE 2S5 the passage of blood into the lungs ; but this should not occur if proper care be taken at the time of the operation. After-Treatment. — Little or no after-treatment is re- quired, except to keep the patient in bed for a day or two in a warm room, and to give soft food until the bruised parts have recovered. A gargle or an alkaline spray, similar to that used for diphtheria (chap, xvii.), may also be employed for a week, and the Eustachian tubes should be inflated regularly, if the deafness remain more than a fortnight or three weeks after the adenoids have been removed. The beneficial effects of the operation are often very striking. The patients rapidly increase in height, weight, and chest girth, and at the same time lose the facial ex- pression which had previously characterised them. ACUTE TUBERCULOUS INFLAMMATION OF THE PHARYNX. The pharynx in children is occasionally the seat of an acute tuberculous ulceration. It may be the result of an extension from the soft palate and uvula, but is usually se- condary to disease of the lower part of the respiratory tract. Drs. Abercrombie and Gay, 28 who have paid special atten- tion to the condition in England, say that the first sign is the appearance of small discrete papules on the soft palate, pillars of the fauces, and still more rarely, on the posterior wall of the pharynx. These papules are tuberculous ; they caseate and then ulcerate, implicating the surrounding parts, and causing great destruction of the tissues. The mucous membrane is swollen, and is covered with a viscid, whitish secretion, which may be mistaken for a diphtheri- tic membrane ; but it is less organised and more friable. The retro-pharyngeal and cervical lymphatic glands become enlarged, and the latter may suppurate, or the glands may 286 THE SURGICAL DISEASES OF CHILDREN subside entirely before the termination of the case. The chronic form of this condition is lupus (p. 57). Symptoms. — The first symptom is pain, with more or less dyspnoea ; a nasal quality of the voice, from impaired action of the palatal muscles ; and pain in the ear from im- plication of the Eustachian tube. Deafness occasionally occurs. Diagnosis. — The ulceration is not always easy to see, on account of the viscid secretion which covers the fauces. Follicular tonsillitis, diphtheria, and the mucous patches of inherited syphilis have to be distinguished from this condition of acute tuberculous ulceration of the fauces. Prognosis. — The prognosis is extremely bad ; nearly all the cases have terminated fatally, for the condition appears to be a part of a general tuberculosis. The immediate cause of death is dysphagia. Treatment. — The treatment is unsatisfactory, for little can be done except to relieve the pain by insufflations of morphia, or by cocain spray. NASO-PHAEYNGEAL TUMOURS. Pathology. — Tumours of the naso-pharynx are not uncommon in children. They are either simple fibromata, the fibrous tissue sometimes having a nsevoid character, so that the tumour is a fibro-angioma ; or they are fibro- sarcomata ; or, more rarely, they are atypical, and contain cartilage cells. The tumours, in either case, are generally single, and have a large base of attachment. They usually grow from the fibrous tissue covering the basilar process of the occipital bone ; but many cases are known to have originated in the pterygo-maxillary fossa. They grow irregularly, and often acquire secondary attachments. Nothing is known of their cause. They are found almost exclusively in boys and in young adults. They are rare DISEASES OF THE TONSILS, PHARYNX, AND NOSE 287 in children under ten, and are most common between the ages of eleven and twenty-five. Symptoms. — The earlier symptoms marking their growth are so slight that the patient is not brought for advice until the growth has attained to a considerable size. The slight epistaxis, the constant nasal secretion, the chronic headache, and the hardness of hearing which mark the early stages of growth, are usually attributed to chronic cold in the head, or to adenoids. It is not until the symptoms increase that the patient is brought for advice, and then, a digital examination of the back of the pharynx readily enables the tumour to be felt. This examination must be conducted with the greatest gentle- ness, for it sometimes leads to a sharp haemorrhage. Prognosis. — The younger the patient the more quickly the tumour grows, and if it be left alone the most disas- trous results follow. The nasal fossae become dilated, and the growth invades the surrounding parts, growing up- wards into the orbit and brain, laterally into the zygomatic and temporal fossae, downwards into the mouth, and forwards into the cheek, producing the most frightful deformity. Death may take place within a few months of the first symptoms, or it may be postponed for a year or two. Diagnosis. — A naso-pharyngeal fibroma or sarcoma is not likely to be mistaken for anything else. It is recorded, however, that a retro-pharyngeal abscess was mistaken for such a growth in one case ; whilst in others, an ence- phalocele projecting into the pharynx led to a similar error in diagnosis. Treatment. — The treatment of the smallest innocent tumours consists in twisting them off with forceps, intro- duced either through the mouth or nostril. The larger polypi and the sarcomatous forms require much more 288 THE SURGICAL DISEASES OF CHILDREN severe measures. Pedunculated fibromata may be re- moved by the galvano-cautery, if the loop can be passed over the pedicle. If this is impossible, Mr. Walsham recommends that the soft palate should be split, and its edges drawn aside by threads passed through them ; and if this proceeding fails to give sufficient room, a portion of the hard palate must be gouged away, until the polypus can be reached with a snare. The edges of the palate are then sutured with horsehair, as in the ordinary operation for the repair of a cleft. In either case the base of the polypus must be destroyed by the actual cautery. Rouge's method of reflecting the upper lip and detaching the alse nasi, until the whole of the anterior nares is exposed, is sometimes serviceable for the removal of polypi which are attached more anteriorly. Sarcomata can only be extir- pated by a formal removal of the superior maxilla, either by the major operation of excising the whole bone, or less commonly by the minor operation, which consists in leav- ing the orbital plate. The operation must be performed at the earliest possible opportunity, and for this reason the earliest recognition of the growth is of great importance. This can be effected in the case of sarcomata springing from the antrum by introducing a small electric light into the mouth in a dark room, when the affected antrum will appear less translucent than its fellow; but this loss of translucency is only diagnostic of an antral tumour, and it may be due to an abscess. Electrolysis is sometimes use- ful in the treatment of the more slowly growing tumours. RHINOLITH. Children so often push foreign substances into the various orifices of their bodies, that it is not surprising if they sometimes remain where they have been put, and are forgotten. This is especially the case with foreign bodies DISEASES OF THE TONSILS, PHARYNX, AND NOSE 289 pushed into the nose. They may lie there for years, and become encrusted with carbonate and phosphate of lime, intermixed with much organic matter, until, by their irri- tation, they cause a discharge, and a complete blocking of one nostril. All cases in which there is a persistent and foetid discharge from one nostril should be examined with a view to detecting the presence of a foreign body, and it is best to make the examination under an anaesthetic. The rhinolith is readily detected, and the only thing for which it is then likely to be mistaken is a piece of dead bone, leading to ozaena. Treatment.— The rhinolith is easily dislodged and removed by means of a pair of dressing forceps. The nostril should be washed out for a few days with a warm solution of boric acid. U CHAPTER XIV DEFORMITIES AND DISEASES OF THE EAR SUPERNUMERARY AURICLES. Supernumerary auricles or pre-auricular appendages are by no means uncommon. Their size and their situation vary greatly. They are sometimes mere tags of skin, with, or more often without, any perceptible elastic or fibro-cartilage. They are attached immediately in front of the pinna of the ear, or at some point in the line extending from it to the angle of the mouth, or more rarely at some distance from it, on the cheek of the same side. They bear a closer resemblance to the auricle in other cases, and are situated along the anterior border of the sterno-mastoid muscle, either opposite the thyro-hyoid space, or immedi- ately above the sterno-clavicular articulation. They may be associated with the remains of branchial clefts, in which case they may lie above a minute fistulous opening in the skin. They are either single or multiple, unilateral or bi- lateral, and the pinna of the ear upon the side on which they grow is often badly developed. Dr. Ballantyne, 27 who has recently studied these growths with great care, says that they are so often associated with other defects, that probably nearly every case on careful search will reveal at any rate minor malformations of the ear, eye, or mouth, and very often major alterations in other parts of the body. Pathology.— Mr. Bland Sutton ingeniously points out 2S0 DEFORMITIES AND DISEASES OF THE EAR 29 1 that the pinna may be regarded as an enormously de- veloped operculum, modified for acoustic purposes, and that some supernumerary auricles may be looked upon as per- sistent opercula, or coverings to the primitive gill-slits. Treatment. — No harm comes from their immediate and complete removal, even in the youngest children ; but the surgeon must be prepared to ligature the small central vessel. HYPERTROPHY OF THE PINNA. Hypertrophy of the pinna sometimes causes great de- formity, for the ears may stand out or flap forwards. Treatment. — When there is only slight deformity, an attempt may be made to keep the ears in position by means of a pair of pads, connected together by a steel spring pass- ing over the top of the head. A formal operation is re- quired in the more severe cases. Prof. Keen recommends that a good-sized and oval flap of skin should be removed from the back of the auricle, and that a V-shaped groove should be made along the whole length of the cartilage. The edges of the wound are then brought together, and as soon as it has healed, the auricle may be attached to the head by a single point-suture so as to keep the ear in place, until cicatrization is sufficiently advanced to render such mechanical means unnecessary. A triangular piece of the auricle may require removal in still more severe cases, the apex of the triangle being directed towards the meatus. ECZEMA AURIS. Eczema of the external ear is a very chronic affection, which often leads to total occlusion of the external audi- tory meatus, at first by granulations, and afterwards by dense cicatricial tissue. It is often associated with a long- n 292 THE SURGICAL DISEASES OF CHILDREN continued discharge through the meatus, due to purulent inflammation of the middle ear. Treatment. — The treatment consists in removing the granulations with a sharp spoon, and keeping the ear plugged until healing takes place under the influence of cod-liver oil and grey powder, with rhubarb. A little powdered oxide of zinc may be dusted over the eczematous patches two or three times a day, or the ear may be plugged with gauze soaked in camphorated naphthol. FOREIGN BODIES IN THE EAR. Foreign bodies in the ear consist of the various sub- stances introduced by children into the external auditory meatus. Impacted wax in the ears is less common in children than in adults, for in children the cerumen gene- rally becomes fluid, instead of forming inspissated masses. Children are somewhat more liable to blocking of the ex- ternal auditory meatus by plugs of epithelial cells, which are densely hard, and require numerous and prolonged applications of a 1 in 10 solution of bicarbonate of soda before they can be softened. Treatment. — The surgeon must first ascertain whether a foreign body is really present in the ear, by actual inspec- tion with an otoscope by means of reflected light, and he must then determine its nature. If wax alone be present, it should be washed away by a gentle stream of warm boric acid lotion ; but if it is hard, it must be softened in the ordinary manner, by dropping a little warm oil into the meatus, night and morning, and then gently syringing it out of the canal as soon as it has become softened. A foreign body may be difficult to discover, as it often lies on the anterior inferior wall of the meatus, where it is DEFORMITIES AND DISEASES OF THE EAR 293 quite concealed. The meatus in such cases must be care- fully explored with a bent probe. Insects are first killed by filling the ear with olive oil, which suffocates them by filling their tracheae, and they are afterwards syringed out of the ear with warm water. Foreign bodies like beads, which will not swell when they are moistened, may be removed by syringing. In each case, the child is so placed that the affected ear is most depend- ent, whilst the stream of water is directed along the upper wall of the meatus, the auricle being pulled backwards and upwards to convert the channel into a straight line. This method cannot be used for peas, beans, or paper leads. They must either be left alone, or an attempt may be made to extract them by anaesthetising the child, and introducing a loop of stout silver wire with the greatest gentleness. When this fails, the agglutinative method may be employed ; but I have never had recourse to it. The child is put to bed, and a camel-hair brush soaked in a little glue is put into the ear, so that the bristles rest upon the foreign body. The brush is withdrawn as soon as the glue has set. It is sometimes necessary to make an incision behind the ear in order to gain access to the exter- nal auditory meatus, when the foreign body may be ex- tracted with a pair of toothed forceps ; but sometimes the wisest plan is to let them alone. CHRONIC PURULENT INFLAMMATION OF THE MIDDLE EAR. Etiology. — Otorrhoea is one of the most frequent and troublesome conditions met with in children. It occurs from many causes, and if it is not due to the impaction of foreign bodies, or to growths in the external auditory meatus, it is most frequently caused by otitis media. 294 THE SURGICAL DISEASES OF CHILDREN Rasch, of Copenhagen, found evidence of middle ear disease in no less than 70 cases out of 82 autopsies made upon the bodies of children under two years of age, whilst Kassel found it in 85 cases out of 108 children under one year, who had died of various diseases. The affection may begin as a chronic suppurative in- flammation, apparently without cause ; but its origin is much more frequently referred to an attack commencing during measles, scarlet fever, or diphtheria, or to some chronic or infective inflammation of the naso-pharynx. It appears to be especially frequent after broncho-pneumonia, when it leads to deafness without perforation, and is then very likely to be overlooked. Dr. Walker Downie, a9 in a recent and interesting paper upon inflammation of the middle ear, in connection with the exanthemata, is inclined to think that the increased tendency to suppuration in these cases can be explained mechanically. He says that when a child is suffering from measles or scarlet fever he is confined to bed day and night, so that during the greater part of the twenty- four hours he lies on his back. This position favours the retention of secretions within the hollow of the naso- pharynx, whilst from the altered direction of the Eusta- chian tubes, the inflammatory products in the middle ear are unable to escape, even supposing the tube to remain patent. The consequences are that the catarrhal inflam- mation accompanying measles and scarlet fever is soon followed by suppuration, the lining membrane of the tympanum becomes necrosed, the tympanic membrane is ruptured, and the bony cells surrounding and communi- cating with the tympanum are filled with the products of suppuration. Damp and insanitary surroundings also appear to exercise a great influence in the causation of otitis media, by the depressing effects which they exercise DEFORMITIES AND DISEASES OF THE EAR 295 upon the general health, leading to an increased predis- position to infective diseases. Pathology. — Dr. Blaxall's investigations show that the most potent factor in the production of otitis media, follow- ing scarlet fever, is the streptococcus pyogenes, and that the next most important organisms are the staphylococci, albus et aureus. The diplococcus pneumoniae of Talamon and Fraenkel, and the bacillus pneumoniae of Friedlander, may however accompany the inflammation in those forms which are not due to scarlet fever. Morbid Anatomy. — Politzer describes very carefully the changes which take place in the various parts of the ear, as a result of chronic suppurative inflammation. The mucous membrane of the Eustachian tube is swollen, the epithelial cells proliferate, and the mucous glands enlarge ; but it is unusual to meet with polypoid granulations. The mucous membrane in the middle ear is at first much thickened by the formation of inflammatory tissue, whilst the mucous glands and the blood-vessels are greatly in- creased in size. There is a formation of new connective tissue in the later stages, associated with polypoid masses of granulation tissue which spring from the ulcerated parts of the mucous membrane. The membrana tympani is most frequently ulcerated at that part which is situated midway between the periphery and the handle of the malleus. The perforation is not always easy to see, for the membrane may be swollen and thickened. Prof. Politzer therefore recommends that in cases where the existence of a perforation is doubt- ful, the external auditory meatus should be filled ' with warm water, and air should be forced through the Eustach- ian tube by means of his bag. Air will then bubble through the water if the membrana tympani be perforated. When the suppuration has ceased, the perforation either 296 THE SURGICAL DISEASES OF CHILDREN remains as a permanent orifice, or it becomes closed by a delicate film of scar tissue. The inflammation extending to the external ear often leads to a condition of eczema (p. 291), to cicatricial con- traction and narrowing of the orifice, to polypi, or to a dense mass of granulations which may eventually cause obliteration of the external auditory meatus. Symptoms.— The symptoms are seldom well defined. There is often pain, which is worse at one time than at another, owing to intercurrent attacks of acute inflammation. There is also local tenderness beneath the pinna of the ear. The headache is usually either lateral or occipital ; and if caries of the temporal bone has taken place, there may be giddiness, vomiting, unsteady gait, and increased tinnitus. The impairment of hearing is generally very marked, and there may be alterations in taste and smell, though as no complaint is made spontaneously by the patient, they are only to be ascertained by testing these senses. The discharge may be bilateral ; it occurs after the mem- brana tympani is ruptured, and it lasts for an indefinite period. It varies greatly in quantity and in colour, and it always contains micro-organisms. Perforation of the mem- brana tympani usually takes place early. The aperture is generally single, and is round, oval, or elliptical in shape. The inflammation runs a very protracted course, and the suppuration usually continues uninterruptedly, though it sometimes ceases spontaneously to return after weeks, months, or years, with or without acute symptoms. These relapses are often due to cold, to naso-pharyngeal catarrh, to the exanthemata, or to the entrance of water into the middle ear through an unclosed perforation. It is well, therefore, to warn boys who have been temporarily cured of otorrhoea due to middle ear disease to avoid plunge baths, unless they put a piece of cotton wool into their ears, and DEFORMITIES AND DISEASES OF THE EAR 297 to recommend them not to practise diving from a height under any circumstances. The discharge ceases in many children during the summer, and returns again in autumn. The chronic nature of the disease appears to be due to the retention of the purulent exudation in the various re- cesses of the middle ear, though it is partly accounted for by the periostitis and caries of the temporal bone, with which it is often associated, and partly by the continuance of the original source of infection in the naso-pharynx. Prognosis. — The prognosis is always uncertain so long as the discharge continues. It is unfavourable when the otorrhoea is profuse and is persistently septic. It is favour- able when the discharge has ceased, so long as the hearing improves. The prognosis for the recovery of the hearing is favourable if the hearing distance remains stationary, but unfavourable if there are continual subjective noises, or if there is a diminution in the sense of hearing conducted sounds, as tested by a tuning-fork placed upon the head. Diagnosis. — Otitis media sometimes simulates menin- gitis very closely, especially in children who are too young to indicate the seat of their pain. There is sometimes marked retraction of the head. The symptoms in otitis, however, are often markedly relieved by puncturing the membrana tympani and by inflating the Eustachian tubes, whilst such treatment is ineffectual in meningitis. Treatment. — The treatment consists in keeping the middle and the external ear scrupulously clean, and it is the great difficulty in doing this which makes the cases so intractable. Dr. Walker Downie says 20 that in the exanthemata from the very beginning of the illness, where there are any catarrhal symptoms, the patient should be directed to use his pocket-handkerchief frequently and strongly, and the attendant nurse should be instructed to see that he does 298 THE SURGICAL DISEASES OF CHILDREN so. By this means the nasal discharge is got rid of through the anterior nares, and the air, in passing with considerable force from the lungs towards the nose, helps to loosen and to dislodge any discharge lying in the naso- pharynx. Politzer's inflation bag should be used when the child is too young to blow its nose efficiently, or when the tonsils are enlarged, or the patient has adenoids. The quantity of secretion dislodged and thrown into the mouth by such inflation is very remarkable. One or other of these methods should be employed, in every case, without waiting for the appearance of symptoms pointing to im- plication of the ear. When, on the other hand, there is dulness of hearing, and when there are sounds or pains in the ears, resort to. inflation should never be delayed, as these symptoms point to closure of the Eustachian tubes, and to retention of secretion within the middle ear, and relief may be instantaneously secured in the majority of cases by complete inflation. Inflation. — There are many methods of inflating the middle ear, for there are many ways of opening the Eusta- chian tubes at the instant when the blast of air is forced out of Politzer's bag. The child may be placed in a re- cumbent or sitting position, and the tube from the bag is placed in one nostril whilst the opposite one is closed, and he is directed to say " hie, hsec, hoc," when the bag is com- pressed. This method, serviceable enough for young adults, is useless in children, and for them the bag must be gently squeezed whilst the child blows through a narrow tube with sufficient force to distend the cheeks. Dr. Dundas Grant suggests that a pipe-stem or a Eustachian catheter answers the purpose very effectually. Air or steam, impregnated with a minimum of chloroform vapour, passes more easily into the Eustachian tubes than it would otherwise do. Myringotomy. — When there is very great pain, and DEFORMITIES AND DISEASES OF THE EAR 299 the symptoms point to acute tension within the ear, great relief is often obtained by counter - irritation, by local blood-letting, and by puncturing the tympanic membrane. The operation is a simple one. The child is placed in a good light, and his head is held steadily by an assistant. The surgeon reflects light into the external auditory meatus from a laryngoscope mirror, until he obtains a good view of the swollen drum. He then makes a slit into the lower and posterior portion where the bulging is most prominent. Proper myringotomes are sold for the pur- pose, but a straight and sharp-pointed eye-needle, such as is used for paracentesis cornese, does perfectly well. When the discharge has become chronic and is very pro- fuse, the ear must be syringed out three or four times a day with boiled water at a temperature of 80° F., twice a day being sufficient after the first day or two. If the discharge be excessive, four or five drops of oil of turpentine may be added to each eight ounces of water. A 1 in 1000 solution of perchloride of mercury may be substituted when the discharge is very offensive. A 2 per cent, solu- tion of peroxide of hydrogen, or a 5 per cent, watery solu- tion of resorcin, has also given me good results. All the solutions should be used warm, as they are less apt to produce giddiness than when they are injected cold. Very tenacious secretions may be removed with cotton-wool twisted round a probe. Dr. Rattel claims that the following method is useful in cases of very chronic suppuration when there are granula- tions. Its great objection seems to be that the amount of the douche is so large. His formula is : — ]}> Chloral hydrate, 1 drachm. Biborate of soda, Ik drachms. Water, 1 pint. Dissolve and make a lotion. 300 THE SURGICAL DISEASES OF CHILDREN A pint of this solution is to be gently injected into the ear night and morning. The hydrate of chloral, he says, is partially decomposed by the alkaline borax into chloro- form and formiate of soda, so that the solution is both sedative and antiseptic. The granulating surfaces are also to be touched three or four times a week with a 1 in 30 solution of zinc chloride applied to the middle ear by means of a Toynbee's speculum. The ear must be carefully dried after every application, and a piece of cotton-wool should be introduced into the ear. Local remedies must be discontinued as soon as the sup- puration has ceased, for they have a tendency to bring it on again. A little boric acid may be insufflated once or twice a week when there appears to be any likelihood of a relapse, and the occasional instillation of a few drops of warm alcohol is often productive of the greatest benefit. Scarlatinal Otitis. The worst form of chronic suppuration occurs in scarlet fever, especially if it be associated with acute membranous inflammation of the naso-pharynx. The inflammation begins at the height of the disease, and is marked by very severe pain with rise of temperature and an increase in all the cerebral symptoms. Perforation of the tympanic membrane takes place early. The course of the disease is usually very protracted, but it may be shortened by in- cising the tympanic membrane, within the first twenty- four hours after the onset of the symptoms, in the manner described at page 298. Severe deafness often remains, owing to the inflamma- tion spreading to the internal ear ; and if this occurs in young children, they may never learn to speak, and so remain deaf and dumb. DEFORMITIES AND DISEASES OF THE EAR 3OI Treatment. — The treatment, after incision of the tym- panic membrane, consists in filling the ear with lime- water, which should be allowed to remain in the external auditory meatus for ten minutes, in order to loosen the membrane. The ear should then be gently syringed with sterilised water, carefully dried, and afterwards filled with powdered boric acid. This proceeding must be repeated three or four times a day. Typhoidal Otitis. Inflammation also occurs secondarily to typhoid fever ; the symptoms usually begin during the fourth or fifth week of the disease, though they may appear much earlier. Severe deafness may continue for a long time, but fairly good hearing is usually regained. Otitis after Influenza. Inflammation of the middle ear sometimes occurs after influenza. A child of a year old was brought to me in February, 1894, suffering from a mastoid abscess, which his mother attributed to the influenza from which he had suffered six weeks previously. The pain is very severe, and is not relieved by the rupture or perforation of the membrana tympani. There is protracted suppuration, and a great tendency to the formation of a mastoid abscess with rapidly extending caries, which renders early opera- tive interference very necessary. A fatal termination from meningitis, cerebral abscess, and thrombosis of the sinuses, is not uncommon. Otitis ix Tubercle and Syphilis. Suppuration of the middle ear may follow tubercle or syphilis, but in either case there are other manifestations of the constitutional condition. There is but little pain in 2,02 THE SURGICAL DISEASES OF CHILDREN tuberculous otitis, and perforation does not usually take place, so that the condition may be overlooked until the occurrence of facial paralysis renders a more careful ex- amination imperative. The superficial and deep lymphatic glands near the mastoid are then found to be affected. There is often very great destruction of the petrous portion of the bone ; and when the case has terminated fatally, the autopsy may show that the base of the skull has been transversely involved, so that an inflammation of the op- posite ear may be the result of a direct extension of the tuberculous process. CHAPTER XV DISEASE OF THE TEMPORAL BONE AND THE CEREBRAL INFLAMMATIONS ARISING FROM IT Infective inflammation of the temporal bone usually affects its mastoid and temporal portions. It either begins as a periostitis, associated with osteomyelitis, rapidly run- ning on to the formation of an abscess behind the ear, or it is the result of the extension of inflammation from the middle ear, leading to disease of the bone, and perhaps spreading to the brain or its membranes. ACUTE MASTOID OSTEOMYELITIS. Symptoms. — The more superficial form of disease lead- ing to mastoid abscess is characterised by severe pain, increased when the patient lies down. There is much con- stitutional disturbance, owing to the unyielding nature of the tissues overlying the mastoid process, and this may be accompanied by vertigo, with vomiting of a cerebral type — that is to say, without nausea. There is great irrita- bility of the nervous system, acceleration of pulse, rise of temperature, rigors, tinnitus, dizziness, sleeplessness, and occasional excitement. The skin over the mastoid process is infiltrated and swollen. It pits upon pressure, and beneath it is a hard swelling, in which it is sometimes easy and sometimes impossible to detect fluctuation. The swelling is itself very tender, and it tilts the pinna of the 303 304 THE SURGICAL DISEASES OF CHILDREN ear forward in a manner which can hardly be mistaken for anything else. The swelling may extend above the mastoid process into the temporal region, and it may lead to bulging of the posterior wall of the external auditory meatus to such an extent as to close its lumen. Treatment.— The swelling should be incised at once, and if possible before suppuration has taken place. When an abscess has formed, its contents should be gently scraped away, and it should be packed with lint soaked in camphorated naphthol (p. 8). It may open spon- taneously after some weeks, if it is left untreated, leaving a sinus ; or it may make its way backwards, to form a retropharyngeal abscess, or forwards into the glenoid cavity, eventually causing unilateral anchylosis of the lower jaw. The fistulas are sometimes very long in heal- ing, but they rarely lead to more extensive trouble. They should be scraped and dressed antiseptically. CHRONIC MASTOID DISEASE. 30 Chronic infective disease of the middle ear is the most fertile source of extensive disease of the temporal bone, though tuberculous disease occasionally causes it. It is of very frequent occurrence in children ; for during the last four years more than thirty cases of disease of the tem- poral bone, connected with ear trouble, have been admitted to, and operated upon in the wards of the Victoria Hospital for Children. Morbid Anatomy.— The inflammation of the middle ear extends either upwards or backwards, and in children it usually passes along the suture of the petrous with the squamous portion of the temporal bone, or it may spread through the bone itself. The dura mater may thus be- come involved in the inflammatory process, which actually CEREBRAL ABSCESS 2>°5 destroys the bone and leads to thrombosis of the lateral sinus. CEREBRAL ABSCESS. Cases of long-standing inflammation of the middle ear and of the mastoid process sometimes terminate in an abscess, formed in the white matter of the brain ; either in the temporo-sphenoidal lobe, or about half as often in the cerebellum, though in rarer cases the abscess is formed between the dura mater and the pia mater. These ab- scesses are always single. They vary greatly in size, some only containing a few drops of pus, whilst others may contain several ounces, and they may open into the lateral ventricle. Some observers think that they are a little more common on the right than upon the left side, owing to the greater size of the right lateral sinus, which is thus more likely to be involved in the inflammatory process. The abscesses usually cause death, unless they are opened by surgical means ; but they occasionally discharge their contents through the external ear, or even through the side of the skull. Sometimes they become encysted, and, under exceptional conditions, they may be absorbed. The pus varies in colour, it is usually bloodstained ; but it may be greenish-j^ellow, and it is sometimes foetid and thin. Causes. — Cerebral abscess may also follow a compound fracture of the skull, when it is more frequent in the upper and anterior parts of the brain ; or it may arise from general infective conditions, as in pyaemia, occurring in connection with foetid bronchitis, empyema, infective peri- tonitis, or osteomyelitis of the long bones. Symptoms. — The symptoms of cerebral abscess in con- nection with middle ear disease are tolerably well defined, though cases occasionally occur in which the most ex- x 306 THE SURGICAL DISEASES OF CHILDREN perienced surgeons are mistaken. The typical history is, that a child, who has long been suffering from a stinking otorrhoea, catches cold, or receives a blow on the side of the head. He complains, either in a few hours or after some days or weeks, of severe headache, at first localised, but later extending all over the side of the head. The pain is accompanied by vomiting of the ordinary cerebral type. There is generally a single rigor, and the temperature is so little above the normal that the surgeon may be thrown off his guard if he trust too much to the thermometric indications. The discharge from the ear either diminishes in quantity, or may disappear entirely. The parents, look- ing only to the pain without taking the trouble to localise it, as a rule think that these symptoms are due to a fresh attack of the earache, to which the child has long been liable. They neglect to seek advice, and so this early stage of the disease rarely comes tinder the notice of the surgeon. In a few cases, a cerebral abscess is formed in connection with an acute inflammation of the middle ear. The violent pain subsides after a time, but the patient is so listless and drowsy that he is kept in bed, and as long as he is recumbent he does not vomit. Examination now shows distinct evidence of intracranial pressure : the temperature becomes sub-normal, the pulse is slow and full, the respirations are slow and regular — slower and more sighing in cerebellar abscess than in the cerebral form. There is well-marked tenderness over the temporal bone on the affected side, and this tenderness is readily elicited by gently tapping the skull with the finger, but there is not necessarily any oedema or swelling. The breath is often foetid, and there may be a rapidly advancing optic neuritis. An endeavour should be made at this stage to ascertain the position of the abscess, for Macbride be- lieves that, if the conduction of sound by the bone is CEREBRAL ABSCESS 2>Oy impaired, owing to disease of the labyrinth, the abscess is more likely to be in the cerebellum than in the temporo- sphenoidal lobe of the brain. The condition of cerebral irritation, which is often indicated by twitching of the muscles, soon passes into paralysis ; the patient becomes first stupid and then comatose, the pulse becomes quick, the temperature rises rapidly, convulsions occur, and death soon terminates the case, unless the abscess is emptied. Prof. Macewen states that he is able to elicit a differential cranial percussion note in children with cerebral abscess ; the patient is supported upright in bed, and gentle percus- sion is made over the pterion on the two sides. I have several times endeavoured to elicit this difference, but my ear is not }*et sufficiently trained to observe it. Diagnosis. — The diagnosis of cerebral abscess has to be made from cerebral inflammation of a more diffuse nature, from diffuse serous meningitis, from infective thrombosis of the lateral sinus, and from cerebral tumour. The absence of delirium or nerve-paralysis, the low temperature until the later stages, and the absence of rigidity in the muscles of the neck, are the chief points by which to recognise a cerebral abscess. They are all negative, however, and they are merely symptoms of in- creased intracranial pressure, so that they are very apt to prove fallacious. Prognosis. — The prognosis is always grave, for unless surgical treatment be adopted early, a cerebral abscess generally ends fatally. An untreated acute abscess runs its course in two to six weeks, whilst a chronic abscess may last as many months or years. Treatment. — The treatment is prophylactic or curative. The prophylactic measures have already been dealt with (pp. 297, 298) in the simple forms ; and if they fail, the parts must be rendered as thoroughly aseptic as possible, 308 THE SURGICAL DISEASES OF CHILDREN in every case in which it is likely that a cerebral abscess may be formed. This, of course, is in every case of long- continued stinking otorrhcea associated with disease of the middle ear. The only way to meet this indication is to cut away a portion of the compact tissue, forming the front wall of the mastoid process, as soon as the ordinary methods of arresting the discharge have failed. There need be the less hesitation in doing this, as the operation is neither difficult nor dangerous, if ordinary care and skill be em- ployed, and it is attended with the most satisfactory results. Professor Macewen, following Professor Schwartze's indica- tions, states that it is justifiable to open the mastoid antrum when : (1) There has been repeated inflammation of the mastoid antrum and its cells, accompanied by swell- ing over the mastoid process, or when there is a fistulous opening in the bone, from which pus is discharging. (2) In acute inflammation of the mastoid antrum and its cells, with retention of pus. (3) When there are initial symp- toms of intracranial disease, associated with chronic and purulent otorrhcea. Finally, where there is a persistent otorrhcea, especially if it be offensive, and if the discharge is mixed with bony particles or steatomatous masses. These rules apply equally to childi^en and to adults. Opening the Mastoid Cells. — The operation of opening the mastoid cells was first performed by J. L. Petit in 1750, though Jasser, a German army surgeon, usually has the credit of introducing it in 1776. The mastoid antrum is the point to be aimed at in young adults, for it communicates on the one hand with the middle ear, and it is only separated from the middle fossa of the skull by a thin shell of bone. It is therefore one of the points through which inflammatory processes are most likely to extend directly from the ear to the dura mater. In children there is practically only a single EXPLORATION OF MASTOID PROCESS 309 large cell in the mastoid process, so that the pus is obvious as soon as the outer wall of the bone is gouged away. The patient should be properly prepared for the opera- tion by shaving the side of the head the day before the operation, scrubbing it thoroughly with soap and water, and afterwards with ether. It should then be covered with a dressing soaked in 1 in 1000 solution of corrosive sublimate, kept in place by a gauze bandage until the opera- tion begins. The parts should be again washed when the patient is under the anesthetic, and rubbed over with a one pro mille solution of corrosive sublimate in alcohol. A perpendicular linear incision is then made a quarter of an inch behind the posterior border of the external auditory meatus. All the tissues, including the perios- teum, should be divided until the bone is reached, and it is a golden rule to expose the posterior bony edge of the external auditory meatus, since this border serves as a landmark throughout the operation. The cancellous tissue of the mastoid process must be exposed by gouging away the bone upwards and a little forwards, at the same time remembering that the bone is very thin, and that, unless great care be taken, the dura mater, the lateral sinus, and even the brain itself, may be exposed and injured. This is especially likely to happen in cases of long-standing inflammation, in which the outer layer of compact bone may become as dense as ivory. The cavity of the mastoid should be thoroughly cleansed, and any epithelial masses ■or caseating material should be removed. No drainage-tube is required if this be done thoroughly, and if the diseased skin be cut away with a scalpel. The side of the head is subsequently enveloped in antiseptic lint, with gauze ban- dages, and the wound is dresseil frequent]}' if there is much discharge. During the operation the following anatomical points 3IO THE SURGICAL DISEASES OF CHILDREN may be borne in mind : — The facial nerve lying in the aqueductus Fallopii generally crosses the inner half of the floor of the mastoid antrum, running obliquely from without inwards ; the lateral sinus is in very close proximity to the roof of the space, which is sometimes defective as a result of the ulcerative process, and con- sequently granulations in this region, which appear to be of the ordinary type, may in reality spring from the dura mater. Professor Birmingham gives the following rules for finding, and for avoiding the lateral sinus in an adult : ' The lateral sinus can always be exposed by a three- quarter-inch trephine, if its pin be placed an inch and an eighth behind the centre of the bony meatus, and in the line of its upper border. To avoid the sinus, a perfora- tion behind the ear should be made, in front of a vertical line drawn a quarter of an inch behind the posterior mar- gin of the meatus. The mastoid antrum can always be reached without wounding the sinus or entering the cranial cavity, if a quarter-inch drill is sent straight in at such a point that the anterior margin of the aperture it makes is as close as possible to the bony meatus, whilst its upper margin is not more than the one-twelfth of an inch above the level of a line prolonged horizontally backwards from the upper border of the meatus. It should be remembered that there is danger of woundino- the labyrinth, if the drill be allowed to penetrate more than three-quarters of an inch into the base of the mastoid process." The position of the lateral sinus is very variable, and Professor Thomson has collected in the Museum of the Anatomical Department at Oxford a series of temporal bones from children, in which it may be seen that in some cases it would be impossible to trephine the mastoid bone without exposing the sinus. EXPLORATION OF MASTOID PROCESS 3 I I Neither exposure nor pricking of the lateral sinus adds materially to the danger of the operation, though of course neither accident should be allowed to happen, if it can possibly be avoided. The bleeding from a small puncture in the lateral sinus is easily arrested by pressure with a pad of lint. The operation of trephining is considered in detail on page 329. It is here sufficient to remember that the presence of pus is suspected when the dura mater bulges into the trephine hole, and when no cerebral pulsation can be felt. A pair of sinus forceps should be introduced into the cerebral substance after the dura mater has been incised. Trocars and hollow needles are useless as exploratory agents, for the soft brain matter blocks them. The ab- scess cavity may be gently scraped, and if the pus has been very foul it should be drained. No form of mer- curial dressing or lotion should be employed, as mercurial salts are liable to form stable compounds with the cerebrum. Mr. Ballance says that a trephine opening to explore the anterior surface of the petrous bone, the roof of the tympanum, and the petro-squamous fissure, has its centre situated seven-eighths of an inch vertically above the middle of the meatus, i.e. above Reid's base lino. The trephine should be half an inch in diameter for an adult. A probe passed along the lower margin of the trephine hole, after the crown of bone has been removed, can be insinuated between the dura mater and the bone, so as to search the whole of the anterior surface of the petrous portion of the temporal bone. Mr. Barker recommends that a teinporo-sphenoidal abscess should bo opened with a half-inch trephine, situ- ated one inch and a quarter behind, and one inch and a quarter above, the centre of the external auditory meatus, 312 THE SURGICAL DISEASES OF CHILDREN i.e. above Reid's base line ; the probe being directed ,at first inwards, and then a little downwards and forwards. The trephine-opening for a cerebellar abscess should be half an inch in diameter. Its centre should be an inch and a half behind, and a quarter of an inch below, the centre of the meatus. Mr. Ballance says that the anterior border of the trephine should be just under cover of the posterior border of the mastoid process. The aperture in the skull is then so far away from the lateral sinus that any instrument introduced into the substance of the brain may be directed forwards, inwards and upwards, until it reaches an abscess situated in the anterior part of the lateral lobe of the cerebellum, which is the usual site of collections of pus in this part of the brain. CHAPTER XVI INTRACRANIAL DISEASE AND ITS SURGICAL TREATMENT THROMBOSIS OF THE CEREBRAL SINUSES. Spontaneous Thrombosis. Primary thrombosis is occasionally seen in the longitu- dinal sinus, and in the tributary veins in marasmic children up to the age of three or four years. It does not appear to give rise to very definite symptoms, for the children are sleepy ; but there is no evidence of any meningitis. There may be some oedema of the nasal mucous membrane, with a little increased fulness at the root of the nose. They sometimes moan continuously. Death results from the constitutional condition, and is generally preceded by coma. No treatment is effectual. Infective Thrombosis. 31 /Etiology. — Secondary thrombosis of a cerebral sinus is always infective, and is generally pysemic in origin. It is most frequently associated with caries or necrosis of the posterior wall of the tympanum, with meningitis, with cerebellar abscess, or with other infective lesions of the head and face. A purulent pachymeningitis is set up in the outer wall of the sinus, and this leads to the forma- tion of a purulent thrombus. The cavernous and lateral sinuses, as well as the upper third of the internal jugu- lar vein, are most frequently plugged, and often by a 313 314 THE SURGICAL DISEASES OF CHILDREN suppurating clot. Gangrene of the lungs may result from the lodgment of infective emboli. Symptoms. — The symptoms of infective thrombosis are usually sufficiently well marked to render the diag- nosis easy. A severe pain radiates from the seat of inflammation, there is repeated vomiting, and a tempera- ture which is remarkable for its rapid rise, and for its wide and irregular oscillations. Rigors recur at definite intervals, they are often severe and very prolonged. The pulse is rapid, small, and thready. The mastoid region may be swollen and tender, and in the worst cases the swelling extends upwards on to the scalp, and downwards along the course of the internal jugular vein, which may sometimes be felt as a more resistant cord in the neck. The patient complains of stiffness in the muscles at the back and side of the neck. Optic neuritis in varying degrees of severity is often present, and there may be some facial paralysis. The intellectual faculties, at first benumbed, are afterwards abolished, for the patient loses conscious- ness. Dyspnoea, with localised pain in the chest, marks the plugging of one of the smaller pulmonary arteries, which may be the first stage towards gangrene of the lung and the death of the patient. Diagnosis. — Although the symptoms are usually so well marked that no mistake can be made in the diagnosis, yet it sometimes happens that they are sufficiently obscure to prevent its recognition even by those who are most familiar with it. The following case shows how easily this condition may be overlooked, owing to the ill- development of the symptoms, even when one is on the alert, for it occurred two or three days after I had written the above account. A child, aged nineteen months, came under my care to be treated for a mastoid abscess in June, 1894. Her father and one sister, out of a family of five, INTRACRANIAL DISEASE AND ITS TREATMENT 3 1 5 were dead of phthisis. The mastoid bone was exposed, and much tuberculous granulation tissue was scraped away. The wound soon closed, and the patient was dis- charged. A month later she was re-admitted to the Victoria Hospital, suffering from diarrhoea. She vomited, but beyond screaming she gave no evidence of cerebral symptoms. She died two days afterwards, her tempera- ture just before death suddenly rising to 108° F. It was found at the autopsy that, in addition to tuberculous disease of the viscera, she bad a clot in the left lateral sinus, with such extensive necrosis of the petrous portion of the right temporal bone, that a round sequestrum as large as a sixpence lay loose in the brain case. Secondary thrombosis may also be mistaken for an attack of typhoid fever, from which it may be distinguished by the repeated rigors and by the oscillating temperattvre marking the pysemic condition. An acute inflammation of the middle ear, leading to the formation of an abscess which bursts through the mastoid and tracks down the neck, is liable to be mis- taken for secondary thrombosis, but the swelling is situ- ated farther back in the neck, and the jugular vein remains unaffected. In such cases the patient is con- scious, and although there may be severe rigors, the temperature is not so high in the intervals. Prognosis. — The prognosis is always serious, and in cases where thrombosis of the lateral sinus is suspected, and the mastoid vein is plugged, the sinus should be ex- plored at once ; for only in very exceptional cases does the abscess burst and discharge immediately through the mastoid, or mediately through the antrum. Treatment. — The internal jugular vein should first be expose I in the neck, ligatured below the thrombus, and it should then be divided, for this will prevent the J 1 6 THE SURGICAL DISEASES OF CHILDREN extension of the thrombosis, and will lessen the risk of embolism occurring during the operation from interference with the clot. The blocked portion of the vein may be opened and irrigated if necessary. A pad of antiseptic gauze is then placed over the wound, or it may be closed at once. The lateral sinus is then explored by trephining over it. This should be done by turning down a flap of soft tissues, including the pericranium, one point of the semicircle com- mencing immediately behind and just above the ear, and being carried backwards for a sufficient distance to enable a 1-inch trephine to be worked with ease. The lateral sinus (fig. 35) runs from just below the inion, or external occipital protuberance, horizontally round the skull until it reaches the parieto-occipital suture. It here makes a sharj) turn downwards on to the temporal bone. The mastoid vein or veins open obliquely into this descending part of the sinus, which again curves forwards out of the reach of surgical interference. If the pin of the trephine be placed over the skull at the point where the mastoid vein enters, there will be no difficulty in exposing the sinus, for the vein opens directly into it and passes through the skull on a level with it. Mr. Ballance states that in an adult the trephine opening to expose the lateral sinus should have its centre one inch behind, and a quarter of an inch above, the middle of the bony meatus, i.e. above Reid's base line ; but in the child's skull from which my figure was drawn, it was necessary to place the pin of the trephine upon the base line, as is seen in fig. 35 D. A trephine is used measuring five-eighths of an inch in diameter, and the opening in the bone should be extended forwards with a gouge or cutting forceps, so as to open up the mastoid cells. The sinus is care- fully laid open as soon as the crown of bone has been INTRACRANIAL DISEASE AND ITS TREATMENT 3 I 7 removed. Its cavity is cleared, and rendered as aseptic as possible by flushing it with a solution of perchloride of mercury 1 in 2000, at a temperature of 105° F. The wound is then freely drained, and both it and the one in the neck are dressed antiseptically. Death in untreated cases usually takes place within three weeks, from gangrene of the lung or from general pj'aemia. CEREBRAL MENINGITIS. ^Etiology. — Inflammation of the cerebral meninges is always infective in origin. It is either simple or suppu- rative, primary or secondary. Idiopathic suppurative meningitis may occur from many causes, the most frequent being tubercle. Recent researches show that it may be produced as a primary or secondary affection by pneumococci, streptococci, staphylococci, and the bacillus coli. The meninges of the brain are directly involved in the primary affection without the production of any general disease, such as typhoid fever, pneumonia, ab- scesses, or furunculosis. Secondary meningitis, on the other hand, occurs in the course of one of these general diseases, in endocarditis, in influenza, or, it may be, after a compound fracture of the skull. NOX-TlJBERCULOUS MENINGITIS. 32 These forms, of non-tuberculous meningitis are therefore either pyogenic or non-pyogenic in origin. They usually affect the convex surface of the pia mater, and they are generally bilateral, although if they originate from a specific focus, as from a fracture, or from middle ear disease, the inflammation may be confined to one hemisphere. The special form produced by pneumococci is said to be nearly always cerebro-spinal, and it is perhaps the cause of the epidemic cerebro-spinal meningitis, which occasionally J 1 8 THE SURGICAL DISEASES OF CHILDREN sweeps over countries with the devastating effects of a plague. The effusion is often very abundant ; it is thick and plastic in character, and may be of a characteristic green colour, with a peculiar sickly smell ; but in other cases it is thin and serous, and has less characteristic properties. The inflammation spreads by means of the lymphatic system, and the micro-organisms may often be found in the peri-arterial lymphatic vessels. Symptoms. — The symptoms sometimes set in with startling rapidity, and this absence of a prodromal period distinguishes the less common forms of infective menin- gitis from that produced by tubercle. There is a short stage of excitement, with a temperature of 103-4° F., headache, vomiting without nausea, con- stipation, and inequality of the pupils. The pulse varies greatly during the attack: at one time it is quick, at another time slow; at one time regular, and at another intermittent. There is delirium later in the disease, followed by convulsions, retraction of the head and belly, due to tonic contractions of the muscles, with paralysis of one or more of the cranial nerves, and more or less hemi- plegia. These symptoms terminate in coma, Cheyne- Stokes' breathing, relaxation of the sphincters, dilatation of the pupil, and death. The disease usually runs an acute course, but it is sometimes subacute or chronic. Diagnosis.— The diagnosis is difficult, for all these symptoms may be present, and yet at the autopsy no meningitis can be discovered. The non-tuberculous men- ingitis has to be distinguished from the much more common tuberculous form. Dr. Gee and Dr. Barlow believe that cervical opisthotonus is an essential sign of non-tuberculous basal meningitis, whilst in the tuberculous form it is an accidental symptom. It is a tonic contrac- tion, and becomes more pronounced as the patient is raised INTRACRANIAL DISEASE AND ITS TREATMENT 319 into an erect position. It is, however, inconstant, and may be absent entirely, or being present, it may disappear whilst the inflammation still progresses. Prognosis. — Recovery may take place spontaneously, or after an operation to relieve the intracranial pressure by providing an exit for the cerebro-spinal fluid. Death, however, is by far the most frequent ending. Treatment. — The indication for the palliative treat- ment of these cases is to get rid of the source of infection if it be possible. This is best done by disinfecting the alimentary canal. The mouth must be frequently washed out with a saturated solution of creolin, whilst /8-naphthol is given every three hours, in one-grain doses admin- istered in milk, or one and a half to three grains of naphthaline as a powder, if it be preferred. The operative treatment consists in trephining (p. 329) the skull when it is possible to localise the inflammation, or if there is evidence of acute distension of the ventricles. The operation, therefore, should always be performed when the inflammation is associated with a fractured skull, and when hemiplegia supervenes after a trivial injury to the scalp, even though the symptoms do not come on for five or six weeks. Tuberculous Meningitis. etiology. — Tuberculous disease of the brain and its membranes is usually secondary to tuberculous disease of the thoracic and abdominal organs, and of the mesenteric glands, even though the cerebral symptoms do not appear until the primary disease is cured. It may originate in a tuberculous inflammation of the middle ear ; much more rarely it is in connection with tuberculous joints, bones, or superficial lymphatic glands. In a few instances it seems to be truly primary in origin. 320 THE SURGICAL DISEASES OF CHILDREN Pathology. — The pia mater at the base of the brain is chiefly affected. Miliary tubercles are also found along the fissure of Sylvius and in the velum interpositum. The latter, by the inflammation to which they give rise, lead to blocking of the venae Graleni, and so to a vascular disturbance, causing distension of the ventricles with cerebro-spinal fluid. This produces such cerebral com- pression as to cause death. Caseating masses are often found in the substance of the cerebellum, and even of the' cerebrum in these cases. The masses appear to have been long antecedent to the meningeal inflammation, for they are sometimes calcified. They rarely give rise to symptoms. Symptoms. — Prodromal symptoms are more frequent in tuberculous meningitis than in the non-tuberculous forms. They are often trivial. A little increase in the child's irritability, listlessness, slight frontal headache, an exaltation of cutaneous sensibility, a few attacks of sudden vomiting, and a slight but intermittent squint, may be the sole indications of the deadly process going on within the skull. The temperature is only slightly raised at first, for it is often not more than 99°-100° F. More acute symptoms manifest themselves after a period of days, or weeks, or months. There is sudden and repeated vomiting, with an agonising headache, often paroxysmal, and accom- panied with the peculiar piercing shriek which used to be described as the " hydrocephalic cry." The hyperaesthesia becomes more marked, slight sounds annoy the child, there is photophobia, and the pupils are contracted. A marked remission often takes place in these cases, but the im- provement is nearly always delusive. Sooner or later the pupils dilate, the temperature rises and becomes remark- ably variable, the pulse becomes irregular, there is Cheyne- Stokes' respiration. General or partial convulsions take INTRACRANIAL DISEASE AND ITS TREATMENT 32 1 place ; but soon the coma deepens, the paralysis becomes more and more marked, there is loss of control over the sphincters, the temperature rises rapidly, and the child dies. Diagnosis. — Tuberculous meningitis has to be distin- guished from the other forms of infective cerebral inflam- mation, as well as from the pressure effects caused by injury and tumours. The tuberculous inflammation is so common in children, and other evidence of tuberculous disease is so easily obtained, that there is rarely any diffi- culty in distinguishing this form of meningitis. The history of hereditary tubercle, the gradual onset, the rapid loss of flesh, and the irregular temperature, go far to verify the diagnosis. Too much reliance must not be placed upon the results of ophthalmoscopic examination, for many cases of tuberculous meningitis run their course without giving rise to visible intraocular changes. The surgeon must be constantly on his guard ; for although the diag- nosis of tuberculous meningitis is usually easy, he should remember that few diseases assume so protean a form, and in few is the course so often atypical. The diag- nosis, however, may be rendered absolute by finding tubercle bacilli in the cerebro-spinal fluid obtained by puncture of the vertebral canal in the lumbar region in the manner described on page 322. Prognosis. — Death is so certain in these cases that the treatment of tuberculous meningitis can only be con- sidered palliative. Treatment. — The cause of death appears to be the in- tracranial pressure, often exaggerated by the vascular dis- turbance caused by venous obstruction. Trephining the skull has therefore often been practised for its relief. One case which fell under my immediate observation was, I believe, cured by the operation. Y 32 2 THE SURGICAL DISEASES OF CHILDREN A girl, aged five, suffering from all the symptoms of tuberculous meningitis, appeared to be rapidly passing into the stage of coma, with paralysis. It was therefore deter- mined to drain the subarachnoid space as low as possible. The trephine was placed upon the left side of the skull, halfway between the occipital crest and the mastoid pro- cess. The dura mater bulged forwards as soon as the crown of bone was removed. It was incised, and a few drops of cerebro-spinal fluid escaped. The cerebellum im- mediately filled the trephine hole, and prevented the escape of more fluid. A silver probe passed inwards towards the falx, between the cerebellum and the arachnoid, allowed several drachms of serous fluid to escape. A drainage- tube was then passed along the probe, and was left lying between the brain and its membrane, and the dura mater was replaced. The crown of bone, which had been kept in warm boric solution, was broken up, the fragments were placed over the dura mater, and the wound was closed. A free discharge of cerebro-spinal fluid occurred for a week after the operation. The child rallied well, and immedi- ately began to improve. She was eventually discharged, and she has since paid many visits to the hospital. The case, which was under the care of my colleagues, Dr. Ord and Mr. Waterhouse, is recorded in detail in the Trans- actions of the Medical Society for 1894. I have since re- peated the operation several times, and with temporary relief ; but no other case has been cured. Puncture of the Vertebral Canal. 33 Ziemssen in Munich and Dr. Essex Wynter in London have recently advocated puncture of the vertebral canal and evacuation of the cerebro-spinal fluid in cases of tuber- culous meningitis. Quincke has shown by dissection that in children of one year old the spinal cord reaches to the INTRACRANIAL DISEASE AND ITS TREATMENT 323 second lumbar vertebra, whilst in the newly born child it extends to the third, and he has advised a similar punc- ture for the relief of hydrocephalus. The child is held in a sitting position, with his back turned towards the surgeon. He is then bent forward to make the space between the vertebral arches as large as possible. A minute incision is made through the skin between the third and fourth lumbar vertebrae, and just to one side of the spinous process. A very fine trocar and canula, which have been freshly boiled, is then pushed in through the skin incision until it impinges upon the lamina, when its point is directed somewhat downwards, and it is driven through the ligamentum subflavum and the theca towards the middle line for a distance of a little less than an inch. The trocar is withdrawn whilst the canula is left in place, and clear cerebro-spinal fluid at once escapes. The nerve roots forming the cauda equina in young children are usually collected into two compact bundles lying upon either side of the vertebral canal, so that there is very little danger of injuring them. The surgeons who have used this method most exten- sively report favourably upon it, for they all agree that temporary relief is obtained which might be permanent if it were possible to establish a fistula through which the cerebro-spinal fluid escaped constantly. The operation is a trivial one if everything is kept aseptic, and it appears to be well worthy of a more extensive trial, as it is of great diagnostic value. Hirschberg objects to the method, on the ground that it is impossible to drain the skull through the vertebral canal under the conditions which are present in tuberculous meningitis. The objection is a theoretical one, and it has yet to be proved whether it is founded on a basis of fact. He prefers, like many other surgeons, the operation of trephining for the relief of these cases. 324 THE SURGICAL DISEASES OF CHILDREN Trephining. The cases of meningitis to be trephined or punctured must be selected with care. Those which are associated with active tuberculous mischief in the viscera or other organs are unfitted for operative interference, as there is a constant source of infection. The later stages of the disease are also unsuitable. Good results may perhaps be obtained when the case is seen early ; when the men- ingitis is primary in origin ; when it follows an attack of pleurisy or peritonitis, from which complete recovery has taken place ; when it is associated with tuberculous lym- phatic glands which can be removed without danger ; when it is in connection with an otorrhoea amenable to surgical treatment ; and when it is due to such local causes as fracture, leading either primarily or secondarily to the formation of a cerebral abscess. The same pathological reasoning which leads us to open the peritoneal cavity in cases of tuberculous peritonitis leads us to evacuate the fluid in cases of tuberculous meningitis ; but both opera- tions are still in a state of probation. THE CEREBRO-CRANIAL TOPOGRAPHY IN CHILDREN. 34 The cranio-cerebral topography in children has been carefully worked out by Eouillehouze (fig. 34), whose results have been verified and accepted by Dana. The differences in the adult (fig. 33) and in the child (fig. 34) are not great. The chief points of importance are that the bregma in the child lies close to the posterior edge of the anterior fontanelle. The upper end of the fissure of Rolando is situated either at, or a little in front of, its position in the adult, for its upper end during the first months of life is from 30 to 35 mm. behind the bregma, the antero- posterior diameter of the brain being 113*5 mm. It is INTRACRANIAL DISEASE AND ITS TREATMENT 325 42-43 mm. behind the bregma during the second to third year, and after this age it rapidly assumes the same rela- tions as in the adult. The lower end of the fissure is pro- portionately higher until the third year, after which it falls to the adult position. The fissure is therefore situated some- what higher up and a little farther back in children than in adults. The fissure of Sylvius is a little more oblique in children up to the third or fourth year, and lies higher above the squamous suture than in adults. Its posterior branch lies either just under the squamous suture at its highest point, or ^ to 1 cm. above it. It runs up to, and usually above and in front of, the parietal eminence, i.e. the parietal eminence in children is relatively lower than in adults. The parieto-occipital fissure is either exactly under the lambda or 1 to 2 cm. in front of it. Exploration of the Cerebral Ventricles. 35 — The operation of draining the ventricles has been performed for compound fracture of the skull with secondary implication of the ventricles, and for the relief of acute hydrocephalus. It is useless in chronic cases. The operation was first pro- posed by Wernicke in 1881, though puncture of the brain for the relief of hydrocephalus dates back to the time when Stevens proposed that it should be employed in the case of Dean Swift in 1744. It was first carried out by Zenner, of Cincinnati, in 1886. It has since been elabo- rated by Keen in -America, and by Broca in France. It appears to be more satisfactory to drain the ventricles laterally than either through the anterior or the posterior horns. Keen gives the following directions for finding the different parts of the lateral ventricle in the adult ; and so far as I have proved them in children, they are sufficiently correct for all practical purposes. (1) Trephine (fig. 35 b) halfway between the external occipital protuberance and the upper end of the fissure of 26 THE SURGICAL DISEASES OF CHILDREN Rolando, at a distance of \ to f inch to either side of the middle line. Puncture towards the inner edge of the supraorbital ridge of the same side. The puncture will pass through the precuneus, and the normal ventricle will be struck at some point in the posterior horn at a depth Fig. 33.— Skull showing the position of the chief cerebral fissures in the adult (cf. fig. 34) with Reid's base-line. A, Glabella; B, external occipital pro- tuberance ; e.a.p., external angular process of the frontal ; B, C, transverse fissure; Sy. fis., fissure of Sylvius; Sy. h. fis., horizontal limb of the fissure of Sylvius ; Sy. a. fis., ascending limb of the fissure of Sylvius ; I), E, perpen- dicular line from depression in front of external auditory meatus to middle line of top of head; F, G, perpendicular line from posterior end of base of mastoid process to middle line of top of head ; F, H, fissure of Rolando; p. o. fis., parieto-occipital fissure; + most prominent part of parietal eminence. (Copied by permission of Prof. Reid from the Lancet, vol. ii., 1884, p. 639.) of 21 to 2| inches from the surface of the scalp, method gives the best drainage. This INTRACRANIAL DISEASE AND ITS TREATMENT 327 (2) Measure the distance from the glabella to the upper end of the fissure of Rolando — a distance of about 6 inches in a child aged two years. Trephine at the junction of the anterior and middle third of this line and h to £ inch away from the middle line of the skull (fig. 35 a). The puncture will traverse the first frontal convolution well in front of the motor zone, and the normal ventricle will be struck in the anterior horn at about 2 to 2\ inches below B re cm a Par/elo G/acie/'a Fig. 3t.— Outline drawn from the skull of a child, aged about three years, to illustrate the main points in the cranio-cerebral topography of children. The position of the lambda and inion are only approximate, as they cannot be seen in a side view. The skull is tilted laterally to show the sagittal suture. Its antero-posterior measurement from the glabella to the inion was 287"5 mm. the scalp. The objection to this method is the real one, that it leaves a scar on the forehead ; and the theoretical one, that injury might be done to the corpus striatum. It is serviceable, however, in a compound fracture of the skull, when there is reason to believe that the ventricle is distended with blood. (3) Trephine 1\ inch behind the posterior margin of 328 THE SURGICAL DISEASES OF CHILDREN the external auditory meatus and 1| inch above Reid's base-line (fig. 35 c), i.e. a line drawn backward from the inferior border of the orbit through the middle of the ex- ternal auditory meatus to the occiput. Puncture towards a point just above the external auditory meatus of the opposite side. The puncture will traverse the second temporo-sphenoidal convolution, and will enter the normal lateral ventricle at the beginning or in the course of the descending cornu at a depth of about 2 to 2\ inches from the Fig. 35. — Outline drawn from the skull of a child, aged about three years. It shows Reid's base-line passing through the centre of the external auditory meatus, and the curved outline of the lateral sinus. A, denotes the point at ■which to trephine for the purpose of exploring the right lateral ventricle through its anterior horn ; B, point to trephine for exploring the right lateral ventricle through its posterior horn; C, point to trephine for exploring the right lateral ventricle through its lateral horn ; D, point to trephine for explor- ing the lateral sinus in cases of infective thrombosis. surface. This is the method best suited to ordinary cases, as it allows a temporo-sphenoidal abscess to be dealt with, if it be found in the course of the operation that an error has been made in the diagnosis. INTRACRANIAL DISEASE AND ITS TREATMENT 329 Trephining is neither a difficult nor a dangerous opera- tion. The head must be shaved and thoroughly cleansed overnight, and an antiseptic dressing should be applied until the time of the operation. The surgeon, having selected the point at which he proposes to trephine, makes a semi- circular flap, cutting down to the bone. The convexity of the incision is directed upwards, as there is less haemor- rhage, owing to the arteries being divided farther away from their origins. As soon as the bone is exposed, the surgeon places the pin of a f-inch trephine at the point where he desires to expose the meninges. He works his trephine with care until a good groove is formed in the bone, when the centre-pin is withdrawn or, better still, is removed. Great care must be taken to divide the bone evenly at each part of its circumference, or the dura mater may be lacerated. The application of a thin raspa- tory or periosteal elevator will enable the crown of bone to be removed easily when it has been cut through. If the dura mater is tense, elastic, and does not pulsate, it may be assumed that the ventricles are distended. The dura mater should be incised in such cases, and the brain explored with a grooved director. The clear fluid readily flows out, and with considerable force, if the ventricles be distended. The rapid evacuation of fluid from the ventricles does not seem to be attended with any evil results, and quite re- cently I removed two and a half ounces from one ventricle with marked temporary improvement in the pulse and respiration. The ventricles may be drained through the brain by inserting into them a drainage-tube of stout rub- ber, or, better still, by a small bundle of horsehairs, for the tube is apt to get clogged. The wound is then closed with point sutures, and antiseptic dressings aro applied. I do not consider it necessary to replace the crown of bone either wholly or in fragments, for trephine holes in children 33° THE SURGICAL DISEASES OF CHILDREN soon begin to dimmish in size. It is better not to use mer- curial dressings and lotions in these cases, as there is a theoretical objection that they may form stable salts with the brain substance. CEREBRAL TUMOURS. Intracranial tuberculous disease takes two forms. It either occurs as a tumour embedded in the cerebral sub- stance, or as a miliary tuberculosis of the membranes. The two forms are only combined in a few cases. The symptoms of embedded tumours are usually marked by an absence of fits, paralysis, or sickness. There may be im- paired vision due to optic neuritis, and drowsiness is often a very marked symptom. These cases of tuberculous dis- ease, however, are unfitted for surgical operation, as the tumours are large, often deeply seated and caseating ; so that they could not be completely removed. Dr. Peterson estimates that 25 per cent, of the tumours occurring in the brains of children are tuberculous. Gliomata and sar- comata form nearly all the rest. None of these growths lend themselves readily to operative treatment under pre- sent conditions, so that the surgical treatment of cerebral tumours in children as yet hardly exists. CHRONIC HYDROCEPHALUS. A considerable number of these cases constantly come under the notice of the surgeon to a children's hospital. Treatment. — My own routine practice in the more severe cases is to draw off the fluid from the lateral ven- tricles by puncturing at the outer angle of the anterior fontanelle with a fine and thoroughly aseptic trocar and canula. The instrument should be directed outwards and a little backwards. It is, I think, better to remove the fluid by repeated punctures than to run the risk of setting INTRACRANIAL DISEASE AND ITS TREATMENT 33 1 up cerebral symptoms by withdrawing the whole of it at one time ; for the intracranial conditions here are very different from those in acute distension of the ventricles. The child is to be properly prepared overnight by having his head shaved, cleansed, and bandaged, as though he were to undergo a serious operation. The skin should be divided with a scalpel, to prevent any particle of unclean epithelium being carried into the ventricles on the end of the trocar. A piece of cotton-wool soaked in collodion is sufficient to close the wound when the operation is com- pleted. The operation is useless in children whose skulls are firmly consolidated. The Treatment of Microcephalus and Idiocy. The operation of craniotomy in all its forms for the treat- ment of microcephalus and idiocy has proved so unsuccess- ful and so dangerous in all the cases which I have had an opportunity of observing, that I do not consider it a legiti- mate surgical procedure. The excellent results obtained by a judicious process of education show how much can be done to ameliorate the condition of these unfortunate children. Treatment of Meningo-Encephalocele. There is no reason why these cases of pulsating tumour springing from the site of a fontanelle should not, in the case of healthy children, be removed by the ordinary aseptic methods. Care must of course be taken that the wound should heal by first intention, and that an aseptic liga- ture be placed round the sac. Several successful cases' are recorded. The operation may be done in two stages : the first to draw off the fluid, and the second to remove the brain substance if it cannot be kept in place by a pad and bandage, or other form of truss. CHAPTER XVII SURaiCAL DISEASES OF THE AIR PASSAGES DIPHTHERIA IN ITS SURGICAL ASPECTS. Pathology. — Scientific inquirers have now satisfied themselves that diphtheria, like many other infective diseases, is really of several types. The simplest but most virulent is associated with the presence of a specific or- ganism known as the Klebs-Loffler bacillus, whilst the more common type is due to a mixture of this bacillus with many forms of septic organisms. The Klebs-Loffler bacilli are moderate-sized rods, usually slightly bent, and of the same average length as tubercle bacilli, but from one and a half to twice as thick, but they vary materially in shape and size, especially in length. The simple bacilli are usually curved, but it is not unusual to find wedge-shaped bacilli and club-shaped organisms. They are frequently divided into segments. They are fixed, and possess no spores. They stain readily by Gram's method and with Loffler's alkaline methyl-blue, their ends staining more deeply than the middle. They are semi- aerobic, and thrive best at the temperature of the body, viz. 98 to 100° P., on a mixture of blood serum and nutrient bouillon. They are found on the surface of the false mem- brane, or in its substance, but they are always separated from the true mucous membrane by a layer of lymph con- taining leucocytes. Dr. Dillon Brown says that the most 332 SURGICAL DISEASES OF THE AIR PASSAGES 333 ready method of detecting this bacillus is to detach a small piece of membrane and place it for five minutes in a 2 per cent, solution of boric acid. The piece of mem- brane is then drawn along the surface of sterilized blood serum in a test-tube, and the serum is afterwards main- tained at a temperature of 98° F. If bacilli are present, characteristic small white and rounded colonies are visible along the track of inoculation, sixteen hours after it has been made. The centre of the colonies are more opaque than the periphery, and they grow so rapidly that they are usually well formed before any other micro-organisms have begun to form colonies at all visible to the naked eye. A second or third preparation, however, must be made before a pure cultivation is obtained. The virulence of the cultivations becomes successively diminished if they are grown on agar-agar, but not if they are cultivated on serum. To overcome the difficulty of obtaining sterilized serum, Sakharof suggests the use of hard-boiled eggs, from one end of which a part of the shell has been removed with ordinary forceps, so that the shell-membrane can be peeled off, to allow of the necessary inoculation being made. To guard against contamination, the egg can be turned upside- down in a common egg-cup, the interior of which has been sterilized by allowing the flame of a spirit-lamp to enter it for a second or two. Dr. Ball advocates growing the bacilli upon blood-clot which has been sterilized by boiling the blood in a test- tube kept in a water-bath at 212° F. for ten minutes, or until it has become quite solid and of a chocolate colour. He claims that the greyish- white colonies are better seen on a dark background than when they are grown upon a transparent surface. It should be remembered, however, that the growth of the organisms is much slower when 334 THE SURGICAL DISEASES OF CHILDREN they are cultivated on a medium which has been heated to a temperature of 212° F. The bacilli in pure cultivations possess the power of producing membranous exudations upon the various mu- cous surfaces of the body. They also form poisonous substances or toxines capable of causing constitutional symptoms when they can gain access to the blood-vessels or lymphatic channels, and through them to the tissues. These toxic products, however, only appear to be active when they are introduced under conditions predisposing to diphtheria, for many persons and animals are immune to their effects. They act especially upon the peripheral nerves, causing segmental neuritis, and upon the muscles, leading to fatty degeneration. The pure and the mixed forms of the disease are some- times clearly defined in the rare joint affections seen after an attack of diphtheria. The neuralgia of the joint, the serous arthritis and the periarthritis are due to the toxic products of the pure bacillus, whilst the acute and chronic suppurations are the results of the bacillus acting in con- junction with septic microbes. The differences in the mortality of the various outbreaks are no doubt to be attributed to the same cause. A knowledge of these pathological facts has recently led to great alterations in the recognition and in the treat- ment of diphtheria. It has shown the necessity of treat- ing diphtheria as a local disease, and as one whose source is in reality outside the body ; so that if the bacilli can be destroyed, the poisonous bodies resulting from their life and growth can be effectively dealt with by the tissues themselves. It should, however, be borne in mind that every croupoiis inflammation of a mucous membrane is by no means to be considered as true diphtheria, and that the only certain means of diagnosis at our disposal is that of SURGICAL DISEASES OF THE AIR PASSAGES 2,35 inoculation upon guinea-pigs and pigeons, and of bacterio- logical examination, which requires an elementary know- ledge of the ordinary methods employed in bacteriology. The bacteriological examination, however, is of great im- portance in regard to prognosis ; for the fewer the bacilli present, and apparently the smaller they are, the less severe will be the attack. Treatment. By Antitoxin. — A certain degree of im- munity from diphtheria can be conferred upon animals for a short time by inoculating them with attenuated cultures of the Klebs-Loffler bacillus, or by injecting a suitable quantity of the serum of an animal who has suffered from the disease in some form which has conferred immunity upon it. The means by which this immunity is obtained are as yet unknown, but it is perhaps due to the formation of antitoxins produced by the cellular elements of the con- nective tissues. In April, 1893, this method of treatment was extended by Behring and Kossel from animals to human beings, for they inoculated the serum of immune goats into thirty diphtheria patients, of whom twenty- four recovered. The method has rapidly become fashion- able. It has been suggested that it may be used as a preventive measure in the case of children who have been exposed to the risk of contagion, in which case only a small dose is required ; but hitherto it has been chiefly employed as a curative method for those actually affected with the disease, when a much larger dose is required. The results appear to have been satisfactory, and the method has been highly recommended, though we still require further evi- dence of its utility in extensive epidemics. Too much, however, must not be expected of it, for it does not pro- tect the individual for any length of time, nor does it in any way influence the action of the septic micro-organisms which play so large a part in the phenomena of ordinary 336 THE SURGICAL DISEASES OF CHILDREN cases of diphtheria. Inoculation of the protective serum, which is now made with horse's blood, will therefore in all probability be found serviceable only in the earlier cases of unmixed diphtheria. The method of inoculation is simple. The injection is usually made under the skin of the abdomen, which should first be washed with a 1 in 20 solution of carbolic acid. The hypodermic syringe must be boiled for five minutes immediately before the inoculation, to render it sterile. The dose for a child weighing twenty pounds is 10 cubic centimetres, which is equivalent to 170 minims, injected in one dose under the skin. In a severe case 5 centi- metres may be again inoculated after twelve hours, but in any case it is advisable to inject 10 centimetres twenty- four hours after the first inoculation. The syringe after it has been used is to be boiled for one minute. The inocula- tion may lead to a little swelling under the skin, but it usually subsides in a few hours, though there may be some tenderness for a day or two. It is maintained by Heubner and Roux that the anti- toxin can be introduced with absolute impunity even when diphtheria is only suspected, the sole evil effect being an erythematous rash which appears in about 25 per cent, of the cases from seven to nineteen days after the injection ; but Hansemann, who is opposed to this method of treatment, states that severe renal symptoms may result from its adoption, whilst Dr. Washbourn has observed slight arthralgia, the hips being most frequently attacked. By Fumigation. — Dr. Northrup has recently advo- cated the method of calomel fumigation for the treatment of acute laryngeal stenosis occurring in children. It was originally introduced by Dr. J. C. Corbin, of Brooklyn, in 1881. SURGICAL DISEASES OF THE AIR PASSAGES 337 A tent-cot is made in the ordinary manner, of such a size that it contains 50 cubic feet of air. A lighted spirit- lamp is placed in a wash-hand basin or in a chamber-pot, and a strip of tin is bent across it. Fifteen grains of chemically pure calomel are heaped upon the strip of tin where the flame of the spirit-lamp touches it. The sides of the cot are closed for a quarter of an hour, and the room should then be freely ventilated. Dr. Northrup re- commends that the fumigations should be repeated in severe cases at intervals of two hours for two days and two nights, the intervals being prolonged to three hours on the third day, four hours on the fourth day, and subse- quently three times a day. There is more or less anaemia after prolonged fumigation, but children do not become salivated though they have diarrhoea, and, if the calomel is mixed with corrosive sublimate, there may be some conjunctivitis. In the simpler forms of diphtheria an ice-collar may be applied to the throat, and a 4 per cent, solution of chlorate of potash should be used every hour as a gargle, or it may be sprayed into the throat and nostrils of a child who is too young to gargle. Hahn, too, recommends that in the early stages of diphtheria half a pint of a warm 2 per cent, solu- tion of boric acid should be injected into the rectum. Operative Treatment. Indications for surgical in- terference. — The surgeon is not usually called upon to make a diagnosis of diphtheria, but he is frequently sum- moned to relieve the symptoms of acute laryngeal dysp- noea. The dyspnoea comes on gradually ; at first there is a little languor with feverishness, and a peculiar " croupy " cough. The movements of the larynx soon become exag- gerated, and the characteristic furrow of inspiratory re- cession becomes marked. It is best seen on the front of the chest at the level of the ensiform cartilage. At each 33§ THE SURGICAL DISEASES OF CHILDREN inspiration the supraclavicular spaces become more deeply hollowed. The breathing in uncomplicated cases is rather laboured than hurried. Attacks of suffocation soon de- velop ; they are paroxysmal at first, and are succeeded by periods of comparative ease ; but as the disease progresses, the respites become briefer and are less pronounced, the restlessness increases, the face and the extremities become blue. Finally, as the lividity increases, the restlessness diminishes, the features assume a leaden pallor, the child becomes comatose and dies. No child should be allowed to die in such a manner, for urgent dyspnoea is the great sj^mptom demanding surgical interference ; and when it is present, the earlier an opera- tion is performed for its relief the better it will be for the patient. Children bear dyspnoea very badly, and soon succumb if the condition be not removed or relieved. The two great means of affording relief to children suffering from dyspnoea are intubation and tracheotomy. Either operation may be performed for the relief of in- creasing and persistent dyspnoea due to mechanical ob- struction in the larynx and upper part of the trachea. The symptoms by which the urgency of the dyspnoea is measured are recession of the soft parts of the chest dur- ing inspiration, stridulous breathing, and lividity. Mr. R. W. Parker's axiom should be remembered, that the younger the child the less we can afford to delay the operation to relieve the dyspnoea. Choice of Operation.— The surgeon has therefore to decide very promptly whether he will perform intubation or tracheotomy. His decision must be final, since he must not intubate with the idea that tracheotomy may be per- formed afterwards ; for when this has been done, the mor- tality has been found to be prohibitive. Intubation is SURGICAL DISEASES OF THE AIR PASSAGES 339 especially adapted for those cases of laryngeal obstruction which are acute in onset and transient in duration, as in scalded throat, or oedema of the larynx, if the case is seen early, in acute laryngitis, and in sudden spasm of the glottis. It has also been successfully performed for cica- tricial stenosis after tracheotomy, and in the contraction following the various forms of ulceration of the larynx, whether it has been due to the exanthemata or to syphilis. Intubation for the relief of dyspnoea in diphtheria is best suited for those cases in which there is great dyspnoea with comparatively slight constitutional symptoms, and without the formation of much membrane. Intubation with the ordinary O'Dwyer's tubes is not adapted for cases in which the trachea is filled with membrane, nor should the opera- tion be performed when the naso-pharynx is extensively involved. It is especially useful in children under two years of age, and it has the additional advantage of not requiring an anaesthetic or an incision. This is advan- tageous to the surgeon in several ways, for it often allows the operation to be done earlier than the child's relatives would otherwise permit, haemorrhage is avoided, there is no chance of the condition being rendered worse by wound infection, and the air is naturally warmed and filtered be- fore it enters the lungs, so that there is a diminished risk of pneumonia. Intubation, on the other hand, requires somewhat greater skill on the part of the operator for the neat and effective introduction of the tube. He should always be at hand, as the tube is sometimes coughed out, and in urgent cases there is danger of suffocation if it be left out even for a short time, although it often happens that after removal of the tube there is complete temporary relief of the symptoms of dyspnoea, apparently due to the pressure exerted by the tube leading to a diminution of the oedematous swelling. This temporary improvement is 34Q THE SURGICAL DISEASES OF CHILDREN apt to prove fallacious unless its true nature be recognised. Intubation therefore appears to be better suited for chil- dren in a public institution or where the surgeon can be obtained without delay. Mr. Staveley, my late house- surgeon, showed some years ago that very considerable quantities of membrane and of tenacious secretion could be discharged through an intubated larynx ; and his obser- Fig. 36. — Instiuments employed during intubation of the larynx by O'Dwyer's method. vations have been fully confirmed by all who have had occasion to perform the operation many times. Intubation of the Larynx. — The operation of intu- bation of the larynx 36 as opposed to its catheterisation was originally proposed by Bouchut in 1857, and was reintro- duced by O'Dwyer in 1885. The indications for the opera- tion are urgent and progressive dyspnoea due to causes chiefly acting above the vocal cords. SURGICAL DISEASES OF THE AIR PASSAGES 34 I The instruments represented in fig. 36 are required in O'Dwyer's operation, of which alone I have had any experience. They are a gag, two or three tubes, an introducer (the second instrument from the top), on to which the pilot or obturator is screwed, the pilot varying in size for each tube, and some stout silk. The tracheo- tomy tubes and instruments should also be in readiness. The tube is a stout perforated piece of metal with an expanded end, provided with a small hole, through which a silk ligature can be passed to recover the tube in case it should fall into the oesophagus whilst it is being intro- duced. The tubes are made self-retaining by increasing their narrow transverse diameter at the centre, so as to make them nearly cylindrical in the middle, whilst they taper off at the ends to form a double wedge. In buying them, care should be taken to see that the pilot projects a short distance beyond the lower end of the tube, and also that the lower end is stout and very blunt, as a sharp edge sometimes causes troublesome symptoms. An indicator, represented in the figure, is supplied to enable the surgeon to ascertain the appropriate-sized tube to use. A tube which reaches from the bottom square edge of the indicator to the figure 1 is suited for an average child of twelve months old, that which reaches from the bottom to the figure 3 is for a child of three years old, and so on up to twelve. It should be borne in mind that the tubes are made for an average child, and they are usually too small for the individual, so that it is better to take a size larger than the index points out ; for if too small a tube be selected, there is a danger of its being coughed out too easily. ' The tube is threaded with a silk ligature, measuring about 18 inches in length, and passed through the hole in its expanded end. It is then warmed and placed upon the pilot, which has been previously screwed on to the 342 THE SURGICAL DISEASES OF CHILDREN introducer. Two assistants are necessary. The child, as in the annexed diagram (fig. 37) is held upright in front of the surgeon by one assistant, whose duty it is to hold him firmly and prevent movements of his body. The best plan of keeping him quiet is to wrap a sheet or rug round him so as to include his arms. A gag is Fig. 37. — Semi-diagratnmatic representation of the method of introducing an O'Dwyer's tube for intubation of the larynx. then placed in the left-hand corner of his mouth and is handed to the second assistant, who holds it firmly, and at the same time steadies the head in such a position that it is neither fully extended nor yet flexed upon the sternum. The surgeon then takes up the introducer in his right hand, and winds the thread attached to the tube round his little SURGICAL DISEASES OF THE AIR PASSAGES 343 finger. He pushes his left index finger down the throat until he is able to raise the epiglottis and feel the rinia glottidis. The introducer, with the tube at its end, is held in the right hand, so that it first lies parallel with the patient's chest ; the handle is then rapidly elevated, and the tube, guided by the left index finger, is passed lightly into the larynx. As soon as the tube is well in position, it is pushed off the pilot by pressing a lever in the handle of the introducer, which is then withdrawn. The tube must be well pushed home until its expanded end lies upon the top of the glottis, or there is a tendency for it to be expelled by coughing ; and a hold must be retained at the same time upon the silk, lest during the manipulation the tube pass into the oesophagus instead of into the glottis. The operation is rapidly and accurately performed with comparatively small practice ;' and for the purpose of ac- quiring a sufficient amount of dexterity, Prof. Heubner has described a phantom or model in the Jahrb.f. kindcrhk., vol. xxxvi., p. 161. The introduction of the tubes should never take more than half a minute, and it can readily be accom- plished in eight to ten seconds. No force must be employed. The silk thread attached to the expanded part of the tube may be secured by looping it round the ear ; or, if the tube is to be left in the larynx for any length of time, it may be removed after an interval of a quarter of an hour, when the first fit of coughing has subsided, and as soon as the surgeon has assured himself that the respiration is satis- factory. The gag must then be re-introduced, the string cut, and the surgeon should keep his finger on the tube .until the string is pulled out. The tube, which was only allowed to remain for twelve hours at most when the operation was first suggested, has been left in the larynx for longer and longer periods, until at the present time three or four clays 344 THE SURGICAL DISEASES OF CHILDREN are often allowed to elapse before it is withdrawn, unless any symptoms arise to render its earlier removal necessary. Treatment after Intubation.— If the tube be removed too soon, sudden and urgent dyspnoea sometimes occurs, and this needs a speedy re-introduction of the tube. The surgeon should not be in too great a hurry to leave a child after he has extracted the tube, even though for the first half -hour it seems to breathe comfortably. A child who has been intubated should be kept in bed and in a room at a uniform temperature of 65° P. His feeding constitutes the great difficulty, and even with every care children take much less food after intubation than after tracheotomy. Soft-boiled eggs, oatmeal porridge made with milk, well-boiled bread and milk, and beef essence with brandy, usually form the staple diet. Soft solids are taken more easily than fluids, which have a tendency to pass into the larynx. The annexed figure (fig. 38), copied by the kind permission of Dr. Ball from his excellent work on intubation, shows the manner in which the food must be administered ; the child being placed either upon its back or on its stomach, and with the head lower than the body. Warm water enemata and small pieces of ice to suck will allay the thirst which is so constant a symptom of these inflammatory conditions. When there is much clogging of the naso-pharynx with membrane, the nostrils must be repeatedly and gently cleansed by means of a probe armed with absorbent cotton- wool soaked in a 1 or 2 per cent, solution of hydrogen peroxide, alone or mixed with two or three parts of lime- water ; or a 1 in 40 solution of carbolic acid. Dr. Jacobi recommends that these solutions should be gently injected from a small glass syringe through a conical nozzle of soft rubber. The local remedies should always be applied in a recumbent or semi-recumbent posture, and SURGICAL DISEASES OF THE AIR PASSAGES 345 the child should not be taken out of bed more frequently than is necessary. Sequelae. — Intubation in a few cases has been followed by extensive ulceration, with necrosis of the Pig. 38.— Method of feeding a child after intubation of the larynx. (Copied by permission from Dr. Ball's work on Intubation.) cartilages ; but this is fortunately quite exceptional. The tube has fallen into the trachea, and has had to bo removed by tracheotomy, and it has been swallowed, but without any bad result. Careful selection of a tube of the proper size will render these accidents less likely to occur. 34-6 THE SURGICAL DISEASES OF CHILDREN Death sometimes occurs during the act of intubation, or the dyspnoea is so urgent that the tube has to be withdrawn and tracheotomy performed at once. In all cases the physical signs in the chest must be carefully examined two or three times a day so long as the tube is left in the larynx. Removal of the Tube.— The removal of the tube is always more difficult than its introduction, and it may be necessary to give the child an ansesthetic, though this shotild not be done if it can be avoided. The patient is placed in the same position as for the introduction of the tube, if it is to be removed without giving chloroform. The gag is introduced, and the surgeon passes his left fore- finger down the throat until he feels the end of the tube lying in the glottis. He takes the extractor in his right hand (represented in fig. 36 as the uppermost instrument). The extractor consists of a pair of forceps whose ends are serrated upon the outside. The instrument is passed along the finger until the points are felt to enter the upper end of the tube ; it is then pushed well home, the blades are opened, and the tube is withdrawn. The handle of the extractor must be carried well downwards towards the child's chest, or considerable difficulty will be experienced in getting the tube past the soft palate. The greatest gentleness and patience are required in extraction, as very serious damage may be done to the larynx and the sur- rounding parts by even a slight amount of violence. Mr. Staveley has attached a small ring to the side of the in- troducer, so that the thread from the tube may be passed through it, and thus give more complete control over the tube than can usually be obtained. Results.— The mortality in cases of diphtheria treated by intubation appears to be nearly identical with that after tracheotomy. Drs. Prescott and Groldthwait find SURGICAL DISEASES OF THE AIR PASSAGES 347 that in 2,815 cases of intubation recovery took place in 32-2 per cent., whilst after 23,941 cases of tracheotomy there were 28-67 cured. The tube in their intubation cases was worn for an average period of five days and eighteen hours, and they say that age has a decided effect upon this time, for the younger the child the longer must the tube be kept in the larynx. Tracheotomy, 37 History. — The air-passages were opened by Asclepiades of Bithynia a century before Christ, and the operation was performed and recommended by Antyllus at the end of the third or beginning of the fourth century. It was reintroduced in the sixteenth century by Benevieni and Fabricius ab Acquapendente ; but the modern operation only dates from the time of Bretonneau and Trousseau, who in 1825 and 1833 re- spectively performed it for the relief of diphtheria. Indications. — Tracheotomy is performed either as a prophylactic measure before operations upon the mouth and larynx in which much bleeding is anticipated, or as a means of providing an additional supply of air in cases of obstruction due either to mechanical causes or to inflammatory conditions, as well as for the removal of foreign bodies from the trachea. The indications for its performance are the same as for intubation, viz. urgent and progressive dyspnoea ; but tracheotomy is usually done at a later period than intubation. It is employed for the relief of obstruction due to the presence of a foreign body, or from that caused by alterations in the shape and position of the trachea owing to goitre or other tumours of the neck. It is sometimes necessary to relieve by this means the obstruction caused by the pressure of a retro- pharyngeal or other cervical abscess, or it may be per- formed for active ulceration of the larynx due to syphilis or tubercle, as well as for new growths in the larynx. 348 THE SURGICAL DISEASES OF CHILDREN It is of the utmost importance that tracheotomy should be performed before the child is moribund. One of the great advances in recent surgery has been a recognition of the fact that early tracheotomy means speedy recovery in suitable cases of dyspnoea, though this maxim applies less to the treatment of diphtheria than to mechanical obstruction to the entrance of air into the lungs. The operation should be performed at once in all cases of diphtheria where intubation has not been tried owing to the abundant formation of membrane, the severity of the tracheal inflammation, and when the naso-pharynx is involved. Pneumonia does not seem to be a bar to the performance of tracheotomy in diphtheria, though a typhoidal condition owing to septic absorption appears to contra-indicate the operation, or at any rate to militate greatly against its success. The Operation. — The instruments required for the operation in a child are Durham's canulas with mov- able collars, Parker's angular tracheotomy tubes, Nos. 18, 22, and 28 being the most useful sizes ; or if it is a preliminary to an operation upon the larynx, a Trendelen- burg's tube, which is provided with an india-rubber ring capable of being blown up so as to occlude the lumen of the trachea, as is seen in fig. 39 ; a two-bladed tracheal dilator ; two or three pairs of pressure forceps ; a couple of aneurism needles or blunt hooks to serve as retractors ; a sharp hook ; two moderate-sized scalpels, which must be very sharp ; tapes, and a few turkey's or pheasant's feathers to clean out the trachea before the tube is intro- duced. It is better to give chloroform, unless the child be already narcotised by the circulation of impure blood ; but only enough should be administered to enable the child to breathe quietly ; and it is not necessary to continue it after SURGICAL DISEASES OF THE AIR PASSAGES 349 the skin incision has been made, unless the child begins to struggle or unless the introduction of the canula produces continued and convulsive coughing. No regard is paid in England to the position of the opening so long as it is in the middle line, but in Germany there is an increasing school of surgeons who advocate the opening of the trachea below the isthmus of the thyroid, and who in any case carefully avoid injuring the cricoid cartilage, as they believe that its division renders it difficult to keep the tube in a satisfactory position ; a displacement of the tube due Fig. 39.— Trendelenburg's tampon tracheotomy tube for blocking the trachea during operations upon the larynx. to this cause, however, is more likely to occur in adults than in children. As soon as the child is unconscious, the neck is made as prominent as possible by removing the pillows from the head, and placing a narrow cushion under the shoulders, and a rolling pin or a wine bottle wrapped in a cloth answers this purpose very well. The skin incision is made exactly in the middle line of the neck, its centre being opposite the point where the surgeon intends to open the trachea. It should only be 350 THE SURGICAL DISEASES OF CHILDREN skin-deep, and shcmld be too long rather than too short, so as to prevent that escape of air into the tissues which some- times happens if the opening in the skin and trachea do not correspond. When the condition of the child allows of a leisurely operation, the different tissues should be carefully and cleanly divided, until the trachea is reached ; scratching and tearing the tissues being especially avoided in cases of mixed infection, as it may lead to troublesome and extensive suppuration. The greatest care must be taken to keep strictly in the middle line, and for this reason retractors should be used as little as possible. They should be given into the charge of a single assistant, who retracts each side. Some little care, too, should be taken not to make too extensive a division into the deep cervical fascia, nor to raise it too freely from the trachea ; for Dr. Champneys has shown that air may pass behind it, and so penetrate into the mediastinum, causing mediastinal emphysema, and that the air may even burst through the mediastinum and distend the pleural sac leading to pneumothorax. It should be divided by a small trans- verse incision. The isthmus of the thyroid can usually be pulled upwards or downwards, as the case may be, or it may be divided. As soon as the trachea is exposed, the sharp hook may be passed beneath the cricoid cartilage to steady it for an instant whilst its second and third rings are divided up- wards and exactly in the middle line, or the larynx may often be sufficiently steadied by holding it lightly between the finger and thumb. In opening the trachea, the point of the knife must not be allowed to injure its posterior wall, and a sufficiently large aperture must be made into it to allow of the free escape of air, mucus, and inflammatory products. The dilator is introduced into SURGICAL DISEASES OF THE AIR PASSAGES 35 I the trachea along the side of the knife, its blades are separated, and the first ring of the trachea may be divided as the knife is withdrawn. The opening in the trachea is now dilated, and if the operation has been performed for the relief of diphtheria, as much membrane is allowed to escape as possible ; a feather is then introduced and twisted round and round to clear the lumen of the trachea still further before the tube is put into place. An interval should always be allowed to elapse between the opening of the trachea and the introduction of the tube. The dyspnoea is sometimes so great that the leisurely opera- tion here described cannot be performed, for the child may cease to breathe before the trachea can be opened. The dilator must be introduced in these cases as speedily as possible, and then artificial respiration must be diligently carried out by Howard's method. The operator stands on the right side of the patient to pass the tube. He takes the dilator in his left hand, and the tracheotomy tube in his right, the upper part of the tube pointing to the right of the patient. He then introduces the lower end of the tube into the trachea, and by a slight tour-de-maitre brings it into its proper position. It should be remembered, in selecting a tube, that the shorter and wider it is the more comfortable it will be to wear. It should be provided with a movable collar, and it is kept in position by tapes tied at the back of the neck. After-Treatment. — The success of the operation de- pends greatly upon the after-treatment, consisting essenti- ally in proper feeding and in causing the child to breathe warm air saturated with moisture. Pain and the obstruc- tion caused by the tube often render deglutition painful and difficult. A good nurse, however, can generally coax the child to take enough nourishment to prevent the necessity of having recourse to artificial feeding. Milk, 352 THE SURGICAL DISEASES OF CHILDREN either plain or peptonised, and with an egg beaten np in it, raw meat-juice or chicken-broth, with stimulants, are generally sufficient. Four to six ounces of food should be given every four hours, according to the age of the patient, and as much as three ounces of brandy may be given in the course of twenty-four hours. The quantity of food may be gradually increased, for the larger the quantity taken the less often will it be requisite to rouse the patient to give it. Twenty to forty ounces of milk a day is an average amount of food for an invalid child of four years old, and an endeavour should be made to get this amount assimilated, for those who take their food badly after tracheotomy are more likely to die than those who take it well. Dr. Habershon points out that vomit- ing, regurgitation, or dyspepsia after feeding, indicate that too much food has been given. Feeding by the nose need not be adopted as a routine proceeding, but when it is necessary I have always followed the plan recommended by my friends Drs. Bullar and Habershon, of introducing a No. 4 or No. 6 soft rubber catheter. A small piece of glass tubing is fixed in the outer end of the tube, and the warm fluid food is placed in a glass syringe holding four to six ounces. The end of the brass syringe is connected with the glass tube by a piece of drainage-tube. There is usually no difficulty in passing the soft catheter into the oesophagus, and after the first feeding the child rarely resents its repetition. The manipu- lation is so easy that the patient may sometimes be fed without being awakened. Perchloride of iron and the tincture of mix vomica should also be administered in full doses. The air which the child breathes may be warmed and saturated in several ways ; many surgeons employ the " steam tent," arranged by fixing a lath to each corner of SURGICAL DISEASES OF THE AIR PASSAGES 2,53 the cot, connecting the uprights by crossbars, and covering the whole framework with a sheet. A thermometer should be hung inside the tent, on a level with the head of the patient, and the air may be kept saturated by means of a bronchitis kettle. The temperature of the room should be maintained as nearly as possible at 70° F. Many surgeons dispense with the steam tent, and content them- selves with a thin and flat sponge, which should be of coarse texture. It is wrung out of a warm solution of boric acid, and is placed over the orifice of the tube. It must be frequently renewed during the first twenty-four hours after the operation, and it may then be replaced by a layer of moistened gauze. When the operation has been done for diphtheria, the tongue should be depressed with a spatula, and the pharynx should be repeatedly sprayed with a hand spray every three hours so long as there is membrane, and afterwards every six hours. The same operation may be repeated at the trachea rather more frequently, the spray being de- livered a short distance from the mouth of the tube. Dr. Collier and Mr. Pitts recommend a spray of one per thou- sand corrosive sublimate (except for the trachea) in preference to the ordinary one of boric acid, which some- times causes irritation of the mucous membrane. A one or two per cent, of peroxide of hydrogen is often useful, or a solution made by mixing ten grains of bicarbonate of soda with an equal quantity of biborate of soda in an ounce of water containing two drachms of glycerine. A drachm of the spray should be used on each occasion, the operation should take three or four minutes, and an interval of five seconds should bo allowed at the end of every half-minute. Dr. Collier also recommends that the nose should be douched with a warm boric acid solution, though either of the "tiiers may be employed, every three hours, and that it A A 354 THE SURGICAL DISEASES OF CHILDREN should be sprayed with the corrosive sublimate after each douching. Constant and assiduous attention must be paid to the tube. It must be cleaned from time to time by passing a feather along it with a rotatory movement ; but the nurse must be taught how to catch the membrane and the mucus as it is coughed up, so that she may not be con- stantly feathering. When a double tube has been used, as is now the rule, the inner portion must be withdrawn and thoroughly cleansed every two hours, so long as any membrane is being ejected ; but the outer part, under ordin- ary conditions, only requires taking out upon alternate days, though if there is very much membrane it should be changed daily. The only dressing required for the wound is a little simple ointment on a piece of lint, for healing generally takes place rapidly, and with very little scarring. The wound sometimes, however, becomes infected with diphthe- ritic or suppurative inflammation, or the whole neck may become swollen from acute inflammation of the connective tissue and lymphatic glands. These conditions add greatly to the gravity of the prognosis, but they are not necessarily of fatal import. The suppurating wound is treated with dressings of peroxide of hydrogen combined with insuffla- tions of iodoform. Iced compresses may first be tried in the diffuse inflammation ; but it is generally necessary to make free incisions into the swollen tissue, carrying the knife through the deep cervical fascia, and taking care to perform the operation with the least possible loss of blood. Dangers of the Operation. — Tracheotomy is not free from danger either to the surgeon or to the patient. Too many deaths are annually recorded from diphtheria con- tracted during the performance of the operation, especially amongst the younger members of the profession, already SURGICAL DISEASES OF THE AIR PASSAGES 355 reduced in strength by the labours and anxieties of their first responsible public appointments. No operator, there- fore, ought to render himself liable to direct inoculation by sucking the wound ; and if there is reason to think that he has become accidentally infected, he should at once take antiseptic precautions by washing out his mouth and gargling with a 1 in 40 solution of carbolic acid. If the patient does not die on the table, the operation having been too long postponed, he may succumb within five days of the operation, either to broncho-pneumonia or to the effects of the disease for which the operation was performed. Haemorrhage at the time of operation is sometimes trouble- some, and it must be treated by seizing the bleeding points with pressure forceps. If blood gains access to the trachea, the two cut edges of the tube may be drawn upwards into the wound, and the trachea may be freed from blood in the ordinary manner. Fatal haemorrhage has taken place in a few very unusual cases some time after the performance of a tracheotomy, owing to a diphtheritic inflammation extending to the innominate or internal jugular veins, or from ulceration of the innominate or common carotid arteries, caused by the pressure of the lower end of the tube. Such accidents need hardly enter into the surgeon's calculations, but he should rather be on his guard to prevent the sudden death which more often takes place from syncope after tracheotomy has been performed for the relief of diphtheria. Removal of Tube. — The tracheotomy tube should be removed as soon as possible. The surgeon may withdraw it four or five days after the operation if all goes well, and watch the child's breathing, with the tracheal dilator handy in case of accidents. The patient sometimes breathes well from the first, hut it much more frequently happens that he has to be educated to laryngeal respiration, for the 35^ THE SURGICAL DISEASES OF CHILDREN muscles of the glottis no longer work harmoniously with the diaphragm and the intercostals. The child must be taught to breathe systematically, first by closing the orifice of the tube, and then by doing without it for a longer or shorter time. The difficulty is often rather mental, from fright : than physical, or due to a want of co-ordinating power. The process of education in these cases is best carried out by the person in whom the child has most confi- dence. It takes on an average about a fortnight. Tracheal Stenosis. It happens in a certain proportion of a large series of tracheotomies that it is impossible for the patient to breathe without his tube. The dyspnoea comes on either directly the tube is removed, or after a shorter or longer interval. Its onset is sometimes very insidious, and the difficulty in breathing may be more marked when the patient is asleep. Many causes lead to this condition ; the obstruction may be due to a narrowing of the glottis, owing to cicatrisation of the cords, or to anchylosis of the arytenoids, followed by atrophy of the posticus muscles, and this is most likely to occur when the tracheo- tomy has been performed for the relief of conditions causing injury to the glottis, such as scalds or the swal- lowing of foreign bodies. It is sometimes due to papil- lomatous growths within the larynx, or more frequently to masses of granulation tissue, which may become con- verted into fibrous tissue, forming bands of adhesion either just above or just below the orifice in the trachea. It is said (p. 349) that these cases are most likely to happen when the cricoid cartilage has been divided in the high opera- tion. Especial care, therefore, should be taken to prevent this unnecessary injury, though from the small size of the parts in a young child such division is by no means SURGICAL DISEASES OF THE AIR PASSAGES 357 infrequent. The granulations are in many cases un- doubtedly due to the irritation of a badly fitting tube, which sets up ulceration of the mucous membrane, and may actually cause the production of valve-like prolonga- tions of the mucous membrane. The obstruction in other cases follows extensive necrosis of the cartilaginous rings of the trachea, loss of elasticity in the rings, or even their displace nent at the point of division. Treatment.— When the inability to breathe without a tube is due to mechanical causes, and respiration is impos- sible even under an anaesthetic, immediate measures must be taken to ascertain the cause, and, if possible, to remedy the defect, as it is useless to wait in the hope that time will improve matters. Trelat has called attention to the fact that in stenosis of the larynx the phonation is first affected, whilst in stenosis of the trachea the dyspnoea is the earlier symptom. The existence of id?.eration in the trachea is recognised by the blood-stained sputum, the cough, and the foetid breath. In such cases the tube should be changed for one which fits the trachea better before the irritation has led to the formation of granulation tissue. The asymmetry and deformity of the trachea will give a clue to the cause of the obstruction when it is due to defects in the cartilaginous framework. There is no satis- factory treatment for these cases, though endeavours may be made to ameliorate the condition by the use of the triple dilating tube. The treatment of laryngeal obstruction is a little more favourable. Macewen's tracheal catheter may be employed in cases of slight obstruction, the instrument being introduce 1 on a long probe through the mouth into the glottis, or upwards through the tracheal opening. It must be so arranged in either case that it extends below the wound in the trachea, and it must be kept in place until the tracheal opening is completely healed. 358 THE SURGICAL DISEASES OF CHILDREN Operative interference is much more frequently needed in these cases. The wonnd in the trachea should be thoroughly explored by enlarging the incision ; all granu- lation tissue and bands of fibrous tissue must be freely dissected away, and an O'Dwyer's tube should be left in the glottis until the external wound is closed. The tube used in these cases is larger and longer than that used for intubation, and it may be left in the larynx for a fortnight at a time ; though if there is any tendency to the formation of granulations at the sides of the epiglottis, Dr. O'Dwyer recommends that the tube should be removed every week, occasionally changing the shape or size of the head or shoulder of the tube. Mr. Bernard Pitts and Mr. Brook, who have had much experience in the treatment of these very troublesome cases, recommend that when the tube is thus left in position for long periods of time, it should not have any string attached to it, as less coughing is then caused. The tracheotomy wound should be kept open by using the hard rubber plug devised by Messrs. Pitts and Brook, so long as the intubation is maintained. All measures prove ineffectual in many of these cases, and I know two or three children who still prove them- selves reproaches to surgery by constantly wearing a tracheotomy tube in spite of all that can be done for them. So long as the tube is being worn, the surgeon should assure himself that the wound in the neck is not being fretted by the tube, that no ulceration is occurring either at the front or back wall of the trachea, owing to any fault in the length or curvature of the tube, and that unduly strong solutions are not being sprayed into the trachea. Inflammatory Conditions of the Larynx. Syphilitic and tuberculous inflammation of the larynx SURGICAL DISEASES OF THE AIR PASSAGES 359 occur occasionally, whilst extensive necrosis of the laryn- geal cartilages is sometimes met with after typhoid fever. There are a few recorded cases in which an enlarged bronchial gland has gained admission to the trachea by a process of ulceration, and has caused sudden death by asphyxia. SCALDS OF THE PHARYNX AND LARYNX. Cause. — A scalded mouth and throat is quite a usnal farm of accident in children. It is caused either by their drinking out of the spout of a teapot or kettle containing very hot fluids, or, more rarely, by the actual inhalation of steam. Morbid Anatomy.— The scalded mucous membrane soon becomes oedematous, and its surface may be covered by plastic deposits bearing a close resemblance to the patches of diphtheria. The oedema does not extend below the vocal cords, as there is an interruption to the sub- mucous tissue at that point. Symptoms. — The symptoms of a scalded throat vary with the amount of the oedema to which they are directly due. Dyspnoea is therefore the most prominent. A certain amount of shock attends all the more severe cases. Diagnosis. — The inflammatory conditions have to be distinguished from the other causes of acute laryngeal inflammation, such as acute cellulitis, diphtheria, and retropharyngeal abscess. The scalding at the angles of the mouth and the peculiar oedematous condition of the injured tissues will serve to distinguish a scald from everything else. Prognosis. — Scalds are always dangerous in young children, and a guarded prognosis mnsr In- given. Re- covery usually takes place in the slighter forms. 3 6o THE SURGICAL DISEASES OF CHILDREN Treatment. — The treatment is essentially symptomatic, and is directed towards the relief of the conditions leading to dyspnoea. The child should be put to bed, and allowed to breathe moist air ; the shock should be treated in the ordinary manner by warmth and the administration of two or three grain doses of ammonium carbonate. An ice-collar may be placed round the neck, and the dyspnoea should be carefully watched. The surgeon should intubate the larynx early, if the difficulty in breathing appears to be increasing. Tracheotomy nmst be performed if for any reason intuba- tion is impossible, and it is well to do the operation before the dyspnoea has become so urgent as to weaken the child. Sequelae. — The sequelse are not usually well marked in children, but some amount of fibrous stricture may be produced. NEW GROWTHS. Chronic laryngeal obstruction in children is caused by new growths, usually papillomatous and multiple, more rarely cystic. They may be situated upon the vocal cords or upon the ary-epiglottic folds, and in some cases they are so numerous as to fill up the whole glottis. They are pale pink in colour, pedunculated, and are set so closely together as to form an uneven and cauliflower-like mass. Symptoms. — They are either congenital, when the child cries huskily from its birth, or they develop later and cause more or less urgent dyspnoea with aphonia. Diagnosis. — The diagnosis in older children is easily made by laryngoscopic examination, but in infants it must be mainly symptomatic. The dyspnoea due to the presence of papillomata must not be mistaken for that caused by laryngismus stridulus, for it is more constant and it is not relieved by improving the general health of SURGICAL DISEASES OF THE AIR PASSAGES 36 1 the child or by removing those causes of reflex irritation to which spasmodic croup is usually attributed. Treatment. — Single growths may be removed by the laryngeal forceps in infants and in older children, but nothing short of tlryrotomy is of use when the growths are multiple and threaten to block up the glottis. A preliminary tracheotomy must be performed in these cases, and at the time of the major operation a small tampon canula, upon the principle (p. 348) introduced by Trendelenburg (fig. 39), should be used to prevent the access of blood to the bronchi. Mr. Bernard Pitts, in some recent lectures upon the " Surgery of the Air Passages in Children," however, says that if proper care be taken to arrest the bleeding in the ordinary manner, the use of such a tube is unnecessary. He employs the ordinary tracheotomy tube, keeping the trachea above it packed with small pieces of sponge, each on a string. - The child is put into the ordinary position for tracheotomy, the thyroid cartilage is exposed, and the alee are transfixed laterally by means of a needle threaded with aseptic silk. The cartilage is then divided in the middle line nearly up to the thyroid notch. The two alee are separated, the silk thread is drawn out and divided, so that two retractors are provided. The glottis is thoroughly exposed, and the growths are then snipped away with a pair of scissors, cocain being applied from time to time to prevent spasmodic contractions during this manipulation. Mr. Pitts thinks that a fine Paquelin cautery passed over the points of section acts more satis- factorily than the chromic acid, which is usually used as a caustic in these cases. The silk threads are withdrawn, and the two alae of the thyroid cartilage are sutured, the needle-holes in the two thyroid cartilages serving as valuable guides in obtaining exact approximation. The skin over it is brought together, and the tracheotomy tube J 62 THE SURGICAL DISEASES OF CHILDREN is left in position for a few clays. The wound usually heals kindly, but the operation may have to be repeated for a second crop of warty growths. FOREIGN BODIES IN THE AIR PASSAGES. 38 The presence of a foreign body in the air passages is always a matter of interest both to the physician and to the surgeon : to the physician on account of the subtlety of its exact localisation, and to the surgeon because of the difficulties connected with its removal. The foreign body is usually sucked into the air passages by a sudden and deep inspiration, but it may gain access to the respiratory tract by the child going to sleep with some small object in its mouth. The foreign bodies in children are usually parts of toys, beads, cherry-stones, and other substances of a similar nature. Such coins as they are likely to have, and larger objects, like marbles, usually find their way into the oesophagus, as the rima glottidis is too small to receive them, and foreign bodies are there- fore much more frequent in the oesophagus of children than in their tracheas. Symptoms. — The symptoms vary according to the position of the body. They are sometimes urgent, as in those cases in which the foreign body lies in the glottis ; but they are often so slight as to make it a matter of doubt whether so serious an accident has really happened to the child. The cases attended with the slighter initial symptoms are usually the most to be dreaded, for the foreign body has then left the trachea, and passed into a bronchus, where it may become impacted, and where it will most probably set up a dangerous pneumonia, or if the bronchial obstruction is complete it will certainly cause collapse of the lung. The examination in all suspected cases must be con- SURGICAL DISEASES OF THE AIR PASSAGES 363 ducted with the greatest care and precision. When the body is lying in the trachea, there is no difficulty in re- cognising its pres >nce : but if it has become impacted in a bronchus, the chil 1 must be stripped to ascertain whether the two sides of the chest are equally movable. Careful percussion may detect the presence of local impairment of resonance, marking the collapsed portion of the lung and so the approximate position of the occluding body. Auscul- tation will confirm the evidence gained from percussion by the absence of breathing sounds over the affected area and its exaggeration upon the opposite side of the chest when there is complete blocking of a large bronchus, or by super- added sounds if the bronchus be only partially obstructed. There may be no dyspnoea, but the respirations are often considerably quickened, and there may be a short cough when any muscular exertion is made. The temperature may remain subnormal, unless the foreign body is septic ; but in several cases a sharp attack of fever has followed the removal of the body. Prognosis. — The prognosis is so serious that an opera- tion must be performed as soon as the presence of the body is found to be interfering with the respiratory functions, even in the absence of urgent symptoms, for spontaneous expulsion is of very rare occurrence. Mr. Good, 38 however, records an interesting case in which a " hale of barley'' passed from the trachea into the axilla, and was discharged by means of an abscess a fortnight later. Deoth usually takes place from oedema of the glottis, from ulceration of the larynx, from pneumonia, or from gangrene of the lung. Treatment. — Tracheotomy offers the only means of treatment which is likely to be of any avail. A large opening should be made in the trachea, preferably below the isthmus of the thyroid; and Mr. Thos. Smith 38 suggests that the edges of the wound in the trachea slioul 1 bo tempora- 364 -THE SURGICAL DISEASES OF CHILDREN rily attached to the skin whilst searching for foreign bodies in the air passages below. It keeps the trachea widely open throughout the operation, and this is a great help to the surgeon, and a source of safety to the patient. The trachea should be held widely open if the foreign body is known to be lying in its lumen, for it often happens that the first blast of air carries it out of the wound ; but if it be impacted in one of the bronchi, it must first be localised by means of a probe, and an endeavour must be made to withdraw it by forceps. The greatest gentleness is needed in these manipulations, or much injury may be done to the lung. The wound should be closed at once if the foreign body can be extracted ; but if, unfortunately, this is found to be impossible, the wound must be left open with a self-retain- ing spring retractor in the trachea in place of a tracheo- tomy tube. The following instructive case shows the utility of this precaution ; the specimen is in the Museum of St. Bartho- lomew's Hospital. A little girl, aged seven years, swal- lowed a glass bead, which " went the wrong way." The bead could be heard, by means of a stethoscope, passing up and down the trachea between its bifurcation and the larynx at each inspiration, and it was decided to perform a tracheotomy. Just before the operation was commenced, it was found that the movements of the bead could no longer be heard ; and as it was supposed to have passed into the pharynx, and to have been swallowed, the opera- tion was postponed. Two days later no breathing sounds were audible in the right lung, and the heart had become displaced to the right, showing that the lung on this side had become collapsed. Tracheotomy was performed ; and although the chill was inverted whilst the wound was held open, and feathers were passed down the trachea, the SURGICAL DISEASES OF THE AIR PASSAGES 365 bead could not be dislodged ; a tracheotomy tube was in- serted, and the child was put to bed. She had a violent attack of dyspnoea during the night, the tube was with- drawn, and the bead was immediately coughed i;p. She made a good recovery. The after-treatment in these cases is the same as after the ordinary tracheotomy operation (p. 351). HERNIA OF THE PLEURA INTO THE NECK. A few examples of this rare condition have been recorded. It seems to be most frequently caused by the rupture of a bronchus in the upper bbe of a lung which strips the pleura from the lung. In a case seen by Dr. Fowler, a child of three months old, who had recently suffered from a severe attack of bronchitis, presented a swelling upon the side of the neck, which became larger when the cliil 1 cried or coughed, but which almost disappeared at each inspiration. In this case the rupture had occurred in both lungs, but the tumour was larger upon the left side. HERNIA OF THE LUNG. A portion of the lung is occasionally protruded through some part of the chest-wall as a sequel of an injury to the thorax. It forms a smooth tumour, which is resonant on percussion and can be reduced by pressure. Treatment. — The treatment consists in the application of a pad and bandage over the affected part. If the swell- ing increases in size, it may be removed, for wounds of the lung heal very readily and completely in children. EMPYEMA.- 1 jffitiology. Empyema is a condition often met with in children after an attack of pneumonia ; less frequently it occurs as a primary disease, acute in its onset. It is rarely 366 THE SURGICAL DISEASES OF CHILDREN tuberculous or traumatic in origin. It is said to be most frequently associated with the presence of pneumococci, though other forms of micro-organisms, including the bacillus coli, are very common ; cases, however, often occur in which no specific organism can be detected. Symptoms. — The less common primary form begins with a convulsion or with vomiting. In all acute diseases, however, convulsions are very much mora common in infants than rigors, so that the diagnostic value of a convulsion is not great. The temperature rises rapidly to 104°- 105 F. The respirations are short, quick, and of the abdominal type. The pulse may be 140 or more in a minute. Cough, which is absent in the earlier stages, afterwards becomes dry and hacking. The dyspnoea is often urgent, and the child is with difficulty kept in bed. The duration of the acute attack is generally from seven to ten days, after which the temperature falls, but does not become normal. An empyema may be suspected when the child remains weak and continues to lose flesh, the cough persisting, and convalescence being retarded. The form is often due to a pure cultivation of the pneumococcus, and it can be cured sometimes by a single aspiration of the pleural cavity. The subacute form, secondary to pleurisy with effusion, pneumonia, typhoid fever, and more rarely to tuberculous phthisis, is often so insidious in its onset that the presence of pus, even in considerable quantities, may be completely overlooked. The long continuance of pulmonary symptoms, with a persistent rise of temperature, and the occurrence of dyspnoea, rigors, sweats and localised pain in a child who has recently recovered from one of these diseases, always raises a suspicion that pus exists in the thoracic cavity, and affords an indication for an exploratory puncture. It is due to a mixed cultivation containing pyogenic organ- isms. SURGICAL DISEASES OF THE AIR PASSAGES 367 Dr. Dickinson has recently called attention to the com- parative readiness with which the pleura suppurates in early life, so that what in a grown person would be a dry pleurisy or a serous effusion gives rise to an empyema in a child. The physical examination of the chest in a case of empyema will show that one side is motionless, and will reveal the existence of extensive dulness, a condition which is rare in the pneumonia of children. The dulness, how- ever, is not always easy to elicit ; but percussion gives a sense of wooden resistance which is characteristic in chil- dren, for in them it is a rule to find resilient chest-walls. The apex-beat of the heart is sometimes found to be dis- placed ; but this is less common in children than in the empyema of adults. The breathing sounds are absent, or distant bronchial breathing, which may closely resemble tubular breathing, may be heard. Dr. Brothers has pointed out that the absence of rales in a child who otherwise presents symptoms of chronic lung disease is also very suggestive of pleural effusion ; and if rales are heard all over the chest, except at a single spot, it is probable that there is a localised empyema. Many physicians have laid stress upon the fact that bulging of the lower intercostal spaces is observed in cases of empyema; but although the sign is a valuable one, it is by no means pathognomonic of the affection. There is often more or less lateral curvature in cases of long-standing empyema, the concavity of the spinal curve being directed towards the affected side, whilst the angles of the ribs become flattened, those on the sound side becoming more acute. There is also some rota- tion of the bodies of the vertebrae, but it is usually less marked than in the ordinary cases of scoliosis. Diagnosis. — The diagnosis is readily confirmed by puncturing the chest with an aspirating needle, and two 368 THE SURGICAL DISEASES OF CHILDREN important facts will thereby be ascertained : first, whether fluid be present at all ; and secondly, if it be present, whether it is serous or purulent. The existence of an abscess in the lung may sometimes be detected by punc- ture, and it may then be mistaken for an empyema. Several things have to be taken into consideration in aspirating a chest. The operation, trivial as it is, must be carried out with strict asepsis, lest a serous effusion be converted into a purulent one. The side of the chest must be therefore thoroughly cleansed, the needle must be freshly boiled, and the skin should be incised with a scalpel, so that no dirty epithelial scale be carried into the pleural cavity. Prognosis. — The rate of mortality in empyema seems to bear a direct relation to the age of the child. Dr. Brothers, in an interesting paper, shows that in very young children, in whom the disease always runs a severe course, the rate of mortality is nearly 50 per cent., and that it gradually diminishes, until after the age of five years it is almost nil- Treatment. — Aspiration should be performed in the sixth or seventh intercostal space in the mid-axillary line, or behind in the seventh or eighth interspace at the junc- tion of the anterior two thirds with the posterior third of the rib. When an empyema opens spontaneously, it usually points anteriorly about the junction of the fifth or sixth costo-chondral articulation. Two mistakes may be made in performing an exploratory paracentesis : the needle may be too short to pass through the tough and thickened pleura, or owing to its gristly nature the needle may fail to penetrate it, and thus false information is ob- tained. The empyema may be localised, so that a single puncture may be insufficient. (1) Drainage. — When pus is found, it is better to draw SURGICAL DISEASES OF THE AIR PASSAGES 369 it all off, f~>r simple aspiration more frequently cures in chiLlhood than in adult age. If mnre pus is formed, it is better to drain the cavity at once rather than to trust to repeated aspiration. Even in the most acute cases, how- ever, pus is not found before the third day, and usually not until after the sixth day from the initial symptoms. The intercostal spaces in children are so narrow that a thorough drainage can only be effected by removing a piece of rib or grooving two ribs so as to allow of the intro- duction of a good-sized tube. Mr. Pantin, my house-sur- geon at the Victoria Hospital, has kindly given me the following account of the routine treatment which he and his colleagues adopt in cases of empyema ; and as the resident medical officers at a large children's hospital have more extensive opportunities of treating the disease than any one, I here append it. "If the empyema be general, and the dyspnoea be not very urgent, the chest is opened in the line of the angle of the scapula behind ; if localised, it is opened at its most dependent part. When the dyspnoea is urgent, aspiration may have to be performed at once, the more severe opera- tion being temporarily postponed. An exploring needle is always put in just above or below the piece of rib it is proposed to excise. The ninth rib is generally chosen for removal in cases of general empyema, on the grounds recommended by Mr. Godlee. First, because it is just above the level at which the diaphragm becomes adherent to the ribs when it has been drawn up as much as possible ; secondly, because it is the most dependent part whon the patient is Lying on his back ; and thirdly, because it is the most advantageous place for draining the whole of the pleural cavity, including its lower and posterior part, which can alone be drained by this means. An incision is made over the rib, about 2 or 2A inches in length, after 1: if 37© THE SURGICAL DISEASES OF CHILDREN the skin has been thoroughly cleansed. The incision is deepened by cutting through the latissimus dorsi and the serratus magnus till the periosteum is reached. This membrane is divided along the whole length of the wound, and is then stripped off the rib with a blunt dissector, until the bone is bare in front and behind. Bone forceps are applied, and about an inch of the rib is removed, the anterior cut being made first. The ends of the bone are rounded off with a burr or raspatory. The operation so far is entirely extra-pleural. The pleural cavity is opened either by introducing a director, and dilating the opening with dressing forceps, or, if the pleura is too thick and gristly, by carefully cutting through it with a knife and afterwards using the finger as a dilator. The patient is now turned over upon his back to allow the fluid to escape, and any large masses of lymph are delivered with the finger. The cavity is never washed out with aseptic water or lotion, unless its contents are very foetid. " A stout, short-flanged drainage-tube of rubber (fig. 40) is inserted, so that the cavity may be freely drained with- out any pressure of the tube upon the expanding lung. The tube, which is easily made out of two pieces of drainage-tube, is not sewn in, but is removed and cleaned at each dressing. A pad of wet cyanide gauze, moistened with boric lotion, is then applied, and the child is put to bed. The dressing usually has to be renewed within twelve hours, and after that daily. Smaller and smaller tubes are substituted, as the discharge gradually decreases in quantity, and eventually the tube is omitted altogether. " New bone appears to be produced very rapidly, for in one case, which died a few weeks after the wound had closed, the rib was found to be completely repaired. " We have on an average one case a fortnight to treat in this manner, and the results are eminently satisfactory. SURGICAL DISEASES OF THE AIR PASSAGES 37 1 The average stay of the children in the Hospital has been six weeks. When death occurs, it is due to nephritis, broncho-pneumonia, and general tuberculosis." There is often some lateral curvature of the spine in cases of cured empyema ; this is best treated by gymnastics rather than by the application of any form of spinal support. (2) Operation for Radical Cure. — When the sinuses refuse to close, adhesions are present, and the lung does not expand, it is often necessary to resect several ribs so as to enable the chest to collapse upon the affected side, Fig. 40.— Short-flanged rubber tube for draining the pleural cavity incases of empyema. the constant purulent discharge is then arrested by allow- ing the parietal and visceral layers of the pleura to become approximated. The operation should not be undertaken lightly, for it leads to marked deformity ; but, on the other hand, it should not be unduly postponed in the cases which need it, for the prolonged hectic may lead to the child's destruction by lardaceous disease. The fourth, fifth, and sixth ribs are usually selected for removal. Tho operation is similar to that already described (p. 369), except that •Jonger pieces of bone are removed, and the incision is made 372 THE SURGICAL DISEASES OF CHILDREN along the intercostal space and not upon the rib itself, so that two ribs may be removed through each incision. The finger is introduced into the cavity of the pleura, and so much and so many of the ribs are removed as is necessary to enable it to become occluded. The mistake usually made is to remove too little bone in these cases rather than too much, for the thoracic walls have very great power of repair. It is therefore better to remove the periosteum and the thickened pleura, and this can usually be done without much bleeding, as the previous inflammation has occluded the intercostal vessels. The number of ribs to be removed is regulated by the size of the cavity ; and it was the recognition of this fact which led Estlander to make that important advance in the surgery of the chest which has just been described, so that the operation of resection of the ribs for the cure of empyema is now generally known by his name. Treatment of Double Empyema. — The operative treatment of double empyema has recently been the subject of much careful thought by surgeons and physicians in this country. The conclusions arrived at by Dr. Coupland and Mr. Pearce Gould appear to represent most accurately the general feeling upon this point. They say {Trans. Clinical Soc, vol. xxiv. p. 83) : (1) That the occurrence of double empyema, instead of being a bar to treatment by drainage, renders the need for such an operation more urgent on account of the greater embarrassment it causes to respiration and circulation. (2) That aspiration should be practised as a preliminary procedure, in the hope that at any rate some contraction of the abscess cavities may result from it and further adhesions of the pleura form. (3) That it is better to allow a few days to elapse between the two operations ; and (4) that if this delay is for any reason impossible, the two empyemata should be carefully SURGICAL DISEASES OF THE AIR PASSAGES 2,73 aspirated a few hours before the operation. By this means the shock produced by the sudden removal of pressure from the lungs is got over, and the simultaneous drainage of the two pleurae is robbed of its chief danger. (5) That double empyema treated by free drainage may be followed in children by very complete recovery. The condition is a rare one, and no case has yet come under my notice ; but when it does I shall have no hesitation in following the advice given by Dr. Coupland and Mr. Gould. Pleurisy. Cases of pleurisy with effusion rarely come under the care of the surgeon, since a single aspiration is often sufficient to cure those children who do not recover under the ordinary medical treatment of rest and counter-irrita- tion of the chest-wall. PURULENT PERICARDITIS. 40 Etiology. — Purulent collections in the pericardium are either primary or secondary to septic infective processes in the thorax or other parts of the body. The pneumococcus and Friedliinder's pneumo-bacillus have been found in the pus. Symptoms. — It occasionally happens, after an empyema has been evacuated, that the temperature, pulse and respi- rations remain abnormally high ; the dyspnoea continues, and the child does not experience the amount of relief which usually follows the operation. A careful examina- tion of the chest should be made in these cases, and it may then be found that there is some oedema of the neck, that the area of precordial duluess is enlarged, that there is an intense interscapular souffle, and there may be the physical signs pointing to a pleural effusion at the base of the left lung — signs which disappear when the child is examined in the genu-pectoral position. These pseudo- 374 THE SURGICAL DISEASES OF CHILDREN pleuritic symptoms are due to atelectasis of the lower lobe of the left lung, caused by the pressure exercised upon it by the pericardial effusion ; and they are better marked in the child than in the adult, becaiise the child's chest is small and narrow, whilst its heart is relatively large. The disappearance of the signs when the genu-pectoral position is adopted, is caused by the pericardial fluid fall- ing forwards, and so ceasing to exercise any pressure upon the lung. This symptom is of course valueless if the pericarditis be associated with broncho-pneumonia, pneu- monia, or pleurisy. Diagnosis. — The presence of a purulent collection in the pericardium is very easily overlooked, so that if there is the least suspicion of its presence an exploratory punc- ture should be made with a trocar and canula which have been freshly boiled to render them aseptic. The side of the chest must be thoroughly cleansed, and the skin should be divided with a scalpel to prevent any chance epithelial scale being driven into the pericardium at the end of the trocar. The incision should be made in the fourth or fifth intercostal space on the left side and at a point about an inch from the sternum, to avoid injuring the internal mammary artery. Treatment. — The puncture should be carefully en- larged if pus appears — for puncture is of no more per- manent value here than it is in a case of empyema — the tissues being divided in an outward direction until it escapes freely. The wound must then be drained in the ordinary way, and antiseptic dressings applied. The cavity of the pericardium may subsequently be washed out daily with a 5 per cent, solution of boric acid at a temperature of 100° F. until the discharge ceases. Korte in one case resected the left fifth rib for the cure of a pericardial empyema. CHAPTER XVIII SURGICAL AFFECTIONS OF THE ABDOMEN AND ITS CONTENTS TUBERCULOUS PERITONITIS. 11 iEtiology. — Tuberculous peritonitis occurs very fre- quently in children, the direct source of infection most often being caseating mesenteric glands. The affection occurs at all ages, but is more frequent after weaning than in sucklings — a fact which, as Prof. McFadyean and Dr. Woodhead have acutely pointed out, raises a suspicion that the use of tuberculous milk may be a source of in- fection. Clinical experience has not yet demonstrated the correctness of this view ; but there is no reason why we should not assume that it is correct, and boil all milk given to children. It is an easy precaution, for a single boiling is sufficient to destroy its infectivity; but if it be adopted, the infant should have a small teaspoonful of orange juice every day, as there is reason to suppose that suae cases of scurvy are attributable to a too exclusive diet of such sterile font Is. Morbid Anatomy. — Tuberculous peritonitis occurs in several forms. There is the acute miliary type of tin' disease, for which little or nothing can be done in the way of operative treatment, and to which the child soon succumbs. It is marked by the frequency with which relapses take place. The ascitic type, in which the 1 J6 THE SURGICAL DISEASES OF CHILDREN exudation is serous, the result of a simple infection with the tubercle bacillus, or purulent, when the infection is a mixed one consisting partly of the tubercle bacillus and partly of septic micro-organisms. This type is amenable to operative treatment, as was shown accidentally by Sir Spencer Wells in 1862, and deliberately by Koenig in 1884. The fibroplastic type differs from the preceding in its extremely chronic course, and in the readiness with which adhesions are formed. It is accompanied by more or less ascites, and is characterised by the readiness .with which dense adhesions are formed. Lastly, there is the ulcerative type, which is a very frequent and fatal form in children. The inflammatory products in this variety soften and ulcerate, so that on opening the abdomen a shapeless mass of material is found, all the structures being glued together and to the abdominal wall by inflam- matory exudation. It is not unusual in these cases to get a fsecal fistula at the umbilicus. This ulcerating form of tuberculous peritonitis is unsuited for operative treatment. Symptoms. — The symptoms of the disease vary some- what with the form, and though it is usually easy to diagnose, the symptoms are sometimes so obscure that many laparotomies have been performed to relieve an acute intestinal obstruction only to find that the peritoneal cav- ity was full of pus. The classical symptoms of pain in the abdomen, with quick breathing, anxious expression, tympanitic and tender belly, are sometimes found in cases of acute miliary tuberculosis ; but the symptoms are usually more ill-defined. There is abdominal pain with fever, better marked in the afternoon and evening than in the morning. The bowels are relaxed, and there are occasional attacks of diarrhoea. The abdomen in the ascitic forms gradually enlarges until it is rounded and shiny, with many large dilated veins SURGICAL AFFECTIONS OF THE ABDOMEN 2)77 on its surface. It is resonant in front, and dull upon per- cussion in the flanks, the line of dulness altering with the position of the patient. The abdomen sometimes feels nodular, and in the cases of localised effusion the cysts are easily detected if, as usually happens, they are situated above the umbilicus. The disease in the fibrous form lasts months or years, and tends to undergo spontaneous recovery, though it may cause many sequelae, due to the bands of adhesion. The patient in the other forms becomes anaemic and wasted ; he is the subject of hectic fever and of lardaceous disease, unless he dies of the exhaustion pro- duced by diarrhoea or from tuberculous meningitis. Sequelae. — The sequelae of tuberculous peritonitis are recurrences due to persistence of the source of infection : faecal fistulas, the result of the inflammation spreading ii - wards through the bowel wall, or more rarely, outwards from tuberculous ulceration of the intestine. These fis- tulas most often discharge themselves at the umbilicus, in the unopened abdomen ; but if a laparotomy has been per- formed, they may appear at the scar. They sometimes close spontaneously, but they often cause death by setting up an acute septic peritonitis. Intestinal obstruction in its various forms is not an infrequent result of cured tuberculous peritonitis. Diagnosis. — The differential diagnosis lies between tuberculous and other forms of peritonitis, as well as of the various conditions which render laparotomy necessary, and from some cases of typhoid fever. The exact nature of the abdominal lesion is always a matter of doubt, and it is this uncertainty which lends so great an interest to every case of abdominal section. Tuberculous peritonitis may be distinguished from the non-tuberculous forms by bacteriological examination, or by inoculation into guinea- pigs of the inflammatory contents of the peritoneum — a 1 78 THE SURGICAL DISEASES OF CHILDREN method not permissible in this country. The differential diagnosis is sometimes spontaneously made for us, as in those cases where about a fortnight or three weeks after the operation, and when the wound has completely healed, the scar becomes affected with tuberculous inflammation. I have several times seen such secondary infection happen ; the ulcerated skin was freely removed, and in each case there was no further recurrence. Treatment. — The ordinary palliative means must be first tried, but if these fail laparotomy yields the most satis- factory results in cases of tuberculous peritonitis which have been selected with moderate care. Children bear the operation well, and it appears to be especially adapted for the ascitic forms, and for the chronic fibrous type associated with much exudation. In the latter form the simple open- ing of the abdomen, and evacuation of the fluid without flushing the peritoneal cavity, gives the best results. Strict asepsis must be preserved by the ordinary methods, and the bowel may be disinfected internally by the adminis- tration of naphthol or naphthaline (p. 319) after the ad- ministration of a drachm of castor oil, though this is of less importance than in cases of septic peritonitis due to the bacillus coli. The incision in the ordinary ascitic cases should be made below the umbilicus, care being taken not to wound the bowel or omentum, for they are often adherent to the peritoneum ; not to injure the bladder, which may extend higher than is expected ; and not to work too cautiously by dissecting with undue care through the thickened subperitoneal fat and peritoneum. These tissues in chronic cases are sometimes so greatly thickened that they may be mistaken for the omentum ; and an extensive dissection, by opening different layers of tissue, militates against rapid healing of the wound. The peritoneum should be SURGICAL AFFECTIONS OF THE ABDOMEN 379 cautiously pricked with a scalpel after it has been raised by forceps, and the incision should be enlarged with blunt- pointed scissors to the full extent of the wound, the fingers being used as directors to prevent injury to the bowel. All fluid should be evacuated, but the adhesions must be treated according to the individual case. The only general rule which can be laid down is that they must be treated as tenderly as possible, and no more should be done to them than is absolutely necessary. If the omentum is not adherent to the intestine, and is much infiltrated with tubercle, it may sometimes be removed with advantage ; but it is often extremely difficult to stop the bleeding when this has been done, as the tissue is too soft to take a ligature. The abdominal cavity may be flushed with sterilised water, a saturated solution of boric acid, a 3 per cent. solution of salicylic acid, or a 0*6 per cent, of common salt when the peritoneal fluid is purulent ; if it be serous, it is better not to flush at all. The flushing must be done with the greatest care, and the stream should be full and gentle, rather than under high pressure, and delivered through a small nozzle. Its temperature should be 10U-105 F. The wound must be closed at once in the simple forms, the edges of the peritoneum being brought together by a row of aseptic catgut sutures, whilst two or three sutures of silver wire are passed through the skin and muscular walls of the alrlomen. Secondary sutures of horsehair are employed to complete the closure of the wound. The ordinary dressings are then applied, and primary union is the rule. The sutures in the skin should be removed about the seventh to the tenth day. It is important that the deep as well as the superficial parts of the wound should be brought into good apposition, for there is a tendency after these operations towards the formation of a ventral hernia, and, to still 380 THE SURGICAL DISEASES OF CHILDREN further obviate this tendency, a belt should be worn for a considerable length of time. Drainage of the abdominal cavity is as far as possible to be avoided, as it leads to the formation of adhesions ; but it must be adopted when the fluid is purulent. I am in the habit of putting a stout drainage-tube into the abdominal cavity in purulent cases at the time of the operation, closing as much of the wound as possible, and of removing the tube as soon as the discharge has diminished, usually in the course of two or three days, for the track of the tube is rapidly circumscribed by granulation tissue. The incision is made directly over the swelling, in the encysted forms of the disease, the contents are evacuated, and the wound is closed at once. It appears that fistulse are rather more frequent in the localised than in the more diffuse forms of tuberculous peritonitis. It should be remembered that in some cases of localised abscess the collection of pus is not always visible as soon as the abdomen is opened, as it may be con- cealed by the adhesion of two loops of intestine, so that careful search may be necessary to expose it. After-Treatment.— The after-treatment upon which much of the success of the operation depends, consists in keeping the patient quiet, but not necessarily motionless, in bed, and in a room whose temperature is maintained at 65° F. Small doses of opium may be given for the first day or two after the operation, if there be much pain : if the temperature rises, and enemata fail to act, a little magnesia or half a grain of calomel will often reduce it. The food should be given in a concentrated form, and it may often be peptonised with advantage. Contra-Indications of Operation.— Laparotomy is contra-indicated in cases where the abdomen is shrunken instead of being distended ; where the disease is of the SURGICAL AFFECTIONS OF THE ABDOMEN 38 1 acute miliary type, and where rapid caseation or ulceration is taking place ; where the peritonitis is only one manifes- tation of a general tuberculosis, and where it is associated with advanced pulmonary disease. Albuminuria due to tuberculous nephritis, and tuberculous inflammation of the bowels marked by melsena and diarrhoea, although they do not absolutely forbid the operation, are such serious complications that I do not myself perform laparotomy in these cases, unless there is some urgent necessity for so doing. I do not hesitate, on the other hand, to open the abdomen in the fibrous form of tuberculous peritonitis in which there is only slight effusion ; in those cases in which the convalescence is protracted, and the patient is daily losing flesh ; where the pain is sufficent to prevent him following his usual avocations; or where he has insuperable constipation apparently depending upon the presence of a constricting band low down in the abdominal cavity. We are ignorant of the mode in which laparotomy cures these cases of tuberculous peritonitis, though there is no doubt that it does so, sometimes permanently, but some- times only in part, for relapses occur, due to fresh in- fection. Cases of relapse, in which a second or even a third laparotomy has had to be performed, have shown how complete is the local cure ; careful microscopical ex- amination of the peritoneal nodules from these cases has shown that they have become more or less completely con- verted into fibrous tissue, so that there is reason to suppose that the cure is brought about by a process of phago- cytosis, or by some other method leading to complete de- struction of the tubercle-bacillus. The French surgeons have recently vaunted the successful results obtained by introducing camphorated naphtlml (p. 8) into the peritoneal cavity in cases of the dry and of the ascitic form of tuberculous peritonitis. The fluid is drawn off with a o 82 THE SURGICAL DISEASES OF CHILDREN trocar and canula, and two to four drachms of camphor- ated naphthol, are then introduced. The canula is with- drawn, and a collodion dressing is applied to the abdomen at its point of entrance. The following case of peritonitis with effusion was cer- tainly of infective origin, and I believe was due to tubercle. It well illustrates the value of laparotomy in these cases. P. B., aged 14 years, was admitted into the Victoria Hos- pital for Children. He had been wasting for a month, and for the fortnight preceding his admission he had com- plained of a cough and of night sweats. His abdomen had been swelling for a week, and he had vomited twice. I found him to be an ansemic, emaciated lad, with a uniformly distended belly, the skin being stretched and shiny. The navel was flattened, and for an inch round it there was a bright red blush, as though an abscess were pointing. There was a similar patch of redness midway between the umbilicus and the ensiform cartilage ; this patch felt oede- matous, and appeared to communicate with the lower one. The abdominal walls were so rigid that nothing could be felt through them. The flanks were resonant, but a dis- tinct thrill could be transmitted from one side of the abdomen to the other. The lungs appeared to be healthy, and the urine was free from albumin. The temperature was 105° F., the pulse being 120. On the day after his admission I made an incision in the middle line of the abdomen, half-way between the umbilicus and the ensiform cartilage. Two pints of a dark yellowish-red fluid escaped from the peritoneal cavity. The fluid coagulated spon- taneously into a thick and jelly-like mass within five minutes after its removal. The wound was closed, and was dressed with cyanide gauze. The patient bore the operation well, and his temperature began to fall steadily and continuously, until it became SURGICAL AFFECTIONS OF THE ABDOMEN 3S3 normal. Fourteen days later he was sent to the convales- cent home at Broadstairs ; and whilst he was there, he complained of a pain in his right side and of troublesome cough. On the following day neither breath sounds nor vocal resonance could be detected upon one side, and the chest was absolutely dull. Paracentesis was therefore performed, and two pints of clear fluid containing some flakes of lymph were withdrawn. The operation was re- peated nine days later, and a pint of effusion was removed. It had to be repeated for the third time ten days after- wards, when the fluid was found to be slightly greenish in colour, but not at all purulent. A year later the boy was working in an office from 9 to 4 daily, and appeared to be in excellent health. The case is of interest in many respects. In the first place all the external appearances were misleading, for they pointed to a purulent effusion into the peritoneal cavity, when in reality the fluid was of an acute plastic type. The spontaneous coagulation of the fluid shortly after its removal from the body was in accord with all that we know of the behaviour of the secretions of acutely inflamed serous membranes. The withdrawal of a fluid with so great a tendency to clot must necessarily have been productive of benefit to the patient by freeing him from much of the material likely to produce bands of adhe- sion with their attendant evil effects, and to this I attribute in great measure his perfect recovery, and the absence of any subsequent abdominal symptoms. PERITONITIS ASSOCIATED WITH PNEUMOCOCCAL 42 Tuberculous peritonitis is likely to be mistaken for another insidious form of peritoneal inflammation associ- ated with the presence of pneumococci. 3^4 THE SURGICAL DISEASES OF CHILDREN iEtiology.— This form of suppurative peritonitis occurs primarily, when it may co-exist with meningitis, pleurisy, or pericarditis, or secondarily in connection with pneu- monia. Symptoms. — It runs a prolonged course, and is cha- racterised by great pain, much meteorism, and constant vomiting. The bowels may remain regular throughout the attack, and there is often a normal temperature. Diagnosis. — If the belly be punctured with an aspi- rating needle, a greenish pus of the consistency of cream, and having a tendency to clot, will be drawn off. This pus has a faint and characteristic smell. Treatment.— The only treatment which affords any prospect of success in these cases is an early laparotomy, and it will then be found that the suppuration is either circumscribed or diffuse. The plastic character of the exudation renders the operation a difficult one, as the in- testines are matted together by adhesions, if the operation has been delayed for any length of time. The surgeon must be especially careful not to overlook any other foci of inflammation, for we suppose that it is as useless to open the abdomen in these cases, when there is a similar condition of inflammation in the pleura and pericardium, as it is in tuberculous peritonitis, when it forms a part of a general tuberculosis. Peritonitis in the New-born. 43 Peritonitis in the new-born usually depends upon puerperal infection, and is brought about by the direct extension of septic inflammatory processes from the umbilical cord. It is due in a few rare cases to rupture of the bowel resulting from an imperforate anus, or still more rarely, to rupture of the sigmoid flexure, which has SURGICAL AFFECTIONS OF THE ABDOMEN 385 been assumed by Zillner and Genersicli to be due to direct pressure upon the bowel during parturition. INFLAMMATION OF THE VERMIFORM APPENDIX AND APPENDICULAR PERITONITIS. Inflammation of the vermiform appendix occurs in males, in 80 per cent, of the cases, and in 48 per cent, of these it is met with between the ages of 15 and 30 years. Dr. Deaver stated that 15 per cent, of the cases occur in children under the age of puberty. Tordeus records a fatal case of perforation of the vermiform appendix occurring in a child of six months, and Balzer met with a similar case in a child aired seven months. O Pathology. — There can be little doubt that many cases of suppurative inflammation of the vermiform appendix are associated with the presence of specific micro-organisms. Ekehorn has shown that some of the numerous varieties of the bacillus coli hold a foremost position in this respect, whilst Barbacci of Florence maintains that more slowly growing and less conspicuous forms of microbe may also cause perforative inflammation. The acuteness of the inflammation appears to vary with the virulence of the particular culture producing it. The micro-organisms in each case seem to act bv gaining access to the lymphoid tissue in the submucous coat of the appendix through a lesion in the lining epithelium. The simpler forms of inflammation are, perhaps, more mechanical in origin. The}' may be caused by disturb- ances in the vascular arrangements of the appendix, due in part to an irregular shape of the organ leading to the formation of curves or angles in its lumen, which in turn facilitate the retention of faecal masses. The per- forative, as wdl as the non-perforative forms, are some- c u 3S6 THE SURGICAL DISEASES OF CHILDREN times associated with the presence of foreign bodies, hut this is a much less frequent cause than has hitherto been supposed. etiology. — The causes formerly assigned to inflamma- tion of the vermiform appendix must now be considered as predisposing conditions or as after-effects. They were tuberculous and typhoid ulceration, foreign bodies, and scybalous masses. The scybala so often found in inflamed vermiform appendices are doubtless produced by the glueing together of the faeces by the increased secretion from the mucous glands of the appendix, the increased secretion being one of the earlier results of the inflamma- tion. Varieties, and Morbid Anatomy. — Inflammation of the vermiform appendix is either simple, perforative, or relapsing, and each form may run an acute, sub-acute, or chronic course. The appendix varies greatly in shape, length, and position. In its simplest form it is a narrow tube of uniform calibre, lying in the long axis of the colon. Its direction, however, is most frequently inwards ; it may lie behind the csecum, or it may even be situated in the true pelvis. The existence of too short a mesentery often leads to its puckering. The inflammatory changes may commence in the mucous membrane and may rapidly involve the whole organ, or the entire thickness of the walls may be involved from the first, and in either case gangrene may result. The more severe forms of inflammation necessarily involve the sur- rounding tissues, and the anatomical arrangement of the peritoneum determines in each individual whether it terminates in a general peritonitis, in a local peritonitis, or in an abscess behind the peritoneum. Dr. Fowler of Brooklyn, to whom we owe so much of our knowledge of this form of disease, has noticed an abscess of the anterior SURGICAL AFFECTIONS OF THE ABDOMEN 387 abdominal wall pointing at the umbilicus, in two cases of inflammation of the vermiform appendix occurring in children. Symptoms. — The symptoms of acute appendicitis are so urgent that they rarely escape notice. The onset is sudden, and in a typical case is marked by very acute pain, which after a short time is attended by nausea and vomiting. The vomiting ceases as soon as the stomach has emptied itself, but it reappears in the later stages of the disease when perforation has occurred, if an abscess has been formed, or if there is much intestinal paresis. The pain after a time is paroxysmal, and is in a t}^pical case localised to " McBurney's point," situated in a line drawn from the anterior superior spine of the ilium to the um- bilicus, and an inch or an inch and a half away from the spine at the outer border of the rectus abdominis muscle. The pain soon becomes diffuse, radiating from the umbilicus and into the pelvis. Young children complain of " belly- ache " and lie curled up on one side, though adults nearly always assume a dorsal decubitus. In a few cases the pain is referred to the right testis or to the neck of the bladder because the appendix is sometimes iu close relation with the right ureter, a point which should be carefully borne in mind whilst operating. Constipation is usually a marked feature in the attack, and Dr. Kyerson Fowler believes that it has some value in prognosis, for when it occurs early it indicates intestinal paresis and indicates a more than usually severe case. Too much reliance must not be placed upon the pulse, respiration, or thermometer in these cases, for the worst, forms may run their course without any great rise of temperature, and without much alteration in the pulse rate. Increase 1 abdominal pain, with distension of the ab- 38S THE SURGICAL DISEASES OF CHILDREN dominal walls and progressive prostration, marked at first by a rise which is soon followed by a fall in tempera- ture, and by a quicker and weaker pulse, is characterised by the occurrence of diffuse septic peritonitis. Collapse, however, soon sets in, the vomiting subsides, and the patient dies. Diagnosis. — The condition is likely to be mistaken for acute intestinal obstruction, for intussusception, and, in the less acute forms, for hip disease. The pain may lead to a diagnosis of biliary or renal colic. The diagnosis may be assisted in the earlier stages by finding that the abdominal muscles are somewhat more tense upon the right side, and by the increased tenderness upon this side, elicited by rectal examination, as well as by the increased frequency of micturition. Rectal examination in children sometimes enables the surgeon to feel the outline of the inflamed appendix. The temperature in inflammation of the appendix rarely rises above 102° F. There is much thirst, and vomiting soon follows the pain, but it does not become faecal until the approach of the fatal termination. There is often a free evacuation of the bowels at the be- ginning and at the end of the attack, though constipation is the rule whilst the inflammation is at its height, and tympanitis occurs in the later stages. There is also an absence of the mucous discharge which characterises acute intussusception. The surgeon is rarely called upon to treat a simple case of inflammation of the vermiform appendix ; but the acute initial symptoms may be followed so quickly by the ordinary signs of a diffuse infective peritonitis, that it is necessary for him to be well acquainted with the disease in all its forms. The signs of perforation often manifest themselves after the first defecation, whether it be spon- taneous or produced by an enema. Some surgeons believe SURGICAL AFFECTIONS OF THE ABDOMEN 389 that the acute pain in these cases marks the instant of perforation ; but I think that this is unlikely. General peritonitis often seems to be delayed, or it may never occur, because the adhesions prevent the local inflamma- tion becoming general. A perityphlic or perinephric abscess is sometimes formed instead of a peritonitis, and the pus may then track up the back for a considerable distance. It must be let out through a free opening in the loin, and the abscess should be thoroughly washed and drained. The inflammation in the appendix is sometimes re- current, the patient appearing quite well in the intervals ; but the frequency of the attacks, coupled with the anxiety incident upon them, may render him a chronic invalid. Prognosis.— The prognosis in cases of simple inflam- mation of the appendix is good, for the vast majority of cases recover under medicinal treatment. The prognosis of perforative inflammation, when the general peritoneal cavity has become involved, is death speedy and painful unless laparotomy be performed. Treatment. (1) Therapeutic— The duration of the uncomplicated form is about a week, and it yields readily to opium, though, if one could be certain that the attack was due to the action of micro-organisms, causal treat- ment would he adopted. Such saline purgatives as Rochelle salts, administered with discrimination, or small d<>ses of calomel with extract of belladonna or spirits of chloroform, are preferred by many surgeons to opium for tin; relief of paill in such cases, the object of the pur-v. bein.u to wash the micro-organisms out of the intestine. Mr. Treves has recently suggested that salo] as a powder, and in ten-grain doses for an adult, should be employed as an intestinal antiseptic. Such means, however, must be used with the greatesl care, and are only to be recom- 390 THE SURGICAL DISEASES OF CHILDREN mended to those who have had great experience in the treatment of appendicular peritonitis. Glycerine of belladonna — a drachm to the ounce— may- be used as an external application to relieve the ab- dominal pain, in addition to the ordinary hot fomenta- tions which are so soothing. The question of diet is also of great importance in the treatment of appendicular peri- tonitis. Only such foods should be administered as are digested by, and can be absorbed in, the upper part of the alimentary canal. Eggs, peptonised milk, and Benger's food are therefore the most suitable forms of nourishment. (2) Operative. — The question of operative interference in cases of inflammation of the appendix has been keenly debated by surgeons. All are agreed that instant opera- tion is demanded when there is evidence of perforation, whether the accompanying peritonitis be general or local, the relapsing cases alone being open to discussion. Many surgeons hold that in these cases no operative inter- ference is admissible ; others, with a greater show of reason, maintain that each case must be decided upon its own merits, that when two or three relapses have taken place, when there is much discomfort in the in- tervals, and when the patient is unable to perforin the daily duties of his life, an operation is not only permis- sible, but is actually indicated. The operation in such cases must be performed in the intervals between the acute attacks, for the patient is then in the most favour- able position for recovery, as no drainage of the wound is required, and union by first intention may be antici- pated with confidence. Recurrent peritonitis must be distinguished from chronic relapsing peritonitis. The re- current forms appear to be due to mechanical causes brought into play by digestive disturbances, whilst the chronic relapsing condition is due to the presence of some SURGICAL AFFECTIONS OF THE ABDOMEN \9 l local infective lesion. The recurrent form should be left alone ; the chronic relapsing type demands operation when the interval between the attacks is short, and there is evidence of the persistence of suppuration. When the abdomen does not contain purulent fluid, the patient may be placed in the position recommended by Trendelenburg (fig. 41), with the abdomen on a slightly higher level than the head and the feet, as it facili- p [f5 _ 4i. Fowler"* modification of Trendelenburg's Operating Table, for use in abdominal explorations. It is capable of lateral rotation. The angle at which the table is set in the drawing is much too acute. [Copied /.»>; permission from the "Annals of Surgery," vol. xix., 1891.] t :i tes an examination of the abdominal cavity. Dr. McBurney then makes an oblique incision in the skin, about 4 inches long in an adult, and nearly at right angles to a line drawn from the anterior superior spine of the ilium to the umbilicus. The incision is carried about 1 inch from the iliac spine, and is so situated that its upper third lies above a line carried from the anterior superior spine of the ilium to the umbilicus, whilst it terminates just opposite the deep epigastric 39^ THE SURGICAL 'DISEASES OF CHILDREN artery. The aponeurosis of the external oblique is next divided, and then the internal oblique and the trans- versalis, but not to the full extent of the skin incision, and more towards the inner than the outer portion. The fibres of the muscles and aponeurosis are separated, and are not cut across, as there is then less tendency to the formation of a hernia. An incision is made through the least tympanitic part, if an abscess can be localised, though in cases of diffuse peritonitis the position of the swelling must determine the line of the incision ; for if it projects into the loin, the abdomen must be opened parallel with Poupart's ligament, whilst if the swelling is well to the inner side of the anterior superior spine of the ilium, the incision must be carried immediately to the inner side of the linea semi- lunaris, so as to divide the rectus muscle rather than the fascia, for the muscle heals better, and there is less chance of a ventral hernia than when the linea semilunaris itself is cut through. Great care must be taken as soon as the peritoneum is reached, lest the appendix or csecum should be inadver- tently injured. The general peritoneal cavity must be cut off at once from the area of the operation, if the peritonitis is found to be localised. This is best done by protecting the parts with gauze, which has been sterilised without the addition of any antiseptic agent. The vermiform appendix is exposed and carefully ex- amined ; if it is distended, discoloured, and unruptured, it may be removed by clamping it close to the caecum, passing an aseptic silk ligature round it about half an inch away from the gut, and cutting off the appendix below the ligature. A cuff-shaped flap may be made in exceptionally favourable cases, or when the operation is performed for relapsing inflammation, in the manner SURGICAL AFFECTIONS OF THE ABDOMEN 393 described by Dr. Fowler (Annals of Surgery, xix., 1894, p. 348), the mucous membrane exposed iu the wound being destroyed by a single application of fuming nitric acid. A similar method of treatment may be adopted when a localised abscess of some days or weeks' duration has ruptured, and if the general peritoneal cavity has become involved in the inflammatory process. The abdomen should be then thoroughly flushed with a 2 per cent, s lution of peroxide of hydrogen. The abscess must be opened and drained when adhesions have been formed between the vermiform appendix and the abdominal wall : but care should be taken not to break down the adhesions separating the abscess from the peritoneal cavity. The appendix in such cases should neither be looked for nor removed. The abscess should be emptied if symptoms of obstruction be present, its cavity should be disinfected ; and if the obstructing adhesions can be identified, they, and they only, should be divided ; but if they cannot be iden- tified, all the adhesions must be separated, and the vermi- form appendix must be removed. The surgeon must decide for himself in each case what must be done to the peritoneal cavity. Thorough but gentle sponging is sufficient when the peritonitis is local ; but if it be general, it should be well fffished with a (Hi per cent, solution of common salt at the temperature of the body. The abdominal wound is eventually sewn up, after a double drainage-tube has been inserted. When from any cause the vermiform appendix cannot be found, or it is deemed inexpedient to break down local adhesions, lest the inflammation should become generalised, it is usual to drain the wound by introducing into its depths a strip or two of sterile gauze, which must be renewed at each dressing. After-Treatment.— The after-treatment consists in 394 THE SURGICAL DISEASES OF CHILDREN feeding with nutrient enemata or peptonised milk for three days, and then gradually increasing the amount and solidity of the food; when the bowels require to be opened, one-tenth of a grain of calomel may be given every hour until defecation takes place. INTUSSUSCEPTION. 44 etiology. — Intussusception occurs in children at all ages, though it is perhaps a little more frequent during the teething period than at other times. It runs either an acute or a chronic course. The predisposing as well as the exciting causes are quite unknown, but it is supposed that peripheral as well as local irritation may produce it. Morbid Anatomy.— Leichtenstern classifies the various forms of intussusception as follows : the ileum into the ileum, or ileo-ileac invagination ; the colon into the colon, or colon invagination ; the ileum at the ileo-csecal valve, and involving it or the colon — ileo-csecal invagination. Lastly, the ileum into the colon without infolding of the ileo-csecal valve, or the ileo-colic invagination. The invagination is nearly always descending ; but a few years since I brought under the notice of the Pathological Society an instance of the true ascending variety which had occurred during life, for the intussuscipiens was united to the intussusceptum by a plastic deposit. Symptoms. — An acute intussusception may occur in a child who is apparently in good health. There is a sudden attack of abdominal pain, with repeated vomiting, and the passage of small quantities of blood and mucus by the rectum. The pain is often very violent ; it is usually con- tinuous, but is liable to paroxysmal increase. It is accom- panied by much straining, with screaming and kicking. After a short time there is usually complete constipation, SURGICAL AFFECTIONS OF THE ABDOMEN 395 though in a few cases this is replaced by diarrhoea. The most characteristic sign of the disease is the formation of a definite tumour, which can be felt through the walls of the abdomen, and in some cases by a finger introduced into the rectum. The tumour is smooth, slightly movable, not very tender, and cylindrical. It is felt in a typical case above the umbilicus, and shades away towards the right flank, extending along the right linea semilunaris. The presence of the tumour may be masked by tympanites. Rectal examination, when the tumour has advanced into the left flank, as it soon does, will sometimes reveal it as a congested mass with a central aperture somewhat resem- bling the adult os uteri. This mass may be seen and felt to advance when the child strains. Prognosis. — Recovery may take place spontaneously in slight cases, or by sloughing and adhesion of the two parts of the intestine in the more advanced forms. This termination is so rare, however, that expectant treatment must never be adopted, or even suggested in acute cases. Death from exhaustion or peritonitis usually takes place between the fourth and seventh days in cases of untreated intussusception, and the pain is so atrocious until gangrene of the intestine occurs, that no child should be left to die in this manner. In some cases, however, it runs a very slow course. Diagnosis.— Intussusception has to be diagnosed from the other forms of acute intestinal obstruction which are common in children. No mistake is likely to be made if the cylindrical tumour can be felt in the left flank ; but if it be not present, the differential diagnosis between intussus- ception, some forms of suppurative peritonitis, inflamma- tion of the appendix, and the obstruction due to pressure from enlarged mesenteric glands, may be very difficult, and can only be made by performing an abdominal section. <•> 96 THE SURGICAL DISEASES OF CHILDREN A marked depression in the right iliac fossa (Signe de Danz), from the displacement of the colon to the left side, may give a cine to the diagnosis of intussusception. Col- lapse usually occurs earlier, and is a more marked symptom in intussusception than in other forms of acute intestinal obstruction in children. Treatment. — The treatment is exactly similar to that adopted for a strangulated hernia ; inflation of the bowel and kneading the abdomen taking the place of taxis, whilst laparotomy replaces herniotomy. Intussusception, indeed, may be considered as occupying that place in the surgery of children which is filled by strangulated hernia in adults ; for just as intussusception is common in children whilst strangulated hernia is rare, so in adults strangulated hernia is common and intussusception is rare. The same arguments for treatment by operative measures apply in both cases. As in hernia no one would think of operating before he had applied taxis, so in intussusception no one would perform laparotomy before he had tried inflation of the bowel. Prejudice dies hard ; and as even to the time of Percivall Pott there were many surgeons who held that the medical treatment of hernia was alone legitimate, so in our own time there are some who have doubts as to the advisability of opening the abdomen in cases of intus- susception ; yet in children laparotomy is not a more dangerous operation than is herniotomy in adults. The success of the treatment depends, both in hernia and in intussusception, upon the case being seen in the earliest possible stage ; but in both diseases the processes may be so acute, and may have run so peculiar a course, as to render death inevitable. At St. Bartholomew's Hospital, in 1893, the abdomen was opened seven times for intussus- ception : in five cases the intussusception was reduced ; all these cases recovered. Three of the patients were under SURGICAL AFFECTIONS OF THE ABDOMEN $97 one year of age. Two infants, aged six months and seven months, died after laparotomy and incision of the intussus- ception. Inflation of the intestine should be tried directly the surgeon has diagnosed the presence of an intussusception, but arrangements should he made for proceeding at once to a laparotomy in case it fails. The child should be clothed in a jacket of absorbent wool, roughly tacked together for the occasion, and its legs and thighs should be protected by wool and bandages, for it is of great importance to keep him warm during the necessary manipulations. He is then placed upon a small water-bed, half-filled with water at a t niperature of lKP F., over which is placed a single fold of blanket and a mackintosh sheet. He is ansesthetised, and an oiled and warmed catheter is gently introduced into the rectum, an assistant compressing the buttocks to keep the anus closed round it. The end of the catheter is con- nected with four feet of india-rubber tubing terminating in a funnel. The tubing, with a qiiart jug of OG per cent. salt solution at a temperature of 100° P., is given into the charge of the second assistant. The child is then inverted and held by a nurse, whilst the assistant is directed to till the tube with salt solution, and to raise the funnel from 2| to 3 feet above the child's anus. If fluid enters the bowel, ;il) out a pint may be introduced, the surgeon at the same time gently kneading the abdomen with his finger-tips and the flat of his hand in the course of the colon from the sigmoid flexure towards the ileo-csecal valve. The success of the injection is marked by the disappear- ance of the tumour, by a gurgling beyond it, and by the distension of the intestine upon its csesal side. When this happens, the child should be laid down, the tube removed, and in a shorl time he should be put quietly to bed, with as little movement as possible. He shoull be carefully 39§ THE SURGICAL DISEASES OF CHILDREN watched, however, for it often happens that the intussus- ception recurs, and the operation of inflation may have to be repeated. Many other means of inflation have been employed — air, water, oil, milk, and hydrogen being the most usual. Some surgeons prefer to inflate with a Higginson's syringe. The operation is always attended by some danger of rupturing the bowel, and it must therefore be performed with the greatest gentleness. Eight to ten ounces of fluid, allowed to make its own way into the bowel from a height of three feet, is sufficient for a child of nine months old ; the amount and the force may be increased with the age- Inflation is useless when the intussusception is beyond the caecum in the small intestine ; it is equally useless when the intussusception projects beyond the anus, and Dr. Taylor thinks that it is an unsuitable form of treatment when a tumour cannot be felt, and the diagnosis depends entirely upon the symptoms. It is, of course, absolutely useless in the latest stages of the disease, when adhesions have taken place, and when there is a suspicion of peritonitis. As a general rule, it should only be adopted within three days from the onset of the symptoms. Laparotomy should be performed as soon as the surgeon has assured himself that inflation is ineffectual ; but he should bear in mind that the earlier the operation is per- formed, the better results will he obtain ; that it is never to be performed as a last resource ; and that if it can be done within twenty-four hours of the onset of the symptoms, the child will probably recover. It is even more necessary to perforin laparotomy early in cases of intussusception than it is to perform herniotomy early in cases of strangulated hernia ; for the intussusception is more acute, and the deli- cate tissues of the child bear the inflammation worse. The incision through the abdominal Avails is to be made so as to SURGICAL AFFECTIONS OF THE ABDOMEN 399 expose the tumour, either in the middle line, in the left or in the right linea semilunaris. The same precautions for keeping the patient warm must be adopted as during inflation (p. 397). The intussusception is reduced by gently pushing and squeezing the intussuscepted portion of the bowel out of the intussuscepting part, but never by directly pulling it out. It will generally be found that a very moderate amount of pressure is sufficient to effect reduc- tion ; but care should be taken to see that the reduction is complete, and if necessary the mesentery may be shortened. The abdomen is then closed with sutures passing through the whole thickness of its wall, including the peritoneum, and it is dressed in the ordinary manner. Many methods have been adopted for the treatment of intussusceptions which have proved, after laparotomy, to be irreducible or gangrenous. These methods may be summed up as longitudinal incision of the bowel, suture of the intussusceptum and intussuscipiens, with removal of the intussuscepted part, resection and immediate suture, the formation of an artificial anus. No case of irreducible intussusception has come under my care, and such cases will doubtless become less frequent as the advantage of early operation becomes more widely known, though they will always occur in the chronic as well as in the most acute forms of the disease. Barker's operation appears most likely to yield satisfactory results. He sutures with chromic gut the intussuscepted portion of the bowel to the intussuscepting part at its point of entrance. He then lays the bowel open by a longitudinal incision, turns out the invaginated part and cuts it short off, sutures the in- cision in the intestine, and thus restores its lumen. After-Treatment. — The child is put to bed and fed upon peptonised milk and beef-juice or essence. Opium may be given if there is evidence of local peritonitis at the time of 4-OQ THE SURGICAL DISEASES OF CHILDREN the (Operation, but it is not required as a matter of routine ; and when it is given, it is better to feed the child by the rectum. Chronic Intussusception. 15 Chronic intussusception runs a very slow course, though it may begin with acute or sub-acute symptoms. The constant pain subsides, but there are daily attacks of paroxysmal pain recurring with more or less frequency. Vomiting may be absent, and there may be no obstruction of the bowels, so that the case may be treated as one of simple enteritis, and the true nature of the disease may only be clear when a portion of the ileum protrudes at the anus, though there is even then a chance that it may be mistaken for a case of simple prolapse. The condition of the bowel in these cases appears to be that of simple invagination rather than of inflammation, strangulation, or inflammatory adhesion of its layers. The circulation through the walls of the intestine, therefore, remains free, and this accounts for the benignant course taken by the disease. Treatment. — The treatment, if the condition is recos:- nised early, consists in inflation ; but laparotomy has yielded good results even a fortnight or a month after the onset of the symptoms. CHAPTER XIX HERNIA AND ITS TREATMENT 40 The subject of hernia is of great importance in children, partly because it is so frequent, and partly because sur- geons are now beginning to recognise that so much can be done to cure it. It is either umbilical or inguinal, but in each case there is an acquired as well as a congenital form. Strangulation is less common than in adults, and it happens that two cases of strangulated umbilical hernia have come under my care during the past year. Well- applied trusses and careful management effect a cure in a very large majority of cases ; but there is always a resi- duum in which these means fail. For such cases opera- tive treatment must be adopted, for it is practically free from danger, and, except in rare cases, is effectual in preventing a recurrence of the rupture. LUMBAR HERNIA. Lumbar hernia occasionally occurs in children as a protrusion of gut in the loin, due in some cases to con- genital defects in the region of Petit's triangle, and in others to a weakening of the abdominal walls, caused by the formation of an abscess connected with perinephric or vertebral disease. The hernia is reducible, and contains colon. The treatment consists in the application of a truss in the congenital forms, or in suture of the muscular walls over the hernia in the secondary variety. 401 D n 4-02 THE SURGICAL DISEASES OF CHILDREN VAGINAL HERNIA. A vaginal hernia sometimes occurs as a congenital defect. It projects at the vulva as an extension from the vesico- vaginal pouch of peritoneum. Mr. Holmes performed a radical cure of such a hernia by first reducing it, and then dissecting flaps of mucous membrane from either side of the vagina and suturing them over the site of the pro- trusion. UMBILICAL HERNIA. Umbilical hernia is either congenital, when it is an exomphalos or omphalocele, the child being born with some of its intestines still protruding into its umbilical cord. It is sometimes acquired, when it is merely a dilata- tion of the navel to a greater or less extent. Exomphalos is not really a hernia in the true sense of the term, for the ectopic intestines were never included in the abdomen. It is always a serious condition, and may be associated with other congenital defects, most frequently, it is said, with spina bifida ; but I have never seen them together. Signs. — The protrusion consists of a neck of skin con- tinued into a translucent sac composed of the coverings of the umbilical cord. The outlines of the intestine can often be distinctly seen through the sac, as is represented in fig. 42. Prognosis. — An attempt should always be made to reduce an umbilical hernia as soon as possible, though this may fail owing to the large amount of gut in the sac, and the small size and very resistant nature of the aperture in the umbilicus. An operation is absolutely necessary if the intestine cannot be reduced ; for if it is not performed, an adhesive and possibly a suppurative peritonitis will be set up by an extension of the process by which the HERNIA AND ITS TREATMENT 40; umbilical cord is separated, the sac may slough, and the child will die of general peritonitis. I saw a good instance of this a short time since, when a child, two days old, was brought to me with a well-marked exomphalos. The sac was black and stinking at the point where the cord had been tied. The child had a subnormal temperature, its bowels had been opened three times since its birth, it had passed urine, and its belly was only slightly swollen and tender. I laid the sac freely open, and in doing so found that its walls were very thick and Fig. 12.— Congenital umbilical hernia— exomphalos. [From the " Transactions of the Pathological Society of London."] 03 Lematous. It contained a large bundle of intestine matted together by tough yellow lymph. The lymph was carefully peeled away with the finger and thumb, and the mass was gradually unravelled until it was found to con- sist of the caecum with the vermiform appendix and about Three inches of the ileum. The intestine was congested, but it was not gangrenous, and it was intimately adherent to the boundaries of the umbilicus. The adhesions were broken down with a probe, the intestines were washed with very hot water, and an attempt was made to replace them. The caecum, however, could not be returned until 404 THE SURGICAL DISEASES OF CHILDREN the abdominal wall had been divided. The sac was cut away, and the ring and the abdominal wall were closed with silver sutures and antiseptic dressings were applied. The child bore the operation well, but died twenty-four hours later. A number of this class of cases have, how- ever, been successfully operated upon by various surgeons. A piece of intestine may protrude at any point in the linea alba, though the umbilicus forms its most common exit. The ordinary cases of ruptured navel are of much less importance than an omphalocele. They are some- times cylindrical or conical, and sometimes rounded or button-shaped. They give rise to little or no trouble, and their spontaneous cure is the rule. Treatment. — They are treated by removing as far as possible any cause leading the child to strain, such as cough and phimosis. The local treatment consists in sewing a penny into a couple of layers of lint. The child is placed flat upon its back, the rupture is returned, and the pad thus made is applied from below upwards, so as to convert the umbilical aperture into a slit. The bowel is thereby prevented from extruding, and the pad is secured in place by two strips of waterproof strapping placed crosswise over it. A broad flannel bandage is then sewn round the abdomen, and the pad and bandage are changed by the surgeon as often as may be necessary, care being taken on each occasion that the rupture does not protrude. It is to be noted that those appliances for umbilical hernia are highly objectionable which are made to project into the umbilical ring. They prevent the natural process of closure. A radical cure may be neces- sary in a few rare cases when, in spite of all treatment, the rupture steadily increases in size. The sac should not be opened during its performance, nor should it be removed. HERNIA AND ITS TREATMENT 405 INGUINAL HERNIA. Everything connected with inguinal hernia in child- hood is of the greatest interest to the surgeon, on account of the frequency with which he is consulted about the affection. It occurs in the children of the poor rather more often than in those of the well-to-do. In each class, however, it presents important features. Rupture in a pauper child precludes a livelihood from mechanical toil, often the only means of subsistence available to it. Fig. 43.— Diagram of the lower part of the abdomen of a child, aged eight months. The external abdominal rinic is immediately below the " fold of Venus." Its situation on the left side is indicated by a transverse line. (After Felizet.) Rupture often renders the son of wealthy parents mor- bidly self-conscious, prevents him from making the best use of his education at a public school, and eventually shuts him out of the public services for which by in- terest or merit ho might be otherwise peculiarly well suited. A truss is often useless for a poor child who has no personal attendant to see that it is properly adjusted, that the skin does not become chafed, and that the pad is not worn over the unreduced rupture. In the rich a truss may become a source of danger by being worn so assiduously as to lead to the apparent and temporary 406 THE SURGICAL DISEASES OF CHILDREN cure of a hernia, the gut often reappearing in later life and perhaps at some critical moment. Predisposing t Causes. — Abnormal conditions of the abdominal wall and defective closure of the upper part of the tunica vaginalis testis are the most common predispos- ing causes of hernia in children. Fere examined sixty-two children under a month old, and found that in only thirty- four was the vaginal process completely closed on both sides. Morbid Anatomy. — Dr. Felizet has pointed out, as Fig. 44. — Diagram of the lcmer part of the abdomen of a child, aped four yeais. The external abdominal ring is situated loner than in the preceding figure, but not so low as in the succeeding one. (After Felizet.) is seen in the annexed diagrams (figs. 43, 44, 45), modified from his most valuable work, Inguinal Hernia in Children, that in young adults (fig. 45) the external abdominal ring lies low in the abdomen, at least two or three finger-breadths below the crease known to artists as the " fold of Venus " ; in infants of a few months old (fig. 43), the external ring lies on a level with this fold, whilst, as they get older (fig. 44), and the pelvis be- comes better developed, the position of the ring slowly approaches the point it occupies in adult life. The HERNIA AND ITS TREATMENT 407 widening of the pelvis also causes the inguinal canal to increase in length, for at birth it hardly exists. These anatomical points are of great importance in considering inguinal hernia in children, and they can be readily verified by invaginating the scrotum, and feeling with the little finger for the abdominal ring. It will then be found that the rings themselves are proportionately larger in the child than in an adult, whilst the inguinal canal is so short that the internal abdominal ring in an infant is in close proximity to the external ring. These are all points Fig. 16. — Diagram of the lower part of the abdomen of a boy, ajjed fourteen. 'Die external abdominal rhiLj nearly occupies ihe position which it does in the adult. (After Felizet.) of normal anatomy in a child ; if it be predisposed to rupture, certain additional defects may be obvious. The, pillars of the ring may bo defective, and this also has been worked out with much care by Dr. Felizet, who finds that the pillars are more often defective in boys than in girls. He. assumes that the normal (fig. 46) pillars should be thick, solid, and so tense that they vibrate when thoy are touched l>y the finger, and contract the ring when the child cries, si rains, or makes an effort. He has paet with pillars of this kind in '21 per rciit.nl' 85 cases 40S THE SURGICAL DISEASES OF CHILDREN in which he has made a careful examination during the performance of the radical operation for the cure of in- guinal hernia. The aponeurosis of the external oblique Fig. 46. — Diagram representing a normal external abdominal ring. Both pillars are well developed. (After Felizet.) Fig. 47. — Diagram representing a defective external abdominHl ring ; the outer pillar is imperfectly developed. After Felizet.) lying above the ring should be firm, well defined, not frayed out, and provided with a sufficient number of inter- Fig. 48. — Diagram representing a defective external abdominal ring; the inner pillar is imperfectly developed. (After Felizet.) columnar fibres running transversely across the canal. The departures from this type of ring are in two direc- tions : the pillars are either weak and delicate, with a HERNIA ANT) ITS TREATMENT 409 sharp edge which is never taut ; or, one or other pillar may be absent either completely or in part. Weak pillars occurred in 17 per cent, of Dr. Felizet's cases, and defective pillars in no less than Gl per cent, of his exami- nations in children affected with hernia. The weak pillars of the ring do not close upon the finger in the same active way as the normal ones do when the child strains, and they are often associated with a flabby condition of the aponeurosis of the external oblique, whilst the muscle itself is not well connected with the rectus of its own Fig. 49.— Diagram representing a defective external abdominal ring ; both pillars are imperfectly developed. (After Felizet.) side, so that the whole of this part of the abdominal wall appears to be badly developed. The intercolumnar fascia, too, is frayed out and badly developed. Defective pillars are characterised by feeble development of the outer pillar, which is not uncommon (fig. 47) ; of the inner pillar of rarer occurrence (fig. 48) ; or of both pillars (fig. 49). The tunica vaginalis in a child ought to be completely separated from the general peritoneal cavity by a more or less complete fibrous cord ; but this separation, as Fere has shown, is often incomplete. In its slightest form the canal in the processus vaginalis may be almost completely 4IO THE SURGICAL DISEASES OF CHILDREN absent, except for a small funnel-shaped depression at its upper part ; in its worst form the tunica vaginalis may retain the foetal condition seen in fig. 50, and be in direct connection with the peritoneum by a widely open canal. The prolapsed intestine may pass into the unclosed tunica vaginalis, and a congenital hernia may be produced in which the gut lies immediately above the testes, and in the same sac. The funicular portion of the tunica vaginalis may be shut off from the lower part of the sac, whilst its upper part is continuous with the peritoneum ; •sv. Fig. 50.— Processus vaginalis about the end of the eighth month of intra- uterine life. Ep., Epididymis ; Gb., gubernaculum ; S.V., spermatic vessels; Test., testicle; V.D., vas deferens. [Block kindly lent by Mr. C. B. Locfcwood.] the intestine passing into the unclosed portion then forms a funicular hernia : these are the two common types of hernia in children. The ordinary form of inguinal hernia found in adults, in which there is a separate sac, as well as the encysted or infantile hernia, also occur in children, but much more rarely. The most important varieties of inguinal hernia in children are those in which a scrotal rupture is associated with an undescended testis ; or its presence is masked by a hydrocele, or by a cystic enlargement of the sac. HERNIA AND ITS TREATMENT 4II The exciting causes which convert a potential into an actual hernia are very numerous : coughing, straining, difficulties in micturition and defecation, associated with the weakness and relaxation of the tissues produced by the various exhausting and wasting diseases of childhood, are amongst the more frequent. The rupture is apparent in nearly half the cases within the first year after birth, and more than a quarter of the remainder appear between the twelfth and the thirtieth months, often as a result of measles, whooping cough, and chronic bronchitis ; whilst the remainder appear later, either from similar causes, from a violent effort, or during convalescence from a severe illness in children with a family history of weakness in the abdominal wall. Diagnosis. — The diagnosis of inguinal hernia is so obvious, and its signs are so well known, that it would be superfluous to dilate upon them. It should be remembered that, owing to the anatomical peculiarities iu children (p. 405), the hernia is often situated much higher in the abdominal wall than is usual in adults ; that it has somewhat less tendency to become scrotal, and, above all, that it has a troublesome habit of completely dis- appearing, so that the most careful manipulation fails to detect any sign of its presence. Such hernia? usually re- appear with as great facility as they have vanished, so that the surgeon should not be too positive as to the condition of a child reported to be ruptured, because he finds no trace of it, and because the abdominal rings and the canal appear to him to be normal, except for a slight degree of enlargement. The presence of a small rupture may be masked by the co-existence of a hydrocele or of a displaced testiclo. The hydrocele is smooth and tense, whilst the rupture is often s ift and irregular, and in every case of suspected rupture 412 THE SURGICAL DISEASES OF CHILDREN the surgeon should make a routine examination of the testicles to assure himself of their exact position, and he will thus escape many pitfalls. Contents of Hernial Sac. — The hernial sac usually contains one or more loops of the small intestine, more rarely omentum only is present. The vermiform appendix alone or in conjunction with the ceecum is found with toler- able frequency in the rupture ; the ovary and the other abdominal viscera are of much rarer occurrence. Differential Diagnosis. — A hernia has to be distin- guished from a hydrocele, either ordinary or encysted ; from an abscess or a cyst occupying the inguinal canal ; from enlarged and inflamed lymphatic glands; from a retained testicle ; and from the lobed masses of fat which sometimes surround the spermatic cord. Prognosis. — The prognosis varies with the character and cause of the rupture. Some congenital hernise in very young children are undoubtedly cured spontaneously, even when no truss has been applied, but very many either remain stationary or become larger if they are left un- treated. Spontaneous cure seems to be more frequent in cases of congenital and scrotal hernise than in those which have appeared in the later years of childhood, or during convalescence from one of the exhausting diseases. We are ignorant of the means by which a spontaneous cure is effected, though it is probably by a continuance of those natural processes which ought to have been completed before the birth of the child. Sequelae. — Irreducible hernise are met with occasion- ally in children, but they are much less frequent than in persons of mature age. Acute strangulation is by no means uncommon, and is attended by the ordinary signs and symptoms of the condition. It presents, however, certain peculiar features which are not usually found in HERNIA AND ITS TREATMENT 413 adults. The bowel, even in acute strangulation, can nearly always be reduced by properly applied taxis ; and in the very rare cases in which herniotomy has to be performed, the smallest possible incision of the point of constriction is sufficient to allow ready reduction ; whilst it often happens that the prolapsed intestine can be replaced as soon as the ring is exposed, without any division of its deeper tissues. Treatment. — The treatment of hernia in children is either by the use of a truss or by an operation. A certain proportion of children can be cured by the systematic and long-continued use of a truss ; and this method should therefore be adopted in every case, unless it is clearly contra-indicated. It has, however, for too long a time been emploj'ed to the exclusion of the operation for radical cure. The operation for radical cure was practised by Sermesius, who says that he learnt it from a Russian feldherr, or apothecary, at the end of the seventeenth century. Freitage in Switzerland followed Sermesius' treatment, and Heister {Surgery, 1768, pt. ii., sect. 5, § 12) strongly recommends the method. Palliative. — The trusses in common use in this country are the skein of white Berlin wool, which is useful for children so long as they wear diapers. It keeps the hernia up, is cheap, can be constantly changed, and does not cause excoriation. It probably has no curative action ; but if it be conscientiously applied, it prevents the parts becoming over-dilated, by not allowing the bowel to be constantly passing in and out of the sac, and so allows of the comple- tion of those developmental changes which should have been intra-uterine. Mr. William Coates, of Wrington, in Somerset, first called attention, on Sept. 4, 1848, to the use of the woollen truss in the hernia of infants, saying that he had learnt it from a gudewifo in his neighbour- 414 THE SURGICAL DISEASES OF CHILDREN hood. " It consists simply of a skein of lamb's wool ; for infants, Berlin wool is preferable. This encircles the pelvis, one end being passed through the other at a point corresponding with the inguinal ring ; the free end is carried between the thighs, and is fastened behind to that portion which forms the cincture. This simple and cheap contrivance can be worn during the morning and evening ablutions, and then changed for a dry one. No attention is required on the part of the nurse, except at the moment of changing. With ordinary care in drying the skin, and the occasional application of magnesia or other nursery powders, I have never seen the skin galled." In older children a truss of rubber with an air-pad is frequently employed. It has the advantage of being washable ; but its pad is not firm, and it frequently causes excoriation. The ordinary spring truss, made by a com- petent mechanician under the immediate supervision of the surgeon and adopted to the individual case, is alone of service as a method of curative treatment. It cannot usually be worn, however, until the child is at least a year old ; it has to be constantly renewed as the child grows. It is expensive, and, except under very excep- tional conditions, it cannot be kept in place in a healthy child who has learnt to walk and play. The most persistent use of a truss will in many cases only prevent the rupture from coming down, and can therefore only be palliative ; but it may actually cure the hernia if the rings are well formed, though they may be unduly dilatable, if the hernia is small, and the canal is free, i.e. when it does not contain either a cyst, a hydro- cele, or a retained testis. A truss is useless, and time is wasted in its application, in cases where the hernia is large, when the pillars are badly developed, when there is a retained testis, and when the hernia is irreducible. There HERNIA AND ITS TREATMENT 415 exist, on the other hand, a class of doubtful eases in which a Large abdominal ring readily admits the linger of the surgeon, and allows it to pass into the abdominal cavity without an}* sense of resistance being felt from the abdo- minal walls, when the pillars of the ring feel soft and membranous, and when they do not approach each other if the child cries or strains. A truss may fairly be tried in these doubtful cases before a radical operation is pro- posed. A truss should be worn night and day for nearly a year, if it is decided to adopt this method of treatment. The child should be made to lie down daily flat upon its back for two or three hours, and it should be taken into the open air whenever the weather is suitable. It may be allowed to walk, but such exercise must not be carried to fatigue. Good food in its most digestible forms must be given, and the greatest care must be taken to keep the bowels in such a state as will lead to the least possible straining during the passage of a motion. Some hernise may be cured by these means, the pillars becoming firm and tense, and the funicular process closed ; but it should not be assumed that because the rupture has disappeared it is necessarily cured, for it often happens that such apparent cures result in a reappearance of the hernia, sometimes at a critical moment, and such relapsed hernise are attended by all the dangers of an acute rupture. The child may be considered permanently and not appa- rently cured when, after the rigorous use of a truss, the pillars are found to be approximated, when there is no sensation of impulse if the child coughs or strains, and if the patient passes through an attack of whooping cough without the rupture reappearing. The method by which a truss cures a rupture is as uu known as that by which a spontaneous cure is effected, and we can only assume that 41 6 THE SURGICAL DISEASES OE CHILDREN it is the result of a slight irritation of the neck of the sac which leads to its gradual obliteration. Operative. — The radical operation for the cure of hernia has been very frequently employed during the last few years, but we still need more evidence of its ultimate effect, as it is too soon to dogmatise. It is applicable to any age, from the earliest infancy to puberty, though there are many surgeons who prefer to wait until the child has reached four years of age before they undertake it. I have no hesitation, however, in considering its advisa- bility in every case of congenital hernia in which the methodical and sufficient application of a truss has failed to effect a cure ; when after such use of a truss the ring remains unduly large as compared with that on the oppo- site side, even though the rupture has not descended. The operation should in my opinion be performed in all cases in which the rings are badly developed, when the rupture is complicated with a retained testis, and when the sac appears to contain adherent omentum. The radical operation, except in cases of acute strangulation, is always one of expediency; but the danger is so slight, the relief is so great and immediate, and the failures are so few, that I perform the operation more and more fre- quently, and each time with a sense of increasing satisfac- tion. The good results are obtained even in the youngest children ; but the operation should not be performed in very feeble babies, during the acute stage of rickets marked by intestinal disturbances, when there is active tuberculous disease of the bones or joints, or during con- valescence from, or the prevalence of, the exanthemata. The operation is performed earlier upon the children of the poor than of the rich, and in slighter cases of rupture, because amongst the poor less personal attention can be given to the children, and trusses are allowed to chafe the HERNIA AND ITS TREATMENT 4 1 7 skin, for they are apt in such neglected cases to be worn over an unreduced hernia. The child is kept in bed for a few days to accustom it to restraint, and the operation is preceded by a thorough cleansing of the thighs and abdomen, and the application over-night of an antiseptic dressing. At the time of the operation the exact position of the external abdominal ring is determined by invaginating the scrotum, and an incision is made through the abdominal wall in such a manner as to expose it. The ordinary oblique incision may be used, and is necessary in cases of strangulation, and if the testis is retained in the canal ; but for ordinary cases of uncom- plicated hernia Dr. Felizet recommends that the incision should be transverse, as the branches of the superficial external pudic artery then escape division, and the wound is almost bloodless. The tissues are divided until the aponeurosis of the external oblique comes well into view, and this often lies at a considerable depth, for the front of the child's abdomen is covered with a very thick layer of fat. The aponeurosis is very dense, so that there is no likelihood of overlooking it, or of cutting through it inadvertently. An assistant maintains a firm hold of the testicle in the scrotum as soon as the preliminary incision has been made, and the edges of the transverse incision are carefully retracted until the spermatic cord is seen. The cord is enclosed in a common fibrous sheath, which contains the hernial sac and the elements of the cord. The assistant, by pulling the testicle downwards, stretches the cord, whilst the surgeon divides the fibrous sheath longitudi- nally, and looks for the hernial sac. The sac is not always easy to find, for in children the knuckle of intestine is not often in it at the time of the operation, and it is so small and thin that it is readily overlooked by those unaccus- E E 4l8 THE SURGICAL DISEASES OF CHILDREN tomed to see it. It usually lies to the inner side and in front of the spermatic cord, although its position is by no means constant, and its bluish white colour is usually a guide to its presence. The next step in the operation is to seize the sac in a pair of pressure-forceps, and then to isolate it — proceedings which are materially assisted by a clean division of the fibrous sheath and cremaster muscle surrounding the spermatic cord. The greatest care and gentleness must be exercised in separating the sac, as the pampiniform plexus of veins, the vas deferens, and the spermatic artery are so intimately connected with it that they have actually to be peeled off, and in doing this there is the greatest danger of injuring them. The separation is facilitated if the assistant keeps the cord tense by pulling the testicle gently downwards in the scrotum, and the sac is usually less blended with the other constituents of the cord at its upper than at its lower part, so that the surgeon begins the separation near the external abdominal ring, and expects to find the vessels on the outer side of the sac, and the vas either in front or behind it. The vas deferens in children is extremely small, and in babies is about as large as a capillary vaccine tube. The sac is laid open as soon as it has been isolated, the same care being exercised and the same methods adopted as are usual in dividing the sheath of an artery before liga- turing it in its continuity. The tip of the little finger is then introduced into the sac, first downwards towards the testicle, and then upwards into the abdomen to deter- mine the nature of the hernia and the emptiness of its sac. The entire hernial sac may be turned out of the scrotum in a few cases, but it happens much more frequently that the rupture is congenital and the sac is the tunica vagi- nalis itself. As soon as the middle portion of the sac has HERNIA AND ITS TREATMENT 419 been isolated in a congenital hernia, a ligature of catgut is tied round it below the pressure-forceps, and the sac is cut across after the surgeon has satisfied himself that he is dealing with the sac, and sac only, and that he has not included the artery or the vas in his ligature. The lower end slips back into the scrotum to form the new tunica vaginalis testis. The upper part of the sac is then exposed by holding its cut end out of the wound by means of the pressure-forceps, and its neck is drawn downwards and ligatured with a simple loop of catgut tied with a reef knot in young children where the sac is very thin ; in older children the neck of the sac is transfixed and tied with a pedicle ligature or with a Staffordshire knot, care again being taken that the neck of the sac only is tied, and that the neighbouring tissues are not included in the ligature. The sac is then cut away about half an inch below the ligature, and it disappears into the abdominal cavity, leaving the surgeon free to deal with the inguinal canal and its pillars. The method of treating the sac is varied in older chil- dren, for in them it is stouter, and can be manipulated with greater ease. In these cases I usually adopt the method recommended by my friend Mr. C. B. Lockwood. The cut end of the sac is twisted and pulled downwards by means of the pressure-forceps attached to it. It is then transfixed by a Macewen's needle, provided with a handle like the ordinary " button-hook " (fig. 51), armed with a loop of aseptic silk. This ligature is tied tightly round the sac in a Staffordshire knot by throwing the loop over the pressure-forceps, and thus round the sac, bringing one end of the ligature above the loop and the other below it, and then tying the ends in a reef knot, so as to include the loop, and compress both halves of the transfixed sac. Each end of the ligature is then separately passed through 420 THE SURGICAL DISEASES OF CHILDREN the eye of the Macewen's needle, which is then made to traverse the fascia transversalis from within outwards, the arcuate fibres of the internal oblique and transversalis muscles, and the aponeurosis of the external oblique, but not the skin. The ends of the ligature are brought through at two different points, so that when they are tied together the stump of the sac is drawn up and fixed beneath the arcuate fibres. If a testis be retained, it must either be removed or sutured to the bottom of the scrotum, as the surgeon considers proper (see p. 479). The operation is completed in children by suturing the pillars of the ring so as only to allow room for the passage of the spermatic cord. Three sutures of silver wire are Pig. 51.— Macewen's Needle, employed in the operation for the radical cure of hernia. usually sufficient, the highest one being inserted first, and care being taken to avoid including the cord or injuring it whilst they are passed. The wound is thoroughly flushed with a 1 in 2000 solution of the perchloride or the bin- iodide of mercury, and the skin is then brought together with sutures of horsehair ; and as it is essential to obtain union by first intention, no drainage-tube is employed. The dressing consists of a layer of antiseptic gauze— preferably cyanide— with a thick pad of absorbent wool kept in place by a double spica bandage of gauze. A square piece of red hat-lining sufficiently large to cover both groins, and to extend as high as the navel, is laid over the gauze spica, and the penis is drawn through a hole in its centre. This HERNIA AND ITS TREATMENT 42 I protection is kept in place by a double spica of flannelette. The dressing should not be changed more often than is necessary, and a week may be allowed to elapse before it is touched. Although the wound heals well as a rule, yet it should be examined from time to time, because here, as in all other surgical diseases of children, neither sensations of pain nor the indications of the thermometer can be trusted in the same way as in adults to afford evidence of clinical value. Absence of pain by no means implies that everything is going well with the wound, for a very slight constitutional disturbance may cause a great rise of temperature, whilst a severe local inflammation may have no effect upon the general body heat. The skin wound is usually soundly healed in a week or ten days, but the child should be kept in bed for a month, and at the expi- ration of that time it may be allowed to go about. Exami- nation of the scrotum will often show that it contains a swollen cylinder, which represents the indurated cord and tunica vaginalis ; but this slowly disappears, and I have never seen any ill-effects from it. When the hernia is double, it is better to allow an interval of three weeks to elapse between the two operations. CHAPTER XX DISEASES AND MALFORMATIONS OF THE RECTUM PROLAPSE OF THE RECTUM. 47 -Etiology. — Prolapse of the rectum and anus takes place in children with great frequency. This appears to be due in part to the fact that the upper portion of the rectum is more movable than the lower ; in part to the fact that the sacrum is nearly straight in children ; and in part because they strain much more than adults in passing their motions. Dr. Jacobi thinks this straining can be explained anatomically by the presence of two or three angular flexures often seen in the lower part of the colon of a child. No prolapse occurs so long as the floor of the perineum remains firm and the sphincter contracts well. The prolapse in the earlier stages is slight, and only occurs during defecation ; but it tends to increase in size and become permanent if precautionary measures be not adopted. The condition is often associated with general feebleness, chronic intestinal catarrh, thread-worms (oxyuris), phimosis, spasmodic cough, and more rarely with stone in the bladder, or with a rectal polypus. These causes should be first alleviated or removed. Treatment. — Medical treatment in the vast majority of cases of prolapse will effect a cure, and I usually re- commend that adopted by Mr. Allingham. The child is 422 DISEASES OF THE RECTUM 423 to be kept in bed, and all its motions are to be passed lying npon its left side at the edge of the bed, the right buttock being drawn to one side by the nurse during the passage of the faeces, as the anal orifice is thereby tight- ened, and there is less chance of the bowel being pro- truded. The parts are then to be well washed with cold water, and if prolapse has occurred, they are afterwards to be sponged with an astringent solution of a drachm of alum in a pint of decoct, quercus. The bowel should then be gently returned. Drachm doses of the compound liquorice powder may be given as a laxative if it is re- quired. The injection of a minim of the injectio hypo- derm, strychnise nitratis or the t £q of a grain of citrate of ergotinine into the rectal wall is also said to act bene- ficially in these cases by increasing the tonic contraction of the sphincter. When the prolapse is not improved by these measures, more severe ones have to be adopted ; and I usually dissect off a spiral strip of mucous membrane, taking care not to cut deeply into the submucous tissue, lest the haemorrhage be severe. In a few cases I have painted the mucous mem- brane with strong nitric acid, afterwards brushing it over with olive oil ; but this method is accompanied by so much pain and straining, that I prefer the former. The bowel in either case must be thoroughly emptied before the operation, an anaesthetic must be given, and the anus should be well dilated. The mucous membrane must be dried before the nitric acid is applied, and care should be taken not to touch the skin or margins of the anus with the acid. After it lias been applied, the surface of the bowel should be thoroughly oiled, and a pad of oiled lint should also be introduced into the rectum. The operation of colopexy, or the cure of the prolapse by the formation of artificial adhesions, has recently been 424 THE SURGICAL DISEASES OF CHILDREN suggested and practised for the worst forms of prolapse ; fortunately, however, these do not often occur in children, and I have had no opportunity of trying it. The operation is performed through the same abdominal incision as for inguinal colotomy. The rectum is found by tracing the colon downwards ; it is pulled straight so as to overcome any tendency to prolapse, its muscular walls are sutured to the deeper parts of the wound, and the skin wound is closed. Verneuil's operation, modified by Dr. Gerard Marchant, consists in exposing the rectum posteriorly beneath the coccyx and then suturing its walls. The operation is described with diagrams in the Bull, et Mdm. de la Soc. de Chirurgie, xvi. p. 828, and xviii. p. 153. RECTAL ADENOMATA. (1) Single. Morbid Anatomy. — The rectal adeno- mata or polypi in children are visually single. They are small and soft tumours, generally with a smooth surface and nearly always pedunculated. The pedicle is often so thin that it may be ruptured whilst the child is straining at stool, and so the polypus maybe spontaneously expelled. They are more often situated upon the posterior than upon the anterior wall of the rectum, and are within one and a half to three inches of the anus. They are usually true adenomata, consisting of Lieberkuhn's crypts grouped irregularly in a stroma of fibrous tissue ; but cystic, fibrous, and dermoid (p. 515) polypi occur as pathological curiosities. Symptoms. — The symptoms are often obscure, and bleeding may first give evidence of their presence. The bleeding is very slight at first, but afterwards it becomes more abundant, though it is only in very rare cases that it is of any importance ; it is often accompanied by a glairy discharge of mucus. DISEASES OF THE RECTUM 425 Diagnosis. — The diagnosis is readily made by a digital examination of the rectum, a mode of investigation which should never be omitted in cases of prolapse, fissure, and purulent discharge from the rectum, for these are the conditions most often associated with rectal polypi. Treatment. — The treatment in the pedunculated forms is to twist them off; but if the pedicle be short or thick, it is better to place the child under an ansesthetic, and to ligature the polypus after the anus has been dilated. (2) Multiple. — Rectal polypi in rare cases are multiple and diffuse. Such multiple polypi occasionally occur in several members of the same family, and the irritation which they produce may give rise to an adenoid cancer whilst the patient is yet under twenty years of age. Cancer of the rectum occasionally occurs in young adults, independently of such growths. It is necessary to excise in these cases ; but they are so unusual that I have never had occasion to resort to the operation. BILHARZIA ADENOMATA. Children in Egypt sometimes present multiple rectal adenomata due to the irritation produced by the ova of Bilharzia hsematobia. These growths have been carefully examined by Dr. Mackie, of Alexandria, through whose kindness I have had opportunities of seeing several specimens. Pathology. — The tumours are true fibro-adenomata and they are very vascular. Abundance of ova are found in the tissue, and the vessels running from the tumour contain fertilised eggs, ready for hatching in the blood stream in which the adult females are found. Symptoms. — There is considerable rectal tenesmus, in addition to bleediug from the bowel, and diarrhoea. 426 THE SURGICAL DISEASES OF CHILDREN Hematuria is a frequent symptom ; but even when the urine is clear, Bilharzia ova may be found in it. The child long survives the symptoms, and leads a miserable ex- istence until, worn out by pain and reduced by anaemia, it dies. Diagnosis. — Digital examination of the rectum, with microscopical examination of the urine, is sufficient to establish the diagnosis. Treatment. — The treatment is necessarily prophy- lactic, for the lesions are so widely spread along the genito-urinary tract that no local remedies are of the least service. NJEVI OF THE RECTUM. Nasvi occur in the rectum as pathological curiosities. Mr. Marsh has reported one which he treated in a girl of ten. It gave rise to haemorrhage from the bowel. CONGENITAL IMPERFECTIONS OF THE RECTUM. 4 * Varieties. — Cases of congenital imperfections of the rectum are brought under the notice of the surgeon with sufficient frequency to put a serious strain upon his surgical resources. The chief varieties of malformation are: (1) Imperforate anus (atresia ani), the rectum being partially (atresia recti) or wholly deficient (atresia ani et recti), the fold of the scrotum extending backwards in an unbroken line to the coccyx. (2) The anus opening into a cul-de-sac, the rectum being wholly deficient, or being separated from the bowel by a thin membrane, which is either complete or is perforated to a greater or less extent at its centre. (3) Imperforate anus in the male, the rectum being partially or wholly deficient, and DISEASES OF THE RECTUM 427 communicating with the prostatic portion of the urethra (atresia ani urethralis), or with the bladder (atresia ani vesicalis^), at its base. (4) Imperforate anus in the female, the rectum being partially deficient and communicating •with the posterior wall of the vagina just in front of the hymen (atresia ani vaginalis). (5) Imperforate anus, the rectum being partially deficient, and opening externally by a narrow outlet in an abnormal situation (atresia ani perinealis aut scrotalis). (6) The anus and rectum may be well formed and of normal size, but the outlet is obstructed by a fold of skin extending from the scrotum to the tip of the coccyx. A small opening may exist on one or both sides of this fold. Cause. — The cause of the condition is well known to be due to a failure of the rectal invagination or proctodseum to effect a junction with the cloacal section of the ali- mentary canal. The condition in which the rectum ter- minates in the genito-urinary tract is the result of a further error in the developmental process, for in these cases the cloaca has not been completely divided into its urino-genital and intestinal portions. Symptoms. — The symptoms both of the complete and of the incomplete forms are usually sufficiently obvious to attract attention within the first few days after birth. When the septum is perforated, however, it may be some weeks or months before the child is brought for advice. I have recently had a case of this kind under my care, which was satisfactorily treated by prolonged dilation with rectal bougies. The opening of the bowel into the urinary passages is productive of much trouble in boys, and may necessitate the performance of cystotomy ; in girls, on the other hand, the opening of the rectum into the vagina is of much less serious import. Treatment. — Cases of true imperforate anus, marked 428 THE SURGICAL DISEASES OF CHILDREN by inability to pass a motion, distension of the belly, and vomiting coming on about the third or fourth day, demand all the energy and skill of the surgeon to prevent the death of the child. Effective surgical interference is imperatively called for in these cases, yet the surgeon should remember that a similar group of symptoms may denote congenital strictures, or even complete absence of a part of the intestines other than the rectum, and that in some cases a volvulus may produce them. A differential diagnosis may sometimes be made, in cases where the stricture is beyond the reach of the finger, by the gentle injection of warm water. The relations of the peritoneum to the bowel are of the utmost importance in regard to the operative measures to be adopted for the relief of this condition, for the large majority of cases have died of peritonitis after operation. When the rectum is only partially deficient, the peritoneum is reflected from its anterior surface, and leaves the posterior aspect of the bowel free to be opened. When the rectum is wholly wanting, the intestine not passing lower than the brim of the pelvis, Mr. Curling says that the peritoneum completely invests the terminal pouch, and must necessarily be wounded before the bowel can be reached from the perineum. This is, of course, of much less importance to us than it was to surgeons who were unable to keep their wounds aseptic. The danger, how- ever, is still sufficiently real to warrant us in laying down the general rule, that in no case should an attempt be made to puncture the bowel with a trocar and canula. When there is a well-formed anus, and the rectum is only separated by a thin septum, the membrane may be divided with a tenotomy knife, after a catheter has been passed along the urethra, the child being ansesthetised, and in the lithotomy position. If no cul-de-sac be present, DISEASES OF THE RECTUM 429 an incision should be carried from the middle of the perineum to the tip of the coccyx ; and if the middle line be strictly adhered to, there is comparatively little bleeding. The bulging bowel may be readily felt after a little careful dissection upwards, taking care to keep close to the hollow of the sacrum, and remembering that the bowel is usually situated within an inch or an inch and a half of the surface. If the bowel is found, it should be opened on its posterior aspect, the meconium washed away, and the opening plugged with gauze, the wound being allowed to granulate without the introduction of any sutures. The value of this operation, as Mr. Keetley has shown, is enhanced by the fact that the wound is easily managed, and that it is unnecessary to take the child away from its mother. If the bowel be not found, after a moderate amount of dissection, the child should be put to bed for twenty-four hours to recover from the shock, and inguinal colotomy should then be performed. Inguinal colotomy in these cases is preferable to Amus- sat's or to Callisen's operation in the loin, first because there is more room to work in, and secondly because the bowel is opened nearer to its termination, and so there is less likelihood of failing to find it when, as often happens, the colon is displaced or presents other abnormalities. In addition to the ordinary arguments for the inguinal rather than for the lumbar operation, I have before me the fate of Mr. Baker's successful case. Colotomy had been performed in the left lumbar region immediately after birth; the case was successful, and is recorded in the Trans. Clin. Hoc, vol. xii. p. 240. The child died at the age of ten, having led a miserable existence. At the post-mortem examination the whole intestine was found to be greatly dilated, but below the colotomy wound it was distended into an enormous cul-de-sac, which, in the fresh condition, 430 THE SURGICAL DISEASES OF CHILDREN held a quart of faeces. At the end of the cul-de-sac was a" small shrivelled portion, representing the connective tissue which intervened between the termination of the intestine and the anus. Mr. Cripps recommends that when the bowel communi- cates with the posterior wall of the vagina, no operation should be performed until the child is a few months old. It should then be anaesthetised, placed in the lithotomy position, and a strong bent probe should be passed through the fistulous opening, and made to project towards the perineum in the natural site of the anus. If the com- munication between the vagina and rectum be lateral, the probe can be cut down upon directly ; but if, as more fre- quently happens, the end of the rectum communicates with the vagina, a considerable amount of dissection will be re- quired before an anus can be formed. Great care must be taken in the after-treatment of these cases to prevent the wound closing. This is best done by the prolonged use of a rectal bougie of about the size of a No. 18 English catheter. It is usually necessary to impress upon the nurse or mother that very serious damage may be done to the child by using this instrument at all roughly. It is even more important that an operation should be performed in atresia ani urethralis than in atresia ani vaginalis, for Mr. Page records {The British Medical Journal, ii., 1888, p. 875) the case of a man who, at the age of fifty-four, was leading a wretched existence with this condition. A staff may be introduced into the bladder in these cases, and an accurate dissection in the middle line towards the prostate should be made until the bowel is reached, the after-treatment being the same as in the previous variety. DISEASES OF THE RECTUM 43 1 FISTULA IN ANO. Fistula in ano sometimes occurs in children, and is the result of an ischio-rectal abscess, often of a tuberculous nature, and more rarely of spinal caries in the lumbar region. Two Italian children, members of the same family, were successively under my care for the treatment of this affection. The sinus was laid open in each case, and the ordinary means of after-treatment used in adults were adopted with slow but satisfactory results. Ischio-rectal abscess in children is rather frequently associated with the presence of foreign bodies which have passed through the wall of the bowel. The abscess cavity should there- fore be explored with a probe after it has been laid open. FISSURE OF THE ANUS. Fissure of the anus is occasionally met with in children It causes a sharp pain at the time the motion is passed, followed by a rhythmical and dull pain, lasting for some considerable time after defecation. A local application of some ointment containing cocain is serviceable in the slighter cases, supplemented with one-drachm doses of hazeline, pulv. glycyrrhizae co., or confection of senna, to prevent the passage of hard faeces. The ointment I usually order consists of : — R. Hydrarg. subchlor., grs. iv. Cocain. hydrochlor., grs. iv. Ext. belladonnse, grs. ii. Ungt. sambuci, ounce i. M. Ft. Ungt. Sig. To be used frequently. In the more severe cases, and when the ointment fails to relieve the pain, the child should be anaesthetised, and an incision made through the base of the ulcer in the manner usually followed in adults. CHAPTER XXI DISEASES AND INJURIES OF THE KIDNEY 49 HYDRONEPHROSIS. Symptoms. — Hydronephrosis, or distension of the kidney by urine, is either congenital or acquired. It is charac- terised by a tumour of definite shape, sometimes smooth and sometimes irregular in outline. The tumour is situ- ated in the flank and does not usually extend beyond the middle line of the abdomen. It is a tense swelling, and a sense of fluctuation is usually attainable. It is dull on percussion, except where it is crossed by intestine. It is likely to be mistaken for an ovarian, mesenteric, or hydatid cyst. Congenital Hydronephrosis. ^Etiology. — Congenital hydronephrosis is the result of local malformations or irregular origins of the ureters leading to kinks or constrictions in some part of their course, or it may result from similar alterations in the urethral passage. In a few cases it is the result of valvu- lar prolongations of the mucous membrane of the ureters or of the urethra. I saw it in one case associated with an imperforate rectum, in which the sigmoid flexure, distended with fasces and abnormally situated, lay over the ureters in such a manner as to prevent the urine flowing freely along them. There are therefore several varieties of 432 DISEASES AND INJURIES OF THE KIDNEY 433 congenital hydronephrosis, for it may be either unilateral, bilateral, permanent, or intermittent ; the intermittent forms being those in which the urine only escapes along its ureter, when it has been pent up until the pressure is sufficient to enable it to overcome the obstruction. The permanent forms of hydronephrosis may show themselves at birth, or only after the lapse of many years. Pathology. — The method by which hydronephrosis is produced has lately been the subject of a careful experi- mental study by Dr. Byron Robinson, 49 of Chicago. He shows that complete occlusion of the ureter produces atrophy of the kidney in a few months, whilst its partial occlusion produces a condition of hydronephrosis. The kidney will bear complete occlusion for some weeks, and will still resume its function as soon as the obstruction and the pressure are removed. Treatment. — The treatment consists in aspirating or puncturing the tumour, and in cases of long standing a thick and brownish fluid is generally withdrawn. The needle is entered half-way between the last rib and the crest of the ilium, about three inches from the vertebral spine, and its point should be directed somewhat forwards. The tumour may be cut down upon and drained, if it re- fills ; and if this fails to cure, or if its contents become septic, a nephrectomy should be performed. In skilled hands, and with due precautions, children bear the removal of a kidney excellently. Care must be taken, however, that the opposite kidney is healthy, and the abdominal incision is pref erred by some surgeons to the ordinary lumbar operation. Traumatic Hydronephrosis. etiology.— Traumatic hydronephrosis is a, convenient term, though it is not scientifically correct in the majority F F 434 T HE SURGICAL DISEASES OF CHILDREN of cases. Monod has shown that the term is used to in- clude two distinct conditions : true hydronephrosis, in which the pelvis of the kidney is dilated, owing to injuries to the ureter leading to its rupture ; to extravasation about the ureter ; or to a clot in the ureter. These cases are rare, and the swelling only appears after a long interval. In a few still rarer cases the injury may give rise to a movable kidney, and this may be followed by hydro- nephrosis. The second group is that in which a tumour appears within a few weeks of the injury without pain or constitutional symptoms. The kidney remains nearly normal in these cases, but the accident has caused some separation of the perinephric tissue, and the urine finding its way drop by drop through a rent in the pelvis or in the ureter, collects in the space thus formed, and slowly enlarges it into a tumour, whose walls consist of the con- densed retro-peritoneal connective tissue. Symptoms. — The symptoms of such a case are a temporary hematuria following an injury to the region of the kidney. There is a little tenderness over the abdomen, but there is a marked absence of shock, and the tempera- ture may hardly be raised above the normal. The child appears to be quite well after a few days' rest. The abdominal muscles, however, soon become tense, and within a fortnight to six weeks of the injury a fluctuating tumour with a well-defined margin is discovered in the belly. The tumour is usually painless, but its formation may be attended with pain and restlessness. Puncture of this swelling shows that it contains a clear urinous fluid, in which is albumin and urea. Treatment. — The tumour has disappeared spon- taneously in a few cases ; in many it has not reappeared after one or more tappings ; whilst in others it has been cured by free incision and drainage. It has often been DISEASES AND INJURIES OF THE KIDNEY- 435 necessary to remove the kidney, though in cases of traumatic hydronephrosis it is better not to adopt this method until all others have been tried, for the kidney may remain healthy. Dr. Aldibert has recently collected the varkms cases on record, and he finds that there are seventeen ; of which one disappeared spontaneously ; seven were treated by punc- ture, and of these six were cured and one died ; nine were drained with or without a secondary nephrectomy, and of these two died and seven were cured. In cases of true traumatic hydronephrosis, it is well to ascertain the con- dition of the ureter before proceeding to extirpate the kidney, as an abdominal tumour in some respects simu- lating hydronephrosis is occasionally produced by dilata- tion of the ureters. WOUNDS OF THE KIDNEY. Wounds of the kidney are of much less frequent oc- currence than ruptures. They are usually associated with intra-peritoneal haemorrhage, and may require the removal of the kidney through an anterior incision. RUPTURE OF THE KIDNEY. etiology. — Rupture of the kidney is by no means an uncommon accident in children, owing to the frequency with which they are run over by vans in the streets of a large town ; but the liver is more often lacerated than the kidney. Symptoms. — Examination of a child whose kidney has been ruptured by direct violence will generally reveal a bruise or other mark of injury on the abdomen or flank, and there is a local tenderness. The urine may or may not contain blood, and there is usually much less shock than after injury to the other viscera. The bleeding is 43^ THE SURGICAL DISEASES OF CHILDREN often intra-peritoneal, due partly to the fact that a child has very little fat round its kidney, and partly owing to the elasticity of the walls allowing the organ to be pushed forwards until the peritoneum is ruptured. Death rapidly ensues if the injury has been severe, or the laceration extensive. Prognosis. — Repair very often takes place in the slighter cases of injury, and the child only requires to be kept at rest in bed. Recovery takes place so rapidly that the accuracy of the diagnosis might be called in question did not the pathologist know how completely the surround- ing tissues become adherent to the injured part of the kidney. In less favourable cases hydronephrosis, pyo- nephrosis, or perinephric abscess may be the result, and will require appropriate treatment. Differential Diagnosis.— The differential diagnosis of ruptured kidney has to be made from similar injuries of the intestines, spleen, liver, and bladder. The regular action of the bowels, the continuance of a normal or only slightly raised temperature, the comparative absence of shock, repeated micturition, and the passage of urine which does not contain blood in excessive quantity, would be signs pointing to rupture of the kidney alone in doubt- ful cases of abdominal injury. Treatment.— Absolute rest in bed is of service in the treatment of slight ruptures of the kidney. In the most severe forms all the symptoms of intra-peritoneal haemor- rhage will appear, and the sole chance of saving the child's life will lie in performing a laparotomy and removing the kidney. Death will ensue in many cases before this can be done, or the surgeon may not feel himself justified in undertaking it ; for he may find it impossible to make an accurate diagnosis, so closely do the symptoms of shock simulate those of haemorrhage into the peritoneal cavity. DISEASES AND INJURIES OF THE KIDNEY 437 RUPTURE OF THE URETERS. The ureters are ruptured by direct violence. They are blocked and inflamed by the impaction of calculi. They are sometimes subject to tuberculous inflammation. They come, therefore, in various ways under the surgeon's cognisance. Diagnosis.— The dilated and inflamed ureter can be felt, as an oblong tumour passing over the brim of the pelvis, by deep pressure at the point of intersection of a horizontal line joining the anterior superior spines of the ilium, and a vertical line passing through the pubic spine. The vesical portion can be felt in man by a rectal examination, and Guyon has called attention to the exquisite sensitiveness of this part of the ureter even when a calculus is impacted in the tube at a much higher point. Symptoms. — The symptoms of impacted calculus are well known ; those accompanying a ruptured ureter are much more obscure. Mr. Page records the case of a boy, aged five, who was run over by a light vehicle. There was no evidence of serious injury, so the patient was sent home. Two days later, however, his parents brought him to the hospital, having noticed blood in his urine. The child complained of pain in his right iliac fossa. He remained well until about twenty days after the accident, when his condition became worse, and it was resolved to operate. The abdomen was opened, and a large fluctuating swelling, about the size of a Jaffa orange, was discovered in the right loin. It was opened and emptied. The kidney was healthy, and it was not thought advisable to make a pro- longed search for a possible rupture in the ureter. Four days after the operation the dressings were found to be saturated with fluid of a urinous odour. The temperature of the patient rose, and there were other evidences of septic 43§ THE SURGICAL DISEASES OF CHILDREN infection. A secondary nephrotomy was therefore per- formed. The child immediately began to improve, and eventually made an excellent recovery. Treatment. — This case exemplifies the difficulty at- tending the treatment of accumulations of urine due to injuries of the ureter. They are very prone to become septic if they are aspirated, and the best treatment is to expose them freely. This may be done either by a median or by a lateral incision through the abdominal walls. The upper two-thirds of the ureter can be explored by a con- tinuation of the lumbar nephrotomy incision from the twelfth rib carried obliquely downwards across the flank one inch anterior to the ilium, and then to the centre of Poupart's ligament. The sac should then be opened and drained. The opening of the ureter into the sac is found by incising the ureter below the sac, and passing a probe upwards into it. The valve on the inner wall of the ureter should then be divided longitudinally, and means should be taken to prevent the recurrence of such a condition by drawing the corners of the longitudinal incision together with a suture to transform the longitudinal into a trans- verse incision, as is recommended by Christian Fenger in his interesting article upon "The Surgery of the Ureter," 50 in The Annals of Surgery for September, 1894, p. 257. PYONEPHROSIS AND PERINEPHRIC ABSCESS. etiology. — Pyonephrosis, or the condition in which the kidney is' dilated and contains pus, arises from a variety of causes. It is very often connected with the presence of renal calculi. It occurs in tuberculous kidneys, and it may be secondary to a hydronephrosis. The term pyonephrosis is also used loosely by some surgeons to denote a peri- nephric abscess resulting from the puncture of a traumatic DISEASES AND INJURIES OF THE KIDNEY 439 hydronephrosis, although, as has been said, such collections are produced by leakage into the tissues round the kidney or injured ureter, and never lead to distension of the kidney itself. Symptoms. — The symptoms of pyonephrosis are usually similar to those of a hydronephrosis, except that the temperature of the patient may indicate by its daily oscil- lations the presence of pus. Here, as in the other suppu- rative diseases in children, the thermometer is not always a trustworthy guide, for there may be a large collection of pus and yet no increase in the temperature. Much pain" radiating downwards may be felt from the tumour pressing upon the lumbar plexus, and the patient often keeps his thigh slightly bent, and leans towards the affected side as though his spine or hip were the seat of disease. Puncture of the tumour will alone make the diagnosis certain in these obscure cases. Treatment. — The treatment of traumatic pyonephrosis consists in laying the abscess cavity freely open by an incision carried through the flank. The pus should be thoroughly washed away and the cavity explored. The kidney should be removed if it is found to be disorganised. If the pus has been formed in the connective tissue around the kidney, nephrectomy should not be performed, but the walls of the abscess should be scraped and its cavity should be well flushed and dried. The wound may then be closed without draining it, and an endeavour may be made to get union by first intention ; but if the surgeon thinks that this is impossible, he should drain the cavity. Complete recovery often takes place, but in some cases a sinus remains. A secondary nephrectomy is sometimes required before this sinus will heal, and the operation is indicated when it discharges pus mingled with urine. The secondary operation, however, is much more difficult 440 THE SURGICAL DISEASES OF CHILDREN than primary nephrectomy, for the kidney is small and the surrounding parts consist of dense fibrous tissue. TUBERCULOUS NEPHRITIS. 51 Pathology. — Tuberculous inflammation of the kidney is by no means rare in children. It occurs in the form of miliary tubercle affecting the pelvis alone, or as a tuber- culous pyelo-nephritis in which the whole kidney becomes a mass of caseating material, separated into lobules by the fibrous framework of the organ. The surgeon is only in- terested in cases of tuberculous pyonephrosis. It appears to be primary in children, for even when the symptoms have lasted for long periods of time it may be impossible to discover other tuberculous lesions ; and although the infected urine has traversed the ureters and bladder for many months, they are often found to be perfectly healthy. The renal disease may, on the other hand, be only a part of a general tuberculosis. Symptoms. — The symptoms may very closely resemble those produced by renal calculus. Frequency of mic- turition, with pain on passing water, is an early and very troublesome sign, and it often persists in spite of all local and general treatment. The urine contains pus, phos- phates, and sometimes blood. It usually smells offensively. There may be attacks of renal colic from time to time, with local pain and tenderness in the loin. Careful examination of the flank with the patient lying upon the healthy side may lead to the detection of a tumour in the situation of the kidney, whilst percixssion shows that the area of renal dulness is considerably increased. There is often a hectic temperature which may serve to distinguish the condition from a calculus formed in a healthy kidney, though it is not by any means a trustworthy guide. DISEASES AND INJURIES OF THE KIDNEY 44 1 Diagnosis. — The tumour iu the loin is liable to be mistaken for an enlarged spleen, or for an hepatic cyst, according as it lies upon the left or upon the right side. It may be distinguished from an enlargement of the spleen, by noticing that the spleen does not extend so far down- wards into the iliac fossa as the kidney ; by remembering that the spleen has a sharp edge which can usually be felt, and by percussing the abdomen ; for the spleen has no colon in front of it, whilst a part, at any rate, of a renal tumour is resonant where the colon crosses it. Careful percussion on the right side will show that there is an interval between the upper border of a renal tumour and the lower border of the liver. Prognosis. — The prognosis is always grave in cases of tuberculous pyelo-nephritis, for both kidneys are frequently diseased. Treatment. — Nephrectomy is advisable when the stir geon can satisfy himself that only one kidney is affected, and the operation should be done at once through a lumbar incision. The tumour may be incised and drained, when there is doubt as to the condition of the opposite organ, leaving a nephrectomy to be performed at a later stage, if it is found to be desirable. Children bear extirpation of the kidney for inflammatory disease so well, that out of thirteen cases of primary nephrectomy for tuberculous nephritis collected by Aldibert, 49 nine patients were cured. RENAL CALCULUS. Stone in the kidney is not a frequent cause of trouble in children, though it is not of rare occurrence, partly because the kidneys of children appear to tolerate the presence even of large calculi, especially if they are embedded in the cortex, and partly because the majority of renal calculi in 442 THE SURGICAL DISEASES OF CHILDREN children are very small, and are soon passed on into the bladder. Symptoms. — The symptoms of renal calculus in chil- dren are practically the same as in adults. There is localised pain felt in the loin, and liable to exacerbations radiating to the penis and causing retraction of the testicle in boys, or felt at the umbilicus. The pain is increased by abrupt movements and is relieved by rest. It can often be elicited by percussing the loin sharply just beneath the tips of the last two ribs, the blow being directed upwards, forwards, and slightly inwards, when the patient is standing up- right in front of the surgeon, who kneels before him. This direct evidence of the existence of a renal calculus is some- times important, for the pain is occasionally referred to the kidney which does not contain the stone, whilst in other cases it is felt in the bladder. Such errors are more common in children than in adults, for children often have great difficulty in localising their sensations. The error in localisation is physiological rather than physical, how- ever; for when the pain of a renal calculus is felt in the bladder, it is accompanied by painful micturition and a false incontinence of urine. Hematuria is a very constant symptom of renal calculus in children, and it is sometimes sufficient to lead to extreme anaemia — a condition which is readily explained by remembering how badly children bear losses of blood, and how long they are in recovering from a serious haemorrhage. The urine may remain clear and acid ; it may be wholly devoid of sediment, even where the patient has repeated attacks of renal colic, but there is usually a little albumin. Microscopic examination of the urinary deposit in such cases will sometimes reveal the presence of numerous crys- tals of oxalate of lime, and will thus clear up the diagnosis of an obscure case. In many cases, however, the urine DISEASES AND INJURIES OF THE KIDNEY 443 contains pus, it is alkaline, there are abundance of phos- phates, and it stinks. Diagnosis. — It is often very difficult to distinguish such cases of pyonephrosis due to calculus from those caused by tubercle, except by the results of inoculation upon guinea-pigs, for the bacteriological evidence is not yet sufficiently reliable. The differential diagnosis lies between tubercle and calculus, and between spinal disease and calculus. Severe attacks of renal colic, with the presence of much blood in the urine and a comparatively small amount of pus, would point to a stone in the kidney rather than to tuberculous disease. The absence of blood or pus in the. urine, when repeated examinations have been made at sufficiently long intervals, would point rather to caries of the spine than to renal calculus, especially if the disease has lasted less than a year, and the symptoms have shown themselves in a tuberculous patient. On the other hand, if the trouble is of several years' duration, if the symptoms have been intermittent, and if there has been hematuria, there is presumptive evidence of a renal calculus. Careful mani- pulation by skilled hands will often detect very slight alterations in the shape, size, and condition of the kidney, especially if the patient be placed upon his sound side and be made to breathe deeply whilst his loin is being examined. Treatment. — The treatment of renal calculus and of calculous pyelitis is still a matter of discussion, although all surgeons are agreed that operative interference is desirable when the pain is so great as to render the patient a chronic invalid. When the diagnosis has been made, it has to be determined whether one or both kidneys are affected, and then whether the affected organ is healthy so that the stone may be removed from it, or whether it is 444 THE SURGICAL DISEASES OF CHILDREN so disorganised that it is necessary to remove kidney and stone together. When nephrolithotomy has been decided upon, there still remains the last difficulty of finding the stone ; for when the calculus is small and lies in the upper part of the cortex, I have seen the most experienced sur- geons fail in their endeavours to find it. Lumbar nephro- lithotomy is usually sufficient ; but when the kidney is very large, and when it is doubtful which organ is affected, or whether both contain calculi, an anterior abdominal incision gives the best results. A large suppurating kid- ney should first be drained through a lumbar incision, the calculi being removed if possible. It may afterwards be removed at the leisure of the surgeon and the desire of the patient. MOVABLE AND FLOATING KIDNEYS. Movable and floating kidneys occur in children, but much less frequently than in adults. Such kidneys may become diseased, but they do not appear to be more liable than kidneys anchored in the ordinary manner- Mr. Warrington Haward has reported a case in which a tuberculous movable kidney was excised. The patient was a girl, aged 16, who had suffered from increased fre- quency of micturition for sixteen months. The operation was performed through an anterior abdominal incision, and the patient died forty-four hours later. RENAL TUMOURS. Pathology.— The tumours of the kidney are innocent and malignant. Innocent Tumours. The innocent tumours are fibromata, adenomata, and cystic. They are sometimes intimately blended with the DISEASES AND INJURIES OF THE KIDNEY 445 kidney substance, and are sometimes isolated from it. They are much less common than the sarcomata, which form the large majority of renal tumours in children. The serous cysts found in connection with the innocent as well as the malignant tumours of the kidney are probably in all cases retention cysts, and have their origin in these remains of the Wolffian body which form the posterior part of the primitive mesonephros. Dermoids in their various forms are occasionally found. Diagnosis. — The innocent tumours of the kidney are not, as a rule, capable of diagnosis unless they attain to a very large size. They give rise to few symptoms except slight hematuria, and they are not therefore of practical interest to the surgeon. Malignant Tumours. 52 Pathology. — Malignant tumours of the kidney in chil- dren are nearly always sarcomata, and they are generally atypical, for it is only in rare cases that they can be said to be of the round, spindle, or other variety of sarcoma. They must therefore very often be classed as teratomata, and amongst these the rhabdomyosarcomata or malignant tumours containing striped muscle fibres are by no means uncommon ; whilst in other cases they may present a cystic and adenomatous type, apparently innocent, but often running a malignant course, for they may recur, and they sometimes disseminate. The cystic growth may form an integral portion of the kidney, but it is usually separated from the glandular substance by a more or less well-marked capsule. The cysts are lined with cubical epithelium. Malignant tumours grow rapidly, anil they are often so soft as to be mistaken for chronic abscesses, for they give the sense of fluctuation. Tho tumours have usually 446 THE SURGICAL DISEASES OF CHILDREN attained to a considerable size before they cause pain or hematuria, and it is then too late to remove them, for they disseminate rapidly, and the lumbar glands are early affected. Treatment. — Many nephrectomies have been performed by different surgeons in the hope of removing them ; but 50 per cent, of the operations have proved fatal, and recurrence has taken place in nearly all the rest. The operation is performed through an anterior incision after the patient has been placed in Trendelenburg's position (p. 391), as this diminishes the venous haemorrhage and improves the heart's action. The tumour should be shelled out of its capsule if possible, and its pedicle should be carefully ligatured. Dr. Robert Abbe 52 has re- cently reported two cases in which a sarcoma of the kidney was removed from a child, and in each case the patient was in good health a year afterwards. He took special care to prevent loss of blood at the time of the operation, and he kept the patient at an angle of 30° during, and for two days after, the nephrectomy. The child was kept very warm, and in addition to the ordinary means of preventing shock, enemata of two ounces of hot black coffee were administered. Secondary sarcomata occur tolerably frequently in chil- dren, and an interesting variety once came under my observation in a boy of ten years old. He had multiple tumours of the orbits, internal ear, cerebrum, dura mater, kidneys, and other organs, which appeared to have been growing for about six months. They were sarcomatous in character and were of a bright green colour (p. 150). CHAPTER XXII DISEASES OF THE BLADDER VESICAL CALCULI. 53 Stoxe is so common in children that, taking all the cases of vesical calculi, it has been estimated that 50 per cent, of the patients affected are under the age of puberty. The calculi are usually single and renal in origin, though in exceptional cases they may be formed around pieces of dead bone which have gained access to the bladder along fistulse connecting it with the acetabulum, or with the spine. Symptoms. — The symptoms are usually more acute in children than in adults, for in children the bladder is very sensitive. The desire to pass water is frequent and urgent. The child is listless and does not play in the simpler cases, whilst in the more severe there is pain either at the beginning or at the end of the act. The pain may continue for ten or fifteen minutes after mic- turition. It is referred to the lower part of the abdomen and to the end of the penis. It is somewhat relieved by pulling upon the foreskin, so that the prepuce is often found to be elongated and either sore or thickened. It can sometimes be relieved when it occurs at the beginning of micturition by inverting the child ; but the unhappy patient usually learns for himself, and adopts instinctively the position in which he can pass his water with the least discomfort. The pain is often very severe, for it gives a worn appearance to the child, somewhat similar to that 447 448 THE SURGICAL DISEASES OF CHILDREN seen in cases of spinal caries. The urine is often passed in small quantities at a time and its flow may be inter- rupted, for the prostate is so rudimentary that the stone may fall over the vesical orifice of the urethra. It is for this reason that vesical calculi in children occasionally become impacted in the urethra. The presence or absence of hsematuria, with or without mucus and pus, will depend upon the nature of the stone ; and as mulberry calculi are tolerably common, bleeding is not of rare occurrence. An inguinal hernia or a prolapse of the rectum may be the result of the constant straining associated with the pre- sence of a stone in the bladder. Diagnosis. — The symptoms produced by a vesical calculus have to be distinguished from those produced by phimosis, by congenital narrowing of the meatus, by foreign bodies impacted in the urethra, by cystitis, and by tumours of the bladder. A small stone is readily overlooked, but it may often be discovered by adopting the plan recommended by Surgeon-Major Freyer. He introduces an evacuating catheter into the bladder, and applies to its end the aspirator filled with a solution of boric acid at 100° F. Alternate compression and relaxation of the aspirator will very soon bring even a minute stone against the eye of the evacuating catheter, with sufficient force to render its presence in the bladder quite certain. The presence of a stone of moderate or of large size is usually determined without difficulty by sounding. The sound should be very blunt and very short in the beak, and it should be kept along the upper wall of the urethra whilst it is being passed. A bimanual examination with one finger in the rectum may always be adopted with advantage in these cases, as owing to the small size of the prostate, the bladder wall is in close contact with the front of the rectum. The child should be anaesthetised DISEASES OF THE BLADDER 449 before a sound is passed ; its bladder should be emptied by means of a catheter, and should then be moderately distended with a solution of boric acid, 15 grains to the ounce, at a temperature of 100° F. Two to four ounces of such a solution are usually quite sufficient for a child of twelve years old. Treatment. — As soon as the presence of the stone has been ascertained, the question arises as to how it should be extracted. There was but one answer to this question until 1885, for until that year lateral lithotomy was always performed and with excellent results. The labours of Keegan, Freyer, and Keith in India, and of Walsham in England, have shown that even more perfect results can be attained by litholapaxy or lithotrity at a single sitting. Many surgeons prefer the suprapubic or high operation to either of the previous methods. Litholapaxy in skilled hands undoubtedly yields the best results. Those who have had the largest experience are able to employ it in nearly every instance; but it requires somewhat more ability than is possessed by the surgeon who has not the good fortune to reside in a district where the operation is of every-day occurrence. The suprapubic or lateral opera- tion is therefore better adapted fa- ordinary use; and because many operators are deficient in boldness, suprapubic lithotomy is often preferred. Litholapaxy aims at remov- ing the whole of the stone from the bladder at a single sitting, and, ideally, by a single introduction of the litho- trite. In children, calculi up to 60 grains — about the size of a Spanish nut — give the best results, though stones as large as an almond and weighing three drachms may readily be removed, and in skilled hands very much larger ones have been crushed, for Brigade-Surgeon Keegan re- ports the successful destruction of mho weighing 703 graius in a boy of twelve. I! Q 450 THE SURGICAL DISEASES OF CHILDREN Pig. 52.— Lithotrite, with evacuator, obturator and catheter, for performing the operation of litholapaxy. (From Surgeon-Major Freyer's paper in the British Medical Journal, 1894, ii., p. 1294.) The instruments (fig. 52) must be of first-rate quality, and no expense or exertion should be spared to ensure this, DISEASES OF THE BLADDER 45 I as the worst accidents have followed upon a want of temper in the lithotrite. The lithotrite selected should he the largest which can be introduced into the urethra with- out force, and if necessary the meatus may be incised to facilitate its entrance. Nos. 5-8 are the sizes most frequently required for children over two years of age. It is important, too, to have the lithotrite fully fenestrated, as it is never used to extract fragments of the stone, and every particle should drop away from it before it is with- drawn from the bladder. The evacuating catheter should only be slightly curved, and must be provided with a capacious eye close to the end and on its concave surface. An obturator or stylet should fit accurately along its whole extent, for it is essential to the success of the operation that no fragment of stone should become impacted in the eye, lest the urethra be lacerated as the catheter is withdrawn. The evacuator should be in good working order and not too stiff. It is almost superfluous to say that everything must be aseptic. The child is first anaesthetised ; and as the operation is often a prolonged one, he may be put upon a warm water- bed. He is then placed in the Trendelenburg position (p. 391), or his hips are raised by placing a pillow beneath them, so that the stone lies upon the posterior part of the floor of the bladder rather than upon its trigone. The urine is drawn off, and the bladder is distended with four ounces of a saturated solution of boric acid at the tempe- rature of the body. The lithotrite is introduced after in- cising the meatus; and if the operator possess a moderate familiarity with the instrument, there is usually no diffi- culty in grasping the stone. The calculus should be reduced to the condition of fine sand, and every single particle must be withdrawn by the 45 2 THE SURGICAL DISEASES OF CHILDREN evacuator, even though the operation last more than an hour. The complete removal of every particle is of such importance that Mr. J. H. Morgan suggests that, if there is any doubt, it is as well to introduce the evacuator and wash out the bladder three or four days after the opera- tion. The patient usually recovers rapidly from the shock, and is fit to go home in two or three days. The dangers attending the operation are : rupture of the bladder, laceration of the urethra, and faulty crushing. The error in crushing may be that too large or too hard a stone is selected ; in such a case the operator had better perform a suprapubic lithotomy without delay. The more frequent error is that the stone is not completely removed, and the fragments left in the bladder act as nuclei for the formation of fresh calculi. Recurrence is extremely rare when the operation has been performed by the more skilful lithotritists. Suprapubic Lithotomy appears to be especially well suited for children, male as well as female ; for in children the bladder is long and narrow, extending above the pubes for a greater distance than in adults. The operation is therefore an easy one, and is resorted to by those who have not had a large experience in lithotrity, and who object to lateral lithotomy on the ground that the reproductive functions are endangered by the bruising or division of one ejaculatory duct by the incision, and the risk of injury to the other in extracting the stone. The child is placed in the Trendelenburg position (p. 391), upon a warm water- bed, after his rectum has been emptied by means of an enema. He is anaesthetised, and his urine is drawn off with a sterilised catheter. A saturated solution of warm boric acid is then gently injected into the bladder until the out- line of the organ is dimly visible above the pubes,— four DISEASES OF THE BLADDER 453 to six ounces are visually quite sufficient, — and a piece of drainage-tube is tied round the root of the penis to prevent the escape of the fluid. There is no need to put a Peter- sen's bag into the rectum. The centre of the upper border of the symphysis pubis is next determined with precision. An incision two inches in length is then made through the skin, so that its lower half-inch lies over the centre of the symphysis. The incision is deepened until the recti muscles are seen. The recti are separated from each other, or their fibres are divided parallel to the incision and in its whole extent. They are afterwards held aside by small retractors. The peri-vesical tissue is usually of considerable thickness, and very vascular. It is, under ordinary conditions, divided cleanly with the knife, and with as little disturbance as possible, the scalpel being laid aside from time to time, so that the surgeon may assure himself as to the exact position of the upper border of the symphysis pubis, lest unawares he be working too high and injure the peritoneum. There is usually no difficulty in recognising the denser and more vascular wall of the bladder, and as soon as it is seen, it is steadied with the fingers, and two aseptic silk ligatures are passed transversely through its muscular wall, one at the upper limit of the wound, the other immediately above the symphysis. The ligatures are held taut by an assistant, and the surgeon plunges his scalpel into the bladder wall and divides it vertically from above down- wards through its mucous as well as its muscular coat. Fluid at once escapes, a linger is introduced, the stone is felt, and is removed by a pair of forceps. The wound in the bladder may be closed at once with two or three catgut sutures by Lembert's method, if the urine be normal and there is no cystitis — the usual condition in children The external wound may also be closed in such cases, and 454 THE SURGICAL DISEASES OF CHILDREN an attempt made to obtain union by first intention, the urine being repeatedly drawn off with a soft rubber catheter. Drainage of the bladder must be adopted when the urine is unduly foul, and Prof. Senn recommends that in such cases the operation should be performed in two stages. The bladder is first exposed, and the peri-vesical fat is dissected away over an oval space with its long axis vertical. The wound is then packed with iodoform gauze, and dressings are applied for four to six days, until plenty of granulations have been formed. The risk of septic absorption is thus reduced to a minimum. The bladder can then be opened in the ordinary way after its wall has been painted with cocain. In these cases of foul urine, Mr. Southam suggests that the bladder may be irrigated satisfactorily by drawing the bladder above the pubes, and by afterwards introducing the nozzle of a Higginson's syringe into the urethra, and thus washing out the bladder per urethram. By this method of " urethral irrigation," which should be practised daily until the wound has healed, a current of boric lotion is passed right through the bladder, entering at its base and leaving at the suprapubic opening, so that it is washed out very effectually. The operation of lateral lithotomy has not undergone any modification ; and as the various steps are described in every text-book on surgery, and with especial reference to the peculiarities of the operation in children, it will not be further considered in this book. Prostatic Calculi. Prostatic calculi occasionally occur in children ; but they must of necessity be extremely rare, owing to the rudi- mentary state of the gland. DISEASES OF THE BLADDER 455 Urethral Calculi. Urethral calculi are not uncommon, and are generally vesical calculi which have become impacted either in the membranous or penile portions ; much more rarely they are formed in the urethra itself. They may give rise to complete retention of urine, and they are readily diagnosed by the passage of a sound into the urethra. When a calculus is so firmly impacted that it can neither be pushed back into the bladder nor withdrawn by the urethral forceps, it may be necessary to incise the penis longitudinally along its under surface. This method, however, should only be adopted as a last resource, as I have seen a troublesome penile fistula result from it. Pr/eputial Calculi. Preputial calculi are sometimes found in the corona glandis during the performance of circumcision. They are usually calcified masses of smegma. In a few cases they may have escaped from the bladder, and Dr. William Hunt therefore suggests that when they are met with the child should be sounded. TUMOURS OF THE BLADDER. Myxomata and papillomata are less frequent in the bladders of children than sarcomata. A primary cancer has only once been recorded. Symptoms. — Vesical tumours cause difficulty in mic- turition, with pain either during or occurring independently of the passage of urine. Hematuria, although it is some- times profuse, is less frequent and is not so marked a symptom as in adults. It sometimes commences spon- taneously, but it is more often observed for the first time 45^ THE SURGICAL DISEASES OF CHILDREN after the child has been sounded or has had a catheter passed. The flow of urine is often impeded, and there is sometimes complete retention. The difficulty of micturi- tion, in the later stages, may lead to the establishment of a fistulous tract in very young children, for the remains of the allantois may re-open, so that the urine is voided through the umbilicus. Diagnosis. — The great capacity for dilatation possessed by the female urethra always allows the tumour to protrude from a girl's vulva, and so renders the symptoms less acute and the diagnosis easy. In boys, where no such dilatation is possible, the symptoms are often mistaken for those caused by a stone in the bladder ; nor is it easy to distin- guish them. The urine hardly ever contains fragments of the growth, and the passage of a sound may reveal a tumour which seems so hard that it is readily mistaken for a stone. Rectal and bimanual examination under an anaesthetic will often enable the surgeon to detect an enlarged bladder with thickened walls, though the result of such an examination may be negative. The distension of the bladder may be mistaken for retention, but it is due to the infiltration of its walls with sarcomatous tissue, for the organ does not contain much urine, and it may remain distended, even after it has been laid open. In some cases the growth of the tumour causes paralysis of the muscular walls of the bladder, and the urine may then accumulate in it. Treatment. — The injection of a solution of 1 in 5,000 of perchloride of mercury at a temperature of 100° F. often relieves the dysuria, especially if cystitis be present ; and, if necessary, its strength may be gradually and cautiously increased. In girls an attempt may be made to remove the tumour through the urethra, but in boys a suprapubic cystotomy must be performed if the symptoms become DISEASES OF THE BLADDER 457 urgent, and the growth must be removed by cutting forceps. Prognosis. — The result of the operation in boys is so disastrous that it is only performed as a last resource, and in girls nearly all attempts to remove malignant growths have terminated fatally within a few months, for the sarcomata of the bladder follow the ordinary rule that in children all malignant growths run a very rapid course. CHAPTER XXIII SURGICAL AFFECTIONS OF THE URETHRA RUPTURED URETHRA. 54 Causes. — Rupture of the urethra takes place rather frequently in boys from direct violence, as by falling astride a bar, whilst sliding downstairs, or from a kick upon the perineum ; but it is sometimes the result of indirect violence, or it is a complication of fractured pelvis. The rupture is either partial or complete, and its diagnosis is usually so easy that it is not likely to be mistaken for any other injury. Symptoms. — There is generally severe pain, with greater or less difficulty in passing water. A tense and tender swelling forms in the perineum, and there may or may not be bleeding from the orifice of the penis. Treatment. — The treatment in the slightest forms, where micturition is not interfered with, when there is little or no bleeding, and when the perineal swelling is very small, must be expectant, for it is possible that the urethra may only be bruised. The boy must be put to bed, and the swollen perineum must be carefully watched, to see that no suppuration or extravasation of urine takes place. If the temperature rises, the perineal hsematoma should be incised, the clot turned out, and its cavity cleansed. 458 SURGICAL AFFECTIONS OF THE URETHRA 459 The condition of the urethra should be examined at the same time ; if it is partially lacerated or completely torn, the two ends must be found and united. It is always easy to find the anterior extremity, for a catheter can be passed through it along the penis ; but it may be impossible to discover the posterior portion. The search is facilitated in such cases by remembering that the posterior portion of the urethra generally lies nearer to the anus than the penile part, and pressure upon the bladder will often enable the surgeon to squeeze a few drops of urine along the urethra, and this will serve to indicate the position of the vesical portion. It is considered advisable by some surgeons to pass a rigid catheter along the urethra into the bladder. They then perform suprapubic cystotomy. The bladder being opened upon the point of the catheter, the open- ing should be enlarged until it easily admits a large- sized drainage-tube. The catheter should be withdrawn, and as many sutures inserted into the urethra as seem to be necessary. Four are generally sufficient for a com- plete rupture : one in the roof, one in each side, and one in the floor. The suture in the roof should be tied first. As large a catheter as the urethra will admit should be passed, to support the wounded edges, and to prevent them from folding inwards. The remaining sutures are tied in, and the catheter is removed with the greatest care, so that its point does not stick either into the roof or into the floor at the sutured part. The whole or part of the perineal wound may then be brought together. The suprapubic drainage may be continued for ten days; ami during this time no catheter should be passed, and no urine should be allowed to flow through the urethra. The bowels may be kept conh'ned for a week. It is difficult, even in children, to obtain union by first 460 THE SURGICAL DISEASES OF CHILDREN inteution in these cases. When there has been extensive laceration, and the ends of the urethra cannot be brought together, a catheter may be passed into the bladder, and the deep perineal tissues may be sutured round it, the catheter being left in position as long as possible. Repair eventually takes place, and the amount of dilatation required to prevent the formation of a traumatic stricture is so much less after operation than after the ordinary methods of treatment have been adopted, that it is quite worth while to suture the urethra in these cases. PROLAPSE OP THE FEMALE URETHRA. 55 There are several cases on record in which the urethra in little girls has become prolapsed. etiology.— The exciting causes leading to the con- dition are unknown ; but the predisposing causes are general weakness, local irritation at the neck of the bladder, and repeated straining, associated with chronic cough or with habitual constipation. Symptoms.— The symptoms are never acute, and the condition often passes unnoticed for long periods of time. There may be increased frequency of micturition, with scalding and sometimes bleeding. Examination of the vulva shows the presence of a red mass, which may be furrowed with longitudinal ridges, and which presents a central depression forming the orifice of the urethra. Diagnosis. — The prolapse may be mistaken for a nsevus, polypus, or for a urethral caruncle. Treatment. — Simple replacement, as in Mr. Bryant's case, is sometimes sufficient to cure the prolapse ; and in other cases, washing with cold water, and the occasional application of solid nitrate of silver, causes sufficient constriction to prevent any recurrence. Guersant has SURGICAL AFFECTIONS OF THE URETHRA 46 1 obtained satisfactory results by drawing forward the prolapsed portion with a tenaculum, and then snipping it off. PHIMOSIS. 56 Phimosis, in its strict sense, is that condition in which the prepuce is unduly long, and its orifice is so narrow that it cannot be retracted ; but the term is often applied to those cases in which, from a persistence of the foetal con- dition, the prepuce is more or less firmly attached to the glans penis. Sequelae. — Phimosis often leads to urinary troubles, either in the shape of dysuria and retention of urine, or, in its more advanced forms, to thickened and contracted bladder, with hydronephrosis (fig. 55). Extravasation of urine in infants is an occasional result of phimosis. It may also be the cause of balanitis, and more remotely of umbilical and inguinal hernia, though there are many good reasons for thinking that phimosis does not usually stand in any direct causal relation to hernia. It is said to lead to the more common forms of hydrocele, whilst masturbation and sexual incontinence may be associated with its presence. In many cases the orifice in the prepuce is not opposite the urinary meatus, so that when the child passes urine, the prepuce is distended into a transparent sac, and he is then promptly brought for surgical treatment. Treatment. — When the orifice of the prepuce is wide, and the adhesions are few, a cure may often be wrought by retracting the prepuce, separating all the adhesions, and clearing away the smegma which has been secreted into the furrow behind the glans. Forcible dilatation of the prepuce in true phimosis is useless. I tried it most thoroughly, and in many cases, 462 THE SURGICAL DISEASES OF CHILDREN for a year, and satisfied myself that it was a failure. The prepuce cannot be retracted without either partially or completely rupturing it. The ruptures often heal badly, or cause a chronic irritation, which leads to so much induration as to require removal of the prepuce. I therefore content myself with circumcision in cases of phimosis, though it is by no means necessary to per- form it on every child, or even on the majority of children who have a long and narrow foreskin. Circumcision. Circumcision is performed at any age, so long as the child is healthy. The ideal to be aimed at, as in all plastic operations, is to obtain so good a result that the fact of surgical intervention having been necessary is not at once apparent ; and to obtain such a result, union by first intention is of the utmost importance. The operation is so frequent in children that each surgeon has his own way of performing it. It is sometimes required for balanitis, and more rarely after paraphimosis. The method I usually adopt is to render the parts aseptic, and, if possible, to retract the foreskin and carefully clean away all the smegma preputii. The child is anaesthetised, and an assistant grasps the \ root of the penis to arrest bleeding and to fix the skin against the pubes. The foreskin is then pulled forwards, and is cleanly snipped off with a pair of scissors immedi- ately in front of the glans; the incision being carried obliqixely forwards from the dorsum to the frsenum. The mucous membrane of the prepuce is now seen as a raw surface, covering the glans ; it is separated from the corona by passing a probe or director through its orifice. This is generally easy, for the adhesions are slight : but the prepuce has sometimes to be actually dissected off the SURGICAL AFFECTIONS OF THE URETHRA 463 glans, and at other times its margin is continuous with the urethral mucous membrane. These cases are often very unsatisfactory, for the prepuce contracts fresh adhesions to the raw surface of the glans, or the orifice of the urinary meatus afterwards contracts, and when it has been slit up, again contracts. There is usually no difficulty in separating the mucous membrane of the prepuce from the glans. As soon as the separation is complete, the preputial mucous membrane is divided longitudinally either with a scalpel or with a pair of blunt-pointed scissors, taking care that the urethra is not cut at the same time. The mucous membrane is then turned to either side, the smegma preputii is removed, and the sulcus is thoroughly cleaned with pieces of wet absorbent wool. The preputial mucous membrane is next cut away, near the glans, but not absolutely on a level with it ; for after a well-performed circumcision there should be a slight but sufficient covering for the lower part of the glans, and there should not be the tight retraction with disappearance of the sulcus which is too frequently seen after the opera- tion. The frsenum in many cases may be left untouched ; but if the tissue in its neighbourhood appears to be redundant, I do not hesitate to trim it up ; and if it be too short, as is often the case, it may be entirely removed, and a new one formed. Dr. Felizet's method is a good one for this purpose. The penis is raised so as to expose the trian- gular raw surface on the under surface of the glans (fig. 53). Two horsehair sutures, 1 and 2, are then passed through the edges of the skin. The suture (1) nearest the meatus is tied in a reef-knot, and cut short. The lower suture (fig. 54, 2) is tied in a " granny," so that the ends lie parallel with the line of incision. 464 THE SURGICAL DISEASES OF CHILDREN A needle is again threaded to the lower end of the suture (fig. 54, 3), and is made to traverse the cut margin of the skin of the penis. It is then tied to the upper end of the lower suture (fig. 54, 2), and by this means the skin of the penis is approximated to the glans. The assistant now relaxes his hold on the root of the penis, and the bleeding is arrested. This is rather sharp in young children, and I attach the greatest importance to its complete arrest, as iinion by first intention cannot be obtained when the two cut edges of the wound are Fig. 53. Fig. 51. Figs. 53, 51.— Diagrams showing Felizet's method of forming a new frsennm during the operation of circumcision. It is therefore worth while to in stopping it. The bleeding These separated by blood-clot. take some little trouble usually takes place from the artery of the fraenum often need a very fine catgut ligature, whilst the venous haemorrhage, which is sometimes troublesome, may be stopped by pressure forceps. The parts are then gently irrigated with a solution of boric acid or perchloride of mercury ; and when the operation has been performed upon a healthy child with an uninflamed prepuce, it is usually sufficient to slide the SURGICAL AFFECTIONS OF THE URETHRA 465 skin forwards over the mucous membrane, so that the two raw edges are in contact. The part is dried, and a single strip of cyanide gauze is wrapped round the wound, and painted over with collodion, taking care to leave the meatus patent. If the foreskin has been inflamed, it is better to unite the edges of the wound at one or two points with sutures of horsehair. The dressing is completed by passing the penis through a hole in the centre of a piece of absorbent cotton-wool or of Gramgee tissue. It is then slung against the abdomen by means of a piece of strapping, which is sufficient to keep it raised, but is not applied tightly enough to cause any risk of strangulation, even though the organ should become swollen. The thighs and knees should be lightly lnund together for a few hours after the operation, to prevent the dressings being disturbed. After-Treatment. — The after-treatment consists in keeping the child at rest until the wound is healed. The dressings will not require changing until the second or third day, if directions be given to the child's attendant to prevent their becoming soiled ; at the expiration of this time they are allowed to soak off in a warm bath. It may be necessary to reapply them, or it may be sufficient to dust the penis with nitrate of bismuth after bathing it in a weak solution of corrosive sublimate. I do not consider it necessary for a child whose urine is healthy to micturate with its penis in an antiseptic solution, as many surgeons recommend. Accidents. — The operation is usually straightforward, but a due proportion of accidents attend it. A certain amount of shock is often noticed during the period of anaesthesia. It is most often seen in the ill-fed, and in children who have been kept too long without food. Daring the operation, when the prepuce is adherent to the epithe- 11 H 466 THE SURGICAL DISEASES OF CHILDREN lial lining of the urethra, the mucous membrane must be picked up with a pair of toothed forceps, and carefully incised along the dorsum of the penis ; it must then be cut circularly, and its anterior portion dissected away from the urethral orifice. In other cases the prepuce may be so hypertrophied, as a result of chronic inflammation, that the inexperienced operator may dissect too carefully, in his anxiety to avoid the glans, and may lose himself in the indurated tissues. Care must be taken, on the other hand, not to remove too much skin in cases where the penis is very small and has become retracted under the influence of cold. The bleeding is usually slight and easily controlled ; but as the vessels of the penis are very contractile, it occasion- ally happens that the operation may have been completed before they have relaxed. Serious loss of blood sometimes takes place from this cause, as the haemorrhage is likely to be overlooked because the blanching which it causes is attributed to the effects of the anaesthetic. The surgeon should therefore assure himself that the child is doing well before he leaves it, or he should, at any rate, give directions to the nurse not to trust too much to appearances, but actually to see for herself from time to time that the dress- ings are not becoming blood-stained. Union by first intention can generally be secured, but suppuration happens pretty frequently, and with it a con- siderable amount of oedema, or the tissues may even slough. In a few cases the child may die of pyaemia or of exhaus- tion. In the slighter cases of suppuration, the penis should be repeatedly bathed in a solution of perchloride of mercury, and gauze dressings should be applied to the in- flamed part. Stimulants and quinine are to be adminis- tered to the patient in these cases. Care should be taken after the operation to see that SURGICAL AFFECTIONS OF THE URETHRA 467 ''■ . " ' Fig. 65.— Bladder and kidneys from a lad of 17 years, showing the baleful effects of an untreated phimosis. [/',- ,■/ L':}70 (o) in I),. Museum of SI. Bartholomew's Hospital.] 468 THE SURGICAL DISEASES OF CHILDREN retention of the urine does not occur. It is well to assure oneself, before circumcising, that the kidneys are healthy in children who have had a tight phimosis, as death may occur from acute suppurative nephritis. The following case, which came under my notice a few years ago, well exemplifies the value to be attached to an examination of the urine in these cases. An apparently healthy lad, who acted as a railway porter at a country station, presented himself fresh from his work, and with so tight a phimosis that a probe could not be passed through the orifice in the foreskin. He was circumcised, and two days later he began to suffer from symptoms of suppression of urine. He became comatose, had ursemic convulsions, and died three days after the operation. The annexed drawing (fig. 55) of the genito-urinary organs shows how greatly the bladder is enlarged and hypertrophied. Its mucous coat is ulcer- ated. The ureters are enormously distended and thickened, except at their point of entrance into the bladder, where they are normal in size. The pelves and infundibula of the kidneys are widely dilated, thickened, and rough from a deposit of lymph upon their inner surfaces. The glandular substance has entirely disappeared. A similar condition of the genito-urinary organs is sometimes found after phimosis leading to incontinence of urine. Dr. Alexander James 56 believes that indications of this condition can be obtained from the persistent low specific gravity of the urine, and the presence in it of small amounts of albumin. Mr. Burn Murdoch has also called attention to similar cases. BALANO-POSTHITIS. The foreskin is a peculiarly vulnerable point in young children, and the surgeon is constantly consulted about inflammatory conditions occurring in it. Posthitis, or in- SURGICAL AFFECTIONS OF THE URETHRA 469 flamination of the foreskin, is nearly always associated with balanitis, or inflammation of the glans penis, and it is therefore convenient to consider the two conditions at the same time. Balano-posthitis is due to general as well as to local conditions. Causes. — Phimosis is one of the commonest causes, for it leads to a retention of smegma, which may decompose beneath the foreskin, or it sets up inflammation owing to the irritation produced by partial adhesion existing between the glans and the mucous lining of the prepuce. The dribbling of urine over a long foreskin may cause an eczema which in turn becomes a balano-posthitis. Diabetes, gonorrhceal discharges, and soft sores more rarely give rise to this condition in older children. Irrita- tion of the urinary tract from the presence of calculi and from Bilharzia, or of the rectum from thread-worms, also causes inflammation of the foreskin. It may be produced by injury, and it sometimes occurs after circumcision. The constitutional causes are the exanthemata, especially scarlet fever and measles, erysipelas, ' diphtheria and tubercle, or rather that predisposition to tubercle which is now called struma. It also occurs in those children of gouty parents who have inherited the uric acid diathesis. Symptoms. — In the simplest form the foreskin be- comes red, swollen, and cedematous, and, if it be left un- treated, soon exudes a clear, serous fluid. The oedema extends some distance down the penis, and generally ter- minates abruptly. Treatment. — This condition usually subsides if the penis be slung against the abdomen after it has been thoroughly cleansed by giving the child a warm bath, and by the local application of subnitrate of bismuth, or of equal parts of starch and oxide of ziuc. The child should be circumcised as soon as the acute symptoms have sub- 470 THE SURGICAL DISEASES OF CHILDREN sided. The inflammation is so acute in some cases that a part or the whole of the prepuce may become gangrenous, or it may be sloughing from the first. These forms require much more active treatment. Two or three ounces of brandy should be administered daily, with two minims of laudanum three times a day for a child of a year old. The penis should be raised, and should be repeatedly bathed with hot water. The prepuce should be slit if there is complete retention ; otherwise no cutting operation should be performed until the child is in a better state of health. Suppuration does not often take place ; but when it does, the abscess must be opened at once. Paraphimosis. Paraphimosis occurs more often in older children than in infants. It necessarily has a phimosis as its antece- dent condition. Symptoms. — The symptoms are due to the venous con- gestion produced by a tight and retracted prepuce whilst the arteries continue to carry blood to the glans. Acute strangulation is thus produced, the prepuce becomes (edematous, and the glans swollen and congested ; but, in spite of this, gangrene is not a very frequent result. Similar symptoms are produced in children by the appli- cation of ligatures to the penis, so that the surgeon should ascertain that nothing is tied round the organ before he attempts to reduce a paraphimosis. Treatment. — The treatment of paraphimosis consists in relieving the constriction as soon as possible. This can be done by returning the prepuce to its normal position by incising it or by cutting it off. Reduction is effected by placing the patient on a bed and ansesthetising him. The surgeon stands upon the right side and takes the penis between the second and third fingers of his left hand, SURGICAL AFFECTIONS OF THE URETHRA 47 I whilst he grasps the swollen glans in the fingers and thumb of his right hand. He squeezes the glans with his right hand, so as to reduce its size as far as possible by rendering it bloodless, and he simultaneously pulls the prepuce forward and pushes the glans backwards until reposition is effected. When this has been done, the sur- geon should be careful to ascertain that the reduction is real and not apparent, for it sometimes happens that the foreskin is pulled into place whilst the preputial mucous membrane is left behind and remains as a constricting band. The operation is often a long and difficult one, and the foreskin may be much chafed. To facilitate the reduc- tion, the glands may sometimes be emptied of blood by bandaging the penis from its point towards its root. The penis should be thoroughly washed after the re- duction with a 1 in 1000 solution of corrosive sublimate, and its end should be wrapped in wet cyanide gauze. The patient must be kept in bed for a day or two. Operative treatment is to be adopted as soon as the sur- geon has satisfied himself that manipulation is useless. A probe-pointed bistoury is slipped between the glans and the prepuce along the dorsum of the penis, and the constric- tion is freely divided. This is usually sufficient to permit the prepuce to be drawn forwards, but it is sometimes necessary to make small oblique incisions from the end of the dorsal wound before the prepuce can be replaced. It is not advisable to circumcise immediately after a paraphi- mosis has been reduced, as the tissues are too inflamed to heal by first intention. Dislocation of the Penis. 57 The penis in children occasionally becomes displaced as the result of direct violence, so that it lies within the 472 THE SURGICAL DISEASES OF CHILDREN scrotum. Reduction lias been effected by careful manipu- lation as late as tlie tenth day after the accident. ENURESIS. 58 Few patients are more often seen by the medical officers attached to a Hospital for Children than those suffering from incontinence of urine, and for few can less good be done by treatment. The incontinence is most frequently nocturnal ; but involuntary passage of urine during the day is not a very uncommon affection in girls between the ages of six and twelve who are overworked at school. The causes of enuresis, and the methods recommended for its treatment, are nearly as numerous as the " piss-a-beds " themselves. etiology. — Essentially a physiological defect con- nected with an ill-developed sphincter vesicse, enuresis is associated with phimosis, with constriction of the urinary meatus, or with other parts of the urethra, and with chronic irritation of the bladder, rectum, or urethra by vesical growths, worms, or stone. It is met with in con- nection with chronic nephritis and pyelitis, with renal and vesical calculus, and with alterations in the specific gravity and in the reaction of the urine. It may also, and more rarely, be associated with disorders of the central nervous system, characterised by epilepsy and night terrors, or with congenital defects of the spinal cord, associated with spina bifida, either of the ordinary type or in the less common form of spina bifida occulta. It may occur as an early symptom of diabetes, and I have seen it rather fre- quently associated with slight but chronic cystitis, pre- sumably tuberculous in origin, and in some early cases of Pott's disease of the spine. It is, perhaps, most often met with in the two extreme types of intellectually developed SURGICAL AFFECTIONS OF THE URETHRA 473 children — those who are unduly bright, precocious, and excitable, and in those who are of low mental calibre. Treatment. — The affection is a very obstinate one, but it should, as far as possible, be treated causally. When no cause can be detected, the passage of as large a sound as the urethra will admit is often followed by good results, especially if the sound is cooled by being placed upon ice before it is oiled. This treatment, first used by Mr. Edmund Owen, has recently been placed upon a scientific footing by Prof. Peyer, who shows that it is most service- able in cases of chronic irritation of the prostatic portion of the urethra — a condition which is often found in boys who masturbate. It is indicated by the presence of a con- siderable quantity of clear mucus entangling crystals of triple phosphates in the sediment of urine which has been allowed to stand for a few hours in a conical glass vessel. Epithelial cells, leucocytes, and, in older boys, more or less well-developed spermatozoa repeatedly found in the urinary deposit, will go far towards establishing a diagnosis of masturbation. The sound in these cases should be passed at least twice a week ; but in bad cases it may be necessary to perform the operation daily. It should be left in the urethra for five minutes on each occasion. The ordinary adjuvants to treatment must be adopted in every case, such as tonics, waking the child to pass water when its attendant goes to bed, giving it light and • ligestible meals with a minimum of fluid in the daytime, and none in the evening. The general tone of the system may be improved, with benefit to the local defect, by spong- ing the body with sea-water, and then briskly rubbing it with a bath-towel until a glow is felt. It is often advis- able also to prevent the child sleeping upon his back. I have only obtained good results in the slightest cases from the administration of belladonna even in large doses, 474 THE SURGICAL DISEASES OF CHILDREN and when mixed with mix vomica ; but the treatment should always be tried before other measures are adopted. Dr. Baruch's method, recommended by Mr. Edmund Owen in his Lettsomian lectures, is easy to recollect, and is as satisfactory a way of administering the drug as any other. He orders — I£. Atropise sulphatis, grain i. Tinct. Aurantii, drachm i. Aq., ounce i. M. et fiat Mist. Dose, one drop for each year of the child's age. Administer it every hour in the late afternoon, or until the pupil is dilated at bedtime, and give a dose or two during the night, should the pupil begin to contract. The object of this method is to get the patient so thoroughly imder the influence of the drug, that the pupil remains dilated whilst the child is asleep. Antipyrin in two-grain doses may also be tried. Two doses should be given at intervals of an hour, the last being taken just before the patient goes to bed with an empty bladder. The drug has been greatly extolled, but I have never obtained any satisfactory results from its use. Astringent injections of a 1 per cent, solu- tion of alum, tannin, or a 1 per 1000 solution of nitrate of silver, may also be tried in very obstinate cases. Three or four suppositories daily, each containing \ grain of nux vomica, are also said to be serviceable ; and Von Tienhoven recommends that the foot of the bed should be raised to an angle of 45°. CHAPTER XXIV SURGICAL AFFECTIONS OF THE TESTICLE TUBERCLE OF THE TESTICLE 59 Lloyd, in his work on scrofula, published in 1821, was the first to refer to tubercle of the testis occurring in a child. The affection is rather a rare one ; but Demme's statistics, which give it as sixteen times in 1,932 cases, appear to be more correct than Jullien s, who only noticed it sixteen times in 5,566 tubercular children. For several years past one or two cases have annually come under my notice at the Victoria Hospital for Children. etiology. — Tuberculous testis affects children of all ages, and it has even been found to be congenital. One gland is, as a rule, infected, and a definite history of injury can often be obtained. The disease may be primary, but it is more often seen as a secondary affection in the course of general tuberculosis. Symptoms. — The disease presents certain differences in the course which it runs from the similar affection in adults, due no doubt to the fact that the gland in children is not functional, and is therefore of far less importance than it is in later years. The onset of the inflammation is often so insidious that the mother only accidentally dis- covers that the child has a swollen testicle. The gland, on examination, is then found to be larger than usual, and to present a hard mass, with a more or less irregular 475 47^ THE SURGICAL DISEASES OF CHILDREN outline. This mass is situated either in the epididymis or in the body of the testicle. The gland is not tender, and usually there is no hydrocele. It may occur in children who otherwise appear to be in such good health as to make one doubt the correctness of one's diagnosis. The affection sometimes begins with more acute symp- toms. The skin of the scrotum becomes tense, slightly oedematous, somewhat reddened, and a hydrocele may be formed. After a few days these symptoms subside, and an enlarged and tender gland or a knobby epididymis can be felt within the scrotum. Prognosis. — The prognosis in cases of simple tuber- culous infection of the testis is good. The swelling usually remains stationary for a longer or shorter period. It then slowly diminishes, and finally disappears completely. This disappearance may be so complete that the testicle atro- phies at the same time, and the child becomes monorchous. The result is far otherwise when the infection has been a mixed one ; that is to say, where other than tubercle bacilli alone are deposited in the gland. An abscess is then produced which opens through the scrotum, leaving a fistulous tract. Hernia testis is rare, but the neigh- bouring glands are early affected. These suppurating cases are often accompanied by tuberculous dactylitis, in- sidious spinal caries, or manifestations of visceral tubercle. The vas, vesiculae, and bladder are only very rarely in- volved. Mr. Bennett's interesting paper on " Tubercular Disease of the Testicle " 59 as a local affection shows that in some cases the vertebral column is implicated in the tuber- culous inflammation which has commenced in one testicle, even before the disease has spread to the seminal vesicles of the same side. The dissemination does not appear to take place until the original focus of the disease has begun to undergo degenerative changes, and the general health SURGICAL AFFECTIONS OF THE TESTICLE 4/7 does not become affected until some time after the forma- tion of an abscess. Diagnosis. — There is usually but little difficulty in making a diagnosis, but care must be taken not to mis- take tuberculous disease for syphilis, sarcoma, or dermoid cysts. A tuberculous testis cannot always be differenti- ated from a syphilitic one. In syphilis, both the glands are generally involved ; in tubercle, only one. Syphilis may transform the testicle into a hard and painless mass, the epididymis remaining unaltered ; whilst in tubercle the gland is usually tender and the epididymis is affected. In syphilis, too, there is often other evidence of the inherited disease ; and, in the earlier stages, there is a rapid and marked improvement when grey powder is administered. Sarcoma of the testis is rare in children ; it grows more rapidly, is.much less circumscribed, and shows less tendency to suppurate. Dermoid cysts are so rare that they need only be mentioned. Treatment. — The treatment in all simple cases, where there is no tendency to suppurate, should be purely palliative. Fresh air, cream or cod-liver oil, good food and plenty of sleep, with a light suspensory bandage and the inunction of blue ointment, are generally sufficient. Care should be exercised, even in those cases which appear the most harmless ; for it should be remembered that tubercle bacilli are present in the gland, and that they may, at any time, and most insidiously, infect the bones and serous membranes, peritoneal, pleural or meningeal. The testicle should be removed at once if there is the slightest evidence of dissemination. It should also be removed, and with it the infected skin, in all cases of extensive disorganisation of the gland which has been allowed to proceed as far as the formation of sinuses. 47^ THE SURGICAL DISEASES OF CHILDREN TUBERCULOUS EPIDIDYMITIS. Chronic inflammation of the epididymis is by no means rare in children who have other manifestations of tubercle. It occurs as an indolent swelling, which gradually in- creases, suppurates, and may burst, leaving fistulous tracts. Jullien, who has paid much attention to this form of disease, says that he has never seen it in a case of un- descended testis, and Grerster maintains that it is embolic in origin. The prognosis is good, though death sometimes takes places as a result of general tuberculosis. Treatment. — The treatment is the same as for tuber- culous disease of the testicle itself. Three or four drops of camphorated naphthol may be injected into the sub- stance of the swelling if it be seen before suppuration has taken place ; but if fistulse are present, it is better to excise the whole testis. ABSCESS OF THE TESTIS. 60 Mr. Sheild quotes two cases of simple suppuration occurring in the testicles of infants. They are of un- common occurrence, and I have never seen a case. They are to be treated by the ordinary method of early incision. Displaced Testis. A testicle may be displaced either from defective action of the gubernaculum testis when it does not lie in its proper position in the scrotum, or it may be displaced owing to irregular action of the muscle, in which case the testicle may not be situated in the scrotum at all. The gland in cases of retained testis may lie within the abdo- men, in the inguinal canal, or at the top of the scrotum. In cases of ectopic testicle the organ may lie either in the groin or in the perineum, for the gubernaculum testis has SURGICAL AFFECTIONS OF THE TESTICLE 479 attachments in the perineum as well as in Scarpa's tri- angle. Ectopia perinealis is the commoner form. It is either scroto-femoral when it occupies the groove between the scrotnm and the thigh, or it is perineal when it lies behind the scrotum near the middle line and at a varying distance in front of the anus. Diagnosis. — There is no difficulty in recognising that one testicle is absent from the scrotum, though the defect is often masked by the presence of a hernia or of a hydro- cele. It is more likely to be overlooked than to be mis- taken for any other condition. The scrotum is sometimes badly developed upon the affected side in cases of an un- descended or of an ectopic testis. Ectopia femoralis may be mistaken for an enlarged lymphatic gland, for only a few years since such a gland was sent to me, removed from the groin, as was supposed, for tuberculous enlargement. Examination, however, showed that it was a healthy and functionally active testis. ^Etiology.— Displaced testes are so rarely functional, that it is a qttestion whether the displacement and the Want of function are not both due to deficiency in the spermatic artery, rather than that they are correlated as cause and effect. The exact setiology, however, is unknown. Treatment. — In cases of inguinal hernia, complicated with retention of the testis, the rupture is generally found below or on one side of the gland. The radical operation for the cure of the hernia must be performed in such cases in the manner already described (p. 417). The testis may at the same time be brought down into the scrotum as far as the cord will allow, and sutures should be passed through the pillars of the ring. The sutures are generally sufficient to prevent the reascent of the testicle, but it is sometimes necessary to still further secure it by means 480 THE SURGICAL DISEASES OF CHILDREN of an aseptic silk ligature passed through the gland and the skin at the base of the scrotum. This method of orchidopexy, as it is termed, has recently been the subject of keen debate amongst the surgeons in Paris, who are by no means unanimously in its favour. The operation should be done early if the rupture is large, if it is difficult to keep up, or if from any cause the wearing of a truss is painful or unsatisfactory. It should never be deferred until the child is more than five years of age, for in such cases there is an arrest of the normal growth of the gland. A testicle lying in the perineum is often only held in place by a band of fibres which may be attached either to the tuberosity of the ischium, to the external sphincter of the anus, or to the skin. The subcutaneous division of this band occasionally allows the testicle to be replaced in the scrotum. When this fails, the simple operation recommended by Mr. Bilton Pollard may be employed, even when the scrotum is badly developed. The testicle is first exposed, and is raised with its coverings, including the cremaster muscle, and turned upwards as far as the external abdominal ring. An incision is then made in the lower part of the scrotum, and a bed is formed for the testicle amongst the connective tissue. A pair of sinus forceps is thrust up from the wound in the scrotum through the cellular tissue to the top of the first incision, close to the external abdominal wound. A track is made by separating the blades of the forceps, and the testicle is pushed along it as gently as possible into its new bed. Both wounds are then closed, and they should heal by first intention. MALIGNANT TUMOURS OF THE TESTICLE. Carcinomata are of less frequent occurrence than sarco- mata. They are usually congenital, and as they run a SURGICAL AFFECTIONS OF THE TESTICLE 48 1 rapid course, they are only seen in the youngest children. Sarcomata occur in older children, and their origin is some- times referred to an injury to the testicle. Symptoms.- — The tumour primarily involves the epi- didymis or the body of the testis, and is often undergoing cystic degeneration. It is generally smooth, heavy, and hard, but its shape and even its existence may be masked by the presence of a hydrocele or a hsematocele. It is painless, and testicular sensation is lost early. Diagnosis. — The affection is most likely to be mistaken for tubercle or syphilis, but the rapid increase in its size will soon point out its true nature. Prognosis. — The lumbar glands may become affected, and I have seen a diffuse sarcomatous infiltration of the entire peritoneum spreading from the epididymis up the spermatic cord without any infiltration of the glands. Treatment. — Early removal of the affected testis is imperative. The prognosis is bad, for secondary deposits nearly always develop. Innocent tumours of the testicle in childhood are rare. There are a few cases of true enchondroma recorded. TORSION OF THE SPERMATIC CORD. 61 Nicoladoni, in 1885, first called attention to a remark- able accident in which the testis becomes strangulated owing to twisting of the spermatic cord up to or beyond an angle of 180°. Mr. Bryant, Mr. Gifford Nash, Mr. Edmund Owen, and Dr. R. W. Johnson have recently published cases in which such an accident has occurred. I am particularly indebted to Mr. Bryant for the readiness with which he placed at my disposal the block (fig. 5G) representing the appearances observed in the case which he published in the 75th volume of the Medico-C/u'r. Trans. 1 1 482 THE SURGICAL DISEASES OF CHILDREN iEtiology. — The condition may occur in a testis lying in the scrotum, but it is more often seen in an undescended or partially descended testis, and it is met with at all ages, though it is most common in young adults. The predisposing cause is the freedom with which the testicle is suspended in the scrotum, associated, Dr. Lauenstein thinks, with a flat form of testis, with division of the cord into two sections, and with abnormal conditions of Fig. 56. — Torsion of the spermatic cord. [Copied, by Mr. Bryant's permission, from the " Transactions of the Royal Medico- Chirurgical Society."'] the tunica vaginalis, leading to an undue widening of the constituents of the spermatic cord. The exciting causes are unknown, for the accident has sometimes occurred after such prolonged jarring as would be caused by a long bicycle ride, by boxing or by jumping ; but in other cases no cause has been assigned. Morbid Anatomy. — The tunica vaginalis is tense and inflamed, and it usually contains fluid. The spermatic SURGICAL AFFECTIONS OF THE TESTICLE 483 cord is twisted upon its axis either once or more than once, and usually in a lsevo-rotatory direction. It is often gorged with blood, and the pampiniform plexus may contain thrombi. The testis or the epididymis, or both, may be acutely inflamed, and, if the strangulation has been left for some time, the inflamed part may become gangrenous and exfoliate, or it may atrophy. Miflet has endeavoured to explain this by showing that the branches of the spermatic artery supplying the testis itself are terminal arteries, whilst those which supply the epididymis anastomose with the artery of the vas. Inter- ference with the blood-flow in the terminal branches of the artery is therefore followed by hsemorrhagic infarction of the superficial layer of the testicle, whilst the epidi- dymis remains comparatively free. This explanation, however, does not hold good for those cases in which the epididymis is alone or chiefly affected. Symptoms. — The symptoms are a painful swelling, which appears suddenly in the groin or scrotum, dull on percussion, irreducible, and without any impulse on cough- ing. The consistence of the swelling is firm and doughy. The scrotum may be red and oedematous. The abdomen in some instances is distended and tender. There is often some rise of temperature, with a quickened pulse, and some symptoms of shock. Sickness is a very constant symptom, and constipation is frequent, though it is not absolute. Diagnosis. — It is not surprising that with such a history and with such symptoms the greater number of cases in which this accident has happened have been diagnosed as instances of strangulated hernia, though it is possible to assume that it was due to gonorrhceal or traumatic inflammation of the testis and epididymis. Differential Diagnosis. — A diagnosis between twisting of the spermatic cord, a strangulated hernia, and a bubo, 484 THE SURGICAL DISEASES OF CHILDREN has to be made. There is more shock in cases of hernia, the external ring contains a tumour, and the spermatic cord is masked by the swelling. A bubo, unless a testicle is absent from the scrotum, is recognised by the absence of shock, the patent abdominal canal and the normal cord. Prognosis. — The result depends upon the severity of the torsion. If the cord is only slightly twisted, it may recover itself, the testis remaining natural in size, but inverted, i.e. the epididymis may lie in front of the testis. In more severe cases, when the vascular supply is inter- fered with and infarction has taken place, the testis becomes swollen, congested, and eventually atrophies. Gangrene of the organ quickly ensues in the most severe cases, when the twisting has been extensive. Treatment.— The spermatic cord and testis must be exposed as soon as the condition is recognised, for taxis is clearly contra-indicated. The cord should be untwisted if it appears reasonable to suppose that the inflammatory conditions have not already advanced too far to save the organ. A retained testicle, or one which is very much swollen or discoloured, is best removed, for it will either atrophy or die. DERMOID CYST OF THE TESTIS. Dermoid cysts of the testicle are occasionally met with. A few years since I showed one which had been removed from a child four years old, in whom it had been observed for three years. Morbid Anatomy.— Examination of such a tumour shows cysts lined with slightly altered epidermis, from which hairs may spring. The solid parts of the tumour consist of dense fibrous tissue with fat, and eyots of car- tilage may also be present. SURGICAL AFFECTIONS OF THE TESTICLE 485 Symptoms. — The tumour iu my case was smooth, ovoid, regular in outline, and heavy ; there was a sense of fluctuation in parts, but there was nowhere any trans- lucency. No nodules could be felt on palpation, but the fluctuating parts were less resistant than the rest of the gland. The testicular substance could not be felt, and the epididymis was imperceptible. The tumour was in- creasing slowly in size. The scrotum appeared to be normal, and was free from any scar. Treatment. — The only treatment for these tumours is removal. HYDROCELE. 62 Varieties. — Hydrocele is of very common occurrence in children of all ages. It is either congenital or acquired. The acquired form is either single, and is a hydrocele of the funicular process shut off above and below, or it is a hydrocele of the tunica vaginalis. Double acquired hydrocele is sometimes met with after acute diseases, and is most frequently seen after scarlatina. The sac is usually simple, but it may be multilocular. Hydrocele of the testicle in children is in reality a chronic serous periorchitis, and may begin acutely. Acute Hydrocele. The acute cases are generally seen in children of fifteen days to six weeks old. The hydrocele is associated with an erythematous condition of the skin of the genitals, and is often associated with digestive disturbances. It is limited to one side, and is very tense and elastic. It lasts from two to six weeks, and is amenable to treatment, for it disappears with the skin eruption. The treatment, therefore, consists in correcting the digestive disturbance, and applying vaseline or boric acid in powder to the affected parts. 486 THE SURGICAL DISEASES OF CHILDREN Chronic Hydrocele. The causes of chronic hydrocele are not yet known. The congenital form is said to be due to the arrest of those developmental changes, cutting off the connection between the peritoneum and the tunica vaginalis, which ought to be completed before birth ; and it is for this reason that such hydroceles often undergo spontaneous cure. An acquired hydrocele is often attributed to an injury, to urethritis, to balanitis or to phimosis ; but we are ignorant as to the manner in which these conditions lead to a collection of fluid in the tunica vaginalis. Symptoms. — The symptoms are similar to those pre- sented by an adult. There is a tense, elastic swelling in the scrotum, which is translucent. The swelling in some congenital cases can be reduced in size by returning the fluid it contains into the abdominal cavity. The testis is generally situated behind the sac, but it may be in front ; it may be retained, or it may not have descended to the bottom of the scrotum. A hernia may complicate the hydrocele either by passing directly into the sac, or by invaginating its upper wall. A hydrocele of the cord is a circumscribed tumour presenting the same general cha- racters as that described above ; but it is situated at, or actually within, the external abdominal ring, and it is therefore more likely to be mistaken for a hernia. Diagnosis. — Hydroceles have to be distinguished from hernise, from cysts of the spermatic cord, and from retained testis. The translucency of a hydrocele will at once dis- tinguish it from a hernia or a retained testis, whilst the presence of a single cyst will distinguish a hydrocele of the cord from a multilocular cystic tumour. Prognosis and Treatment. — The prognosis of all forms of hydrocele in children is good ; and if the hydro- SURGICAL AFFECTIONS OF THE TESTICLE 487 cele does not disappear after a few months, it may be punctured with a very fine trocar and canula. All the fluid should be drawn off, and the puncture should be closed with a piece of absorbent wool soaked in collodion. In the congenital forms, where there is a wide aperture of communication with the peritoneum, a woollen truss (p. 413) may be worn for a few months, to prevent the formation of a hernia whilst the developmental changes are being completed. When the hydrocele refills after puncture, it may be in- jected with a 1 in 5000 solution of perchloride of mercury, for the hydrocele fluid is rich in globulins, which are precipitated by the mercuric salt. I have recently been treating troublesome cases which refill in spite of tapping and injections, by laying open the scrotum and dissecting out the sac, ligaturing its neck, if necessary, with aseptic silk. The wound on every occasion has healed by first intention, and the results have appeared to be so satis- factory that I propose to continue it. DISEASES OF THE FEMALE GENERATIVE ORGANS. Ovarian Tumours. 63 Varieties. — Ovarian tumours occur in quite young children, and they are occasionally congenital. They may be classified as innocent and malignant. The innocent tumours are either cystic, fibrous, or dermoid. The malig- nant tumours are either simple or cystic sarcomata, or, more rarely, carcinomata. Diagnosis. — Ovarian tumours in young children may be mistaken for sarcoma of the kidney, hydatids of the liver, congenital hydronephrosis, cysts of the mesentery, or even for tuberculous peritonitis. Precocious pregnancy 488 THE SURGICAL DISEASES OF CHILDREN should always be excluded in older children. The diag- nosis must be made by a physical examination conducted bimanually through the rectum and abdomen — a proceed- ing which is greatly facilitated by the administration of an anaesthetic. The exact seat and nature of the tumour can often be cleared up only by an exploratory incision. Tuberculosis of the ovaries and Fallopian tubes may some- times be recognised by this method. Treatment. — The first ovariotomy in a child was per- formed by Mr. Bryant ; but there are now many cases on record. The operation for innocent tumours is attended by satisfactory results, unless the adhesions are very extensive, or there are intimate attachments to the viscera. The mortality after operations for malignant tumours is so high that it is doubtful whether the operation is justifiable. Pyosalpinx. A few cases are recorded in which one or both Fal- lopian tubes in young girls have been found to be dis- tended with pus. The condition is usually associated with general tuberculosis, and as yet has only a patholo- gical interest. Sarcoma of the Vagina. This occurs occasionally in children of three to four years old as a primary affection. The growth eventually protrudes from the vulva, and readily recurs after removal. Vulvitis. Vulvitis is more common in children than vulvovagi- nitis, for the vagina and the glands in its neighbourhood are not yet functional, and the inflammation is therefore less likely to spread. etiology. — The ordinary causes are local inflammatory conditions occurring in neglected and tuberculous children ; SURGICAL AFFECTIONS OF THE TESTICLE 489 but it is sometimes seen in connection with the exanthe- mata, as has been already described (p. 21). Treatment. — The treatment consists in the removal of any causes of local irritation, such as thread-worms, and it then yields readily to the ordinary antiseptic applica- tions, with cod-liver oil and a little grey powder in the more debilitated children. Dr. Amand Routh suggests the use of a lotion consisting of warm milk and water, to each pint of which a teaspoonful of borax and a teaspoon- ful of liquor plumbi subacetatis have been added. The lotion should be applied several times a day by making the child sit in a basin or bath containing it. The parts should be well dried, and a piece of lint soaked in the lotion should be kept over them. VULVO- VAGINITIS. Vulvo-vaginitis also occurs in children, but it is usually the result of gonorrhoeal infection. An epidemic of the gonorrhceal form has lately been traced to the indiscri- minate use of a thermometer introduced into the vagina of several children in succession and without proper cleansing. The Treatment is the same as for cases of vulvitis ; but if the discharge is very irritating, Dr. Routh advises that a solution containing a scruple of nitrate of silver in each ounce of water should be painted over the inflamed area, which should then be covered with a layer of oint- ment made by mixing thirty minims of extract of hama- melis with an ounce of vaseline. Adherent Labia Minora. Children are often brought to the surgeon with a slight adhesion of the labia minora. The two labia must be separated with a probe, and a pledget of oiled lint should be kept in the vaginal orifice for twenty-four hours. CHAPTER XXV DISEASES OF BLOODVESSELS AND KEV1 ANEURYSMS. 64 Aneurysms are rarely met with in children, but traumatic and intracranial aneurysms are more frequent than the spontaneous forms. Traumatic aneurysms may occur in any part of the body, though they are most frequent at the wrist, on the dorsum of the foot, and in the posterior tibial artery. The only one which I have seen came under my care when I was acting as ophthalmic house- surgeon at St. Bartholomew's Hospital. It was intra- orbital, and resulted from a gunshot wound, in a young adult. Furious hsemorrhage from the nose took place, which was permanently controlled by ligature of the common carotid artery. Spontaneous aneurysms are either primary or secondary. The primary forms are extremely rare, and the recorded cases have been carefully tabulated by Mr. R. W. Parker in the 67th volume of the Transac- tions of the Royal Medico-Chirurgical Society, and more recently by Prof. Keen. 64 The secondary aneurysms are embolic in origin, and are usually associated with valvular disease of the heart. They are often intracranial, and may be multiple. Treatment. — The treatment does not differ from the treatment of similar conditions in adults. The traumatic forms, if they are accessible, must be cut down upon, the 490 DISEASES OF BLOODVESSELS AND N/EVI 49 1 • artery ligatured upon either side with aseptic silk, the sac removed, and the wound should be made to heal by first intention. The spontaneous aneurysms may first be treated by pressure, and if this fails, an interval of several days should be allowed to elapse before the artery is ligatured by the Hunterian method, but with aseptic silk. NJSVI. 64 etiology. — Naevi are usually innocent, and they are often purely local. Little or nothing is known of their cause, except that they may be hereditary, and are perhaps the result of congenital trophic neuroses. Mr. R. W. Parker believes that they are due to abnormal conditions of the capillary plexuses which surround the appendages of the skin, especially of the hair follicles, or of the vascular loops found in the papillae of the true skin. They occur in all parts of the body, for I have seen them in the liver and in the membranes of the brain ; but only those which grow in connection with the skin and mucous membranes at the orifices of the body can be treated by surgical means. Varieties. — Nsevi are either vascular, lymphatic, or pigmented. The vascular nsevi are either capillary, cavernous, or arterial — the lymphangiomata forming a separate group. The pigmented occur as hairy moles, or simply as pigmented portions of skin in connection with a system of dilated bloodvessels. The " capillary " nsevus is the most common form of vascular nsevus. It is a small and bright red patch in its si in 1 ilest condition, situated upon some part of the skin, or upon the mucous membranes of the inner canthus of the eye, the lip, or tongue. This form of nsevtis is sometimes multiple ; it grows rapidly or slowly, or it may disappear 492 THE SURGICAL DISEASES OF CHILDREN entirely during the first year of life. It is said that 76 per cent, of these nsevi grow upon some part of the head. Treatment. — The treatment in the simplest form con- sists in the application of ethylate of sodium, or, as Drs. Boing and Caesfield 64 have each recommended, a 1 in 8 solution of corrosive sublimate collodion ; though, as this is usually too strong an application for young children, I use a 1 in 12. It is a most effective remedy, but the skin surrounding the nsevus must first be protected by a layer of simple collodion, which should be allowed to dry before the sublimate collodion is applied. Two or three coats of the collodion are applied, and are left on for ten or twelve days, when the pellicle falls off, leaving an ulcer which soon heals, or a smooth and white scar. These applica- tions are only serviceable in the very slightest cases, and fuming nitric acid has generally to be applied to the ordinary capillary nsevi, though such applications cannot be made to growths near the eye. The skin round the nsevus is protected by painting over it a layer of olive oil, and the nsevus is then brushed with fuming nitric acid until the epithelium is destroyed. It is covered with a layer of gauze, cemented over the sore place with collodion if the nsevus is small, or a wet dressing is applied if the growth is so large that there is likely to be much dis- charge. Capillary nsevi may be very extensive ; they may grow rapidly for some time, and may then become stationary. They sometimes form " port- wine stains," or pigmented nsevi, which are disfiguring, but which are not yet amenable to any form of treatment, for the scar left may be worse than the original mark. Subcutaneous or " venous " nsevi are met with nearly as often as the capillary forms. They are soft tumours situ- ated beneath the skin, and they often have a capillary nsevus immediately above them. They occur in any part DISEASES OF BLOODVESSELS AND N.EVI 493 of the body ; they may be multiple, and they are sometimes found to develop beneath a capillary naevus. They may attain to an enormous size, when they may take the form of a general telangiectasis, and may be associated with the presence of a rete mirabile in place of some of the large venous trunks, as in the late Mr. Hulke's case. They are soft swellings which can be reduced by gentle and sustained pressure. Pathology. — These nsevi are either capillary or venous. The capillary form consists entirely of altered capillaries, which communicate freely one with another, forming large spaces. The venous form is partly produced by dilatation of the veins, and partly by dilatation of the capillaries. They undergo many secondary changes in the course of their growth, for they may become converted into fibrous tissue, they may undergo cystic and fatty change, or they even become sarcomatous. Mr. Stephen Paget has shown that some of the less well-defined forms may be cured spontaneously by a process of indolent ulceration, com- mencing at the centre, and spreading to the periphery. The ulceration, though usually slow and painless, some- times runs an acute course, apparently as a result of thrombosis, and in such cases sloughing may occur. Treatment. — There is no doubt that in a healthy child the ideal method of treatment is by cleanly dissecting the tumour away, if it is situated in any part except the face. The capsule should not be opened, for the nsevus can then usually be removed without much loss of blood. This method, however, is frequently impossible, on account of the size or position of the nsevus, and electrolysis then offers the best substitute for it. The treatment of nsevi by electrolysis was systematised in this country by the late Dr. Steavenson, and has been worked out by Dr. Lewis Jones. It is best fitted for the 494 THE SURGICAL DISEASES OF CHILDREN cure of subcutaneotis nsevi, which can sometimes be de- stroyed by this method without leaving any scar except the marks made by the entrance of the needles. It has the great advantage over excision and the application of caustics, of being painless, but it has the disadvantage of requiring several sittings to effect a cure. The needles employed are either single or multiple, and they are of platinum, for use both at the positive pole and at the negative pole of the battery. They are insulated, except at their points, and they must be thrust into the tissues as far as the insulated portion before the current is passed, so that the skin may remain unaffected. When it is essential that the scarring should be as slight as possible, the platinum needles connected with the positive pole are put into the naevus, whilst a pad moistened with salt solution is applied to some other part of the body, and attached to the negative pole. A current of 10-30 milliamperes is sufficient for delicate nsevi. It is passed for five minutes, and the position of the needles in the tumour is then altered, but without withdrawing their points, and the current is passed for a second period of five minutes. Needles from both poles may be passed into the tumour when scarring is of less consequence, and the nsevi are large. A current of 30-50 milliamperes may be employed in such cases, the position of the needles being frequently changed. (An ampere is the unit of current strength in the same manner that an inch is the unit of length. It is roughly the current generated by a single Daniell's (copper sulphate) cell or volt passing through the resistance of one ohm, which is a column of mercury one square millimetre in cross section and 100 centimetres in length. The electrical unit em- ployed in medicine is the one-thousandth part of an ampere or a milliampere). A battery of Leclanche (sal DISEASES OF BLOODVESSELS AND N.*:VI 495 ammoniac) cells or of Stohrer's (bichromate) cells is gene- rally employed to generate the electricity ; whichever is nsed must be provided with a galvanometer graduated in milliamperes, so that the surgeon may know the strength of the current he is using. The needles having been introduced, the current is slowly raised until gas is evolved round the needles at both poles. The current must be shut off before the needles are withdrawn, and any slight bleeding which may occur from the site of the positive pole is easily arrested by the application of a pad and bandage. No attempt should be made to do too much at a time, and the child must be anaesthetised. The object of the operation is to break up the bloodvessels, and to coagulate the blood, but not to cause necrosis or destruction of the skin. The method is a useful one, and by it a large nsevus may often be converted into a mass of fibrous tissue, which can in due course be excised. In very many cases, however, nsevi are beyond the reach of surgery. They are sometimes very troublesome to treat when they occur near the inner canthus of the eye, for the scar produced in curing them may give rise to ectropion, or to stillicidium lachrymarum, from displacement of the punctum ; on the other hand, if they are not completely removed, they grow again with astonishing pertinacity. Akterio- Venous Angiomata. These are frequently congenital, but they are sometimes only observed after an injury. They may occur at any part of the body, and sometimes involve the soft tissues, and even the bones, so extensively as to render their removal an impossibility. Thrombosis of the main veins has occurred in some of these cases, whilst others have been attended by gangrene of the soft parts. 496 THE SURGICAL DISEASES OF CHILDREN Arterial Njevi. Arterial nsevi nearly always occur upon the head, though they have been seen upon the dorsum of the foot, in direct connection with the dorsalis pedis artery. They may form a small pulsating swelling, communicating with one of the main branches of the temporal artery, or more often they are very large tumours, occupying the greater part of one side of the skull — the true cirsoid aneurysm, or aneurysm by anasto7nosis. They are occasionally found in the orbit, in the nasal fossae, and amongst the deep muscles of the neck ; but in these positions they cannot be treated surgically. They should, if possible, be starved by liga- turing the main trunks of the arteries ; and when this has been done effectually, the tumour may afterwards be re- moved at leisure and without much loss of blood. BLOOD TUMOURS OF THE SCALP. C5 iEtiology. — Prof. Lannelongue 65 and Dr. Mastin have called attention to various forms of blood tumours found on the scalps of children. These tumours communicate with the superior longitudinal sinus. They are sometimes con- genital, and sometimes the result of injuries. The trau- matic forms appear to be due either to direct injury of the sinus, or to rupture of some of the veins. The congenital tumours are true angiomata, accompanied by a dilatation of the veins connecting the intracranial with the peri- cranial circulation, and communicating with a dilated longitudinal sinus. They are often associated with re- tarded ossification of the cranial bones. Symptoms. — A soft, irreducible tumour, with the characters of a subcutaneous naevus situated upon the scalp near the middle line, but differing from an ordinary DISEASES OF BLOODVESSELS AND NvEVI 497 nsevus in possessing a pedicle which passes through the sagittal suture. Treatment. — Well-applied pressure appears to be the most satisfactory treatment in the traumatic cases, if it be commenced as soon after the accident as possible ; whilst in the congenital cases nothing should be done so long as the tumour is small and stationary ; but if it is increasing in size, and there appears to be a danger of its rupture, the pedicle should be ligatured and the tumour removed. LYMPHANGIOMATA. 6 * 5 Varieties. — Lymphangiomata exist either as dilated vessels forming a lymphangiectasis or as lymphangioma. True lymphangiomata have already been dealt with in that form which occurs as macroglossia or macrocheilia (p. 266). They are congenital tumours, formed by the distension of pre-existing lymph paths, with a general hyperplasia of the surrounding tissue. Cavernous lym- phangiomata are found in various parts of the body either as small and well-defined vesicular tumours, or as diffuse growths leading to a condition of false elephantiasis. These tumours are often congenital, but they are some- times said to bear a direct relation to injuries. Mr. Harold Stiles, 06 in a recent and interesting paper, has shown that a cavernous lymphangioma growing upon the forearm contained a considerable quantity of unstriped muscular tissue in its substance. Cavernous lymphangio- mata may undergo cystic degeneration when they form cystic hygroinata. Symptoms. — The symptoms of a cavernous lymphan- gioma vary with the character of the growth from a small vesicular tumour filled with a clear fluid, which cannot be mistaken, through the subcutaneous form which may be looked upon as a lipoma, up to the most diffuse form which K K 49§ THE SURGICAL DISEASES OF CHILDREN enlarges the part affected to a condition of elephantiasis. The circnmscribed form of subcutaneous lymphangioma is most often seen upon the shoulder, either in the supra- clavicular or in the supraspinous regions, and it is liable to sudden haemorrhages into its substance. Fig. 57. — A child, aged H days, with cystic lymphangioma of the left side of the face, before its removal. Treatment. — The treatment of lymphangiomata, like that of the angiomata or neevi, consists in compression, electrolysis, excision, or, if the surgeon prefers to adopt it, the injection of iodine, carbolic acid, or dilute solutions of corrosive sublimate. DISEASES OF BLOODVESSELS AND N/EVI 499 Cystic Hygroma. — These tumours form an extremely interesting group of cases. They are pathologically cystic lymphangiomata, and although they are always congenital, the child may attain to some age before they are observed. They grow from any part of the body, but they are most Fig. 5i. — The same child, aged 10 weeks, after removal of the cystic lym- phangioma. common in the neck and axilla. The tumour varies very remarkably in different cases. It is quite transparent in some, and is clearly a simple sac filled with serous fluid ; whilst in others it is covered with normal opaque skin (as in fig. 57), and its fluctuation is so indistinct that it is 5. Abscesses, articular, treatment of, 105. — chronic, in tuberculosis of knee, treatment of, 187. — cold, treatment of, 88-92. — in hip disease, lis. — in joint disease, 105, 1 1 2. — in joint disi -anient of, 137. Acetabulum . di 1 15. Actinomycosis, 28, so, . Acute hydrocele, 485. — infantile paralysis, 193. — necrosis. 30 ; see Osteomyelitis. — osteomyi 1 i is, 30. Adams, Mr. William, on congenital displacement of hip, ^50. Adenoid vegetal ions, 279. ima of u ague, 2>\i . — rectal, 424, — renal, 411. Adherent labia, 489. Air passages, diseases of, 332. foreign bodies in, 362. Albert, Prof., on arthrodesis, 195. Albuminuria in phimosis, 468. Aldibert, Dr., on hydronephrosis, 135. Allbutt, Dr. Clifford, on enlarged glands, 51. Allingham, Mr., on prolapse of rec- tum, 422. Ampere, definition of, 491. Amputation, Syme's, 139. Anaesthesia in children, 3. Anal fistula, 431. Anus, fissure of, 431. — imperforate, 426. Anchyloglossa, 268. Anchylosis, artificial, 195. — of jaw, 236. — of joints, 120, 124, 174. — treatment of, 123, 133. Aneurysm, 490. — embolic, 190. — intracranial, 490. — intraorbital, 490. — spontaneous. 490. — traumatic, 490. Aneurysm by unustomosis, 490. — cirsoid, 496. A ageioma, 490 ; si e Angioma. Angina Ludovici, 20. Angioma, L50, 266, 191. — arterio-venous, 495. — of bone, 15o. — of scalp, 196. — of tongue, 206. Angio-sarcoma, 150, 193. ol bone, 150. Angular curvature of spine, 72. Ankle, arthrectomy of, 138. — arthrodesis of, 196, 197. — tuberculosis of, 137. A uti'i'ior poliomyelitis, 193. A nt ipyrin, in enuresis, 47 I. i.i ic treatment of burns, 5nl. Antiseptics not well adapted for children, 8. Antitoxin, rash after inoculation of, 16. t reatmenl of diphtfaeri i by, 335. M M 53° INDEX Antyllus on tracheotomy, 347. Aphthous ulceration of tongue, 265. Appendicitis, 385. Appendicular peritonitis, 385. Arm, broken, 170. — dislocation of, 238. Arsdale, Dr. van, on subluxation of bead of radius, 242. Arterio-vennus angioma, 495. Artery, ruptured middle meningeal, 165. Arthralgia, diphtheritic, 334. Arthrectomv, 109, 129. — ankle, 138. — elbow, 109. Arthritis, 97, 225. — after measles, 226. — after mumps, 226. — chondro-, 230. — diphtheritic, 226, 334. — displacement after, 245. — dysenteric, 226. — gbnorrhoeal, 127, 227. — gummatous, 228. — hemophilic, 232. — infective, 35, 37, 226. — non-tuberculous, 225. — of hip, 113. — osteo-, 227. — scarlatinal, 226, 227. — secondary to osteomyelitis, 37. — syphilitic, 228. — traumatic, 225. — tuberculous, 97. — typhoidal, 226. — variolous, 226. Arthrodesis, 195, 246. Arthrotomy, 174, 240. Asclepiades on tracheotomy, 347. Asphyxial form of Raynaud's disease, 12. Aspiration in empyema, 368. — in pericarditis, 374. — in pleurisy, 372. Atresia recti, 426. Atypical excisions, 123. Auricles, supernumerary, 290. Axial rotation of testis, 481. Baker, Mr. Morrant, on imperforate anus, 429. on whitlow, 49. Balano-posthitis, 468. Ball, Dr., on cultivation of diphtheri- tic micro-organisms, 333. — on intubation, 344. Ballance, Mr., on disease of the middle ear, 311,312. — on thrombosis of lateral sinus, 316. Ballantyne, Dr., on pre-auricular appendages, 290. Balzer, Dr., on appendicular peri- tonitis, 385. Bandaging in children, difficulties of, 9. Barbacci on appendicular peritonitis, 385. Barker, Mr., on cerebral abscess, 311. — on excision of hip, 123. — on intussusception, 399. Barker's treatment of cold abscesses, 88. — flushing scoop, 89. Barlow, Dr., on cervical opistho- tonus, 318. — on scurvy, 198. Baruch, Dr., on enuresis, 474. Bar well, Mr., on congenital displace- ment of hip, 248. Base-line of Beid, 311, 312, 326. Batteries, varieties of, 494. Battle, Mr., on dislocations of phal- anges, 243, 244. Beads in ear, 293. Beans in ear, 293. Behring, Dr., on diphtheria, 335. Belladonna, in treatment of enure- sis, 473. Benevieni on tracheotomy, 347. Bennett, Mr. W. H., on tuberculous testicle, 476. Bilharzia a cause of balano-posthitis, 469. — rectal adenomata caused by, 425. Birmingham, Prof., on situation of lateral sinus, 310. Bismuth nitrate, treatment of burns by, 502. Bladder, fistula of, 518. — hypertrophy of, after circumci- sion, 468. — sarcoma of, 455, 518. — stone in, 447. — tumours of, 455. Blaxall, Dr., on pathology of otitis media, 295. Bleeders, 232. Bleeding, arrest of, in children, 4. — after circumcision, 466. — after cleft palate operations, 262. — after removal of tonsils, 278. — after tracheotomy, 355. — transfusion after, 5, 6. Blood tumours of bone, 150. of scalp, 496. Boils and their treatment, 21. Bding, Dr., on nffivi, 492. Bone, angeiomata of, 150. — blood tumours of, 150. — caries of, see Tuberculosis. — chisel, 214. — chronic abscesses in, 66. — cuneiform osteotomy of, 214. — decalcification of, 154. — dislocations of, 235. — epiphyseal separation, 162. — forcible straightening of, 209. — fractures of, 158. — fragilitas ossium, 161. — greenstick fracture of, 158. INDEX DJ Bone, injuries of, 158. — innocent tumours of, 146. — linear osteotomy of, 211. — malignant tumours of, 149. — mastoid, exploration of, 308. osteomyelitis of, 303, 304. — na?vus of, 150. — necrosis of, 11. due to syphilis, 151. — osteoklasia of, 209. — osteopsathyrosis, 161. — osteotomy of, 211. — petrous, disease of, 302, 315. — rarefying osteitis due to syphilis, 151. — ricketty changes in, 201, 205, 208. — sarcomata of, 119. — spontaneous fractures of, 160, 198, 200. — syphilitic decalcification, 151. disease of, 153. disease distinguished from tubercle, 154. — temporal, disease of, 303. — tuberculosis of, 62. of epiphyses, 66. of shaft, 68. — tuberculous disease distinguished from syphilis, 154. — tumours of, 146. actinomycotic, 149. angeio-sarcoma, 150. blood, 150. chlorosarcoma, 149. chondromata, 146. cystic, 149. dentigerous, 149. endosteal sarcoma, 149. — — epulis, 118, 151. exostoses, 147. green sarcoma, 149. hydatid, 149. innocent, 116. lipomata, 148. malignant, 149. myeloid sarcoma, 150. naevus, 150. ossifying sarcoma, 152. parasitic, 119. parosteal lipomata, 1 (8, periosteal sarcoma, 151. sarcomatous, 119. Boric acid, treatment of burns by, 503. Bosworth, Dr., on adenoids, 282. — on nightmare, 274. Bottini, Prof., on anchylosis of jaws, 237. Bouchut's operation of intubation, 340. Brain, abscess of, 305. — exploration of middle fossa, 309- 312. of ventricles of. 326. — fissure of Rolando, position of, 321. Brain, fissure of Sylvius, position of, 325. — hydrocephalus, acute, 325. chronic, 330. — meningitis of, 317. — parieto-occipital fissure of, 325. — puncture of, 167, 325-330. — thrombosis of sinuses, 313. — topography of, 324. — tumours of, 330. — water on, 325-330. Branchial arches, cysts in connection with, 513, 517. Bregma, position of, 321. Bretonneau on tracheotomy, 347. Brisement force, 209. Broca, Prof., on exploration of lateral ventricles, 325. Broken arm, 170. — collar-bone, 168. — forearm, 179. — jaw, 168. — knee-cap, 190. — leg, 190. — nose, 167. — ribs, 183. — skull, 164. — thigh, 184. Bronchus, foreign bodies in, 362. Brook, Mr., on tracheal stenosis, 358. Brossard, Dr., on incomplete *frac- tures, 181. Brothers, Dr., on empyema, 367. Brown Buckminster, Mr., on con- genital displacement of hip, 250. — Dr. Dillon, on cultivation of diph- theritic micro-organisms, 332. Bryant, Mr., on ovariotomy, 488. — on prolapse of urethra, 460. — on torsion of spermatic cord, 481. Bryant's splint, 183. Bullar, Dr., on feeding after tracheo. tomy, 352. Burckhardt's incision for opening an acute retropharyngeal abscess, 27. Burns, after-treatment of, 503. — antiseptic treatment of, 501. — bismuth treatment of, 502. — boric acid treatment of, 503. — iodoform treatment of, 503. — picric acid treatment, of, 502. — plastic operations after, 505. — skin grafting in, 503. — thiol treatment of, 502. — treatment by baths, 503. — treatment of, 501. BurBSB, tuberculosis of, 139. Busch's, Prof., treatment for frac- tures, 171. Caesfield, Dr., on naevi, 492. Cailltf, Dr., on removal of tonsils, 'J77. Calculi vesical, size and weight of, 419. 532 INDEX Calculus, enuresis in, 447, 472. — preputial, 455. — prostatic, 454. — renal, 461. — urethral, 455. — vesical, 447. treatment of, 449. Calomel in appendicular peritonitis, 394. — fumigation in diphtheria, 336. Calvaria, fractures of, 164. Camphorated naphthol, 8, 43, 56, 92, 106, 129. formula of, 9. injections of, 381, 478. Cancellous exostoses, 147. Cancer of lip, 263. — of rectum, 425. Cancrum oris, 21. Capillary nasvi, 491. Capitellum, fracture of, 178. Carcinoma, adenoid, 425. — of lip, 263. — ovarian, 487. — recti, 425. Caries of bones, see Tuberculosis. — cervical, diagnosis of, 80. — dorsal, diagnosis of, 81. — lumbar, diagnosis of, 81. — necrotica, artificial production of, 66. — sicca, 107. — spinal, wryneck in, 221. Carpus, tuberculosis of, 70, 111. Carr, Dr. Walter, on tuberculous dis- ease, 51, 52. Carr's splint, 183, 192. Caseating lymphatic glands, 56. — psoas abscess, 82. Catheter, Macewen's tracheal, 357. Cavernous lymphangioma, 497. — nsevus. 493. Cellulitis, 19. Celsus on removal of tonsils, 276. — on subluxation of head of radius, 242. Cephalhydrocele, traumatic, 165. Cerebellar abscess, 305-307. Cerebral abscess, 305. — hernia, 165. — meningitis, 317. — puncture, 167, 325, 330. — sinus, exploration of, 310-312. thrombosis of, 313. — symptoms ill-defined after fracture, 165. — tumours, 320, 330. Cerebrum, exploration of ventricles of, 325. — meningo-encephalocele, treatment of, 331. — tapping, 167. — topography of, 324. Cerumen in ear, 292. Cervical hydrocele, 517. Cervical caries, diagnosis of, 80. — lymphatic glands, treatment of enlarged, 55. — opisthotonus, 318. Champneys, Dr., on tracheotomy, 350. Cheeks, lupoid ulceration of, 59. Chemotaxis, 141. Chest, exploration of, for empyema, 369. pericarditis, 374. pleurisy, 373. — operations upon, 368-374. Chewing-gum, surgical uses of, 238. Cheyne, Mr. Watson, on treatment of lupus, 61. Chiene's incision for opening an acute retropharyngeal abscess, 26. Children, cerebro-cranial topography in, 324. — diagnosis of disease in, 2. — difficulties in bandaging, 9. — dressings for, 9. — hernial peculiarities of, 405-411. — peculiarities of stone inbladder,447. in kidney, 442. — thermotaxic peculiarities of, 7, 421. — trusses for, 413-416. Children's fractures, peculiarities of, 158, 164. — surgeon, qualifications of, 1. Chloro-sarcoma, 150, 446. Chondromata, 146. Chondro-arthritis, 230. osteitis, 154. Chronic abscess, treatment of, 39, 88- 92, 118, 145. — spinal abscess, 73, 82. Circumcision, bleeding after, 466. — after paraphimosis, 471. — gangrene after, 466. — method of performing, 462. — suppuration after, 466. — treatment of frsenum in, 463. Cirsoid aneurysm, 496. Clavicle, fracture of, 168. — tuberculosis of, 69. Cleft palate, 258. haemorrhage in, 262. nipple for feeding children with, 258. sutures, 261. Club foot, treatment of, 195. Clutton, Mr., on arthrectomy, 110, 130, 139. — on syphilitic synovitis, 230. Coates, Mr., on trusses, 413. Coccygeal cysts, 514. Cold abscesses, treatment of, 88-92, 118. Collar-bone, broken, 168. Colles' fracture, 182. Colley, Mr. Davies, on cleft palate, 262. Collier and Pitts on tracheotomy, 353. Collodion sublimate for nam, 492. INDEX 533 Colopexy, 123. Colotomy, 129. Compact exostoses, U7. Congenital coccygeal cysts, 514, 515. — cysts, treat , 61 1-517. — deformities, 507. — displacement of humerus, 252. — dislocations, 2 16; see Displacements, congenital. — giant growth, 519. — hydrocele, 186. of the neck, 517. — hydronephrosis, 13.'. — inguinal hernia. 409. — malformations, 507. — overgrowth, - r >h>. — umbilical hernia, 402. polypi, 518. Conner, Dr., on traumatic meningo- cele, 165. Cooper, Sir Astley, on reduction of dislocation of elbow, 210. — on subluxation of jaw, 236. Corbin, Dr., on diphtheria, 336. Corrosive sublimate collodion, 492. Costal resection, 371. Counter-irritation in sacro-iliac dis- ease, 113. Coupland,Dr.,on double empyema,372. Craniectomy, 331. Cranio-cerebral topography, 324. Craniotabes, syphilitic, 155, 156. Cranium, fractures of, 164. Cripps, Mr. Harrison, on imperforate anus, 430. Croft, Mr., on plastic operations, 505. Cuneiform osteotomy, 214. Curling, Mr., on imperforate anus, 428. Curvature, angulur, of spine, 72. — lateral, 77, 216. — ricketty, 78. Cystic hygroma, 497, 199. — tumours of bone, 149. Cystotomy, suprapubic, 450, 459. Cysts, congenital, 512. — in mouth, 263. — pelvic, 517. — sacro-coccygeal, 51 1. — of urachus, 518. Czermak, Prof., on adenoids, 279. Dactylitis, tuberculous, 63, 70. Dalby's artificial nail, 281. Dana on cerebro-cranial topography in children, 321. Daniell's cell, in. Danz, Signe de, 396 Deaver, Dr., on appendicular perito- nitis, 385. Demme on tuberculous testicle, 475. Deal igi n rn - ■■ ■ - 1 , 149. Dermoids, 512. — in month, 2i;i. — ovarian, 487. — of testicle, 477, 481. Dermoids, treatment of, 513. Deutschmann on osteo-arthritis, 227. Diabetes, enuresis in, 472. — baJano-posthitis in, 469. — fractures in, 160. Dickinson, Dr., on empyemn, 367. Difficulties in bandaging children, 9. Diffuse osteomyelitis, 30. Diphtheria, 832. — bacteriology of, 332-335. — balano-posthitis in, 469. — choice of operation in, 33?. — dyspnoea of, 337. — feeding in, 314, 351. — joint affections in, 331. — treatment by antitoxin, 335. fumigation, 336. intubation, 34 1. tracheotomy, 347. — wryneck after, 221. Diphtheritic arthritis, 226. Dislocation of arm, 238. — backwards of radius and ulna, 239. — forwards of radius and ulna, 241. — congenital, 246. of arm, 252. of elbow, 252. of knee, 250. of hip, 216. of humerus, 252. of patella, 251. of shoulder, 252. — — of tibia, 250. — of fibula, 251. — of fingers, 243. — of hip, 215. — of lower jaw, 236. — of nasal septum, 235. — of penis, 471. — of radius, 241. — passive, of fibula, 251. Dislocations, 235. — of phalanges, 213. — secondary, 2 15. — traumatic, 235. Displacement, congenital, 246. of arm, 252. of patella, 251. of shoulder, 252. Dorsal caries, diagnosis of, 81. Dorsalis pedis artery, neevi of, 496. Double empyema, 372. — hip disease, 125. Downie, Dr. Walker, on otitis media, 294, 297. Drainage of ulidornen, 380. — of cerebral ventricles, 329. — of pleural cavity, 870. — suprapubic, lf> I, l.V.i. Dressings fur children, 9. Dulles, Dr., on fractured elbow, 177. Dunn's Boshing scoop, 89. Dllpin I n-:f ex isto '-, I 17. Durham, Dr. If. E., on congenital tumours, 513. 534 INDEX Dysenteric arthritis, 226. Dyspeptic nlceration of tongue, 265. Dyspnoea, symptoms of, 337. Ear, beads in, 293. — beans in, 293. — cerumen in, 292. — eczema of, 291, 296. — epithelial plugs in, 292. — foreign bodies in, 292. — incision of drum, 298. — insects in, 293. — lupus of, 59. — mastoid osteomyelitis, 303. — middle, inflammation of, 293. influenzal, 301. scarlatinal, 300. syphilitic, 301. tuberculous, 301. typhoidal, 301. — otorrhcea, 293. — peas in, 293. — pre-auricular appendages, 290. — supernumerary auricles, 290. — wax in, 292. Ectopia intestinalis, 402, 518. — testis, 478. — vesica 1 , 508. Eczema, 291, 296, 462, 469. Ekehorn on appendicular peritonitis, 385. Elbow, arthrotomy of, 240. — disease of, 109. — dislocation of, 238-243. — excision of, 110. 240. — fractures of. 173. — secondary displacement of, 245. — synovial relations of, 96. — T-fracture of, 176. Electrical treatment of nasvi, 493. — treatment of paralysis, 195. of Raynaud's disease, 13. Electrolysis of nsevi, 494. — for naso-pharyngeal tumours, 288. Elefson, Dr., on broken thigh, 188. Embolic aneurysm, 490. — tuberculous sequestra, 66. Emphysema, gangrenous, 23. Empyema, 365. — aspiration of, 368. — cardiac, 373. — double, 372. — drainage of, 368. — exploration of, 369. — radical cure of, 371. — spontaneous opening of, 368. — treatment of, 369. Emulsion iodoform, formula for, 104, Encephalocele, treatment of, 331. Enchondromata, 146. Enchondroma of testis, 481. Endosteal sarcoma of bone, 149, 150. differential diagnosis, 64. Enlarged lymphatic glands, treat- ment of, 53-57. Enlarged tonsils, 273. Enterectomy, 399. Enuresis, 472. — antipyrin in, 474. — astringents in, 474. — Baruch's treatment of, 474. — cold sound in, 473. — masturbation associated with, 473. — nux vomica in, 474. — treatment of, 473. Epicondyles, fractures of, 177. Epididymitis, 478. Epilepsy, enuresis in, 472. Epiphyseal changes in rickets, 204, 205. — changes in scurvy, 197, 198. Epiphysis of clavicle separated, 170. — femur separated, 184. great trochanter, 186. lower, 188. upper, 185. — of humerus— great tuberosity — separated, 172. — of humerus — lower — separated, 174. — of humerus — upper — separated, 171. — of olecranon, separation of, 179. — of radius, separation of lower, 182. of upper, 180. — injury to, after osteoklasia, 210. — separations of, 158, 163. — separated, dangers of, 163. — separation of, suppuration after, 163, 186, 190. — synovial relations of, 96. — syphilitic, inflammation of, 228. — tibial tubercle, separation of, 190. — tuberculosis of, 66. Epulis, 148. ■ — malignant, 150. — sarcomatous, 150. Erasion of joints, 109, 129. Erysipelas, 18. — a cause of balano-posthitis, 469. — neonatorum, 18. Evysipele bronze, 24. Erythema from antitoxin treatment, 16. Eskridge, Dr., on nervous symptom* in vertebral caries, 74. Esmarch, Prof., on anchylosis of jaws, 237. Estlander's operation, 372. Ethylate of sodium, treatment of nam by, 492. Eustachian tube, method of inflating, 298. Eve, Mr., on excision of wrist, 112. Exanthemata a cause of balano-pos- thitis, 4H9. — as a cause of osteomyelitis, 31. of septic gangrene, 22, 23. — dislocations secondary to, 245, 248. Excision, intestinal, 399. INDEX 535 Excision of ankle, 138. — of elbow, 110, 111, 240. — of bip, 121. — of joints, 103, 110, 132. — of knee, 132. — of shoulder. 108. Excisions, atypical, 110, 123, 129, 138. Exomphalos. 402. Exostoses, 1 17. — intra-articular, 1 17. Exploration of cerebral ventricles, 325. Extension apparatus for short leg, 121. — in hip disease, method of applying, 116. — in joint disease, method of apply- ing, 116. Extravasation of urine, 458, 461. Fabricius on tracheotomy, 317. Faecal fistula, 51s. Pa -bender on tuberculosis of ribs, 69. Feeding after intubation, 311. — after tracheotomy, 351. — forced, 253, 351. — nasal, 352. Felizet, Dr., on circumcision, 463. — on inguinal hernia, 406, 409. Femur, fracture of, 184. — intracapsular fracture of, 185. — separation of epiphysis of groat trochanter, 186. lower, 188. upper, 185. Fenger, Dr., on surgery of ureter. 438. Fere\ Dr., on inguinal hernia, 400, 109. Fibro-angioma, naso-pharyngeal, 286. Fibroma, naso-pharyngeal, 236. — of tongue, 267. Fibula, fracture of, 191. — passive dislocations of, 251. Fingers, dislocation of, 2H. Fischer, Dr., on cesophagotomy, 271. Fissure of aims, 431. Fistula, faecal, 518. — in ano, 181. — penile, 155. — vesicoumbilical, 518. Flail joints, treatment of, 195. Floating kidneys, 111. rifludeil, 511. Fold of Venus, 106. Forced feeding, 251, 351. Forcible Straightening of ricketty bones, 209. Forearm, fractures of, 181. Foreign bodies in air passages, 362. — in ear, 292. — in nose, 288. — in oesophagus, 270. Foreskin, inflammation of, 4C9. Fouillehouze, Dr., on cranio-eerebral topography in children, 32-1. Foiirnier on subluxation of head of radius, 242. Fowler, Dr. Ryersnn, on appendicular peritonitis, 336, 391,393. Fox, Dr. Colcott, on scurvy, 200. Fracture of capitellum, 178. — clavicle, 168. — Colles', 182. — elbow, 173. — epicondyles, 177. — femur, 184. — fibula, Ml. — humerus, 173. — jaw, 168. — metatarsal bones, 192. — nasal bones, 167. — non-union after, 159. — natella, 190. — Pott's, 191. — radius, 181. — ribs, 183. — spiral, 182. — spontaneous, in ribs, 155. — T, of elbow, 176. — tibia, 191. — ununited, 159. Fractures, anchylosis after, 174. — greenstick, 158, 163. 169, 181, 185, 187. — incomplete, 158, 181. — intra-uterine, 162. — multiple, 161. — peculiarities of.in children, 158, 164. — skull, 164-167. special dangers of, in children, 165. — spontaneous, 155, 160, 198, 200. — subperiosteal, 158, 169, 181, ]s">. — supracondylar, of humerus, 176. — treatment of, 174. — ununited clavicle, 169. femur, 185. humerus, 178. tibia, 191. Fraenum praeputii, treatment in cir- cumcision, 463. Fragilitas ossium, 161. Freitage on hernia, 113. Freyer, Surgeon-Major, on lithola- paxy, 449. — on vesical calculus, 113. Frontal bone, tuberculosis of, 68. Fumigation in diphtheria, 336. Fungating caries. 00. I'urneaux-Jordan's hip amputation, 124. Furunculosis, 21. Gaillard, Dr., on congenital' disloca- tions of shoulder, 252. Gangrene in afterio-venous angto- mata, 495. — after circumcision, 466. — asphyxial form of Raynaud's dis- ease, 12. — erysipelatous, 19. — non-infective, L0. — of prepuce, 470. 53^ INDEX Gangrene of the fauces and soft palate, 23. — Raynaud's, 11. — spontaneous, 11. — symmetrical, 11. — syncopic form of Raynaud's dis- ease, 12. — traumatic, 11, 175, 189. — typhoidal, 15. Gangrenous emphysema, 23. Gay, Dr., on acute pharyngeal tuber- culosis, 285.| Gee, Dr. S., on phagedena and septic gangrene, 21. — on cervical opisthotonus, 318. Generative organs, male, diseases of, 458-487. female, 487-489. Genu valgum, 207. Gerster, Prof., on epididymitis, 478. Giant growth, 519. Girls, urethral prolapse in, 460. — vesical calculus in, 452. sarcoma in, 456. — vulvitis in, 488. Glands, tuberculous, 53. Glandular tumours of tongue, 267. Glioma, cerebral, 330. Glossitis, 264. Glottis, stenosis of, 356. Godlee, Mr., on empyema, 369. — on fractures of skull, 164. Golding-Bird,Mr.,on wryneck, 220,222. Gonorrhoea a causeof ba'lano-posthitis, 469. of vulvo-vaginitis, 489. Gonorrhoeal arthritis, 127, 227. Gooch's splint, 173, 187. Good, Mr., on foreign bodies in the air passages, 363. Gottstein's curette for removal of adenoids, 283, 284. Gould, Mr. Pearce, on double em- pyema, 372. — on umbilical polypi, 518. Gout a cause of balano-posthitis, 469. Grafting skin, 60, 503. Grant, Dr. Dundas, on inflation of Eustachian tubes, 298. Greenstick fractures, 158, 168, 169, 181, 185. Gubernaculum testis, attachments of, 478. Guerin, Dr. Jules, on congenital dis- placements, 246. Gummatous arthritis, 228. Gums, lupus of, 59. — tumours of, 148, 151. Gymnastics, Swedish, in scoliosis, 219. Habershon, Dr., on feeding after tracheotomy, 352. Hajmatoma, perineal, 458. Hematuria, 426, 434, 442, 455. Haemophilia, 232. Hemophilic arthritis, 232. Haemorrhage after circumcision, 466. Haemorrhage after removal of ton- sils, 278. — after tracheotomy, 355. — arrest of, 4. — scorbutic, 198, 200. — transfusion after, 5. Hasmorrhagic disease, 231. Hamilton, Dr., on subluxation of jaw, 236. — on traumatic dislocation of hip, 245. Hammond's splint for broken jaw,168. Hansemann, Prof., on diphtheria, 336. Harelip, 253. — asphyxia after, 257. — dangers in operating upon, 257. — Kronlein's suture in, 256. — treatment of premaxilla? in, 256. Haward, Mr. Warrington, on mov- able and floating kidneys, 441. Head, pneumatocele of, 518. Head-swing for wryneck, 223. Heath, Mr. Christopher, on injury of clavicle, 170. Heaton, Mr., on umbilical cysts, 518. Heister on hernia, 413. Hernia, abdominal, 401. — cerebral, 165. — complicated by undescended testis, 411,416, 420,479. — congenital inguinal, 410. — cured by truss, 415. — exomphalos, 402. — funicular, 410. — inguinal, 405. anatomical, peculiarities of, in children, 406-409, 416. — — causes of, 411. contents of sac, 412. defective pillars in, 407. differential diagnosis of, 412. radical operation for, 413, 416. spontaneous cure of, 412, 415. — — treatment of, palliative, 413. operative, 416. ■ treatment of sac in, 418. varieties of abdominal ring in children, 406-409. with undescended testis, 410, 416,420. — irreducible, 412. — lumbar, 401. — needle, 420. — of spinal membranes, 507. — omphalocele, 402. — pleural, 365. — pulmonary, 365. — scrotal, 410. — strangulated, 396, 401, 412. inguinal, 401. umbilical, 403. — testis, 476. — umbilical, 402. — vaginal, 402. INDEX 537 Heubner, Prof., on diphtheria, 33G. — on intubation, 3 Hip, amputation of, 124. — atypical excisions of, 123. [genital displacement of, 248. — disease, 79, 118 L26. abscess in, 118. cause of pain in, 114. cause ot wasting iu, Hi. diagnosis of, LIS. displacement of femur in, 119. double, 126. — — night screaming in, 99, 119. operative treatment, 121. osteotomy in, 124. palliative treatment, 121. — — the management of lordosis in, treatment of, 116. 118. treatment of abscesses in, 11 3. treatment of anchylosis in, 123. when cured, 115. — dislocate c i , 2 15, 246. — excision of, 121. — extension in, 116. — hysterical, 11.5. — obscure injuries about, 184. — osteomyelitis of, 116. — secondary displacement of, 245. — synovial relations of, 96. Hippocrates on subluxation of head of radius, 2 12. Hirschberg, Dr., on lumbar puncture, 323. Historical, Celsus on removal of tonsils, 276. — mastoid exploration, 308. — Maundeville, Sir John, 519. — on giant growth, 519. — Philoctetes, illness of, 43. — radical cure for hernia, 413. — Bead, Dr., on tongue-tie, 268. — Scott, Sir Walter, illness of, 194. — Swift's case, 325. — tracheotomy, ■', 17. — tuberculous testis, 475. Hoffa on congenital di>placement of hip, 25o. — on spondylitis, 72, 77. Holden, Mr., landmarks quoted, 239. Holmes, Mr., on hip disease, 120. — on vaginal hernia, 102. Horrocks' method of transfusing, 6. Howse on arthrodesis, L95. — on excision of joints, 1:^2, 136. Hulke, Mr., on nsevi, 193. Humerus, congenital displacement of, 252. — fractures of, 173. — separation of epiphyses of, 171, 172, 171. — supraci ndj lar, fractures of, 176. Humphrey, Sir George, on knock- . 207. Hunt, Dr. William, on preputial cal- culus, 455. Hutchinson, Mr. Jonathan, jun., on separated epiphyses, 164, 171, 175, 17s, 179, 181, 191. — on subluxation of head of radius, 180, 212. Hutchinson, Mr. Jonathan, on syphilis of skull, 155. Hydatids of bone, 149. — of spine, SO. Hydrocele, 485. — of the neck, 517. — treatment by excision, 487. injection, 487. puncture, 4S7. truss, 187. Hydrocephalic cry, 320. Hydrocephalus, fractures in cases of, — acute, 325. [160. — chronic, 330. — in spina bifida, 511. Hydrogen peroxide, 8, 353, 354, 393. Hydronephrosis, acquired, 161. — congenital, 432. — traumatic, 433. Hydrops articuli, 126, 127, 225. treatment of, 129. — of ankle very rare, 137. Hygroma, 497, 499. Hyperesthesia, 75, 78, 115, 509. Hypertrichosis in spina bifida, 609. Hypertrophy, chronic, of tonsils, 273. — of pinna, 291. — of tongue, 266. Hypertrophic pulmonary osteoar- thropathy, 93. Hysterical hip, 115. — spine, 78. Idiocy, 331. Imperforate anus, 426. Included foetus, 514. Incontinence of urine, 172. Infantile paralysis, 193. fract lives in, 160. — scurvy, 197. infection by tubercle, 51, 140. Infective ai tin it is, 226. — diseases, non-tuberculous, 16. - osteitis, 29. — thrombosis, 190, 313. Inflammation, laryngeal, 358. Inflation, intestinal, in intussuscep- tion, 397. Influenza, osteomyelitis after, 31. — otitis alter, 301. Inguinal hernia, 105. i ts in ear, 293. intestinal ob traction, acute, 394. chronic, -too. intestine, gangrenous, treatment of, — rectal prolapse, 422. 3>«i. 1 otestines, proti 101. ectopia of, 402 [ntra-articular fracture of capitellum, 17s. 538 INDEX Intracapsular fracture of femur, 185. Intracranial aneurysms, 490. — tumours, 330. Intraorbital aneurysm, 490. Intra-uterine fractures, 162. Intubation, 339-317, 358, 360. — after tracheotomy, 358. — feeding after, 344. ■ — introduction of tube, 341. — removal of tube, 346. — sequelae of, 345. Intussusception, 394. — chronic, 400. — gangrenous intestine in, treatment of, 399. — inflation in, 397. — laparotomy in, 398, 400. — Signe de Danz, 396. — taxis in, 397. Iodoform in treatment of burns, 503. — emulsion, formula for, 104. Irreducible hernia. 412. Ivory exostoses, 147. Jacobi, Dr., on diphtheria, 344. — on prolapse of rectum, 422. Jacobson, Mr., on arthrodesis, 195. — on dangers of harelip operation, 257. James, Dr. A., on effects of phimosis, 468. Jasser quoted, 308. Jaw, anchylosis of, 236. — dislocation of, 236. — fracture of, 168. — subluxation of, 236. Johnson, Dr. R. W., on torsion of spermatic cord, 481. Joint, arthrotomy, 240. — disease of hip, 113. of knee, 126. of sacro-iliac, 112. of shoulder, 107. of sterno-clavicular, 106. of wrist, 111. triple displacement in, 126. — diseases, treatment of sinuses in, 137. — operations on wrist, 196. Joints, abscesses in connection with disease of, 118. — abscesses, treatment of, 1.37. — anchylosis of, 124, 174. — ankle, arthrodesis of, 197. disease of, 137. — arthrectomy of, 129. — arthrodesis of, 195. — artificial anchylosis of, 195. — cause of wasting in disease of, 114. — changes in haemophilic, 233. — congenital displacements of, 246. — diphtheritic inflammation of, 334. — diseases of elbow, 109. of hip, osteomyelitis of, 115. — dislocations of, 236-252 ; sec Dis- locations. — displacements in, 245, 246. Joints, erasion of, 129. — excision of, 108, 110, 112, 132. — flail, treatment of, 195, 196. — gonorrhceal inflammation of, 127,. 227. — hydrops of, 129, 225. — hydrops articuli, 126, 127, 225. — inflammation of, 225 ; see Arthritis. — iodoform injections into, 104. — knee, arthrodesis of, 196. — knee, Thomas' splint in, 128. — Lannelongue's treatment for disease of, 102. — neuralgia of, 334. — night screaming in disease of ,99,1 19. ■ — operation, arthrectomy, 109, 129. arthrotomy, 240. erasion, 109. excision, 108, 110, 112, 132. on ankle, 138. on arthrodesis, 195. on elbow, 109. on hip, 121. on jaw, 237. -on knee, 129. on shoulder, 108. — paralytic treatment of, 194-197. — pseudo-paralytic, in scurvy, 198. in rickets, 205. -in syphilis, 153. — sacro-iliac disease, 112. — sclerogeny in, 102. — scorbutic, 198. — secondary displacements of, 245. — Senn's treatment for disease of, 104. — subluxation of jaw, 236. — subluxation of radius, 180, 212. — synovial membranes of, 96. — treatment of abscesses in disease of, 105, 118. — tuberculosis of, 97. — wrist, arthrodesis of, 196. Jones, Dr. Lewis, on electrolysis of nsevi, 493. — Mr. Robert, on arthrodesis, 195. — on spinal caries, 77, 80, 81. Jugular vein, thrombosis of, 313. Jullien on tuberculous testicle, 475, 478. Kassel, Dr., on otitis media, 294. Keegan,Brig.-SurgeonLieut.-Colonel, on litholapaxy, 449. Keen, Prof., on aneurysm, 490. — on exploration of lateral ventricles, 325. — on hypertrophy of pinna, 291. Keetley, Mr., on imperforate anus, 429. Keith, Mr., on litholapaxy, 449. Kettle-holder splint, 173, 187. Kidney, abscess of, 438. — calculus of, 441. — diseases of, 432. — wounds of, 435. Kidneys, floating, 444. — hydronephrosis of, 432. INDEX 539 Kidney, movable, ill. — nephrolithotomy, -14-1. — pyonephrosis of* 43S. after circumcision, 463 — repair (if, 436. — rupture of, 435. — tuberculous, 410. — tumours of, adenomata, 411. cystic, 415. dermoid, 445. fibromata, 441. rhabdomyosarcoma^, 415. sarcomata, 445, 44S. teratomata, 445. Klebs-Lomer bacillus, 332, 335. Knee, arthrodesis of, 196. — congenital displacement of, 250. — disease of, 120. — secondary displacement of, 245. — splint, method of applying, 128. Thomas', application of, 128. — synovial relations of, 90. — tuberculosis of, 126. Knock-knee, 207. Konig, Prof., on haemophilia, 234. — on tuberculous peritonitis, 376. Korte on purulent pericarditis, 374. Kossel on diphtheria, 335. Krouecker's transfusion fluid, formula for, 5. Kronlein's suture in harelip, 256. Labia, adherent, 489. Laminectomy, 81-88. Landerer's formula for transfusion fluid, 5. Landmarks, Mr. Holden's, quoted, 239. Lang-ton, Mr., case of fragilitas ossium, 161. Lannelongue, Prof., on blood tumours of scalp, 196. — sclerogeny, 102, 103, 250. Laparotomy, 378, 391. — contra-indications for, 380. — for chronic intussusception, 400. — in intussusception, 39s K)0. Laryngeal ob-t ructiim, 30u. — stenosis, symptoms of, 337. — treatment of, 335-365. Larynx, foreign bodies in, 302. — inflammation of, 358. — intubation of, 339-347, 358. — necrosis of, 359. — new growths of, 360. — scalds of, 359. — stenosis of, 356. — syphilitic inflammation of, 358. — thyrotomy, 361. — traumatic inflammation of, 358. — tuberculous inflammation of, 358. — ulceration of, 359. Lateral curvature, 78, 216. ricketty, 205, 210. — sinus, exploration of" 810-312, — ventricles, exploration of, 325. Lauenstein, Dr., on torsion of sper- matic cord, 482. Leclanche battery, 494. Lee, Dr. Robert, on rickets, 204. Leg, broken, 190. Leichtenstern on intussusception, 39 1. Linear osteotomy, 211. Ling's gymnastic system for scoliosis, 219. ' Lingual abscess, 265. Dip, cancer of, 203. — epithelioma of, 263. — malignant disease of, 263. Lipoma of tongue, 207. Lipomata, parosteal, 1 18. Litholapaxy, 449. Lithotomy, lateral, 151. — suprapubic, 1">2. Lithotrites, 150. Lithotrity, 449. Lockwood, Mr. C. B., on inguinal hernia, 410, 419. Loewenberg's curette for removal of adenoids, 281. Long bones, tubercle of, 60. Lordosis, importance of overcoming, in cases of hip disease, 118. — its management, 118. Lorenz on scoliosis, 220. — on torticollis, 223. — operation in congenital displace- ment of hip, 249. — treatment of spinal caries, 83. Lower jaw, fracture of, 108. Lucas, Mr. Clement, on traumatic meningocele, 100. Ludwig on submaxillary cellulitis, 20. Lumbar caries, diagnosis of, 81. — hernia, 401. — puncture, 322. Lung, hernia of, 365. Lupoid ulceration of ear, 59. of gums, 59. of tongue, 59. Lupus, 58. — of pharynx, 57, 286. — of tongue, 266. — producing general tuberculosis, 59. — skin grafting in, 00. — use of sulphur in, 60. Lymphadenitis, tuberculous, 53. Lymphangiectasis, 497. Lymphangioma, 200, mi, 197. Lymphatic aSBVUS, 2iiii, 491, 197. Jfacbride, Prof., on cerebral, abscess, 306. Mcliurney, Dr., on appendicular peri- tonitis, 391. McBurney'a point, 387. Macewen, Prof., on cerebral abscess, 307, 308. — on laminectomy, 86. Macewen 's hernia needle, 419. — osteotomy, 211. 54o INDEX Macewen's tracheal catheter, 357. McFadyean, Prof., on tuberculous peritonitis, 374. Mackenzie's, Sir Morell, styptic for bleeding from tonsils, 279. Mackie, Dr., on Bilharzia, 425. Macrocheilia, 497. Macroglossia, 266, 497. Malar bone, tuberculosis of, 69. Malaria, wryneck after, 221. Malformations of ear, 290. — rectal, 42(5. Malignant disease, fractures in, 160. — epulis, 151. — oedema , 23. Malposition of testis, 478. Marchant, Dr., quoted, 165, 424. Marsh, Mr. Howard, on differential diagnosis of tuberculous osteitis,64. — on rectal nasvus, 426. Mason's treatment of broken nose, 168. Massage, oesophageal, 271. Mastin, Dr., on cranial angioma, 496. Mastoid antrum, exploration of, 308. relations of, 310. — bone, disease of, 303. — indications for exploration of, 308. — osteomyelitis of, 303. — tuberculosis of, 69, 314. Masturbation, signs of, 473. Maxilla inferior, dislocation of, 236. Maxillary bones, tuberculosis of, 69. Mears, Dr., on anchylosis of jaws, 237, 238. Measles, arthritis after, 226. — a cause of balano-posthitis, 469. — osteomyelitis after, 31. Melsena, 425, 426. Membrana, tympani incision of, 298. Meningeal artery, rupture of, 165. Meningitis, cerebral, 317. — non-tuberculous, 317. — simulated by otitis media, 297. — tuberculous, 319. Meningocele, 507, 510. — traumatic, 165. Meningo-encephalocele, treatment of, 331. — -myelocele, 507, 508, 510. [336. Mercurial fumigation in diphtheria, Metacarpal bones, epiphyseal separa- tions of, 192. — fracture of, 191. Metatarsal bones, fractures of, 192. Meyer, Prof., on adenoids, 279. Meyer's ring-knife, 284. Miorocephalus, 331. — a cause of, 155. Micturition, peculiarities of, in vesical calculus, 447. Middle ear, inflammation of, 293. Millet, Dr., on vascular supply of testis, 483. Milk as a source of tuberculous in- fection, 61. Milliamperes, 195, 494. Monod, Prof., on hydronephrosis, 434. — and Trelat on giant growth, 519. Morbus coxae, 113 ; see Hip, disease of. Morgan, Mr. J. H., on litholapaxy, 452. Morton's fluid, injection of, 511. Morvan's disease, 44, 507, 509. Moullin, Mr. Mansell, on injury to radins, 180. — on subluxation of head of radius, 180, 242. Mouth, cysts of, 263. — ■ tuberculous disease of, 57, 285. — wounds of, 269. Movable kidneys, 444. Mucous membranes, tuberculosis of, 57. Mumps, arthritis after, 226. Murdoch, Dr. Burn, on effects of phimosis, 468. Murray, Mr.R. W., on osteoklasia, 209. Miitter lectures quoted, 24. Myeloid sarcoma of bone, 150. Myers, Prof., on spinal caries, 77. Myotomy in hip disease, 123. Myringotome, 299. Myringotomy, 298. Myxomata, vesical, 455. Nasvus, 491. — of bone, 150. — of cerebral meninges, 491. — naso-pharyngeal, 286, 496. — rectal, 426'. Na;vi, arterial, 496. — capillary, 491. — cavernous, 493. — degenerations of. 493. — lymphatic, 266, 491, 497. — of nasal fossa?, 286, 496. — of tongue, 266, 491. — pigmented, 492. — port- wine stains, 492. ■ — sarcomatous, 493. — subcutaneous, 492. — treatment by corrosive sublimate collodion, 492. by extirpation, 493. ■ by nitric acid, 492. by sodium ethylate, 492. — ■ vascular, 491. — venous, 492. Nfevo-sarcoma, 493. Nail, artificial, for adenoids, 284. Naphthaline, 319, 378. Naphthol, 319, 378. — camphorated, 43, 92, 129, 138, 381. — — formula for, 9. injections of, 381. Nasal bones, fracture of, 167. — fossas, naevus of, 496. — septum, dislocation of, 235. Nash, Mr. Gifford, on torsion of spermatic cord, 481. Naso-pharyngeal tumours, 286. INDEX 541 Nasopharynx, chronic inflammation of, 294 Navel, ruptured, 404. — tumours of, 518. Necrosis of bone, total, 41. — epiphyseal, 163. — fractures in, 160. — laryngeal, 3 — syphilitic, IS l. — tuberculous, 63, 31 1. Nephrectomy, 189, 146. Nephritis, chronic, enuresis in, 472. — in phimosis, 468. — tuberculous, 440. Nephrolithotomy, Hi. New-born children, peritonitis in, 384. Nicoladoni on torsion of spermatic cord, 181. Nightmare, causes of, 271. Night-enuresis, 472. — terrors, 280. — screaming, 99, 1 19. Nitric acid, treatment of nsevi by,492. Nodes, Parrot's, 155. — soft, 155. — typhoidal, 40. Noma, 81. Non-infective gangrene, 10. — -suppurative osteomyelitis, 40. — -tuberculous infective diseases, 16. — -tuberculous meningitis, 317. Northrup, Dr., on diphtheria, 336. Nose, dislocation of septum of, 235. — fracture of, 167. — lupoid ulceration of, 59. — noevus of nasal fossse, 496. — Rouge's operation on, 288. — tumours of, 286-288. Nuhn, glands of, 263. Obstruction, acute intestinal, 394. — chronic intestinal, 400. Obturator, lithotrity, 450. — for tracheal stenosis, 358. O'Connor extension apparatus, 121. ( tdontomata, 1 10. O'Dwvei tdon of intubation, 839-347,358. (Edema, malignant, 23. (Esophagotomy, 271. (Esopha^u , bodies in, 270. — stricture of, 272. Ohm, definition 1 if, I'M. Olecranon, separated epiphysis of, 179. Omphalocele, 402. Operation, atypical excisions, 110, 123, 129, L38. — cerebral puncture, 325, 330. — colopexy, 123. — enterectomy, 399. Kstlander's, 871. — Furneaux - Jordan's amputation, 121. — in empyema, 371. [ ion in pericarditis, 374. — in pleurisy, 373. — inrlatiouof bowel, 3 17. — injection of Morton's fluid, 510. — intubation of larynx, 339-317. — laparotomy, 378, 391. in intussusception, 398. — litholapaxy, 1 IS. — lithotrity, 151. nephrectomy, 139, 146. — nephrolithotomy, in. - orchidopexy, 180. — plastic, 60 264, 268 — radical, Ei c hernia, 404, 416. — resection of ribs, 371. — Rouge's, 288. — spina bifida, 510. — Thiersch's. 60, 503. — thyrotomy, 361. — tonsillotomy, 27r.. — tracheotomy, 317, 348. — trephining for lateral ventricles, 325. — trephining, mastoid, 309. — vermiform appendix, removal of, 3:12. Operations, after-treatment of, 8. — precautions to be adopted in children, 3. Opisthotonus, cervical, 318. Orbital nam, 496. Orchidopexy, 480. Orchitis, tuberculous, 175. Ord, Dr. U'allis, quoted, 198, 322. Ossifying sarcoma, 127, 152. Osteitis, infective, 29. — rarefying syphilitic, 154. — Syphilitic, 15 1. — tuberculous, 62. Osteo-arthritis, 227. -arthropathy, pulmonary, 93. Osteoclast, 210. eoklasia, 209. myelitis, acute, 30. — ■ course oi abscess in, 33. ol' femur, 1 1 '<■ — of hip, 115. — mastoid, 303. — non-suppurative, 40. sequela of, 41. — syphilitic, in children, 151. in infants, 153. tuberculous, 66. — typhoidal, 10. ■ - vertebral, 80. Osteopsathyrosis, 161. Osti osarcoma, 152. 1 1 teotome, 211, 214. 1 1 teotomy, 211. — chisel, 214. — cuneiform, 21 1. linear, 211. — of the neck Of the femur, 121. — subtrochanteric in hip disease, 124. 542 INDEX Otitis, influenzal, 301. — media, 293, 315. bacteriology of, 295. method of inflating Eustachian tube in, 298. simulating meningitis, 297. — scai-latinal, 300. — syphilitic, 301. — tuberculous, 301. — typhoidal, 301. Otorrhcea, 293. Ovarian tumours, 487. Owen, Mr. Edmund, on arthrectomy, 130. — on acute osteomyelitis, 34. — on axial rotation of testis, 481. — on enuresis, 473, 474. Page, Mr. Fred, quoted, 430, 437. Paget, Mr. Stephen, on nsfivi, 493. Painless whitlow, 44. Palate, gangrene of, 23. Pantin, Mr., on empyema, 369. Papilloma, laryngeal, 360. — of tongue, 267. Papillomata, vesical, 455. Paralysis, false, 153, 198, 205. — infantile, 193. — in spina bifida, 509. Paralytic joints, treatment of, 193-197. — symptoms in spinal caries, 74, 82. Paraphimosis, 470. — circumcision after, 471. Paraplegia in spinal caries, 75, 82. Parasitic cysts of bone, 149. Parietal bone, tuberculosis of, 68. Parieto-occipital fissure, position of, 325. Park, Dr. Roswell, on malignant oedema, 24. Parker, Mr. C. A., on adenoids, 280. — Mr. R. W., on aneurysm, 490. — on na?vi, 491. — quoted, 20,338. Paronychia, 43. Parosteal lipomata, 148. Parrot's nodes, 155, 156. Passive dislocation of fibula, 251. — haemorrhages, 231. — movement in joint disease, 108, 111, 177. Patella, congenital displacement of, 251. — fracture of, 190. Pathology of infective osteomyelitis, 30. — of tubercle, 52, 63, 101, 140. Pelvic cysts, 514-517. Penis, dislocation of, 471. — fistula of, 455. — gangrene of, 470. Penrose, Dr., on effects of removing tonsils, 276. Pericarditis, purulent, 373. Perinephric abscess, 438. Periosteal sarcoma, 151. Periostitis albuminosa, 40. — infective, 30 ; see Osteomyelitis. — ossifying, 39. — suppurative, 33, 39. Peritoneal abscess, 392. Peritoneum, relations in imperforate anus, 428. — tuberculosis of, 375. Peritonitis, appendicular, 385. — due to pneumococcus, 383. — in the new-born, 384. — recurrent, 390. — relapsing, 390. — suppurative, 402. Peroxide of hydrogen, use of, 8, 353, 354, 393. Petersen's bag, 453. Petersen, Dr., on intracranial tu- mours, 330. Petit, J. L., on mastoid disease, 308. Petit's triangle, hernia through, 401. Petrous bone, disease of, 302. Peyer, Prof., on enuresis, 473. Phageda?na and septic gangrene, 21. Phagocytosis, 141. Phalanges, chondromata of, 146. — dislocation of, 243. — exostoses of, 147. — necrosis of, 44, 46. — septic osteomyelitis of, 44, 46. — syphilitic disease of, 154. — tuberculous osteomyelitis of, 70. Pharyngeal tonsils, hypertrophy of, 279. Pharyngitis sicca, adenoids a cause of, 281. Pharynx, acute tuberculous inflam- mation of, 285. — lupus of, 57, 286. — scalds of, 359. — tuberculosis of, 285. — tuberculous disease of, 57. Philoctetes, his malady, 43. Phimosis, 461. — accidents from, 461. — albuminuria in, 4H8. — circumcision in, 462. — dilation of, 461. — low sp. gr. of urine in, 468. Phosphaturia, fractures in, 160. Pick, Mr. Pickering, quoted, 32, 143, 179, 200. Picric acid, treatment of burns by, 502. Pigmented naevi, 491. Pinna of ear hypertrophy, 291. Pitte, Mr., on tracheotomy, 353, 358, 361. Plaster case, how to make, 212. Plastic operations, 6«, 254, 258, 505. Pleura, cervical hernia of, 365. — operations on, 368-374. Pleurisy, treatment of, 373. Plug, tracheal, 358. Pneumatocele cranii, 518. INDEX 543 Pneumoeoccus in meningitis, 317. — in peritonitis, 383. Pneumonia, osteomyelitis after, 81. Polikier, Dr., on oesophageal massage, Poliomyelitis, anterior, 193. Politzer, method of inflating Eusta- chian tube, 298. — Prof., on otitis media, 295. Pollard, Mr. Bilton, on ectopic testis, 480. on excision of hip, 122. Polypi, rectal, 121. — umbilical, 618. Port-wine stains, 492. Posthitis, 468. Post-nasal growths, 279. — pharyngeal abscess, acute, 25. abscess, chronic, 81. Pott's disease of the spine, 72. — fracture, 191. Powell, Dr. Douglas, case of actino- mycosis, 28. Praemaxilla, treatment of, in harelip, 256. Preputial calculi, 455. Pre-auricular appendages, 290. Pregnancy, precocious, 487. Prepuce, dilatation of, 461. — gangrene of, 47<>. — inflammation of, 468. Prescott and Goldthwait, Drs., on diphtheria, 346. Pringle, Dr., case of actinomycosis, 28. Prolapse of rectum, 422. — urethra, 460. Prostatic calculi, 454. Pseudo-paralysis in scurvy, 198. ricketty, 205. syphilitic, 153. Psoas abscess, treatment of, 82, 88- 92. Pulmonary osteo-arthropathy, 93. Puncture of vertebral column, 322. Purulent pericarditis, 373. Pyasmia, 17, — after epiphyseal separation, 163, 186, 190 — of lateral sums, 313. Pye, Mr. Walter, on osteoklasia, 209. Pyelitis, calculous, 443. — enuresis in, 17-. Pyelo- nephritis, 4W. Pyonephrosis, 138. Pyo-pericardinm, 373. I' "salpinx, Ins. Pyothorax, 305. Quarter-evil, or Hausch-brand, 24. Quincke, Dr., on lumbar puncture, 322. Rachitis, 203. Radical operation for empyema, 371. Radical operation for hydrocele, 487. for inguinal hernia, 116. for nsevi, 493. for spina bifida, 511. for umbilical hei ma , 104. Radius and ulna, backward disloca- tion of, 239. — dislocation of, 211. — epiphyseal separation of, 180, 182. — forward dislocation of, I'll. — fracture of, 181. — subluxation of head of, 180, 242. Ranula, 26.'i. Rarefaction of bone, 43, 63, 68, 70. tying syphilitic osteitis, I i. Rasch, Prof., on otitis media, 293. Rash after treatment with antitoxin, 16. Rattcl, Dr., on otitis media, 299. Ray fungus, 28, 80, 1 19. Raynaud's disease, asphyrial form, 12. syncopic form, 12. Read, Dr. Alexander, on tongue-tie, 268. Rectum, adenomata Bilharzia, 425. multiple, 425. single, 424. — atresia of, 426. — cancer of, 425. — dilatation of, 430. — malformations of, 426. — nsevi of, 126. — prolapse, 422. Recurrent peritonitis, 390. Reeves, Mr., on treatment of spinal caries, 83. Reid, Prof., on cranio-cerebral topo- graphy, 326. Relapsing peritonitis, 390. Renal calculus, 111. ■ enuresis in, 472. Residual abscess, 82. Host, in joint disease, 10*. Retention of urine, 470, 515. Retro-pharyngeal abscess, 25, 81, 287. Rheumatic spine, 77. Hiioumatism, infective, 35. Rhinolith, 288. Ribs, fracture of, 183. — resection of, 37 1 . — ricketty fracture of, 184. — spontaneous fracture of, 1T>5. — syphilitic fracture of, 1 B t — traumatic fracture of, 184. — tuberculosis of, 69. Richardiere on osteoarthritis,. 227. Rickets, 203. — forcible straightening of bones in, 209. — OHteoklasia in, 209. Ricketty pseudo-paralysis, 205. spine, 78, 205, 216. Ridlon, Dr., on double hip disease, 125. on spinal caries, 77. 544 INDEX Ring-knife, Meyer's, 231. Rolando, fissure of, its position, 324. Rose, Prof., of Berlin, on cleft palate, 259. — Prof. William, of London, on cleft palate, 260, 261. Rotation of testis, 481. Rouge's operation, 283. Rcra.gb.ton, Mr. Edmund, case of, 150. Routh, Dr. Amand, on vulvo- vaginitis, 499. Roux, Prof., on diphtheria, 33G. Ruault, Dr., on removal of tonsils, 278. Rupture, see Hernia, 401. Ruptured urethra, 458. Sacro-coccygeal cysts, 51 1. Sacro-iliac disease, 79, 112. counter-irritation in, 113. Saddle-back, 248. Sakharoff, Prof., on cultivation of diphtheritic micro-organisms, 333. Santi, Mr. de, on tonsillar bleeding, 278. Santvoord, Dr. van, on subluxation of head of radius, 242. Saprffimia, 16. Sarcoma of bladder, 455, 518. — of bone, 119. — cerebral, 330. — in children, differential diagnosis, 64. — endosteal, differential diagnosis of, 64. — fractures in cases of, 160. — lingual, 268. — nsevoid, 493. — naso-pharyngeal, 236, 288. — ossifying, 127, 152. — ovarian, 487. — periosteal, 151. — of spine, 80. — of testis, 477, 480. method of secondary infection in, 481. — of vagina, 488. — vesical, 455, 518. Sayre, Prof., on hip disease, 115. Sayre's treatment for fractured cla- ' vicle, 169. Scalds of larynx and pharynx, 359. — laryngeal, treatment of, 360. — treatment of, 501. Scalp, blood tumours of, 496. Scapula, tuberculosis of, 69. Scarlatinal arthritis, 226, 227. — otitis, 300. Scarlet fever, balano-posthitis in, 469. — hydrocele in, 485. — osteomyelitis afrer, 31. — wryneck after, 221. Schmalfuss on tuberculosis of ribs, 69. Schwartze, Prof., on mastoid dis- ease, 308. Sciopodes, 519. Sclerogeny, 102, 251 Sclerosis of bone, 43, 154, 156. Scoliosis, 216. — torsion in, 217. Scott, Sir Walter, illness of, 194. Scurvy, 197. — rickets, 197. Sebaceous cysts, 513. Senn, Prof., on sclerogeny, 104. — suprapubic lithotomy, 454. Separation of epiphyses, 162. Septic gangrene, 21. — osteomyelitis, 30. — poisoning, symptoms of, 16, 34. Septicasmia, 16. Septum nasi, dislocation of, 235. — tuberculous disease of, 57. Sequestra, central tuberculous, in bone, 68. — embolic, tuberculous, 66. — treatment of, 42. Sermesius on hernia, 413. Serum, treatment of diphtheria by, 335. Sheaths of tendons in forearm, 45. tuberculosis of, 57. Shoulder, disease of, 107. — dislocation of, 233, 252. — secondary displacements of, 245. — synovial relations of, 96. Signe de Danz, 396. Sinus lateral, exploration of, 310-312. — longitudinal, thrombosis of, 313. — prajcervicalis, tumours connected with, 512. Sinuses, treatment of, in bone, 137. Skin-grafting, method of, 60, 503. Skin, tuberculosis of, 58. Skull, syphilitic disease of, 155. ■ — fractures of, 164, 167. — synostosis of, 155. — trephining, 309, 321, 324, 329. — tuberculosis of, 68. Smallpox, arthritis after, 226. Smith, Mr. R., on congenital displace- ments, 246. Smith, Mr. Thos., a case of, 148. — on cleft palate, 261. — on foreign bodies in the air pas- sages, 363. Snoring, cause of, in adenoids, 230. Sodium ethylate, treatment of nsevi by, 492. Soft nodes, 155. — palate, gangrene of, 23. Sonnenberg, Dr., on pneumatocele cranii, 519. Southam, Mr., on suprapubic litho- tomy, 454. Spermatic cord, torsion of, 481. Spicer, Mr. Holmes, on scurvy, 198. — Dr. Scanes, on adenoids, 281. Spina bifida, 44, 76, 402, 507. enuresis in, 472. INDEX 545 Spina bifida occulta, 508, 509. radical operation for, 511. — ventosa, 63, 08, 7". Spinal abscess, 73, 81, 82. treatment of, 88-92. — actinomycosis, 80. — caries, abscess in, 81, 82. associated with tuberculous tes- tis, 470. enuresis in, 472. wryneck in, 221. — column, puncture of, 322. Spine, actinomycosis of, 80. — caries of, diagnosis of scat, 80. — curvature of, angular, 72. lateral, 216. — differential diagnosis in disease of, 77. — hydatids of, 80. — hysterical, 78. — lateral curvature in caries of, 73. — nervous symptoms in tuberculous disease of, 74, 82. — osteomyelitis of, 80. — Pott's disease, 72. — rheumatic, 77. — ricketty, 78. — sarcoma of, 80. — syphilitic, 80, 151. — typhoidal, 79. Spiral fracture, 182. Splint. Bryant's, 188. — Carr's, 183, 192. — for wryneck, 222-224. — Gooch's, 173, 187. — Hammond's, for broken jaw, 168. — Howse's, 136. — Mason's, for broken nose, 168. — plaster, preparation of, 122, 212. — Thomas' hip, 122, 186 knee, 127. Spondylitis, 72 ; see Spine. Spontaneous aneurysm, 490. — fracture of rilis, 155. — fractures, 155, 160, 198, 200. — gangrene, 11. Staveley, Mr. \V. H. C, quoted, 164, 340,3 k), 503. Steavenson, Dr., on naevi, 493. Stenosis, laryngeal, symptoms of, 337. — treatment of, 335-360. — of trachea, 356. Sterno-clavicular joint, disease of, 106. — -mastoid, tenotomy of, 222. Sternum, tuberculosis of, 69. Stiles, Mr. Harold, quoted, 4©7. i-er's battery, 106, Stone in bladder, 417. -- in kidney, 411 . — in prepuce, 466. — in prostate, 164. — in urethra, 166 Strangula a, 396, 401, 103, 02. — testis, i si. — umbilical hernia, 103. Stricture of oesophagus, 272. Stromeyer's cushion, 175. Sturrock, Mr., quoted, 164. Subcutaneous na?vi, 192. Subluxation of jaw, 236. — of radial head, 180, 212. Submaxillary cellulitis, 19. Subperiosteal fractures, 158, 169, 181, 185. Subtrochanteric osteotomy in hip dis- ease, 124. Sulphur, treatment of lupus by, 60. .Supernumerary auricles, 290. Suppurating lymphatic glands, 55,56. Suppuration after separated epiphy- ses, 163. — in mastoid, 308. Supracondylar fractures of humerus, 176. Suprapubic cystotomy, 456, 459. — lithotomy, 452. Surgical tuberculosis, 51. Sutton, Mr. Bland, quoted, 290, 512. Sutures in cleft palate, method of in- serting, 261. Swain, Mr., on anchylosis of jaws, 237. Swedish gymnastics in scoliosis, 219. Swift, Dean, 325. Sylvius' fissure, situation of, 325. Syme's amputation, 139. Symmetrical gangrene, 11. Syncopic form of Raynaud's disease, 12. Synostosis of skull, 155. Synovial membranes of joints, 96. — sheaths in forearm, 15. Synovitis, gummatous, 228. — tuberculous, 98. Syphilis of skull, 155. — of tongue, 265. Syphilitic arthritis, 228. — chondro-arthritis, 230. — craniotabes, 166. — disease of bone, 153. — laryngitis, 358. — osteitis, 154. — osteomyelitis, 153. — otitis, 301. — spine, 80. — testicle, 477. Syringo-myelia, U, 76, 507, 609. Syringo-myelocele, 507-510. T-fracture of elbow, 176. Talipes in connection with infantile p:i ralysis, I'.U. — in conneci ion with spina bifida, 608. — treatment of, L96. Tampon canula, 31s, :i(il . Tarsus, tuberculosis of, 137. Taxis in intussusception, 396. Taylor's 1 1 race for spinal ciricH, H5. Taylor, Dr., on intussusception, 398. Tea le, Mr. Pridgin, quoted, 63. N N 54 6 INDEX Telangiectasis, 493. Temporo-sphenoidal abscess, 305,307. Tendon sheaths, tuberculosis of, 57. in the forearm, 45. Tenotomy in hip disease, 123. — in congenital displacement of hip, 249. — of sterno-rnastoid, 22*. — in talipes, 195. Teratoma, 445, 514. Testicle, abscess of, 478. — acute strangulation of, 481. — atrophy of, 476. — axial rotation of, 481. — carcinoma of, 480. — dermoid cysts of, 477, 484. — displaced, 478. — ectopia femoralis, 479. perinealis, 478. — ectopic, 478. — enchondroma of, 481. — gubernaculum of, 478. — hernia of, 476. — innocent tumours of, 481. — malignant tumours of, 480. — orchidopexy, 480. — syphilitic, 477. — tuberculous, 475, 478. — undescended, 410, 416, 420, 478. Thecal abscess, 47. Thermometric indications sometimes of little value in children, 7, 421. Thiersch's method of skin-grafting, 60, 503. Thigh broken, 184. Thiol, treatment of burns by, 502. Thomas' double hip splint, 113, 122, 125. — knee splint, method of applying, 128. — single hip splint, 121, 186. Thomas, Mr., on harelip, 255. Thoracoplasty, 371. Thorax, exploration of, in empyema, 369. — in pericarditis, 374. — in pleurisy, 373. Thorburn, Mr., on laminectomy, 85. Thrombosis of cerebral sinuses, 313. — infective, 190. — of mastoid vein, 315. — venous, 495. Thyreo-glossal duct, 264. tumours in connection with, 512. Thyroid lingual tumours, 267. Thyrotomy, 361. Tibia, tubercle of, separation of lower epiphysis, 190. upper epiphysis, 190. Tongue, abscess of, 265. — adenoma of, 267. — anchyloglossa, 268. — aphthous ulcers of, 265. — carcinoma of, 268. — diseases of, 264. Tongue, dyspeptic ulcers of, 265. — glandular tumours of, 267. — inflammation of, 264. — injuries of, 264. — lipoma of, 267. — lupus of, 59, 266. — microglossia, 266. — mucous patches of, 265. — papillomata of, 267. — sarcoma of, 268. — soft fibroma of, 267. — syphilis of, 265. — thyroid tumours of, 267. — -tie, 268. — ulcers of, 265. Tonsil, hypertrophy of pharyngeal, 279. Tonsillitis, chronic, 273. Tonsillotomes, 276. Tonsils, chronic enlargement of, 273. — chronic hypertrophy of, 281. — methods of removing. 276-278. — tuberculous disease of, 57. Tordeus on appendicular peritonitis , 385. Torsion producing fracture, 182. epiphyseal separation, 188. — of spermatic cord, 481. Torticollis, 80, 220, 221. — tenotomy in, 222. Total necrosis of bone, cause of, 41. Townsend, Dr., on passive haemor- rhage, 231. Toxines, diphtheritic, 334. Tracheal catheter, 357. — stenosis, treatment of, 356. Tracheotomy, after-treatnieut of, 351. — catheterisation after, 357. — dangers of, 354. — dilator, 355, 356. — emphysema after, 350. — feeding after, 352. — for foreign bodies in the air passages, 363. — haemorrhage after, 355. — indications for, 347. — infection during, 355. — operation of, 348. — plug for use after, 358. — stenosis after, 356. — tube, care of, 354. removal of, 355. Transfusion, 5. — directions for, 6. Traumatic aneurysm, 490. — arthritis, 225. — cephalhydrocele, 165. — gangrene, 11. — hydronephrosis, 433. — meningocele, 165. Tr^lat, Dr., on laryngeal stenosis, 357. — and Monod on giant growth, £19. Trendelenburg's operatiug table, 391. — position, 391, 446, 451, 452. — tampon canula, 348, 361. INDEX 547 Trendelenburg's tampon tube, 318. Trephining for lateral ventricles of brain, 325. — mastoid process, 309. — skull, 309, 321, 324, 329. Treves, Mr., on arrest of bleeding, 278. Triple displacement in joint disease, 126. Trochanter of femur, separation of, 186. Trophic changes in hip disease, 114. in spinal disease, 75. Trousseau on tracheotomy, 3 17. Truss for spina bifida, 510. Trusses, 401, 413. Tubby, Mr., quoted, 164, 186, 188. Tubercle of tibia, separation of, 190. Tuberculosis of ankle, 137. — distinguished from syphilis in bone, 154. — enuresis in, 172. — inoculation of, 58. — of bone, 62, 66. — of bursa?, 139. — ■ of carpus, 70. — of elbow, 109. — of epiphyses, 66. — of hip, 113. — of kidney, 4W. — of knee, 126. — of larynx, 358. — of the long hones, 66. — of lymphatic glands, 53. — of mastoid, 69,301, 314. — of middle ear, 301. — of mouth, 57. — of mucous membranes, 57. — of palate, 57. — of peritoneum, 375. — of pharvnx, 57, 285. — of ribs, 69. — of scapula, 69. — of septum nasi, 57. — Of shafts of bones, 68. — of shoulder, 107. — of skin, 5s. — of skull, 68. — of spine, 72. — of sterno-clavicular joint, 100. — of sternum, 69. — of tarsus, 70. — of tendon sheaths, 57. — of testicle, 475. — of tongue, 266. — of tonsils, 57. — pathology of, 52,63, 101, 141. — pharyngeal, 57, 286. — produced from lupus, 59. — 8acro-iliac, 112. — simple and mixed infection in, 63. — surgical, ".I . — synovial, 98. Tuberculosis, vertebral, 72. Tuberculous dactylitis, 63, 70. — epididymitis, 478. — infection, 61. — lymphadenitis, 53. — meningitis, 319. — osteitis, 62. — osteomyelitis, 66. — otitis, 301. Tuberosity of humerus, separated, 172. Tumor albus, 98, 106, 109, 127. Tumours, adenomata, 267, 121, 445. — of bladder, 455. — of bone, 146. — laryngeal, 360. — myxoma, 455. — of naso-pharynx, 286. — ovarian, 487. — papilloma, 455. — pneumatocele cranii, 518. — renal, 444. — rhabdomyomata, 415, 511. — sarcoma, 64, 149, 455. — teratoma, 514. — of tongue, 267. Tympanic membrane, incision of, 298. Typhotdal arthritis, 226. — gangrene, 15. — osteomyelitis, 40. — otitis, 301. — spine, 79. — wryneck, 221. Ulceration, lupoid, of pharynx, 57, 285. — tubercular, of pharynx, 285. Ulcers, aphthous, 26.">. — dyspeptic, 265. — lupoid, 266. — of tongue, 265. — tuberculous, of tongue, 266. Ulna and radius, backward disloca- tion of, 239, — forward dislocation of, 241. separated olecranon, 179. Umbilical fistula, 51S. — hernia, 402. radical oure of, UH. — polypi, 518. Undescended testis, 410, 416, 420, 478. Ungual phalanx, exostosis of , 147. Union by first intention common in children, 5. Ununited fracture, 159, 16 9, 178, 185, 191. Urachus, abnormalities of, 618. Ureter, surgery of, 138. Ureters, rapture of, nr. Urethra, prolapse of, 460. — rupture of, 458. Urethral calculi, 165. Uric acid diathesis a cause of balano- posthitis, 109, 54S INDEX Urine, extravasation of, 458, 461. — incontinence of, 472. — in spina bifida, 509. — low sp. gr. in phimosis, its import, 468. — retention of, 470, 515. — suppression of, after circumcision, 468. Uvula, method of repairing clefts in, 260. Vagina, sarcoma, of, 488. Vaginal hernia, 402. Vaginitis, 489. Variola, arthritis after, 226. Vascular naevi, 491. Vas deferens, size of, in infants, 418. Veins, alterations of, in telangiecta- sis, 493. — ligature of, for pysemic thrombosis, 18, 190, 315. — mastoid, thrombosis of, 315. — thrombosis of, 190, 313. Ventricles, exploration of cerebral, 325. Venous nasvi, 492. — thrombosis, 495. Venus, fold of, 406. Vermiform appendix, inflammation of, 385. removal of, 392. Verneuil oncolopexy, 424. — on differential diagnosis of tuber- culous osteitis, 64. Vertebrae, 72; see Spine. Vertebra?, rheumatism of, 77. — scoliosis of, 216. — syphilitic disease of, 80, 154. Vertebral caries, 72. — column, puncture of, 322. Vesical calculus, 447. enuresis in, 472. treatment of, 449. Villate, liqueur de, formula for, 103. Vitello-intestinal duct, 518. Vocal cords, tumours of, 360. Volt, definition of, 494. Von Tienhoven on enuresis, 474. Vulvitis, 488. Vulvo-vaginitis, 489. Walsham, Mr., on dislocation of sep- tum nasi, 235. Walsharn, Mr, on litholapaxy, 449. — on naso-pharyngeal tumours, 288. Washbourn, Dr., on diphtheria, 336. Wasting in arthritis, cause of, 114. Water on the brain, 325, 330. Waterhouse, Mr., a case of, 144. — on tuberculous meningitis, 322. Wedge osteotomy, 214. Weight-extension, amount of, in chil- dren, 116. Weinberg's apparatus for wryneck, 224. Wells, Sir Spencer, on tuberculous peritonitis, 376* Wernher, Dr., on pneumatocele cranii, 519. Wernicke, Prof., on puncture of late- ral ventricles, 325. Whitlow, 43. Whitman, Dr. Royal, on intracapsular fracture of femur, 185. Whooping cough, hernia after, 404, 411, 415. — osteomyelitis after, 31. Widenmann, Prof., on giant growth, 519. Winiwater, von, Prof., on arthrodesis, 196. Woodhead. Dr. Sims, on tuberculous infection, 51, 375. Woollen truss, 413. Wounds, after-treatment of ch ildren's, 8. — of mouth, 269. Wrenching joints, 123. Wright, Prof. A. E., on haemophilia, 233. — Mr., on arthrectomy, 130. — on dangers of harelip operation, 257. Wrist, arthrodesis of, 196. — disease of, 111. 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Diseases... 19 Syphilis 21 Technological Books 4 Temperature Charts 6 Therapeutics 12 Throat 20 Toxicology 13 Tumors (see Surgery) 19 U. S. Pharmacopoeia 16 Urinary Organs 20 Urine 20 Venereal Diseases 21 Veterinary Medicine 21 Visiting Lists, Physicians'. (Send for Special Circular.) Water Analysis (see Chemis- try) 11 Women, Diseases of. 21 'The prices as given in this Catalogue are net. Cloth binding, unless otherwise specified. No discount can be allowed under any circumstances. Any book will be sent, postpaid, upon receipt of advertised price. SUBJECT CATALOGUE OF MEDICAL BOOKS. &g- All books are bound in eloth, unless otherwise speci- fied. All prices are net. ANATOMY. MORRIS. Text-Book of Anatomy. 791 Illus., 214 of which are printed in colors. Clo., £6.00; Lea., £7.00 ; Half Russia, $8.00. " Taken as a whole, we have no hesitation in according very high praise to this work. It will rank, we believe, with the leading Anato- mies. The illustrations are handsome and the printing is good."— Boston Medical and Surgical Journal. Handsome Circular of Morris, with sample pages and colored illus- trations, will be sent free to any address. CAMPBELL. Outlines for Dissection. Prepared for Use with " Morris's Anatomy" by the Demonstrator of Anatomy at the Uni- versity of Michigan. J1.00 HEATH. Practical Anatomy. A Manual of Dissections. 8th Edition. 300 Illustrations. $4.25 HOLDEN. Anatomy. A Manual of the Dissections of the Human Body. 6th Edition. Carefully Revised by A. Hewson, m.d., De- monstrator of Anatomy, Jefferson Medical College, Philadelphia. 311 Illustrations. Leather, $3.00 HOLDEN. Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Develop- ment. With Lithographic Plates and numerous lllus. 7th Ed. #5.25 HOLDEN. Landmarks. Medical and Surgical. 4th Ed. $1.00 MACALISTER. Human Anatomy. Systematic and Topograph- ical, including the Embryology, Histology, and Morphology of Man. With Special Reference to the Requirements of Practical Surgery and Medicine. 816 Illustrations, 400 of which are original. Cloth, $5.00; Leather, $6. 00 MARSHALL. Physiological Diagrams. Life Size, Colored. Eleven Life-Size Diagrams (each seven feet by three feet seven inches). Designed for Demonstration before the Class. In Sheets, Unmounted, $40.00; Backed with Muslin and Mounted on Rollers, $60.00; Ditto, Spring Rollers, in Handsome Walnut Wall Map Case (send for special circular), $100.00; Single Plates — Sheets, 85.00; Mounted, $7.50. Explanatory Key, .50. Descriptive circu- lar upon application. POTTER. Compend of Anatomy, Including Visceral Anatomy. 5th Edition. 16 Lithographed Plates and 117 other. Illustrations. .80; Interleaved, $1.25 WILSON. Human Anatomy, nth Edition. 429 Illustrations, 26 Colored Plates, and a Glossary of Terms. $5.00 WINDLE. Surface Anatomy and Landmarks. Colored and other Illustrations. $1.00 ANESTHETICS. BUXTON. On Anesthetics. 3d Edition. Illustrated. In Press.- TURNBULL. Artificial Anesthesia. The Advantages and Accidents of; Its Employment in the Treatment of Disease ; Modes of Administration; Considering their Relative Risks; Tests of Purity; Treatment of Asphyxia; Spasms of the Glottis; Syncope, etc. 4th Edition, Revised. 54 Illustrations, fust Ready. $2.50 SUBJECT CATALOGUE. BRAIN AND INSANITY. BLACKBURN. A Manual of Autopsies. Designed for the Use of Hospitals for the Insane and other Public Institutions. Ten full- ' page Plates and other Illustrations. $1 .25 GOWERS. Diagnosis of Diseases of the Brain. 2d Edition. Illustrated. $1.50 HORSLEY. The Brain and Spinal Cord. The Structure and Functions of. Numerous Illustrations. J2.50 IRELAND. Mental Affections of Children. Idiocy, Imbecility, Insanity, etc. Nearly Ready. LEWIS (BEVAN). Mental Diseases. A Text-Book Having Special Reference to the Pathological Aspects of Insanity. 18 Litho- graphic Plates and other Illustrations. New Edition. In Press. MANN. Manual of Psychological Medicine and Allied Nervous Diseases. Their Diagnosis, Pathology, Prognosis, and Treatment, including their Medico-Legal Aspects ; with chapter on Expert Testimony, and an Abstract of the Laws Relating to the Insane in all the States of the Union. Illustrated. $3.00 REGIS. Mental Medicine. Authorized Translation by H. M. Bannister, m.d. $2.00 STEARNS. Mental Diseases. Designed especially for Medical Students and General Practitioners. With a Digest of Laws of the various States Relating to Care of Insane. Illustrated. Cloth, $2.75; Sheep, $3.25 TUKE. Dictionary of Psychological Medicine. Giving the Definition, Etymology, and Symptoms of the Terms used in Medical Psychology, with the Symptoms, Pathology, and Treatment of the Recognized Forms of Mental Disorders, together with the Law of Lunacy in Great Britain and Ireland. Two volumes. £10.00 WOOD, H. C. Brain and Overwork. .40 CHEMISTRY AND TECHNOLOGY. Special Catalogue of Chemical Books sent free upon application. ALLEN. Commercial Organic Analysis. A Treatise on the Modes of Assaying the Various Organic Chemicals and Products Employed in the Arts, Manufactures, Medicine, etc., with concise methods for the Detection of Impurities, Adulterations, etc. 2d Ed. Vol. I, Vol. II, Vol. Ill, Part I. These volumes cannot be had. Vol. Ill, Part II. The Amins. Pyridin and its Hydrozins and Derivatives. The Antipyretics, etc. Vegetable Alkaloids, Tea, Coffee, Cocoa, etc. $4- 50 Vol. Ill, Part III. Animal Bases, Animal Acids, Cyanogen Com- pounds, Proteids, etc. $4-5° Vol. Ill, Part IV. The Proteids and Albuminoids. In Press. ALLEN. Chemical Analysis of Albuminous and Diabetic Urine. Illustrated. J2.25 BARTLEY. Medical and Pharmaceutical Chemistry. A Text-Book for Medical, Dental, and Pharmaceutical Students. With Illustrations, Glossary, and Complete Index. 4th Edition, carefully Revised. Cloth, $2.75 ; Sheep, $3.25 BLOXAM. Chemistry, Inorganic and Organic. With Experi- ments. 8th Ed., Revised. 281 Engravings. Clo.,$4.25; Lea., $5.25 CALDWELL. Elements of Qualitative and Quantitative Chemical Analysis. 3d Edition, Revised. >i-5° MEDICAL BOOKS CAMERON. Oils and Varnishes. With Illustrations, Formulae, Tables, etc. $2.25 CAMERON. Soap and Candles. 54 Illustrations. $2.00 CLOWES AND COLEMAN. Elementary Practical Chem- istry and Qualitative Analysis. Adapted for Use in the Labora- tories of Schools and Colleges. Illustrated. Just Ready. $1-25 GARDNER. The Brewer, Distiller, and Wine Manufac- turer. A Hand-Book for all Interested in the Manufacture and Trade of Alcohol and Its Compounds. Illustrated. $t-5° GARDNER. Bleaching, Dyeing, and Calico Printing. With Formulae. Illustrated. $ I -S° GROVES AND THORP. Chemical Technology. The Appli- cation of Chemistry to the Arts and Manufactures. 8 Volumes, with numerous Illustrations. Vol. I. Fuel and Its Applications. 607 Illustrations and 4 Plates. Cloth, $5.00; Half Morocco, $6.50 Vol.11. Lighting. Illustrated. Cloth, $4.00; Half Morocco, $5.50 Vol. III. Lighting — Continued. In Press. HOLLAND. The Urine, the Gastric Contents, the Common Poisons, and the Milk. Memoranda, Chemical and Microscopi- cal, for Laboratory Use. 5th Ed. Illustrated and interleaved, $1.00 LEFFMANN. Compend of Medical Chemistry, Inorganic and Organic. Including Urine Analysis. 4th Edition, Rewritten. .80; Interleaved, $1.25 LEFFMANN. Progressive Exercises in Practical Chemis- try. Illustrated. 2d Edition. $1.00 LEFFMANN. Analysis of Milk and Milk Products. Arranged to Suit the Needs of Analytical Chemists, Dairymen, and Milk Inspec- tors. 2d Edition. Enlarged, Illustrated. $'-25 LEFFMANN. Water Analysis. Illustrated. 3d Edition. $1.25 LEFFMANN. Structural Formulae for the Use of Students. Including 180 Structural and Stereo-Chemical Formulae. i2mo. Interleaved. $1.00 MUTER. Practical and Analytical Chemistry. 4th Edition. Revised to meet the requirements of American Medical Colleges by Claude C. Hamilton, m.d. 51 Illustrations. $'-25 OETTEL. Practical Exercises in Electro-Chemistry. Illus- trated. Just Ready. -75 OETTEL. Introduction to Electro-Chemical Experiments. Illustrated. Just R .75 RICHTER. Inorganic Chemistry. 4th American, from 6th Ger- man Edition. Authorized translation by Edgar F. Smith, m.a., ph.d. 89 Illustrations and a Colored Plate. $ I 15 RICHTER. Organic Chemistry. 3d American Edition. Trans, from the last German by EoGAK F.Smith. Illustrated. In Press. SMITH. Electro-Chemical Analysis. 2d Edition, Revised. 28 Illustrations. $i-*5 SMITH AND KELLER. Experiments. Arranged for Students in General Chemistry. 3d Edition. Illustrated. .60 STAMMER. Chemical Problems. With Explanations and An- swers. .50 SUBJECT CATALOGUE. SUTTON. Volumetric Analysis. A Systematic Handbook for the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids, and Gases. 7th Edition, Revised. 112 Illustrations. $4-5° SYMONDS. Manual of Chemistry, for Medical Students. 2d Edition. #2.00 WATTS. Organic Chemistry. 2d Edition. By Wm. A. Tilden, d.sc.,f.r.s. (Being the 13th Edition of Fowne's Organic Chemistry.) Illustrated. $2 00 WATTS. Inorganic Chemistry. Physical and Inorganic. (Being the 14th Edition of Fowne's Physical and Inorganic Chemistry.) With Colored Plate of Spectra and other Illustrations. $2.00 WOODY. Essentials of Chemistry and Urinalysis. 4th Edition. Illustrated. /« Press. *** Special Catalogue 0/ Books on Chemistry free upon application. CHILDREN. CAUTLIE. Feeding of Infants and Young Children by Nat- ural and Artificial Methods. Just Ready. $2.00 HALE. On the Management of Children in Health and Dis- ease. -5° HATFIELD. Compend of Diseases of Children. With a Colored Plate. 2d Edition. .80 ; Interleaved, J1.25 IRELAND. Mental Affections of Children. Idiocy, Imbe- cility, etc. In Press. MEIGS. Infant Feeding and Milk Analysis. The Examination of Human and Cow's Milk, Cream, Condensed Milk, etc., and Directions as to the Diet of Young Infants. -5° MONEY. Treatment of Diseases in Children. Including the Outlines of Diagnosis and the Chief Pathological Differences Between Children and Adults. 2d Edition. $2.50 POWER. Surgical Diseases of Children and their Treat- ment by Modern Methods. Illustrated. $2.50 STARR. The Digestive Organs in Childhood. The Diseases of the Digestive Organs in Infancy and Childhood. With Chapters on the Investigation of Disease and the Management of Children. 2d Edition, Enlarged. Illustrated by two Colored Plates and numerous Wood Engravings. $2.00 STARR. Hygiene of the Nursery. Including the General Regi- men and Feeding of Infants and Children, and the Domestic Manage- ment of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. Just Ready. $1.00 TAYLOR AND WELLS. The Diseases of Children. Illus- trated. A New Text-Book. Nearly Ready. CLINICAL CHARTS. GRIFFITH. Graphic Clinical Chart for Recording Temper- ature, ^Respiration, Pulse, Day of Disease, Date, Age, Sex, Occupation, Name, etc. Printed in three colors. Sample copies free. Put up in loose packages of fifty, .50. Price to Hospitals, 500 copies, $4.00 ; 1000 copies, $7.50. With name of Hospital printed on, .50 extra. KEEN'S CLINICAL CHARTS. Seven Outline Drawings of the Body, on which may be marked the Course of Disease, Fractures, Operations, etc. Pads of fifty, Ji.co. Each Drawing may also be had separately, twenty-five to pad, 25 cents. MEDICAL BOOKS. DEFORMITIES. REEVES. Bodily Deformities and Their Treatment. A Hand-Book of Practical Orthopedics. 228 Illustrations. $'-75 HEATH Injuries and Diseases of the Jaws. 187 Illustrations. 4th Edition. Cloth, $4.50 DENTISTRY. Special Catalogue 0/ Dental Books sent free upon application. BARRETT. Dental Surgery for General Practitioners and Students of Medicine and Dentistry. Extraction of Teeth, etc. 3d Edition. Illustrated. Nearly Ready. BLODGETT. Dental Pathology. By Albert N. Blodghtt, m D., late Professor of Pathology and Therapeutics, Boston Dental College. 33 Illustrations. $ T - 2 5 FLAGG. Plastics and Plastic Filling, as Pertaining to the Filling of Cavities in Teeth of all Grades of Structure. 4th Edition. $4-°o FILLEBROWN. A Text-Book of Operative Dentistry. Written by invitation of the National Association of Dental Facul- ties. Illustrated. $2.25 GORGAS. Dental Medicine. A Manual of Materia Medica and Therapeutics. 6th Edition, Revised. Cloth, $4.00; Sheep, $5.00 HARRIS. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, and Mechanism. 13th Edition. Revised by F. J. S. Gorgas, m.d., d.d.s. 1250 Illustrations. Cloth, $6.00; Leather, $7.00 HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 5th Edition. Revised and Enlarged by Fer- dinand F. S. Gorgas, m.d., d.d.s. Cloth, $4.50; Leather, $$. 50 HEATH. Injuries and Diseases of the Jaws. 4th Edition 187 Illustrations. $4-5° HEATH. Lectures on Certain Diseases of the Jaws. 64 Illustrations. Boards, .50 RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- oughly Revised and Enlarged by Dr. Geo. W. Warren. 691 Illus- trations. Cloth, $5.00; Leather, $6. 00 SEWELL. Dental Surgery. Including Special Anatomy and Surgery. 3d Edition, with 200 Illustrations. $2.00 TAFT. Operative Dentistry. A Practical Treatise. 5th Edition. 100 Illustrations. In Press. TAFT. Index of Dental Periodical Literature. $2.00 TALBOT. Irregularities of the Teeth and Their Treatment. 2d Edition 234 Illustrations. $300 TOMES. Dental Anatomy. Human and Comparative. 235 Illus- trations. 4th Edition. $3-5° TOMES. Dental Surgery. 3d Edition. 292 Illustrations. J4.00 WARREN. Compend of Dental Pathology and Dental Medi- cine. With a Chapter on Emergencies. 3d Edition. Illustrated. Just Ready. -8o; Interleaved, $1:25 WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25 WHITE. The Mouth and Teeth. Illustrated. .40 *»* Special Catalogue of Dental Books free upon application. SUBJECT CATALOGUE. DICTIONARIES. GOULD. The Illustrated Dictionary of Medicine, Biology, and Allied Sciences. Being an Exhaustive Lexicon of Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry. Dentistry, Parmacology, Microscopy, etc., with many useful Tables and numerous fine Illustrations. 1633 pages. 3d Ed. Sheep or Half Dark Green Leather, $10.00; Thumb Index, #11.00 Half Russia, Thumb Index, #12.00 GOULD. The Medical Student's Dictionary. Including all the Words and Phrases Generally Used in Medicine, with their Proper Pronunciation and Definition, Based on Recent Medical Literature. With Tables of the Bacilli, Micrococci, Mineral Springs, etc., of the Arteries, Muscles, Nerves, Ganglia, and Plexuses, etc. 10th Edition. Rewritten and Enlarged. Completely reset from new type. 700 pp. Half Dark Leather, $3.25; Half Morocco, Thumb Index, #4.00 GOULD. The Pocket Pronouncing Medical Lexicon. (12,000 Medical Words Pronounced and Defined.) Containing all the Words, their Definition and Pronunciation, that the Medical, Dental, or Pharmaceutical Student Generally Comes in Contact With ; also Elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc., a Dose List in both English and Metric System, etc., Arranged in a Most Convenient Form for Reference and Memorizing. Full Limp Leather, Gilt Edges, $1.00 ; Thumb Index, $1.25 70,000 Copies of Gould's Dictionaries Have Been Sold. *** Sample Pages and Illustrations and Descriptive Circulars of Gould's Dictionaries sent free upon application. HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 5th Edition. Revised and Enlarged by Ferdinand J. S. Gorc;as, m.d., d.d.s. Cloth, $4.50; Leather, $5.50 LONGLEY. Pocket Medical Dictionary. With an Appendix, containing Poisons and their Antidotes, Abbreviations used in Pre- scriptions, etc. Cloth, .75; Tucks and Pocket, J1.00 MAXWELL. Terminologia Medica Polyglotta. By Dr. Theodore Maxwell, Assisted by Others. $3-oo The object of this work is to assist the medical men of any nationality in reading medical literature written in a language not their own. Each term is usually given in seven languages, viz. : English, French, German, Italian, Spanish, Russian, and Latin. TREVES AND LANG. German-English Medical Dictionary. Half Russia, $3.25 EAR (see also Throat and Nose). HOVELL. Diseases of the Ear and Naso-Pharynx. Includ- ing Anatomy and Physiology of the Organ, together with the Treat- ment of the Affections of the Nose and Pharynx which Conduce to Aural Disease. 122 Illustrations. $5-°° BURNETT. Hearing and How to Keep It. Illustrated. .40 DALBY. Diseases and Injuries of the Ear. 4th Edition. 38 Wood Engravings and 8 Colored Plates. #2.50 PRITCHARD. Diseases of the Ear. 3d Edition, Enlarged. Many Illustrations and Formulae. $*-5° WOAKES. Deafness, Giddiness, and Noises in the Head. 4th Edition. Illustrated. l 2 -°° MEDICAL BOOKS. ELECTRICITY. BIGELOW. Plain Talks on Medical Electricity and Bat- teries. With a Therapeutic Index and a Glossary. 43 Illustra- tions. 2d Edition. $1.00 JONES. 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Their Prescription and Adjustment. 2d Edition. 49 Illustrations. $1.00 SWANZY. Diseases of the Eye and Their Treatment. 6th Edition, Revised and Enlarged. 158 Illustrations, 1 Plain Plate, and a Zephyr Test Card. $3.00 THORINGTON. Retinoscopy. 2d Ed. Illus. Just Ready. $1.00 WALKER. Students' Aid in Ophthalmology. Colored Plate and 40 other Illustrations and Glossary. |i-50 FEVERS. COLLIE. On Fevers. Their History, Etiology, Diagnosis, Prog- nosis, and Treatment. Colored Plates. $2.00 GOODALL AND WASHBOURN. Fevers and Their Treat- ment. Illustrated. $3-oo 10 SUBJECT CATALOGUE. GOUT AND RHEUMATISM. DUCKWORTH. A Treatise on Gout. With Chromolithographs and Engravings. Cloth, $6.00 GARROD. On Rheumatism. A Treatise on Rheumatism and Rheumatic Arthritis. Cloth, $5.00 HAIG. Causation of Disease by Uric Acid. A Contribution to the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. $3.00 HEADACHES. DAY. On Headaches. 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With Plates and other Illustrations. $6.00 HISTOLOGY. STIRLING. Outlines of Practical Histology. 368 Illustrations. 2d Edition, Revised and Enlarged. With new Illustrations. |2.oo STOHR. Histology and Microscopical Anatomy. Translated and Edited by A. Schaper, m.d., Harvard Medical School. 268 Illustrations. fo.oo MEDICAL BOOKS U HYGIENE AND WATER ANALYSIS. Special Catalogue of Books on Hygiene sent free upon application. CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and Others. Being a Brief Consideration of Asepsis, Antisepsis, Dis- infection, Bacteriology, Immunity, Heating and Ventilation, and Kindred Subjects. $'-25 COPLIN AND BEVAN. Practical Hygiene. A Complete American Text-Book. 138 Illustrations. Cloth, $3.25 ; Sheep, $4. 25 FOX. Water, Air, and Food. Sanitary Examinations of Water, Air, and Food. 100 Engravings. 2d Edition, Revised. $3-5° KENWOOD. Public Health Laboratory Work. 116 Illustra- tions and 3 Plates. $2.00 LEFFMANN. 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" We know of no series of books issued by any house that so fully meets our approval as these ? Quiz-Compends?. They are well ar- ranged, full, and concise, and are really the best line of text-books that could be found for either student or practitioner." BLAKISTON'S ? QUIZ-COMPENDS? The Best Series of Manuals for the Use of Students. Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. 4®* These Compends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly re- vised, so that they may thoroughly represent the present state of the subjects upon which they treat. 4®" The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. &S~ They are arranged in the most approved form, thorough and concise, containing over 6oo fine illustrations, inserted wherever they could be used to advantage. 4Sf* Can be used by students ot any college. 4ST" They contain information nowhere else collected in such a condensed, practical shape. Illustrated Circular free. No. i. POTTER. HUMAN ANATOMY. Fifth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d., Professor of the Practice of Medicine, Cooper Medical College, San Francisco ; late A. A. Surgeon, U. S. Army. No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Fifth Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot Clinical Medicine, Jefferson Medical College, Phila. No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. Fifth Edition, Revised and Improved. Same author as No. 2. No. 4. BRUBAKER. PHYSIOLOGY. Eighth Edition, with new Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Brubaker, m.d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery ; Demonstrator of Physiology, Jefferson Medical College, Philadelphia. No. 5. LANDIS. OBSTETRICS. Fifth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., Assistant Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 47 Illustrations. No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition (U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of Practice, Cooper Medical College, San Francisco ; late A. A. Sur- geon, U. S. Army. MEDICAL BOOKS. 23 PQUIZ-COMPENDS ?— Continued. No. 7. WELLS. GYNECOLOGY. A New Book. By W11. H. Wells, m.d., Assistant Demonstrator of Obstetrics, JeffersOD College, Philadelphia. 150 Illustrations. No. 8. GOULD AND PYLE. DISEASES OF THE EYE AND REFRACTION. A New Book. Including Treatment and Surgery, and a Section on Local Therapeutics. By George M. Gould, m.d., and W. L. Pyle, m.d. With Formulae, Glossary, Tables, and m Illustrations, several of which are Colored. No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- ing. Fifth Edition, Enlarged and Improved. By Orvillb Horwitz, b.s., m.d., Clinical Professor of Genito-Urinary Surgery and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Lbfpmann, m.d., Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. No. 11. STEWART. PHARMACY. Fifth Edition. Based upon Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, m.d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- delphia College of Pharmacy ; Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. No. 12. BALLOU. VETERINARY ANATOMY AND PHY- SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. No. 13. WARREN. DENTAL PATHOLOGY AND DEN- TAL MEDICINE. Third Edition, Illustrated. Containing a Section on Emergencies. By Geo. W. Warren, d.d.s., Chief of Clinical Staff, Pennsylvania College of Dental Surgery. No. 14. HATFIELD. DISEASES OF CHILDREN. Second Edition. Colored Plate. By Marcus P. Hatfield, Profes- sor of Diseases of Children, Chicago Medical College. No. 15. HALL. GENERAL PATHOLOGY AND MORBID ANATOMY. 91 Illustrations. By H. Nkwberry Hall, ph.g., m.d., late Professor of Pathology, Chicago Post-Graduate Medi- cal School. No. 16. DISEASES OF THE SKIN. By Jay T. Schamberg, m.d., Instructor in Skin Diseases, Philadelphia Polyclinic. Illus. Price, each, Cloth, .80. Interleaved, for taking Notes, $1.25. In preparing, revising, and improving Blakiston's ?Quiz-Com- pendsT the particular wants of the student have always been kept in mind. Careful attention has been given to the construction of each sentence, and while the books will be found to contain an immense amount of knowledge in small space, they will likewise be found easy reading; there is no stilted repetition of words ; the style is clear, lucid, and dis- tinct. The arrangement of subjects is systematic and thorough ; there is a reason for every word. They contain over 600 illustrations. Tyson's Practice of Medicine. ::l!i?z Text-Book of the Practice of Medi- cine. With Special Reference to Diagnosis and Treatment. By James Tyson, m. d., Frofessor of Clinical Medicine in the Univer- sity of Pennsylvania; Physician to the Hos- pital of the University and to the Philadelphia Hospital ; Fellow of the College of Physicians of Philadelphia, etc. With Many Useful Illustrations. Octavo. 1180 Pages. Cloth, $5.50; Sheep, $6.50; Half Russia, $7.50. Extracts from a Review in the American Journal oj Medical Sciences, March, 1897: " Externally it is the largest and handsomest single volume on the practice of medicine." " Clinical features are usually described in a masterly way." "The directions (ior treatment) are full and clear, and as a rule, eminently judicious and conservative." "Dr. Tyson's style is already so well known in medical literature that it is only necessary to say the present work is one of the best examples." "We welcome Dr. Tyson's Practice as a most valuable addition to medical literature." Descriptive circular and sample pages upon application. UC SOUTHERN REGION/ AA 000 221 247 o