THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT of MRS. J. R. WALKER / TEXT-BOOK ON S U E G E R Y GENERAL, OPERATIVE, AND MECHANICAL BY JOHN A. AYYETH, M.D. PROFESSOR OF SURGERY IN THE NEW YOKK POLYCLINIC ; SURGEON TO MOl^NT SINAI HOSPITAL : CONSULTING SURGEON Tu THE YORKVILLE DISPENSARY AND HOSPITAL FOR WOStEN AND CHILDREN : TO THE woman's HOSPITAL OF BROOKLYN ; EX-PRESIDENT OF THE NEW YORK PATHOLOGICAL SOCIETY : UEUBER OF THE NEW YORK SURGICAL StfCIETV : OF THE ACADEMY OF MEDICINE : OF THE NEW YORK STATE MEDICAL ASSOCIATION ; OF THE NEW YORK COUNTY MEDICAL StXIETY ; HONORARY MEMBER OF THE TEXAS STATE MEDICAL ASSOCUTION ; OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF LITTLE ROCK. ARKANSAS. AUTHOR OF AN ESSAY ON THE SURGICAL ANATOMY OF THE TIBIO-TARSAL REGION, WITH SPECIAL REFERENCE TO AMPUTATIONS AT THIS JOINT. AWARDED THE JAMES R. WOOD ANNUAL PRIZE OF THE BELLEVUE ALUMNI ASSOCIATION. IWR ; AN ESSAY ON THE St'RGlCAL ANATOMY AXD HISTORY OF THE CAROTID ARTERIES. AWARDED THE FIRST PRIZE t)F THE AMERICAN MEDICAL ASSOCIATION. 187K ; AK ESSAY ON THE SURGICAL ANATOMY AND HISTORY OF THE INNOMINATE AND SUBCLAYIAN ARTERIES, AWARDED THE SECONT) PRIZE OF THE AMERICAN MEDICAL ASSOCIATION. 1878. ETC. NEW YORK D. APPLETON AND COMPANY 1889 COPTRIOHT, 1887, Bt d. appleton and company. iiliraor 100 TO THE MEMORY OF MY FRIEND, J. MAEION SIMS, M. D.. WHOSE BRILLIANT ACHIEVEMENTS CARRIED THE FAME OF AMERICAN SURGEEY THROUGHOUT THE CIVILIZED WORLD. THIS BOOK IS AFFECTIONATELY DEDICATED BY THE A I T H O R . P REFAO E The author lias endeavored to give in the following pages the accepted facts in surgical pathology and diagnosis, together with the methods of treatment which modern surgery has introduced, or has elected as worthy of continued application from the practice and teaching of the past. In the effort to condense into a single volume, of about eight hundred pages, the essentials of the science and art of surgery, not only is a discussion of theories out of the question, but many measures of treatment— the comparative usefulness of which has been demonstrated— must of necessity be omitted. In an age when books upon this subject are plentiful, this work was undertaken not without misgivings, yet with a determination to leave nothing undone which would add to its usefulness and make it an exponent of modern and progressive surgery. Such rapid advances are being made, that marvelous results are to-day achieved by meas- ures unknown to the profession but a few months earlier. The intro- duction of cocaine JiydrocMorate as a local anaesthetic marks an epoch in surgical practice ; and yet this wonderful agent has scarcely been mentioned in works on surgery. Again, the antiseptic method of treating wounds, originated within the last few years, has brought with it such protection to life and usefulness, that it deserves a more thorough consideration than is often allotted it by surgical writers, and should be universally accepted and practiced. The author believed that the general profession was not sufficiently impressed with the dangers in delaying surgical interference in lesions of the cavities and their viscera, notably the craniiim, abdomen, and pelvis. These, and other considerations which will be found in the text, were among the reasons which led him to hope that this book *^07^27 vi PREFACE. would prove acceptable to his fellow-workers, and especially to that numerous class of physicians who are compelled to do a general prac- tice, and who can lind neither time nor opportunity to select from the vast quantity of surgical literature the facts essential to the prompt and successful management of their cases. That this hope was not without foundation is attested by the reception accorded to the work by the medical press, and by the necessity of a second issue within three months after its publication. To the many' sources fi'om which much needed help in its com- pilation and illustration was obtained — however accredited in the text — the author desires to acknowledge an especial indebtedness, and to the engravers, Messrs. H. Senior and Company, for the general excel- lence and pi'ompt execution of their work. An examination of the volume will attest the liberality of the publishers, who have contrib- uted greatly to its success. The Author. April 20, 1887. COI^TENTS. CHAPTER I. PAGE Surgical dressings — Ligatures and sutm-es — Preparation of material — Silk, silk-worm gut, silver wire — Antiseptic solutions — Corrosive sublimate, carbolic acid, iodoform, alcohol, chlovide- of-zinc — Irrigators — Sponges — Drains: rubber, bone, catgut, and horse-hair — Protective — Carbolized, sulilimated, and iodoformized gauze — Borated and absorbent cotton — Peat — Sawdust — Jute — Wood-wool 1 CHAPTER II. Bandaging — Materials and methods of preparing — Application of the various methods — Simple spiral, reverse spiral, figure-of-8 turn, figure-of-8 reverse — Hand and fingers — Forearm, arm, and shoulder — Toes, foot, leg, and thigh — Spica — Head and face — Knotted bandage — Handkerchief bandages 9 CHAPTER III. Anajsthesia — Local anaisthesia — Cocaine — Ether-spray — General anesthesia — Administration of ether by inhalation — By the rectum — Chloroform and chloroform narcosis . . .21 CHAPTER IV. Surgical operations — Instruments — Operating - table — Furniture — Operating -gown — How to hold the scalpel — Hienjostasis — Tying the ligature — After-treatment of the case . . 34 CHAPTER V. Inflammation — Venesection and blood-letting — Compression — Application of cold — Internal medication — Suppuration — Pus — Slicrococci — Bacteria — Abscess — Treatment . . .53 CHAPTER VI. Wounds — Process of repair — Cicatrization — The tourniquet — Closing wounds — The inter- rupted, continuous, mattress, quill, wire, and pin sutures — Transfusion — Intra-venous in- jection of a saline solution — Poisoned wounds — Snake-bite — Tarantula-poison — Wounds by bees, wasps, hornets, and centipedes — Hydrophobia — Glanders — JIalignant pustule — Dissection wounds — Erysipelas — Dermatitis — Erythema — Cellulitis — Tetanus — Shot- wounds 65 CHAPTER VH. Bums and scalds — Skin-grafting — Frost-bite — Furuncle — Carbuncle — Ulcers — Gangrene — ^Dry or senile gangrene — Hospital gangrene 90 viii CONTENTS. CIIAPTKK Vlir. PAGE Amputations — Method of operating— Circular solid ll.ip. with perpendicular slit — Obliipic solid flaps by transfixion — The same, bv cutting from the sm-face inward — Skin-flaps — Cir- cular method — Modified circular — Oval — Double cresccntic — Double rectangular — Mixed flaps — Open method — Special amputations — Fingers — Hand — Forearm — Klbow-joint — Arm — Shoulder — Toes — Through the metatarsus — Through the tarsus — Methods of I'iro- gofT, Chopart. Forbes. Hey. Lisfranc, Le Fort, Lignerolles, and Hancock — Tibio-tarsal disarticulation — Method of Syme— Leg — Method of Stephen Smith— Knee-joint— Thigh— Hip-joint — Method of Ersljine Mason, etc 103 CHAPTER IX. Surgical diseases and surgery of the lymphatic vessels, veins, and arteries — Lymphangitis — Adenitis— Phlebitis — Arteritis — Arterial thrombosis and embolism— Vascular tumors — Arterial varix — Cirsoid arterial tumor — Angeiomata — Venous varix or varicose veins — Moles — Port- wine mark 158 CHAPTER X. Aneurism — Varicose aneurism — Aneurismal varix — Method of Tnfnell and Valsalva — Tjigature by the methods of Antyllus, Wardro]). Anel. Hunter, and Brasdor — Digital and mechan- ical pressure — Galvano-puncture, massage, flexion, introduction of wire, horse-hair, catgut, etc. — -Aneurism of the thoracic aorta — Innominate — Common external and inti'rmil ca- rotid arteries — Subclavian — Abdominal aorta— Iliac arteries — Femoral — Popliteal . . 198 CHAPTER XI. Ligation of arteries — Innominate — Common, external, and internal carotid and internal jugu- lar vein — Superior thyroid, lingual, facial, ascending pharyngeal, occipital, ])Osterior auricular, temporal, and internal maxillary— Subclavian— \'crtebral and internal mam- mary — Axillary — Brachial — Radial — Uliuir — Intercostal — Abdominal aort.a — Iliac arteries —Gluteal, internal pudie, and sciatic— Femoral— Profunda femoris— Popliteal— Poste- rior tibial — Anterior tibial — Dorsalis pedis 230 CHAPTER XII. Surgical diseases and surgery of the bones— Ostitis— Osteo-iieriostitis-Osteomalacia-Rachitis —Fractures— Of the skull— Trephining— Nasal l)ones— Malar— Superior nuixilla- Inferior maxilla— Clavicle— Acromion and coracoid process— Glenoid process— Spine of the scapula —Humerus — Comlyles — Olecranon process — Ulna — Radius — Colles's fract ure — Carpus— Metacarpus— Phalanges— Sternum— Ribs— Vertebrie— Sacrum— Coccyx— Osinuominatum —Femur— Patella— Leg— Potfs fracture— Tarsus and metatarsus— Ununited fractures . 371 CHAPTER XIIT. Surgery of the articulations- Dislocations— Lower j.iw-Claviclc-Shoulder-joint— Elbow- joint — Wrist-joint — Carpo-metacarpal joints — Phalanges — Hip-joint — Knee- joint— Pa- tella— larsus—A'ertebr,T— Ribs— Arthritis— Hip-joint disease, or mnrhua cara-— Knee- joint disea-sc— Ankle-joint— Shoulder-joint— Elbow-joint— Wrist-joint— Exseetions of tin- joints CHAPTER XIV. Regional surgery— The head— Tumors of the scalp— Absccss—Pneiimatocele— Encephalocele— Meningocele— Neoplasms of the meninges— Hydroceiihalus- Wounds of the scalp— Of the 319 CONTENTS. ix brain — Cerebral localization — Surgery of the face — Surgery and surgical diseases of the eyelids and of the orbital cavity (not including lesions of the globe) — Sebaceous tumors — Hordeolum — Chalazion — Blepharitis — Conjunctiritis — Ophthalmia neonatorum — Oonor- rhceal ophthalmia — Symblepharon — Ectropion — Entropion — Ptosis — Trichiasis — Eiiiphora — Neoplasms of the orbital cavity — Surgery of the ear — The nose — Epistaxis — Foreign bodies — Rhinolites — Neoplasms — Deviation of the septum — Plastic surgery of the nose, lips, and cheeks — Lupus — Ilare-Iip — Cleft-palate — Cheiloplasty — Parotid gland and duct — Submaxillary gland — The jaws — Removal of tumors from the antrum of Highmore — The teeth — Palate — Staphylorraphy — Tongue and buccal cavity — Tonsils .... 373 CHAPTER XV. The neck — Wounds — Abscess — Tumors — Thyroid body — Thyrotomy — Laryngotomy — Laryn- go-traeheotomy — Tracheotomy — Exsection of the larynx — Intubation of the larynx — Foreign bodies in the air-passages — Neoplasms of the larynx and trachea — Pharynx — (Esophagus — Foreign bodies — CEsophagotomy for stricture — New formations — OEsopha- gectomy • 444 CHAPTER XVI. Thorax — Mammary gland — Mastitis — Abscess — Hypertrophy — Tumors — Exsection of the clavi- cle — Empyema — Wounds of the chest 465 CHAPTER XVII. Abdomen — Stomach — Gastrostomy — pyloreetomy — Gastrectomy — Gastro - pyloreotomy — Gas- tro-enterostomy — Duodenum — Obstruction of the alimentary canal — Impaction of fecal matter — Foreign bodies — Intussusception — Volvulus — Constriction by bands — Adhesions — Omental and mesenteric slits — Diverticula — Neoplasms — Stricture — True hernia — Ab- dominal section for intestinal occlusion — Exsection of the intestine — Fecal fistula — En- terocele — Epiplocele — Inguinal hernia — Congenital — Infantile — Femoral, umbilical, ven- tral, diaphragmatic, gluteal, obturator, lumbar, and v.aginal hernia — Colostomy — Peritoni- tis — Alidominal abscess — Liver — Hepatic abscess — Hydatid cyst — Spleen — Wounds of the abdomen — Intestinal suture 47 CHAPTER XVIII. Rectum and anus — ."Vtresia ani et recti — Pruritus ani— Foreign bodies — Fistula; in ano at recto — Fissure — Ulcers — Stricture— Neoplasms of the rectum and anus — Neuralgia — Pro- lapsus — Haemorrhoids 528 CHAPTER XI.X. Genito-urinary organs — Kidneys — Suppression of urine — Nephrotomy and nephrectomy — Ure- ters — Bladder — Wounds — 1 ufilt ration of urine — Cystitis — Paralysis — Incontinence — Neo- plasms — The urine — Stone — Lithotrity — Lithotomy — Prostate body — Spermatorrhoea — Asperraatism — Urethra — Gonorrhoea — Balanitis — Posthitis — Gonorrhavil rheumat is:n — Gleet — Stricture — Mcatoniy — Internal urethrotomy — Dilatation — Jlodilied inti'rnal ure- throtomy — External urethrotomy or perineal section — Sounds — Foreign bodies in the ure- thra — Congenital and acquired malformations — Neojilasms — Cancer of the penis — .Vnipu- tation — Humphrey's operation — Phimosis — Circumcision — Dilatation of the prepuce — Ulcers of the penis — Syphilis — Scrotum — Hydrocele — Varicocele — Epididymis — Testicle — Hysterotomy — Hysterectomy — Ovariotomy 555 X CONTENTS. CHAPTEK XX. PAGfU Deformities of tlie spine — Torticollis — Lateral iiiul rotarv-lateriil curvature — Scoliosis — Cypho- sis — Spoiiilylitis — Spina bifitla — Deformities of the lower extremity — Preternatural mo- bility of the hip — Sub-troehantcric osteotomy — lienu valgum — (ienu varum — Talipes — Polydactylus — Syndaetylus — Hallux valgus — Ilaiumer-toes — In-growing Nail — Deformi- ties of the iipper extremity — Club-hand — Weli-(inger — Snap-finger 691 CHAPTER XXI. Tumors — Carcinoma — Epithelioma — Lymphadenoma — Sarcoma — Papilloma — Adinoma — Cysts — Lipoma — Fibroma — Myxoma — Myoma — Neuroma — Angioma — Lymphangioma — Chondroma — Osteoma 'I4ii A TEXT-BOOK ON SURGERY. CHAPTER I. SURGICAL DRESSINGS. The materials used in the performance of a surgical operation, and in its after-treatment, form such an important part of the surgeon's outfit that I have determined to devote the initial chapter of this book to a description of the methods of preparing and preserving the apparatus needed for dressing wounds in the antiseptic practice of to-day. This practice, which embodies the great principles of cleanliness and carefulness in surgery, is nt)w so well established among the best sur- geons in America and Europe that any argument in its favor, as compared with the methods of one or two decades ago, I consider to be wholly unnecessary. Ligatures and Sutures. — Catgut, silk, silk-worm gut, and silver wii'e will meet every requirement in tying vessels and closing wounds. Catgut has practically superseded all other substances as a ligature. The con- ditions which would justify the application of a silk, metal, or any non- absorbable ligature to an artery are rarely present. Strings or cords made from animal tissues, as buckskin, ox-aorta, nerve, tendon, and whalebone, known under the general name of "broad ligatures," have been successfully employed in the occlusion of the larger vessels, but their use is limited in comparison with that of the violin-strings, which are easily obtained, prepared and preserved, and are, moreover, cheap. In the preparation of catgut select four sizes of the best quality of violin- strings in about this proportion : one dozen each of the E and A strings, six D strings, and two or three harp-strings about twice as large as that of D, violin. The smaller sizes are most generally needed for the smaller vessels and bleeding points, the D string is best adapted to ves- sels as large as the radials, idnars, or tibials, while the larger or harp- strings should be iised upon the iliacs, subclavians, common carotids, and femorals. Preparation. — Cut and remove the small red threads which are tied around each bunch, and place the catgut in a glass bottle or jar which 1 A TEXT-BOOK ON SURGERY. Fin. 1. contains enough pure oil of juniper-ben- ies to completely cover tlieiii. The vessel should be tightly corked to prevent evaporation. AVithin twenty-four hours the niatt-rial is safely aseptic, and will remain so in- deMnitely ii' kei)t iniiuersed in the Huid. Tlie strength ^v of the gut is not impaired, while its firmness is in- ^L^ creased by the oil. ^™^ If oil of juiiipet can not be obtained, 95 per cent alcohol is etjually aseptic, and may be used instead. Alcohol, however, softens the strings more than juni- per, and is not to be preferred. Fig. 1 represents a convenient apparatus for holding tliese ligatures. It consists of a glass jar or bottle, with a wide mouth, in wliich a perforated cork is fitted. Within the bottle are several glass spools upon which the ligatures have been wound. The ends i)roject through the perforation in the cork, and are held here by a small(>i- cork fitted into the perforation. Upon removing the smaller plug, the threads may be drawn out and cut off as required. Another vessel is pictured in Pig. 2. In this the ligatures are wound around a central shaft, wliicli is ])ulled completely out of the bottle when the threads aiv mi'ded. Maceweu has introduced a rlnoii/ic-dcid catgut liga- ture, wliich resists absorption much longer than juniper or alcohol gut. His method is: chromic acid one part, water live parts (by weight). To one part of this solution add twenty parts of glycerin, and allow the violin-strings to remain immersed for seven or eight months. They are then preserved in carbolic acid one part, to glycerin ten (1 to 10). Thus prepared, catgut will resist absorption from twenty to sixty days. 8ilk is invalualde for sutures. It is not to be used for ligatures, ex- cept in certain operations within the abdominal cavity, or in wounds which are to be treated by the open method. This material should be selected of all sizes. I prefer the twisted to the braided threads, although the latter is less likely to become tangled. The very finest black iron- dyed silk is needed in the plastic surgery of the neck and face, in the white individual. "White sutures often became so discolored that they are with difficulty found when the time for their removal arrives. The larger silk sutures, such as those employed in tying hemorrhoidal mass- es, should be so strong that any ordinary force can not break them. All silk threads should be kept dry, and well wrapped in protective or oil- silk, or corked in jars. A half-hour before using them they should be soaked in a 5-per-cent solution of carbolic acid. Silk-worm gut comes in bristles, or stiff threads, about ten inches in length. It may be used as a suture in any part of the economy, but it is essential only in the operation for cleft i)alate. It is not absorbable, is very strong, ties easily, and does not slip. It should be kept in an ordi- Fu; SURGICAL DRESSINGS. nary dry box, and need not be rendered aseptic for operations on the palate. Silver loire is invaluable as a suture-material. Beyond the operations upon the genito-urinary oi'gans of the female, where it is indispensable, it is preferable to silk in many wounds of other portions of the body. The sizes most required range from Nos. 24 to 31, inclusive. A most convenient, way of carrying silver for immediate use is to cut it in pieces about ten inches in length, and place it in a metal cylinder (Fig. 3), which is divided into three or four compartments, and closed by a screw-top. Or the wire loops may be wrapjDed in jji'otective or blotting-paper, and thus kept free from moisture in order to prevent rust. They are rendered aseptic by immersion in 1 to 20 carbolic acid one half-hour before using them. Solutions. — For ii'rigating wounds, submerging instru- ments, and disinfecting in general, solutions of corrosive sub- limate and carbolic acid are necessary, and pure alcohol, iodo- form, and chloride-of-zinc solutions may at times be used. Koch has demonstrated that, as a germ-killer, corrosive sublimate excels all known agents. The sublimate solutions vary in the proportion of one part of the bichloride to five hundred parts of distilled water by weight, or 1 to 500, 1 to 1,000, 1 to 2,000, 1 to 3,000 for use outside of the gi-eat cavi- ties, and 1 to 8,000, 1 to 15,000, and 1 to 20,000 within the cavities. The sublimate solutions are only used for irrigation and for disinfecting the hands, sponges, and gauze. All instru- ments are submerged in carbolic-acid solutions or in alcohol. The stronger solutions, 1 to 500 and 1 to 1,000, are rarely employed in irrigation, and then only when the jjart exposed has been made bloodless by the Esmarch bandage. Even when thus employed for the disinfection of an abscess cav- ity, ulcer, or sinus, the excess of sublimate should be imme- diately washed away by flooding the part with the 1 to 3,000 solution. In any ordinary operation no stronger sublimate than 1 to 3,000 will be required ; a 1 to 10,000 solution may be used in the peritoneal or thoracic cavity where the con- ditions are such that the fkiid may run out or be removed at once by sponges. I have filled the entire abdominal cavity i"""- 3. with warm sublimate, 1 to 18,000, mopping it out with sponges, and repeating this procedure three times without any bad symptom resulting. For convenience, any required solution may be made from the follow- ing : Corrosive sublimate, gr. xxx ; water and glycerin, each, § ss. Some add to this about gr. x of table-salt. One teaspoonful of this solution added to a pint of water approximates 1 to 2,000. "Water containing lime should not be used. Tablets of corrosive sublimate are now manufact- ured, and are very convenient for transportation. Each tablet contains A TEXT-BOOK ON SURGERY. Flu. 4. — Weir's antiseptic spray-machino. enougli sublimate to make, when dissolved in a pint of water, a 1 to 1,000 solution. It is best to make fresh solutions when needed, for, un- less kept tightly corked and away from light, they deteriorate in value. CarbuUc acid (1 to 20, or a 5-per-cent solution) is employed for the cleansing and submersion of all instruments used in a surgical ojiera- tion. It is not used in irrigation on account of its irritating properties. The steam and carbolic spray so much in vogue a few years since is now only used to lay the dust, or as an aid to- ward the more thorough cleansing of operating- rooms and wards which are especially exposed to infection. The spray- machine (Fig. 4) is start- ed one half-hour before the operation is to commence, and is allowed to run until that time. The strength of the solution in the bottle is 1 to 20. As ordinarily sold, carbolic acid is dissolved in alcohol, and is about 95 per cent strong. In this condition an ounce by measurement is an ounce by weight. To this quantity add glycerin 3 j, and water 3 xix, which will make a 1 to 20, or 5-per-cent solution. All instruments are immersed in this solution a half-hour ])efore the operation, except the blades of the knives, which should be dipped in only a minute or two before being nsed. Pure alcohol is also nsed for this purpose by some operators who dis- like the benumbing effects of the acid. loduform, one part dissolved in seven parts of ether, is used at times to wash the parts where an operative wound is to be made. It is not an uncommon practice with some of the German surgeons to immerse all the ligatures and suture-material in this solution for about twenty minutes before the operation is begun. Chloride-of-zlnc solution in water (1 to 12, about 8 per cent) may be used to wash out ulcers or old sinuses which ere in the neighborhood of, or communicate with, the wound of operation. This and the iodoform solution are not, however, essential, and are now rarely employed. Irrigators. — A rubber bag, capable of holding two quarts of solution, with extra long tubing attached, makes a convenient irrigator for use and transportation. The ordinary fountain-syringe, represented in Fig. 5, is commonly used. The nozzles should be of smooth glass, sufficiently heavy to resist breakage, about three or four inches in length, not more than a quarter of an inch in gross diameter, slightly pointed, and with a lumen of one eighth of an inch. Sublimate solution should not l)e allowed to remain in contact with rubber for any considerable time on account of SURGICAL DRESSINGS. its con-osive action. When an operation or dressing is completed, after the sublimate escapes, pure water should be run through the irrigator. A good emergency irrigator is shown in Pig. 6. It is made by placing a perforated cork in an ordinary wine-bottle, fitting a piece of glass tube, or cane, or goose-quill into the perforation to which the rubber hose is at- tached. The bottom of the bottle is broken Fig. 6.— (Esmaroli.) Fi.i. 5. in, and a string netting, thrown around for susj)ension, comjjletes the apparatus. If there is no stop-spring to shut off tlie flow, it may be readily aiTested by placing the nozzle in the upper end of the bottle. The assistant who attends to the irrigator can always regu- late the flow by slight pressure of the tube between the thuml:) and finger, just where the nozzle is attached. Tin or brass vessels may also be em- ployed, but the corrosive action of the mercury soon destroys the metal. When no irrigator can be had, the sublimate solution may be poured on from a i^itcher or cup. For continuous irrigation, as in an amputation treated by the open method, a constant dripping may be secured by twisting a piece of muslin or cotton cloth into a loose wick-like string, moistening it, and placing one end in a vessel holding the solution, while the other hangs over the edge from a point where the fluid ^^^ll fall on the wounded surface (Fig. 7). Sponges. — In selecting sponges, secure those of softest and finest text- ure, measuring, when dry, from one to two and three inches in diameter, the greater number spherical in shape, with a half-dozen flat jneces a half-inch thick, three or four inches wide, and from six to ten inches long. When purchased in the rough they should be thoroughly whipped until aU the sand is removed, and then washed in cold or lukewarm 6 A TEXT-BOOK ON SURGERY. water. Two methods may be employed for blearliing. Tlie simpler way is to soak them for from six to eighteen hours in a mixtui'e of one X'art Fig. 7. of liquor s(xl;e chlorinatje to five of water, rinse them in elear cold water, and dry thoroughly. A more complicated but very efficacious method is the following :* Place the sponges in a solution of permanganate of po- tassa, 1 to 100 (about gr. v- 3 j of water\ for one half-hour ; rinse in clear cold water, squeeze thoroughly, and immerse them in a solution of oxalic acid (1 to 50) for ten minutes. Rinse again in clear water, leave them there for one hour, and then dry quickly in a warm oven. Sponges may be kept dry either in tightly corked glass or stone jars, or wrapped up in protective, and put away in a clean drawer. They may also be kept indefinitely in a 1 to 20 carbolic-acid solution, but should not be kept any length of time in sulilimate solution. f When a sponge has been once used it should be destroyed, unless the circumstances are such that other and fresh pieces can not he obtained for a succeeding operation. Even under such conditions, if tliey have been brought in contact with septic matter, it should be imperative to destroy the sponges and proceed with- out them, using clean cloths, or towels, or borated or absorbent cotton in their stead. To cleanse sponges which have been used, wash them thorough- ly in different changes of warm water (not hot), and, when they no * To Mr. Anselo, druggist, of Fourth Avenue and Thirty-first Street, New Yorlv, I am indebted for this formula. t Mr. Charles G. Am Ende, 108 Washington Street, noboken, New Jersey, prepares sponges that are soft, clean, and very satisfactory, as well as cheap. SURGICAL DRESSINGS. longer discolor clear water, immerse them in 1 to 500 sublimate for one hour. In all operations, sponges, before being used in the wound, should be dipped in 1 to 3,000 sublimate solution, and then squeezed as dry as possible. Drains. — Ruhher tubing, Neuber's hone drains, and twists of catgut or horse-liair, are chiefly to be relied upon in draining wounds. Rubber is most generally useful. The softest tubing should be selected, of vari- ous sizes, from that which has a lumen of one half-inch in diameter down to one sixteenth. Before it is inserted it should be bent over the flnger, and with a j)air of curved scissors clipped full of holes about a half-inch apart, as seen in Fig. 8. Rubber drains shoidd be kept dry in clean jars, from which they are taken and placed in 1 to 20 carbolic acid solution when the operation for which they are needed is begun. When a wound is to be dressed only once — the "permanent dressing" — absorbable ani- mal drains should be inserted. For this purpose Neuber's bone tubes (Fig. 9) are preferable. They are made from the bones of young and healthy animals. The crude bone is cut of j^roper length and size, bored out, turned on a lathe round and smooth, and perforated laterally. Immersion in 33- per-cent muriatic acid for twelve hours com- pletely decalcifies them, after which they are kept (as recommended by the inventor) in 1 to 20 carbolic-acid solution, frequently re- newed. I prefer to keep them in alcohol, 95 per cent, or oil of juniper, which preserves them aseptic and hardens them, rendering a too rapid absorption less likely. The tubes are from three to five inches long. There are four sizes : the caliber of No. 1 is six, No. 2 is five. No. 3 is four, and No. 4 three millimetres in diameter (one millimetre is approximately 5^ of an inch). The walls are from one to one and a half millimetre in thickness. These drains can be prepaied readily from Fig. 8. the bones of fowls by scraping the perios- teum off and the marrow out, soaking in muriatic acid (33-per-cent solu- tion) as above, and then in ether for a few hours before transferring them to the alcohol.* Bone drains will be absorbed in from five to twenty days, and are excellent in permanent dressings. Catgut or Jiorst'-Jiair twists or skeins are at tunes employed for drain- ing small wounds, and are very satisfactory. The violin-strings are twisted into a bunch, as shown in Fig. 10, and laid in the wound at vari- * If the bones used are from fowls wliich have been cooked, Macewen reponimocds tliat the hydrochloric-acid solution should he one to five of water, and that the tube, when in- serted into the wound, should be threaded with horse-hair to prevent collapse from pressure, and to facilitate the removal of clots without taking' out the tube and irritating the wound. Fio. 9. Fig. 10. 8 A TEXT-BOOK ON SURGERY. oils points, so as to project at the lower angles or in such i)ositions as will secure the most perfect drainage. The hair is taken from the mane or tail, washed clean, and immersed for twenty-four hours in oil of juniper. It is twisted iu the same manner as the catgut. Protective. — Thin rubber tissue, oil-silk, or Mackintosh cloth, may be used to protect the part from atmospli(>ric clianges, and to ])r('vent the evaporation and volatilization of the antiseptic agents. The former is preferable, and the oil-sOk is next in order. Rubber tissue must be kept in a cool, dry spot, and should be dipped in 1 to 3,000 sublimate before it is applied. Gauze. — Ordinary cotton muslin f)f light texture, commonly known as cheese-cloth, impregnated with corrosive sublimate or iodoform, is widely used as antiseptic gauze. Carbolized gauze has passed out of use. To make sublimate gauze proceed as follows : Cut a bolt of cheese- cloth into pieces a yard long, and place in boiling water for eight hours. Then rinse thoroughly in cold water, and bleach in liquor sodse chlorinatae (one part to five of water) for twenty-four hours. Rinse again in clear water, and leave the cloth in a tightly covered jar or tank of 1 to 500 sublimate indefinitely. When the gauze is about to be used, squeeze the water out of it and wet it in fresh 1 to 3,000 solution, and again squeeze it until it is only fairly moistened, not dripping, with the solution. Am Ende's sublimate pink gauze is an excellent pi-eparation. It is stained with eosine, which is a color-test upon the purity of the gauze, for, if the mercury is decomposed or volatilized, the eosine goes with it and the gauze is left white. lodoformized gauze is made by moistening the washed cheese-cloth in 1 to 3,000 sublimate, sprinkling it with powdered iodofomi from a pepper-box, and then working the powder into the meshes of the cloth until it is a golden-yellow color. It should be made fresh, although it may be preserved for one or two weeks in tight glass jars, wTapped in red or blue paper to prevent the decomposition of light. Borated absorbent cotton is now almost indispensable in surgical practice. It is used not only to protect the part and to exercise com- pression, but, for purposes of cleansing and dressing wounds, it has en- tirely superseded sponges, and is not only cheaper, but preferable in every respect. It is so difficult to prepare, however, that the practitioner is almost compelled to patronize the manufacturer. When an emergency demands it, ordinary ginned cotton of clean fiber may be bleached and softened by treating it in the same way as given for the cheese-cloth. It can be charged with boracic acid by immersing it in a solution con- taining gr. XV to 3 j of water. It is then dried and wrapped in protect- ive until needed for use. Well-prepared borated cotton is, next to gauze, the most suitable ab- sorbent of discharges from wounds. Beyond these two substances noth- ing is really needed. Pads or bags of peat, sawdust, jute, wood-wool, etc., are practically useless. CHAPTER 11. BAJfDAGI^'^G. Baxdages are employed in surgical practice to retain dressings in position, to secure compression and supi^ort to any portion of the body, to maintain any required degree of immobility, and to render an extremity partially or completely bloodless. They are made of cotton muslin of various degrees of fineness, crino- line, woolen goods, and India rubber. Cotton bandages are most gener- ally employed, but, on account of the greater elasticity of flannel, these are preferable for certain special di-essings. Ci'inoUne is only used for plaster-of-Paris bandages. Martin's rubber bandage and Esma'rch's blood- less tourniquet are very useful in maintaining the finn compression of a part, either as a means of support or of emptying the vessels. The muslin should be soft, not starched, and of two kinds — a fairly heavy quality, and the light cheese-cloth. Both should be cut in pieces from eight to ten yards in length. The fonner can be torn ; the latter must be cut. The selvage edge is removed, and the cloth divided into strips varying in width from four, three, two and a half, and two inches, with some one inch or less in width. For the chest and alxlomen the wide bandages are needed, the two- and three-inch strips for the arms, legs, head, and neck, and the narrow strips for the hands and tingers. All the loose ravelings along the edges should be pulled off, and the bandages made into compact, smooth rollers. Bandages may be rolled by hand, yet it is a tedious and tiresome business, and an utter waste of time, when the work can be better and more rapidly done by machinery. In Fig. 11 is pictured a bandage- roller, simple in construction and cheap. It should be fastened to the edge of a solid table by screws or movable clamps. The end of the strip to be wound is passed in and out over the four bars at the base and apex of the machine, and then around the sliaft, so that one edge of the bandage touches the end of the u])right. As the crank is turned, the strip is held tightly, and. as it runs over the rods, wrinkling or fold- ing is pi'evented. A home-made apjiaratus may be constructed as fol- 10 A TEXT-BOOK ON SURGERY. lows : Tiike a cigar-box, remove the top and one end, bore a liole in each side-piece near the open end, and through these pass a piece of telegraph- wire bent in the shape of a windhiss and crank. Wires may be run through at other i)oiuts to serve tlie same purpose as tlie four rods in the other machine. In making plaster-of-Paris l>andages, these same machines may be em- ployed, but the crinoline must be loosely rolled, and tlie powdered plaster worked in with the hands so well and thoroughly that the meshes of the cloth can not be seen. Considerable experience is required to prepare a good plaster bandage, and a poor one will spoil a dressing. Plaster band- ages should be made from fresh gypsum on the day they are to be ap- plied. Cotton and flannel bandages should be kept in a chest or closet away from dust and moisture. Ilethods of applying Bandages. — The various portions of the body may be bandaged by the simple spiral, reverse spiral, s imple Jtgure-of-H, and the figure-of-S reverse. The simple spiral tiirn is most useful in bandaging those parts of the body where there is no sudden increase in the diameter and volume of the part. It is impracticable xmder other circumstances. Hold the bandage .in the hand most convenient, with the back of the roller toward the limb (see Fig. 12) ; with the unoccupied hand take the Fig. 12, Fig. 13. free end of the liandage, lay and hold it upon the inner border of the limb, and carry the turn by the front to the outer side of the part to be bandaged. Having cariied the roller twice ai'ound the part to secure it, ascend the limb spirally, leaving about one thii-d of each turn uncovered by the last. BANDAGING. 11 The recerse-spiral turn (Fig. 13) is applied as follows : Taking tlie left arm to be bandaged, hold the roller in tlie right hand, with its convexity toward the limb, and carry it from the inner or ulnar border, by the front, to the outer or radial border, and thus around tho arm by two circular turns to secure the roller. Then, having carried the l:)andage to the outer side, ascending the limb gradually, lay the thumb of the left hand upon the lower edge of the bandage, press it fii'mly against the limb to prevent slipping, loosen the roller considerably in the right hand, at the same time turning it one-half turn toward the operator. This process is to be repeated as often as necessary, keeping the reverses well upon the outer border and anterior aspect of the extremity. Th e Simple. Fig ii re - of- 8 Turn. — After the bandage is se- cured, as heretofore described, ascend the limb shaq^ly, from the inner to the outer border, so that at this outer border the lower edge of the roller shall be several inches above the start- ing-point. Carry the roller di- rectly across and behind the limb to the same point on the opposite side ; then obliquely downward in front, crossing the ascending turn at a right angle. AVhen the outer border is again reached, carry the roller behind and directly across the limb to the starting-point (see Fig. 14). The Figure- of -8 Reverse. — Commence exactly as for the simple figure-of-8 until the band- age has passed across the pos- terior aspect of the liml), and is about to descend obliquely along the inner aspect to the front. With the index-finger of the unoc- cupied hand hold the lower edge of the bandage tightly against the part, while the roller is .slackened and turned half over in a direclion away from the limb. This reverse in the figure-of-8 may also be made ante- riorly, and, when the conformation of the part demands it, may be made both anteriorly and posteriorly. Of these four methods, the simple spiral is more readily applied. When the diameter of the extremity increases rapidly it will not suffice, since it grasijs the part at the upper edge of the roller while the lower stands out free and loose. For all purposes the spiral reverse is more generally useful. In competent hands it can be applied to all portions of the body exce])t where the members join the trunk, when it nuxst give place to the simple Fin. 14. — The fiortion of this bandage which goes around the thigh, groin, and pelvis is called the sinr/le spica for the groin, and is admira- bly adajited to the retention of a dressing upon a bubo or wound of this region, and also makes an efficient temporary compress for the sup- ]iort of an inguinal hernia. A double spica with a single roller may be made by carrying the roller, which has already partially covei'ed in the groin and hip of one side, directly across the back to a point half-way between the trochanter and anterior iliac spine of the opposite side, over the front of the thigh to the inner side, and thence behind and outward, describing a ligure-of-8 around the thigh and pelvis in a direction the reverse of the preceding (Fig. 20). The abdomen and thorax should be bandaged hw the simple or re- verse spiral until the axilla is reached in the male, and the mammary gland in the female. Fig. 20.— (After Fischer.) Fig. 21.— (After FUcher.) To bandage the mammary gland it is best to place a thin layer of absorbent cotton over this organ, and under the axilla as well. The roller, about three inches wide, should be carried two or three times around the thorax just below the breast, which, if pendulous, should be lifted well up toward the clavicle. If the right breast is to be bandaged, the operator, standing in front, should carry the roller from the patient's right to the left side, around the body, and then obliquely upward across the front of the chest, catching the under stirface of the gland, passing over the left clavicle, making a figure-of-8 around the .shoulder and axilla, and then across the back to the starting-point (see Fig. 21). It is now carried directly around the chest, and, when the circuit is completed, again travels obliquely upward on a plane about one inch higher than the preceding turn. This is repeated until the organ is entii'ely covered. When both BANDAGING. 17 (Afa-r Fischer.) breasts require support, the second may be bandaged in the same way by an additional roller, or, as shown in Fig. 22, a single bandage may be thrown around the thorax and neck in fig- ure-of-8 fashion, so as to support both organs. Bandages for the Head and Face. — For retaining ice-caps, or other dressings to the head, the hood-bandage will be found convenient, while its modifications will suffice to keep a dressing upon any limited portion of the scalp (Fig. 23). To apply this, take a roller twelve yards long and two and a half inches in width, rolled from both ends to the center. Hold- ing one head of the roller in each hand, the surgeon, standing behind the patient and laying the middle of the bandage across I the forehead just over the eyebrows, car- ries one roller in the right and the other in the left hand around the head, above the ears, and crosses them under the occiput, so that the roller which went to the rear in the left hand will travel again to the front over the same path. The roller in the right hand is then carried over the head, in the median line, from the occiput to the nose, and at this point it is caught and held down by the encircling turn carried in the left hand. Then cany the roller which came over the median line of the head back again to the I / -.f^^ rear, so that its right edge will rest on the middle ((,^\ of the first turn. It is again caught under the " " encircling turn at the occiput, is carried to the front on the opposite side, and continues to travel fi-om before backward in an ellipse that is con- stantly increasing, until it blends with the encir- cling turn upon the sides of the head, near the ears. Each successive turn of the elliptic should leave al)Out one third of the turn that preceded it uncovered in the cen- ter. Of course, the ends will meet at the same point, before and behind, where the reverses are made. If it is only required to maintain a dressing in the median line of the scalp, it will suffice to carry a circular turn or two around the head, just above the eyebrows and ear.s, and below the occiput, AvhUe an antero- posterior strip is pinned to this in front and behind. The Head and Chin Bandage (Fig. 24) may be made to serve sev- eral purposes — namely, to retain a dressing on the chin and lower face, the same upon the scalp at any portion, and also for temporary fixa- tion of the lower jaw after fracture of tliis bone. It is applied as follows : 2 Fig. 23. 18 A TEXT-BOOK ON SURGERY. The end of a bandage from one inch and a half to two inches in width is held about half-way between the left ear and the occipital protuber- ance, while the roller is carried to the front and obliquely across the head, just in front of the right ear, uuder the chin, up in front of the left ear, then across the scalp, passing backward between the right ear and occiput to l)eneat]i this protuberance, when it is cairicd beiu'ath the left ear straight across the front (u* labial aspect of the chin, and around by the right side to the point of commencing. This manoeuvre should be repeated several times, and the dressing then completed by carrying the roller twice around the head above the ears and eyebrows, and be- neath the occiput, and pinning a strip along the median line of the scalp at the various points where the turns cross each other. Knotted Bandaffc. — This dress- ing (Fig. 2.')) is sometimes em- Fio. 24. Fio. 25.— (After Berkeluy Hill.) ployed in the aiTest of haemorrhage from wounds of the temporal and other vessels of the scalp. Take a piece of cork or wood, about an inch in diameter and one quarter of an inch in thickness, and wrap it with sublimate gauze or lint to make a compress. Apply this to the bleeding point, and lay over it the center of a double-headed roller, carrying the turns around the head, above the ears. They are then crossed over the comjjress, one end is carried under the chin, the other over the top of the head, and are again crossed on the opposite temple. Having carried the rollers again around the head, and crossed them firanly over the compress, the ends are pinned securely and cut off. A horizontal slip may then be pinned to the anterior, middle, and posterior slips of the knotted bandage, be- ginning in the median line on the forehead, then back to the center of the middle slip, and then to the slip underneath the occiput, to hold the dressing securely in position. To band?jge the eye (the left, for example), hold the end of the strip half-way lietiveen the right ear and occiput, and bring the roller forward over the left eye and malar eminence, and around backward beneath the ear and occiput to the i)oint of starting, and repeat once. When the second turn arrives at the right ear it should pass above this and com- BANDAGING. 19 pletely around the skull, just above the eyebrows and below the occiput, in order to secure the oblique turn. Complete the dressing by alternating between the horizontal and the oblique direction of the roller (Fig. 26). For the upper lip a dressing is readily secured by a narrow band- age passing horizontally around Fig. 27. Fig. '2Ij.— (After Esniarch.) beneath the nose and ears, and held in place by the head-stall attachment, as in Fig. 24. HandJierchief Bandages. — In addition to the foregoing, emergency dressings for different parts of the body may be extemporized from pieces of cloth cut in vax-ious shapes — the so-called TiandkercMef bandages. Head and Face. — A simple hood (Fig. 27) may be made as follows : A piece of soft muslin is cut, 27 by 23 inches, folded over for 6 or 7 inches along its greatest measurement, and laid upon a table, with the short piece underneath. Place the index-finger at the middle of the folded edge, and turn the nearest corners toward the center, forming a pyramid. Now roll the remaining straight edge up until it is on a level with the edge which was turned under, and place upon the head, so that this edge will be put above the eyebrows, while the rolled portion comes across the occiput, and the ends are pinned beneath the chin. The conical tip may be pinned down, if desired. The four-tailed cap is made from a piece of muslin, 45 inches long by 10 wide, split from each end to mtliin 4 inches of the center. Each of the four tails is 5 inches in width. Lay the center of the piece across the vertex, carry the posterior tails forward over the ears, and tie them under tlie chin and the anterior backward beneath the occiput (Fig. 28). The Jiead and face hood is made as follows : A piece of soft, light cloth, 40 inches square, is Fio. 28. 20 A TEXT-BOOK ON SURGERY. folded and laid across flie head in such a manner that tlie sliortest fold which is on top comes to the Jevel of the eyebrows, while the longer reaches to the tip of the nose (Fig. 29). The corners belonging to the < Fio. 'J!!.— (After Esmaroh.) Fic. 30.— (After Esmaroh.) fold which is parallel -with the line of the eyebrows are tied snugly be- neath the chin. The longer fold is now turned up to the level of the eyebrows, while the corners belonging to it are drawn forward until freed, and are then carried back and tied beneath the occiput (Fig. 30). For holding an ice-bag or dressijig upon the head, the sJcuU-net (Fig. 31) will be found of use. It is made of cot- ton threads, is tightened around the head by a tape, which di'aws it to- gether like the strings of a reticule, and is further secured by a strap tied under the chin. The four-tailed dress- ing for the eliiii and low- er jaw is made by split- ting a strip of muslin, 6 inches wdde and 45 inches long, from each end to within H inpb of the cen- ter, placing its middle over the chin, and turning the posterior tails up- ward in front of the ears to be tied over the vertex. The anterior tails are now carried back below the ears, crossed once, and pinned beneath the occiput, while the ends are carried upward and forward and tied upon the forehead (Fig. 32). Other special dressings will be described in the chaiJters on Regiona Surgery. Fio. 31.— (After Esmarch.) Fig. 32. CHAPTER HI. ANAESTHESIA. AncEsthesia. — Anfestliesia means loss of sensibility. It may be local or general. In the former, the sensibility of a limited portion of the body is more or less completely lost, while the patient remains conscious ; in the latter, both consciousness and sensibility are lost. Local anaesthesia may be obtained in a remarkable degree by the Ju- dicious employment of the hydrochlorate of cocaine, for the application of which agent to surgical use the world will ever be indebted to the Austrian, Roller. The 1-, 2-, and 4-per-cent solutions are chiefly used. Applied to the cornea, conjunctiva, or any mucous surface, cocaine is rapidly absorbed, the capillaries are contracted, and the end organs of the sensory nerves paralyzed. Upon the unbroken integument it px-oduces no effect what- ever. Injected into the tissues, it produces anaesthesia wherever it reaches — in bone, muscle, or the subcutaneous structures. Thrown into the sub- stance of a nerve, or immediately around it, it is readily absorbed, and produces anaesthesia in all parts in the range of distribution of the nerve- trunk beyond the point of injection. The quantity which can be safely used has not yet been determined. Applied to the eye, there is no dan- ger of absorption of a quantity capable of doing hami. Upon the mucous surfaces of the buccal cavity and pharynx several drachms of a 4-per-cent solution may be l)riished with acamers-hair pencil in the course of an operation lasting an houi-, for here the excess is washed off and diluted with the saliva, which, of course, should not be swallowed. Injected into the deeper tissues, below the face and neck, from twenty to thirty minims of a 4-per-cent solution should be the limit within at least one hour before the dose is repeated. The larger quantity should be used with great care in the selection of cases. Partial respiratory paralysis has occurred in several instances after the injection of fifteen minims of ■a 4-per-cent solution in the supra-orbital region, and in other portions of the face. Artificial respiration was necessary for about fifteen minutes. Within the distribution of the fifth nerve its administration should be especially cautious. Chlorofdi-m or ether narcosis should never be per- mitted while a patient is under the influence of cocaine. For the eye, drop two or three minims of a 4-per-cent solution into this organ every four or five minutes until from twenty to thirty minutes have elapsed. For light work, such as the removal of a foreign body, or 22 A TEXT-BOOK ON SURGERY. touching tlie lids with blue-stone, the smaller quantity will suffice ; for corneal section, iridectomy, etc., the ansesthesia should be more pro- found. In the mouth, it will suffice to paint the jiart to be an;esthetized with the 4 per-cent solution by means of a camel's-hair brush, every two or three minutes, for a half-hour before, and at intervals during the opera- tion. In this way ulcers may be cauterized, or limited incisions made with perfect insensibility, and by the employment of this agent any irritable condition of the mouth and throat may be relieved. I have operated for cleft of the soft palate in an adult with perfect ansesthesia by this method. In minor surgical operations upon the extremities, a prolonged and perfect anaesthesia may be secured by the method of Corning, which con- sists in injecting the fluid into the tissues of the part to be anjesthetized, waiting from two to five minutes for absorption of the solution by the vessels, and then keeping the cocaine in the tissues, by arresting the cir- culation, with a rubber tourniquet applied between the injection and the heart. The efficiency of this method has been amx)ly demonstrated. The twenty or thirty minims of 4-per-cent solution should be distributed equally in the line of the incision. A single puncture with the hypoder- mic needle will suffice to allow the fluid to be thrown over an area an inch in length, and the effect is so rapid that the second puncture can be made through the ansesthetized skin. The needle, after passing through the integument, travels along just beneath it to its full length. One or two minims are then forced out, the needle withdrawn a quarter or half inch, and a like quantity discharged. If a deep incision is re- quired, the needle should go into the deeper tissues. One advantage of this method is that a smaller quantity of cocaine will produce a greater degree of anfesthesia, and with less constitutional effect. When as much as thirty minims are used, the excess may be squeezed or pressed out of the part, or washed out with the irngator. As to the length of time for which a tourniquet may safely remain holding the part beyond full of stagnant blood, I would say that a half-hour would be within the limit of safety. I have constricted the penis continuously for an hour in cir- cumcision, the great toes on several occasions for more than half an hour in removing ingrowing nails, and the arm for half an hour in a number of cases. It is, however, not always necessary to entirely arrest the cir- culation of a part, for, if the elastic be applied close behind the part to be incised, the superficial compression wiU retard the flow at this point, while the deeper vessels and remote capillaries are not materially inter- fered with. In minor operations upon the trunk, face, head, and neck, greater precaution must be taken, for here the solution is carried directly to the center. This is especially necessary in the head and face, for reasons above given. A weaker solution should be employed. The deeper injections into muscle and around the ends of broken bones are equally efficient, though of necessity infrequent, since no for- midable operation should be undertaken which would require the use of a large quantity of cocaine. The details to be obsei-ved in special opera- ANiESTHESIA. 23 tions, such as amputati(m of a finger or toe, cii'cumcision, extirpation of ingrowing toe-nails, etc., will be given under the headings to which these various procedures belong. Another method of producing local anajsthesia is by means of ether spray. For this purpose the ordinary Richardson's atomizer (Fig. 33) will suffice. In purchasing this apparatus, secure one with a silver tube, not of glass, for this is too fragile, nor of gutta-percha, which is always getting stopped up. The minute atomization of the ether, and the con- sequent rapid evaporation, produces an intense cold, retards or arrests temporarily the capillary circulation, and thus paralyzes the end organs of the sensory nerves. Everything being in readiness, an assistant com- mences the atomization, holding the end of the tube from three to six inches distant from the skin, so that the shower of vapor will fall upon the area to be incised. The first sensation is one of ex- treme cold, and is at times quite painful, but this is soon followed by a sense of numbness, and later by a loss of all sensation. When this is occurring, the skin under the spray changes from the normal flush to a whitish- purple, which, by a continu- ation or sudden increase of the force of the spray, will turn white and become stiff and frozen. This last condition is to be avoid- ed in general, for the reaction from it is painful and sloughing may occur, while a sufficient antesthesia may be obtained without real freezing. When, by pinching with the forceps or pricking with the knife, insensibility is assured, the oiieration should begin, and the sjjray be continued. Ether spray can not be employed about the eye, on account of the irritation it produces, nor about the nose and mouth, on account of its being inhaled. It is in general inferior to cocaine anjesthesia, because the latter secures a more comj)lete insensibility, and the reaction is far less painful. Rhi- goline may be used instead of ether, but it is so difficult to obtain that it has been superseded by the ether. A mixture of equal parts of cracked ice or snow, and salt, applied directly to a part or wrapped in a thin cloth and laid upon the skin, will produce perfect local anesthesia, and is a fair substitute when neither the cocaine nor ether can be secured, and the emergency demands opera- tive interference. For fear of over-freezing, the mixture should be lifted frequently and the part inspected. General AncestJte.sia. — For any sini])le oi)eration which must of neces- sity be prolonged, and for all formidable procedures in surgery, complete and general narcosis should be secured. The deliberate conduct of an operation which is scarcely possible when a i)atient is not profoundly anesthetized, gives an assurance of success not to be hoped for under Fig. 33.— Richardson's atomizer, for the production of local aneestliesia. 24 A TEXT-BOOK OX SURGERY. any other conditions ; and when to this is added the ahnost ])erfect free- dom from danger in properly conducted general anjjesthesia, liow much more should the profession strive to educate the public out of tht> un- founded dread of taking an aniBsthetic. It is this fear whicli induces many patients to conceal or silently bear a malady which, if operated upon early, would prove insignificant, but which, when left until pain, exhaustion, or impending death drives them to seek relief at the hands of the surgeon, is too often formidable. One cause, and the chief one, for this unfortunate condition of affairs, is the reckless emi)loyment of these agents, the lack of precaution in i)reparing a patient for narcosis, as well as in the method of administration. Of the various ana'stlietics which have been introduced for surgical use, only two deserve to be con- sidered, and in order of preference tliey are ether and chloroform. In general, there is no comparison between these agents. Etliei- is so much safer than chloroform that the latter is fast disappearing in pi-ac- tice. In the present rapid progress of science it can not Imt be a short while until chloroform will only be employed in a very limited number of cases. The estimated death-rate after ether is 1 in 20,000, in chloro- form 1 in 3,000. All of the ol ejections to ether by the advocates of chloroform narcosis — namely, its slowness of action, irritation of the respiratory tract, nausea and vomiting, inflammability, extra quantity required, etc. — fade into insignificance when brought face to face with the fact that about seven lives are sacrificed by chloroform to one by ether. In my opinion, chloroform narcosis is only justified under the follow- ing conditions : 1. In children under six years of age, where it is less apt to cause an accumulation of mucus in the trachea and bronchi than ether. Its more rapid and less irritating action renders it preferable in this class of patients. 2. In women in childbirth where the recumbent posture is impera- tive. 3. In an emergency where ether can not be obtained. 4. In a patient who has pi'eviously been in ether narcosis, in which dangerous symptoms were caused by the ether. .5. In an emergency where it becomes necessary to perform an opera- tion within two or three hours after the ingestion of a quantity of solid food. 6. In some exceptional cases of laryngeal or tracheal stenosis. In all other conditions ether should be given. The slowness of its action is an objection unfounded in fact, for, if desired, ether narcosis can be effected within ten minutes. Irritation of the respiratory tract is only objectionable in younger children, at which age the windpipe is always narrow and easily occluded, and the fi"ame-work of the glottis soft and readily compressible. IS^ausea and vomiting are objections with- out value when the proper precautions are taken to prevent the ingestion of solid food or milk for eight hours before the administration begins. The inflammability of ether requires ordinary precaution in not allowing AX^STHESIA. 25 a light or cautery point to be brought within live or six feet of the ether cone or flask. Although I have used ether many times with artificial light, I have never seen an accident, and do not hesitate to recommend its invariable employment for night-work. The questicm of bulk or quantity can only come up in remote military or frontier practice, where transportation is difficult. The Adinhiidration of EtTier. — Complete narcosis may be obtained from ether administered by inhalation, or by being introduced into the rectum. The latter method is rarely practiced. The following points are essential in the successful administration of ether: Only the best quality of ether fortior should be employed. That manufactured by Dr. Squibb is universally adopted in America. It should have a .specific gravity not greater tban 0728, should boil violently when placed in a test-tube, subjected to the heat of the hand, and a bit of glass is dropped into it. The quantity to be used will depend in part upon the length of time required for the performance of the operation, the construction of the inhaler, and the idiosyncrasy of the patient. As ordinarily given with the All is inhaler, which allows of a free admixture of air and considerable evaporation, to maintain complete narcosis for one hoiir will consume from six to twelve ounces. The prepa- ration of the patient is important. As just stated, solid or coagulable food shoidd be foi'bidden for at least eight hours before an operation. The bowels should be moved by a laxative on the night before the an- sesthetic is to be given, and, if necessary, by enema on the morning of the same day. Great care should always be given in the selection of proper nourishment for the patient for several days at least prior to the operation. Solid food, with the exception of the eight-hour limit, is not contra-indicated unless the abdominal viscera are involved in the opera- tion. A half-hour before the anaesthesia is commenced, about two table- spoonfuls of rye whisky or brandy in a teacupful of water should be taken into the stomach. If the patient is unusually nei-vous and ex- citable, or suffering great pain or any marked iiTitation of the air-pas- sages, from one fourth to one third of a grain of morphia should be injected hypodermically about twenty minutes before the inhalation. It is important to explain to the j)atient the action of tlie agent, and, above all, to impress iipon him the entii-e absence of danger ; that, although it will at first cause him to experience a sense of strangiilation or suffoca- tion, yet this will last only for a minute. Finally, artificial teeth or any loose substance should be removed from the moiith, and the clothing loosened about the neck, chest, and abdomen. Upon a table, within reach of the etherizer or his assistant, the follo\ving articles shoiild be arranged in order : 1. A wedge- or screw-shaped piece of wood for forcing and holding the jaws apart (Fig. 34). A Sayre's periosteal elevator is a good substitute. Fig. S-l.— llurd-rubber oral scre\i~' 26 A TEXT-BOOK ON SURGERY. Fio. 35. — Goodwillie's mouth-^'a''. Goodwillio's moutli-gug iii position. Mott-Heister speculum oris. 2. A Goodwillie's month-gag (Figs. 35 and 36) for keeping the jaws permanently separated if the emergency arises. The Mott-Heister gag will do as a substitute (Fig. 37). 3. A strong tenaculum, or forceps, for drawing out the tongue. 4. A large- sized curved nee- dle, armed with a good silk thread, for transfixion of the tongue if the emergency arises. 5. Two or three curved pro- bangs with small sponges tied on, for mopping out the pharynx, throat, and mouth (see Fig. 43). 6. Several ounces of whisky or brandy undiluted ; a hypodermic syringe filled with this and ready for use ; an ordinary syringe for a whisky or warm-water enema. 7. An extra can of ether. 8. A silver trachea-tube. 9. A pus-basin or pan, in case of vomiting. 10. When an ojieration which may involve great lo.ss of blood is un- dei'taken, a ten-ounce saline solution for transfusion. The formula is : Common salt, gr. xxx ; carbonate of soda, gr. v ; water, 3 x. If necessary, the ether may be poured directly from the can into the inhaler, but the bottle shown in Fig. 38 will be found very convenient, and, as it is graduated, the quantity used can be readily estimated. As to the form of inhaler, I pre- fer that of AUis (Fig. 39) : ''The apparatus consists of a wire frame- w^ork sufficiently large to cover the lower part of the face. The wires are parallel, and about an eighth of an inch apart. Between the wires, from side to side, a stiip of bandage two and one half inches wide is J h Fig. 38. f IG. 39.— Tlie AUis inhaler. ANESTHESIA. 27 passed. The instrnnient is only about four inches long and three inches at its greatest width, and yet it consumes more than three yards of band- age when passed between all the wires. By further reference to the fig- nre it vnH be seen that each section of the bandage is separate from the adjoining one, thus ijermitting the air to pass freely to both sides of it. "Its advantages are these: The ether being very thoroughly mixed with air, the patient does not suffer from the suffocation usually felt at first inhaling ; there is a large evajjorating surface. A very much smaller quantity of ether is used, and less escapes into the room than with the usual mode of giving this ausesthetic ; the ether can be dropped from a bottle on the distal end of the inhaler without removing it fi'om the face ; the mask is soft and pliable, fitting accurately to the nose and mouth ; and, lastly, it is of very simple construction, and can not get out of order. "Over this frame is drawn a piece of stout sheet India rubber, or patent leather, which has been stitched together at the edges, so as to make a cov- ering for the frame, projecting over one end two inches, to form the mask, and at the other one inch. The ether is poured on the bandage, which fonns a close, well-made artificial sponge." A very efficient inhaler is represented in Fig. 40, consisting of a rubber flange, or mouth- and nose-piece, about 3 inches in diameter and 2 in width, slipped over the larger end of an ordinary lamp-chimney. A sponge is placed in the expan- sion of the chimney, into which the ether is sprin- kled, without removing the apparatus, and through which the proi)er quantity of air can pass in and out. In an emergency an inhaler can be made by cutting a piece of pasteboard, 12 inches long by 7 wide, shaping and pinning it in into a cylinder, and lining it with a folded towel, or other cloth. A notch should be cut out to fit over the nose, and the edges softened by wetting. Thickly folded newspaper will serve the same purpose. A hat- crown, with a segment removed and the top perforated, will answer. The cloth and paper cone should not be employed, being objectionable in not allowing a sufficient admixture of air, and in having to be lifted from the face when additional ether is required. In commencing the administration, which should be done in a room away from the preparations for the operation, a tea spoonful of ether is sprinkled into the inhaler, and the apparatus held about two inches from the lips, the assistant standing at and above the patient's head. After a minute or two a teaspoonful more is added, and the rim is now allowed to rest on the face. The i)atient is directed to breathe freely and to force all the air out of the lungs, to blow through the inhaler, and to inspire deeply. No talking should be permitted within hearing, except the Fir.. 4n.— H. >r. Sims's etber-inlialer. 28 A TEXT-BOOK ON SURGERY. words of direction and encouragement fi'Dm tlie one in authority. If at the start an inhaler is surcharged with ether, and placed closely over the mouth and nose, the irritation is so great that s]iasni of the glottis, with violent coughing, occurs, and a sense of strangulation, whicli friglitcns tlie patient, and causes an unnecessary struggle and commotion. Indiscrimi- nate conversation in the presence of a patient who is being anaistiietized should be forbidden, since it often induces boisterous conduct or un- guarded expressions from the half-intoxicated subject. In the course of five or six minutes the degree of tolerance estal)lislied will allow the ad- dition of 3 j to 3 ij of the anjesthetic, and this may be repeated in three or four minutes. At this X)eriod, about ten or fifteen minutes after com- mencing the inhalation, the face becomes flushed from capillary disten- tion, the pulse is considerably increased in power and frequency, accom- panied by delirium varying in character and degree. If the patient should now begin to struggle and resist the inhalation, the assistants should hold the arms and legs firmly against the bed or table. When help is scarce, this feature should be anticipated, and a leather strap or rope passed around the table or bed and over the legs, just above and below the knees, which should be tightened at the proi)er time. The ai-ms should be held against the bed close to the sides in full extension and supination. Every few minutes from twenty to thirty drops of the anjcsthetic should be sprinkled into the inhaler. In from fifteen to twenty minutes all movements of volition cease, the respirations are regular and soft, the pulse is slightly full and accelerated ; the pupil, which at first contracted, is now dilated, and the finger, rubbed along the eyelashes or over the cornea and conjunctiva, produces no sjiasm of the orbicular muscle of the eye ; the arms fall limp and hel])less, and I'emain in any position in which they may be placed. The patient is now in the second stage, and it should be the aim of the etherizer to keep the nar- cosis just a little beyond consciousness. If he is thoroughly trained, this can almost always be done ; and to the operator the sense of security from the danger of asjihyxia, on the one hand, and the annoyance of the patient's becoming conscious, on the other, is invaluable. In operating without a tourniquet, the color of the blood which escapes should be noticed, for black blood indicates asphyxia, its sudden cessation heart- failure. When in the course of narcosis the respiration becomes markedly ir- regular and infrequent, and the breathing stertorous in character, the indications are those of too jiro found paralysis, and the ether sliould be temporarily discontinued. Lividity of the face indicates asphyxia, and demands immediate attention. Asphyxia may occur from several causes, and in any stage of etherization. In the first stage, or stage of excite- ment, from muscular fixation, the respiratory muscles may be seized with tonic spasm, the chest and abdominal walls remain immovable, and the teeth clenched by the contraction of the muscles of mastication. The veins of the forehead, face, and neck become enormously distended, and the skin blue. Tliis condition is not infrequent in subjects addicted to chronic alcoholism. It is rare in other patients when the narcosis is gradu- ANESTHESIA. 29 ally and carefully accomplished. It should be relieved by temporary dis- continuance of the ether, forcible separation of the jaws by means of the screw-gag, or other instrument, pulling the tongue out of the mouth with Fio. 41. — I Modififd from Esmarch.; a forceps or tenaculum (Fig. 41), and compression of the thorax by lay- ing the hands spread out upon the lower antero-lateral surface of the ribs and pushing inward until the lungs are emptied, then allowing the ribs to expand. A few repetitions of this mancenvre will suffice, and the administration of the ansesthesia should be resumed. In the second stage^ or that of complete nar- cosis, respiration is fre- quently interfered with by the tongue gravitat- ing backward upon the larynx. This can usual- ly be corrected by plac- ing the index-finger be- hind the angle of the Jaw, and pressing this bone directly forward (Fig. 42). The hyoid bone, fastened to the chin by the genio-hyoid muscles, is thus pulled forward, and the tongue is lifted from the larynx. If this does not succeed, the gag should be inserted, and the tongiie held out by the tenacu- y Fig. 42. — (Esmnrch.) lum, forceps, or silk thread. AVhenever mucus accumulates in the pharynx and mouth, it should be mopped out by the sponges tied to curved holders (Fig. 43). These should be carried well back to the larynx, and along the sides of the tongue and buccal walls. In opera- tions about the mouth, or when in the stage of muscular spasm the Fig. 43. 30 A TEXT-BOOK ON SURGERY. tongue has been woimclecl by the teeth, coagulated blood may get into the larynx, and require removal by the sponges. AVheu vomiting occurs in ether aufcsthesia, it is preceded by a number of sijasmodic movements of the muscles of deglutition and of the abdomi- nal walls. Ujjon the supervention of these symptoms thejiatient should be turned well over to one side, and the head further rotated and de- pressed, so that any ejected matter will gravitate readily out of the mouth and into a basin held in readiness for this emergency. Not infre- quently food ingested against the advice of the surgeon, or more than eight hours before an operatiim, remains in the stomach undigested, and is vomited during the ansesthesia. This accident occurs usually late in the narcosis, and is often caused either by elevating the patient's head too much, or by allowing him to come partially out of the narcosis. If a clot of blood, or any occluding substance, be caiTied into the larynx or ti-achea, and fatal asphyxia becomes imminent, proceed rapidly as fol- lows : Direct the windows to be opened, so that all the oxygen i)ossible may be admitted ; slide the patient over the end of the table until the head hangs down, and tilt the foot of the table up by placing the lower legs upon a stool or chair. Direct an assistant to stimulate the respira- tory movements by bi-manual compression of the thorax at intervals of from five to ten seconds, while the operator does a rapid tracheotomy and inserts the tube, grasping the edges of the wound with fc^rceps to arrest bleeding. If a tube is not at hand, the windpipe should be held open by retractors, which will also compress the bleeding vessels. The method of Fio. 44. Sylvester should now be carried out : Standing at the patient's head, as he rests upon the inclined tal)le, the operator seizes the arms, at or near the elbow, and pres.ses them down upon the thoracic walls, thus forcibly emptying the lungs (Fig. 44), and immediately thereafter extends them ANESTHESIA. 31 upward parallel with the long axi$ of the body, aiding in the free expan- sion of the chest (Fig. 45). This is repeated from ten to fifteen times a minute, and kept up by relays of assistants, if necessary, until voluntary Fio. 45. respiration is established, or the heart has ceased to beat. All tliis while the mouth should be kept open, and the tongue pulled foiT\ard and out of the mouth. Heart-failure is exceedingly rare in the early stage of ether narcosis. A weak heart, as a rule, is stimulated by the anjesthetic. It is more apt to be a part of the later stage, and after a prolonged administration with loss of blood or the added shock of the operation. It is indicated by a gradual weakening in the force and an increased rapidity of the pulse, or by the rapid supervention of pallor from sudden stoppage of the heart. When the first condition prevails, pure rye whisky, or brandy, should be administered hypodermically, two or three syringefuls at once (each syringeful = 3ss.), and repeated at intervals of a few minutes until improvement is noticed. A like result may be obtained by injecting a teacupful of warm water and whisky (equal parts) into the rectum. Elastic bandages should be thrown around the extremities in order to drive all the blood to the centers. When sudden syncope occurs, place the patient's head lower than the body by allowing it to hang over the upper end of the table, while the lower end is well elevated (Fig. 44). At the same time strike sharply upon the precordial region with the palm of the hand, and shower the chest and epigastiium with cold water. Ether narcosis may be also secured and maintained by administering this agent by the rectum. This method was introduced by Pirogofif about the year 1847. It consists in the introduction of the vapor of ether as follows : A graduated l)ottle is fitted with a perforated cork, through which passes a glass tiibe. To this pipe a rubber tube is at- tached, and at the other end is a glass tube for introdiu-tion into the anus. The anal tube being introduced well into the rectum, the bottle 32 A TEXT-BOOK ON SURGERY. of ether is placed in a flat-bottoiqed basin containing warm water, which causes rapid vaporization of the anjesthetic, tlie vapor passing into the rectum, where it is alisorbed by the vessels. The quantity can be regu- lated by pressure upon the tube and removal of the warm water. An unpleasant sensation is at first experienced, and this is soon followed by the constitutional eifects of the agent. Rectal etherization is a dangerous practice, and should not be undertaken under ordinary circumstances. Several deaths occurred in New York city within a few months after the method was put in practice. In one case rupture through a rectal ulcer occurred fnnu the over-disteution caused by the gas, and in others there was marked injection of the colon and rectum. If practiced at aU, it should be reserved for those extensive operations about the mouth and pharyu.x, in which the presence of the inhaler seriously interferes with the performance of the operation. Even here the narcosis should be first effected by inhalation, and then, if necessary, maintained by the rectum. Cliloroforvi. — Pure chloroform is a colorless volatile liquid, with a specific gravity of 1'480, not highly inflammable ; it has a peculiar odor, at first sweetish to the taste, and afterward burning and pungent. Ap- plied to the skin, and prevented from rapid evaporation, it i)roduces red- ness and vesication. When shaken with ]nire sulphuric acid in equal parts, no discoloration ensues. Impure chloroform, on the other hand, colors the acid brown. The preparations for chloroform narcosis differ in no essential feat- ures from those just given. Since this anjesthetic is more powerful, a much smaller quantity is used. A simple napkin folded into a square of five or six inches will suffice as an inhaler. The apparatus of Esmarch (Fig. 46) is, however, preferable. It is composed f)f a wire frame shaped Fio. 46.— (Esmarcli.) to fit over the nose and mouth, the center wire extending up an inch or more, and bent into a hook. Over this a piece of canton-flannel or soft cloth is stretched so tightly that the threads are parted sufficiently to allow the free passage of air through the covering. To the upper end or hook a tape is attached, and tied around the head in such a position that ANESTHESIA. 33 the inhaler falls over the mouth and nose. The administration is begun by pouring twelve or fifteen drops of the anaesthetic upon the inhaler or napkin. A free admixture of air is necessary. The napkin should not be held in contact with the lips or nose, for fear of shutting off the proper quantity of air, and also because of the iiiitating effect of chloroform upon the skin. In two or three minutes the same quantity is renewed, and so on until sensil)ility and consciousness are lost. Chloroform nar- cosis may also be divided into three stages. The first is the stage of excitation. In this the pulse is usually in- creased in force and frequency, the face is flushed, the pupil normal or contracted ; delirium is jjresent, and a condition of muscular rigidity ensues, varying in degree in different subjects. It is almost always well mai-ked in patients of the alcohol habit. The second stage is that in which sensibility and consciousness are lost, yet in which the functions of the heart and respiratory organs are performed in an almost natural manner. The pupil is now dilated and arterial tension diminished. In the third stage, that of profound paralysis, the breathing becomes shallow and stertorous, the heart-beats rapid and weak, and the arterial tension is markedly diminished. The second is the operative stage. The third should be avoided. Death during the inhalation of chloroform occurs from both heart and respiratory failure, and may take place in any stage of the narcosis. CHAPTER n^ SURGICAL OPERATIONS. Instruments. — Much of success in practice depends upon the pos- session of a variety of instruments which shouhl be of the very best material, made after well-approved patterns, and as simple in construction as possible. The best instruments are now made with good-sized handles, not large enough to be cumbersome, but sufficiently large to be grasped firmly in the hand. For all knives, retractors, gouges, etc., the handles are made of vulcan- ized rubber, which is molten on to the steel, and does not therefore requu'e to be riveted. This material is suscep- tible of a high polish, and is easily kept clean. All sur- faces should be perfectly smooth and plain, even to the extent of omitting the stamp of the maniifacturer. For amputations and ordinary operations on the soft parts and bones, the following articles are required : For making flaps by transfixion, two ampuhttinf/- l- It ires. The largest of these (Fig. 47)* measures 17 inch- es over all, or 12 inches for the cutting blade, the width of which is five eighths of an inch. The rubber handle has a cii'cumference of two and a half inches. Fig. 48 represents a smaller knife of a similar pat- tern, the blade of which is only eight inches long by half an inch wide. The scalpels are eight in number, the blades ranging from two and a half to three fourths of an inch in length. t Fig. 49. Fig. 50. Fig. 47. Fig. 4S. The handles are large enough to be firmly held, and the end of each is shaped into a dry dissector (Figs. 49 and 50). A probe-pointed and a sharp, curved bistoury (Figs. These cuts are niiide from the instrniiients in inv general operating-ease. SURGICAL OPERATIONS. 35 Fig. 53. — Little's lithotomy-knil'c. 51 and o2), with l)lades of tliree and a half inches cutting edge, are in- valuable in.struments. Twf) lithotomy-Tcnlves (Figs. 53 and 54), one probe-pointed, the other sharp, with blades of four inches cutting surface.. The probe-pointed knife is for the lateral, the oth- er for the median opera- tion. For the cutting part of tlie opera- tion for cleft pal- ate, three blades are need- ed. A donhh'-edffed bis- toury for commencing the incision in trimming the edge of the soft palate I Fig. 55), the cutting edge of wliich is five eighths of an incli long ; a curved prohc-pointed hlstuury of one and a quarter ^ inch blade ( Fig. 56), ^jiiiiiniiiiiiiiiiinimiii!iii!iiir,f:ii:i:;i::':::::"!N:!iiii'iiiiiiiiii and a short blade turned at almost a right angle to the .shaft {'■'■ gum -lan- cet") for dividing the mucous and pe- riosteal tissues on the hard palate (Fig. 57). For the subcutaneous section of tendons and fascia, a. probe-pointed tenotome, the shaft and l)lade together measuring two inches, the cutting Fig. .54. — Blizzard'^ probe-pomtt-d lithutomy-knile. Fig. 5.5. Fig irajjjmjinjj^^ lil!:!!iiB::ii Fig. o7. Fig. 58. Fig. 59. edge of the blade three fourths of an inch long (Fig. 58), and a small fascia-knife (Fig. 59) for multiple division of the palmar or plantar fascia. Retractors, or instruments for holding the edges and walls of wounds steady and out of the way, should have long shafts and handles, so that the hands of the assistants may not .shut out the light, or otlierwise inter- fere with the operator. j,i^ «o. 36 A TEXT-BOOK ON SURGERY. They should also have sharjj or hooked claws k>r catchiug lirni hold iu tissues away from important vessels, organs, or nerves (Fig. 60), while others should be dull, and curved, or bent on the flat (Fig. 61). A tenacu- lum (Fig. 62) should be in every case. The aneurism-needle (Fig. 63) will often serve a useful purpose as a re- tractor. The essential features of this important instrument are a capa- cious eye, a simple curve in one direc- tion, and a dull point which can not be forced into the wall of a vessel. The instruments for operations upon the bones are prob- ably the most important in the surgeon's outfit. The list should include saws, chisels, gouges, elevators, drills, forceps, an exsector, and a mallet and trephine. f Fls, an excellent instrument, is shown in Fig. 75. A rongeur, or forceps-gouge, is es- pecially useful in operations upon the cranial bones, where any projecting angles may be gnawed off, the em- ployment ui' a mallet and chisel being always contraindicated (Fig. 7(5). Fig. 77 represents a strong sequesfruvi-for- eeps, and Fig. 78 the TIEUIAtJN &. CO Fio. 75. — ilamilton'.s seciuestrum-tbrcepa. -p>-=^ lion-jawed /orcepfi, a s:^^^ necessary instrument for lixation. Fig. 7ii. For exsections of the long bones, excepting the expansions of the femur and tibia, at the knee-joint, and in tarsotomy and other radical Flo. 77. — Improved sequebtrum- uiid treiianuiiig-lonq --. operations, which will be given in the text, the exsector (,Fig. 79) is one of the most useful instruments known to this date. I have employed it Fig. 78. now in about all the exsections possible, and it has always met every requirement. Upon the very hardest bones, such as the inferior maxilla, SURGICAL OPERATIONS. 39 it is essential to have the saw well sharpened. The original instrument was modeled by Mr. Gowan, of London, but it was so complicated in its mechanism that I have had it extensively modified and at the same time simijlitied. As now manufactured, it consists of a four-jointed forceps, the jaws of which are at a right angle to the !' I handles. At 7^ is seen a shield which not only ro- '{ f tates, but is reversible and readily shifted to one \ i or the other side. The saw, t, is chisel-shaped. \ I The outer edge of the last tooth is dulled to ./ ^-, prevent wounding the soft parts surrounding the bone. The handles are held closed by a clamp. ./". After the periosteum has been lifted, separate the jaws to the required extent, and slip them on between the periosteum and bone until the latter is well in the grasp of the instrument. Close the handles sufficiently tight to hold the bone steady without crushing it, and lock them in the required position with the clamp. The saw is now slid into the Hanges upon the shield until it rests upon the bone, when, by a short lateral sawing motion, it may be made to travel rapidly through the bone. A very little care will prevent the adjacent soft parts from being injured. The best trephine for all purposes is that of Gait (Fig. 80), the burr of which is conical. A convenient size is one which measures five eighths of an inch in diameter at the cutting teeth, and gradually enlarges to 7;£.'.;.^J. '.rnc Fig. so. seven eighths of an inch in diameter at the base where the spiral teeth terminate. The mechanism of this instrument is such that, as soon as the resistance in front ceases, the side-teeth take hold so greedily that the further rotation of the trephine is difficult. The resistance is, how- ever, not so great that it may not be overcome, and the teeth driven on into the dura mater and brain, yet it is sufficient to warn the operator that the section is complete. For the prevention or arrest of haemorrhage there are needed a foiir- niqurt, elastic ligatures, various forms ot forceps, and a wii-e ecraseur or clamp. 40 A TEXT-BOOK ON SURGERY. '"''^■M1M1I,I|||II|J Fig. 81. Esmarch's elastic bandage (Pig. 81) has superseded all other tourni- quets for operations upon the extremities. The rubber damp usually- sold witli the bandage is, however, use- less. Ea(!h opei'ating-case should be provided with two bandages of strong elastic material (T jirefer plain white rubber, which can be kept cleaner than the webbing) about two inches wide, and each bandage about four yards long. The elastic ligature is a cord of jilaiii rubber about two feet long, and of dif- ferent sizes, varying from one twelfth to one fifth of an inch in diameter. Ilcemosfdiic forceps should be of various shapes. The four varieties which I employ are illustrated in Fig. 82. A general operating-case should contain a total of at least six- teen forcej)s, and in the proportion of two fenestrated mouse-tooth, six broad, solicl-Jaioecl, four slencler-Jdwed, and four scissor - clamps ; the first three have sliding catches, while the clamp has a spring-catch near the end of the handles. The mouse-tooth fenes- trated forceps is for ac- curate adaptation to su- perficial vessels of small size, while the broad- jawed instrument is for grasping either large vessels or masses of bleeding tissue. The points should be club- shaped and perfectly smooth, so that when the ligature is tightened upon the instrument it will slide over its tip and on to the vessel. These pieces are five inches long and three eighths of an inch across the widest portions of the jaws. The sharp-pointed forceps are useful in picking up a vessel which has retracted or is deeply situated in a wound. The scissor- clamps may be used for applying the double ligatures in a dry dissection, or for temjiorary hfemostasis of smaller bleeding points which need to be compressed for a few minutes, and then remain permanently occluded. In operations in the various cavities, and in deep external wounds, as FiH. 82. SURGICAL OPERATIONS. 41 well as for various jjurposes, to be given in detail hereafter, sponge- holders, similar to those represented in Fig. 83, can not be dispensed CTVtMKHH 8itQ Fig. 83. with. They should be solid in oon.struction, 10 inches long, some straight and others curved. Every opera ting- ease should also contain the following instruments : At least four pairs of scissors — one pair 8 inches long, curved on the flat, Avith both points o dull (Fig. 84) ; another 6 inches long, curved on the flat, with both points shai'p, for re- moving sutures, etc. (Fig. 85) ; one straight sharp-pointed Sinis's scissors, 8 inches long (Fig. 86) ; and a blunt- pointed, plain dress- ing-scissors, 6 inches long (Fig. 87). These should all be strong, with the exception of the small sharp-pointed pair, with the curve on the flat. Fig. 85. — Curved iris- scissors ; iilso used for removing fine sutures. Fig. 86. — Sims's straight scissors. Fig. 87. — Dressing-scissors. One sliding-catch needle-holder, the shape and mechanism of which are fully explained in Fig. 88. The point should have a plain and carved surface, for straight and curved needles (Figs. 80 to 93). Two paiis of plain anatomical forceps (Fig. 94), fully 7 inches long, so 42 A TEXT-BOOK ON SURGERY. Fio. 88. — Wvuth's nuudlu-holJur. J)"io. 89.— Assorted curved and half-curved tine needles. G. TIEMANN & CO Fii;. 112. — Wire suture-needles. Fig. 'Jl. — Straight and curved needles. Fig. 93. — Full-eurved suture-needles. that the haud may be kept at a sufficient distance away from the wound ; and one mouse-tooth, 8 inches long, with a sliding catch. One Nela ton's porcelain-t Ijjp e d htdlet - probe ( Fig. 9o), one lonf/ silver jjrobe, with an ej^e at one end (Fig. 96), and one or two gal- vanized copper jjrohes, from 10 to 12 inches long and from yV to \ inch in diameter (Fig. 97). o- riEWA'.N-CO. Jrio. yo. — iSelaton's bullet-probe, with porcelain head. SURGICAL OPERATIONS. 43 Two good-sized silver fjrooved directors, to 7 inches long and from \ to -^^ of an inch in width (Fig. 98). g P. I i£; Fig. 98.— Grooved director. Other instruments will be given in the text, with the fl operations for which they are especially designed. Plane of Operation. — In the performance of a surgical operation, light and a free supply of fresh air are of first im- portance. The supply of light, in order to be most effective, shonld fall npon the operating-table from jooints above the level of the patient. In the open air and in daylight, when protected from the direct rays of the sun, the best conditions for light and air prevail. Under shelter, a sky-light, or a tall, wide window, are preferable. At night, gas, lamj)s, candles, or torches, must often do the best service possible in an emergency. The Edison electric light, in which the incandescent carbon is held within an air-tight globe, fur- nishes the safest and most eflfective artificial light. It is always desirable to control the temperature of an operating-room, and to keep it at a figure above that neces- sary, or even comfortable, to the operator and attendants. The patient's body is almost always in part exposed, and, in addition, is apt to be deprived of the normal body-heat by haemorrhage and shock. Moreover, in the event of as- phyxia, the rapid introduction of fresh air from the open windows may be imperative, and the temperature lowered to a dangerous degree, if the room is not provided with the proper means of heating. The room in which an operation is to be performed should be large enough to hold all the necessary apparatus and furniture, and to allow the free and rapnd movements of the attendants in the execution of orders. The tloor should be of wood, tiles, asphalt, or marl)le, uncarpeted and clean ; the walls and ceilings equally clean, and free fi"om unnecessary drapery. In a dusty country the steam-spray (1 to 20 carbolic acid) should be iised before and during an oi)eration (see Fig. 4), and likewise in all conditions of exposure to infec- tion, such as a room in or near which a contagious disease has once appeared, etc. The furniture required consists of an operat- ing-table, at least two side- tables, or cabinets, for Adjustable stool. holding trays of instruments, sponges, di-essings, 44 A TEXT-BOOK ON SURGERY. solutions, irrigators, etc. An adjustable stool (Fig. 99) for the surgeon should be among the accessories. An operating-table should be made of strong material, solidly put together, 6i feet long, 34 inches liigh, and 22 in width, padded with cotton, wool, hair, or felt, to. the tliickness of about one inch, and coA-ered with some good water-proof material, drawn tiglitly and tacked to the edges, so that no folds or creases are left upon the sur- face. In modern practice, with the free use of irrigating solutions, it is necessary to arrange the operating-table so that the oil-cloth ujjon which Fin. 100. the patient is laid will convey the fluids in the required direction into a receiving vessel. This can readily be effected by the following device : Around two poles of a length equal to that of the table, and an inch or two in diameter, roll cotton-batting, or pieces of blanket, until the Avhole is about three inches in diameter. Two ordinary blanlvets rolled tightly, as shown in Fig. 100, will suffice. At intervals of a foot connect these side-bars by wisps of bandage-cloth long enough to hold the bars parallel with each other, and with the long edges of the table on which thev rest. SURGICAL OPERATIONS. 45 This skeleton, or frame, is lashed securely to the table, and an oil-cloth laid over it (Fig. 101). If the head of the table is raised four or five inches on blocks, the patient rests in a kind of trough, along which the solutions are canied away from the parts of the body not to be irrigated. When such a table is not convenient, one may be extemporized from an ordinary dining- or side-table, or two of these placed endwise. All household furniture so used should be thoroughly washed and scrubbed, and then covered with clean sheets. The side-tables for dressings should Fig. 101. be also cleansed and covered with sheeting. It is always important to have plenty of room, so that the various articles and instruments may be arranged in the order in which they will be needed. A hard- wood cabinet (Fig. 102), about 3 by 2 feet (surface measurement), will serve an excellent purpose for holding trays of instruments, ligatures, etc., while the draw- ers supplied vnth. materials in reserve may prove convenient at any stage of the operation. The trays for holding instruments submerged in carbolic-acid solution should be made of porcelain or tin, not more than two inches deep, and of various lengths, to meet the requirements of the largest instruments. 46 A TEXT-BOOK OX SURGERY. SURGICAL OPERATIONS. 47 For ijuiposes of convenience, the tin tray may be divided into compart- ments for the several outfits— one for the hemostatic apparatus, another for knives, a third foi' bone instruments, and a fourth for odds and ends. Every basin so used, and each compart- ment, should have a turned corner like the mouth of a pitch- er for readily emp- tying the solution when necessary (Figs. 103, 104, 105). Fig. 103.— U. M. Sims's instrument-trav. riE/.IAUiJ S. CO Fig. 100. Pus-basins (Fig. 106) are very useful for receiving vomited matter or for catching pus, imgating solu- tions, etc. Such vessels should be made of tin or brass, and not of hard rubber, for these are easily broken, and can not be repaired. Larger vessels, such as bottles or pitchers, of glass or porcelain, or clean wood, should be filled with the various solutions to be used, and kept at a temperature between 100° and 110° F. As the operation is about to begin, the irrigator should be filled with sublimate (1 to 3,000), and the spo7iges placed in a warm solution of the same strength from which they are taken as required. The dressings to be applied should be cut and laid in order, so that no dehiy may be experienced. Ligatures and sutures should also be cut beforehand and placed in appropriate receptacles, the catgut in oil of juniper, the silk or wire in 1 to 20 carbolic acid. The preparation of a patient has a moral as well as a physical aspect. The surgeon and attendants should labor judiciously to dispel anxiety by assui-ing the patient of the safety of ether, and the freedom from pain which follows even the most extensive incisions. The question as to whether an unfavorable i^rognosis should be made known to the patient must be determined by the circumstances which prevail. The profes- sional obligation is discharged when the nearest relations and friends are so informed. If the temperament of the individual is such that great depression would probably follow the knowledge of impending disaster, and thus add to thn dangers of the case, it will be wise to advise the friends to withhold the information. The surroundings of all such pa- 48 A TEXT-BOOK ON SURGERY. tients should be as bright and cheerful as possible. Good light, food, and air, and kind attentions from friendly hands, add inucli to secure a successful issue. The physical preparation uuiy be general or special, and the time to be devoted to it must depend in great measure upon the nature of the disease or injury, and the condition of the individual. If a condition of marked sepsis jn'evails, delay is dangerous, for all efforts at nutrition will be more than offset by continued absorption of the poison. The same rule will apply in luemorrhage not conti'ollable by comju-ession. In most instances, however, much good can be achieved by devoting several days, or even weeks, to increasing the nutrition of the tissues. Properly selected food and tonics, the regulation of the bowels, sound and refreshing sleeji, and freedom from pain, are all essential. When the abdominal organs are to be ex- posed, esj^ecially in operations upon the alimentary canal and the re- moval of large tumors, solid food should be withheld for at least five days prior to the operation, and concentrated liquid nourishment, such as beef -juice and nnlk, taken in its stead. In addition to this, a laxative should be administered on the day before, and an enema on the morning of, the operation. Fi- nally, just before the anaesthesia, the i)arts about the field of opera- tion should be shaved and cleansed, lirovided that this is not painful to the patient. The other features of I)reparation have been given in the chapter on Ansesthesia. The preparation of the surgeon and attendants is also of great im- portance, and is comprehended in the greatest possible personal clean- liness. No one should be admit- ted to the presence of the patient who has been in a room with a con- tagious disease within twenty-four houi's thereafter, or who has not made a perfect change of clothing, and thoroughly washed all over. The nails should be closely trimmed and cleansed, the hands and arms washed with soap and water and brush, and afterward in 1 to 3,000 sublimate. The operator should wear a water-proof gown, long enough to reach to the feet. The arms should Fiu. 107. — Surgeon's water-proof operating-fiovvn. SURGICAL OPERATIONS. 49 be covered with sleeves of the same material, pinned at the shoulders and extending half-way between the elbow and wrist (Fig. 107). A linen coat will also suffice, but will not always protect the person from the irrigat- ing solutions. The attendants should all be clad in clean gowns. Everything being in readiness, and the patient angesthetized, brought in, and placed upon the table, the following arrangement and assignment of duties sliould be made : The table must be so turned that the best light falls upon the field of operation. All parts of the body out of this field should be well wrapped up and protected from getting wet by blankets, and an oil-cloth over all. The parts within range of the operation are now washed with ether, and then with 1 to 3,000 sublimate. If the tourniquet is to be applied, say, to an extremitj", towels dipped in wiirm sublimate, 1 to 3,000, are wrapped about the part, over this a sheet of protective, and the elastic bandage applied over these. When the bandage is removed up to the point where the limb is to remain constricted, this and all parts near the wound should be covered over with warm sublimate towels. The assistants should be as follows : A trained etherizer, and a first assistant to sponge and immediately help the operator, who stands usu- ally just opposite him. A second assistant, to stand conveniently to the instruments and the operator, whose duty it is to hand each instrument or article as called for with promptness, and as promptly to remove those which have been laid aside. A third assistant attends to the irrigation, regulating the supply at the indication of the chief. One supernumerary, for holding retractors, or perfoi'ming any duty which may be required. A nurse to rinse the sponges and hand them to the first assistant. A second nurse to assist the etherizer. A supernumerary nurse for general usefulness. When the knife (or other instrument) is lifted from the solution, the assistant, before handing it to the operator, shakes from it the few drops of fluid which adhere, for the acid irritates the skin and obscures to some extent the incision. Different methods of holding the scalpel in making an incision are rep- resented in Figs. 108 and 109. Holding the handle between the thumb and middle finger, while the tip of the index- finger rests upon the back of the blade, will be found most useful in cutting through the skin, and in rapid work in parts of the body away from the more important vessels and nerves, such as the removal of the breast. The advantages of this position are, that more of the cutting-edge is utilized, while the pressure 4 Fio. 108. 50 A TEXT-BOOK ON SURGERY. upon the blade carries it through the tougher tissues with less exertion. ^Vhen, however, a careful dissection is required — as in clenring out the axillnry space — the second method, similar to that in wliicli a ])('n is held, is preferable. It is always necessary to stretch, and thus steady, tlic integu- ment with the thumb and index of the other hand when an incision is made (Fig. 110). Fio. 110 Irrigation may be continuous or interrupted, owing to the demands of each case. Operations in the joints, or near an idcer, sinus, abscess, or any inflamed area, require exce})ti()nal precautions. In clean opera- tions, such as an amputation in continuity, where no inflammation exists, or the removal of a benign tumor, etc., interrupted irrigation, or flushing the wound thoroughly every live minutes, will keep the wound aseptic. In an operation which opens into any of the cavities the irrigator can not be used for fear that the solution may remain, and poisoning residt from absorption of the corrosive sublimate. Asepsis must be here secured by mopping the surfaces of the wound with wet sponges. The stronger sublimate solutions can not be brought in contact with the eye without annoying inflammation resulting. The methods of JicEmostasis differ in different parts of the body, and under varying conditions. Thus, when amputating an extremity ren- dered bloodless by Esmarch's elastic bandage, or when the limb has been elevated and an ordinary tourniquet adjusted, the ligatiires are not ap- plied until the wound is completed and the bone divided. On the other hand, when operating without the tourniquet, it is essential that each bleeding point be secured as soon as possible ; or that the vessels be tied with double ligatures and afterward divided between them. This excel- lent practice not only serves to prevent excessive loss of blood, but keeps the wound dry and clear, enabling the operator to make a more intelligent dissection. In order to be explicit in detail, take, for exam- ple, any major amputation by the bloodless method. The flaps having been made, the soft tissues are cut clearly through, and the l)one divided with the saw. The stump is now thoroughly cleansed by irrigation, the cut surfaces dried off with sponges, and the ends of the vessels sought for in their known positions. In picking up the end of an artery or vein it is necessary to exclude all other tissues, and especially the nerves, from the grasp of the forceps and ligatures. To accomplish this, catch the vessel by one edge with a delicate-pointed forceps, draw it out from the wall of the wound, and from its sheath, and vaih. a duU instrument, such as the point of a gi'ooved director, strip the tissues backward from the artery until about one fourth of an inch of the tube is exposed. A large, round-pointed forceps (Fig. 82) may now be applied, and the liga- SURGICAL OPERATIONS. 51 tiire tied over this. The ligature should be appropriate to the size of the vessel to be secured, as heretofore given. la making the knot, one of two methods may be selected, namely, the single knot, or the double or friction knot. The former is so well represented in Fig. Ill that it will not require description. A little practice will show the superiority of this over i\n^ false knot shown in Fig. 112, which is more apt to slip. In Fig. 111.— liuet' knot. Flo. U'j.— Fiilsc- kuot. Flo. 113.— Friction knot. the friction or double knot (Fig. 113) the end of one side is passed twice under and over the other for the first loop, instead of once, as just given. When the ends of the ligature are drawn upon, and the vessel con- stricted, the first knot holds without danger of slipping until a second single knot is added to it. As to the application of one or the other of these loops, the single knot will suffice for all vessels which are freely exposed and superficial, where the surgeon can be assured that the first turn holds fast until the second has secured it. In deep wounds, where the knot must be run down with the finger-tips, as in the deligation of an artery in its continuity, the double knot should be preferred. After being tied, the ends are cut with the scissors about one quarter of an inch from the knot. As to how much force it is necessary or proper to exert in the application of a ligature to an artery it is impossible to say. This point will be fully discussed in the chapter on Surgery of the Arteries. It is always better to use too much than too little force, for one of the greatest possible annoyances to the operator is to be compelled to open a wound. When a vessel can not be otherwise foiind, its presence may be demonstrated by squeezing the flap and pressing out the small quantity of blood remaining in it. In this way all vessels of any size or conse- quence can be secured before the tourniquet is loosened. Before this is done the wound should be thoroughly irrigated, the flaps opened and filled with squeezed-out antiseptic sjionges, the whole covered with warm sublimate towels, and compression made with the hands while the stump is elevated and the tourniquet loosened. After five or ten minutes the wound is opened and the sponges removed, one at a time. Any bleed- ing points which may have been overlooked will now be easily seen, and should be grasped with the forceps and tied. In applying the forceps to these points it is impossible to exclude the tissues immediately around the vessels from the grasp of the instrument and the ligature. When using the broad-shouldered forceps, if the catgut-thread is tied around the jaws of the insti'ument and the loop tightened, the thread slides along to the tip, and, in slipping off to constrict the bleeding vessel, pushes the other soft tissues to one side. In tying such a ligature care 52 A TEXT-BOOK ON SURGERY. must be taken not to imU upon one end with more force than the other, for by so doing the vessel is torn off ; and also to ajjply the force to the thread on a level with the tip of the forceps, for if tliis is not done tlie vessel is also pulled out of the wound and torn away. When all h;eniorrhage has ceased, except the slight oozing which may occur at any part of the wound, and always does come from the l^one, the iri'igation is repeated, and a diainagetube (the b(jue-diains are i)ref- erable) inserted at each angle of the wound at a point where, with the part in the position in which it must rest during repair, the drainage of serum or other tluid will be free and uninterrupted. The ilai)s are adjusted by interrupted catgut sutures, and safety-pins placed in the ends of the tubes Avhich ])r()ject. The nozzle of the irrigator is now placed in the tube of one side and then the other, and the wound dis- tended with 1 to 3,000 sublimate, which is then thoroughly pressed out and the dressing applied as follows : A strip of sublimate gauze about two inches \\ide is button-holed, so as to fit over each of the tubes, and laid over the line of sutures, and on top of this several other pieces of the same size. The stump and tliigli, up to the groin, is now enveloped in sublimate gauze in layers until the whole is about one inch thick. Over this a layer of absorbent cotton of the same thickness, and outside of this a sheet of jjrotective which has been dipped in sublimate solution. The whole is held in position liy bandages, which should be put on tight enough to hold the muscles quiet and arrest all oozing from the wound, and yet not press the flaps against the end of the bone, and thus cause sloughing. Such is the permanent antiseptic dressing, which remains unmolested unless pain or a rise in temjjerature indicates that, despite the precautions taken, inflammation and swelling or sepsis have occurred, or until the discharge from the wound has soaked through the dressings and has become offensive, hav- ing undergone decomposition beyond the zone of antisepsis. The after-treatment of a patient who has undergone a major surgical operation will depend a good deal upon the character of tlie operation. The immediate care should be to maintain the vitality of tlie tissues, wliich has been endangered by the shock of the procedure and loss of blood, by judicious stimidation and relief from pain. A hypodennic injection of morphia guarantees relief from pain. If the pulse is weak, and the temperature low. an enema of whisky or the hypodermic admin- istration of this agent will stimulate the heart, while hot applications will aid in the restoration of the normal temperature. One important jwint must not be lost sight of — namely, that after a surgical operation there is always a reaction, accompanied by increased heart-action and elevation of temperature, and that while stimulants are often necessary in the stage of depression, their administration should be guarded, so that they may not add to the fev^er of reaction. As long as the effects of the ansesthe-sia last, a trained attendant should remain at the bedside to guard against the danger of asphyxia in case of vomiting, to restrain the pati(Mit from unnecessary movements, or it may be to guard against hajmorrhage. I CHAPTER V. INFLAMMATION. Literally defined, inflammation means a preternatural heat. In surgery it is ajiplied to a condition of animal tissues which are undergo- ing certain disturbances in nutrition which produce abnormal Jiypercemia, heat, redne.i.^, swelling, viml'pain. Taken singly, none of these features of the inflammatory process can be said to express this morbid condition ; they must all be present. It is well known that each of these conditions may exist without inflammation, and, indeed, some of them are present in purely physio- logical processes. Thus, vascular tumors and the dilated capillary net-works of certain forms of naivi, though characterized by permanent hypersemia and red- ness, are not inflammatory conditions. Blushing, which is associated as part of the expression of certain emotions, is accompanied with no other symptom of a morbid process than that of redness. The temj^erature of the blood in the hepatic vein in conditions strictly physiological has been registered as high as 107° F., and this extraordinary heat is not inflammatory. Swelling is present in non-inflammatory processes, siich as oedema and emphysema, while pain is not infi-equent in certain neuroses, where all other symptoms of inflammation are absent. Whether the cause of inflammation be one of direct injury and irritation of a part, or whether it be due to lesions of the inhibitory nerves or trophic centers remote from the local expression of the morbid process, the pathological changes are practically the same. The activity and violence of the process will depend in ]>art upon the character and extent of the injury, as well as upon the anatomical character of the part involved, together with the ability of the tissues to resist death, and to repair the damage inflicted. The study of the phenomena of inflammation may, with propriety, be arranged in the following order: 1, irritation; 2, C(mtraction; and 3, dilatation of the vessels ; 4, acceleration of the current and hypersemia : 5, retardation, partial or complete ; 6, redness ; 7, swelling ; 8, heat ; 9, pain; 10, escape of vessel contents; 11, general cell-proliferation; 12, formation of pus ; 13, reorganization and repair ; 14, cicatrizatit)n. It is known that when a vascular living animal tissue is subjected to irriiation, the vessels in the zcme of irritation undergo an instant con- traction, and almost instantly thereafter become abnormally dilated. 54 A TEXT-BOOK ON SURGERY. The cause of this contraction is siqiposed to be due to stimulus of the vaso- motor nerves, while the dilatation is explained as due to i)a)a]ysis of the vessel-walls from injury to tlie inhibitory nerves, to chau.nes in the walls proper, as the result of iriltatiou, or to fatigue and relaxation after the primaiy contraction. With these changes in the vessels which occur in such rapid succession, the blood-current is accelerated ; hyper;e- mia ensues, and this, in turn, is followed by more or less conii)lete blood- stasis. This last condition is most marked in the center of the inflamed zone, and when complete arrest occurs it is first seen here. At this stage leucocj-tes, in greatly increased proportion in the blood, ajipear in the venules and capillaries, to the walls of which they adhere, and through which they are seen to pass by active amoeboid movement, until they wander free in the intervascular spaces (wandering or emigrant cells). The bi-concave disks and liquor sanguinis also escape in the wake of the white corpuscles. Conheim has shown that the points of escape are in the intervals between the flat cells of which the vessel-walls are composed. In the area of complete stasis emigration does not occur. Stasis is very probably due to a pathological change in the walls of the vessels, which in turn induces in the blood of the inflamed area cer- tain changes whereby the "normal equilibrium existing between the blood and the containing vessels, which is physiologically essential to the integrity of the circulation, is impaired or lost." The presence of the white corpuscles should not l)e overlooked in seeking for an explana- tion of stasis, for paraglobulin, the coagulation factor of the blood, is the normal property of the leucocytes, and, as stated, they are present in increased numbers. Redness, swelling, local increase of temperature and pain, occur with, and as a result of, inflammatory hyperfemia. The discoloration is due to luematin in increased quantity, not only within the vessels, but in the spaces between the capillaries. Tumefaction is due to increased blood- supply, to extravasation, and cell-proliferation. Abnormal heat is caused by increased cell activity and the abnormal conditicm of the blood with- in the inflamed area, while pain is due to pressure upon the end organs ■ of the sensory nerves. With the appearance of the leucocytes in increased numbers, and the escape of these into the intervascular spaces of the inflamed area, cell- proliferation occurs, resulting in the formation of a common embryonic tissue. Examined microscopically, this embryonic tissue is seen to be com- posed of protoplasmic bodies or cells, spherical in shape, or slightly polygonal from reciprocal pressure, varying in size from about y^Vir ^^^ j^'ttt of ^^ iiich, and often larger than this. They may be nucleated, but usually appear as slightly cloudy or granular protoplasmic bodies with no distinct nucleus or nucleolus. Of the normal cells, wdiich are most active in proliferation, and there- fore chiefly involved in the formation of the new tissue, it is difficult in the present condition of patholo()-ical research to say. The followers of Conheim hold with him that the leucocyte is the chief factor in this INFLAMMATION. 55 process. Others look to the connective-tissue cells as of equal impor- tance with tlie leucocytes ; while a third theory is that all cells of a part responding to the general stimulus of the inflammatory process undergo proliferation, and that the embryonic tissue is a common product. From this it is probably a safe and wise deduction to consider that the chief role in the inflammatory process is played by the leucocytes ; that they not only proliferate, but by their presence stimulate active nutritive changes and proliferation in the cells in general, and that the embryonic tissue is in truth a product of all these elements, vai-ying in degree of fertility. This conclusion seems to me rational, inasmuch as it rests iipon a physiological foundation, for since the normal role of every cell element of the body — whether in the ^lalpighian layer of the coverings, or the endothelium, medullo-cell, or connective-tissue corpus- cle — is one of proliferation and the fonnation of a new element to replace one which has flnished its life-history, it seems reasonable to infer that a more rapid proliferation of the same cells would occur under conditions of increased hypera?mia and nutrition. The products of the inflammatory process may be organized into a permanent tissue, or, failing in this, may perish. The peculiar type of the new tissue is probably detennined (1) by the nature of the original cell from which it sprung. Thus the experiments of Goujon showed that the medullo-cells and myeloplaxes of bones in young animals, when injected into the muscular tissue, developed into bone even remote from the parent tissue. (2) By the location and function of the new tissue, as is shown in the development of exostoses from a common embryonic tissue near the insertion of tendon into bone. When the inflammatory process is rapid and severe, the new tissue perishes suddenly, and with it occurs the rapid death or gangrene of the old tissues involved.. Under milder conditions the supply of nutrition may be more gradually diminished, and the embryonic cells undergo fatty degeneration and absorption. It is then said to have undergone resolution. Again, and not lancommonly, the cells of the new tissue, partly granular and partly unchanged, are found floating in a fluid, the liquor j)ijrls. Sj/mptoms. — In the milder forms of inflammation no symptoms may be observed beyond the local disturbance. In other and severer types the elevation of temperature is often well marked, and not infrequently preceded by or accompanied with a series of rigors, or a pronounced chill. This is especially apt to occur in erysipelas, dermatitis, and any form of phlegmon. The pulse is accelerated, the tongue is dry and coated, thirst, anorexia, and headache follow in the train of syni2)toms which are com- mon in septic fever — the fever of inflammation. Treatment. — The measures to be employed are local and general. The immediate indication is rest of the part inflamed. If one of the extremi- ties is involved, an elevated positicm by means of a sAvinging cradle (Fig. 114), or upon a pillow, will, as a rule, give the greatest degree of comfort, especially in cases where, by reason of the swelling, the circulation in the 56 A TEXT-BOOK OX SURGERY. veins beyond, the infiltrated portion is interfered witli. In siirli con- ditions;! flniini^l iKindiiiif, jjroperly iipplii'd Troin Ihe end of the <'xtrenuty up to the inlhimed area, will he ad\isable. If the swelling becomes so intense as to threaten gangrene, or even, by excessive tension of the part, Flo. 114. — Fluhrur'ri swin-jrini^ cradle (Mt. Sitiai Hospital). to 2;iv-e extreme pain, free incisions should be made i)aiallel with the axis of the limb, extending well through to the deep fascia, and through this if necessary. These incisions, made so as not to divide the vessels, should be left open and treated with strict antisepsis. Blood-letting, either by venesecticm or by leeches, or scarification and cu])ping, are to be employed in certain selected cases. In plethoric indi- viduals, with high febrile movement and bounding pulse, venesection may be done with marked and immediate benetit. The operation should be performed in the median cephalic vein as follows (Fig. 115) : Apply a bandage around the middle of the u])per arm sufficiently tight to occlude the veins, but not to arrest the arterial circulation. Produce local anjes- thesia at the point of incision by injecting fi-om 5 to 10 minims of 4-per- cent cocaine beneath the skin in the line of th(» median cephalic vein [not median hasilir). Ether spray, or salt and ice, may be employed if cocaine can not be obtained. Make an incision from a half-inch to one inch long, varying with the amount of sulx'utaneous fat, and directly over the vein until it is well ex[)o.sed. With a curved i)air of scissors now make a valvular slit about half through the vein. The amount of blood to be withdrawn will lie detennincd by the impression made upon the radial pulse of the opposite arm, and in part by the sensation of the patient. From 8 to 16 ounces will usually suffice. INFLAMMATION. 57 When ready to arrest the flow, jilace a pellet of absorbent cotton, moistened in 1 to 3,000 srd^limate, over the wound, hold it fir-mly here, and then remove the ligature. A jdece of sublimate gauze is now laid over the wound, and held in place by a moderately tight bandage. If leeches are to be employed, from six to a dozen or more should be applied directly to the inflamed area. If a drop of blood is drawn ont by the i>rick of a needle, or warm milk dropped on, they will take hold more readily. Once attached, they should be allowed to drop off of their own accord. If the oozing from the wound is too prolonged, it can be arrested by a sublimate compress. Fig. 110— Tcn-bladed scarificator. Scarification is now rarely practiced, since freer incisions are to be prefeiTed. When per- formed, it consists of making a series of small cuts into or through the inflamed integu- ment by means of a number of lancets, driven by a spring with almost painless rapidity (Fig. 116). Compression applied to the main artery, going to the part inflamed at a point removed from the zone of inflammation, is impracti- cable and of doubtful l)eneflt. The constriction of the artery without also partly occluding the vein is scarcely possible except by digital compression, or the u.se of the pole- com press, shown in the treatment of aneurism. The local application of cold is of great benefit, and usually affords much comfort in the treatment of inflammation. One of the most useful and cleanly methods of applying it is to ^ilace crushed ice in the well- Fio. 115. — (Jloditied from Esmarch.) 58 A TEXT-BOOK ON SURGERY. known rubber ice-bag (Fig. 117). AVlien these ciin not be obtnined, the blad- ders and stomachs of animals, properly cleansed, can be substituted. Ice-water can be employed by means of an irri- gator, with a stop-cock to regulate the flow, or by placing a pitcher or basin containing the water immediateh' above the part, and dipping into this a twist of soft cotton or linen cloth, allowing one end to hang directly over the inflamed area in such a ]iosition that the constant drip will fall upon it (see Fig. 7). Or a Fig. 117. — (From Esmarch.) Fui. 118. — , MoJifiuJ from Fischer.) INFLAMMATION. 59 piece of tubing may be used as a siplion to the flow, regiilated by a safety-pin clamp. A coil of rubber tulnng wound ai'ound or upon an inflamed surface, through wliich cold water i^ allowed to run continuously, is an efl'ective method of applying cold (Fig. 118). This apparatus is objectionable in some instances on account of its weight. Submerging an inflamed ex- tremity in a vessel of cold water may also be efiicacious. Heat may be applied by employing the same apparatus as'for cold. The ice-bag may be filled with hot water, or hot iiTigation used. Cloths rinsed in hot water and laid over the inflamed surface is one of the readiest and best methods of utilizing heat in the treatment of inflammation. Poultices of flaxseed-meal, or of bread, applied and kept moist and warm, are also useful local applicatitms. A poultice used on a broken surface should be made with 1 to 10,0'00 sublimate solution. In determining whether heat or cold will be used in any given case, the surgeon must be guided in part by the sensibility of the patient, for that which is most grateful to the part inflamed will usually produce the most satisfactory results. Counter-irritants, such as blisters, sinapisms, or the cautery, are use- ful at times in the therapy of inflammation, especially in chronic pro- cesses in the joints and deeper tissues. Internal Medication. — As far as the constitutional treatment of inflam- mation is concerned, each case will be a law unto itself. In the stronger and plethoric patients a saline or a calomel purge is indicated in the beginning of the process, and restricted diet should be insisted upon. For the more feeble class of cases, tonics, cod-liver oil, good air, and well- directed nourishment are essential. To counteract the high febrile move- ment and rapid pulse, antipyrine in doses of gr. x to xx, repeated in two hours, is an excellent remedy. Aconite tincture, gtt. ij, and one drop additional every half hour until the pulse falls, is also to be recom- mended. Quinia in doses of gr. x twice a day, or even oftener, in case of chills or rigors. Morphia, or one of the hypnotics, should be given when positively indicated by the patient's suiferings from pain or loss of sleep. Suppuration. — In its recent state, pus is a cream-like fluid, in specific gravity varying from 1 "020 to 1 '040, and at times higher. In closed cavi- ties in the tissues it is usually alkaline in reaction, but when exposed to the atmosphere (and in some instances even within the tissues, where it is protected from the air) it becomes acid. Chemically it may contain para- globulin, myosin, fatty acids, leucin, tyrosin, cholesterin, chloride of sodium, and phosphates. Healthy pus is odorless, but when decompo- sition has occurred the odor is often exceedingly offensive. Examined microscopically, numerous corpuscles, varying in size from stVtt to -^-^ of an inch, are seen floating in a transparent fluid — the liquor puris. These cells have no limiting membrane, contain one or several nuclei, and at times a number of fine granules, and can not be differen- tiated from the white l)lood-corpuscle or the common embryonic cell. Another cell-like body found in pus, especially in older abscesses, or 60 A TK XT-BOOK ON SURGERY. where a chronic inflammatory process has occurred, is tlie granular eor- puNcIe, or, as it is more commonly CiilUnl, the compound n;ation of .ii-raiiules, the detritus of leuco- cytes, embryonic tissue, or other cells, which liave undergone fatty or granular metamor- ])hosis. These adhere together in spherical or oval masses of all sizes, often as large as a dozen pus -cells together, or the granules may float I'l'ee in the liquor puris. The ditt'erentiation of these elements is not difheult. Upon the ad- dition of acetic acid the pus -corpuscles become swollen, and lose their granular, cloudy ap- ])earance, while their nuclei, otherwise scarce- ly recognizable, stand out in strong relief. Acetify acid does not affect the granular corpuscle, which, however, is soluble in ether. Pus-cor- puscles proper are at times endowed with the amoeboid movement. This is only true of the white blood-cell, which has not yet jjerished. The dead embryonic cells do not possess the power of motion. These various elements of pus, as well as the cholesterin crystals, which are sometimes met with, are shown in Fig. 119. Fio. 119. — fllodifiefl from Tlionias.) a, Compound granuliir coijrns- cles. b, Crystals of cliolestcriii. c, I'us-cclls. re an abscess complicates a hernia or other important viscus, a careful dissec- tion should be made from without inward. The point of greatest impor- tance is to have the opening or openings in such a i^osition that the drainage will be from the most dependent portion of the cavity. In cutting down upon an abscess it is often necessary to insert a small-sized aspirator-needle and determine the exact distance to the pus. The needle should be left in i^lace as a guide. In some of these cases, in order to avoid haemorrhage, a very good use may be made of the ordi- nary dressing-forceps, by closing the jaws of the instrument and pushing it through the tissues into the pus, and then stretching the puncture thus made by forcibly separating the handles. As soon as an abscess is opened the nozzle of the irrigator should be introduced, and the cavity well washed out with sublimate (1 to .3,000). After this rubber drains should be inserted, and a thick dressing of subli- mate gaxize applied. When an abscess occurs in parts of the body where it is desirable to avoid leaving a scar, as the neck or face, and wliere the symptoms of sepsis arc not marked, a cure may be effected by means of the aspirator. For this operation the instrument reitresented in Fig. 123 is preferable. It consists of a syringe, with a glass cylinder, armed with a double tip, a stop-cock, and two adjustable rubber tubes — to one of which the needle is tightly screwed. When about to be used, the apparatus should be thorougiily cleansed in 1 to 20 carbolic-acid solution, and, if the needle has been used in any suspicious matter, it should be heated to a red heat over a spirit-lamp, and cooled off in 1 to 20 carbolic-acid solution. TIk^ method of hyper-distentinn of an abscess with an antiseptic fluid was flrst prominently brought before the profession by Mr. Callender. The cylinder should be filled with the solution, and then, while holding the needle upward so that any air which may have entered by accident will escape first, the contents should be forced out until only about one third of the INFLAMMATION. 63 cylinder is full. By this manoeuvre the needle and tube are also filled with the solution, and the former is thrust into the cavity of the abscess and held steady by an assistant. The operator now withdraws the piston slowly, so as to give the contents sufficient time to fill the tube, which Fig. 123.— Combined a.posiiig side should be exaclly on the same level. In order to effect this, it is often necessary to lift one side with a director or liook, or depress the other to the proper level with a (lull instrument. No fat or shred of tissue should be allowed to bulge up between the edges, but should be 2)ushe(l out of sight with a probe or forceps while the suture is tied. In order to prevent slipping, the fiist knot shoidd be the double friclii)U-looi;) (see page 51), which is 1/ "X ■^ N Fici. 13(i. Fio. 135. Fio. the only one that will hold its grip while the sec(md single loop is being tied to secure the knot. It is best to keep the knots away from the line of the approximated edges. In tiglitening the sutures the effort should be made to bring the lips of the wound together nicely without sullicieut tension to pucker or wrinkle the skin, or to cau.se it to be infolded or to be turned white from too mucli pi-essure. AVlien expedition rather than nice adjustment is desired, the cojitiniivus suture (Fio- l-^'^) rU'iy l'^' practiced. The needle is always passed at a right angle to the axis of the wound, although that part of the suture which is visilde crosses it of)liquely. The mattress suture, shown in Fig. 138, and the quill suture, at Fig. 139, are practically obsolete. They possess no advantages which do not belong to the intemtpted or rontiimous methods. The silrer-wire suture is always interrupted. The application is well shown in Fig. 140. After the proper apposition is secured by the first WOUNDS. 73 twist, made with the fingers down at the level of the skin, the ends should be clasped in an artery-forceps and turned eight or ten times. Fig. 13S. Fig. 139. Fig. 140. The pin-suture is still popular with a number of surgeons. Silver l)ins, or the ordinary iron pin of commerce, may be employed, and the adjustment of the opposing surfaces made more complete by throwing a silk or catgut interrupted loop, or figure-of-8, around the ends of the pin (Fig. 141), or a continuous figure-of-8 applied, as shown in Figs. 142 and 143. m ^ hi I «■ Fig. 142, Fig. 143. t'l.^ Ul. Fig. 145. When it l)ecomes necessary to close a three-cornered wound, a cross- suture (Fig. 144) may be utilized, or the double-needled suture (Fig. 145) may be substituted. Superficial lesions may be closed by adhesive strips, although this method is less exact and less cleanly than the sutures. The strips should be cut narrow, and it is always necessary to have the parts to which they are to be applied dry and warm, else it will not stick. The adhesive strips hold readily when warmed, as they are ap])lied, or when moistened with turpentine. The strips may be dovetailed, or, while the edges of 74 A TEXT-BOOK ON SURGERY. the wound are held in apposition, laid directly across the line of approxi- mation. Another method, less frequently employed, yet useful at times, is to take a i>iece of plaster and fasten it to tlie skin parallel with the edge of the wound. A half-inch of this margin is folded back, and to this hooks are attached and elastic threads drawn directly across or in figure-of-8 fashion, graduating the pressure necessary to a ]n'oper apposition. The needles for carrying sutures should be of various patterns, and of all sizes, for different purposes. Some are straight and round, ofln'is ai'e lance shai^ed ; scmie should be crescentic, others straight for the half or two thirds of the shaft nearest the eye, and curved toward the ])oint. In general a needle should not cut laterally while it is being introduci'ipette in order to be sure that no air is introduced. If then the stop-cock is turned, or the rub- ber tube compressed, the canula will be held full ot fluid. After it is carried into the vein it shoidd be held in place by a ligature tied around the vessel just beliind the expansion at the nozzle. If the stop- cock is now turned on, the fluid gravitates into the vein. The quantity and rapidity of the injection may be regulated by press- ure upon the tube, or by elevation of the funnel. The introduction should be slow- ly and gradually accomplished. Any ordi- nary syringe, if thoroughly cleansed, may be employed. Care should always be taken to prevent the introducticm of air. The aspirator heretofore figured is an ex- cellent instrument for transfusion into a vein or artery. The older methods of transfusion with defibrinated blood, or direct transmission from the arm of the giver to that of the patient, ai'e now completely superseded by the saline solution. Successful transfusion of simple water at the temperature of the blood has also been accomplished. Poisoucd Wounds. — When a, venom or mrus is introduced into the tissues through a solution of continuity, it is called a poisoned wound. Snake-Bite. — The venom of certain reptiles carried into the circulation through a wound produces alarming and, at times, fatal results. The intensity of its action is in pi-oportion to the quality and quantity of the pois(m absorbed, as well as to the rapidity of its introduction. Tlius, the venom of the cobra and rattlesnake is more fatal than that of many other fcn'ms. Again, the venom lodged in the skin and subcutaneous areolar tissues, and absorbed by the lymph-vessels and caijiUaries, is far Fio. 141;. 76 A TEXT-BOOK ON SURGERY. less potent for evil than that which is injected into a vein, overwhelming the lieart and sensorium by its rapid introduction. The order of toxicity in serpent-venom, so far as known at this date, is as follows : 1. Cobra (Nala tn'jjud/aiis), a native of India ; rattlesnake {Crotalus durissus and C adamanteus), of southern North America; Bothrop jararacaKsa and B. jararaca, closely allied, aocordinfj to Dr. Robert Fletcher,* in the intensity of its venom to its congenei', the North American rattlesnake ; American copper-head ( Trigonocephalus contor- trlx) ; the American moccasin {I'oxleophif! atrajiiscus and T.piscivorus) ; the spreading adder, of the order Vqjera benis. The venom of snakes is excreted by a gland situated near the eye. In the act of striking or biting it is forced by a compressor muscle along a channel, or groove, in the fang. In the quiescent state the fangs (one on either side) are folded backward, and are buried in grooves in the mucous membrane of the roof of the moutli. When ready for nse, they are drawn forward by erector muscles. Rattlesnake-venom, according to Dr. S. Weil- Mitchell, f has a specific gravity of I'O-t-t, and an invariably acid reaction. Its color is from a greenish to a straw tint. Conjointly with Dr. Edward T. Reichert,^ lie has isolated three proteids— namely, venom-peptone, venom-globulin, and venom-albumen. Venom-globulin is intensely toxic, producing rapid extravasations of blood ; venom-pep- tone is less poisonous, but produces, when injected into the breasts of pigeons, intense sloughing. The albumen-venom is not vet fullv under- stood. Bromine, iodine, sodium, and potassium hydrate and potassium permanganate destroy chemically the toxic property of the venom of the rattlesnake, copper-head, and moccasin. Serpent - venom produces no poisonous effect in the tissues of the reptUe which produces it, or in the tissues of any venom-producing reptile. As just stated, the symptoms resulting from snake -bite in man vary with the toxicity of the venom, the amount introduced, and with the rapidity with which it is carried into the circulation. A keeper in the London Zoological Grardens was bitten on the nose by a cobra, and died in a little more than one hour.* Dr. Wainwright, of New York city, died ^vithin six hours after being bitten l)y a rattlesnake. |[ Dr. G. A. Kunkler ^ reports the case of a boy six years old, who died during a convulsion on the fourth day, after being bitten on the foot by a copper- head. The venom is seemingly as potent in cold as in warm weather. Dr. E. P. King ^ treated a patient in whom well-marked toxic symptoms were developed after being bitten by a copper-head which, although torpid, had recovered its activity under the influence of heat. When the * " American Journal of the Medical Sciences," July, 1883. t Smithsonian Contributions, 1860. "New Yorlc Medical Journal," 1868. + '-Philadelphia Medical Xews," 1883. * Bryant's •' Surgery." J Hamilton's '■ Surgery." •^ "Cincinnati Lancet and Observer," 1859. '• Americran Journal of the Medical Sciences," April, 1883. "American Journal of the Medical Sciences," April, 1884, p. 428. WOUNDS. 77 clothing intervenes, the venom is likely to be in part arrested, and the effect less severe. Pain of a sharp or stinging character is usually felt in the wound. Fright or shock may mask this symptom. Swelling rajiidly ensues, and in rattlesnake-bite ecchymosis is not uncommon. The swelling extends in all directions, but is most marked in the line of the lymphatics toward the center. Headache, fever, rigors, irregular breathing, and a low, fee- ble pulse, with nausea, may be present. Adenitis, abscess, or sloughing usually occur. If death does not ensue, the case may terminate favor- ably in two or three days, or last for weeks and months. Treatment. — The immediate indication is the removal of the venom. Labial suction is an efficient method, and may be safely practiced, pro- vided that there is no abrasion on the lips or contiguous mucous sur- faces. Inoculation is more dangerous about the mouth and neck than elsewhere, since the great swelling may close the trachea or larynx. Next in order of readiness is free and immediate excision of the tissues within a radius of half or three fourths of an inch from the puncture, or free incisions may be made so that the flow of blood may wash the venom out. Permanganate of potassium is probably the best chemical, and whisky (or alcohol in some other form) the best physiological antidote. Dr. de Lacerda,* of Brazil, recommends the immediate injection in and around the wound of a 1-per-cent (gr. v to 3 j) solution of the permanganate in water, and also an intra-venous injection if the venom has had time to enter the circulation. Dr. Robert Fletcher f states that Richards, of Cal- cutta, after repeating Lacerda's experiments, recommends a o-per-cent solution in cobra-poison ; 3 j to " iv of a solution, varying from gr. v to gr. X to water 5 j, would lie aljout the safest treatment for rattlesnake- venom ; and the weaker solutions for coj^per-head and moccasin bites. It must not be forgotten that this salt is toxic in overdoses. Vulpian pro- duced death in a small dog with an injection of gr. vij. Whisky, or any form of alcohoJ, is a favorite cardiac stimulant, and may be taken in adults in large quantities without intoxication. Care must be taken in administering alcohol to children, since it has occasionally proved fatal. When great swelling occurs, and gangrene is threatened on account of tension, free incisions or punctures should be made. The venom of some of the lizard family, as the Gila monster:}: {Helo- derma suspect urn) and the toad** {Bu/o Tidgaris), also possesses toxic jjroperties. The treatment should be about the same as given above for serpent- venom, though not quite so energetic. Venom introduced with the sting of the scorpion not infrequently causes death in the Orient, although the sting of the Xorth American scorpion is not dangerous. I have failed to hear of a death fi-om this * " Gazette des h6pitaux;" 1881, pp. 597 and 891. Also, a valuable paper by Dr. H. C. Yar- row, " Anieriean -Journal of the Medical Sciences," April, 1S84. t "American -Journal of the Medical Sciences," July, 1883. t Mitcliell and Roichert. " Medical News," Philadelphia, 1883. » " Gazette des bopitaux," 1881, p. 598. 78 A TEXT-BOOK ON SURGERY. accident, although I have made personal inquiry from numerous prac- titioners in the South and West, who have had much experience with these cases. In a personal experience, in which T was stun. 179. 80 A TEXT-BOOK ON SURGERY. au animal to man, but from one person to another. Schutz and Loftier, in Koch's laboratory, have recently announced the discovery of the bacil- lus of glanders, which is said to resemlile the bacillus tuberculosis. These organivsms were seen by WassilielT in the blood of a man sick with this disease. Inoculated with this virus, the parts about a wound become ra])idly inftanied and swollen. Cellulitis, lymphangitis, and adenitis ensue, with high febrile movement and the usual ccjuditious of septi- c;emia. Inoculated upon a mucous surface, the morbid process is prac- tically the same. The inflanmiation spreads rapidly, and the adenitis and ulcerations occur in man as in animals. In severe cases metastatic nodules occur in the skin, not infrequently breaking down into pustules. Abscesses may be general. In the severer cases death is the rule. The indications in treatment are to support the tissues by all possible measures of nutrition. A wound freshly inoculated should be treated as advised in rabies. 3falir/nan,t Pustule. — This disease in man results from the inoculation of a peculiar virus which is found in the tissues of animals infected \A-ith a micro-organism, the antlirax bacillus (Fig. 147). This bacillus is believed to be the disease-germ. Carnivora are rarely susceptible. The virus is intensely toxic, and exceedingly contagious. By some it is held that an abrasion of the integument or mucous surfaces is not always necessary to the invasion of the germ.* The bite of an insect which has been feeding upon anthrax carrion, or the in- gestion of infected meat, or the mere contact with Fig. 147.— (After Sternberg.) the hair. Wool, bones, or any part of an animal dead with anthrax, is dangerous.f Tanners, butch- ers, and fun'iers are more often the sufferers from this disease than oth- ers. The virus retains its potency almost indefinitely. Sheep allowed to graze in localities where carcasses of cattle dead with anthrax have been buried many years acquii'e the disease by ingestion of germs lodged upon the grass, and in the earth over these graves. Contagious from animal to animal, and from animal to man, it is likewise contagious from one in- dividual to another. The face aud hands are, on account of exposure, most frequently the seat of the inoculation. The symptoms are redness, swelling, induration, a throbbing sensation and pain at the point of contact of the virus. AVithin twenty-four hours an ulcer usually is de- veloped in the center of the indurated area, soon followed by lymphan- gitis and adenitis. High temperature, rapid pulse, headache, nausea, and the usual condition of general septicjemia, foUow as the disease pro- gresses. Microscopical research has demonstrated bacilli, in great numbers, not only in the tissues immediately around the seat of contagion, but, also in the later stages of the disease, a general dissemination of these organ- * Afmew's " Snrjrery," vol. i, p. 214. t " New York Medical Journal," 1884, p. 410. WOUNDS. 81 isms. Hfemorrhagic infarctions and ceclema are frequent symptoms. When the disease results from the ingestion of the poison, the diagnosis is difficult. Swelling and puffiness of the face have been observed, vrith high febrile movement and great prostration. Treatment. — Local and constitutional measures are demanded — ex- cision or free incision, and the application of a strong sublimate solution (1 to 1,01)0). Supporting measures are demanded when the infection is general and prostration is threatened. Dlxscrfion Wounds. — A wound is not apt to become poisoned from contact with the tissues of a cadaver which has been thoroughly injected with chloride of zinc, arseniate of soda, or sublimate solution. Septic matter from non- injected subjects is always a source of danger when brought in contact with abrasions of the skin or mucous surfaces. The contents of the peritoneal and pleural cavities are especially virulent. The fluids from persons dead from any septic or malignant disease, such as erysipelas, small-pox, etc., are unusually dangerous. Patients suffering from suppurative arthritis, with general sepsis, are dangerous subjects. In a recent case of this nature in IMount Sinai Hospital, a colleague and one member of the house-staff and the nurse were all seriously inoculated from the same operation. Susceptibility varies with the individual. Some enjoy lasting immunity under all conditions of exposure, while others are easily inoculated. Symptoms. — Intiammation and soreness at the wound are first noticed. In a few days lines of redness extend in the route of the lymphatics, and the arm (since the hand is usually the seat of the primary lesion) becomes painful, stiff", and hot. The epitrochlear and axillary glands enlarge, and in many cases suppurate. Rigors, fever, headache, aching of the joints, coated tongue, and other symptoms of sepsis follow. The jwtient may pass into a low tyjDhoid state, or general metastatic abscesses may occur, ending in death. Treatment. — Ablution of the wound in sublimate solution fl to .'lOO) and suction should be instantly performed, or suction alone may remove the poison. It should be kept open and washed frequently. Cold cloths or the ice-bag will be found very grateful in the lymphangitis and adenitis which follow the inoculation. Caustics, or coveiing in an abra- sion with liquor gutta- perch ?e, collodion, or plaster (except for protec- tion against further inoculation), is an absurd and dangerous practice. If abscesses form, early incision is demanded. The constitutional reme- dies are quinia, tonics, stimulants, antipyrine, judicious feeding, and ventilation. Erysipelas. — Erysipelas is a contagious as well as an infectious dis- ease, caused by tlie invasion through an abrasion of the integument, or by the mucous surfaces, of a specific poison or virus. The presence of an almost constant micrococcus in the inflammatory area of erysipelas has led some obsen-ers to ciuisider this organism as the cause of the disease ; but the fact that it has been wanting in some instances ex- amined by careful investigators would seem to disprove this theory. It may spread from one infected person directly to another, or indirectly 82 A TEXT-BOOK ON SURGERY. by means of the clothing or hands of an intennediate party. It is char- acterized by an inflammation of the skin or mucous surfaces, of the sub- cutaneous and submucous tissues, and at times, passing the liarrier of the deep fascia, it attacks tlie nuiscles and deeper organs. The period of incubation varies from eight to twelve hours to three or four days. For constitutional or even marked local symptoms to occur within twenty- four hours, however, after exposure of a wound to the virus, is the excep- tion rather than the rule. In the large majority of cases the symptoms declare themselves usually between twenty-four and forty-eight hours. Locally the part becomes hot, throbbing, tense, and painful, csijccially on direct pressure. The color varies from a pale rose to a luight red hue. In well marked cases the inflamed integument ajijiears to be glazed, and tlie limit of redness is regularly and sharply deliiit-d. Wlien the inflammatory process is rapid, and the integrity of tlu» circulation markeilly iinpaired, the bright flush of the skin gives way to a dull mottled discoloration. Pressed by the tip of the flnger, the skin becomes pale, but the color returns and the indentation is soon effaced, except in those cases of marked oedema. Lym]ihnngitis and occasionally ])hle- bitis occur. The spread of these complications is indicated by lines of redness and tenderness leading in the route of these vessels. In some instances vesicles or bulla; form beneath the epidermis. An attack of erysipelas is almost always ushered in by one or more chills, or by dif- ferent and recurring chilly sensations or rigors. The exacerbation of temperature varies from 100° to 104' or 105° F. The pulse is propor- tionately increased in frequency. The febrile movement and constitu- tional symptoms vary with the character of the attack. In simple cutaneous ei-ysipelas the clinical history is usually mild. In the ceUiiIo- ciitaneous or phlegmonovs variety severe and fatal sepsis is not uncom- mon. Gangrene is occasionally met with alwut the center of the in- flamed zone, and, when attacking an extremity, the circulation may be an-ested and the part beyond the disease sacrificed. The duration may be from seven to ten days in mild cases to several weeks in the severer and not fatal forms. BldfinoHifi. — Erysipelas, within the first twenty-four or forty-eight hours of its appearance, may be taken for dermatitis, or simple erythema, phlebitis, lymphangitis, or cellulo-dermatitis. Dermatitis occurs, as a rule, from local irritation, and is not accom- panied by any of the constitutional disturbances which always occur with erysipelas. In simple inflammation of the skin the color is red, Imt it never has the glazed appearance which is always i>resent in a typical erysipelas. Erythema, a mild foi-m of dermatitis, may also be mistaken for erysipelas. In erythema papiilatum the exposed and extensor sur- faces, as the dorsum of the hand and the posterior aspect of the forearm, are apt to be involved. There is no wound of inoculation ; very slight, if any, infiltration of the skin proper. Children and younger adults suffer most frequently. It lasts for only a few days, then fades away, leaving a dry scale to indicate the location of the papule. Omng to the various shapes and the different shades of color assumed by the papules, and WOUXDS. 83 efflorescence of the erythema, it has been divided into erythema annu- lare^ erythema gyratum, and erythema iris.* In erytliema intertrigo there is a general redness of the skin in parts subjected to friction or irritation from persj)iration. Erythema nodo- sum is almost peculiar to chlorotic females. The color, at first bright red, soon changes to a dark hue. The patches are oval, elevated, and nodular. Phlebitis and lymphangitis are more severe forms of inflammation tlian those just given, and are accompanied with constitutional symptoms not unlike those present in a typical erysipelas. The chief point of diag- nostic value relates to the anatomical arrangement of the vessels, for in phlebitis and lymphangitis the lines of inflammation and discoloration travel along the course of tlie vessels without the general and wide-spread efflorescence of erysipelas. Diffuse cellulitis occtirring from a poisoned wound, as with a dissect- ing-knife, or after the bite of a serpent, will offer no difficulty in diagnosis. It may, however, occur without a recognized cause. The subcutaneous tissues are first attacked, and the skin may or may not be involved in the process of inflammation. There is swelling and painful tension of the part affected, and, if the process be uninterrupted, transudation of serum occurs, causing oedema, and giving a doughy feeling on pressure. Pus may be formed in quantity, and infiltration become extensive. This result is more apt to occur in ditt'use non-specific cellulitis than in phlegmonous erysipelas. This condition, especially when the skin be- comes invi>lved, offers considerable difficulty to a positive diagnosis. If, however, the peculiar symptoms heretofore given be carefully considered, and a comparison instituted between them and the phenomena of the various diseases which may simulate or complicate erysipelas, it will be found that, in the great majority of cases, a correct diagnosis may^ be made. Prognosis. — Simple cutaneous erysipelas, as a rule, is not a dangerous disease. In several epidemics in hospital i^ractice I have never seen a fatal case. Occurring about the face, head, or neck, the prognosis is less favorable than when the inoculation occurs elsewhere. When it compli- cates a wound in a patient already prostrated by haemorrhage or surgical fever, it may hasten a fatal issue. In phlegmonous or cellulo-cutaneous erysipelas the prognosis is not so favorable. Suppuration and the general infiltration of the tissues with pus and inflammatory products induce a condition of septicaemia often rapidly fatal. Treatment. — In an outbreak of erysipelas the treatment in those attacked is both local and constitutional, while in others strict measures of prophylaxis should be instituted. Immediate isolation should be effected, and the gi-eatest care observed to prevent contact with other subjects. All bedding, furniture, and apparatus nsed upon or about an erysipelatous patient should be burned, or thoroughly scrubbed and soaked in a solution of corrosive sublimate varying in strength from 1 to * Neumann, '■ Hand-Book of Skin Diseases." Bulkley. D. Appleton & Co., 18V2. 84 A TEXT-BOOK ON SURGERY. 500 to 1 to 1,000. Any instrument subjected to contamination shoixld be submerged in 1 to 10 to 1 to 20 carbolic a('id, and afterward tlioi'oughly dried. The walls and floors of a ward or room in which an outbreak has occurred should be moi:)ped and washed in the sublimate solution. The attendants upon such cases should be excluded from all possible contact with other individuals. When a physician is compelled to visit a case of erysipelas, he should wear clothing which should be changed immediately after leaving the room, which precaution should be emphasized by a thorough disinfection of his hands, face, beard, and hair in 1 to 3,000 sublimate solution. The local measures always include ;is of iirst inqtor- tance the investment of the part involved with sublimate gauze and a moist dressing. Continuous irrigation of cold, tepid, or wai'm sublimate (1 to 5,000) may be added to the loose gauze dressing, or not, as may l)e determined by the demands of any case. This method is mainly prophy- lactic. Cold irrigation will be most generally gratefiil. Extreme heat or cold, however, should be used with caution in all cases where the circu- lation of the part is seriously impaired by the inflammatory process. When an extremity is affected, elevation of the part is indicated. Ten- sion should always be relieved by puncture or incision, even when sup- puration and pus inflltration are not evident. The principle of drainage applies here as in other wounds, and the free outlet of all purulent mat- ter is essential. Incisions, when x^i'^cticed, should be in the direction of the veins of the part, so that these need not be divided, and should always extend deep enough to relieve tension and to give free exit to all septic matter. The method of injecting carbolic acid into the skin and subcutaneous tissues, at a distance of from one to two inches from the red limit of the erysipelatous flush, in order to check the further invasion of the disease, is of doubtful efficacy and propriety. The same should apply to "firing" with the actual (cautery or lunar caustic for the same purpose. The constitutional measures look to the support of the patient, and to the antagonism of the specific poison. Since constipation and gastric disturbance are the rule, a saline laxative should be given, but not to the extent of producing exhaustive diarrhoea. Purgation is not indicated in enfeebled and emaciated subjects. For the rapid pulse, tincture of aco- nite-root may be employed, and antipyrine, 10 to 20 grains every two or three hours until the temperature falls to al)out the normal. Tincture of the chloride of iron, 8 to 15 drops three or four times a day, has long enjoyed a high reputation in the treatment of this disease, and the same is true of quinia in full doses. Tetanus. — Traumatic or surgical tetanus differs from the idiopathic variety of this affection only in the presence of a wound, which is the starting-point of the irritation which ends in imjelifis. Any lesion, how- ever small or seemingly insignificant, and upon any portion of the body, may serve as the starting-point of this affection. Wounds, however, of the plantar and palmar surfaces, and in the distribution of the trifacial nerves, are believed to be especially liable to induce a central myelitis. Irritation, however, without a solution of continuity, may i^roduce this WOUNDS. 85 ten'ible disease, and it has been observed that the epidemic form of tetanus is more likely to occur when, added to an injury, the atmospheric conditions are unfavorable. It is more fj-equently met with in hot than in temperate climates. Thus, as cited by Gross and Hamilton, among the wounded of Aber- crombie's command, who, after the defeat at Fort Ticonderoga, in the summer of 1758, were exposed to inclement weather, in open boats upon Lake George, during tlie entire night following the engagement, an epi- demic of tetanus prevailed, in which nine cases died. Sudden and pro- longed exposure to cold or in a damp atmosphere after a wound always adds to the danger of being attacked by this disease. The impression prevails among the inhabitants of Long Island, especially along the east shore, that they are especially susceptible to lock-jaw ; and that this is more than conjecture I am convinced, for I know personally of several cases occurring in this vicinity. The time which may elapse between the receipt of the injury and the appearance of the muscular spasms varies from a few hours to several weeks ; usually within the first three weeks after the injury. The earlier symptoms refer to an unusual degree of irritation and pain in the wound, which is apt to be out of proportion to the degree of inflammation present. The sense of pain is often referred along the sensory tracts toward the centers. Irritability, a sense of unusual muscular excitability, a feeling of malaise and apprehension, are among the symptoms which precede the convulsive attacks. The muscles supplied by the motor filaments of the fifth nerve are among the earliest to respond to this abnomial stimulus, hence the commonly accepted term of lock-Jaw. In the milder cases the tonic spasms may be altogether confined to these muscles. In severer cases the sense of distress is referred to the ei)igastric region, and this is followed by tonic muscular contraction, ccmimencing with the diaphragm, and involving in quick succession the muscles of the jaws, larynx, and back of the neck and dorso-lumbar region. Respiration is interrupted, the expression of distress is extreme, the face becomes cyanotic, and death may occur from fixation of the respiratory muscles. The chief distortion is that of more or less complete extension of the spine {opis- 86 A TEXT-BOOK ON SURGERY. thotonos). An exaggerated illnstration of this condition is given in Fig. 148, from the well-known i)icture of Sir Charles Bell. When the tonic spasms are confined to the anterior iimsries, and the l)ody is bent foi-ward, the condition is known as empioslhofonos, and if curved laterally, pleu- rothotonos. The spasm continues uutil the muscles are unable longer to contract, when a gradual and partial relaxation occurs. Successive attacks f(jllow rapidly, being precipitated by the slightest cause, as the jar communicated by walking upon the floor, or the contact of the hair or clothing upon the hypera^sthetic integument. Notwithstanding the violent nature of this affection, the mind, in the great majority of cases, i-emains clear until carbonic-acid poisoning occurs from prolonged fixation of the respiratory muscles. The pulse and tem- perature vary between great extremes, records of the former running from the normal up to 160 beats per minute, and of the latter from 98"5° to 112° F. The intense heat which is premonitory of a fatal termination, and which continues for a considerable while after death, is supposed to be due to coagulation of the albuminoid principle of muscle, the myosin (Fricke). Death may take place in a single paroxysm, or the patient may survive a number of attacks. Prognosis. — The danger of death diminishes if the i^atient survives the fifth day, although the vast majority of cases end fatally before this. The gravity of the i)rognosis usually depends upon the violence of the paroxysms, the rise in pulse and temperature being also propcjrtional to the severity of the convulsions. The period which elapses between the receipt of the accident and the appearance of the tetanic spasms is not without importance in jirognosis, the chances of recovery being increased with the longer interval. The death-rate in those cases in which tonic spasms occurred within two weeks after the injury is 62 per cent ; from 14 to 21 days, 17 per cent ; 21 to 44 days, 17 per cent ; 50 per cent of all fatal cases terminate within 5 days after the first paroxysm ; 33 per cent ivom the fifth to the tenth day. l>iagnosls. — Hysteria is niore apt to be mistaken for tetanus than any other disease. In hysteria there is usually no elevation of tempera- ture, and the s\^nptoms of great and acute distress are wanting. Hys- teria occurs chiefly in females ; tetanus, in a large majority of cases, in the opposite sex. It may be necessary at times to differentiate between the tetanoid spasms of strychnia-poisoning and true tetanus. Strychnia tetanus ensues within a few minutes after the poison has been taken ; the muscles of the jaw are not first affected as in tetanus, and are not always rigid during the attack. The convulsive movements in strychnia-poison are of short duration, and complete relaxaticm occurs, while in tetanus the muscular rigidity is continuous. Hydrophobia may be distinguished from tetanus in the character of the lesion which causes it, the peculiar clonic or interrupted spasm of the muscles, especially those of the larynx, and in the generally longer period of incubation in rabies. Pathology. — The lesion of tetanus is believed to be a myelitis. Th3 GUNSHOT WOUNDS. 87 gray matter of the cord and medulla is found deeply injected, or it may have undergone granular degeneration. In some instances no appreciable interference with the nutrition of the gray matter can be discovered. Treatiiwnt. — The Iccal measures should be employed to reduce the irritation in the wound. Relief of all tension should be secured by inci- sions, if necessary, and free discharge should be maintained, if there is septic matter in the tissues. Amputation when the wound is situated upon one of the extremities, stretching or division of the sensory nerve leading to the spine, excision of the wound, and other surgical measures, have been tried, but without a success which would warrant a repetition of these measures. The most perfect quiet is to be maintained, and the administration of concentrated nourishment must be insisted upon in the intervals of the attacks ; and rectal alimentation should be practiced if there is inability to swallow. Chloral hydrate in large doses has been successful in some cases. From thirty to forty grains have l^een given and rejDeated at intervals of one hour and a half.* The inhalation of chloroform is also highly recom- mended. The extract of cannabis Indica (Squires) in doses of gr. ss. every two hours, together with tlie application of ice to the spine, is a jilan of treatment highly recommended. GinisJiot Wounds. — Wounds of this variety may properly be divided into thos^e in ciril and those in miUtary practice. In civil life the wounds inflicted by the shot-gun, small-bore himting-rifle, pocket-pis- tol, and toy guns, are much less dangerous than those made by the more formidable weapons emploj^ed in warfare. "With the exception of the charge projected by the shot-gun and the small hunting-riiie, all missiles now used are conoidal or oblong in shape (Fig. 149). Projectiles fired from ordnance are both round and conoidal, solid and hollow, the latter being usually explosive. Grape, canister, l)ombs, and some solid shot; are spherical, while most of the shells are cylindro- conoidal. A gunshot wound is always contused or lacerated. It may be simjile or compJicuted : simple when the missile alone passes through the tissues ; complicated when fragments of cartridge, wadding, jDOwder, clothing, or other foreign matters are carried in with it. The degree of laceration made by a gun-projectile is, as a rule, in an inverse ratio to the rapidity of its projection. It may also depend upon the shape of the missile, and the additional destruction caused by dis- ]ilaced fragments of bone, etc. A conoidal projectile is more destructive than one wliich is spherical, for when in its transit the point meets with resistance, it tends to turn over and over on its long axis, loses in great part its axial rotnticm, and thus plunges through the tissues. When a l)all passes in and out of the body, it will be found that the wound of entrance is smaller than tluit (jf exit, and is seemingly much smaller * Hammond, '• Diseases of the Nervous System." D. Appleton & Co. 88 A TEXT-BOOK ON SITIGERY. than the projectile. Tlie infolding of tlie skin anrl its elasticity will account for the small size of the entrance. The diiniimtion of the momentum, and the tumbling of the projectile as it jjluiiges through the tissues, together with the non-resistance of the skin at the exit, will account for the larger size of this opening. When a ]>i-ojectile pass- es completely tlirougii the tissues there is usually a single opening of exit. Occasionally the object is divided after entrance, and makes two or more holes of exit, or one part of the bullet may lodge and the other pass out. Fig. 149. — Table of weights (in grains) of the balls at present in use in the armies of various nations. With the exception of No. 6, the cuts approximate the actual size of the missiles. 1, Sprini;field rifle, 500 grains (.A^'new). 2, Kntield rifle, 530 trrains (Agnew). 3, Austrian rifle (old), -400 grains (Agnew). 4, Chasscpot rifle, .387>f grains (Fischer). 5, Needle-L'un, 5.30 grains (Agncw). 6, Mitrailleu>c, 840 grains (A,'new). 7, Bavarian rifle, 386 grains (I'I^cIrt). 8, Snider rifle, about 400 irrains. 9, Musket- ball, 4S0 grains C\gnew). 10, Belgian rifle, 385 grains (Fischer). 11, Martini-Henry rifle, 4S5 grains (Fischer)i li, Italian rifle, 310 grains (Fiseheri. 13, Netherland rifle, . 3.37 grains (Fischer). 14, Austrian rifle (nen), 872 grains (Fischer). 15, Russian rifle, 372 grains (Fischer). IG, Swiss rifle, 310 grains tFischer). Fragments of bone or teeth displaced by a missile may be driven out through the integument. If the velocity of a missile is great, and the tissues traversed offer no special resistance, the wound of exit will be in the direct line of that of entrance. Bodies traveling with diminished velocity or meeting with formidable resistance will be deflected, and may piirsue a most unex- pected course. Instances are recorded of l)ullets which have made a half or the entire circuit of the body, passing just beneath the skin. Still more remarkable are the instances of extensive fracture of bones which have been produced without any evidence of injury to the integument. Longmore * relates the case of a soldier who had the whole shaft of the ♦ Holiiies'9 " Surgery," vol. ii, p. 134. William Wood & Co., 1875. GUNSHOT WOUXDS. 89 humerus shattered by a cannon-ball, yet the skin remained as white and as sound as if it had not been touched. Numerous instances of similar lesions are recorded. Treatment. — As with all other wounds, the arrest of hsemori'hage is the iirst indication in gunshot injuries. The various means to accom- plish this end have already been given. It should be the recognized duty of the profession to instruct the general public in the use of the simpler means for arresting hsemorrhage. In military service each soldier should be taught by actual demonstration where and how to make com- pression in order to control the blood-supply to a part. In actual warfare the vessels should be outlined by nitrate-of -silver tracings, and with especial indications at those points where pressure will prove most efficient. The ready construction of a tourniquet l)y means of a belt, coat-sleeve, bridle- rein, etc., tied around the Umb at the proper place, and then twisted by a bayonet, sword, gun-barrel, or stick, is an important lesson for an emergency. Xext in order, and no less essential in the successful man- agement of a gunshot wound, is cleanliness and dralnarje. In the best- regulated armies of to-day each soldier carries in his cartridge-box a well- protected ball of iodofomiized gauze, with the instructions to lay this over the wound as sixui as possible, and to hold it there by a belt or bandage until the surgeon arrives. In the antiseptic treatment of these injuries irrigation with 1 to 3,000 sublimate solution is thoroughly done. All foreign matter or fragments of bone or destroyed tissues are removed, bone, catgut, or rubber drains inserted, and the regulation antiseptic dressing applied. When sublimate solution can not be had, 1 to 20 to 30 carbolic acid is next in order of jsreference ; and, if neither of these articles is avaU- able, the freshest and purest water should be employed. Following a serious gunshot or other injury (or at times a violent emotion without any appreciable lesion), a condition of prostration or partial collapse occurs, which is known as shock. 8hock may be defined as a condition of collapse resulting from jjhysical injury or mental emo- tion (one or both) whereby the functions of the nerve-centers are more or less completely suspended. The degi-ee of shock is often determined by individual susceptibility, and is not always in proportion to the severity of the injury. The symptoms are pallor, coldness of the skin, thready, irregular, or rapid pulse, nausea, vomiting, clammy perspiration, and an anxious and fixed expression. Judicious stimulation is the great indication, for, while reaction must b3 brought about, the quantity of stimulants should be kept at the pos- sible minimum, for an excess will only add to the fever of reaction. Rye whisky by the mouth, rectum, or hypodermically, should be preferred. Hot bottles, warmed blankets, friction, etc., are Txseful adjuvants in the treatment of shock. The advisability of searching for a gunshot missile which has lodged in the body, or which has traversed any of the cavities, as well as the treatment of wounds of special organs, will be discussed hereafter. CHAPTER VII. BUKNS AND SCALDS. — FROST-BITE. Burns and scalds are classified in degrees varying from the mildest form, which produces a simple inflammation of the epidermis, to the most severe form, which destroys all the tissues or organs of a i)art. The gravity of the prognosis is usually in proi^ortion to the extent of surface of the integument destroyed rather than to the depth of the destructive process. Burns of the head and face are most dangei-ous ; those of the extremities least grave. Recovery is exceptional after destructi(m of one third of the cutaneous surface. Death may result from shock, ulcer of the duodenum, or exhaustion from prolonged suppuration and septic absorption. The history of a slight burn or scald involving only a limited area of the integument, and not extending beyond the skin, is simjily one of local disturbance. Cold-water immersion is the indication in treatment. When, however, a considerable extent of tissue is involved, symptoms of profound constitutional disturbance rapidly supervene. The x>atient is seized with chills or rigors, suffers excruciating pain, betrays in his expression the extreme anxiety felt as to his condition, and sinks into a condititm of collapse, wliich is often the prelude to a fatal issue. When not rapidly fatal, the duration of this stage is fi-om six to thirty-six hours. It is followed by the stage of reaction and inflammation. The character of the febrile movement depends uj^on the extent of the destruc- tion of the tissues, and upon the concurrence of certain lesions of the thoracic and abdominal viscera. Inflammation of the duodenal glands, and the formation of ulcer with perforation, is not of infrequent occur- rence during the second week after the accident. Peritonitis, pleuritis, or pneumonitis may add to the gravity of the prognosis. Laryngitis and bronchitis are apt to follow the efforts at inspiration in the presence of scalding steam. Treatment.— The immediate indication is to relieve pain by the admin- istration of morphia hypodermically, or some form of opium by the rec- tum or stomach. Stimulation with whisky or brandy by enema, or by the mouth, is also indicated to prevent collapse, or to modify the intensity of shock which is apt to follow a scald or burn. The use of both opium and alcohol should be made with a certain degree of caution, for there is danger from a too j)rofound narcosis \vith the former, while alcohol in BUKNS AND SCALDS. 91 excess will unnecessarily add to the fever of reaction, which always fol- lows if the patient should rally from the shock. The clothing should l)e carefnlly removed, and the burned surface shielded from the atmosphere by an immediate application of a mixture containing equal parts of Unseed-oil and lime-water. If this preparation can not l)e obtained, a coating of ordinary Avhite-lead, as mixed for use in painting dwellings, is an efficient protective when poured over the burn. Flour sprinkled over until all the excoriated surface is well hidden is a method of treatment which may be carried out in almost any emergency. Rubber-tissue protective laid over the raw surface, and cotton batting applied on top of this, is equally efficient. Lint dipjied in 2-per-cent car- liolized oil may be used directly on the wound. Any great degree of X)ressure should not be permitted upon the excoriated surfaces. In the not infrequent form of bum in which the back and posterior aspects of the extremities are chiefly involved, the prone position should be main- tained, i "When suppuration and sloughing commence, great cleanliness should be observed, to prevent the absorption of septic matter. The dressings should be changed as often as the thermometer indicates septicaemia, but not oftener. Absorbent cotton pellets moistened in 1 to 3,000 sublimate should be used in cleansing the burned surface. A mixture of vaseline (the white variety is preferable) and iodoform, in the proportion of ? j of the former to 3 j of the latter, is a useful dressing in the stage of granula- tion. This should be applied on surgeon's lint, and covered over with rul)))er protective. It often becomes necessary to arrest exuberant granu- lations by the free use of lunar caustic, or the projecting buds may be clipped off with the scissors — a method objectionable, however, in the bleeding which always follows this practice. Compression by strips of adhesive (diachylon) plaster is a better method of repressing the over- grown granulation-tissue. When the destruction of integument has been so extensive that cicatrization can not be effected on account of the ten- sion of the part involved, the transplantation of skin should be practiced. The various methods are gra/Nng, sliding, or transplantation in mass. Grafting may be done by clippings about one twentieth of an inch in diameter, and cut out so that only the epidermis and Malpighian layers are included. The epidermis is pinched up with a jiair of mouse-toothed forceps, and clipped off close to the forceps with sharp curved scissors. A spot of the granulating surface free from pus is selected, and the graft laid on bottcmi-side down and pressed snugly into the granulating bed. A similar graft for every quarter-inch of surface will suffice. These should be left uncovered from one half to one hour. A layer of pro- tective is then laid over the entire surface, and a light sublinuite-gauze dressing applied, held on with a roller or adhesive strips. This dressing should remain unmolested for at least forty-eight hours, in order to give the grafts time to take hold, and, when the dressing is changed, great care should be taken to pi-event their dislodgment. Water should not be used in the dressing. At the end of about the third day, if the graft has "taken,'' a bluish white spot will be seen, the color fading away gradu- 92 A TEXT-UOOK ON SURGERY. ally at the edges until it is merged in the general granulating mass. Grafts situated near the skin will unite and proliferate more rai)idly and surely than tluiso farther out in the - - -^ wound. y^^^it^SlJ^^ ^*''- •^- ^^- tJirdner* has demonstrated f 'flSl^g-^tf rT^m that i)ieces of skin taken from a healthy man six hours after death by accident "cut into a great many small pieces," and laid upon a healthy granulating surface, will become revitalized. The results of this demonstration are very valuable (Fig. l.W). Transplantations of skin in large pieces by entire removal, or with a ped- icle left until the vascular suj^ply is establishecj between the granulating sur- face and the transplanted integument, may also be successfully acc()m])lished. It is essential that the skin which is completely detached should be clii>ped or scraped on its under surface until only the Mal])ighian layer and epider- mis are left. The presence of fat on the reticulated corium will prevent success. When sliding is attempted, it is essen- tial that the pedicle should be of good width, and that the tension on it should not be great, so that the integrity of the blood-supply may not be inter- fered with, and sloughing ensue. Ui^on the face and neck, where the vascularity is so great, a smaller pedicle may be used, and gi'eater tension employed than on other portions of the body. AVhen there is not sufficient integument immediately about a Inirn to supply the want, the flap may be secured from some other portion of the body. Thus in a case of extensive desti'uction of the integument on the front of the leg, I have succeeded in covering in the surface by turning a flap from the posterior aspect of the opposite leg, leaving a wide pedicle, and fastening the two members in an immovable position, so that the flap remained in its proper place and free from strain. After about ten days the pedicle may be divided. In the case of a boy who had been severely burned in the hand and forearm, and where the cicatricial con- tractions displaced the fingers, deformed the hand, and threatened am- putation of the member by obstruction of the radial and ulnar, I did the following operation with success : All the cicatricial tissue about the wrist and arm was dissected off down to the tendons and bones, which were in good condition. Two parallel incisions, six or seven inches long and four inches apart, were then made from the ensiform cartilage down Fio. 150. * "Medical Record," vol. sx, p. 119. BURNS AND SCALDS. 93 to the umbilicus, and the strip of skin dissected up in the middle and left attached at both ends. When the small amount of bleeding had been arrested, the hand was slid beneath this tlap, the under surface of which was brought in contact with the raw surface, where the cica- tricial tissue was removed from the arm and held in Fio. 152. — The author's case of transplantation from the men to the arm. abdo Fio. 151. l^lace by stitching the edges together with silk. Iodo- form - sublimate dressing was applied, and the hand and ami held immovable by adhesive plaster. Fig. 151 shows the condition of the hand, and Fig. 152 the method of transplantation. On the tenth day the strip of skin was divided above and below, and the ribbon folded around the wrist and stitched in position. The operation succeeded, and amputation was avoided. A second similar operation was done to restore the integrity of the palm. In all cases of transplanting skin no more of the sub- cutaneous tissue should be lifted with the integument than is necessary for the vitality of the flap. In short ilaps a very thin dissection should be effected ; in longer pedicles a good deal of tissue shoiild be left to insure the safety of the lilood-vessels. Transplanting in mass, in which the piece of integument, at least one inch in surface-measurement, is entirely severed from its original attach- ment, and laid uj^on the granulating surface, is not so successfxd as the preceding methods. The smaller grafts are much preferable. "When this operation is done, the piece to be transferred should be ti'immed or scraped so thin that nothing but the epidermis and Malpighian layer remains. Destruction of tissue by acids or alkalies requu-es no especial consideration beyond the adoption of measures to neutralize the excess of the agent in the part involved. The after-treatment does not differ 94 A TEXT-BOOK ON SURGERY. from that of the granulating surfaces of bums and scalds from fire, boil- ing water, or steam. Frust-Bite. — The effect of prolonged and extreme cold upon the aiumal tissues is to cause occlusion of the capillaries, loss of sensation, and death by gangrene. The treatment is to attempt a gradual restoration of the circulation by friction in a low temperature. A part of the body benumbed by cold should never be submitted suddenly to a high temperature, but should be bathed and rubbed in snow or cold water, the temperature of which is slowly elevated. When gangrene results, amputation is demanded after the line of demarkation is established. Furuncle. — A boil is a circumscribed inflammation, commencing usually in the hair follicles and sebaceous glands, and extending to the snbcutaneous tissues, in which it may at times originate. The chief cause is either a traiimatic or idiopathic inflammation in the glandular apparatus of the skin, and the arrest of the nutrition of the jjart by obstruction of the capillaries by pressure from without or by embolism or thrombosis from within. The inflammation spreads to the STirround- ing tissues, and localized gangrene ensues. Bods occur very frequently during the history of certain diseases, as diabetes mellitus, tuberculosis, scrofula, derangements of nutrition, etc. The diagnosis is not difficult, being chiefly between carbuncle and the localized necrosis in certain forms of sypliilitic gumma of the skin. From carbuncle it may be differentiated by the more acute inflammatory process of the furuncle, the single point of suppuration, the well-defined limit of the redness, and the acute character of the pain. In carbuncle the inflammation extends more widely and deeper, the induration is greater, there are several poiats of suppuration, and the febrile symptoms more appreciable. The syphilitic lesions will be recognized from the history of the disease. The treatment lf)oks to an early relief from tension in the integument, and the separation and discharge of the slough and pus. Incision should be performed at once. The judicious use of cocaine hypodermically will prevent pain, and much suffering will be avoided by prompt action. The application of cold or heat is at times useful. Poultices are almost universally employed to soften the skin and hasten the discharge of the dead tissue. It is a waste of time to wait for so slow a process. After incision a warm, moist sublimate flaxseed poul- tice or dressing should be applied, and continued until a cure is effected. The constitutional treatment should be directed to the correction of any existing dyscrasia. The preparations of iron and mercury are, in my opinion, the best general remedies. Tonics, good food, regulation of the alimentary apparatus, and good hygiene, are essential. Sulphide of calcium, gr. ^ to \, three or four times a day ; arsenic, the iodides, cod- liver oil, with the hypophosphites of lime and soda, are among the remedies most recommended. Carbuncle. — This disease— which, as Prof. A. R. Robinson* Justly * " Manual of Dermatology," 1884. CARBUNCLE. 95 remarks, has been misnamed '•'•anthrax'''' — is characterized by an inflam- matorj^ process of a low order, involving chieiiy the skin and the con- nective tissues immediately beneath it, and in some instances extending into the deeper organs. Carbuncle is a disease of malnutrition. The process is akin to that of furuncle, though indicative of a more depraved condition of the tissues. The cause is capillary thrombosis or embolism, and subsequent inflammation spreading from the necrotic focus. Gan grene always occurs, and the inflamed area breaks douTi in several places, giving discharge to pus usually in small quantity, as well as to dead tissue. It is apt to occur as a complication of the same diseases with which furuncles are seen — namely, diabetes mellitus, tuberculosis, scrofula, etc. It is apt to occur in parts of the economy subjected to more than ordinary ii'ritation, as the back of the neck, where the collar presses, and in the gluteal region. The symptoms of this affection are a sense of malaise, loss of appetite, headache, fevei', varying in intensity, which is followed by or accom- panied with a deep-seated and severe pain in and about the local expres- sion of the disease. The sldn at this point becomes tense, injected, doughy to the touch, throbbing and painful ; the epidermis becomes lifted at various spots in the inflamed area, vesicles form, localized gan- grene occurs, and the dead matter sloughs away. Not infi-e(iuently the necrotic j^rocess rapidly extends through the areolar tissue beneath the skin some time before the integument breaks down. The extent of necrosis varies under different conditions, and may be general or limited. The constitutional symptoms are deteimined by the amount of septic absorption and the degree of pain experienced. The process of repair is by granulation, the development of an em- bryonic tissue which advances from the sides and bottom of the cavity as the slough is carried away. As to the length of time carbuncle may last, nothing positive can be stat^-'d. Usually from three to seven weeks ; at times, when the process is subacute, several months. The prognosis depends upon the condition of the patient, the age, the location and extent of the lesion, and the ability of the capillaries and IjTuphatics to resist septic absoi-ption. Occurring in diabetes or any dangerous malady, it hastens a fatal issue. Situated upon the face, the gravity of the prognosis is increased. This is in gi-eat part due to the intenst^ pain which follows an invasion of that part of the body in which the trifacial nerve is distributed. When located on the thorax, the pleura may become involved, thereby causing a grave complication. The treatment should look to the immediate improvement of the patient's vitality by all available means. The local treatment should be directed to the relief of tension, the arrest of the invasion, and the dis- charge of septic matter. The only possible objection to earl}- and free incision is h;emon-hage, and the operator has only to decide between the danger of sepsis from delayed diainage on the one hand, and that of loss of blood on the othei*. To my mind, the fear of hjemorrhage is unfounded, and slit>uld not cause a delay in making the incisions. The patient should be anjesthetized. 96 A TEXT-BOOK ON SURGERY. and the indurated mass incised well down to the bottom in several direc- tions. Crucial cuts, or several ]):ii':i1Ip1 incisions, or lines radiating from the center, may be made as the location and size of the carbuncle may indicate. If undermining has been extensive, drainatre-tubes should be employed. Hjemorrhage may be controlled hj packing with sublimate gauze. The after-treatment should be hot or warm, sublimate-gauze dressings applied loosely, and covered in with protective or oil-silk. Poultices, if employed, should be made with sublimate solution, as here- tofore directed. Ulcerfi. — An ulcer is the result of molecular death in the integument or mucous membrane, and the underlying areolar or submucous tissue. The process of necrobiosis may at times extend below the deep fascia. Of whatever variety, an ulcer is caused by a failure of nutrition in the part affected. The arrest of nutrition may be local, as in the ulcer of chancroid or with a varico.se condition of the veins, or constitutional, as in the late manifestations of syphilis, in scorbutus, etc. Occurring with a dyscrasia, ulcers are even then more apt to occur in parts of the body subjected to abnormal interference with the circulation. Specific ulcers will be considered Avith the diseases of which they form a part. Ulcers may be divided into two clinical groups — the active and indolenf. In one, the material for repair is in excess ; in the other, it is deficient. The most frequent seat of ulcer is upon the anterior aspect of the tibia at its middle and lower portions. i They occur almost always in the aged, and chiefly \ ^^ among the poorly fed and laboring classes, where the \ , ) erect posture is of necessity maintained for many suc- cessive hours. Varicosities of the veins of the lower extremities must be put down as the most common non-specific cause of ulcers. The treatment of ulcers must be directed to the cause of the tissue destruction. In varicosities the in- tegi'ity of the circulation should be restored by sup- porting the vessels by mechanical means, or relieving the overpressure by position. For the former the elas- tic stocking, properly adjusted, is invaluable. Mar- tin's elastic bandage is an excellent apparatus, but re- quires considerable care in its even and skillful appli- cation. When neither of these methods is available, pressure may be successfully employed by means of flannel or muslin bandages. An elevated iiosition of the foot and leg should be maintained in all ulcers of the lower extremities. An indoJent iilcer demands stimulation. This may be effected by the oakum -dressing. Soft, clean oakum should be well soaked in 1 to 3,000 sublimate, squeezed out, laid over the ulcer, and held well in plnce by a roller. It should be changed every three or four days. ^■\ Fio. 153. Sublimate gauze is also an efficient stimulating dress- GANGRENE. 97 ing. Either of these methods should take the place of the old practice of burning such ulcers with escharotics. Supporting the edges of the sore with well-adjusted strips of diachylon plaster is also a conimendaV)le practice. The strips should be cut about three fourths of an inch wide, and crossed in a si:)iial manner (Fig. 153). Irritable ulcers require rest and soothing applications. lodoform- vaseline ointment ( 3 j to 5 j i will be found of value. It should be applied on .soft canton-tlannel or lint, and not strapped down tightly. The con- stitutional treatment of all patients suffering from ulcers is of lirst im- portance. Gangrene is death of a part of the body from the gradual or sudden an-est of its nutrition. It is usually applied to the process of mortifica- tion in the softer structures. The analogous condition of bone is called necrosis. Animal tissues have two modes of dying — the one is molecu- lar, or death by granular metamorphosis, in which no trace of the ana- tomical or histological properties of the tissues remains ; the other is death hi bulk, in which, although the tissues deprived of life undergo rapid decomposition and ultimate disintegration, they retain for a time something of their original form. It is to denote this last variety of tis- sue-death that the term gangrene is employed. There are three varieties — namely, the acute, or moist ; the chronic, senile, or dry ; and the contagious, pTiagedenic, or hospital gangrene. Acute Gangrene. — The chief cause of moist gangrene is the sudden obstruction of the afferent or efferent vessels of a part. Whether the artery is alone occluded, as by an embolus, the ligature, or an accidental solution of its continuity ; or whether the venous current is arrested while the artery is permeable ; or whether the arrest in both systems is simultaneous, as by the constriction of a finger with a ring, or in the case of a strangulated hernia — the part beyond the lesion is charged with blood which, arrested in its flow, loses its vitality and takes an early part in the work of decomposition which ensues. "When an artery is obliterated, tlie vitality of the tissues on the periph- eral side of the occlusion depends upon the integrity of the collateral cir- culation. If the occlusion is gradual, the enlargement of the collateral branches is usually sufficient to carry the necessary supjily of blood. There is scarcely a point in the arterial system where a collateral route may not be established, provided that the process of obliteration is not too sudden, and that the blood has not, by reason of constitutional dis- turbance, been deprived of its nutritive properties. When these condi- tions do not prevail, mortification ensues with a rapidity i:)roportionate to the partial or total arrest of nutrition. Pallor is the immediate and earliest symptom of arterial obstruction, followed by coldness of the skin, and pain, which is usually not aciite. Beginning in the parts farthest removed from the heart, the phenomena of death extend toward the center iintil the border-line is reached between the living and dying tissues. Congestion and swelling are not marked features of arterial gangrene. The normal contractility of the tissues, an elevated jiositifm, and the influence of the return cui-rent in veins with which those of the 98 A TEXT-BOOK ON SURGERY. part involved communicate, tend to empty the vessels beyond the seat of obstruction. Of necessity, however, a considerable quantity of blood remains, and when its flow is arrested its function is lost, and its elements join in the general decomposition which ensues. In the putrefactive process, gases, notably sulphuretted hydrogen and those resulting from decomposition of the fatty tissue, are evolved, and the coloring-matter of the blood is liberated. Myosin, the albuminous jirinciple of muscle, coagulates, giving a temporary sense of rigidity, and the serum wliich remained in the vessels undergoes transudation, and is generally dis- tributed among the tissues. Cutaneous sensibility is soon lost, and the momentary paUor gives way to a grayish hue, which deepens into a greenish-black color. Though not so marked as in the condition result- ing from venous occlusion, the skin and subcutaneous tissues become infiltrated with fluid and gases, giving a doughy feel upon pressui'e, and at times the peculiar crackling of emphysema. Serum and hydrogen, in the effort to escape, may at various points be caught under the imper- vious epidennis, wliich is lifted up into blisters. In resisting gangrene, certain tissues retain their anatomical features longer than others. Bone and tendon are slow to disappear, and at times the arteries will resist destructive change, when the tissues through which they pass have been entirely destroyed. In a case which recently came under my ol)servation, through the courtesy of Prof. Fluhrer, at Mount Sinai Hospital, in which gangrene was induced by a plaster-of-Paris dressing (applied in another institu- tion for supposed fracture of the humerus), mortification was present lu'st in the thumb and the tip of the index-finger, gradually involving the other fingers and the back of the hand to the carpus, where the pro- cess seemed arrested in an apparent line of demarkation in the integu- ment. The gangrene continued, however, beneath the skin, involving the extensor muscles, which, after amputation above the ell)ow, were found to have entirely disappeared, while much of the integument over them retained its vitality. When once inaugurated, mortification extends to a point where nutritive changes in the tissues are suflSciently active to resist death. The imtation of the dead tissues produces inflammation and the formation of a zone of embryonic tissue between the living and dead structures. The line between this embryonic zone and the black- ened slough is called the line of demarkation. The line of demarkation is, as a rale, irregular in extent. AATien a part has been constricted imtil death ensues, the line of separation may be a weU-defined circumference ; but in arterial occlusion this is a rare exception. Following the phenomena above detailed, rapid putrefactive changes occur ; the soft parts drop away in offensive sloughs, leaving the bone projecting from the stump of this natural amputation. The symptoms of gangi-ene from venous obstruction differ in some essential features from mortification after arterial occlusion. Engorgement is more marked, since the cardiac and arterial forces are at work in packing the tissues beyond the obstruction with blood. The GAXGREXE. 99 skin is of a purplisli hue from the start, pain is intense, and the swelling great, and, until coagulation is accomplished, there is a sense of throb- bing in the affected part. There is at first an elevation of temperature, which, however, is of short duration. Blisters are more numerous, and l^utrefaction occurs more rapidly. Gangrene from combined arterial and venous occlusion has its type in a strangulated hernia, or in mortification of a finger which has been constricted by a ring. In this varietj^ arrest of the circulation and co- agulation of the blood are more abrupt. The remaining features of this form of mortification do not differ materially from those heretofore described. Treatment of Moist Gangrene. — When an artery is obstructed, the first indication is to remove the obstruction. Failing in this, to ]iromote the establishment of a collatei'al circulation, and to maintain the tempera- nire of the part affected. The position of the limb should be such that l)ressure upon the structures through which the anastomotic branches run should be avoided. Cotton-batting should be carefully wrapped about the part to the thickness of several inches, and oil-silk or rubber- tissue protective wrapped around this. No pressure by bandages should be employed. The ai^plication of hot water, du'ecth' or by bottles, is to be deprecated, for heat is now known to produce capillary contraction. The extremity may be slightly lowered, in order to invite the flow of blood, although care shoiUd be taken to prevent obstruction of the veins. While these local measures are being adopted, certain constitutional remedies may be indicated. These relate primarily to cardiac stimida- tion, opium to relieve pain and palliate shock, and to an early improve- ment in the nutritive quality of the blood ; the administration of alcohol and beef -juice, and the careful combination of those articles of food which are acceptable to the patient, and are known to be rich in nitrogen. Any intercuri'ent disease or complication will indicate a modification of the treatment to suit the emergency. As death progresses and the sloughing begins, all stnictures which can be removed easily and without pain should be cut away with dressing forceps and scissors. Iodoform, freely sprinkled over the sloughs, will prove a good deodorizer, or the dead part may be kept wrapped in sublimate gauze, soaked in 1 to 500 solution, and kept moist by protective. When the line of demarkation is formed, sublimate gauze (1 to 1,000) may be laid around this locality, to guard against septic absorjjtion. IL'emorrhage is rare in this variety of gangrene, yet when it does occur it demands the ligature or compression. The treatment of gangrene where the vein alone is obstructed, in which, as has been stated, the condition of engorgement is extreme, demands the elevation of the part in order to facilitate the escape of blood through the venous channels. Tlie tension of the part may at times demand incisions through the deep fascia. The same precautions as to temperature must be taken here. The constitutional treatment will V)e less stimulating, yet supporting, and the local management of the dead part will be the same as given. 100 A TEXT-BOOK ON SURGERY. When all the vessels are subjected to pressure, it is essential to relieve the constiiction as early as possible. However, the vitality of an organ seemingly dead should not be despaired of, since restoration of function, after prolonged strangulation is occasionally witnessed. \Vlu'n, as in phlegmonous or other intianimation, the tension is so extreme that gan- grene is threatened by pressure of the exudation ui)on the c;ii)illarios or larger vessels, free incisions should be made, parallel with the general direction of the vessels, and of sufficient depth and number to relieve the tension. AVhen, as in threatened gangi-ene of a finger, the swelling is severe, increasing, as it does, the tension of the organ and its own destruc- tion, incisions are also demanded, and may prevent mortification before the constricting body is removed. Chronic, Senile, or Dry Gangrene. — Dry gangrene may occur in any period of life. Although children and adults are occasionally attacked, it is in the vast majority of cases a disease of the aged ; hence it is called senile gangrene. Calcareous degeneration of the arteries, which is given as a cause of senile gangrene, is of itself a result of general impairment of nutrition ; and it is to this failure of the heart to force the proper quantity and quality of blood to the tissues that we must look for the cause of this disease. With a circulating fluid so deficient in nutrition, and a heart so crippled in its action that its function is illy performed, it is not difficult to understand that the pressure of a shoe, a contusion of the foot, or the lodgment of atheromatous or calcareous particles in the terminal arte- rioles or capillaries, would precipitate a morbid process, scarcely awaiting even an accident for its inauguration. Symptoms. — In many cases of dry gangrene there is no history of an injury. Symptoms of constitutional debility from general imi)airment of nutrition usually precede the local expression of the disease. The lower extremities are most frequently affected. The patient suffers at times from coldness of the hands and feet. Shooting pains are not infre- quently felt, and cramps occur in the muscles of the feet and calf of the leg. In exceptional cases there are none of the above premonitory symp- toms, the first indication being the appearance of a brown or black dis- coloration on the foot or toe, or an insignificant excoriaticm may be the starting-point of the moi-bid process. From this the disease travels in the direction of the heart with vary- ing rapidity. If the condition of antemia is extreme, there will be no inflammatory discoloration in front of the advancing line of mortification, the skin changing from its nonnal pale color into the black, dead hue of the mummified part. The putrescent odor of wet gangrene is absent, and, instead of the swollen, doughy appearance of acute mortification, the part involved becomes hard and shriveled. The march of the disease is comjiaratively slow, and not infrequently death from exhaustion ensues before the line of demarkation is formed. In exceptional instances the disease confines itself to the toes, or anterior part of the foot. Treatment. — The part affected should at once be enveloped in cotton- t1 GANGRENE. 101 batting and oil-silk or protective, and placed in a position consistent with the comfort of the patient. No operative procedure is justifiable until a well-defined line of demarkation is established, unless septic absorption occurs to threaten the safety of the patient. The most important treat- ment is directed to the nutrition of the individual and the increased vigor of the heart. Opium, to relieve pain, is as much of a necessity as stimulants and food. Contagious, Phagedenic, or Ilospital Gangrene. — Although this dis- ease occurs most frequently in hospitals crowded with wounded, where ventilation and drainage are deficient, instances are recorded of outbreaks where the most careful sanitary regulations had been enforced. No season of the year offers an immunity from its ravages, although a warm, moist atmosphere is most favorable to its development. It is intensely contagious. The inoculation may be effected not only throiigh instru- ments, sponges, dressings, or the hands of the attendants, but through the medium of the atmosphere. As to its infectious character there exists a difference of opinion. It is held by observers equally competent and experienced that an abrasion is essential to the introduction of the disease, and, on the other hand, that it may result from inhalation of the geiTOS, the vesicle and ulcer appearing as a local expression of the sys- temic infection. The epidemics of phagedenic gangrene may vary in severity. Appearing in a malignant form, it suffers no wound to escape, while less frequently only isolated cases may occur. While a healthy condition of the individual will favor a recovery from the effects of this malady, it affords no exemption from its inoculation upon the wounded surface. It may be ingrafted ujion any form of abrasion, at any stage in the process of repair. Sgmijtoms. — The effects of this disease may be studied as local and constitutional. When a recent puncture, or fresh and minute abrasion, is attacked, the first symptoms are the formation of a vesicle and the appearance of a limited zone of redness at its base. The rupture of the vesicle gives escape to a thin, serous fluid, and the excoi-iated base becomes covered \vith a grayish mold. The infected part becomes painful and swollen, and, if the disease is not immediately arrested in its progress, a rapid dissolution of the tissues ensues. The skin breaks down, leaving pre- cipitous margins to the diseased area. The underlying tissues are desti-oyed more rapidly than the integument, which frequently becomes undernuned to such an extent that, if repeated careful explorations are not made, the true condition of the part may escape observation. If at the time of inoculation the wound is covered with a graniilating surface, it will be observed that at various points the granulation-tissue loses its florid color, becomes pale, and this pallor is immediately followed by the appearance of a grayish-black mold, which rapidly spreads over the entire wound. The normal secretion gives way to a dirty, watery discharge. The odor emanating from the gangrenous sore is exceedingly offensive and peculiar. The constitutional symptoms are those of acute septicaemia, and are 102 A TEXT-BOOK ON SURGERY. wholly dependent npon the absorption of poisonous material at the seat of the disease — headache, jiain in the part affected, irregular febrile movement, hectic suffusion, followed by cold perspiration, rapid and weak pulse, and, as the malady ])rogresses, great prostration, diarrhoea, delirium, and death, which results usually in from one to three weeks. Pror/nosis. — Once the dread and scourge of civil as well as military hospitals, contagious gangrene, in the achievement of modern suigery, has taken its place as a complication of a wound annoying and painful rather than dangerous to the life of the individual. A fatal termination may ensue when the wound is contiguous to important vessels, where haemorrhage may occur, either from death of the tissues from gangrene, or their destruction by caustics in the effort to arrest the disease. The prognosis may also be grave when, from the nature of the injury, the deeper portions of the slough can not be reached, and drainage secured. Under such conditions death is apt to ensue from septic absorption. Treatment. — As soon as a wound is attacked with gangrene it should be mopped with pure bromine or undiluted nitric acid.- Care should be taken not to allow the escharotic to run over and ])urn the uninvaded skin. If the neighboring integument is protected with vaseline this acci- dent may be prevented. If the disease has been in progress for one or two days, and the wound is covered in with the pulpy mold peculiar to this malady, the entire wound should be scraped out with a Yolkmann's spoon, and the acid or bromine thoroughly applied. When the skin has been undermined, or the deeper tissues, as the miiscles, involved, free incisions should be made in order to expo.se every porticm of the diseased tissue to the action of the caustic. After this a plug of iodoform gauze should be laid in the bottom of the wound, and a pile of loose sublimate gauze (1 to 1,000) added to this. Where a penetrating wound, as a bullet or puncture, has become infected under conditions that will not permit incision, the entire track of wounded tissiie must be subjected to the process of cauterization and disinfection. In order to accomplish this, the opening or openings of the wound may be enlarged, the cavity scraped thoroughly with sponges fastened to holders, and then the entire track inundated with bromine. Ether should be administered to relieve the pain of the applications, and opium afterward. The constitutional treatment looks to the nourishment of the patient. The sanitary management of a case is of the greatest importance. Isola- tion of the cases attacked, and the immediate removal of other patients from the same ward, tent, or locality, is urgent. All instruments should be disinfected in 10-per-cent carbolic-acid solution, or by being submitted to a red heat, and all sponges, dressings, etc., instantly burned. The floor, walls, and ceiling of a hospital- ward in which a case of phagedenic gangrene has occuiTed should be washed and irrigated wiih. 1 to 1,000 sublimate solution, and the mattresses burned. CHAPTER VIII. AMPUTATIONS. An amputation is the complete separation of any projecting organ or member from the body. While the term may be applied to operations in which the breast, penis, sci-otum, cervix uteri, etc., are cut away, by long usage and common consent it is now restricted to removal of the extremities or their sulxli visions. An amputation may be accidental, as when a Umb is torn, cut, or crushed off by machinery ; natural, when, as in senile gangrene from gradual failure of the heart, or pathological changes ia the arteries, the dead portion is separated at the line of demarkation ; or surgical, when scientihcally perfonned. When in an amjiutation the line of section is through the substance of the bone, the operation is said to be in continuity, and when through an articulation, in conti(/uit)j. The removal of a part which is useless or deformed, the pi'esence of which, however, does not threaten the life of the individual, is called an amputation of expediency ; under more urgent conditions, the operation is one of necessity. Amputations of necessity are further subdivided into those after accident and those after disease. In amputations after accident, the period in which the operation may be performed is divided into the immediate, primary, and secondary. An immediate amputation is done during the prevalence of shock, and usually within from two to six hours after the receipt of the injury neces- sitating the opei'ation ; primary, after reaction from shock, and before inflammation is established — usually within twenty-four hours after the injury ; secondary, when performed after this limit, and during the preva- lence of inflammation. The danger of death after amputation depends chiefly upon the character of the injury, and the location of the line of section. The prognosis becomes grave in proportion to the exhaustion of the patient as a result of hsemorrhage, shock, sepsis, or of any dyscrasia or inter- current disease. As to the line of section^ there are practically no exceptions to the law that the rate of mortality is proportionate to the diameter of the part divided and the proximity of the section to the trnnk. Thus, amputa- tions of the lower extremity are more fatal than those of the upper, those of the hip more fatal than through the middle and lower third or through the leg, while the same comparison holds good fi'om the shoulder out. 104 A TEXT-BOOK ON SURGERY. As to the age of the patient, it may be said that the death-rate gradu- ally increases with each decade of life. Oi)eniti()ns of expediency, when properly perfoi-med, may be consid- ered as practical!}^ free from danger, for the reasons that the genci-vl con- dition of the patient is good, and the section through clean and liealthy tissues. Amputations after iwii-mallgnant (lisease, such as dcstnictive artliritis and osteitis, are conii)arutively free from danger, jirovidcd that general sepsis and consequent exhaustion have not occurred prior to the operation. 'Amputations necessitated by malignant neoplasms aie espe- cially dangerous only in proportion to the degree of malignancy in the tumor, together with the general deterioration of the tissues as a result of the prevailing cachexia. Amputations after accident are most fatal, and the statistics show that primary operations are, in general, more dangerous than those done in the secondary period. Lastly, the value of the bloodless operation, together with the safety from inflammation and sepsis, which a thorough knowledge and prac- tice of the antiseptic metJiod guarantees, can not be overestimated in diminishing the death-rate after amputation. The employment of Es- march's bandage, the deligatitm of the vessels, the use of sublimate irrigation, and the permanent antiseptic dressings, have been heretofore described. Amputations are much less frequent now than formerly, and there is little doubt that, in the present rajjid advance in the science of surgery, and the greater perfection in its art, the time is not far removed when amputations for other cause than gangrene will be comparatively rare. To the consummation of this hope the education of the laity becomes the first duty of the practitioner. Very few deformities would lead to the necessity of amputation if in their incipiency the services of a skillful surgeon were obtained. And this is equally true of those lesions of the joints and bones for which the necessity of amputation would be excep- tional if, at the earliest symptoms of disease, the proper treatment were instituted. Even when, from neglect, extensive necrosis or destructive arthritis shall have occurred, exsections of the diseased tissues should always be preferred to amputation, notwithstanding the shortening which may result, for a stiff joint and a short limb, capable of even limited motion and body support or function, is far better than the most perfect prothetic apparatus. Malignant or non-malignant neoplasms often lannecessarily lead to amputati(m when an early and wide excision of the growth would in great probability have arrested the disease and saved the limb. In cases even of doubtful diagnosis, in the earlier days of the appearance of the tumor, the benefit of the doubt should be given to the ultimate safety of the part, and the knife freely used. As to the propriety of performing an immediate amputation after in- jury, it is exceedingly questionable. The conditions which would justify this practice will rarely prevail. Even primary operations should be exceptional in this age when the value of drainage is so fully appreciated, AMPUTATIONS. 105 and the danger of sepsis diminished by the faithful employment of that cleanliness which is found in the antiseptic method. In extensive lacerations of the soft parts and fracture of bone, the indications in treatment entitled to the first consideration may be stated as being : arrest of haemorrhage by the catgut ligature or direct pressure, through drainage, iodoform and sublimate dressings, fixation of the part — usually in an elevated swing (Figs. 7, 114, 164)— with constant irriga- tion as a last resort. If, despite all these precautions, septicfemia should occur, or gangrene result, amputation is necessitated. The first general law in performing an amputation is that no more of the member should be cut away than is absolutely essential to the safety of the patient. Anj^ exception to this rule will be given along with the special amputation to which it may apply. While it is always desirable to make an amputation wound throiagh healthy tissues, this should not be done at the expense of the part in- volved, for tiaps made through inflamed tissues heal readily enough, and offer no element of danger to the life of the patient when properly drained. Method of Operating. — In making an amputation, no matter what shape the incisions may take, the jjoint of first importance is, that the soft parts which are to forai the covering or hood for the bone shall be long enough to be free from tension after the sutures are adjusted and the dressing completed. It is always wiser to err on the safe side, and make the flaps a little too long than too short, for it is a simple matter to trim them down to the proper length. In doing this, some allowance must always be made for the additional retraction which occurs after the tourniquet is removed and consciousness is restored. The direction of the line of incision, and the shape of the cuflf or tiaps, will depend in part upon the shape of the limb at the point of section, as well as the condition of the soft tissues from which the covering is to be made. While the rale just given — namely, to have plenty of flap — is essential, it is scarcely of less importance to guard against all interference with the nutrition of the integument which covers in the stump. To this end rough handling, and the employment of strong and irritating solu- tions, should be avoided. In general, that flap will unite most readily, and prove most satisfactory, in the formation of which the normal rela- tion of the skin to the subcutaneous soft tissues is least disturbed. Following this rule, preference should be given to solid flaps which are composed of all the soft tissues lifted from the periosteum. Again, it is always preferable to divide the skin, muscles, vessels, and other soft tissues squarely across, and not ebliqnely, as must of necessity be done in forming flaps by transfixion. This, the solid-flap method, is applica- ble to most amputations — as will be shown farther on — in patients of slight muscular development, and ^\ith little or no siibcutaneous areolar tissue, for a closely dissected skin-flap in this class of cases is always objectionable, on account of the danger of sloughing. When the soft tissues at the line of section are very thick, and when the integument is well guarded by a fair quantity of underlying fat, the solid flaj) will at 106 A TEXT-BOOK ON SURGERY. times be found to be objectionable, and flai)s composed of skin and tlic subcutaneous tissues, down to the deep fascia, preferal^le. The metliods of amputating an extremity may therefore be : First, solid flap, composed of all the soft tissues lifted from the periosteum ; second, skin-flap, composed of the integument and the subcutaneou;} tissue, down to the deep fascia ; third, mixed flap, composed of skin on one side, and of all the soft tissues on the other. Flaps composed of the integument, together with all the underlying soft tissues, may be made by the circular method, forming a single cuff, or by the double-beveled flap, made by transfixion and cutting from within out, or by cutting directly down from the surface. Circular Solid Flap, with Perpendicular Slit — First Mrfliod. — Sup- posing that the section is through the right humerus, at tlie juiu'tion of the middle and lower thirds, proceed as follows : Place the patient so that the member to be removed projects well over the edge of the table. Envelop the rest of the body with necessary wraps, and cover all in with rubber cloth, so arranged that the irrigating fluid wOl not reach any por- tion but the aiTU. If folded proj^erly into a trough-shaj)e, the solution will be conducted into a vessel beside the table. The entire hand and arm should be washed with soap and water, cleanly shaved for six inches above and below the line of section, and in succession washed with sul- phuric ether and a solution of corrosive sublimate (1 to 3,000). If any inflamed or suppurating surfaces are exposed, close to the line of am- putation, these should be irrigated with sul)limate, and thorotighly scraped out and again irrigated, after the Esmarch bandage has been applied. Towels wet in warm (1 to 3,000) sublimate solution are now wi'apped about the hand, forearm, and arm, the extremity elevated, in order to facilitate gravitation of blood toward the center, and the Esmarch bandage tightly applied, from the finger-tips to the axilla. As soon as the constricting band is secured at or close to the axilla, the bandage beyond is removed, and all exposed parts not in the field of operation covered with fresh, warm sublimate towels. The assignment of positions about the table are shown in Fig. 154. The operator stands so that the non-preferred hand (usually the left) grasps the member between the line of section and the trunk, and thus steadying the tissues, the instruments are used by the right hand. The first assistant stands where he can most easily reach the wound, for purposes of sponging, retracting flaps, etc. ; the second is placed directly between the operator and the instrument-trays ; the tlilrd attends to the anaesthetic, holding the cone so that the expired air and ether vapor will not annoy the opera- tor ; the fourth holds the member to be removed, grasping the elbow with his left hand, and the wrist and f oreann with the right ; the fifth attends to the irrigator ; the sixth and seventJi are intrusted with the sponges, one of whom holds in one hand a basin of freshly squeezed out sponges, and in the other a second basin for those which have become soiled or bloody. Both should be within easy reach of the first assistant. The duty of the seventh assistant is chiefly to rinse the sponges, procure fresh towels, etc. "VVlien possible, it is always convenient to have two extra orderlies or AMPUTATIONS. 107 nurses — one for waiting upon the ansesthetizer, and the other for purposes of general utility. Operation — First Method. — With the left hand slide the skin toward the shoulder, and at a point sufficiently below the line of section through I'lG. 154. the bone to afford ample covering (something more than one haK the diameter of the Umb, measured where the saw is to be applied), make a circular cut around the member, dividing the skin and subcutaneous fat down to the deep fascia (Fig. 155). The upper margin of this wound is retracted toward the body as far as possible, and, at this line of retraction. Fig. 155. — Circular incUion tlirouofh the skin. with the same knife (a good scalpel is preferable"* cut all the remaining soft tissues squarely down to the periosteum (Fig. 15(3). An incision is next made, parallel Avith the axis of the humerus, on the outer (or non- vascular) side of the arm, dividing everything to the periosteum, and extending up to the point where the bone is to be sawn through (Fig. 108 A TEXT-BOOK ON SURGERY. 157). With a dry dissectdrfthe handle of the scalpel will usually suffice) — ouly using a sharp instrument where necessary— lift the tissues closely fiQ. 156. — TLe same, contiuuoil down to the bone. from the periosteum until the solid cuff can be folded back (without over- traction or bruising) sufficiently to expose the bone at the point of Fio. 157.— Lougitudinal incision. section. A towel moistened in 1 to 3,000 sublimate (or a split retractor) is now wrapped about the cuff or flap and the bone, so that the tissues which compose the flap may not be bruised or torn by the saw, and at the same time be protected from having the bone-dust scattered over the cut surface (Fig. 158). AMPUTATIONS. 109 In applying the saw, it is best to place the center df this instrument against the bone close up to the retractor, always holding its blade in such relation to the bone that the sawn surface will be perpendicular to the axis of the bone. A few short strokes will suffice to cut a trench or hold for the saw, which may then be more rapidly used. The operator steadies the member with his left hand on the central side of the wound, while the assistant holds the exti"emity. As the section is about being completed, he is directed to cease all traction, simply supporting the weight of the limb, and thus splintering may be avoided. The last few- strokes of the saw should be very lightly and carefully made, to avoid the same accident. The retractor is allowed to remain after the bone is divided and the amputated part removed, and until, with a bone-cutter or cartilage-knife, the circumference of the cut surface is smoothed and rounded off. In doing this, the force applied should always be toward the center of the bone, to prevent stripping up the periosteum or splin- tering. The practice of dissecting a periosteal cuff, at one time recommended for the purpose of covering over the end of the bone, is now justly abandoned. While it succeeded in some instances, in many it gave rise to great annoyance, necessitating a second operation on account of ex- ostosis or necrosis. The retractor is now removed, the stump imgated, and the surface then thoroughly dried with sponges, so that the vessels may be secured. The larger arteries and veins may be readily found, and the ends seized with the forceps. All the tissues should be care- fully stripped from these by a blunt instrument (grooved director), and, when the catgut is thus aj^plied, the operator is sure that no nerve- tissue is caught along with the vessel. For the larger vessels the double or friction loop (Pig. 113) should be employed ; the single knot wiU suffice for the smaller. When ligatures have been applied to all the vessels which can be recognized by the eye, other " bleeding points " may be discovered by grasping the limb a few inches above the line of section and then forcing out the small quantity of blood which remains after Esinarch's bandage. As it oozes out over the cut surface, its point of exit may be caught up by the broad-jawed forceps, and in doing this it is usually necessary to pick up a small bit of whatever tissue may be immediately about the vessel. In tying a catgut thread around these vessels, the loop should be tightened upon the jaws of the instru- ment on the slope nearest the point, for as it is further tightened it grasps the metal closely and slides over the end, including no tissue but that already in the grasp of the forceps. Having proceeded thiis far, the stuni]) being elevated, the wound should be filled with clean Avarm sponges, covered with sublimate towels, and firmly compressed by the operator while the assistant removes the tourniquet. After waiting two or three minutes for the vessels to fill, one by one the sponges are care- fully removed, and any bleeding points caught with the forceps. "When these shall have been tied, the wound should again be flooded with warm 1 to 3,0()() sublimate, packed with sponges well squeezed out, the whole covered in with sublimate towels, and bimanual compression employed 110 A TEXT-BOOK ON SURGERY. for five mimites, when it will be seen that all bleeding has i)ractically ceased. The general oozing, especially that from the end of the bone, may be controlled by pressure and position after the sntnrcs are applied. In sewing up the cuff, alternate deep and superlicial sutures should be employed ; the former, about half an inch apart, should enter the skin from one half to three fourths of an inch from the edge of the wound, pass about the same de2)th through all the tissues, and emerge at the same distance from the wound on the opposite side. The intervening row should be half way between the deeper sutures, and sliotdd be intro- duced to a depth of one fourth of an inch. In tying the sutures the double or friction knot should be employed for the first loop, for this holds and keeps the edges from separating while the second knot is being tied. The knots should be kei)t to one side of the line of ajjposition. A considerable degree of care is essential in bringing the edges nicely and accurately in apposition, for if the skin is infolded and the epidermal surfaces brought in contact, bad union will result, and the same is true if any of the subcutaneous tissues project between the edges. As the threads are being tightened, infolding may be obviated by lifting the edges with a grooved director, while the same instrument may be employed to push any projecting fat or other tissues back under the skin. In tying the knots, the degree of traction should just be suffi- cient to bring the plane surfaces of the wound together without wrink- ling. The drainage-tubes should be inserted as the wound is being closed, and should be numerous enough to drain the cuff at all points. In clean amputations Neuber's bone-drains should always be used. In cutting through inflamed or infiltrated tissues, the rubl)er tubes are safer. If (as is preferable) the stump is kept elevated after the operation, it will be necessary to bring at least one of the tubes out at the upper end of the longitudinal incision, while another may project at the tip of the stump. No matter what style of flap is used, the tubes should always lead from the deepest portion f)f the wound, and have exit at such declination that the free outflow of all fluids will take place into the dress- ings. A safety-pin should be passed through one side of the tube to prevent its being pressed into the wound by the bandaging, or a suture may serve to hold it in position. The nozzle of the irrigator should now be introduced into one of the tubes and the cuff flooded until the water runs out clear and until the entire flap has been well distended. The excess of the solution is squeezed out, a strip of iodoformized gauze is wound around the tubes (not obstructing their caliber), and carried along the line of approximation, extending about three fourths of an inch on either side. The stump is now wiped ofl" with sponges and immedi- ately enveloped with sublimate gauze to the thickness of about one inch. This should be applied in layers, starting from well above the end of the stump, by carrying a layer around the limb, and following this A\ith a second, which overlaps the first about two inches, and so on until the last layer projects well beyond the end of the stump. Over the end a large, thick sheet of gauze is laid. A layer of absorbent cotton, about one inch thick, is now wrapped ai-ound and over the end, and this AMPUTATIONS. Ill enveloped by a large sheet of rubber-tissue protective. A roller is car- ried over all to hold the dressing in place, and to make compression sufficient to arrest oozing. It is impossible to say how much pressure should be employed, since this knowledge can only come from practice, but the bandage should be fairly tight. Over-pressure at the tip should be avoided, especially where the iiap folds down on the end of the bone. As the last bandage is l)eing applied, a short splint, the end of which projects a couple of inches beyond the stump, should be inserted. This steadies the limb, and is useful in keeping the stump elevated, especially when an amputation is made near the trunk. If the last roller is made wet before being applied, it will be less liable to slip. Such a dressing, under the strict antiseptic method, is not usually removed before the tenth or twentieth day, and in the majority of cases where an amputation is made through comparatively healthy tissues a single dressing is sufficient. The indications for its removal are haemor- rhage of an alaiTning nature, great pain, high febrile movement (not counting the reactionary fever which follows within twenty-four hours after the operation), and excessive discharge beyond the zone of anti- sepsis, with decomposition. Ordinary bleeding may be controlled and permanently arrested by an extra tight roller, or Esmarch bandage, loosely applied for an hour or two. A rise in the temperature of 102° to 103° on the second day, or later, suggests iniiammation and sepsis. Lastly, when the serum or tiuids from the stump seep under the dressing and decompose, the change is necessitated on account of the odor. "When a new dressing is made, the same antiseptic precautions should be employed. Second Method — Oblique Solid Flaps by Transfixion. — Seize the ann with the left hand so that, as all the soft tissues are pinched up on its anterior aspect, the thumb and index-finger on opposite sides will be just above the point at which it has been decided to divide the bone. The point of a long knife is pushed from the outer side (right arm) horizon- tally down until it impinges upon the center of the bone ; the handle is depressed, the point grazes over the bone, the handle is now elevated, and flaps by transfixion. the point made to project exactly opposite and on the same plane with the point of entrance (Fig. 159). By a long sawing movement the knife is made to cut directly along the bone until within from one half to one inch of the 112 A TEXT-BOOK ON SURGERY. limit of the flap, when it is turned rather abruptly out, shaping a blunt, rounded flap. This is held back by the operator's left liand, the point of the knife is insinuated between the muscles and the bone, is made to glide along the posterior surface of the bone, and to come out at or very near the periosteum on the opposite side. A second symmetrical flap is made in the same way as the first. The retractor is applied, and tiie operation and dressing completed as before. In making an amputation by transfixion, it is usually advised to cut the non-vascular flap first ; but, with a safe tourniquet applied, this pre- caution is unnecessary. Third Method — Oblique Solid Flaps, hy cutting from the Surface. — Cutting from the surface toward the bone, the first crescentic incision out- lines one flap and goes down to the deep fascia (,Fig. 16U). After the skin Fio. 160. — Oblique BoUd flaps, made by cutting downward from tlic skin. retracts, the muscles and remaining soft tissues are divided from its edge obliquely down to the point of section through the bone. The opposite flap is made in the same manner, and the operation completed as before. Skin- Flaps — Circular, Modified Circular, Opal, Douhle Crescentic, and Double Rectangular. First Method— Circular. — Before commencing the incision, grasp the arm fii'ndy near the line of incision, and slide the integument upward as far as it will go. In doing this operation, a good scalpel is preferable to the long knife. The incision should go straight down to the fascia which covers the muscles, and directly around the limb by successive strokes with the scalpel, so that the radius of the circle described will be at an angle of 90° with the axis of the humerus (Fig. 161 a). When this is completed, catch the edge of the flap with a mouse-tooth dissecting-forceps, put the connective tissues which attach it to the fascia about the muscles on the stretch by pulling the sldn upward, and with well-directed strokes or touches with the point of the knife, which should be kept from wounding the skin, raise the flap throughout the entire circumference of the wound. As this dissection proceeds, the loosened sleeve of integument may be roEed up until the point where the muscles and bone are to be divided is reached (Fig. 161 b). Just at the margin of the reflected flap the soft tis- sues are now divided straight down to the bone, the line of section being AMPUTATIONS. 113 perpendicular to the axis of the limb. The periosteum should next be cut thi-ouo;h in the circumference of the bone where the saw is to enter. Second Method — Modified Circular. — The foregoing method should always be modified by a pei-pendicular incision through to the muscles, since this not only renders the dissection more rapid, but does away with the unnecessary bruising to which the unspUt cuff is subjected as it is roUed upon itself. Third Method — Oval.— It not infrequently occurs that the condition of the soft parts near the line of amputation will not permit of an incision directly around the limb without a too great sacrifice of the member. Under such circumstances, an oval or elliptical incision may be made, and in this way integument enough secured to cover in the stump. The longitudinal slit may be added to this operation. Fourth Method — Double Crescentic. — The circular operation may be further modified by making two crescentic skin-flaps of equal size, the Fig. 1G2.— (After Esmarch.) bases of these being at the line of section of muscle and bone. The same precautions as given above are necessaiy to secure enough integument to form a hood for the stump (Fig. 162). 8 114 A TEXT-BOOK ON SURGERY. Fifth Method — Double Rectangular. — The first step is to po around the limb just as if a circular operation were intended. This being done, two inoisions, one on either side and exactly opposite to each other, are made perpendicular to the circular cut, and extending up the litnb to a point on a level with the line of section through the muscles and bone (Fig. 163). The two flaps are now dissected up to this line, and the ampu- v^^^^^^- tation completed as before. The commendable features of this procedure are the rapidity with which it may be accomplished, the small degree of violence inflicted in manipulating the flaps, and the readiness with which a stump is drained when the proximal angles of the lateral incisions are used as outlets for the tubes. Mixed Flaps, composed of integument alone on one side and of all the soft tissues on the other, are the least commendable of all meth- ods. The proper apposition of surfaces so uneven is difficult. When from any cause this operation is adopted, care must be taken to give proper support to the heavy solid flap to prevent dragging upon the sutures. Resume. — The solid flaps should be prefeiTcd to the sMn flaps, for the reasons that the nutrition of the skin is least disturbed by this method. In thin and emaciated subjects, and in the arm and thigh regions (as will be seen hereafter), it is especially applicable. In limits of large diameter and a goodly quantity of subcutaneous tissue, the skin-flaps are prefer- able, since a covering under such conditions can be ol)tained with less sacrifice in the length of the bone. Of the solid flaps, the circular method is better than the oblique, since it divides all the tissues squarely. In making oblique flaps, transfixion is better than cutting from without inward. Of the skin-flaps, the circular with a single longitudinal incision should be preferred to the other methods where the limb is not very large ; the double rectangular flaps where the stump is to be elevated and there is a large surface to drain. Open Method.— Vs\s.fVL an amputation is made through tissues infil- trated with pus or other Inflammatory products, where, in the judgment of the surgeon, the dangers of sepsis would be increased if the wound were closed, the open method should be employed, with constant or in- terrupted ii-rigation. AMPUTATIONS. 115 Before the days of antisepsis the success of this method was thor- oughly demonstrated by Prof. James R. Wood and Prof. Dennis, in Bellevue Hospital, where the rate of mortality after amputations, in wards which had been recently vacated on account of puerjieral fever, was reduced to the minimum in the history of that hospital. I have employed this method in a number of septic cases with great satisfaction. l-'li,. iw. In performing the amputation, the flaps must be so shaped that in'iga- tion can be easily accomplished without moving the stump. A circular cut, with a longitudinal incision on the upper surface, or bilateral flaps, are preferable. When the patient is put to bed the stump is placed in a position suitable for drainage, and rests upon an oil-cloth so arranged tluit the irrigating fluid runs away from the patient and into a basin at the bedside. The flaps should at first be held well open by a wad of sublimate gauze, and the stump loosely enveloped in a thin layer of this 116 A TEXT-BOOK ON SURGERY. niatei-ial, so arranged that, as the water drips on it, it will pass through the gauze and over the raw surface. Fig. 164 shows a ready-made irrigator in use in my service at Mount Sinai Hospital. A piece of slieet-tin, about a foot Avide and of any re- quired length, is shaped into a trough, the bottom of which is punched full of holes with an awl. A rulibei- tube leads the water from a tank into this trough, from wliicli it trickles on to the wound in any required quantity. Or, as represented in the cut, the tube — whicli, in tlie cnse of tlie ])atient from whom the drawing was made, conveyed the irrigating Huid into a suppurating knee-joint — may also be employed to carry the water into the wound. Pure water should be used for irrigation. The danger of absorption from an extensive granulating surface precludes the sublimate or carbolic- acid solutions. The only objection to which this method is open is the slowness with which the process of repair goes on in its employment. TJiis is, however, an objection of little weight when the ultimate recovery of the patient is secured. As soon as the temperature shows an absence of sepsis the irri- gation may cease, and the granulating Haps may be approximated grad- ually by bandages or adhesive strips. Special Amputations. Hand and Fingers. — A primary amputation of any portion of the hand is rarely if ever justifiable. If there is only a small strip of tissue, the integrity of which is evident, an effort at the restoration of the nutri- tion and function of the part beyond should be attempted. If any doubt exists as to the result, the benefit of this should be given to the side of conservatism. It is essential to arrest hjemorrhage, cleanse the wounds under strict antisepsis, secure drainage, and place the parts in the best position for usefulness in case of recovery. Amputation may be done when necessitated by gangrene or necrosis. Fingers — Interphalangeal Operations.— 'Betv^Q^n the second and third ])haianges of the fingers, proceed as follows : Flex the terminal phalanx at about an angle of 90° to the axis of the second bone, and, one eighth of an inch anterior to the angle on the dorsal aspect, with a small, shai'p-pointed scalpel make a transverse incision, extending half way down the sides of the finger. From this point carry the incision forward, parallel with the axis of the digit, to within a quarter of an inch of the end, then across the palmar aspect of the tip to the opposite side, finishing the incision at the angle of the transverse cut (Fig. 165). Dissect ^-f-—^ ;,: - ~ — — - the palmar flap up, keeping close to the C^' r^. ,-'^ /^'W^ bone, lifting the flexor tendon, with the skin, back to the articulation ; divide the tendon opposite the joint, and dis- articulate. The flap is now turned back, trimmed with the scissors to tit f'"- los. AMPUTATIONS. 117 nicely, and stitched with catgut sutures. By this method the acute tactile sense of the palmar aspect of the finger is preserved, and adds to the usefulness of the stump. This, and other amputations of the fingers, may be made without general anaesthesia, and with perfect in- sensibility, by the local use of cocaine. Just anterior to the second in- terphalangeal joint insert the needle of a hypodermic syringe, and inject in the entire circumference of the finger twenty minims of a 4-per-cent solution of cocaine hydrochlorate. Two minutes later constrict the root of the digit with an elastic ligature. In this way a painless and bloodless operation may be performed. If the insensibility is not com- plete at all points of the incision, inject additional cocaine in the line of the cut. Any danger of the constitutional effects of this drug may be obviated by squeezing the excess out thi-ough the cut before the sutures are applied. In dressing these amputations the pressure on the end of the stump should be light, for fear of slough in the long flap. Usually no vessels need to be tied. The covering of cartilage does not reqiiire to be scraped or sawn off. When only a slight jiortion of the anterior tip of the second phalanx is involved in a destructive osteitis or injury, the remaining portion should not be sacrificed by a disarticulation at the posterior interphalangeal joint. The line of section through the bone should be aliout at the junction of the middle and anterior third of the phalanx. The incisions and flap are made as in the preceding operation. In amputation with disarticulation at the posterior interphalangeal joint, flex at an angle of 90°, make a transverse incision over the dorsum of the finger, from one eighth to one fourth of an inch in front of the angle, which includes half the circumference of the member. From the ends of this line carry the incision directly forward on each lateral aspect of the finger to the crease.on the palmar surface opposite the anterior interphalangeal joint. A second transverse incision in this fold com- pletes the rectangular flap, which is now dissected back, and the dis- articulation effected by placing the ligaments on the stretch and divid- ing these with a narrow, sharp scalpel. If any difficulty is found in entering the joint from the sides or front, it may be easily done by division of the extensor tendons over the dorsum, for these take the place of posterior ligaments. The method of ampiitation, as given for the operation at or near the articulation of the first and second pha- langes of the finger, applies also to the thumb in amputation at the last joint, or through the first phalanx, within one fourth of an inch of its anterior extremity. This plan of making the flaps is far superior to that advised by Erichsen, Esmarch, and other authors who recom- mend cutting down and through the joint from the dorsum, and then forward along the palmar aspect of the phalanx, making the disarticu- lation and flap with a single stroke. In the first place, this is done with no little difficulty, for, however thin the blade, the character of the joint will scarcely allow an easy passage to the knife. Secondly, by the method of transfixion the flap is apt to be cut too pointed and bev- eled at the end. 118 A TEXT-BOOK ON SURGERY. At the Metacarpo-PJialangealJoint — Thumb. — AYhen the condition of the soft parts -will permit, proceed as follows : First Method. — Just over the joint, and in the middle of the dorsal aspect of the thumb, commence an incision and carry it along the surface next to the index-finger until half the circumference of the member is included. Along the dorsal and palmar aspects carry parallel incisions forward until near the interphalangeal joint, and connect these by a sti-aight transverse cut across the palmar surface. Dissect the flap back, divide all tendons opposite the joint, disarticulate, tie the dorsales pollicis (one (m either side of the back of the thumb), and the arteria princeps pollicis, which lies along the side of the metacarpal bone near- est the index-finger and divides into its terminal branches opposite the metacarpo-phalangeal joint. When the flap is stitched, the scar will be in good part concealed on the ulnar aspect of the stump. Second Method. — A transverse dorsal incision is made over the articu- lation, extending half around and ending at opposite points on the external and internal lateral aspects of the thumb. Parallel lateral incisions are Fio. 166. Fio. 167. Fig. 1G8. made as far forward as the interphalangeal joint, and the anterior ex- tremities of these are joined by a transverse palmar cut (Fig. 166). The end of the metacarpal bone of the thumb should be left undisturbed, when not necrosed, when there is sound skin enough to cover it in. Under other conditions it may be divided with a fine saw or the exsector. The question of the appearance of the stump should be secondary to the usefulness of the member. It is especially important to a laborer that the end of the metacarpal bone of the thumb be preserved (Fig. 167). When the operation is performed upon one not compelled to do manual work, a more symmetrical api^earance may be obtained liy an oblique section of the metacarpal bone about half an inch behind the articular surface. When this is intended, the incision through the skin should be such that the long part of the flap is obtained fi-om the radial and palmar aspect of the thumb, while the line of sutures is situated well on the dorsal surface of the stumj) (Fig. 168). AMPUTATIONS. 119 Index-Finger — At the Metacarpo-Phalangeal Joint — First Method. — When possible, the following method should be adopted, the object being to preserve the tactile sense and to leave the scar less prominent : From the ulnar side of the knuckle, and just over the joint, make an incision which extends from this point forward as far as the web between the index and middle finger, and, in case of a large knuckle, a little beyond this point at the side of the digit. From the anterior end of this incision make a second cat directly across the palmar aspect of the phalanx until the middle of the radial side of the finger is reached, and complete the flap by cutting in a straight line from this point to the commencement of the first incision. When the disarticulation is com- I)leted, the dorsalis and radiaUs indicis arteries, and the external digital branches, tied with fine catgut, the corner of the flap is carried into the receding angle on the dorsal surface of the metacarpal bone and secured by sutures. When the head of the metacarpus is to be removed, the section of this bone should be slightly oblique, and the line of incision a partial oval, beginning at the web between the two fingers, and traveling along the crease formed by flexion of the finger on the metacarpus well up on the dorsum of this bone, about three fourths of an inch back of the joint. An incision, almost in a straight line, should now be made between the ends of this curved line (Fig. 166). Dissect the flaps clear and without making a disarticulation, expose the bone, and with a fine saw divide it obliquely from before backward, and from the ulnar toward the radial aspect. In amp^utation of the middle or the ring finger, the following method should be preferred : Fig. 169.— (After Eamarch.) Middle Finger. — Locate the articulation exactly, and over this point make a transverse incision extending on either side to the middle of the depression between this digit and the index- and ring-fingers (Fig. 166). From either end of this cut carry a lateral incision directly forward about 120 A TEXT-BOOK ON SURGERY. n half way up the first phalanx, and connect these by a transverse incision across the palmar aspect of the digit (Fig. 167). Disarticulate and fold the palmar end of the tlap back upon the dorsal transverse incision where it is stitched. Another method is the oval incision, shown in Figs. 169 and 170. By the first method the tactile surface is better preserved. The head of the metacarpal bone should be left intact for the laboring classes. AVhen the round expansion of this bone is removed, the gap between the index- and ring-fingers is not so wide. The bone should be sawed squarely across a half inch behind the articular surface. All that has been said of this digit applies with equal force to the ring-finger. Little Finger. — The method recom- mended in amputation of the index at the metacarpal Joint should be pre- ferred in removing the little finger at the same level. The flap should be so shaped that the cicatrix will fall on the dorsum and toward the ring-finger. When the metacarpal bone is to be di- vided it should be cut with a slight ob- liquity. In this operation the oval in- cision shown in Fig. 171 shoiild be made. "Wlien two or more fingers require to be removed at the metacarpo-phalan- geal joint, each one may be amputated by the methods described as especially suited to it, or a common antero-posterior flap may be made. As to the propriety of removing the ends of the metacarpal bones, the same rules apply as already given for the single amputations. Through the Metacarpus. — When the end of the metacarpus can not be saved, these bones should be divided at any point three fourths of an inch or more anterior to the carpo-metacarj^al articulation. If the injury extends behind this line, it is better to disarticulate at the carpo-meta- carpal junction. In amputation through the metacarpus, the flap should be made chiefly from the palmar tissues, so that the line of sutures and the scar will be well on the dorsum of the hand, and as much of the tactile sense preserved as is possible. Carpo- Metacarpal Disarticulation. — When all the bones of the meta- carpus require to be removed, on account of a lesion not involving the anterior row of the carpus, the amputation should be made through the metacarpo-carpal line. If the anterior row is involved, the entii'e carpus should be removed. When the thumb is intact, and the metacarpal bones of the four fingers require removal, the incision as given by Esmarch should be followed. A curved incision is made across the palm, beginning at the middle of the web between the thumb and index-finger, and carried outward to the idnar side of the base of the fifth metacaii^al bone (Fig. 172). The dorsal incision commences at the web between the thumb and finger, and is carried obliquely upward toward the carpus Fig. 170.— (After Esmarch.) Fig. 171. AMPUTATIONS. 121 until the junction of the middle and upper third of the metacarpal bone of the index-finger is reached, whence it travels across the back of the hand to join the end of the i:)almar incision (Figs. 173, 174). Fio. 172. Fig. 173. Fig. 174. Fig. 175. Amputation of the thumb with disarticulation at the carpo-metacarpal junction .should be done as follows : Just over the carpo-metacarpal joint on the dorsal aspect of the hand commence an incision, and carry it directly along the metacarpal bone until half way to the metacarpo-pha- langeal articulation, from which point it is made to travel along the groove between the thumb and index-finger to the middle of the web between these two members, thence on around the base of the thumb until the dorsal incision is reached (Fig. 175). In the case shown in Fio. 17i'>. — Epithelioma "f thumb. (From a patient at Mt. Sinai Hospital.) Fig. 177. — The same, after amputa- tion at the car[X>-iuelac;jpal joint. Figs. 17G and 177 this operation was jierformed. In amputation of the little finger, at the carpo-metacarpal joint, a similar incision is made (Fig. 178). The character of the injury, the geuei'al condition of the individual, 122 A TEXT-BOOK ON SURCJERY, the vitality of the parts involved, may necessitate various modifications of the foregoing methods. In the surgery of the hand, the rule in piac- tice should be never to amputate when possible to avoid it, and never to remove any more than is absolutely necessary. Fig. 179 is that of an amputation after an injury from the explosion of a shot-gun, in which the thumb, in- dex, and ndddle lingers, and their respective metacarpal bones, were blown oflf. The line of incision was a lateral one, and the disarticulation was at the carpo-metacarpal joint. liddlo-CarjKtl Joint. — In ampu- tation at the wrist the carpus should be removed, even when all the bones of this group are not involved. The / , line of incision will depend upon I the extent of the healthy tissues |; / availalUe for fcM-ming the covering j.,^ j-3 to the stump. The long palmar and short dorsal flaps are preferable on /J}-^ account of the iiuer tactile sense of //" i the covering thus secui'ed. More- / / / over, the vitality of the palm is / / / ^ so great that, if ordinary precau- / / I /-..h tions are observed in its dissection, I / \ / / sloughing will not occur. ./' First Method. — Place the thumb \ \ and finger of the left hand respect- ively upon the styloid of the radius and ulna, and make an incision Fio. iro. across the dorsal surface of the wrist which shall divide everything straight down to the bones and into the cavity of the joint. This incision reaches half-way do\\ai the lateral aspects of the wrist. At the radial end of this cut enter the scalpel, and, in shaping the long flap, follow the center of the dorsum of the metacarpal bone of the thumb as far as the meta- carpo-phalangeal articulation. From this point cut di- rectly across the palm to the ulnar side of the fifth metacarpal bone, and back along this to join the dorsal incision. Dissect the flap closely from the flexor ten- dons, and divide all tendons opposite the wrist-joint. Apply a cloth retractor, and saw through the styloid of Fio. 180. the radius and ulna just at the level of the articular surface of the radius, but not necessai"ily taking a sec- tion from this surface. The radial, ulnar, anterior, and posterior carpal vessels are tied, the palmar flap is trimmed down to fit snugly, and stitched in proper position. The drainage-tubes come out on either side (Fig. 180). AMPUTATIONS. 123 Second Method. — If the condition of the soft tissues is such that tlie long palmar flap can not be obtained, the circular incision shown in Figs. 181 and 182 may be practiced. It is always advisable to make a longitu- dinal split in the cuff along its ulnar asi^ect. Under other conditions, a y ,^^=1-}-?=?^ Fio. le ^ \ Fig. 182. — Showinarcuff stitched and e.\-it of drains after the circular method. (After Es- march.) Fig. 181. Fig. 184. lateral flap may be utilized, after the thii'd method (Figs. 183, 184), in the flap from the thumb side ; or the fourth method in which the flap is taken from the ulnar aspect of the hand. Forearm above the Wrist.— hx amputation through the forearm, the rule ah-eady given as general applies with equal force — namely, that that operation is best which least disturl)s the nutrition of the flaps. For this reason, in all parts of the extremity, when the conditions of the tissues permit, the solid flap should be used. First Method. — At a distance beyond the point at which it is deter- mined to divide the two bones, sufficient to provide an ample covering for the stump, with a scalpel or long knife, as may best suit the opera- tor's taste, make a circular incision through the skin, and just do\vn to the deep fascia. When this incision is completed, and the skin retracted up- ward, at the level of the proximal edge of the wound, divide all the tissues squarely and smoothly down to the bones and interosseous meml)rane. Along the ulnar bordei', and immediately over the inner aspect of this bone, make an incision parallel with the axis of the ulna. This incision, which splits all the tissues down to the bone, will vary in lengtli with the thickness of the member at the point of amputation. With the dry dis- 124 A TEXT-BOOK ON SURGERY. sector for the most part, and the knife-point when necessary, lift all the tissues closely from the periosteum and interosseous membrane. Fold the soft parts back as far as the jjoint of section with the saw, apply a ckjth retractor, and divide the bones smooth- ly. The saw should be en- tered on the ulna, which is the fixed bone, but the sec- tion of the radius should be first completed. The vessels are next secured, the sutures inserted, and the di-ainage- tube brought out at the up- l^er or proximal end of the longitudinal incision. This method of amputation will be found preferable in all cases where the section is through the lower half of the forearm. In patients of great muscular development, or in whom the subcutaneous fat is excessive, the skin-Jlap operation may be necessitated in the upper half. Here the circular incision, with a per- pendicular slit along the ulnar aspect of the forearm, is the next in order of preference, or the rectangu- lar or crescentic symmetrical tiaijs may be made. The anatomical relations of the parts concerned in amputa- tions through the forearm are admirably shown in Figs. 185, 186, 187, and 188, which, with only slight modifications, I have copied from Prof. Braune's mag- nificent work. When the line of amputa- tion is so close to the elbow- joint that division of the bones is necessitated ^nthin an inch of the articular surface of the head of the radius, the operation to be prefeiTed is a disarticulation at the elbow, with removal of the olecranon. When the bones Fig. 185.*— Transverse section tlirout'li the rii;lit upper ex- tremity, one Iburtli of an inch anterior to the plane of the nidio-earpal articulation. Looking at the surface of the stump. 1, Railial arten' and veins. 2, Ulnar artery, veins, and nerve. .3, Tendons of deep and supei-ficial fle.xors. 4, Tendon of extensor ossis metaearjii and prirai internodii poUicis. 5, Flexor carpi radialis. C, Palmaris longus. 7, Fibers of the flexor brcvis minimi di^riti, from the'annular ligament. 8, Flexor carpi ulnaris. It, 1", Extensor cai-pi^radialis longior et brevier, ami teiidon of secundi internodii pollicis. 11, Extensor communis digi- torum. 12, E.xtensor minimi digiti. 13, Extensor carpi radialis. Superficial veins and nerves are seen in the subcutaneous tissues. Fig. ISii. — Transverse section showing the relations of the ti>sues divided in amputation throu'.'h the lower third of the riirht forearm. Lookinir from below upward. 1, Radial artery and veins. Just below this, tendon of supinator longus, radial nerve, and close to the radius the tendons of the extensor ossis metacarpi pollicis and extensor carpi radialis lon^or and brevior. 2, Ulnar artery, veins, and nerve. Z, Median nerve. 4, 5, The posterior and anterior interosseous arteries. * Al! of these cuts represent the surface nearest the patient's hody, i. e., the surface over which the vessels are searched fur after iin amputation. AilPUTATIONS. 125 can be preserved at the level of the lower border of the bicipital tuber- osity, of the radius, the joint should not be invaded. Fig. 187.— Transverse section througli the middle of tlie right forearm. Looking from the periplier.v towr.rd the center. Showing the relations of the tissues divided in amputation at tiis point. 1, Kadial artery, veins, and nerve. 2, Ulnar ditto. 3, Median nerve. 4, Anterior interosseous vessels. Fig. ISS.— Transverse section tlirouprli the upper third of the right forearm. Looking from the periphery toward the center. 1, Kadial artery, nmscuhir I'rani'hes, veins, and radial nerve. 2. Ulnar and mter- • osseous arteries, veins, and median nerve. 3, Ulnar nerve. The tendon of insertion of the biceps is seen with tlie radius. 12(5 A TEXT-BOOK ON SURGERY. Amputation at this level (Fig. 188) should be made, as in other portions of the forearm, below. At ihe ElhoiD-Joinf — First BfefJiod. — Make a circular incision do\\Ti to the deep fascia from one to two inches anterior to the tip of the inter- nal condyle of the humerus, and, when the skin has retracted, at the level of the line of retraction divide all the tissues to the bones. Along the posterior surface of the ulna make an incision extending as high as the olecranon process. Dissect the soft tissues neatly from the peri- osteum and capsule back to the condyles on the lateral and anterior aspects of the humerus, and along the olecranon somewhat higher, in order to facilitate disarticulation and the complete removal of the synovial bursa, beneath the insertion of the triceps. When the disarticulation is completed, apply a cloth retractor and saw a portion of the articular sur- face off at the level of the lower j)ortion of the internal condyle. The flaps are now sutured, leaving the drainage-tube out at the upper limit of the incision, over the olecranon. Second Method. — Make a circular incision through tlie skin from one inch to one inch and a half below the level of the internal condyle. Along the posterior aspect of the ulna make a second incision, splitting Fio. 189.— Transverse section of ri;ht arm ,iust bclnw the elbow-joint. Lookinfr at the surface nearest the body. 1, ijr.ichial artery at tlie point of ilivision into ulnar and radial. L', Median basilic vein com- municating; with brachial. 3, The radial and interosseous divisions of the musculo-spiral nerve and radial recurrent artery. 4, Tendon of biceps. 5, Median nerve and anterior ulnar recurrent artery. 6, Ulnar nerve and posterior ulnar recurrent artery. the sleeve of skin as far back as the end of the olecranon. Dissect up the flap from the muscles and deep fascial attachment until the joint is exposed in front, and the olecranon posteriorly. E.xtend the forearm fully, enter the articulation between the head of the radius and the AMPUTATIONS. 127 humerus, disarticulate, and saw off the articuhir surface as in the pre- ceding operation. The drainage is from the liighest point in the perpen- dicular incision. Fig. 189 shows the anatomical rela- tions near the line of section of the soft parts involved in this amputation. Arm. — The circular skin-and-mus- cle flap is always preferable, except in cases of extraordinary muscular development, or an excessive quanti- ty of subcutaneous areolar tissue. First Method. — Make a circular cut through the skin at a point suf- ticiently below the line of section through the humerus to permit a suitable covering. Allow the skin to retract up the arm, and at this point divide everything smoothly and squarely dowTi to the bone. Render the skin and muscles tense, push the point of the scalpel down to the bone on the outer side of the arm, and lay the flap open by an incision which is parallel with the axis of the humerus, periosteum up to the point where the saw is to be applied, and, after pro- tecting the soft parts with a retractor, divide the bone. The drainage should be from the upj)er extremity of the perpendicular cut, which, %m^)^^ Fig. ICO. — Showinff sutures applied and exit of drains in amputation at the lower and middle thirds of the humerus. Dissect the tissues closely from the Fio. lill.— Section throush the eondvloid expansion of the risrht arm. Looking at the surface nearest the body. 1, Brachial aiterv and vein.^, antl the median basilic vein. *2, ilusculo-spind nerve and superior profunda artery about the point of anastomosis with the radial recurrent. 3, Median nerve. 4, Biceps tendou. 5, Ulnar nerve. 6, Triceps tendon. 128 A TEXT-BOOK ON SURGERY, Flo. 1S2. — Transverse section tlirougli junctinn of middle and lower thirds of riiht arm. Lookincr from lielow upward. 1. Brachial artery, vein, median nerve, and basilic vein. Near liy tiie ulnar nerve and inferior protunda artery. 2, Musculo-siiiral nerve, .superior profunda artery, and sujiiuator longus mus- cle. Cephalic vein to outer side of the hiceps muscle. Fio. 193. — Transverse section showiiig the relations of parts divided in amputation just above the middle of the humerus. Right side. Looking toward the center. 1, Brachial artery. Near this the median nerve and brachial veins. Internal to it the ulnar nerve and inferior profunda artery. More superficial, the basilic vein. 2, Miisculo-spiral nerve and superior ]irofunda artery. 3, Nutrient artery in the sub- stance of the coraco-brachialiti muscle. 4, Cephalic vein. AMPUTATIONS. 129 with the stump properly elevated, will be the most dependent portion of the wound. An extra tube may be inserted at the end of the stump. Second Mdliod. — Make a circular cut down to the muscles, and a longitudinal incision to the same depth along the outer side of the arai. Dissect the sleeve of skin carefully up to the line of section of the humerus, and at this point divide the muscles and bone. Drainage as in the preceding, or as shown in Fig. 190. The anatomical relations in the several regions of the arm are shown in Figs. 191, 192, 193. When the line of amputation is so near the shoulder-joint that section of the bone is requii-ed at a point not more than two inches below the under surface of the acromion process of the scapula, the entire humerus should be removed by disarticulation. At the Shoulder- Joint — First Meth- od. — The patient should be placed so that the shoulder is near the corner of the table and con- venient to the oper- ator. After render- ing the extremity bloodless, ajjply the elastic tourniquet around the axilla and over the clavi- cle and spine of the scapula. Hold- ing the arm so that the internal condyle points directly to the i^atient's side, enter a long, sharp scalpel directly down to the capsule of the joint, just at the articulation of the clavicle with the acromion process, and expose the head and upper part of the humerus by a perpendicular incision, which splits the deltoid down to its insertion. At the lower end of this incision make a circular cut through the skin, and, allowing it to retract, divide at this line the remaining soft tissues down to the bone. In order to prevent any bleeding, in case the tourniquet should not be sufficiently tight, an assistant should be j-eady to grasp the flap just below the tourniquet, or press the subclavian against the first rib. The entii-e flap is now dis- 9 Fig. 194. 130 A TEXT-BOOK ON SURGERY. sected up from the pericjsteum and capsule, and disarticulation accom- plished by cutting the capsule as close to the margin of the glenoid cavity as possible {Fig. 194). The vessels are now secured, ami the wound sutured and drained, as shown in Fig. 195. This method is a modili- cation of the old operation of Larrey,* to which it is much superior. Esnuircli has still fur- ther modified this amputation by sawing the bone immediate- ly after the circular incision is completed, and then disarticu- lating. Lower Extremity. Amputation of the Toes. — The same methods given for the fingers should be emi:)loyed in amputations of the toes. The long plantar Hap is always pref- erable in these operations, not so much for the jireservation of the more perfect tactile sense Fig. 195. of this surface in covering the stump, but chiefly in order to bring the cicatrix on top and away from pressure. When an anii)uta- tion is necessitated for a lesion near the articulation between the first and second phalanges in which only the anterior extremitj- of the first * iMrrey's Method. — A straight incision, dividing all the tissues down tlirongh the capsule to the hone, extending from the tip of the acromion process to about one inch below the articu- lar surface of the head of the humerus. From the center of this cut an incision on either side of the arm, running obliquely downward and forward, dividing all the tissues down to the peri- osteum, and extending about two thirds of the distance from the apex of the shoulder to the axilla. Elevate the tissues so as to fully expose the joint, press the arm upward, in order to dislocate the head of the bone through the incision in the capsule, carry a long, thin knife across and through the capsule, and complete the oval flap by cutting along the under surface of the humerus in the line of the oblique incisions already made.- Dupuytreri's Method. — Place the arm to be amputated at a right angle to the trunk, grasp and raise the deltoid with the left hand, and transfix the shoulder from before backward with a long knife, which is introduced anterior to the axillary vessels, perforates the capsule, and emerges on the posterior aspect of the arm. A long (deltoid) flap is now made by cutting down- ward, close to the bone, to near the deltoid tubercle. While an assistant holds this flap up out of the way, the arm is carried to the side of the body, and the humerus pressed upward, in order to facilitate its dislocation. The long head of the biceps, and the tendons, inserted into the tuberosities, are now divided, and, if necessary, the incision in the capsule lengthened. iVfter the luxation is accomplished, insert the knife as in the operation of Larrey, making the posterior flap by the same manoeuvre. [Many other methods have been devised for the performance of this operation, but the method first given meets all the indications so fully that it must supersede all others.] AMPUTATIONS. 131 phalanx is involved, section through the bone should be preferred to disarticulation at the metatarso-phalangeal joint, provided that the line of section is through the anterior thud of the phalanx. Disarticula- tion of two or more consecutive toes at the metatarso-phalangeal Joint may be effected by a continuous incision. Amputation of all the toes at this articulation is performed as follows : Urasp and forcibly flex the toes, and make an incision, commencing just posterior to the inner aspect of the metatarsal joint of the great toe, curving forward along the side of the first phalanx to a point as far advanced as the web between the toes, and then across the base of each digit on this ]>lane until the outer side of the metatarsal bone of the fiith toe is reached at a point corresponding to that at which the incision was begun. With the toes now fully extended, a symmetrical flap is next cut along the plantar as- pect by an incision which almost merges into the first line at the ante- rior margin of the web (B^igs. 196, 197). Dissect up each flap as far back as the metatarso-phalangeal articulation, leaving the tendons to be divided at this point. The disarticulation may be best effected with a strong narrow scalpel, while the ligaments are made tense by forced flexion. Second MetJiod. — A separate amputation may be made for each toe. Throvgh the Metatarsus. — When the loss of tissue requires an ampu- tation behind the metatarso-phalangeal articulation, section of one, or even all, of the metatarsal bones should be effected rather than unneces- sarily sacrifice any portion of the foot by disarticulation at the tarso- metatarsal joint. The line of section should alwaj-s be as near the anterior extremity as possible, and when it falls within three fourths of an inch from the tarso-metatarsal, joint, a disarticulation should be made at this point. Amputation through the entire metatarsus should be made with a long plantar and short dorsal flap, so that the scar wUl fall on the dorsum of the foot and away from pressure. The dorsal incision should be made almost directly across the foot, and on a line with the plane of section through the bones. The plantar flap should begin on the inner side of the first metatarsal bone, and follow this forward as far as is necessary to secure a flap of sufficient length. It is always wise to make this a little too long, so that it may be trimmed down and made to fit nicely as the sutures are being adjusted. The incision is next carried across the sole of the foot to the outer surface of the metatarsal bone of the little toe, and back along this to the point of junction with the end of the dorsal cut. All of the tissues should be divided directly down to the bones in this incision, and the flap dissected up, keeping the knife- FiG. 196. Fio. 197. 132 A TEXT-BOOK ON SURGERY. point always in contact with the periosteum, so that the vessels may be avoided. After the bones are sawn through, the lower flap is turned into jiosition and suitably trimmed. The vessels are next secured, the sutures applied, and the drainage-tubes brought out at each side. At file Tarso-Metatarsal Articulation — First Metatarsal. — Ami)uta- tion of the great toe, with disarticulation of its metatarsal boup at the tarsal Joint, is effected as follows : At a point about half an inch behiiul the articulation of the metatarsal bone with the internal cuneiform, and immediately between the dorsal and internal lateral aspects of tliis bone, commence an incision which is carried forward to the phalangeal junction. Thence it is continued around the base of the toe, across its plantar sur- face, and back through the web between the first and second digits, and back to the end of the straight incision over the metatarso-phalangeal joint (Fig. 198). Dissect the soft parts closely from the bone, taking care not to wound the plantar vessels, and disarticulate. The preservation of the jwsterior portion of the first metatarsal bone is always desirable, on account of its giving insertion to the peroneus-longus and pai-tially to the tibialis-anticus muscle, the former being a strong supporter of the trans- verse arch of the foot, and the latter offering the chief resistance to the sural muscles. ..Mi Fio. 198. Fig. 190. Fifth Metatarsal. — One fourth of an inch behind the tubercle of the fifth metatarsal, and over the center of the dorsal aspect of this bone, commence an incision, w^hich is carried directly forward until near the first phalanx, when an oval is described around the base of the little toe (Fig. 199). Keep close to the bone in the dissection. The disarticulation is more easily effected by division of the jieroneus brevis and peroneus tertius, and by entering the articulation from the outer side. The importance of the posterior portion of this bone is less than that of the metatarsal bone of the great toe, but it should never be needlessly sacrificed. One or more of the intervening metatarsal bones may be removed in an amputation of their respective toes in practically the same manner as the preceding. The incision should be begun far enough behind the tarso-metatarsal joint to thoroughly expose the ligaments and facilitate disarticulation — not an easy process when only a single bone is to be removed. The incision should be made exactly along the middle line of the dorsal aspect. AMPUTATIONS. 133 Amputation of the entire metatarsus should always be made through the articular plane (Lisfranc). The modification of this procedure by Hey, which consisted in disarticulating the four outer metatarsal bones and sawing the end of the internal cuneiform off at the line of the second metatarsal bone, is altogether unnecessary. Method — Dorsal Incision. — Place the thumb and index of one hand respectively half an inch behind the articulations of the first and fifth metatarsal bones with the .cuneiform and cuboid, and at the most con- venient one of these points commence the dorsal incision, carrying it directly forward to the base of the metatarsus, and then across the foot one fourth of an inch in front of the tarso-metatarsal articulation, finish- ing at the opposite side (Fig. 2()0). This incision should have a slight forward convexity, and should di- vide all tissues down to the bones. Dissect the flap closely from the periosteum to about one fourth of an inch behind the line of articula- tion. Plantar Flap. — From the same point as for the dorsal incision, carry the knife directly forward on the lat- eral aspect of the metatarsal bone to the metatarso-phalangeal joint, where the line of incision should begin to describe a curve until the interdigital web is reached, along which it travels across the foot, and thence back along the opposite metatarsal bone to the level of the tarsus (Fig. 201). This flap should be lifted by deep dissection, keeping close to the under surface of the bones, in order to interfere as little as jwssible with the vascular sui:)ply. An assistant should now hold both flaps well back, while with a narrow, short scalpel the disarticulation is effected as follows : Grasp the metatarsus with one hand and forcibly depress it until the ligaments are put upon the stretch. Enter the knife just behind the tip of the fifth metataisal bone and carry it inward with a slight forward inclination, disarticnlatiug on this plane, and in succession the fifth, fourth, and third bones, until the knife is arrested by the outer surface of the second metatarsal. The line of this articulation is almost parallel with that just followed, but it is placed from one eighth to one fourth of an inch posterior to it, and may be readily found by moving the meta- tarsal bone upon the cuneiform. The joint between the metatarsal bone of the great toe and the internal cuneiform is about one fourth of an inch anterior to that of its fellow, being continuous with the line of the three outer bones. The flaps should now be trimmed and nicely fitted, and any ragged ends of tendons clipped off by the scissors, after which the Fifi. 200. Imo. 201. 134 A TEXT-BOOK ON SURGERY. I'iiogoS. vessels are tied and the sutures adjusted, leaving the drainage tubes out at each angle. One point of precaution is essential, namely, to avoid division of that part of the tendon of the tibialis anticus wliich is inserted into the internal cuneiform near its metatarsal articulation. One of the objections to this operation is the elevation of the heel, and the consequent depres- sion of the stump by the action of the sural muscles, which action is practically unopposed if the inser- tion of the tiliialis anticus is divided. Should this occur, or shoidd the heel be too greatly elevated, the tendo Achillis should be divided as in talipes equinus. The line of sec- tion through the internal cuneiform bone is shown in Fig. 202. This — the operation of Hey — is objection- able for two reasons. In the tirst l)lace, it cuts away a part of the bony framework of the foot, which need not be sacrificed ; and, sec- ondly, it completely severs the at- tachment of the tibialis - anticus muscle. Through the Tarsus. — When re- moval of any part of the anterior row of tarsal bones is required, the fol- lowing rules should be adoj^ted : If the internal cuneiform is involved only on its anterior articular surface, it may be sawn through on the line of Iley (Fig. 202). If a section pos- terior to this plane is necessarj', dis- articulation at the scaphoid should be done. If the middle or external cuneiform is involved only to a limited extent upon its anterior por- tion, as much as one fourth of an inch of this surface may be sawn or scraped off. Behind this limit a disarticulation from the scaphoid should be made. Through the culioid the line of section may pass at any point anterior to the middle of this bone — the line of Forbes (Fig. 202). Forbes\s Method. — Disarticulatitm f)f the three cuneifonn bones from the scaphoid, and section of the cuboid parallel with the plane of the anterior surface of the scaphoid (Fig. 202). The dorsal and plantar in- cisions are slightly anterior to and practically the same as in Chopart's amputation. The dissection should be made closely from the bones, and Metatarsus in continuity. I Phalanges in continuity. Fig. 202. AMPUTATIONS. 135 the flaps trimmed and adjusted as in the preceding operation. Section of tendo A chillis may be done later, if necessary. 3Iedto-Tar-sal — Operation of Chopart. — The dorsal incision is begnn on a level with and an inch posterior to the tip of the base of the tifth meta- tarsal bone (for the adult foot). This point is about one fourth of an inch behind the articulation between the cuboid and calcaneum (Figs. 199, 203). With a slight forward convexity the incision is carried across the top of the foot to the posterior margin of the tuberosity of the scaphoid, and then directly back from one fourth to half an inch (Fig. 198). The skin, tendons, vessels, and nerves are di- vided on this line, and the flap lift- ed until the joints between the astragalus and scaphoid and the calcaneum and cuboid are well ex- Fio. 203. posed. From the'ends of this first incision a long plantar flap is fashioned by cutting forwai'd, as in shaping the flap for the operation of Lisfranc (Figs. 198, 199). Disarticulation is effected with a short, strong scalpel, while forcible extension is employed. The flaps are now to be properly trimmed, and the vessels secured. Division of the tendo Achillis may be done later. AVhen required, this operation may be modified by sawing off the anterior half-inch of the astragalus and calcaneum. The incisions are practically the same. Calcaneo-Astragaloid Disarticulation. — This operation was first sug- gested by LigneroUes, first perfonned by Textor, but brought into promi- nence by Malgaigne. When in an ampiitation of the foot at the medio- tarsal joint it is discovered that the as catcis must also be removed, and if the astragalus is sound, the subastragaloid operation should be pre- feiTed to the amputation of Syme at the tibio-tarsal joint. By this method a shortening of about two inches is prevented, and, although the under surface of tlie astragalus is uneven, experience has shoA\Ti that the pressure is safely distributed, and a useful stump results. Moreover, the degree of mobility maintained at the tibio-astragaloid articulation adds to the ease and comfort of locomotion. Seize the foot with the left hand, and with a strong scalpel commence the incision by dividing the skin and tendo Achillis just at the level of the upper surface of the os calcis. From this point the incision is continued along the fibular side of the foot forward, dividing everything down to the bone, and curving slightly downward until, as it passes below the tip of the external malleolus, it is four tenths of an inch below this point (Fig. 204). The line of incision is now carried du-ectly forward until near the tuber- osity at the base of the fifth metatarsal bone, where it curves to the dor- sum of the foot, crossing to the inner side over the anterior edge of the scaphoid, and then straight down and under the foot a half-inch beyond the middle of the sole (Figs. 205, 206). From this jjoint a straight incision is made directly back to the point of beginning at the inner edge of 136 A TEXT-BOOK OX SURGERY. the tendo Achillis (Fig. 206). Lift the plantar flap by deep and careful dissection from the bone, leaving nothing but the periosteum, until the Fig. 204.— (.\fter Malgaigne.) Fio. 205.— (After Malj^-aigne.) Fig. 206.^(After Mal- gaigne.) calcaneo-astragaloid articulation is well exposed. The flaps being held by an assistant, the disarticulation is begun by opening the asti-agalo-scaphoid joint and removing the anterior pait of the foot at the medio- tarsal joint. The os calcis should now be seized with a lion-tooth forceps, and the disarticulation of this bone effected. The exposed tendons should be smooth- ly divided with the scissors at the higher portions of the incision. After deligation of the vessels the flap is properly trimmed and sutured, the cicatrix falling upon the dorsal and external lateral aspects of the stump.* * Hancock's modification of this pro,-edure, or the su'oastragaloid- osteoplastic amputation, is as follows: One incision begins beneath and at the posterior angle of the outer malleolus, and is carried along the outer surface of the foot to a point a half-inch anterior to the pro- jecting base of the fifth metatarsal bone. A second incision is made along the inner border of the foot, commencing posteriorly about the center of the internal malleolus anil terminating anteriorly at a spot opposite the end of the external incision. The anterior ends of both cuts are joined by a curved in- cision made with its convexity forward across the plantar aspect of the foot, and dividing all the tis- sues well down to the bone. Reflect this flap back as far as the projections at the under surface and in front of the tuberosity of the os calcis, and make a fourth incision across the dorsum of the foot imme- diately behind the head of the astragalus. Apply the saw upon the under surface of the calcaneum a little anterior to its center, and cut through the bone ob- liquely from below upward and t)ackward (Tig. 207). With the knil'e enter the mediotarsal joint, pass the instrument under the hejid of the astragalus, and, cat- ting from before backward, sever the interosseous ligament and detach the anterior part of the foot, together with the segment of the os calcis. Saw otf tlie head of the astragalus, and with a sharp bone-cutter (or saw) remove the two articular cartilages (and a thin slice of bone) from the under surface of the astragalus. As the flaps are adjusted, the sawn surface of the calca- neum is brought into apposition with the under surface of the astragiilus. See "Lancet,'^ September, 1866, p. 257. Fig. 207. — Section of os calm mid astragalus in Ilancocli s operation. AMPUTATIONS. 137 Amputation of the Foot — Tiblo-Tarsal {Syme's). — When the astraga- lus must be removed, together with the foot, the amputation of Syme, which involves a disarticulation of the tibio-astragaloid joint, and a sub- sequent section of the articular surfaces of the tibia and fibula, should be made. In its successful performance certain precautions are neces- sary, chief among which is the preservation of the proper vascular sup- ply to the posterior flap. The failure to appreciate the importance of making the plantar incision far enough forward, as laid down by Syme, has brought this procedure somewhat into disrepute, for Prof. Stephen Smith, in his comprehensive report, says the necessity for re-amputation is 3 per cent greater in this than in any other amputation. In my "Prize Essay," published in 1876,* I demon- strated that the ar- terial distribution to the calcaneo- plantar flap was chiefly derived from the external plantar artery, and from the posterior tibial so near the bifurcation of this vessel into its ter- minal branches, that any line of in- cision in the forma- tion of this flap which necessitated the application of a ligature at or very near its bifurcation was not justifiable. I do not doubt that the sloughing so often met with at this point is caused by carrying this incision too far back toward the tuberosity of the calcaneum. The arte- rial supply is shown in Fig. 208, from my "Essays in Surgical Anatomy and Surgery." f Modified Procedure. — With the foot held at an angle of 90° to the axis of the leg, place the thumb at the tip of one malleolus, and the index at the other, and from the center of the maUeohis intenius carry an incision directly across the sole of the foot to a point one fourth of an inch anterior to the tip of the malleolus extemns. This incision should divide all the tissues to the bones, and. as wiU be seen in Figs. 209 and 210. its perpendicular portion descends in a direction slightly anterior to Fig. 208.— pia^T.im showing the arterial supply to the calcanean reirfon, on the tibial side of the foot. (Drawn by tne author, from the average of eighty-seven dissections.) m, Internal malleolus, pmcu, Tibio-tarsal quadrilateral, tlie surgical region of this articulation, k. Posterior tibial artery, o, Its point of bifurcation into g, Internal plantar, and /", Ex- tenml plantar artery. Hi, Calcanean branches of external plantar, t, Articular branches from posterior tibial. A, Articular braneu from in- ternal plantar, j, Tendon of tibialis posticus muscle, r. Tendon of fle.xor longus digitorum. «, Tendon of flexor longus poUieis. m c, The line of incision of Gro:*s. vi /, m ..l - ,^' ' A-< )-tm mm f< 4\ V%a //. c^'^; A^'^i ,^^' f'7^1 ?!•: C,^' ^v^^^>' ^v "1, 1^. Fig. 234. — Section through upper third of right leg. Surface nearest tlic body. 1, Anterior tibial vessels and nerve. 2, Posterior ditto. 3, Peroneal vessels. 4, Musculo-cutaneous nerve. 5, Internal saphena vein and nerve. this incision upon the opposite side ; raise the flap, consisting of all the tissues, down to the bone until the articulation is reached, divide the \, Fio. 235.— (Modified from Esmiireh.) liffaments, and remove the leg as in the ])revious operation (Fig. 237). The flap should be lifted ivom the patella, and this bone removed. "Care should be taken that the incision is inclined moderately for- ward down to the curve of the side of the leg, to secure ample covering 148 A TEXT-BOOK ON SURGERY. for the condyles, and that upon the internal aspect it should have addi- tional fullness for the purpose of insuring sufficient iiap for the internal or larger condyle" (Smith). After the flaps are stitched the drain- age-tube makes its exit through the upper posterior angle of the wound.* Fig. 236. — (After Esmarch.) Fio. iST. Thigh. — Tlie method to be selected in amputations through the lower two thirds of the thigh will depend iipon the size of the mem- ber at the point of election. In limbs of ordinary size, and particu- larly in emaciated persons, the operation advised in the arm should be followed here. First Method. — Below the Ihie of section through the femur, at a dis- tance sufficient to furnish an ample flap, by a circular incision divide the integument down to the muscles, allow the skin to retract, and at the line of retraction divide the remaining soft tissues down to the bone. On the anterior and external aspect of the thigh, by a perpendicular incision extending as high as the i:)oint of section of the bone, divide everything to the bone, and from the periosteum, with a dry dissector, lift the solid flap. Apply the cloth retractor and saw through the bone. As the stump is placed in an elevated position, with the thigh also abducted and rotated outward, the drainage is naturally at the upper angle of the perpendicular incision. This same iirocedure may be carried out in this class of cases in all parts of the thigh, and in disarticulation at the hip-joint as well. When the diameter of the limb is great, or when there is abundant subcutaneous areolar tissue, the modified circular skin-flap operation is preferable. * Tlie method of Carden — namely, long anterior skin-flap, and tlie short posterior skin and muscular flap, made by the lonp knife carried tliroush the joint — is inferior in every respect to either of the forejroing operations. Carden recommended section through the condyles. Gritti introduced an osteoplastic modification by making a long rectangular skin-flap from the front of the knee and leg, which is dissected up deeply, lifting the patella in the flap. Behind, a short flap is made simihar to that in Carden^) method. Section is made through the bone about an inch above the tip of the internal condyle, and the articular surface of the patella is then sawn off. This procedure may be best accomplished by grasping the flap with the left hand and stretching it over the knuckles, so that the articular surface of the patella looks directly upward, where it is fixed quite immovably. As the flaps are adjusted, the sawn snrface of this bone is brought into contact with that of the femur. Some operators secure it here by transfixing with an ivory pin. The whole procedure is not only difficult and tedious, but wholly unnecessary. AMPUTATIONS. 149 Second Method. — Make a circular incision through the skin and fascia, joined by a perpendicular cut on the lower external aspect of the limb. Dissect up tiie flap from the muscles, and divide all the remaining soft tissues squarely at the point of section of the bone. Suture the flap, and drain from the outer upper (and, if necessary, lower) angle. Fio. 238.— Section tlirousrh the riglit femur at the condyles and at the middle of the patella. Looking at the central surf^ice as o.xrosed altei- amputation at this point. 1, Popliteal artery, vein, and internal popliteal nerve. 2, E.xtcmal popliteal or peroneal nerve. The capsule and the synovial cavities arc admirably shown, as well us the bursa mucosa paUllce. At the Hip. — AVhen possible, the first method just given should be employed here, for the reason that it allows the division of the arteries at the greatest possible distance from the trunk. Proceed as follows : Place the patient so that the hip at which the operation is to be per- formed projects well over the corner of the table. The member to be amputated is emptied of blood by elevation and the Esmarch bandage, and is held by an assistant while the opposite thigh is abducted and allowed to drop over the end of the table, the foot resting upon a stool. Hsemorrhage may in great part be controlled by placing a compress iipon the iliac, as it runs along the rim of the pelvis, and holding this down 150 A TEXT-BOOK ON SURGERY. and in position by a strong rubber tubt', carried obliquely around the groin from the perinseum, above the anterior spine, and over the crest of the ilium. An abdominal tourniquet should be applied, so as to com- press the aorta at a point one inch to the left of the umbilicus. This need not be tightened unless compression below proves inadequate.* Operation. — Half way between the anterior-superif)r spine of tlie ilium and the npper surface of the trochanter major (the extremity being held parallel with the axis of the body, and the foot normally everted) intro- duce a strong scalpel straight down to the bone, and by a single incision divide all the tissues along the head and neck, over the nuddle of the great trochanter, and down the outer aspect of the femur lor three or four inches, and as much as six if possible, below the tip of the trochanter. Arrest the bleeding as the operation proceeds. Dissect the tendons Fio. 239. — (Modified from Esmarch.) from their insertion into and near the trochanter, using the cutting edge of the knife only when necessary, preference being given to lifting the soft parts from the periosteum and capsule with the dry dissector. With strong hook retractors the edges of the wound are separated, the joint exposed, the capsule and ligamentum teres divided, and disarticulation effected. The soft parts are now still farther lifted from the bone, to a point at least six inches below the trochanter. The entire mass of soft * If no other means is at hand, the iliac may be compressed by introducing a padded statf into tlie rectum, and over this vessel as it runs along the pelvic rim. Trendelenburg recommended transfixion by means of a round steel pin, which is passed between the head of the femur and the femoral vessels. Compression is maintained by the elastic bandage, thrown over the end in figure-of-8 fashion. A3IPUTATI0NS. 151 tissues is now constricted by a second elastic tube, or ligature, as close to tiie body as possible, and tiiis intrusted to an assistant, whose hands also grasp that part of the tiap in whicli the large vessels are located. At a jioint as low as possible, or about six inches from the trochanter, make a circular sweep around the thigh, dividing the sldn, and allow this to retract. On this level the amputa- tion is to be completed by passin'g a long knife behind the bone, cutting squarely back through all the re- maining tissues (Fig. 239). As rap- idly as possible all the larger vessels are grasped with forceps, after which the ligatures are applied. The drain- age should be from the cavity of the acetabulum, out at the upper angle, and at each of the two lower angles of this stump. Second MetJiod. — Six or seven inches below the trochanter make a circular incisioai through the skin and fascia, and allow this to retract. At the level of the retracted skin divide all the tissues down to the bone, and saw through the femur at this level, as in Dietfenbach's procedure. Fio. 240.— (After Esmarcb.) Secure all vessels at once, and disarticulate by the same incision as prac- ticed in the preceding operation. Third MetJiod (Erskine Mason's Operation *). —The circulation is con- ♦ " New York Mi.d'n.^al Journal," December, 1876. 152 A TEXT-BOOK ON SURGERY. trolled by the abdominal tourniquet, Esmarch's bandage having been applied up to the line of incision. About seven inches below the level of the joint make a cin-ular incision through tlie skin, turn and dissect this up as high as the head of the femur. With the scalpel divide the Fkj. 242.— Section through risht thigh at Hunter'.s canal. Looking at tlie surface att.nched to the body. 1, Fem- oral vessels and long saphenous nerve. 2, Great sciatic nerve and aitcria comes. 3, Long sapliena vein. muscles on this plane, open the capsule, and dislocate the femur. The anterior vessels should be first secured. Fourth Method— Transfixion.— X knife, the blade of which should be at least fifteen inches long, is introduced half-way between the tro- chanter major and the anterior-superior iliac spine, the thigh being AMPUTATIONS. 153 slightly abducted and the foot in the normal degree of eversion. The blade is held at an angle of 90° to the axis of the body, until the point is felt to stiike and pass into the capsule of the joint, when the handle is elevated, so that the knife is parallel with Poupart's ligament, and so directed that its point vnW emerge on the inner aspect of the thigh, near the perinseum (Fig. 240). As the last step in this mancpuvre is being effected tlie thigh should be slightly flexed on the abdomen, in order to Fio. 243. — Section throuih left tliish at its middle. Looking at the surfiice attached to the body. 1, Surcrficial femoral artery, vein, and saphenous nerve. 2, Great sciatic nerve, and the arteria comes nervi iscliiadici. 3, Terminal branch ot'iirofunda t'emoris. 4, Descending branch of external circumflex. 5, Long saphenous vein. relax the tissues here and allow the knife to pass well beneath the great vessels. Two precautions are necessary, namely, not to push the knife- point into the obturator foramen, and also to avoid wounding the sctotum or labium. By to-and-fro sweeps of the knife, which is made to pass along upon the bone for about seven inches, a flap about eight inches in length is cut on the anterior and inner aspect of the thigh. As soon as 154 A TEXT-BOOK ON SURGERY. the knife shall have traveled downward a sufficient distance to permit it, an assistant should insert liis middle- and index-tingers into the wound, and, with the aid of the tliumhs applied externally, control the vessels by direct pressure. The two femoral arteries and veins should be at once secured. The cnpsule should now be divided with a short, strong scalpel, the head of the bone forcibly luxated, the long knife laid across tin; wound behind the caput femoris, and a short Hap formed by cutting along the FiQ. 244. — Section tlirou;^h left thijjh in the upper third. 1, Superficial femoral artery, vein, and sapbcna nerve. 2, Deep femoral vessels ; near by the obturator nerve and vessels. 3, Sciatic iiervc and vessels. posterior surface of the femur as far down as one inch beyond the gluteal fold (Fig. 241). Of the.se various procedures at the hip, the first, although requiring more time for its performance, should be preferred, since the greatest of all dangers in this operation — hsemorrhage — is jiractically avoided. In fat subjects, or where the muscular development is very great, the pro- cedure of Mason should be followed. When rapidity of execution ia essential, the fourth, or transfixion method, is preferable. AMPUTATIONS. 155 Fig. 245. — Transverse section of left thigh throutfh lesser trochanter. Lookina from helow upward. 1, Saphenous vein. 2, Superficial femo'ral vein and ai-tcry. 3, I'rofunda femoral vein and artery, anterior crural nerve between the two arteries. 4, Obturator nerve and artery. 5, Sciatic nerve and artery. Note. — The following summaries, compiled by Dr. F. C. Sheppard, are taken from Prof. Ashhurst's article in the " Eucyclopiedia of Surgery." * It is safe to assert that the improved methods of htemostasis and antisepsis will yield a lighter rate of mortality, in both military and civil practice, than that shown by a study of these tables. I. Summary of Two Hundred and Thirtu-eight Cases of Hip-joint Amputation in Military Practice. NATURE OF OPERATION. Recovered. Died. Undeter- mined. Total Mortailty per cent Primary . 7 4 10 4 5 89 59 17 3 39 1 96 63 27 7 45 92-7 93-6 Secondary 62-9 Reamputatioa of thigh-stump. . . . Not stated 42-8 88-6 Total number of cases 30 207 1 238 87-3 * William Wood & Co., New York, 1881. 156 A TEXT-BOOK ON SURGERY. Fio. 246. — Section throujh the left hip. Looking from helow upward. Reduced from life size. 1, Fem- oral vein, artery, and crural nerve in order fmm within outward. 2, Great sciatic nerve, artery, and vein. 3, Epigastric vein. 4, Vessels to acetabulum. II. Summary of Seventy-one Cases of Hip-Joint Amputation for Injury in Civil Practice. NATUKF, OF OPEEATION. Kccovered. Died. Totol. Mortality per cent. Primarv 6 5 5 4 4 25 7 6 1 8 31 12 11 5 12 80*6 Intermediate Secondarv 58 -.3 54-5 Reamputation of thigh-stuint) 20-0 Not stated 66 6 Total number of cases 24 47 71 66-1 III. Summary of Tico Hundred and Seventy-six Cases of Hip-joint Amputation for Disease. KATUEE OF OPEEATION. Kccovered. Died. Undeter- mined. Total. Mortality per cent. Amputation of entii-e limb Reamputation of tliigli-stump 136 20 95 10 14 1 245 81 41-1 33-3 Total number of cases i.^e 105 15 971! 40''' AMPUTATIONS. 157 IV. Summary of Forty-eight Cases of Hip-joint Amputation for Unkiioicn Causes. Eecovered. Died. Cndeter- mined. Total. Mortality per cent.' Number of cases 10 34 4 48 77-2 V. General Summary of Six Hundred and Thirty-three Cases of Hip-Joint Ampu- tation for all Causes. NAT0EE OF CASE. Recovered. Died. Undeter- mined. Total. MorUlity perccnL 156 54 10 105 254 34 15 1 4 276 309 48 40-2 Tra\iiuatic Cause unknown 82-4 77-2 Total 220 393 20 633 641 * Undetermined cases omitted in computing percentages. CHAPTER IX. the surgical diseases, and sttrgert of the lymphatic vessels, veins, and arteries. The Lymphatic System. — Lymphangitis. The pathological conditions in inilammation of the lymphatic vessels closely resemble those of the veins, with which they are intimately asso- ciated. The histology of the two systems is almost identical. One essen- tial point of difference, and one which has a pathological significance, is that the lymphatic vessels are practically closed tubes, since at varying intervals in their route to the center each trunk breaks lap into small and smaller branches, until they end in closed capillaries in the substance of a lymphatic gland. Although it is not yet positively proven that there is no direct communication between the afferent and efferent vessels, the weight of evidence is in favor of the theory that the vessels end and begin as closed tubes. It follows that whatever of septic or intiammatory matter may pass into these vessels, it can not rapidly enter the systemic circulation. Each lymphatic gland is a sieve which arrests its i^rogress and modifies its effect. In the venous system, however, there is no resistance to rapid and direct systemic infection. We conclude, then, on anatomical grounds, as well as from clinical experience, that the effects of phlebitis are more rapidly felt, and in general more disastrous, than those of lymphangitis. Lymphangitis means an inflammation of all the stnictures which make up the wall of a lymph-carrying vessel ; the endothelial lining, the musctilar and connective tissues, are involved. Hypersemia and thicken- ing occur, with or without coagulation of the lymph and occlusion of the ducts. As in other inflammatory jirocesses, the native and wandering cells undergo proliferation, and form in the extra-vascular spaces a com- mon embryonic tissue, which, under certain favorable conditions, may undergo gi-anular metamorphosis and absorj^tion (resolution), or, if the process be violent and the tissues of a low order of vitality, suppuration may occur. Lymphangitis may be traumatic in origin, or result as a part of some idiopathic inflammation. It may also be described as an acute, subacute, and chronic disease, involving the superficial or deep vessels, or both. The symptoms of acute lymphangitis, while varying in intensity pro- portionate to the virulence of the cause and the condition of the tissues THE LYMPHATIC SYSTEM. 159 affected, are the same in the essential features in every case. Following an inoculation with any septic matter, within a few hours there is a sense of uneasiness and burning in the immediate vicinity of the wound. Pain is not usually severe until the swelling is well marked. At the end of from twenty-four to thirty-six hours the injection of the suiiei-ficial vessels which lead from the local inflammation toward the center may be recognized. These red lines give a i)eculiar sensation to the touch. While the outline of the vessel can rarely be made out by palpation, there is often an appreciable thickening and tension in the tissues imme- diately over and around it. Pain is present in some instances, while in others even direct and strong pressure causes little or no disturbance. When the nearest gland or plexus is reached by the inflammatory pro- cess, by pressure upon these a sharj) sense of jjain is experienced. The febrile movement, wliich may ensue within twenty-four hoiirs, though usually not well marked at this early period, is generally introduced by a chill or a series of chilly sensations, characterized by pallor and the "picked-goose" roughness of the skin. The temperature rises rai)idly above the normal, and may reach a high degree. Nausea, vomiting, delirium, and the train of symptums wliich accompany septic;emia may follow ; but this is, fortunately, tlie exception. If the conditions are unfavorable to the progi'ess of the disease, the temperature declines gradu- ally, resolution occurs, and the symptoms of inflammation disappear in from one to two weeks. In the diagnosis of lympliangitis it is well to bear in mind that in pJilebitis the lines of red discoloration are wider than in the disease under consideration, that there is a more general condition of oedema, that the Lines of inflammation follow well-known and appreciable veins, that these veins are very painful to pressure, and that they are easily recognized as hard, semi-elastic, knotty cords. In erythema^ erysipelas, and dermatitis the discoloration is deep and diffuse, and the supeiiicial lymi^hangitis which exists can not be made out in the general staining. It is evident, however, in one unfailing symi)tom — adenitis in the glands in the direct route of the vessels. The treatment is local and general. Cold applications are preferable, if cold is agreeable to the patient. Employ the ice or cold-water bag, or cold cloths. Heat may be applied in a similar manner. The sense of comfort experienced is the only criterion in determining the employment of these agencies. The lead and ojiium wash is a valuable remedy. When an extremity is affected it should be kept in perfect repose and in an elevated position. If suppuration occurs, the pus should be evacu- ated. If cellulitis and great tension complicate the lymphangitis, make free parallel incisicms to obviate threatened strangulation. The consti- tutional remedies look to the regulation of the alimentary apparatus — quinia, iron, etc.,- and, above all, pure air and cheerful surroundings. Subacute and citron ic lymphangitis are associated with forms of gen- eral systemic infection, as in syphilis, which is typical of the subacute variety, and in "Hodgkin's disease" and the so-called scrofulous dys- crasia, which are chronic forms of this disease. 160 A TEXT-BOOK ON SURGERY. Adenitis, or inflammation of a lymphatic gland, usually exists with the disease just considered, or it may be independent of it. The pathological cJianges vary as the process is acute, finhacute, or chronic. In acute adenitis tlie cells of tlie reticulum and the leucocytes proliferate with great rapidity, resulting in pressure upon, and occlusion of, the periglandular blood-vessels, and consequent suppiu'ation. In the subacute and chronic forms the proliferation is confined cliietly to the connective- tissue cells of the reticulum, or net-work of the gland, causing an abnormal thickening of the stroma, and a diminution of the corpuscu- lar elements of the gland. Acute adenitis may result from a blow, from excessive muscular action, or, as above stated, it may follow an acute lymphangitis. The si/mptoms are a sense of soreness and tension, sharp throbbing pain, increased on slight pressure, swelling, and redness of the super- jacent skin. The suppuration commences in the center of the gland, and gradually extends until the tissues around are involved. The con- stitutional symptoms are similar to those given in lymphangitis. If the inflammatory process be of the subacute form, the enlargement is more gradual, and pain and the other symptoms of acute adenitis are absent. Examined microscopicallj", the tumor will be found to be composed of cellular elements, varying in size and conformation from that of the normal lymphatic corpuscle to the giant cell. Later in the history of this process fatty and caseous degenerations may occur, ending in resolu- tion or suppuration. In chronic adenitis the tumors are more solid and firmer to the touch, since the enlargement is due in greater part to the proliferation and hyperplasia of the connective-tissue stroma. In the treatment of acute adenitis perfect quiet must be enforced. Local applications are indicated as in lymphangitis. If suj^puration is evident, early incision is indicated. The process of repair is usually slow. Frequently one after another of the glands in a group breaks down in the process of suppuration, forming sinuses which undermine the neighbor- ing tissues, when it is necessary to lay each abscess open freely and scrape out every particle of diseased tissue with a Volkmann's spoon. Thus treated, the wound should be packed with sublimate gauze, and treated as an open wound throughout. Chronic enlargements of the lymphatic glands require chiefly consti- tutional treatment. Local measures may be deemed advisable, in order to protect the part from pressure. Plasters of mercury, belladonna, or galbanum, are among the most useful remedies of this kind. The jilaster may be changed at intervals of two or three days. Painting with tincture of iodine is painful, and of doubtful benefit. Among constitutional reme- dies the protoiodide of mercury, combined with tonics and proper ali- mentation, will in general prove most satisfactory. Wonnds of the lymphatic vessels may occur in common with solutions of continuity in other tissues. The escape of lym]ih, and occlusion of the vessels involved, back to the first collateral branch, is the rule, as with the blood-vessels. If the vessel be large, as when the deeper channels of the leg or the thoracic duct is divided, the ligature or compression of the PHLEBITIS. 161 distal end is necessary to prevent a lympli fistula. It has been demon- strated that tlie lymph and chyle can be carried into the circulation by collateral routes, after occlusion even of the thoracic duct. Varicosities occur at times in the lymphatic vessels, as in the veins. The causes and treatment are essentially the same. As a result of ob- struction, in some instances, cystic dilatations occur, which, according to Bellamy,* are usually found in the tongue, lips, and about the neck. Hydromata of the neck are at times congenital. In their structure they are trabeculated, the caverns filled with lymph. The location is beneath the occiput, and the tumor is sjnnmetrical, the cyst of each side of the median line being lined with lymphatic endothelia. New formations (lymphomata) of lymphatic vessels occur occasionally, and blood-vessels developing in these give rise to a mixed new gi'owth, known as lympho-angeioma. Phlebitis, t Definition and Morbid Anatomy. — PhleMtls means an inflamma- tion of all the tissues which enter into the formation of the walls of a vein. Endophlebitis, mesojyMebitis, and periphlebitis are terms used to designate the inflammatory process involving respectively the internal, middle, and external layers of the venous wall. The progress of inflammation in the tissues of veins is closely analo- gous to that of the same process in all other structures, namely, inita- tion, hyperemia, tumefaction, infiltration of the extra-vascular spaces with emigi-ant, embryonic, and i)us cells ; the proce.ss terminating in cicatrization (often with adhesions), calcareous degeneration, suppuration, or gangrene. The mode of termination will depend upon the severity of the attack, the character of the lesion, and the power of resistance and recuperation existing in the tissues. The inflammatory process involves a tubular structure, the waUs of which are composed of an inner layer {iritimax made np of flat, polygonal cells (the endothelia), a middle layer chiefly made up of elastic tissue, and an outer layer, containing elastic loops, connective tissue, and unstriped muscle. Blood-vessels and nerves traverse the outer and middle tunics, following the bundles of connective tissue. The cells of the lining membrane are smaller than the arterial endo- thelia, and are imbedded in a fil)rillated, intercellular substance (Cornil and Ranvier). The elastic and muscular tissues are less developed than in the arteries (Heitzmann). Tliese are so irregularly arranged that any division into middle and external coats is, in great part, artificial and imaginary. Moreover, many of the veins contain no muscular tissue, * ■' Encydopicrlia of Surgery," vol. iii, p. 34, Aslilnirst. William Wood & Co., 1883. t That portion of this chapter between pages IGl and 198 is taken from my article in the " International EncyclopiBdia of Snrgery," edited by Prof. John Ashhurst, Jr., .M. D. ; pub- lished by Messrs. William Wood & Co., of Xew York city, for whoso kind permission to intro- duce it in this book in its original form the author begs to make his sincere acknowledgment. 11 162 A TEXT-BOOK ON SURGERY. while their connective tissue varies in (|uantity in different jKirts of tlic body. Tlie sinuses of tlie dura mater, the veins in bones, and those of the retina, have no muscular libers, wliile tlie juii;ulars, subclavians, and venae cavjc have a relatively small quantity, or are entirely devoid of this tissue. Af^aiu, the arrangement of tlie muscular tissue differs in different veins. The inferior vena cava and the portal and renal veins have an inner, circular, and an external, longitudinal layer, while the femoral and popliteal veins have the longitudinal libers more internal. This tissue is still more complicat(Ml in the saphenous veins, where the internal layers are arranged longitudinally, with a numlKT of alternating, or transverse and longitudinal, layers placed externally to these. The elastic layer begins immediately external to the basement sub- stance which su])ports the endothelial layer, and is here somewhat iso- lated and well defined ; but from the external surface of this central, elastic lamina springs a net-work of elastic fibers, through the loops and in the meshes of which are woven the muscular and connective-tissue fibers. The vasa vasorum follow the connective-tissue bundles in their distri- bution to the tissues of the wall down to the elastic layer. Nerves from the sympathetic system have been demonstrated in the larger veins. The valves are delicate reduplications of the internal coat, having a well-defined, elastic reticulum, especially on their distal or convex sur- face (Heitzmann), and muscular fibers at the point of attachment to the venous wall. The vascular area — the outer and middle layers — is first concerned in the infiammatory process. The endothelial tunic, as a result of these structural changes, is subsequently involved in the process. It then appears cloudy, thickened, and rough, and may become separated in shreds. (Prey.) In the vascular area, during the earlier stages, the capillaries of the vasa vasorum become swollen, the white corpuscles migrate into the extra-vascular spaces, and the normal connective-tissue (^ells are stimu- lated into rapid proliferation, resulting in a thickening of the wall, due to the presence of these embryonic cells, and the excessive hyperamda. As in arteritis, the vitality of the endothelial tunic becomes impaired, and it is more or less projected into the cavity of the vein, the endothelia undergoing rapid |)roliferation. After a few days, granulation-buds push out from this eml)iyonic tissue of the endothelia, and new capillaries are developed in the granulation - masses, anastomosing and becominjj a part of the circulation of the vasa vasorum, as well as leading into the coagulum which occupies the caliber of the vein. At the point of contact of the outer surface of the thickened endo- thelial layer with the internal surface of the middle (elastic) layer, large sinuses are developed, which receive the blood from the capillaries of the middle tunic. These sinuses are lined with an endothelial layer, which rests uj^on the contiguous connective tissue. From these large vessels fine capillaries are given off, which permeate the thickened internal layer, and some of which pass into the organizing coagulum. PHLEBITIS. 1(53 When a thrombus, caused by the sudden coagulation of the blood in a vein, is examined in its recent state, it is found to be composed of suc- cessive laminae of fibrin and corpuscles, and the more recent ol these lamina? are external. Wlien the vein is first occluded l)y this sudden coagulation of the blood, the pressure from behind is so great that the coagulum is compressed toward its center, while the current, more and more impeded in its progress, flows between the periphery of the clot and the inner surface of the vessel, adding, layer by layer, fresh deposits of coagulation upon the thrombus. A microscopical examination of such thrombi reveals a vast number of white corjauscles in various stages of fatty degeneration, with layers of fibrin intervening. Exi^eriments have shown that not only does the inflammatory pi'ocess, by reason of its invasion of the intima, produce changes in the blood which lead to stasis, but that thei'e is also a dangerous endosmosis of septic matter, which is swept along toward the heart and lodged in the capillaries of the various organs {emboli), producing infarctions, abscesses, and, almost invariably, irreparable damage. The adhesion of the intima, and the formation of a fibrinous clot — which may completely occlude the vessel {occlusion tJirombus), or may merely plaster over the endothelial tunic {peripheral thronibus) — are efforts toward prevention of this endos- mosis. The process of repair in tissues capable of successful resistance, i:i venous inflammation, is one of organization of the embryonic cells, fibril- lation, and contraction, resulting in partial or complete occlusion. In tissues of low and impaired vitality, the progress of the inflammation is rapidly toAvard suppuration, usually terminating in septic fever and death. Microscopical sections from such specimens of phlebitis show that the leucocytes and embryonic cells have undergone retrogressive changes, and that the tissues are infiltrated with pus corpuscles. Gan- grenous sjjots are not infrequent, often opening into the caliber of the vessel, and allowing the influx of septic jiroducts, or the efflnx of blood. Since phlebitis is a frequent cause of thrombosis, and since venous thrombosis is the most frequent form of intra-vascular coagulation, a consideration of the pathogeny and pathology of this process must natu- rally find a place here. Virchow has endeavored to show that primitive lihlebitis is extremely rare, and that, when a clot is produced in a vein which is inflamed, the coagulation has more often preceded than followed the inflammation. Cornil and Ranvier, from whom the above account is taken, do not accept this theory. Fibrin, the immediate factor in coagulation of the blood, does not exist as such in the normal condition of this fluid. Under healthful con- ditions, the blood would circulate always without any deposit of fibrillated fibrin in the economy. Accoi'ding to Denis, the normal plasma of the blood can be separated into a semi-solid substance, 2^l(fsmi/ie, and a liquid, serine. Plasmine is further separable into fibrin and metalbiimen, and it is held that the coagulation of the blood is due to the conversion of plasmine into fibrin. Foster holds that coagulation is the result of the interaction of two bodies, paraglobulin and fibrinogen, brought about 164 A TEXT-BOOK OX SURGERY. by the agency of a third body, fibrin -ferment. A. Schmidt has carried experimentation further, and is led to believe that paraglobulin and fibrin- ferment lioth originate in the white blood-corpuscles. This tlieory is exceedingly seductive, and it can not be denied that actual pathology proves that around and within inflammatory areas where white blood- corpuscles are most abundant, coagulation and fibrillation are more apt to occur, and a study of thrombi, which have been gradually formed, reveals alternating layers of white corpuscles and fibrillated fibrin. (Green.) What may be the principle in the blood which is the factor of coagula- tion, or what reaction it may be which ])recipitates the fibrin, we can not in the present conditon of science jiositively assert. The facts, however, "point to the conclusion that when blood is contained in healthy, living blood-vessels, a certain relation or equilibrium exists between the blood and the containing vessels, of such a nature that, as long as this equilibrium is maintained, the blood remains fluid ; but when this equilil)rium is disturbed by events in the blood or blood-vessels (or by the removal of the blood), it undergoes changes which result in coagu- lation." (Foster.) So delicate is the sensibility of the blood to mechanical irritation or hindrance in its flow, that the slightest injury or roughening of the endothelial lining membrane may produce a deposit of fibrillated fibrin. A delicate needle, or wire, or thread, thrust into the lumen of a healthy vessel, precipitates coagulation upon the foreign body. The white cor- puscles are found clustered in great numbers on the foreign body, and, when the mass is examined with the microscope, the corpuscles seem to serve as starting-points for the development of fibrin. (Reichert.) Causes and Clinical History of Phlebitis. — Phlebitis has been termed traumatic and idiopathic, and the latter term has been applied indiscriminately to all forms of phlebitis not directly due to an appre- ciable lesion. Idiopathic ijldebitis is comparatively a rare affection (Yirchow). It may occur without a traumatism, as from exposure to cold, or as a sequel to fevers and varicosities (Hamilton). It may occur as a complication of syphilis (Hutchinson), or as a result of the gouty diathesis (Paget). From whatever cause it may proceed, idiopathic phlebitis usually affects the veins of the lower extremities. Traumatic phlebitis may be caused by a partial or complete solution of continuity of the venous walls, by contiguity of inflamed tissues, or by violent muscular action and pressure. The inflammation of the uterine sinuses during and after parturition, which Cornil and Ranvier style "la phlebite spontanee," is really a fomi of traumatic phlebitis, due to the irritation resulting from pressure and muscular action. Phlebitis has been described as acute and chronic (Gross) ; adhesive and suppurative (Bryant) ; gouty and diffuse (Hamilton). These terms but express varying conditions of one pathological process, and whether this inflammatory process shall result in adhesion or suppuration, shall become diffused, or shall assume a chronic form, will depend solely upon PHLEBITIS. • 165 the character and cause of the disease, and upon the capacity of the tissues to resist its progress. 1. Idiopathic Phlebitis. 1. ^yphiUUc PJdeMtis. — Mr. IIutchinsf)n lias called attention to the very few cases of syphilitic phlebitis which have been recorded, and yet he says that most surgeons are familiar with the fact that inflammations around varices, and even about otherwise healthy veins, are not infrequent in syphilitic subjects.* Mr. Hutchin- son further says: "1 think also that I have seen several cases in which the thrombosis and phlebitis were attended by other conditions sufficiently peculiar to justify a belief that they were of specific origin. In some there has been great excess of infiammation, a large hard mass forming in the cellular tissue, and threatening to slough, much as subcutaneous gummata often do. These cases are much benefited by the iodide of po- tassium, so far as jirevention of -sloughing is concerned, but the thrombotic plugging remains." f 2. Gouty Phlebitis. — Subjects (says Mr. Bryant) who are gouty from hereditary or acquired causes are liable to phlebitis. Paget has described the affection in his "Clmical Lectures," and Mr. Gay has written upon it. In such cases the phlebitis may have no intrinsic characters l\v which to distinguish it, yet not rarely it has peculiar marks, espeoiallj- in its cymmetry, apparent metastases, and frequent recurrences. Like other forms, it is more common in the lower than in the upper extremities, yet it may be found anywhere. It affects the superficial rather than the deep veins, and often occurs in patches, affecting on one day, for example, a short x>iece of the saphenous vein, and the next another portion of the same vein, some other distant vein, or a corresponding piece of the oppo- site vein. The inflamed portions of the vein usually feel hard and are painful to the touch. The soft parts covering the vein become slightly thickened, and often have a dusky, reddish tint. When the deej) veins are involved, oedema appears, with the well-recognized results of obstruction : the limb becomes big, clumsy, featureless, heavy, and stiff ; its skin is cool, and may be pale, but more often has a slightlj' livid tint, which may be recog- nized by comparison with the other limb ; and it has mottlings from small cutaneous veins, visibly distended. The limb, thus enlarged, feels oedematous throughout, but firm and tight-skinned, not yielding easily to pressure, and not pitting very deeply. The constitutional symptoms associated with this affection vary from some slight febrile condition to those met with in acute gout. Comjjlete recovery may take place in this as in other forms of phlebitis, the veins becoming pervious in some cases and obstructed in others. The risks of embolism are also the same. (Bryant.) 3. Acute Idiopathic PTtlebitis (not gouty or syphilitic). — This form of venous inflammation — caused, as has been said, by exposure to cold, due to the presence of a varicosity, or coming in the course of a severe febrile attack — may involve one or more veins. The disease travels along * J. II. C. Sillies aod J. Williuui White, in Coruil on Syphilis. t Ibid. 166 A TEXT-BOOK ON SURGERY. the vessels in the direction oi' the heart. The veins become swollen, and are hard to the touch, resembling the normal veins when the return cir- culation is momentarily arrested, though more cord-like in h^el and less elastic. Their course can be traced by the dull-red color of tlie skin immediately over the diseased vessels. Pain is generally constant, and is rendered more acute by pressnre. The o'dema oi the ])arts on the distal side of the lesion is commensurate with the obstruction to the return circulation caused by the inflammatory process. The febrile movement varies with the violence of the attack, the rai)idity of its l)rogress, the intensity of the inflammation, and the cajjacity of the tissues to resist invasion. In the severe forms, the clinical history is similar to that of traumatic phlebitis, which will l)e fully desc-ribed hereafter. Idiopathic phlebitis is not as dangerous to life as the trau- matic variety. It may run a short course, and the patient recover promptly, or it may assume a subacute or chronic form, and remain indefinitely. II. Traumatic Phlebitis. — When a vein is injured, inflammation will result, if the vessel is penetrated to its cavity, or suffers a solution of continuity in any portion of its wall. Examples of traumatic phlebitis, resulting in thrombosis and occlusion of the popliteal vein, are known to have been caused by prolonged forced flexion of the leg on the thigh. The simplest form of traumatic phlebitis is that resulting from the opera- tion of venesection. No matter what may be the character of the trau- matism, the pathological process is the same. The mode of termination of this process will depend upon the extent and severity of the lesion, and upon the recuperative powers of the tissues involved. Traumatic phlebitis extends from the original lesion along the vessels in the direction of the heart. In the deeper veins it is with difficulty recognized in the earlier stages. The course of the inflammation is marked by a dull, coppery-red staining. Pain is invariably present, and upon pressure is acute. In severe cases the tumefaction spreads from the vessels to the suiTounding tissues. Oedema of the parts on the distal side of the lesion will occur in a degree commensurate with the interference with the return circulation. The febrile movement is that of septic fever: chills or rigors, flushes of heat ending in cold and exhausting sweats, sleeplessness, hectic, anxious ex]iression, and often the "pyjemic breath." The rectal temperature is variable and high ; the pulse is thready and rapid, reaching in some instances 160. Sudden and dangerous symptoms may arise in the course of the disease, when particles from the venous thrombi are carried tcjward the heart. These usually lodge in the lungs, giving I'ise to sudden pul- monary complications, the result of infarction. The liver, in phlebitis of the veins which go into the portal circulation, is frequently the seat of embolic abscess. Hfemorrhage from perforation of the venous wall, by iilceration or gangrene, is another source of danger in severe cases of phlebitis. Treatment of Phlebitis. — Positive and complete rest is the first great essential in the treatment of phlebitis. Manipulation or movement is dangerous, since interference wiU not only exaggerate the inflammatory ARTERITIS. 167 process, but may possibly cause the separation of thrombi and produce infinite harm in remote organs. If the disease should assume the sup- })arative form, the inflammation being diffuse and the oedema severe, free incisions parallel to the veins should be made in order to secure drainage. A wet dressing should be applied, and the wounds frequently u-rigated with 1 to 10,000 siiblioiate solution until the more urgent sjnnptonis have disappeared. Quinia is indicated, not only on account of its well-known tonic and antifebrile properties — although not strictly antiseptic in its action, the bacteria of septic fluids resisting its action to a great extent (Bartholow) — but because it exercises an inhibitory influence upon the emigrant corpuscles (Binz), important factors, as Conheim has shown, in the inflammatory process. The use of iron, careful feeding, and a free supply of pure air, will complete the constitutional treatment. If an extremity is involved it should be slightly elevated to favor the return circulation. Arteritis. Arteritis is a term applied to an inflammatory process which involves the entire thickness of the arterial wall. AVhen the inflammatory change is confined to the inner coat, or intima, it is designated as endarteritis ; when to the outer coat, or adventitia, as periarteritis ; and v.hen to the middle coat, or media, as mesarteritis. Endarteritis, which does not rapidly disappear soon after its inception, is apt to result in lesions of the media and adventitia, and in like man- ner a lesion of the external tunic will in all probability involve, by the extension of the morbid process, the other coats. There are, however, certain well-defined, circumscribed lesions of the separate tunics. Endarteritis is, as an isolated lesion, capable of demon- straticm. We shall see that a supei-ficial inflammation of the endothelia, with its resultant fatty degeneration, is not infrequent. Again, mesar- teritis exists as a primary and separate inflammation, for primary calci- fication (denied by some pathologists), which is strictly a disease of the tunica media, precipitates an inflammation in this middle tunic. And since atheroma and other arterial lesions are due to interference with the blood-supply through the vasa vasorum, or to defect in the quality of the blood distributed to the adventitia through which the vessels ramify, we must recognize a periarteritis as the initial stage of this lesion. Inflammation may be established in any or all parts of the arterial system. One form of arteritis will involve the larger trunks, while another will pass these without molestation, and establish itseK in the distant arterioles. Simple endarteritis is most apt to occur in the aorta and arteries of the second magnitude, while sy|ihilitic arteritis, the most marked feature of which is an endarteritis, rarely attacks the larger trunks, chiefly confining itself to the more or less complete occlusion of the small and smallest arteries. The internal coat of the lai'ger arteries is composed of two parts : 1. An endothelial lining membrane, consisting of a single layer of flat, po- 168 A TEXT-BOOK ON SURGERY. lygonal, nucleated cells, sliyhtiy elongated in the axis uf the vessel ; ia edge view, these cells appear si)indle-shaped, on account of the elevation of the nucleus at its center Uleif'^niann) ; 2. A suliendothelial layer of flattened, nucleated, anastomosing cells resting in a Jibrillated basement substance, the direction of the fibrilho being generally i)arullel with the long axis of the artery (Cornil and Ranvier). In the sm^aller arteries this layer is exceedingly fine, while in the aorta it is comparatively thick, being composed of two distinct layers. Here the internal of these two layers is longitudinal, the external transverse in direction. The middle coat in the larger arteries, such as the aorta and carotids, is composed of elastic laniinjie and of libers, forming by their anastomoses a continuous system, and holding in the meshes of their loops the muscular tissue, transverse in its direction, and a relatively small amount of connective tissue (Cornil and Ranvier). According to C. ToMt, the niiiscle-libers of the middle coat are wanting in the initial portion of the aorta, in the pul- monary artery, and in the arterioles of the retina. In the descending aorta, the common iliac, and the jjopliteal, small bundles in an oblique or longitudinal direction are interspersed between the circular ones, and in other arteries, such as the renal and spermatic, at the inner boundary of the muscular coat, scanty longitudinal bundles occur, which by some are considered to belong to the inner coat. At times, in the correspond- ing arteries of different pei'sons, differences are observed in the distribu- tion of the muscles of the middle coat (Heitzmann). On the side nearest the inner coat the middle tunic is limited by a denser and more defined elastic lamina, which shows, however, on transverse section, a festooned appearance — very important in the study of the pathology of arteritis — and is named the internal layer of the elastic coat. Upon the side of the tunica media nearest the external coat the elastic fibers pass outward, interlacing, freely with the connective tissue of the adventitia. In the femoral, brachial, and other arteries of middle size, the middle coat pos- sesses only one layer, namely, the internal elastic. The muscular fibers are transverse in direction, and form themselves into flattened bundles, separated by connective-tissue bundles and by elastic fibrillar, which are continuous on the one hand with the inner, elastic layer, and on the other with the elastic net-work interwoven with the adventitia. There are no vessels in the middle and internal coats. In the external coat are found arteries, capillaries, vein.s, lymphatics, and nerves. The small arteries have a middle coat, formed of involuntary muscle- cells, so interwoven that they forai a continuous membrane (Cornil and Ranvier). C. Heitzmann * describes this layer as seemingly twined round the artery. The adventitia here is composed of small bundles of con- nective tissue, arranged in the main in a longitudinal direction. Pathogeny of Arteritis. — The causes of arteritis are numerous. The most frequently recognized form is that resulting from injury, and known as traumatic arteritis. The pathogeny of the non-traumatic {idiopathic) arteritis embraces every form of dysci-asia. It follows in the train of * "Microscopical Morphology of the Auimal Botly in Health and Disease," New York, 1883. ARTERITIS. 169 syphilis, rheiimatism, gout, alcoholism, and nephritis with great regu- larity, and may occur as a residt of any morbid process which poisons the blood or impairs its nutritive qualities. These varieties will be con- sidered under special headings. The sequelse of arteritis, as far as the arteries are conceraed, may be fatty infiltration and degeneration, atheroma, secondary calcification, occlusion, dilatation, aneurism, suppuration, ulceration, and rupture. Remotely, partial or complete loss of function of the organs beyond the lesion, and partial or general necrosis or necrobiosis. I shall consider arteritis under two great heads, traumatic and 1 ton-traumatic, subdivid- ing these as their pathogeny or pathology may justify in the considera- tion of each separate type. I. Trau.matic Arteritis. — Arteritis may result from violence, either from without or from within. External violence will produce an inflam- mation of all the tunics of an artery, in the majority of cases, while vio- lence from within is more apt to cause an endarteritis. Arteritis from external causes is never an uncomplicated injury. The perivascular tissue is of necessity involved in the inflammatoiy process. In the arte- ritis resulting from deligation of an artery, from the forcible comjiression of a vessel, as in bending the knee, from the pressure of a tumor, or from a blow in the track of the artery, there is always an accomj)anpng inifam- mation of tlie surrounding, injured tissues. The i^athology of traumatic arteritis doe.s-not differ greatly from the in- flammatory process which occurs in other vascular tissues. Immediately fol- lowing the injury there is a marked increase in the vascularity of the adven- titia. The vasa vasorum become swollen, the white blood-corpuscles crowd in- to the capillaries, and pass into the extra - vascular spaces, while a rapid pro- liferation of the normal ceU-elements of the arte- rial tunics takes place. The connective-tissue cells of theadventitia, the white coiiiuscles, and the flat and polar cells of the in- tima, all take part in the morbid process. The walls of the vessel become ab- normally thickened, while, owing to the projection in- wai"d of the intinia, the Fig. 247. — Traumatic arteritis. Tiansvei-se section of the carotid artcrj' ofa dog, fifteen days alter lijiuture : 4, granulation buds formed from iirojoction of the intiraa. In the center of the figure one of these buds has been completely cut across; ot, portion of the media modified by the mfljunmatory process ; <". adventitia; (' I', vessels cut acrosSj one of which is newlv formed in the intima. Magnified 15 diameters. ^ After Cornll and Kanvier.) 170 A TEXT-BOOK ON SURGERY. N r.:^- ^•T^' '"/.'ii'i' iiijiiiy, the encroachment upou tlie caliber of the vessel will be more rapid, for, - -"-■ -"^"^-'---^ in addition to the mass of embryonic tissue l)us]iin,n of the internal coat of the aorta. Minute yellowish-white patches scattered over the lining membrane of the vessel. A very thin layer peeled off and magnified '200 diameters, showing fat molecules and the distribution of fat in the intinja. (From Green.) If we examine the intima of an artery which has been the seat of recent endarteritis, it will be seen to be swollen, and thicker and softer than in healthy vessels. The swelling is not usually general and con- tinuous, but occurs in patches or hillocks of quite regular contour, which project into the lumen of the vessel. The intima is usually injected, and reddish in color, though, according to Cornil and Eanvier, when the in- flammation has been of a very severe type, the swollen intima is paler than normal. If the inflammation be of recent origin, these patches will present an unbroken surface ; but if softening has occurred, the centers of the elevations break dowTi, resulting in erosions or ulcers, as they have been styled by some pathologists. Green says that they are due to soft- ening of the intercellular substance, and that the cells and granular matter, becoming loose from this softening, are washed out by the blood- current. These erosions resemble considerably the supei-flcial erosions found often in the mucous membrane of the stomach. At times they are covered over with a layer of flbrin, which, upon close inspection, is found to be composed of one or more laminje of flbrillated flbrin, with corpus- cular elements entangled in or resting between them. Beneath the projecting intima is found a mass of inflammation-tissue, consisting of embryonic and lai'ge anastomosing ceils resembling the normal connective-tissue cells of the most external structure of the intima. Hyperplasia of the noi-mal cell-elements is more marked as we approach the inner layers of cells of which the intima is composed, the prolifera- tion growing gradually less extensive as the elastic lamina is neared. This condition is a feature of acute endarteritis, and differs both from the inflammation of the atheromatous process and from syi)hilitic endar- teritis. This mass of new-formed embryonic tissue is. in all probability, the immediate result of proliferation of the normal ceU-elements of the intima. ARTERITIS. 173 Emigrant corpuscles could only reach this location by traversing the media, for as yet the capillaries have not been projected into the inner tunic. Xor is it probable that leucocytes, from the blood-current within the artery involved, migrate through the endothelia into the proliferat- ing mass. The adventitia does not long remain undisturbed by the pathological changes which have occurred in the intima. It takes on an inflammatory process in a varying degree, and this tunic is found thickened from the proliferation of its connective-tissue cells. If the process be obstinate and persistent, a true arteritis is developed, and all the jxithological con- ditions which have been described on a previous page may be present. The media is not greatly altered in the early stages of endarteritis or periarteritis, though in calcification it is apt to be first attacked, as it is likewise in fatty infiltration and degeneration. Acute endarteritis may tenninate in recovery, leaving no peimanent trace of its having existed, or it may pass into a chronic inflammation, which usually ends in fatty de- generation. This degeneration begins in the endarteritis proper, and trav- els toward the media. The ap- pearances of an artery which has undergone this change are well shown in Fig. 252. Fatty degeneration, in its mi- croscopic appearances, resembles very much the atheroma which is, at times, found in the intima. It can, however, by gentle and care- ful scraping, be removed, reveal- ing the more or less normal tissues underneath, while in advanced atheroma, which involves the deeper structures first, no trace of the normal tissues can be dis- ^ll///^i'fi!llilliHili'!n * Fig. 252. — Arteritis with fatty dezeneration. Fiitty de- generation of the intenial coat of the arteries from a thin layer stripped from this membrane, a, Fat grauules In irre^TiIar patches over tlie surface. The granules have resulted from fatty deaeneration of the cells of the intima. ^', Fibrillated tissue. Mag- nified 200 diameters. (Comil and Kanvier.) covered. Chronic arteritis may follow an acute endarteritis, as has been indi- cated above, although the chronic arterial lesions, as a rule, begin with perir.rteritis or mesarteritis. II. 'N'ox-Traumatic ok Idiopathic Arteritis. — The inflammatory process in idiopathic arteritis dift'ers only in degree from that heretofore described as occurring in traumatic arteritis. When not due to syphilis, gout, rheumatism, ne]ihritis, or some dyscrasia, it is tisually a part of an inflammation of the tissues immediately surrounding an arten'. The process commences in the adventitia, and is analogous to that of trau- matic arteritis. Attieroma and Calcification. — One of the frequent and most .'serious terminations of chronic arteritis, no matter what may have produced the 174 A TEXT-BOOK ON SURGERY. arterial lesion, is the condition known as atheromatous degeneration (Fig. 253). It is essentially a disease of malnutrition. It is a senile change, not of necessity co-existcut with anotiier disease. It is, as will be proved hereafter, prone to attack the arteries, especially those of the brain, in ^niiiiiio vcaacio^jaosiuf; Lii- iiitima; c c, media; d, adventitia; bb, calcareous patches. TPptlv tn tViP intimn T.r\as Llnar arterv. Magnified about 60 diameters. (Kromaspeci- tei uv lO I lie mrima. IjOSS ^^^ prepared by Dr. W. L. WardweU.) of the elastic tunic is one of the immediate causes of spontaneous aneurism (Cornil and Ranvier). 17(3 A TEXT-BOOK ON SURGERY. This condition of atropliy of tlie elastic lamina is well shown in Fig. 2o4, which was drawn from one of my specimens. Calcification of arteries has been especially studied by Dr. W. L. ^Vard\vell, of New York city, in Conhoim's Laboratory. His experience includes examinations made from twenty-five cases at the request of Cdnheini, who as- sents to his conclusions. Dr. Wardwell says all authorities recognize a inorbid change in the arteries known as calcifi- catiDn, and the majority look upon it as a change second- ary to atheroma or endarte- ritis. Few of these recognize a primary calcification not dependent upon a preceding infiaramation. This condi- tion is, however, the chief ^ilF change in the senile calcifi- FiG. 255. — Arteritis u'itii ]»rimarv caleification. i^ectinn from human radial artery, showing at c primary calciiieation of the media, c. a, the intima comparatively unchanged. (Drawn from specimens prepared by Dr. \V. L. Ward- well, at Conheim's Laboratory. Magnified about 350 diameters. ) cation of arteries. The mi- croscopic appearances of pri- mary calcification are well shown in Fig. 235. Conheim states that in senile arterial calcification sometimes the media, sometimes the interna (its outermost layer), is affected, and that in them the lime salts are deposited. Moreover, that this deposit of liuie takes place here because these tunics have been sub- jected to the greatest strain. AVeigert * describes a " hitherto undescribei " process known as co- acixdaUon. necrosis. Beginning with the theory of Schmidt concern- ing the coagulation of the blood, in which the white corpiiscles play the leading part, he argues that all tissues have the power of sj^ontaneously coagulating, it being necessary for such an occurrence that the cells should die, give up their ferment and fibrino-plastic material, and then becf)me saturated with a fibrinogen-holding lymph. This morliid process he holds may occur in tissues the most diverse in character, as in cheesy glands, infarcts of the spleen or kidneys, tumors, the inflammatory ma- terial around parasites, tubercle, etc. Macroscopically, these coagulated spots have a peculiar, stiff appearance, and, microscopically, they are recognized by the fact that the cell nuclei have disappeared, and can not be made to appear by reagents or by the material used for staining in microscopical examination. Following the line of research indicated by Conheim and Weigert, it may be concluded : 1. That in the arteries of middle-aged or old persons * Virchow's "Archiv," Bd. l.";xix, S. 87. ARTERITIS. 177 Fig. 256. — Arterites witli eoagulation-necrosis. Section fiora liuiaan artery treated witli acetic acid, showing at d spots of coacrulation-necrosis which contained calcareous salts before being trea'ed with the acid ; a, intinia ; b, media ; c, adventitia. (Drawn from specimen prepared by Dr. W. L. Wardwell. ilaguiticd about 40 diameters.) there are often found spots of diseased tissiie which present all the ap- l)earances of having undergone a '^ coar/ulation necrosis.'''' 2. That in these spots there is a tendency to the deposition of lime salts. 3. That in primary calcification the media is always first affected, the intima and adventitia only secondarily and by contiguity. 4. That this change is in- dependent of a preceding in- ilammation. 5. That, on the contrary, these calcitied spots act as foreign bodies, setting up a secondary inflammation in theii- vicinity, and leading sometimes to thickening of the intima. C). That one of the changes in atheroma of the arteries is coagulation-necrosis, that lime salts are often deposited in siach necrotic spots, that the position of such spots is in the intima instead of the media, viz., in the newly formed inflammatory tissue. 7. That primary calcihcation attacks the small arteries rather than the larger, and especially those portions of the arteries which are subject- ed to the greatest strain.* These conditions are shown in Figs. 256 and 237. Sy2)hilitic Arteritis. — Arteritis is a part of the pathology of syjihilis. The first danger to life in this disease comes from the changes in the ca- pacity of the arteries. No part of the arterial system is exempt, though the most serious lesions are found in the vessels of the brain, and next in the aorta. They become grave in the larger trunks R o^- D . ■ .u- , -. o ■ u • , .■ on account of the athero- riG. a5i. — rostcnor tibial artery. Section showing coagulation-ne- crosis. A, intima; b, media; c. adventitia; », spot of eoagu- ma resulting from the lation- necrosis. Magnitiod 300 diameters. (From a specimen -,.... \ /• -i preparedby Dr. W.L. Wardwell.) SyplulltlC pOlSOn (induc- * For tbese conclusions the author is iudebted to Dr. W. L. Wardwell. 13 178 A TEXT-BOOK ON SURGERY. iiig iim-iirism), and in the smaller arteries (especially those of the braiu) from occlusion or atheroma. Even in the initial lesion of syphilis (the chancre), accord in'j; to Biesiade(d\.i, the capillaries of the papilhe have in their thickened walls many nuclei, some of which are seen to project into the lumen of the vessel. The arteries of the baae of the brain, especial)}' the basilar and those at the commencement of the fissure of Sylvius, are often seriously in- volved. I have seen two cases in private practice in which death lesulted from anjemia of the medulla, due to a more or less complete thrombosis of the basilar artery. A jjatient of Dr. Weber's, to whom I was called, died in my jiresence. A few days previous to his death he had com- plained of dizziness, and of a sensation as of insects crawling over the integument of the extremities. Death was quite sudden, and was due to respiratory failure. He became quickly unconscious, the respiratory movements were irregular, and co-ordination of movement between the expiratory and inspiratory muscles was seemingly lost. The mode of death was different from anything I had ever witnessed. At the autopsy, the basilar, just where it divided into the two posterior cerebrals, was found almost completely occluded by a thrombus. There was no other lesion which could have accounted for death. Syphilis had existed for several years. In the second case syphilis had existed for nineteen years, with right hemiplegia for the last sixteen years of life. This patient was under my care for nearly five years. She would never consent to take the iodides or any medicine. Her mind was clear up to the time I last saw her before death, which occurred suddenly one night. I did not see her until life was extinct, l)ut, from the description of the mode of death given me by Dr. F. J. Ives, who was present, I was led to express the belief that a similar condition existed as in the case first referred to. On examination, I found a thrombosis of the basilar artery in exactly the same location. Fig. 258 repre- sents a section of the artery near the thrombus. The lumen of the vessel is seen to be about two thirds occluded. The adventitia is slightly thickened, and the cell-elements in it are distinctly fusiform, and regularly parallel with each other and with B — Fig 258. — Svpl)ilitic arteritis. Section of basilar; i;, lumen of ve.*sel about two tliirils filled witli new tbrmation at ab; c, media ; d, muscular layer and adventitia. From a patient dead i'rom syphilis. (Specimen of the author's, drawn by Dr. Wardwell. Magnified about 40 diameters.) ARTERITIS. 179 the contour of the adventitia. The wavy elastic layer is easily recognized, and in that portion of the artery in which the sypliilitic intiammatory material is deposited the waves of the media are more numerous and shorter than in other portions of the vessel. In the center of the mass, occupying a portion of the caliber of the artery, is found a hyaline-look- ing spot which took the carmine stain more readily than the general mass of the thrombus. It contains embryonic cells in about the same quantity as the surrounding tissue. The adventitia is not regularly thickened, being three or four times as deej:) in some portions as in others, and pre- senting in the section a nodulated appearance. Viewed with a magnify- ing power of about five hundred diameters, that portion of the arterial wall external to the wavy line (the elastic layer), seen in Fig. 258, presents the following appearance : In the most external limit of the section of the adventitia there are found clusters of iniiammatory corpuscles, true embryonic cells, round, and larger than the cells found in any other portion of the sj^eciraen external to the elastic lamina. These cells are somewhat smaller in size than those found in the new-formed tissue of the intima, though they differ in shape, since those in the intima appear both round and fusiform, while the cells in the outer edge of the externa apj^ear almost invariably round. It may be possible that they are fusiform cells cut transversely in thtt section ; though after careful examination I am led to conclude that they are round. At various points tliese cells do not exist, the external layer being that of fusiform cells arranged with great regularity parallel to the contour of the wall of the artery. AVhere the wall of the vessel external to the elastic lamina is thickest, these spindle cells are more numerous, and have a greater transverse diameter than at the narrower portions, where they seem to have elongated and become thinner — seem- ingly a true process of fibrillation and contraction of embryonic (inflam- matory) cells. Continuing the examination farther inward, as the white, wavy, elastic zone is crossed. Just within and almost in exact apposition with this is a somewhat irregular and thin layer of cells, fusiform in section, varying in de]ith from a single row to two or three rows, and in some points entirely absent. These are doubtless a remnant of the original endothelia of the intima ; just internal to these, and in fact continuous with them, is the great mass of new-formed, inflamma- tory tissue which juts into the lumen of the vessel. This mass is com- jiosed of large, mostlj^ fusiform, cells, distinctly nucleated and occupy- ing about as much space as the intercellular substance in which they are imbedded. Syphilitic arteritis has been made the subject of special study by Cornil, Heubner, Greenfield, Barlow, Buzzard, Davidson, Simes, White, and others. Greenfield, in the " Transactions of the London Pathological Society for 1877," gives an analysis of 22 cases of visceral syphilis. Of the 22 patients, 13 were females, 9 males. Their ages varied from 23 to 50 years. Of the females, 4 were between the ages of 23 and 25, 1 180 A TEXT-BOOK OX SURGERY. was 35, 1 was 38, the remainder between 40 and 50. Of the males, 4 were between 30 and 40, the rest between 40 and 50. These jiatients did not all die from syphilis, some perishing from f)ther and concoiuitant diseases. Of those who died from the effects of syphilis, the greater number were comparatively young. Of the four females under twenty-hve years of age, two died from the effects of thi-ombosis of the cerebral arteries, one from syphilitic disease of the larynx, and one from accident. Of the six males under forty, one died from sj^phi- litic disease of the cerebral arteries, one from gummata of the l)i:iiii and dura mater, one from pneumonia due to sj-philitic disease of the larynx and trachea, one' from renal disease consequent upon stricture, and another by accident. In the total of twenty-two cases, the condition of the vascular system was noted in aU but six. In one case there was no lesion of the arteries. In the remaining fifteen cases the arteries were more or less seriously involved. In other words, out of sixteen cases in which the condition of the arteries was noted, in fifteen these vessels were diseased. The author says that the condition of the aorta and large vessels, as regards atheroma, is of importance in connection with the dependence of aneurism upon syphilis, and that, as regards the smaller vessels, the nature of the disease of the cerebral arteries is of the greatest interest. In three females, aged twenty-three, twenty-five, and twenty-five, there was marked atheroma of the aorta. In one, the atheroma was general in the aorta and its larger branches, the condition being that of diffused, irregular swelling, with but little fatty degeneration. In one female, aged twenty-five, in the first part of the arch of the aorta were several patches, rounded, prominent in the center, and thicker than usual. On section these appeared homogeneous, and presented scarcely any fatty degeneration. Throughout the rest of the aorta there Avas geneiTil athe- roma, with no peculiar characters. In another female, aged thirty-five, there were large patches of endarteritis defonnans in the alxlominal aorta. In several other cases there was marked atheroma, and in most cases where there was no renal disease the patches were much raised, some- times almost hemispherical, at other times with sharply defined edges of gelatinous appearance and pearly luster ; and on section there was but little fatty degeneration or calcification. Whether in these cases the disease would have gone on to the forma- tion of aneurism, can not of course be decided ; but it is evident that a marked tendency to the occurrence of endarteritis deformans at an early age, and in an advanced degree, exists in visceral syphilis. The cerebral arteries were very markedly affected with syphilitic dis- ease in five cases, and in a sixth were probably diseased. As to the pathological changes which syphilitic arteritis causes, they are given by Dr. Greenfield in two cases of disease of the cerebral arteries. The specimens were taken from the middle cerebral and basilar arte- ries. They are typical, and probably represent two different stages of the process. In the first case the disease is seen in the earlier form, in which it consists almost entu-ely of a cell-growth which has as yet under- ARTERITIS. 181 gone but little organization. In the second case considerable changes liave occuiTed, and a large part of the new growth is converted into more or less fuUy developed connective tissue. In the specimen sketched in Fig. 2o9, the artery is seen to be somewhat irregular in shape, this being due to obliquity of the section. The lumen (a) is very small, but is clearly defined, rounded, and free from throml)us. The outer coat appears somewhat thickened, and is infiltrated in con- tinuity with the pia mater (/). The muscular coat (d) is distinctly seen at the upper and lower parts of the section, elsewhere being somewhat infiltrated, and not clearly separated from the adventitia. The fenestrated membrane is clearly seen at b, where it is indicated by the dark lines ; it could be clearly ti'aced, on altering the focus, all around the vessel, lying as usual immediately internal to the muscular layers, and separating them from the inner coat. It is to that part of the vessel lying between a and b (Fig. 2.-)9) that attention must be specially directed, the thickened inner coat constituting the essential feature and the peculiarly character- istic element of the morbid change. With a higher powei", the thicken- ing of the inner coat is seen to consist entirely of a cell-growth which closely resemldes granulation-tissue. In the deeper parts, nearest the fenestrated membrane, the cells appear to be flattened, running parallel with the elastic layer, growing, however, more irregular in disposition toward the center. No distinct transition-line can be discovered between this deeper layer and the central part, in which, however, the cells appear to be larger, often branching and more loosely ari-anged, with more numerous capillaries running among them. Many of the cells in the intermediate layer ap^jear to be rounded ; but it is not improbable that Flo. 259. — Sypliilitie iirterilis. Shows sec- tion of smiiU cerebral :irtiTy near a gum- ma, matrniSed 30 dianKtcrs. a, lumen of vessel; li, boundary of iiuier middle coats; c, thickened inner coat ; M:v::/:^'-''''' -'^ ,^l. e Fig. 261. — Syphilitic arteritis. Segment of the precedin? specimen, mafrnified 170 diameters, a, lumen of vessel: 6, fenestrated membrane; a, f, thickened i ' formed imperfect elastic lamina. (Alter Greenfield.) !rs. vessel: 6, fenestrated membrane; a, f, thickened intinia; att'ecrion are understood, its therapy is not difficult. Arterial T]iroinJ>osis and Entbolisiu, — Though not as fiequentasin phlebitis, throm- bosis and embolism often I'e- sult from arteritis. The pa- thology of thrombosis has been given in the section on phlebi- tis. The ])rocess in the arteries is closely analogous to that in the veins. The perfect type of throm- bosis from acute, traumatic arteritis, is found after the application of an occluding ligature around an artery. By reason of arrest of the blood-current and disturbance of the equi- librium normally existing between the blood and the containing vessels, coagulation takes place on the cardiac side of the ligature, extending back as a rule to the first collateral branch. Immediately following the injury to the vessel, the process of infiamniation — true arteritis — com- mences. The tension of the ligature to such a degree as to divide the rniiic nejMintis. Section trnm posterior tiltial artery o!' patient aead Irom lirij^lit's dis- ease, showing; at a L^reat tbiekeuing of the intiiiia. the result of eiironic endarteritis. The elastic lamina, i>, nnphanijed. The inuseular layer, b, slightly thicUened. r, alace of entrance. The needle is again introduced at the point from which it has just emerged, and is carried around the remainder of the tumor, and out at the tirst point of entrance. The base of the tumor is thus looped by a wire which can be tightened beneath the skin at will. Barwell uses a slot of vulcanized rubber, which he slides down upon the wire to tighten it around tlie tumor. If the growth be very large, he advises the needle to be brought out at frequent intervals. Dii'ect local compression has been tried by patient and expert sur- geons, Init has not met with success. Gosselin^ in his classical paper reports several successful cases in which he employed hypodermic injections of perchloride of iron into the mass. This idea was original with Broca, who applied the styptic ender- mically with success. Pitha, of Prague, and Schuh, following Broca, thus cured three cases (Gosselin). BergerJ rejiorts a case of cirsoid aneurism of the hand treated by this method. Yelpeau, Gherini, and Demarquay have jjerformed the same operation. In Demarquay's case, the radial anil ulnar arteries had been tied. The method of procedure is as follows : The tumor must be com- pressed, so that, while the circulation ceases, the growth remains full of blood. This condition must be maintained for at least ten minutes after the injection. The syringe being tilled, the air is carefully excluded, and the needle is introduced aboiit a quarter of an inch into the mass, when the solution is discharged. Kneading, to disseminate the fluid, is then practiced, and the finger is placed ui:)on the hole made by the needle, or the needle and syringe may be left in, during the ten minutes. Pain is immediately present, and persists for several hours. After an interval of ten or fifteen days, the operation may be repeated, if neces- sary. Eight or more operations have been required to effect a final cure. Ulceration may follow, but it is usually limited. At times, unhealthy granulations bud iip from these ulcerating patches, requiring repeated burning with nitrate of silver or with the actual cautery. * Holmes's "System of Surgery," seeoml edition, vol. iii, p. .j-tO. t " British Medical Journal,"' June, 1875, p. 835. X "Lancet," 1882. * See the author's "Essays in Surgical Anatomy and Surgery," New York, 1879. II " Medical Times and Gazette," August 21, 1875, p. 209. •»■ " Lancet," May 8, 1875, p. 642. (j "Archives gen. de medecine," torn, ii, 18G7, pp. G36-659. % " Gazette des btipitaus,'' 1882, p. 1082. 190 A TEXT-ROOK ON SURGERY. In one of Gosselin's cases, hEomorrliage was so frequent and persistent that deligation of the parent vessel — the femoral — was at one time con- sidered ; but this was happily avoided by repeated use of the actual cautery.* The results of this method of treating cirsoid vascular tumors are gratifying, and the operation is worthy of repetition. In growths of small size I should prefer to try the method of Barwell, and, if this failed, then the injection of perchloride of iron or other coagulating solution. The success achieved by Spence and Nelaton Avitli galvano-pnncture was such as to justify further trial of this method. Cases of spontaneous cure of vascular tumors are reported. Dr. Krackowizer presented to the New Yoi-k Pathological Society a patient in whom pulsation had entii'ely ceased in a cirsoid tumor which was contracted, solid, and shriveled at various points ; the peculiar rustling noise, also, of which the patient had complained, was now entirely absent when he was quiet. The man was forty-live years of age ; the tumor was congenital, and had grown to a considerable size, but without pain or liaMuorrhage. Dr. Krackowizer referred to two other cases re- corded by Oriila and Chevalier. * Gosselin's cases wore three in number: Case I. — Cirsoid Arterial Tumor of llie Left Leg. — Tlie patient was a woman, aged twenty- five. At birth slie had a small red stain or spot in the skin at tlie upper and anterior i)art of the left leg, which up to her twelfth year had grown about as large as an almond. At lifteen she first noticed that pulsation began in it. After this date it grew more rapidly, projecting, however, very sliglitly from the surface, until, at the ago of twenty-two, it began to ulcerate without any assignable cause. Hajmorrhage occurred, which ceased by compression, but not until syncope had ensued. Repeated bleedings occurred up to her twenty-fifth year, when the injections were commenced. From July 12th to August 23d, seven injections were made. Ulceration began, and frequent liaBinorrhages occurred between October 12th and 18th, which were arrested by the actual cautery .and compression. Cure resulted at the end of eleven months. Case II. — Cirsoid Arterial Tumor of the Foreliead with Arterial Varices; nmmorrhage during Many Years; Four Injections of Perchloride of Iron ; Cvre. — Patient was a man, aged thirty-nine; was born with a red mark on his forehead, which disappeared at his tenth year. About nineteen years later, when in Lis twenty-ninth year, a tumor was noticed in the same place, about as large as a cherry-stone, and two years later he felt it begin to ])ulsate. After that time it continued to grow, and was the source of frequent htemorrhages without any direct injury or known cause. The patient had controlled the bleeding by compression. At the time of oper.ntion, the growth was about two inches in diameter, and projected from the skin about one third of an inch. February 12th, while pressure was made on both primitive carotids, injections were made with two syringes, one needle being introduced on each side of the tumor. The compression of the carotids was continued ten minutes. The tumor still pulsated at points. Compress applied; pain was severe during the day of operation and the nest day following. Operation repeated on the 1st of March. March 1.3th, tumor was solid and without pulsation throughout two thirds of its extent. Two injections made. March 20th, tumor began to ulcerate at two limited i)oints, which were soon filled with exuberant granula- tions. These resisted alcoholic dressings and the application of nitrate of silver. March 24th, pulsation reappeared at one point, and the injection was repeated. M.ay 2nth, the granula- tions persisting, actuiil cautery was ai)plied. Same on June 6th. July 8th, patient discharged, cured. Case III does not differ materially from the two preceding cases, either as to its clinical history or as to its treatment. VASCULAR TUMORS. 191 Angeiomata. — The three next varieties of "vascular tumor," which may be grouped togetlier under the name of Angeiomata, are : (1) The Arterial Cutaneous Tninor, or Aneurism by Anastomosis, composed of dilatations or elongations of the arterioles, either nomial or new-fonned, in the skin ; (2) the Capillary Cutaneous Tumor, consisting of dilata- tions and elongations of the normal or new-formed capillaries of the skin ; and (3) the Venous Cutaneous Tumor [Cacernous JVoicus), composed of dilatations of the normal or new-formed venous radicles of the skin. The angeiomata are considered by some writers as strictly new-forma- tions of blood-vessels. There is little doubt, however, that many vascular tumors are chiefly made up of normal vessels which have undergone dilatation or hypertrophy. Other names that have been given to angeio- mata are congenital nsevus, erectile tumor, telangiectasis or plexiform augeioma, aneurism by anastomosis, ecchymoma, cavernous nsevus, and fungus hteniatodes. According to Depaul, one third of the children born in one of the eleemosynary institutions at Paris had congenital najvi, the greater number of which disappeared spontaneously during the first few months of life. They occur chiefly in the skin, and are especially apt to appear on the forehead, face, ears, and neck. Structure and Symptoms. — Angeiomata commonly form flattened, slightly projecting tumors, varying in size from a mere speck to as much as an inch in diameter, and are composed of new-formed, dilated, freely anastomosing capillaries, arterioles, and veins, in irregular, labyrinthine masses. They vary in color, being at times grayish-blue or red. Often the only indication of their presence is the appearance of a diffuse red- ness over a considerable surface. Examined microscopically, the walls of the vessels are crowded with cells, and the vessels are imbedded in a netwoi'k of fil)rous and adipose tissue. The superficial and deep cutane- ous vessels — including the vessels of the haii-follicles, sweat-glands, and adipose tissue — join in the formation of these tumors. The disease may extend into the muscles and deeper tissues. The majority of angeiomata are soft and yielding, and can be emptied by pressure ; but when of great vascularity and long standing, when there has l)een an extensive proliferation of the perivascular connective tissue, pressure will not cause their disappearance. Some are very painful, and others entirely free from sensibility. Venous cutaneous tumors are composed, in great part, of new- formed, erectile tissue, analogous to that found in the corpora cavernosa. Their structure is white and dense, the caverns communicating freely with each other. In rare instances they are known to contain chalky concretions, which are known as pliJeholites. The circulation is active in these tumors, and their volume variable. The walls of the sinuses contain a dense, fibrous stroma, involuntary muscular tissue, and striated muscular fibers when the tumor is encroach- ing on the muscles. They are lined by the same endothelium as the normal veins. In specimens removed and immediately immersed in alcohol, it is found that the blood presents the same appearances as the normal, with the exception that the white corpuscles are less numerous 192 A TEXT-BOOK ON SURGERY. (Fig. 2G7). They do not adhere to the walls of the vessels. This is con- sidered as proof of a rajjid circulation, since in veins where the ciirulation is weakened or retarded the leucocytes tend to adhere to the walls. After excision, the vessels contract, forcing out their contents, and the mass shrinks to a comparatively small size. These tumors are not all erectile, and some which have been erectile for a time lose this property. Gross describes a form of ngevoid tumor as ncvroid elrpJiaiifinsis, consisting of a hyi^ertrophied condition of the skin and subcutaneous connective tis- sue. The affection, which is either con- genital or comes (m soon after birth, is found usually in the lower extremities, though it may occur elsewhere. Fio. 2G7. — Caveruous angeioina of tlie liver. Suction made after the tumor liad been immediately submerged in alcohol, a, cavernous sjtaees filled with blood-cor- pu>cles ; /;, lihrou- walls of the sinuses. Jlairniliid l.i" diameters. (From Cor- nil and Kanvier.) The theories as to the origin of these neoplasms are various. Some hold that simple dilatation of contiguous veins oc- curs when, the sacculated vessels coming in contact, the walls are absorbed, and thus many cavities, which formerly were separate, may form one or more large, multilocular, cavernous tumors. These dilatations occur not only in the skin and subcutaneous tissues, but also in bone and muscle. No tissiie can be considered exempt. Eokitansky holds that they originate in the areolar tissue, from embryonic, new-formation tis- sue, and that the vascularization of this new tissue is one of the last processes of its develoi)ment. He compares the alveoli of the cavernous angeioma to those of carcinoma. Rindtleisch believes that the appearance of these tumoi-s is preceded by a proliferation of eml)ryonic material in the intervascular spaces, and that this material, undergoing the usual process of cicatrization and con- traction, causes a shrinkage in the intervascular arens, when the vessels dilate to occui)y the space left vacant by the contracting tissues (Billroth). Cornil and Ranvier say that in the active development of angeiomata there is a proliferation of embryonic tissue, rich in new-formed vessels, which, increasing rapidly in size, come in contact and communicate with each other by absorption of contiguous surfaces. Angeiomata may develop in fatty and other neoplasms. Billroth mentions a case in which a large cavernous angeioma was found in a lipoma removed from the scapular region. They have been known to originate as a result of injury. Gross cites a case, reported by Dr. .T. Mason Warren, of a man thirty-six years old, who had a large aneurism by anastomosis, situated on the lobe of the ear, which resulted from a frost-bite which the patient had suffered in his sixteenth year. In addi- tion to the tissues already mentioned in which angeiomata are develoj^ed may be mentioned the spleen, kidney, liver, and lung. The liver is fre- VASCULAR TUMORS. 193 IP^^^'^^ 268. — Aneurism by anastomosis in parietal bone. (Erichsen.) quently, the lung very rarely, involved. In bones, this disease exhibits the same erectile characters as iu other structures (Fig. 268). It occurs iu the fiat bones by preference, especially those of the cranium, Jaws, and scapula, being often very painful, and grave as to prognosis. Angeiomata are not infrequently situated on the labia of women. Holmes , ^.-.-j-ij: '-'';' -•-^^■>. Coote has observed serous cysts in connection with these vascular growths. An explanation of their forma- tion is, that communication of a portion of one dilated vessel with other vessels is cut oflf, and that the corpus- cles and coloring matter of the blood disappear, the se- rum remaining as a cystic fluid. The question of the rela- tion of these tumors to carcinomata and sarcomata is worthy of consider- ation. J. Miiller has reported a malignant (recurrent) angeioma. A case of melanotic degeneration of a congenital nsevus iu a woman aged forty has been reported by Dr. Styles. The vascular dilatations in osteo-sarco- mata, and in other forms of carcinoma and sarcoma, are analogous to those found in cavernous angeiomata. Some of the malignant tumors pulsate like the angeiomata. An angeioma may be diffuse or encajjsulated. The prognosis depends upon the size and location of the neoplasm. The diagnosifi is not difficult in the superficial tumors, but in those deejjly situated, and in the track of large vessels, the differentiation from aneurism is not easy. The arterial and capillary cutaneous tumors are almost always con- genital ; the venous tumors are rarely so. Angeiomata may be distin- guished from osteo-sarcomata, which have perceptible pulsation, by the crackling impression conveyed to the sense of touch from the malignant tumors of bone. Several consecutive telangiectases may occur in the same individual. Htitchinson, of London, reports the case of a child which had over one hundred Uccvi, all distinct and superficial. Vascular tumors on the scalp have an element of danger not present in angeiomata elsewhere, in that they at times grow to such an extent as to cause necro.sis of the calvaria. Treatment. — Angeiomata have been known to heal without surgical interference, as a result of an idiopathic inflammation. Transflxion and multiple deligation is one of the most radical and successful methods of treatment. Direct and prolonged pressure has been employed, though not with encouraging results. Perforation with hot needles, either with or without the galvanic ciirrent, injection of coagulating fluids, particu- larly Monsel's solution, .50 per cent carbolic acid, or of ergot, local apjili- cations of nitric acid or other escharotics, and extii'i^atiou by the knife. 13 194 A TEXT-nOOK ON SURGERY. have all been practiced. Vaccination over the growth has effected a cure in a few cases. In treating snpei-ficial angeiomuta, not too extensive, and not situated where the cicatrix would prove a deformity, 50 j^er cent carbolic-acid in- jections should be emi)loyed. In many cases coagulation f)f the blood- contents and ultimate absorption will occur without a scar. For extensive simple and cavernous angeiomata, he recommends the knife or scissors. Haemorrhage is to be controlled by pressure, rapid use of forceps, or preliminary ligature. Angeioma of the face, or of any exposed surface where a scar is to be avoided, is best relieved by the clean cut of the knife, since the cicatrix is less deforming than that produced by other modes of treatment. I have removed a number of these growths from the scalp and face. The incision should be made one fourth of an iiicli from the edge of the tumor, cutting only through healthy tissue. AVhen this precaution is taken, hfemorrhage is not dangerous. Of course the operation is not justifiable if telangiectasis involves more surface than can be covered by stretching or sliding the sound integumpiit. In cavernous tumors of large size the method of Erichsen is advisable. A long, straight, or slight- ly curved needle, aimed with a double thread, one half of which is stained black, is passed through the tumor at its base, and deeply from side to side. This process is repeated at in- tervals of three quarters of an inch, until the entire mass is transfixed ^vith threads which are parallel with each other (Fig. 269). The loops are then divided — the black on one side and the white on the other — and tied tightly until the strangulation is complete. Kepeated injec- tions of from five to twenty minims of a 5()-per-cent solution of carbolic acid, at intervals of several days, have succeeded in several cases of small najvi about the lii)s and eyelids. Venous Varix, Varix, or Varicose Vein. — This variety of "vascular tumor" consists of a dilatation and elongation of the deep or subcutane- ous veins. This condition may exist in any jiortion of the body, even in the bones (Cornil and Ranvier). It may involve a small portion of one vein, superficial or deep, or, as is most usual, a chain of veins. It is most frequently observed in the superficial veins, though Yerneuil says that varix is really as common in the deep-seated as in the superficial vessels (Bryant). It is especially prone to occur in the saphena veins. Hsemor- rhoids and varicoceles are common forms of varix. Unusual types are the dilatation of the jugulars from stenosis of the vena cava descendens, and that of the superficial abdominal veins from stenosis of the ascending Fig. 269.— Ericlisen's method of introducing the double li-'ature for the cure of vascular tumors. VASCULAR TUMORS. I95 cava. Such conditions are described by some authors as simple hyper- trophies or dilatations of veins. Any long-continued dilatation consti- tutes a varix. Hyperplasia of the normal tissues of the venous wall is the natural sequence of prolonged pressure and increased function. The hypertrophy of the wall is not always equal to the resistance of the in- creased pressure ; hence sacculated pouches occur when the vessel- wall becomes much thinner than normal, not infrequently resulting in rupture. Varix is of frequent occurrence in women who have had rejieated preg- nancies (Billroth). Poorly-fed and hard-worked persons, especially those who wf)rk in the upright posture, are more prone to varix than others. Tliere can be no doul)t that gravitation is the chief and immediate cause of this disease. The veins most subject to the greatest, prolonged blood-weight, and least protected by pressure, are involved in the great majority of cases. Pa- ralysis of the muscular walls, either by atrophy of the muscles or inter- ference with the function of the nerm vasorimi, may cause varix. This is proved by the fact that a small segment of a single vein in the upper por- tion of the body, where the anastomosis is free and gravitation can not be considered as a factor in the dilatation, may be the seat of this affection. In well-marked varix the veins are greatly increased in caliber and in length, so that they seem coiled and twisted upon themselves in knotted masses. They are narrowed in caliber at frequent intervals, these contractions ojjening into expanded pouches, in general a]ipearance not unlike the sacculated large intestine. The valves are wholly ineffi- cient, often flattened against the wall, or at times partially destroyed. At the level of the valves the walls are exceptionally thickened. The thickening is due to a multiplication of the muscular elements and hyper- plasia of the connective tissue. The connective-tissue new formation is aluindantly distributed in the meshes of the elastic net-work, and the bundles of fibers are usually arranged parallel with the long axis of the vessel. This accounts for the longitudinal ridges seen on the inner sur- face of the affected veins (Cornil and Ranvier). Even the nutrient vessels of the walls of these varicose veins — the vasa vasorum — have undergone hypertrophy, and are themselves the seat f)f varix, forming at times venous caverns in the wall of the vessel, which communicate with the vein. The internal tunic is not, properly speaking, thickened, except at the points of attachment of the valves, or when a thrombus has formed. Immediately external to the middle elastic tunic, the muscular tissue appears increased in quantity, arranged in transverse and perpendicular laminfe, separated by bundles of hypertrophied connective tissue, which are not infrequently stained with granular pigment. Calcareous deposits occur primarily within or l)etween these connective-tissue bundles (Cornil and Ranvier).* Hyperplasia of the connective and other tissues in the immediate vicinity of a varix of long standing presents the usual appearances of * In tlio arteries, these deposits occur first around and witliin the nucleus of the unstriped muscle, and jjradually increase until they fill the cell, which becomes converted into a small calcareous flake (Green). See section on " Arteritis." 196 A TEXT-BOOK ON SURGERY, elephantiasis. Small si)ots of ulceratiou occur as a result of malnutri- tion, and, coalescing, form the large and obstinate ulcers seen so fre- quently in varix of the legs. Ev<'n a new formation of })on(^ niny result from tlie irritation of a neighboring varicosity (C(jrnil ami llanvier). The veins become greatly elongated and assume different shapes, irregu- lai'ly sinuous or corkscrew-like, twisted npon theii- axes, and frequently, on account of perivascular inflammation, matted togetlier by new-formed connective tissue into venous tumors. Occlusion of varicose veins may result from thrombosis, and a cure may thus ensue. Frequently concre- tions are found in varicose veins, at times adherent to the walls. These concretions are called phlebolithes or pldchol'des (Dunglison). They are laminated on section, and are said to contain by analysis 20 per cent of protein matter, with phosphate and sulphate of lime and sulphate of potassium (Franklin and I3ryantj, and, according to Gross, a trace of oxide of iron. They are found most frequently in the veins of the pelvis, about the bladder and prostate, especially when the latter is enlarged. Hodgson says that they are formed in other tissues, and work their way into the vessels. This theory would seem to receive a partial support from the statement just made, that they are most frequently found near the prostate, and when this organ is diseased. It is well known that small calculi are frequent in this body. Phlebolites are also found in veins not subject to varix. Cruveilhier believed that they were developed from coagula (Holmes). Treatment. — Varicose veins are to be treated chiefly by artificial sup- port to the weakened and dilated walls. Eczema and the various forms of ulcer occurring in connection with varix are relieved by proper sup- port. The varix, however, is not often cured by this means alone, which is merely palliative. Martin's elastic bandage is of great use. Bandages of muslin or flannel, properly applied, give great relief. The elastic silk apparatus, for constant, equable pressure, cleanliness, and comfort, can not be surpassed in the treatment of varix. The i-elief of pressure by position is always advisable. All supporting ajiparatus should be re- moved at bedtime and adjusted before rising. The only method of radical cure is by occlusion. The use of a subcutaneous catgut ligature, passed at several points under and not through the veins, is the most ai)i3roved method. With careful antisepsis and the use of cocaine this procedure is painless and not dangerous. The cases are, however, exceedingly rare where such procedures are necessary. Moles. Closely connected with the more superficial forms of vascular tumor are the almormal, circumscribed hypertrophies of the skin, which are known as moles. They may be, and usually are, congenital, or they may be developed at any period of extra-uterine life. All portions of the cutaneous surface may be the seat of this form of hypertrophy, but the exjjosed surfaces, such as the face, neck, and hands, are most fre- MOLES. 197 qnently affected. The hypertrophy which constitutes the mole may involve all or any one of the tissues which enter into the anatomy of the integument. The most frequent variety is that which occupies the face, as a simple elevation from which a few stiff hairs grow. It is not stained with pigment, and differs very slightly, if at all, in color from the normal skin. The lesion here is a true hypertrophy of all the tissues of the skin, chiefly in the derma and papillary layer. The vascularity is slightly increased, and the sebaceous glands connected with the hair-follicles take part in the hypertrophy. On other portions of the bf)dy this form of mole {ticeims vulgaris) will have no hairs growing from its surface. Ncevus pigmentosus is not usually a thickening of the entire cutis, as is the simple mole just described, but its pathological condition is an excessive deposit of pigment in the Malpighian layer and in the epider- mis. It varies in color from a slate-gray to a blue, mahogany, reddish- brown, or wine-coloi-. At times the pigment mole will extend over a large area, occupying as much as one third or one half of the face. The lobule of the ear, and the integument between the eyes and over the temple, is the most common location of this deformity. Another name for these spots is '■^port-wine marJc.'" When the hypertrophied area of skin is studded with hairs, it is known as ncBous pilostis, or hairy mole. It follows from the name that this form of hypertrophy can only occur on those portions of the cutis in which the hairs grow. The plantar surfaces of the feet and the palms of the hands are never affected. They may or may not be stained with pigment. The majority of hairy moles are not colored. Moles, whether simple, hairy, or pigmented, are benign. As a result of irritation, they may inflame and become ulcerated, or may develop into malignant growths. Carcinomata, especially of the melanotic variety, are frequently described as having resulted from inflamed jiigment moles. Alarming haemorrhage has been known to occur from a mole more than usually vascular, in which ulceration had been established by friction of the clothing. Treatment. — As long as no deformity or inconvenience results from these formations, it is better to let them alone. When situated upon the face, of such size or position that they become offensive to the eye, they may be removed by simple excision. The incision should be elliptical, and well away from the growth, going entirely through the thickness of tlie skin. Tho wound should be closed with line sutures, or drawn nicely together with adhesive strips. The simplest method of procedure is to x^roduce local anaesthesia by cocaine, and operate quickly. Port- wine marJis may also be excised. If a mole should at any time take on inflammatory action, or give any indication of malignant proliferation, immediate excision would be im- perative, and the incision should be wide of the supposed area of the disease. The enqtloyment of caustics or irritants of any kind is to be deprecated, as they would increase the tendency to malignant change in these growths. CHAPTER X. A>^ETJKISM. Fig. 2V0. Ax aneurism is a sacculated tumor, the caA'ity of which communicates with an artery, and in rare instances also with a vein. They may be classified as spherical, fusiform, and dissecting. A S2)lterical aneurism is one in which the tumor is well defined, the diameter of its cavity being larger than the diameter of the opening of communication with the vessel. It may spring from any portion of the arterial wall (Fig. 270, e), or, in rare instances, the vessel-walls may yield in all directions to foi'm the tumor (Fig. 270, c). A fusiform aneurism is one in which there is a gi-adual and gen- eral dilatation of an artery in its entire circumference (Fig. 270, a, h). A spherical aneurism may oc- casionally develoii from the wall of a fusiform dilatation. A dissecting aneurism is one in which, owing to pathological changes in the intima, with necrosis, the blood insinuates itself between the inner coat and the adventitia, dissects the intima from the media and adven- titia, and reenters the vessel at a distant opening. Aneurisms are further divided into the true and false. To the former belong all tumors the walls of which are composed of the walls of the vessels from which they spring ; to the latter belong those tumors the walls of which are composed of inflammatory new-formed tissue. Cause. — A true aneurism is always preceded by arteritis, which results in atheromatous degenei'ution of the normal elements which compose the arterial wall. ThejxitTiologi/ of arteritis and the relation of this condition to various dyscrasiffi — as syphilis, nephritis, gout, rheumatism, etc. — have been fully dwelt on in a preceding chapter. These are among the diseases which are favorable to the development of aneurism. The relation of violence to these tumors must not be lost sight of. No matter how severe the dyscrasia and the general condition of arteritis, which is a part of it, it is well known that in the large majority of cases aneurisms develop at those points in the arterial system which are subjected to the greatest ANEURISM. 199 violence from hear* -action, or muscular or mechanical pressure. Thus the arch of the aorta, and that portion of the arch in the direct axis of the left ventricle, is very prone to aneurism, as are the great vessels near their origin from the aortic curve. The popliteal arteries, subjected as they are to violence in forced flexion of the legs, are frequently the seat of aneurismal dilatations. From a study of the various conditions which produce aneurisms, it is evident that the normal wall of an artery can not form the sac of the aneurism. Some of the normal anatomical elements may be present in the sac, but the integrity of the whole is impaired ; and it may be that, in the progress of an aneurism which began in atheromatous degeneration of a part of the elements of the vessel-wall, all of these elements will eventu- ally disajjpear, being replaced by an inflammatory new formation. A sacculated aneurism (Fig. 271) may in rare instances communicate with a vein {varicose aneurism). The direct communi- cation of a vein and artery without a sac is known as aneurismal varlx. If an aneurismal tumor be examined, it will be found to contain coagulated blood in all stages of til)rillation. The peripheral portion of the clot is composed of irregu- lar lamina, and, if examined with the mi- croscope, the laminated appearance is found to be due to alternate layers of white cor- puscles, and upon these a deposit of fibrin (a condition which goes to sustain the theory of A. Schmidt, already cited, that fibrin ferment, the coagu- lation factor of the blood, is resident in the leucocytes). As the center of the tumor is approached, the coagulation is evidently more recent, while in the cavity of the aneurism a soft post-mortem clot is usually found. Fusiform aneurism occurs most frequently in the thoracic aorta, with esjiecial preference for the arch. It may affect the entire aorta, and the great vessels derived from it. Not only is the diameter of the arteries increased, but the hypertrophy results in a considerable increase in their length. Not infrequently a grou]) of fusifoi-m expansions may be seen with strips of sound and non-dilated artery intervening. Calcareous deposits occur in patches, and seem to give strength to the walls, since those portions give way more readily which are not the seat of calcifica- tion. Coagulation is not apt to occur, as in sacculated aneurisms ; in fact, it is a rare condition. Fusiform aneurisms develop slowly, and, as a rule, are painful and dangerous cmly when, by reason of their large growth, they exercise undue jiressure upon important organs. Thus, in dilata- tion of the transverse arch, or of the right subclavian, spasm of the glottis occurs from irritation of the recurrent larjTigeal nerves, or respi- ration and deglutition may be seriously embarrassed by direct comj)res- Varicose Aneurism. Aneurismal Varii:. Fig. 271. 200 A TEXT-BOOK ON SURGERY. sion of the trachea or o'sopha^r gesamrater Augeulieilkunde," Lcipsic, 1880. t " Prize Essays of the American Medical Association, 1878," William Wood & Co., New York. SPECIAL AXEURISMS. 219 have been already detailed will serve as a guide to proper differentiation. Difficulty may arise, even after the aneurismal character of the swelling has been recognized, in determining from what vessel the tnnior springs. As has been said, the progress of aortic aneurism gives rise to pulsation and pressure symptoms, located in the thorax for a considerable period prior to tlie approach or ajipearance of the tumor at the root of the neck. In fact, aneurism of the aorta, in many instances, produces death before it attains such magnitude. On the right side, this knowledge will aid materially in recognizing the seat of the lesion, and. fortunately, aneu- rism of the arch and subclavian occurs most often on this side of the body. The differentiation of aneurism of the thoracic portion of the left artery, from the same lesion of the arch, near the origin of the subclavian, is somewhat more difficult. When the tumor involves the subclavian its appearance in the neck is more rapid than in aortic aneurism, while in- terference with the return circulation in the ann, which may appear early in the history of subclavian aneurLsm, is rare when the aorta is the seat of this lesion. Again, in aneurism of the second or third portion of the arch, which does not involve the subclavian, the pulse-wave in the left radial wiU be of equal force and synchronous -n-ith that of the right side. The treatment of subclavian aneurism is a subject of great importance, and one which, from a study of a number of cases, has led to great diver- sity of opinion and practice. The methods may be divided into the surgical ; the postural, medical, and dietetic ; and the palliative or expectant. The employment of any of these means will, again, be in great part determined by the portion of the artery involved in the disease. The surgical ti-eatment comprises the ligature on the cardiac or distal side ; compression on the distal side, or applied directly to the sac ; and massage. The innominate artery has been tied on account of subclavian aneu- rism seventeen times with sixteen deaths. The operators and results were as follows : Y. Mott, died twenty-sixth day, haemorrhage from distal side. Graef e, died sixty-seventh day, hjemor- rhage fi-om distal side of ligature. Xonnan, died thu'd day, hfemorrhage. Arendt, eighth day, pneumonia. Hall, fifth day, exhaustion and venesec- tion. Bland, eighteenth day, haemorrhage from distal side of ligature. Lizars. twenty-second day, h^emorrliage from distal side. Gore, seven- teenth day, hfemorrhage from cardiac side of ligature. Cooper, eighth day. Cooper, thirty-fourth day, hemorrhage. Pirogoff, two days, pneumonia. A. B. Mott, twenty-third day, haemorrhage, sac burst into pleiira. Bick- ersteth, sixth day, hfemorrhage from distal side of ligature. Thomson, forty-second day, hsemorrhage from distal side of ligature. Smyth, recov- ered, after ligature of innominate and carotid at first operation, and the vertebral fifty-four days later, to arrest violent bleeding. This patient died, ten years later, from haemorrhage from the sac of the old aneurism. Thomson, died forty-second day, exhaustion from repeated ha?morrhage from distal side of ligature. Bull, thirty-third day, haemorrhage from proximal side of ligature on thirtieth and thirty-third days ; right carotid and vertebral also tied at same time with the innominate. 220 A TEXT-BOOK ON SURGERY. Tlie subclavian artery has been tied in its first siirgical division for the relief of aneurism involving this vessel, or its third portion, conjointly with the first part of the axillaiy (siibclavio-axillary), in the following instances : Culles, death on fourth day, from haMuorrhage at seat of liga- ture. Y. Mott, death on eighteenth day, haemorrhage. Bayer, death in twenty-four hours, from bursting of sac. Ilayden, death on twelfth day, from hjemorrhajje at seat of ligature. O'Reilly, death on thirteenth day, hfemorrhage. Partridge, death on fourth day, pericarditis, pleuritis, pj'ajmia. Liston, death on thirty-sixth day, hfemorrhage from distal side. Rodgers, death on fifteenth day, hamiorrhage from distal side of ligature. Auvert, death on eleventh day, h;eniorrhage, distal side. Auvert, death on twenty-second day, luemorrhage from distal side. Liston, death on thirteenth day, hjemorrhage (right carotid tied at same time). Parker, death on forty-second day, haemorrhage from distal side of ligature (right carotid tied at same operation). Of these twelve cases all died soon after the ligature. Only in one case (Rodgers) was the left subclavian tied. For subclavian or subclavio-axiUary aneurism the ligature has been applied in the second portion in four cases. Liston, death on fourteenth day, haemorrhage at seat of ligature. Nichols, recovered, cured. Au- chincloss, death on third day, from cerebral complications. AVarren, recovered, cured. Gay, death on ninth day, bronchitis and pneumonia. Giving four cases, with two deaths and two cures. Deligation of the subclavian artery, in its thii-d portion, for subclavio- axillary or axillary aneiirism, has been performed one hundred and thir- teen times, with forty-seven deaths.* Naturally the mortality is greater in proportion to the jiroximity of the aneurism to the heart and to the seat of the ligature. Thus, in thirty-four of these cases the disease in- volved the third portion of the subclavian or the axillary, or both (prop- erly named subclavio-axillary aneurism). As a result of the operation exactly one half perished. Of the seventeen i-ecoveries, thirteen are re- ported cured. For aneurism of the axillary proper I have the histories of seventy- nine cases in which the ligature has been applied to the third portion of the subclavian, with thirty deaths, forty-nine recoveries, and forty-six of these reported as cured. In seven of the fatal cases the aneurism was traumatic, and resulted from gunshot wounds (six in military, one in civil practice). The value of the expectant plan may be estimated in the following cases : Stnopsis of 22 Cases of Sfbclavian Axecrism ix which " no Treatment" was undertaken. IS deaths, ^ spontaneous ctires. Eighteen fatal cases. Dates of death after tumor was noticed (and when surgical interference might have been undertaken). * x\.uthor's Essays, already cited. SPECIAL ANEURISMS. 221 1 case. Aneurism had existed for " some time." Died twelve weeks after admis- sion to liosjjital. 1 case. Not known how long aneurism had existed. 1 case. Lived " some months." Died of exhaustion and suppuration caused by- pressure of sac. 1 case. Died of rupture of sac twenty-four years after recognition of aneurism. 1 case. Died from asphyxia caused by pressure of sac, eight years. 1 case. Died from external rupture of sac two years and eight months after recog- nition of aneurism. 1 case. Died from exhaustion from pressure of sac, two years after recognition. 1 case. Died from dyspnrea from pressure of sac, two years after recognition. 1 case. Died from dyspncea and exhaustion from pressure of sac, one year and a half after recognition. 1 case. Died from rupture of sac into lungs, one year and a half after recognition. 1 case. Died from rupture of sac into lungs eight months and a half after recog- nition. 1 case. Died from rupture of sac into tissues, becoming diffused, and causing death by pressure, five months and a half after recognition. 1 case. Died from rupture of sac, death by pressure, live months after recognition. 1 case. Died suddenly (probably from cerebral clot) one year and a half after recognition. 1 case. Died suddenly, cause not stated, not rupture of sac. 2 cases. Died from rupture of popliteal aneurisms. 1 case. Died from typhoid pneumonia, three years after recognition. Of the four cures, three remained well ; one died about f(.)ur years later from rujiture of an aortic aneurism. Of these eighteen fatal cases in which no treatment was undertaken, three died of other disease than the aneurism. Of the thirteen cases in which the duration of life is noted after the recognition of the aneurism, the sum total is forty-seven years and nine months. The sum of life in the thirteen cases after deligation of the innominate is about eight months, a difference in favor of non-interference (in an equal number of cases) of about forty-seven years of life. Synopsis of 14 Cases treated by Valsalva's Method. {More or less modified. ) 1 case. M. ; R. Subclavian aneurism. Size, hen's egg. Venesection ; cold and lead lotion locally. Recovered. Two and a half years later was work- ing as a carter in the city. 1 case. M. ; R. Subclavian. Immense size. Venesection. Cold and astringents locally. Tumor reduced in size and firmer ; lost sight of while in pro- cess of cure. 1 case. M. ; R. Subclavian (syphilitic). Valsalva's method and antisyphilitics. Cure complete. 1 case. M. ; R. ; age forty-five. Subclavian (sy])hilitic). Valsalva's method and antisyphilitics. Cured and seen well six years later. 000 A TEXT-BOOK OX SURGERY. 1 case. M. ; age forty-two. Subclavian. Venesectiou. Digitalis. Rest. Marked improvement, so tliat patient left hospital and was lost sight of. 1 case. M. ; age fifty. Subclavian. Was treated for an intercurrent attack of rheumatism by rest, strict diet, and antiplilogislics. Cured. 1 case. M. ; age thirty-nine. Subelavio-axillary (Pancoast's case). Valsalva's method had been tried and considered a failure. Operation determined on. Carried into operating-room. Patient fell into collapse and opera- tion was jiostponed. Recovered cured. (It is staled that a large dose of aconite had been given by mistake just before the operation was to have taken place.) 1 case. M. ; age thirty-seven. Subclavian. Venesection. Valsalva's method and careful and persistent direct compression for one year and a half. Cured. 1 case. M. ; age fifty-one. Subelavio-axillary (by Pelletan). Valsalva's method. Cured. 5 cases treated by this method (in part) were fatal. Venesection was not practiced except in one case. Only local and constitutional treatment. All died within twelve months of the recorded recognition of the disease ; one from ulceration into trachea, hasmoptysis, and exhaustion ; two from external bursting of sac ; two from exhaustion and coma (with pressure on the trachea in one case). Summar//. — Fourteen cases. Cured, seven ; improved, and in process of cure when lost sight of, two ; died, live. No venesection in four of live fatal cases. One successful case modified by direct pressure. Syxopsis of 6 Cases treated by Direct Pressure rpox the Sao (Modifications givex). (All subclavian aneurism.) 1 case. M. ; forty-six years ; R. Leather "cup" molded over tumor and held in place by figure-of-8 straps around shoulders and axilla. Cured in four- teen months. Did light work during treatment, and had no other medi- cation. 1 case. M. ; thirty-nine years ; L. Enormous size. Treated by cold and pressure " in turns." Small cannon-ball suspended so as to press comfortably. Discharged relieved. Some months later violent inflammation (from fall), sup])uration, rupture of sac ; discharged two quarts of pus and blood. Cured. Debility of arm probably permanent. 1 case. M. ; forty-one years. (Thirteen months' duration.) Kept in bed, on back ; ice locally ; restricted diet. Third day air-cushion for twelve hours, with intermissions amounting to three hours. Every half-hour interval of ice. Treatment for seven days. Tumor began to subside, and was cured in twelve mouths. 1 case. (T. Holmes.) ("Lancet," February 12, 1876, p. 237.) Subclavian. Treated by direct pressure from rubber-ball. Cured. 1 case. (Dupuytren.) Direct pressure. Resulted fatally. 1 case. (Porter.) Exposed axillary and passed needle under it. Thirty-five days later exposed innominate and passed the " acupressure needle " under it. Died from haemorrhage from innominate on tenth day. SPECIAL ANEURISMS. 223 (In one case given in preceding table, direct pressure was practiced with Valsalva's method.) Summanj. — Five cases of ''direct j)ressure" (without operative pro- cedures). Cured, four ; died, one. Synopsis of Cases of Massage or Kxeadixg ix the Treatment of Subclavian Aneuris-ai. Of this method there are six cases. Three cured ; viz., by Fergusson, Little, and Porter. Three died ; viz., by Fergusson, Hilton, and Morgan. (See '• Guy's Hospital Reports," vol. xvi, p. 42 et seq.) In addition, Mr. Bryant, in his " Practice of Surgery," p. 190, gives a case by Dutoit, of Berne, in which a subclavian aneiuism was cured by in- jection of ergotin around the sac under the skin, and digital compression. Poland cured one case by digital pressure on cardiac side. A third case was tried for forty-six hours and abandoned on account of pain from press- ure. The i:)atient died from exhaustion. Paget tried mechanical pressure in a fourth case, but abandoned it as a hopeless undertaking. A fifth case by Verneuil was improved, but lost sight of before a cure was effected. From the stiidy of the foregoing history of subclavian, subclavio- axillary, and axillary aneurism, I have reached the following conclusions : Deligation of the innominate artery, or the subclavian in its first sur- gical division, are operations so dangerous that they should be under- taken onh^ in extreme conditions. The first indication in the treatment of these lesions is pressure, judi- ciously applied. If possible, the compres.sion should be exercised be- tween the tumor and the heart. Next in preference, direct pressure upon the body of the aneurism. Perfect and persistent rest should be enforced, and with this the method of Tuflnel offers the surest and safest means of l)alliation and cure. In making direct compression, the elastic ball introduced by Mr. Holmes seems best adapted. This should be applied gradually, in order to accustom the patient to its presence. Massage is so inferior to the plan just detailed that it may be omitted from practice. Should all these means fail after a persistent trial, should the sac by Tilcerati(m open and threaten instantaneous death, or should the surgeon, from the appearances, judge that this accident was on the eve of occur- ring, ligature of the innominate should be perfonned, provided that the ligature could not be applied to the subclavian proper. "When the aneurism involves the last portion of the subclavian or the axillary, the ligature may be applied to the third division of the sub- clavian. Compression should always be tried in these, as in all other cases, before resorting to the ligature. Aneurism of the brachial, radial, and ulnar arteries, or their branches, is comparatively rare, and when seen is almost always the result of a wound. Tlie diagnosis is not difficult. The treatment required is digital or mechanical coraj)ression on the cardiac side of the tumor. If this fail, 224 A TEXT-BOOK ON SURGERY. direct compression of the sac may be added, and, if a thorough trial of these two methods is not successful, a catgut ligature should be api)lied, after the method of Hunter. Aneurism of the Vertebral Artery. — Aneurism of the vertebral is almost always the result of a punctured wound. A rare exception to this rule is the case of idiopathic aneurism of both vertebrals reported by Dr. Anderton, of New York city.* It occurs most frequently in tliat portion of the vessel between the atlas and the transverse ]3rocess of the sixth cervical. The chief point in diagnosis is the diifereritiation between the lesion in question and carotid aneurism. The difficulty of distinguishing vertebral from carotid aneurism in the neck arises from the fact that direct pressure from before backward, in the lower portion of the neck, will interfere with or aiTest pulsation in aneurisms of both vessels. If, however, the head be flexed upon the chest, and the sterno-mastoid muscle thus relaxed, the carotid can be compressed by grasping the mus- cle between the thumb and linger, which are pressed deeply behind the outer and inner borders. This will not involve the vertebral. Again, if the carotid be forcibly compressed by the thumb, backward and inward, against the vertebral column, at any point above the trans- verse process of the sixth cervical, the vertebral will not be included, since it is protected by the processes. In my Essays are recorded five cases in which the common carotid was tied for supposed carotid, but in reality vertebral, aneurism. All ended fatally. In the treatment of this lesion direct pressure may be employed, since prolonged compression of the artery before it enters the foramen in the sixth transverse process is impossible. One successful result of this method is recorded. If the disease continues to increase, deligaticm of the vessel in its first portion may be effected. This is a very difficult operation, and has rarely been attempted. The only operators so far are Smyth, Parker, Alexander, and myself. Aneurism of the internal mammary, and other smaller branches of the subclavian, does not demand separate consideration. Aneurism of the intercostal arteries occurs in rare instances, usually as a result of fracture of a rib or a stab-wound. Aneurism of the Abdominal Aorta. — Aneurismal dilatation of this section of the aorta occurs most frequently near the diaphragm. The entire vessel may be the seat of fusiform aneurism. Females are less frequently attacked than the opposite sex. In corpulent perscras the diagnosis is dilficult. Tumors of the central organs, as the stomach, pan- creas, transverse colon, and the superjacent mesentery, may be mistaken for aneurism. On the other hand, in emaciated persons, unnatural ex- pansion of the aorta duiing the cardiac systole has led to a mistake in diagnosis. The history of the development of the tumor, the presence of the aneurismal tremor and bruit, and the recognized general exi)ansion of * " Medical Record," vol. xx, p. 354. SPECIAL ANEURISMS. 225 the sac, with the arterial pulse, will enable the careful observer to arrive at a correct diagnosis. The Treatment is chiefly expectant. The method of Tuffuel, combined ^vith interrupted compression by means of the tourniquet, should be em- ployed. Pressure may be cardiac, direct, or distal, the former being preferable, if the location of the tumor renders it possible. If operative interference is demanded, the introduction of juniperized catgut ligatures through the canula, heretofore described, would be advisable. Anaesthesia is required, and the duration of compression may vary from fifteen min- utes to one hour. Deligation of the aorta for aneurism of the same is scarcely possible. Aneurism of the BrancJies of f Tie Ahdominal Aorta. — Aneurism of any of the visceral or jjarietai branches of the abdominal aorta may occur. The location of the tumor and the characteristic symptoms of aneurism will point to the vessel affected. When ti-eatment is necessarj-, the same method should be employed as for aneurism of the main trunk. Explo- ration under strict antisepsis may be made, and deligation with the ani- mal ligature practiced, if the tumor is sufficiently removed from the aorta to allow the application of the ligature to non-diseased tissue. Aneurism of the Iliac Arteries. — Aneurism of the common, external, or internal iliac arteries is, fortunately, of rare occurrence. The diagnosis may be made by a study of the history of the individual case, and by abdomi- nal palpation, coupled with physical exploration by the rectum or vagina. In the treatment of aneurism of the common iliac, compression of the abdominal aorta should be faithfully tried. With this may be combined the treatment by rest and restricted diet, and carefully graduated direct pressure. Should these methods prove useless, and death be imminent from rapid expansion and threatened rupture of the sac, deligation of the abdom- inal aorta may be performed, or the external iliac or femoral may be tied. The abdominal aorta has been tied in the following cases of iliac aneurism : . * No. Operator. Date. Bex. Age. Kesnlt. 1 Astlcy Cooper. 1817 M. 38 Died in forty hours. Ligature applied three fourths of an inch above bifurcation of aorta. Tumor measured eight inches in long axis. 2 James 1829 M. 44 Died in three and one half hours. Femoral tied thirty-three days before aorta. Tumor increased in size and aorta tied. Liga- ture applied seven ei^iiths of an inch above bifurcation. 3 Murray 1834 M. 33 Died in twenty-three hours. Tumor extended as high as the unibilieiis. External iliac involved. Gangrene was tlireat- cned. Ligature half an inch above bifurcation. 4 Monteiro 1842 M. 31 Died in ten days. Large diffuse aneurism of femoral. Aorta ulcerated at seat of liL'ature, and death took place from haemorrhaire. 5 South 1856 H. 28 Died in fortv-three hours. External and common iliac involved. 6 McGuire 1868 M. 30 Died in eleven hours. Sac, which involved hoth common iliacs. burst during operation, when a hasty ligature was thrown around the aorta. 7 Watson 1869 M. ? Died in sixty-five hours. Xinc weeks after ligature of common iliac h»morrh:i2;e occurred, when aorta, external and inteinal iliacs were tied. No haemorrhage after operation. 8 Stokes 1869 M. 60 Died in twelve hours. Right common and external iliac and femoral involved. 16 * Gross's " System of Surgery." 22 fi A TEXT-BOOK ON SURGERY. When the aneurism is located upon the external iliac, compression witli the tourniquet may be employed over the aorta or common iliac artei'v. Prof, ^^ands has advised and ])i'acticpd digital ])i'essure of the common iliac by means of the hand introduced into tlie rectum. Pressure from within the rectum may also be accomplished by means of a bougie or jnece of wood projierly padded (Davy's method). As a last resort the common iliac may be tied. Tliis operation, though dangerous, has been successfully accomplished in several instances in late years. A patient recently operated upon by Dr. Lange, of New York, recovered and was cured. Aneunsm of the internal trunk is amenable to treatment by com- pression of the aorta or common iliac, or by deligation of the primitive trunk. Aneurism of the branches of this vessel usually occurs in the gluteal and sciatic. The origin is almost invariably traumatic. The earliest symptoms are referable to the presence of the tumor. It must be distin- guished from abscess or hernia. Aspiration would determine the ]irospnce of the former, and the s}'m})toms of hernia, with absence of pidsatiou, would indicate the escape of the viscera through the great sciatic fora- men. The treatment is difficult and often ineffectual. Direct compres- sion sliould 1)6 tirst tried. Incision into the sac, turning out the clot, and tying both ends, has been successful in four of six cases reported by Fischer. The ligature may also be ap])lied between the sac and the point of exit of the artery, or, as a last effort, the common iliac may be tied. Aneurism of the Femoral Arteries. — Aneurism of the superficial femoral artery is comparatively frequent. It occurs by preference in the upper half of the artery, and in males in the great majority of in- stances. In rare instances the disease is symmetrical. The diagnosis is not difficult, since the expansile pulsaticm of the tumor can, in most cases, be readily appreciated by palpation. A tumor in the line of the artery, with the characteristic pulsation, tremor, and murmur, all of which signs disappear when the iliac artery or aorta is tirmly compressed, point almost unerringly to a diagnosis. The greatest danger of error lies in the presence of an abscess. Abscess is, however, of rare occurrence in this region, except as a sequence of spinal caries or hip-joint disease, and these conditions, existing with the other common symptoms of the development of abscess, would lead to its recognition. If doubt should still exist, after even the most careful survey of the case, the hypodermic needle would settle the diagnosis. Treatment. — Aneurism of iive femoral artery will, in the vast majority of cases, yield to judicious and patient compression. When the tumor extends as high as Poupart's ligament, or above this point, the chances of success are diminished, since pressure will have to be ai)plied to the common or external iliac or the aorta. Under such conditions direct compression, by means of Holmes's elastic ball, applied so gradually that inflammation of the sac will not be precipitated, should be first faithfully tried. Ligature of the common or external iliac should be deferred until all other remedies have failed, and, when there is a choice between these two procedures, the deligation of the external iliac should be preferred, SPECIAL ANEURISMS. 227 on account of the anastomoses of the branches of the internal iliac with the vessels of the thigh. Direct compression of the sac was once success- fully practiced by Dr. Brown, of Boston, in a case of femoral aneurism at Poupart's ligament. The weight employed may be as much as twelve pounds. Iron balls were used in this ca.se. The patient was confined to bed for ten months. When the tumor is so far away fi'om Poupart's ligament that digital or mechanical compression of the fem(jral upon the OS pubis is possible, this treatment should be adopted. Extreme tiexion of the thigh upon the abdomen has succeeded in producing a cure in a few instances. Direct pre.ssure upon the tumor, with the limb ex- tended, is less painful and equally efficacious. When the necessity for the application of the ligature occurs, the effort .should be made to reach the artery below the origin of i\\^ profunda femor is, since the danger of gangrene is much less if this great collateral route is open. The treatment of aneurism of the lower portion of the femoral does not matei'ially differ from the above. Aneurism of the profunda femoris is rare, occurring usually as a comi)lication of this condition in the common trunk, or as a result of a punctured wound. The treatment will include pressure on the cardiac side, or direct compression, and, as a last resort, ligature of the common femoral, or iliac. Aneurism of the Popliteal Artery . — About one fourth of all aneurisms occur in this vessel. Subjected, by reason of its unfortunate location, to the accidents of compression in extreme flexion of the leg, it frequently suffers those pathological changes which end in aneurismal dilatation, and is only second in order of frequency to the aortic arch, which yields to the violence of the cardiac systole. As with aneurism in other loca- tions, it occtirs most frequently in males, and in the active period of life, being rare in childhood and youth, and most common in the years from twenty-five to fifty. Diagnosis. — On account of the infrequency of tumors in this region, other than aneurism, the diagnosis is not difficult. The characteristic symptoms of this malady will determine its differentiation from glandular enlargements, exostoses, over-distended bursee, or abscess. Treatment. — In the treatment of popliteal aneurism the patient should be placed in the recumbent posture, with the leg of the affected side slightly flexed. A soft mattress should be used, and the thigh and leg held in a comfortable and fixed position by means of a pillow under the popliteal space, and sand-bags laterally. Under the influence of an opiate, or in extreme cases complete etherization, digital or mechanical pressure should be employed upon that portion of the artery lying in Scarpa's triangle (Fig. 273). Within this limit the point of compression may be shifted, in order to prevent too great local irritation. In obstinate cases compression on the cardiac side may be re-enforced by forced flexion of the leg on the thigh, or by direct pressure upon the tumor. The instances will be exceedingly rare where a patient and skill- ful employment of these methods of compression will not succeed in 228 A TEXT-BOOK ON SURGERY. effecting a cure. Consolidation may result in one or two hours, or it may require several hours or days. Acujjressure and massage are not to be employed. The elastic bandage of Esmarch has not given results wliicli would justify its further use. When comijression, either on the cardiac side or directlj^ upon the anenrism, fails, the deligation of the femoral, in the extreme lower angle of Scarpa's space, is demanded. Aneurism beyond the Popliteal. — Aneurism of the peroneal or tibial arteries, or their branches, is rare. In diagnosis and treatment this lesion, when situated in this i)ortion of the arterial system, requires little or no special consideration. When the tumor is so situated that the vessel immediately involved can not be occluded by compression, this nuiy be directed to the femoral, or, in aneurisms of small size, direct pressure may be sufficient to effect a cure. The ligature will be demanded if other methods fail. Arterio-venous Aneurism. — Arterio-venous aneurisms aio of two kinds. In one variety the communication is direct, the contiguous walls of the artery and vein being closely adherent immediately around the opening leading from one vessel to the other. This is called direct arterio- venous aneurism, or aneurisma.l rarix. When a sac intervenes it is called an indirect arterio-venous or vari- cose aneurism (Fig. 271). The cause is usually tj'aiiniatic, resulting most frequently from punct- ured wounds, although any intianimatory process which induces necrosis of the arterial and venous walls may lead to this form of aneurism. In exceptional instances the communication has either not been established, or at least has escaped observation for several years after the injury. This lesion may occur in any portion of the economy. In former years it was observed most frequently in front of the elbow-joint, where it was produced by the accidental puncture of the brachial in the operation of venesecfton. It occurs not infrequently in the neck, as a result of wound of the carotid artery and internal jugular vein. The chief points in the differential diagnosis between varicose aneu- rism and aneurismal varix are the presence of a tumor and the peculiar aneurismal hriiit and tremor, which conditions exist in the former. In both varieties of this disease the veins become greatly distended and tortuous, and pidsate forcibly with each C(mtraction of the heart, while the pulsation in the artery beyond the lesion is perceptibly dimin- ished. In the treatment of varicose aneurism, compression of the artery should be employed on both sides of the tumor, while direct pressure should be made upon the sac, between the two vessels. When, from the location of the lesion, this method is not feasible, or when, after a faithful trial, it has failed to produce a consolidation of the aneurism, the ligature will be required. Catgut should be used, one thread being i)assed around the artery just above, and another just below the tumor. When so situated that the vein involved in the lesion is not necessary to the integrity of the part, as in the forearm, this may also be secured on the distal side of the foramen of communication. SPECIAL ANEURISMS. 229 Operative interference in cases of aneurismal varix is not so fre- quently indicated as in varicose aneurism, owing to the comparatively slow progress of the disease. Experience has shown that deligation of the affected artery is far more dangerous in this condition than in the indirect variety. Fatal secondary hsemoiThage is recorded in a numlier of in- stances, wliile in others gangrene has resulted from closure of the artery. Compression should be employed as in the ti'eatment of the form just considered. When the lesion is situated in the vessels of an extremity much comfort may be secured liy the employment of an elastic bandage or stocking, as in the treatment of venous vaiix. As a last resort, ampu- tation may be practiced. CHAPTER XL LIGATION OF ARTERIES. Operative F>urgery of tlie Arteries. — In tyino; an artery, all of tlip de- tails of the antiseptic method given heretofore shoiikl be scrupnlously carried out. While the incision should be along the line of the artery, it should lean as far from the accomi^anying vein as possible. In ap- proaching the vessel after the skin is divided, the fascia and aU inter- vening tissues should be grasped between two long, delicate dissecting forceps (Figs. 277, 278), untU the sheath is reached, and this is opened LIGATION OF ARTERIES. 231 in tlie same manner. As soon as tlie wall of the artery is exposed the sharp-pointed instruments should be laid aside. A dull-pointed aneu- rism-needle (Fig. (J3j, or a flexible silver probe, should now be passed between the sheath and the vessel, and carried carefully around the artery, keeping the point close to the wall of the vessel. When a nerve or vein is in close relation, the instrument should be introduced on the side nearest these, thus insuring their exclusion. The dull-pointed probe, bent to the proper curve, may be used to great adviintage in almost all operations upon the arteiies. After the point is carried around the vessel and brought up out of the sheath, the ligature may be tied over the slight bulbous expansion of this instrument, whicli, when withdrawn, leaves the ligature around the vessel. In tying the catgut the double loop (see Fig. 112) should be used for the first, and the single loop for the second knot. The force employed should be sufficient to occlude the vessel, yet not enough to infiict unne- cessary violence upon its walls. The ends of the string should be cut off for one fourth to one half of an inch from the knot, and the wound closed for a permanent dressing. Ligation of tlie Innominate Artery — Anatomy. — The arteria-innomi- nata is derived from the transverse segment of the arch of the aorta, immediately in front of the trachea, just behind the middle of the ster- num, at a level varying from one half to one and a half inches below the upper margin of the manubrium. From this origin it travels obliquely upward, backward, and to the right (crossing the trachea from its center), and bifurcates, near the upper margin of the clavicle, between the sternal and clavicular origins of the sterno-mastoideus into the carotid and subclaman arteries, the first of these coming from its anterior aspect, the last a direct continuation of the arch of the innominate. The innominata in rare instances originates to the left of the trachea ; more frequently it is given off before it reaches the windpipe. As a rule, it is longer in females than in males. In twenty-eight cases in which I measured the distance of the origin of the innominate from the commencement of the aorta, the average was three inches and a half. In thirty-seven measurements made to determine the length of the innominate artery, the average was one inch and a half, the shortest specimens being three fourths and the longest two inches. Operation. — Place a firm cushion crosswise beneath the shoulder- blades, so that the head will fall well back, and thus draw the artery upward. Have an assistant draw the arm and shoulder of the right side forcibly downward, while the chin is elevated and the face turned slightly to the left. AVith the patient completely anaesthetized, and every arrangement made for expedition, make, from the center of the interclavicular notch, an incision about three inches in extent along the clavicle. A second incision, commencing at the inner border of the sterno-mastoideus, about two inches and a half above the clavicle, is made to unite with the first incision at the middle of the interclavicular notch. Dissect the flap up- ward until the sterno-mastoid muscle is exposed, the sternal and two 232 A TEXT-BOOK ON SURGERY. thirds of the clavicnlar origins of which should be divided upon a grooved director carefully introduced. Superficial to the muscle some small veins wiU. be found, and underneath its clavicular portion is the junction of Fig. 2V9. — Showing the relations of the part* involved in delijation of the innominate artery ; the right sub- clavian and carotid in their first divisions. the subclavian and jugular veins, in dangerous proximity. The anterior jugular veins will be seen immediately beneath the muscle, and should be tied and divided. Dissecting carefully, with the handle of the scalpel, the connective and areolar tissue in which these veins are imbedded, the LIGATION OF ARTERIES. 233 orio;ins of the sterno-Tiyoid and ster no-thyroid muscles will be reached, and, when these are divided carefully upon the director, the right carotid will be seen near the center of the wound. Following this down, the arteria innominata will be found just behind i\\e sterno-clavimlar ariicw- lation (Fig. 279). Being exposed with the scalpel-handle, or any dry dis- sector not likely to wound the vessel, the aneuilsm-needle should be passed from right to left behind the artery, care being taken to avoid wounding the right vena innominata and the pneumogastric nerve, or puncturing the pleura, in which the artery is partly imbedded. It is well to bear in mind that the left innominate vein crosses this artery, although usually very low down. When the aorta is situated low in the thorax, it may be necessary to remove the sternal end of the clavicle and a segment of the sternum, as was done by Cooper, of San Francisco, in two instances. An element of danger in this operation is the origin of an abnonnal branch from the innominate. In the cases of Lizars and V. Mott this anomaly existed, and death was caused by Jicemorrhaye at the seat of the ligature. In thirty-four consecutive subjects which I examined as to this feature, I found an abnonnal branch to be derived from the innomi- nate in five. "When the necessity for occlusion of the arteria innominata ai'ises, and the conditions are such as to permit it, the following method should be followed : The right common carotid should first be tied, one inch above its origin. By a careful dissection the first division of the subclavian and its branches should then be exposed, di-awing the internal jugular to the outer side until the vertebral is secured. Avoiding the phrenic nerve, as it descends to the inner side of the scalenus anticus, the mternal mammary and branches of the thyroid axis should be secured, and finally a ligature of large, smooth catgut, or prepared nerve placed around the subclavian artery, about the middle of its first portion. A careful study of the anatomy and surgery of this region leads me to con- clude that this procedure, though difficult of execution, offers a better prospect of success than deligation of the larger and primitive trunk, nearer the heart. In the operation and after-treatment of the wound the most careful antisepsis should be practiced, and perfect drainage maintained. Ligation of the Common Carotid Arteries and the Internal Jugular Vein— Anatomy . — In one hundred and twenty dissections I found the common carotid artery to liifurcate on a U*vel with the notch between the two aliB of the thyroid cartilage in one hundi'ed and sixteen. The anoma- lies of this vessel are so rare that they do not deserve mention in this work. Operation. — A firm cushion should be placed under the shoulders and lower part of the neck, with the chin elevated, and the face turned in the du'ection away from the side upon which the operation is to be per- formed. A line extending from the tragus of the ear to the sterno-cla- vicular articulation will cover, and be parallel with, the internal and common carotid arteries in their surgical length. This line will strike the center of bifurcation of the primitive carotid almost invariably on a level with the upper border of the thyroid cartilage, and the anterior edge of the sterno-mastuideus from one inch and a quarter to one and a half 234 A TEXT-BOOK ON SURGERY. below this level. The point of election is al)out one inch below this bifurcation, and at the npper border of the anterior belly of the omo- hyoid niu.sele. ly -I J" Fio. 280.— Showing lines of incision and relation of parts involved in deligntion of the common carotid, above and below the anterior belly of the omo-hyoid, and the external carotid below the lingual and above the facial. The incision, being made with its direction as above given, its center about one inch below the bifurcation, extending from one-and-a-half to two inches above and below this point, will divide first the integument. LIGATION OF ARTERIES. 235 and with this the thin platysma myoides, some filaments of the super- ficialis colli nerve, of no importance, and some small veins passing from the anterior, either to the internal or external jugular veins. About the center of the wound the edge of the mastoideus will be seen, and below this (usually) the anterior belly of the omo-Tiyoideus (Fig. 280, lower half). The sheath of the carotid and jugular vein is now exposed, often crossed by the thyroid veins, and the cervicalis descendcns artery, the descendcns noni nerve almost invariably lying upon the center of the sheath, being i^arallel with the axis of the common and internal carotids. In two instances I have seen the superior thyroid artery turn du-ectly down, in front of the common trunk, for an inch or more, and then turn abrui)tly inward to be distributed to the thyroid body. Under such ab- normal conditions this vessel would probably be divided. The communi- cans noni is occasionally found crossing the sheath from without inward, to anastomose with the descendens. These nerves will be drawn to the outer or inner side of the wound, as is most convenient. The sheath should be opened on its tracheal side, as far as possible from the jugu- lar vein, and the needle passed from without inward, being kept close to the artery in order to avoid wounding the rein or including the pneumo- gastric or sympathetic nerves. The sheath should be well oi:)ened, and the artery clearly exposed, so that the needle may be manipulated with more of certainty and less danger from these too common and unfortu- nate accidents. In several instances the artery has been transfixed ; the jugular has been wounded ; the pneumogastric or sympathetic nerves included in the ligature, for want of precision in separating the artery from the vein. Certainly the danger of slough in the artery is not so great as the dangers above enumerated. Just as the needle is being in- troduced, pressure above upon the vein would empty it of blood, and of course diminish the danger of wounding it. The operation of tying the carotid, just below or behind the omohyoid, is practically the same as that just described (Fig. 280). In order to secure this vessel at the root of the neck, an incision shoidd be made in the carotid line, extending from the sterno-clavicular articu- lation upward a distance of three or four inches, and between the two heads of origin of the sterno-mastoid muscle. This wUl divide the integu- ment, superficial fascia, platysma, and deep fascia, and some descending superficial nerves. The fibers of the sterno-mastoid may be sei)arated and held to either side by retractors. Immediately beneath it will be found the anterior jugular vein, and some small branches emi)tying into it. If not easily displaced, they should be secured with a double liga- ture, and divided between the threads. The fibers of the sterno-hyoid or sterno-thyroid muscles should next be divided on a grooved director, and turned aside or separated in the line of the artery. The vessel will be seen deeply situated in the line already given. The ligature should be passed from the outer side. Or an L-shaped incision, similar to that made for deligation of the innominate (Fig. 279), may be made, and the carotid found by separating the sternal tendon of the mastoideus muscle and turning this outward. F©r the left carotid see Fig. 281. 236 A TEXT-BOOK ON SURGERY, The approach to the vessel in this region should be very cautious, espe- cially ui)on the left side of the neck, since the internal jugular vein crosses from the outer to the inner side by the front. On the right side 4 I'm m Fig. 281. — Showincr the relations of parts involved in deli'jation of the left carotid, at the root of the neck, and the letl subclavian in its tirst surgiciil division. the vein is a little more external. The pneumogastric nerve lies behind and to the outer side of the artery, while the inferior thyroid artery and sympathetic nerve are more deeply situated. The aneurism - needle LIGATION OF ARTERIES. 23^ Flo. 282.— Showing the relations of the important organs at the root of the neck and apex of the thorax. Frozen horizontal section at the level of the third dora;il vertebra. (After Braune.) 1. Innominate. 2, Left carotid. 3, Left subclavian. 4, Right subclavian arteries. 5, 6, Left and rii;lit innominate veins, 7 and 8, Subclavian veins. 9, Inferior thyroid vein. 10, Trachea. 11, (Esophagus. 12, Spinous process of second dorsal vertebra, a a, Pneumogastric nerves. 6, Phrenic nerves. 238 A TEXT-BOOK ON SURGERY. should be passed around the artery, from the outer toward the innei side. In the "Prize Essay" of the American Medical Associnticm for 1878 I collected histories of 789 cases in which the common can it id artery had been tied for all causes, of which 323, or 41 per cent, died. An analysis of these cases is impossilde hei'c. I do not believe tiiat the death-rate will ever again reach this alarming iigure. The introduction of animal ligatures and antisepsis have already greatly diminished the death-rate in operations upon the arteries. Fio. 283. — Horizontnl section at the level of the seventh cervical vertebra. 1, 1, Tlie right and Ictl com- mon carotiil urtcrie* and the internal .ju.'ular veins. 2, The rii.'lit and left vertebral arteries and veins. Directly between the vertebral and carotid arteries is seen the svmpatbetie nerve and the interior thyroid artery and sotne of itii branches. Tlic pneumoijastric nerves are seen between and sliiihtly posterior to the internal jugular veins and the common carotids. 3, Trachea. 4, (Esophajriis. .'j, Transversalis colli artery and veins and descending branches of the subclavian ailery. 6, Cords of brachial plexus. 7, 7, External jugular vein, (.\fter Braune.) Thirty-four cases are on record in which both trunks were tied, of which twenty-five recovered.* Ligation of fhe Internal Carotid Artery — Anatomy. — This vessel is a direct continuation of the common trunk, and, while straight in its lower portion, it becomes slightly tortuous as it approaches the carotid canal. An abnormal branch was found to be derived from its first portion in seven of one hundred and twenty dis.sections. Operation. — The positicm is the same as for tying the common trunk. * Op. cit. See also Riegner's case, "Centrulblatt fiir Chirurgie," No. 26, 1884. LIGATION OF ARTERIES. 239 The incision should be made in the carotid line, with its center from one half to three quarters of an inch above the upper border of the thyroid cartilage. The same structures will be divided supei-tioially, and the veins will be seen superficial to the artery. As shown in C7, Fig. 285, they Fio. 284.— The usual relation of the contents of the surgical triangles of the neck. From the author's dissections. may cross the internal carotid almost at a right angle, or (as in A or B) they may empty into a single trunk, and run parallel with the external carotid. This last is the most usual way. but it will be scarcely possible to ligate the internal carotid without ligature and division of some of 240 A TEXT-BOOK ON SURGERY. these veins. The descend ens-noni nerve will be seen running along the artery, the liypocjlossal crossing it about one inch from tlie bifurca- tion. The vessel being ex])osed, the needle is introduced on the out- Fig. 285. — Relation of tho veins to the carotids. (Life size.) er side, avoiding the jugular vein and pneumogastric nerve exter- nally, the external carotid internally, and the hypoglossal nerve su- perficially. The pharyngea ascendens is in intimate relation to the internal carotid, running parallel with it on its inner aspect. Occa- sionally the first cervical ganglion of the sympathetic extends as low- as this point. It will be avoided by keeping the needle close to the artery. The internal carotid artery has been tied nineteen times, w^ith twelve recoveries.* In six of the fatal cases the common trunk had been pre- viously and ineffectually secured, and in the remaining case I tied the common, external, and internal carotids, in removing an immense tumor which involved these vessels. The patient died from shock in eighteen hours. Ligation of ilie External Carotid Artery . — From the extensive dis- tribution of its branches to the exposed portions of the neck and face, the external carotid artery demands a more careful consideration than any single vessel of the human body. * Op. cit. LIGATION OF ARTERIES. 241 Anatomy. — Leaving the common trunk at the upper border of the thyroid cartilage, well forward of the anterior border of the sterno- mastoid muscle, this vessel arches forward and upward (its concavity looking toward the lobule of the ear) until, on an average of "92 inch above the bifurcation, after giving off the facial branch, it turns ob- liquely upward and backward to a point opposite the insertion of the external pterygoid muscle into the neck of the condyle of the lower jaw, where it tenninates by dividing into the temporal and internal maxillary arteries. Eight regular branches belong to this vessel (though some anatomists, among whom are Hyrtl, Wilson, and Richardson, describe nine). On its anterior aspect arise from below, upward, the thyroidea superior, lingual is, maxillaris externa, and maxillaris interna. On its poste- rior and internal aspect the pharyngea ascendens, and posteriorly the occipitalis, auricular is, and temporalis. Anterior temporal. Posterior temporal. Auricular. Occipital. — Stemo-mastoid. Pharyngeal. Transverse facial. -- Internal maxillary. -- Parotid branches. — Ascending palatine. -- Tonsillar. '" Facial. Lin^'ual. '--Hyoid branches. Superior thyroid. Descending cervical. Fig. 286. — The external carotid and its branches. The average arrangement of one hundred and twenty-one dissections by the autiior. (Life size.) The usual arrangement of these branches is seen in Fig. 286, which is the average of one hiindred and twenty-one dissections. Abnor- mal deviations from this relation of the branches to the parent trunk .16 242 A TEXT-BOOK ON SURGERY. occur occasionally, and types of these may be seen in Figs. 287 and 288. The relations of the veins to these arteries are shown in Fig. 283. Operation. — The external carotid may be tied in the majority of cases at two points, viz., between the origins of the thyroidea superior and Ungiuilis, about one quarter of an incli above the sei)tuni of bifurcation (see Fig. 280), or between the origins of the max/Uari.s exlcnut and auri- cularis, about one inch and a half above the thyroid cartilage. At the lower point of election the operation is the same as for ligature of tlie internal carotid on the same plane, except that the external carotid is usually from one quarter to one half inch nearer the median line than the internal. Notwithstanding that the analysis of one hundred and twenty-one consecutive dissections has convinced me of the propriety of ligatuiing Fig. 287. ^Unusual arraneement of the branches of the external carotid. 1, The linjual and facial from a common oriirin. 2, "The lingual and facial superior thjroid from a common ori^'in. 3, Close relation of first five branches to each otlier. this vessel, and that the history of the cases in w^hich it has been tied shows a rate of mortality far below that of ligature of the common carotid, yet the proximity of large and important branches to each other, or to the bifiircation of the common carotid in many instances, makes it of the utmost importance that the surgeon should proceed with great care and discretion. The wound should be thoroughly cleansed, and the vessel LIGATION OF ARTERIES. 243 examined with sci'upulous care above and below the ligature, and any collateral branch or branches within less than one quarter of an inch should be also secured. Should the artery be found to be normal (as in Fig. 286), I would place the ligature nearer the lingualls than the bifurcation, and tie this vessel separately. If (as in Fig. 287, 3) a rare form should exist, I would ligature close to these branches, and tie each of them in its turn. This same conservative rule iiiust apply to every case. The operation at or above the posterior belly of the digastric is com- paratively safer, and is applicable to all lesions above this point. The incision should extend from the lobule of the ear along the ramus of the jaw, down to the level of the thyroid cartilage. Cutting through the superficial structures, the artery will be found just behind the posterior belly of the digastric muscle. Above this level — that is, after the artery enters the parotid gland — it is so situated that it should not be cut down upon. The incision would involve tl^ie facial nerm, causing paral- ysis of the muscles of expression. In malig- nant disease of the parotid, where this gland is removed, the vessel may as well be secured here as not, since the operation itself usually destroys the facial nerve. It is a remarkable fact that, notwithstanding the close proximity of the branches of the ca- rotid, in a number of instances in which it has been ligatured without the precaution of secur- ing immediate collateral branches, there has not followed secondary haemorrhage. No explana- tion of this fact has appeared so delinite as the one given by Prof. H. B. Sands, "which takes into account the remarkable reparative power of the tissues surrounding this vessel. Sui:)pu- ration is extremely rare, the wounded tissues soon become consolidated by plastic material, and secondary haemorrhage is prevented by changes occurring outside of, as much as by changes taking place loithin, the vessel liga- tured." On account of the importance of maintaining the integrity of the circulation to the brain, ligation of the common carotid, for a lesion in the distribution of the external carotid, should never be perfonned when a sufficient distance remains between the lesion and the bifurcation of the common trunk to allow of the ajiplication of the ligature. I have the histories of ninety- three cases of ligature of the external carotid, in sixty-nine of which this vessel alone was tied. Of these sixty-nine cases only three died, while Fio. 288. — An enlarsjed superior thyroid artery. 244 A TEXT-BOOK ON SURGERY. the death-rate after ligature of the common trunk, for the same period, was 41 per cent. Ligation of tlie Superior Thyroid Arterij — Anatomy. — Tliis branch was present in every instance in one hundred and twenty-one dissec- tions. It originated almost invariably on a level with the thyroid notch. In one of twenty-five cases it wiU be found to have a com- mon origin with the lingual, or the lingual and facial. See Fig. 287, 1, 2. Operation. — With the neck in the surgical position, i. e., with the head thrown back and the face turned to the opposite side, make an in- cision two inches long, parallel with, and one fourth of an inch in front of, the carotid line. The center of this incision must be on a level vdth the thyroid notch. Immediately beneath the skin and platysma myoidea will be seen the thyroid., lingual, hyoid, and other veins, which may assume either of the forms or relations shown in Fig. 285, A, B, being most conmion. These being tied and divided, the artery will be found opposite the point above indicated. The thyro-hyoid nerve wiU occasionally be seen passing across this artery, although usually nearer the median line. The external laryngeal passes beneath it. Ligation of the Lingual Artery — Anatomy. — From its origin, usu- ally opposite the cornu of the hyoid b(me, it ascends obliquely upward and inward, and is superficial until it passes underneath the xtyJo- hyoideus and digastricus (posterior belly), and then more deeply behind the hyo-glos.ms. In two of one hundred and twenty-one cases it originated in common with the superior thyroid, and in two other instances with this vessel and the facial. In thirty-one of one hundred and twenty-one cases it arose from a trunk common to it and the facial, being abnormally associated in one in every three and a half dissections. Operation. — The lingual artery may be secured either below the digastric or above this point, where it passes beneath the hyo-glossus. For the low operation make an incision as in the case of the superior thyroid, except that its center should be opposite the os hyoides. The artery Avill be found in the lingual triangle, bounded posteriorly by the external carotid, above by the digastric muscle, below by the os hyoides. The middle constrictor muscle is behind it ; the platysma myoides in front, and under this the veins above noted. The hypoglossal nerve is usually just ahore it as it ci'osses the carotid, while the thyro-hyoid branch of this nerve crosses the artery on its way to the muscle it supplies. The high operation is one of considerable difficulty. The face should be well turned to the opposite side, the chin elevated, and held per- fectly immovable. Beginning immediately over the os hyoides, near the median line of the neck, an incision is made outward, and parallel with this bone as far as the great comu, where it is curved upward to the angle of the jaw (Fig. 289). Tliis crescentic Hap is turned up, and with it the sub-maxillary gland, in a gi'oove on the under surface of which LIGATION OF ARTERIES. 245 the facial artery runs. As soon as the hyoid bone is exposed it should be fixed with a tenaculum and drawn steadily down. The posterior # .^^ Fig. 289.— Ligation of the right subclavian in its third surgical division ; the facial in the neck and the lingual beneath the hyo-glossus muscle. belly of the digastric will now l)e seen passing obliquely downward and forward to the central tendon in the hyoid bone. Passing beneath this muscle, and superficial to the hyo-glossus, is seen the hypoglos- 246 A TEXT-BOOK ON SURGERY. sal nerve, wliich runs ])arallel with and above the artery, depress the posterior belly of the digastric, insert a director beneath the posterior fibers of the hyo-glossus, and divide these. The artery will be found just beneath this muscle, resting upon the middle constricitor of the I)harynx. The ligation of this artery is frequently practiced ])reliminary to ex- cision of the tongue for malignant disease, and occasionally to arrest hajmorrhage. Ligation of the Facial Artery — Anatomy. — The facial artery was present in one hundred and twenty of one hundred and twenty-one dis- sections. In the instance in wliich it was missing its facial distri'.nition was taken by the transverse facial from the temporal, and its cervical by branches from the linyital and the external carotid. Its origin is usually about one fourth of an inch above the lingual. It is the long- est branch of the external carotid. In thirty-one of one hundied and twenty cases it arose in common with the lingual, and in two in- stances it was from a trunk in conuncm with this artery and the su^^e- rior thyroid. Operation. — In its cervical distribution this vessel will require to be tied at or near its origin from the carotid. The incision alpng the axis of the carotid, as given before, with its center a quarter of an inch above the hyoid bone, will lead to the facial. The posterior belly of the digas- tricHS wiU be found with its center usually above the origin, but soon crossing the artery. The ninth nerve is just below. For lesion of this vessel in the face it can be readily secured as it crosses the inferior maxilla in the depression at the anterior border of the masseter (Fig. 290). Before making the incision, which should be parallel with the horizontal portion of the inferior maxilla, the skin should be well pulled up from the neck, so that, after healing, the cicatrix will fall be- low the jaw. Ligation of the Ascending Pharyngeal — Anatomy. — This artery was derived from the external carotid in one hundred and eleven of one hundred and twenty-one cases, and from the infernal ca- rotid in four others. It usually comes off at a point opposite the origin of the lingual, and occasionally from the bifurcation of the primitive carotid. A pharyngeal branch is not uncommon from the occipital. Operation. — The external carotid must be exposed by an incision the center of which is opposite the level of the hyoid bone. The vessel wUl be seen ascending between, and parallel with, the external and internal carotids. One fatal case is recorded from haemorrhage after a wound of the ascending pharyngeal. Ligation, of the Occipital Artery — Anatomy. — The occipital was present in one hundred and twenty of one hundred and twenty-one dis- sections, and it was found to be opposite the facial in the majority of cases. In the subject in which it was missing, a large branch from the inferior thyroid (not the ascending cervical) took its distribution. Not LIGATION OF ARTERIES. 247 infrequently the posterior auricular or a pharyngeal branch arose from this vessel. Operation. — It may be secured near its origin, or behind the mastoid process. For the low operation, make an incision in the carotid line, the center of which is about one inch above the thyroid notch. After divid- Fio. 2a0. — Ligation of the posterior tcmporul at iLe zygoma, and ol' tlie I'ucial upon the interior maxilla. ing the deep fascia the hypoglossal nerve will be seen, which, if followed backward, will lead unerringly to the artery, underneath which it winds. The posterior belly of the digastric muscle will usually require to be lifted upward. Behind the mastoid the occipital may be tied where it passes beneath 248 A TEXT-BOOK OX SURGERY. tiie cranial attachment of the sterno-mastoid miisch' (Fig. 291). From one half to three fourths of an inch behind the mastoid process an in- cision about two inches long should be made, extending upward and backward. The aponeurosis of the sterno-mastoid muscle is divided on a directoi', and the artery exposed. The constant relation of this vessel Fio. 291. — Ligation of the occipital behind the mastoid process and the common temporal near the zygoma, also showing the relations of the facial nerve to the terminal portion of the external carotid. to the gi'oove on the under surface of the mastoid process will serve as a valuable guide. The common carotid has been tied in several instances for lesions of the occipital. This should never be done. Ligation of the Posterior Anric^dar — Anatomy. — In eleven of one hundred and twenty-one dissections this vessel arose from the occipital, and in four it was absent. Its origin is usually one inch and four lifths above the thyroid notch. LIGATION OF ARTERIES. 249 For anatomical reasons, in lesions of this artery tlie external ca- rotid should be tied, just above the posterior belly of the digastric, between its origin and that of the occipital . It runs under the pa- rotid gland, is crossed by the facial nerve, and has beneath it the spinal accessory. Ligation of the Temporal and Internal 3faxillary Arteries — Anat- omy. — The temporal and internal maxillary arteries begin at the termi- nal bifurcation of the external carotid, in the substance of the parotid gland, at an average distance of two inches and nine tenths from the thyroid notch. Operation. — The temporal artery may be secured by a perpendicu- lar incision immediately in front of the tragus of the ear, where it crosses the zygoma superficially (Fig. 291). For lesions of this vessel above the temporal fossa, and often in wounds in this region, the ligature will be unnecessary, since direct compression, by means of the knotted bandage, will suffice. AVhen either this artery or the internal maodl- lary are wounded in the substance of the parotid gland, the external ca- rotid should be tied at the posterior belly of the digastric. The same procedure is indicated in lesions of the internal maxillary, in its deej)- er portions. Ligation of the Internal Jugular Vein. — The intimate relation of this vein to the internal and common carotid arteries renders it accessible by the same incisions laid down for the ligation of the arteries. The vein is contiguous to the artery, and is external and slightly superficial to it. On the left side, at the root of the neck, the Jugular comes more to the front, while on the right side it tends to the outer side. The rules which apply to the ligation of arteries apply with equal force to the ligation of veins. The jugulars should be encircled vdth a,n animal ligature, not tied with a lateral loop, as has been practiced. The aneurism-needle should be passed from the inner side.* The anterior, external, and posterior jugular, and other veins of the neck, do not demand especial consideration. When, in operations in the neck, it becomes necessary to divide them, a double catgut should be applied, and the vessel divided between the two ligatures. The Subclavian Arteries and their Branches — Anatomy. — The right subclavian, lai'ger, shorter, and more superficial at its origin than the left, is derived from the innominate behind the origin of the carotid, about the level of the upper margin of the clavicle (more frequently above than below this line), behind the interval between the two tendons of the sterno-mastoideus. It is the direct continuation backward, upward, and outward of the (trch of the innominate, and is continuous with the axil- lary artery, at the lower edge of the first rib. Its average length is 2'83 inches. The left snhclavian, derived l"2'i inch beyond, to the left of, and more deeply situated in the thorax than, the innominate, travels almost verti- * See Prof. S. TV. Gross's admirable article in " Ataerican Journal of the Medical Sci- ences," 1867. 250 A TEXT-BOOK ON SURGERY. cally upward, until it mounts above the upper surface of the first rib, when it curves very abruptly outward and downward, passing behind the scalenus anticus and thence to the lower edge of the first rib. Its length, in the average, is 3 '74 inches. Each subclavian has three surgical divisions. The first division of the right artery is from its origin from the innominate to the inner bor Cerviealis ascouduna. Thyroiden 1 inferior, f Transversa- ) _ .^ ■ M Werfebnalis lis colli, f Scapuliiria [losterior. f jg^^ ^^ig^ _jxs ,mK, " "" ILr*, Suprascapu- i ■^^-»^»^ «.m -^bk,. ^ lario. f Intcroostalis ( superior, f Mammaria I interna. | Arteriae Coronariae Flo. 292.— Relation of the {jreat vessels to each other at their origins from the arch of tlie aorta, and the rela- tion of Ujc branches of the subclavian arteries to each other, i'rom the author's dissections. der of the scalenus anticus. That of the left artery, from its origin at the arch of the aorta to the inner border of the left scalenus anticus (Fig. 292). The second and third portions of bf)th vessels are identical as re- gards direction and relation, being different in the origins of their respective branches. The second surgical division of each is entire- ly to the inner side of the inner border of the first rib. The tJdrd portion rests chiefly on the upper surface of the first rib, and extends from the outer border of the scalenus anticus to the lower border of this rib. The first portion of the rigJd subclavian varies from three fourths to one inch and a half in length, the average length being 1'15 inch. The first portion of the left ai-tery varies from one inch and a half to three inches, the average length being 2 "06 inches. LIGATION OF ARTERIES. 251 Transverse Cervtcaf The second portion of the rigM subclavian averaged '58 inch, the same division of the left subclavian being -56 inch in length. The third portion of the right artery is a little less ; the same division of the left subclavian a little more than I'll inch in length. Nine important branches arise directly or indirectly from tlie subcla- vian arteries : the vertebral, internal mammary, transversalis colli, suprascapular, inferior thyroid, cervicalis ascendens, superior inter- costal, profunda cervicis, and posterior scapular. The rigid vertebral, the branch most constant in origin, arises from the superior and posterior aspect of the main trunk (Fig. 293) and passes upward to the verte- bral foramen, in the AscendingCervical \ sixth cervical verte- bra ; at times to the ■fifth ; less frequently to the fourth. The relation of this branch is important. In the vast majority of sub- jects it will be found between one fourth and three ft)urths of an inch to the inner side of the inner mar- gin of the scalenus anticus. The left vertebral (Fig. 292) arises, in ^ t,, ^ , • , ^ , • ^ ■ , , r. ^ ° ' Fig. 293.— Plan of the ritrht subclavian artcvv and its branches. From 4 per cent of cases, the author's dissections. (.Alter (Juaiu.) from the aorta. In most subjects it will be found within three fourths of an inch of the left scalenus muscle. The internal m am ma rg artery arises at the inner border of the sca- lenus anticus. It is occasionally from the thyroid axis. The phrenic nerve passes usually in front, occa,siona]ly behind it. Beliind the costal cartilages it runs parallel with the edge of the sternum, about half an inch external to it. The thyroid axis arises also just within the scalenus. The inferior thyroid branch arises from the axis, in almost every case on the left side. On the right, in twenty-six cases examined, it originated from the in- nominate in three, and directly from the subclavian in three instances. It passes upward (inclining at first a little inward) until it arrives at a point between the third and seventh (incomplete) rings of the trachea, where it turns abruiitly inward, going behind the common carotid and jugular, in front of the vertebral, and is distributed chiefly to the lower portitm of the thyroid body. The transversalis colli passes outward in front of the scalenus muscle and the phrenic nerve, underneath the omo-7iyoid, and in front of or 252 A TEXT-BOOK ON SURGERY. between the cords of the brachial plexus, and is distributed to the tra- pezius muscle, sending a branch in the direction of the posterior border of the scapula, which anastomoses with the jmdcrior .vapiilar artery ; and, when this last vessel is not present, this des(!(mding branch is con- tinued along the border of the scapula to anastomose with the subscapu- lar liranch of the axillary. The suprasrapular artery, intimately associated with the preceding, travels suddenly downward and outward from its origin near the inner edge of the scalenus antlcus, passes between the subclavian artery and vein, in front of the phrenic nerve, crosses in front of the third division of the main trunk, and goes to the suprascapular fossa under the protection of the clavicle, anastomosing with the dorsaUs scapulae. of the subscapidaris. It gives off a branch (frequently wounded in operations in this vicinity) which pass(;s behind the steriio-niastoideiis and along the upper border of the manubrium. (It is nut usually men- tioned.) The right siqM'rior iidercostal artery comes from the second division of the subclavian in almost every instance ; occasionally from the first. The left is usually from the fii-st division. The posterior scapular, one of the most important branches of the subclavian, in a surgical view, since it must be in dangerous proximity to a ligature applied in the third surgical division (not given in many standard text-books, except as an occasional branch of this artery), was present in thirty-six of fifty-two dissections, or 69 per cent. It was jiresent in nineteen of twenty-six on the rigJit side, and in seventeen of twenty-six on the left. In twenty-three of the thirty-six cases in which it was present it was derived from the third division ; in the remaining thirteen, from the second division, close to its outer limit. On the right side 74 per cent came from the subclavian, within one fourth of an inch to the outer and inner side of the external border of the scalenus muscle ; 26 per cent external to this. On the left side 82 per cent were within one fourth of an inch to the outer and inner side of the line dividing the middle and external thirds of the main trunk ; 18 per cent were to the outer side of this. The tend- , ency of this important branch is to originate near the scalenus, i. e., within one fourth of an inch of its outer edge. When this vessel is present the transversalis colli is small, and when absent the descending branch of the transversalis takes its distribution. Passing outward be- hind the most superficial cords of the brachial plexus, it tiirns sliarjily downward, along the posterior border of the scapula, to anastomose with the subscapular branch of the axillary. Operation — The Right Huhclaman in its First Surgical Division. — The incisions are the same as for the arteria-innominata (Fig. 279). When the sterno-hyoid and sterno-thyroid muscles have been divided on the director, the internal jugular vein will be seen directly in front of the artery. It may be drawn to the inner side (or outer, if more convenient), carefully using for this purpose a dull retractor. Care must be exercised not to injure the pleura which rises against the LIGATION OF ARTERIES. 253 artery in deep inspiration. A dull-pointed aneurism-needle may now be passed around the vessel, taking care not to wound the subclavian or innominate vein, or the recun-ent laryngeal nerve. The vertebral, internal mammary, and branches of the thyroid axis, should also be secured. The conditions which will justify this operation will rarely occui-, yet, when the operation is demanded, every source of danger from haemor- rhage should be avoided. The necessity of securing the carotid at the same operation must be determined by the ojjerator. I am of the opinion that it is safer to occlude this vessel also. The suhclaman artery has been tied in its first surgical division eight- een times, and all fatal. In five of these cases the common carotid was also tied. In only one case was the left subclavian tied. Of the thirteen single operations, two (Ay res and Bullen) were for the arrest of hgemor- rhage from shot wounds in military practice, with one death in half an hour and one on the eighth day, from hsemorrhage. The other eleven cases are given on page 221. In only five of these thirteen cases is the source of hemorrhage stated, and in each of these the bleeding was from the distal side of the ligature, the proximal side being closed.* A knowledge of this fact leads me to insist upon the ligation of the verte- ])ral and other branches of the first division. In five instances the right carotid was also tied simultaneously by Liston, Parker, Hobart, Cruveilhier, and Kiihl. In three of these, fatal haemorrhage ensued from the distal side of the ligature. The left suholavian artery was tied in its first division once by Rodgers, and fatal ha?morrhage occurred from the distal end of the artery. Ligation of the Left Subclavian Artery in its First Surgical Divis- ion — Operation. — From a point on the clavicle one fourth the distance from the center of the interclavicular notch to the acromion process com- mence an incision, and carry it to the inner border of the sternal tendon of the mastoid muscle. From the inner extremity of this line carry a second incision for three inches along the anterior border of the sterno- mastoideus. In dissecting this flap lift with it the mastoid muscle divided upon the director, then divide the sterno-hyoid and thyroid muscles, and feel for the pulsation of the artery, which ascends deeply behind and a little outside the sterDO-clavicular articulation. The internal jugular vein will be drawn outward, and, passing the finger along the inner bor- der of the scalenus muscle, the artery will be felt to pulsate (Fig. 281). The thoracic duct usually is to the right of and a little behind the artery opposite the upper border of the sternum. On a level with the insertion of the scalenus it arches to the left, crosses in front of the subclavian, in front of the scalenus, behind the internal jugular, and curves down- ward to empty into the subclaiiian at its junction with the jugular to form the left innominate vein. On account of the intimate relations of the thoracic duct to the left subclavian artery as this vessel goes behind * The autlior's "Essays," William Wnod & Co., 1878. 254 A TEXT-BOOK ON" SURGERY. the scalenus, the ligature should not be attempted close to this muscle, nor should the dissection be carried fully to the scalenus. The artery should be tied as low down as possible, the duct being less likely to be injured here, since in passing behind the aorta it is deeper than the artery. It will be found behind and to the right, the pneuniogastric in front and to the right, the left vena innominata crossing in front, while the pleura is directly behind. The vertebral and other branches of the left subclavian are in such proximity to the thoracic duct that it will be dangerous to attempt to tie them at this point. Ligation of the Subclavian Arteries in their Second and Third Sur- gical Divisions — Operation. — The procedure is essentially the same on the two sides. Place the shoulders upon a cushion, pull downward on the arm of the side to be operated upon, and turn the i)atient's face to the opposite side. Find the location of the scalenus anticus, as in the pre- ceding operation. Slide the skin well down upon the clavicle, and along this bone make an incision three or four inches in length, commencing one inch to the inner side of the scalenus muscle and terminating near the anterior edge of the trapezius. Allowing the skin to resume its nor- mal relations, the incision will be carried above the clavicle. Upon a director divide the outermost of the clavicular fillers of the mastoid muscle. The internal jugular vein, seen in the anterior portion of the wound, will be carefully drawn to the inner side, the operator keeping well above the junction of this with the subclavian, and thus avoiding the lymphatic duct. A x>i'<>niinent plexus or group of veins, viz., the external Jugular, transversalis colli, and suprascapular, will be seen traversing the wound, coming from their respective oiigins, tf)ward the subclavian, near the Jugular. These should be secured with a double ligature, and divided, or held aside. Dissecting carefully, the suprascapular and transversalis colli arteries will be observed running, in general, in the dii'ection of the first incision. The posterior belly of the omo-hyoid may be found in the upper margin of the wound, crossing the scalenus at about a right angle. The transversalis colli and the suprascapular may be secured or held to one side, the finger passed along the scalenus until the tubercle on the first rib is felt, immediately behind which the artery will be found. If it shall have been detennined to tie the artery in its second portion, the scalenus anticus muscle will be cut upon a direc- tor, the operator being careful to avoid the phrenic nerve, which cr.osses the muscle in front, coming from above downward and inward, (It is between the layers of the sheath of this muscle.) The ligature is next passed around the artery from before backward, care being taken not to wound the pleura. If the third division of the artery is to be secured, the part of the above operation relating to the division of the scalenus will be omit- ted. The nearest cord of the brachial plexus must be carefully ex- cluded, posteriorly to the artery ; the subclavian vein in front and be- low (Fig. 289). LIGATION OF ARTERIES. 255 The subclavian arteries have been tied behind the scalenus anticus thirteen times, with four recoveries. All of the fatal cases were on the right side. In one of the "Prize Essays" of the American Medical Association I j)ublished the histories of two hundred and fifty-one ligations of the sub- clavian artery in its third surgical division, of which one hundred and thirty-four ended fatally. As far as these histories relate to aneurism they have been given. A study of the remaining cases led me to con- clude that in all lesions causing dangerous haemorrhage in the upper l>rachial or axillary regions an effort should be made to control the bleed- ing at the seat of injury. Failing in this, deligation of the subclavian, in its third division, is demanded. Ligation, of the Vertebral Artery — Operation. — Locate by pressure the carotid tubercle (the transverse process of the sixth cervical vertebra). The point at which the artery is to be secured is one inch directly below this bony prominence, which must be the center of a perjaendicular in- cision, four inches in length. Commence the incision at the outer bor- der of the sterno-mastoid muscle, where the external jugular vein crosses. The internal jugular is seen and drawn inward. The transverse cervical artery, and one or two smaller veins, are met with next, and drawn to the outer side of the wound. The scalenus anticus muscle is now brought into view, and to the inner side of this a depression be- tween this muscle and the lougus colli. In this sulcus the artery lies, the vein being in front of it. In my case I had to tie the vein with a double ligature, divide, and turn the ends aside in order to secure the artei'y. Ligation of the Internal Mammary — Operation. — This vessel may be secured, as has been described, close to the parent trunk, or ir may be tied in one of the intercostal spaces. In the third or fourth space make an incision, about two inches in length, obliquely from without inward and d(j\\Tiward, the center of which should be about half an inch external to the edge of the sternum. Divide the fibers of the pectoralis major and the intercostal muscle, and clear away the tissues with a blunt-pointed instrument. The artery, with its vense comites, will be seen in front of the libers of the triangularis sterni, which sepa- rates it fi'om the pleura on the right and the mediastinum on the left side. In separating the veins from the artery, care should be taken not to break through the tliin structui-e between the vessel and the cavity. The other branches of the subclavian artery do not require especial consideration. The inferior thyroid is often tied in the removal of goitre. I have, in six operations, found and deligated it prior to ab- lation of a bronchocele. It ^vill usually be seen on the tracheal side of the common carotid, just below the anterior belly of the omo- hyoid. Ligation of the Axillary Artery — Anatomy. — This artery may be tied at any i)art of its course. On account, however, of the difficulty of approach of that portion beneath the pectoralis minor, it is usually 256 A TEXT-BOOK ON SURGERY. secured in the axilla, below this point, or between the npper margin of this muscle and the lower border of the first rib. Operation. — AVith the head thrown back and the shoulders elevated, allow the arm to remain by the side of tlie body. About two inches from the sternal end of the clavicle, and half an inch below its inferior border, carry an incision outward, parallel with this bone, a distance of from three to four inches. This incision may divide a sui)erticial vein which passes from the cephalic over the clavicle. The clavicular libers of the pectoralis major and the costo-coracoid mend)rane are divided ui)on the director. The axillary vein will then be seen in the auteiior por- tion of the wound, lying in front of the artery, which may be felt to pulsate, or seen Just external to it. More extcrniil still may be seen the anterior cord of the brachial plexus, while in the lower poition of the wound the cephalic vein crosses over to empty into the axillary, below the clavicle. Beneath the clavicle the subclavius muscle may be seen. The needle should be passed from before backward. If necessary, a second incision may be made, beginning in the center of the first and carried in the direction of the axilla, as recommended by Cham- berlain. This operation is somewhat more difficult than ligation of the stih- clavian in its third division, but it is preferable, on account of being farther removed from the heart. Delpech advised an incision beginning at the junction of the middle and outer third of the clavicle, and sepa- rating the deltoid and pectoralis muscles. Operation below the Pectoralis J//«o/\— Shave and cleanse the axilla, and extend the arm at a right angle to the body. Divide the dis- Fia. 294. — Ligution of the axillary in its lower third, tance between the two folds of the axilla into thirds, and the junction of the anterior and middle thirds will indicate the position of the artery. On this line make an incision in the axis of the arm, well up into the ax- illa. Cutting through the sldn and fasciie, the contents of this space will LIGATION OF ARTERIES. 257 be seen. The vein lies internal to the artery, often overlapping it, and should 1)6 drawn carefully backward. The median nerve overlies the artery, or is on its anterior aspect, and should be drawn forward when the needle is passed from behind forward (Fig. 294). Ligation of the BracTiial Artery — Anatomy. — This artery lies in the furrow along the inner border of the coraco-brachialis and biceps muscles, tending more and more to the front as it nears the elbow-joint. In the lower half or three fourths of its course it has its venae comites on either side, with occasional commu- nications across the track of the ar- tery. The median nerve crosses it by the front, from the outer side, on its way to the forearm, while the basilic vein is well to the in- ner side. As this vein passes up toward the axilla it pierces the deep fascia, and lies on the inner side and close to the artery. Joining with the venae comites to form a single large trunk. Operation. — A line drawn from the junction of the middle and ante- rior thirds of the axillary space (as above given) to the middle of the elbow-joint, in front, will pass over the brachial artery in its entire length. The place of election is the middle of the arm. At this point make an in- cision, three inches in length, over the artery and in its axis. Divid- ing the skin and deep fascia, the white cord of the median nerve will be first seen, on the outer side of the lirachial, overlapping the comjjanion vein on this side. Just internal to this is the artery, with the other ac- companying vein and the basilic in close relation (Fig. 295). The liga- ture should be passed from the in- ner toward the outer side. The op- IT Fio. 295. — Ligiitioa of the biiK-liial oear the middle and the lower third. 258 A TEXT-BOOK ON SURGERY. eration above this i^oint is essentially the same. lu the lower third of the arm proceed as follows : On a level with the condyles of the Immenis, and between the median basilic vein and the tendon of the biceps, commence an incision, which is carried upward three inches in the brachial line. Cutting througb the deep fascia, the artery is readily found to the radial side of the median nerve, and surround- ed by its veins (Fig. 297). The needle is passed from the inner side. Occasionally the brachial artery is double, while more frequently it bifurcates into the radial and ulnar, at a varying distance above the elbow. Ligation, of the Ulnar and Radial Arteries. — The radial artery may be tied immediately above the Avrist, or in the upper third of the arm. Operation at tlie Wrist. — A vertical incision, one inch and a half long, is made in the center of the depression, between the outer bor- der of the radius and the radial border of the extensor carpi radialis muscle. Immetliately beneath the deep fascia the artery will be ob- served, -with its vence comites, from which it is separated and tied (Fig. 296). To tind the artery in the upper third, draw a line from the middle of the elbow-joint, in front, to the styloid process of the radius. Along this line make an incision, about three inches in length, avoiding the supeiiicial veins, if possible. Cutting directly down, the artery will he found between the supinator longus externally and the pronator radii teres on the idnar side. The radial nerve is well to the radial side, and the venpe comites on either side (Fig. 297). The ulnar artery may be tied at the bend of the elbow, and near the wrist. As it passes beneath the pronator radii teres and Hexor muscles, it is so deeply situated that an attempt to deligate it here is not justifi- able. Above this point it may be secured by a downward extension of the incision given for Kgature of the brachial at the bend of the elbow (Fig. 297). Near the wrist- joint an incision should be made about a quarter of an inch to the radial side of the tendon of the flexor carpi idnaris miiscle. This incision should commence one inch above the level of the pisiform bone, and extend upward one inch. The ulnar nerve will be seen jjartly concealed by the tendon, while the artery and its accompanying veins are immediately on its radial side (Fig. 296). Ligation of the Intercostal Arteries — Anatomy. — The artery lies be- hind and near the lower border of the rib, the vein above, and the nerve below it. From near the angle of the rib to the vertebral column it is separated from the thoracic cavity by the pleura alone, but in front of this it runs between the two layers of intercostal muscles. Operation. — An incision should be made just along the lower bor- der of the rib. After passing through the outer plane of intercostal muscles the artery may be seen and secured. Or, failing in this, take a long, curved aneurism-needle, and through a puncturf^ near the lower border of the rib pass it behind the artery and around the LIGATION OF ARTERIES. 259 ^ M 3? Fig. 296. — Lipration of tlie ulnar aud radial arteries of the wrist. Fig. 297.— Lifsition of the radial in the middle of the forearm and of the brachial at tlie bind of the elbow. 260 A TEXT-BOOK ON SURGERY. rib, taking care not to imnctuie the pleurii. Wlu'u tlie point of the needle is felt at the upper margin of the bone, another punctnre is made to allow its escape. The needle is now armed with a strong cat- gut and withdrawn. A pellet of sublimate gauze is laid over the skin, between the points of exit and entrance, around which the ligature is tied. In excei^tional cases it may be necessary to remove a portion of the rib. Ligation of the Abdominal Aorta — Anatomy. — The aorta iisually bifurcates upon the body of the fourth lumbar vertebra, a little to the left of the median line. This point is on a level with the high- est point of the iliac crests, and is a little to the left of and below the umbilicus. The point of election is one inch above the bifurca- tion. Operation, 3fedian. — In the linea alba make an incision, six inches long, the center of which corresponds to the umbilicus. "When within an inch of the navel, curve to the left three fourths of an inch, aiid one inch farther on regain tbe middle line. Divide all the tissues down to the parietal peritonseum, and then arrest all bleeding before opening this. After opening into the cavity, the transverse colon should be displaced upward, and the small intestines brought out through the wound and secured in a soft rubber cloth, kept wai-m with sublimate towels. With the finger-nail or a blunt director scratch through the peritonjpum and expose the aorta, around which a large animal t^or silk) ligature should be passed from the right side. Lateral Incision. — From the free end of the left eleventh rib com- mence an incision, which carry downward to ^\^thin three fourths of an inch of the antei'ior superior iliac spine, thence i)arallel with Poupart's ligament to its middle. Divide the three abdominal muscles down to the parietal peritonseum. When this is reached, use the lingers, the nails of which have been closely pared, and lift the ])eriton,'eum from the posterior abdominal wall. Passing over the posterior iliac crests and into the iliac fossa, the ridge formed by the psose muscles is reached and must be crossed. The lumbar nerves and ureter should be avoided, and, by a free dilatation of the wound and concentration of light, the aorta may be seen and tied, about three inches above the lumbo-sacral junc- tion. Of these two procedures the former is anatomically and surgically preferable. * Ligation of the Common Iliac Artery — Anatomy. — The common iliac arteries extend from the left side of the body of the fourth lum- bar to the sacro-lumbar junction. It is crossed by the iireter in front, near its bifurcation, and by some filaments of the sympathetic nerve higher up. The left common iliac vein lies wholly internal, and is on a plane somewhat deeper than the artery. The inferior mesen- teric vein crosses the left artery, but is within the peritoneal folds. The right iliac artery crosses in front of both the iliac veins, passing at a right angle to the left vein and obliquely over the right, until * The abdominal aorta has been tied ten times, all fatal. LIGATION OF ARTERIES. 261 near its termination the artery is in front of and external to the vein (Fig. 298). Operation — Anterior Incision. — Make an incision in the linea alba ex- tending from about one inch above to about live inches below the umbili- cus. Avoid the umbilicus as directed in the ligation of the aorta. Arrest all bleeding before the parietal peritongeum is opened. When this is done, di-aw the small intestines out through the wound and protect them in a Fig, 298. — Dissection showint' the relation of the right common external and internal iliac arteries and reins. The ureter is seen crossing the iliac near the biitircation. soft, clean rubber cloth, kept warm by sublimate towels. The posterior wall of the peritonaeum is scratched through by means of two dissecting- forceps and the aneurism-needle passed from A\ithin out. 262 A TEXT-BOOK ON SURGERY. Lateral Incision. — Same as for the aorta.* The anterior incision is preferable. Liffation of the Infernal and External Iliac Arteries — Anatomy. — The internal iliac artery, less than two inches in length, has the ureter in front, its accompanying vein and the lurabo-sacral nerve behind. Operation. — Throtir/Ji the Peritonaum. — Proceed as in the same operation for the primitive iliac. If necessary, a transverse incisicm may be added to that in the linea alba. Betiind tJte Peritona'inn. — One inch and a lialf internal to the anterior superior spine of the ilium begin an incision, which travels downward and inward across the track of the external iliac. Be careful not to carry the deep incision far enough internally to divide the epigastric artery. Cut down to the parietal peritonaeum, and separate this from its attach- Fio. 299. — Ligation of the gluteal, internal pudic, and sciatic arteries. * This artery has been tied about seventy times. For anenrism aboat 33 per cent recovered, while for hsemorrhage almost every case ended fatally. LIGATION OF ARTERIES. 263 ment to the abdominal wall and iliac fossa, along the iliac artery. When the bifurcation is reached, draw firmly with a retractor upon the upper lip of the wound and pass the needle from the inner side.* This opera- tion may be demanded in sciatic or gluteal aneurism, or hsemon-hage from these vessels. The fonner method is preferable. The Gluteal Artery. — Make a five-inch incision, on a line extending from the spine of the last lumbar vertebra to the trochanter major. The center of this line wiU indicate the point at which the artery emerges. Separate with a dull instrument the fibers of the gluteus maximus, dis- place anteriorly the gluteus medius, and find the groove between the minimus and the pyriformis. Follow this groove upward to the bony edge of the notch, and the artery and veins will be found (Fig. 299, upper incision). i Fio. 300.— Ligation of the internal pudic in the perinseum. The Sciatic. — Make an incision, five inches long, on a line from the middle of the sacral spines to the trochanter major. Separate the fibers of the gluteus maximus and find the lower border of the pyriformis. The * The internal iliac has been tied about thirty times, with a death-rate of 66 per cent. 264 A TEXT-BOOK ON SURGERY. great cord of the sciatic nerve will now be seen emerging from beneath the muscle, and Immediately in front of this the small sciatic nerve and the sciatic artery. The iiitentdl jnidfc artery is Just anterior to this, upon the spine of the ischium (Fig. 299, middle incision). The sciatic artery may also be secured opposite the ttiber ischii, along the outer bor- der of which it runs (Fig. 299, lower incisi(m). The Internal Fadic in the Perinccum. — With the patient sujiine and the thigh abducted, make an incision in a line with the symphysis pubis and tuber iscliii. The artery will be found as it runs along the inner margin of the ramus of the pul)is (Fig. 300). Ligation of the Ex- ternal Iliac in its Loioer Portion. — The external ■iliac has in relation to it the accompanying vein internally. The spermat- ic vessels cross it, and in the male the vas deferens is internal to it at the in- guinal ring. Operation. — One inch to the Inner side of the anterior superior spine of the ilium commence an incision, which is car- ried in the direction of the middle of Potipart's ligament, and terminates one inch above this point, without entering the in- ternal ring. Divide the three muscles down to the transversalis fascia, arrest all bleeding, divide the fascia carefully, re- tract the upper lip of the wound, and lift the peri- toneeum from the iliac fossa and artery (Fig. 301). Displace any overlying lymphatics and in- troduce the needle from the inner side.* Fi. 301. — Ligation of the external iliac in its lower portion, and of the femoral in Hunter's caual. * Ligation of the external iliac li.is proved fatal in almost every instance in which it was tied for hajmorrhage. For aneurism about 07 per cent recover. LIGATION OF ARTERIES. 265 The deep circumflex and the epigastric branches, which arise about half an inch above the ligament, may also be tied by this incision. In its upper portion this vessel may be secured by the same operation as for the commcjn iliac. Ligation of the Femoral Artery — Anatomy. — At Ponpart's ligament the vein is on the same plane as the artery, and immediately internal to it. One quarter of an inch to the outer side, and deeper than the artery, lies the anterior crural nerve. 'One inch and a half from the ligament the 2yrnfitndn femoris arises from the outer aspect of the common trunk, and from one to two inches lower passes behind the superficial femoral. Pour inches fi'om Poupart's ligament the relations have changed to such x\< Fig. 302. — Ligation of the superficial femoral in Scarpa's space. an extent that the femoral vein is deeper and slightly behind the artery. Tlie long saphenous nerve lies upon the sheath of the artery, in its middle third, and occasionally sends a branch through Huntefs canal. The sartorius muscle covers the femoral artery in all of its course except the first four inches, where it is superficial. Operation. — A line from a point half way between the symphysis pubis and the anterior superior spine of the ilium to the internal condyle 266 A TEXT-BOOK ON SURGERY. of the femur will run over and parallel with the femoral. It may be secured in any part of its course. 1)1 Scar/>a-f> Space. — The point of election for tying the su]ierricial femoral is from four to live inches below Poupart's ligament. AVitli this as the center, make an incision three inches long on the line already indi- cated. Beneath the skin and fascia some superficial and unimi)ortant vessels may be divided ; the libers of the sartorius will be seen in the lower portion of the wound, and should be drawn downward with a re- tractor. The sai)henous nei've will next be seen on the outer side of the common sheath of the vessels. The sheath should next be incised, and the artery carefully isolated by inserting a dull director beneath and around it from the inner side. The ligature is passed the same way. Fio. 303. — Ligation of the deep and superficial femoral near the bifurcation of the common femoral, and in tlie apes of Scai-pa'.s triangle. In this same plane an incision may be made to expose the artery lower down, where it is completely hidden by the sartorius. This mus- cle may be drawn to the side most convenient to the operator (Figs. 302, 303). In Hunter* s Canal. — Find the junction of the middle and lower thirds of the thigh. In the femoral line, with this point as the center, make an incision, about four inches in length, directly down to the sheath of the LIGATION OF ARTERIES. 267 sartoriiis, which is incised and the muscle displaced outward. Imme- diately upon opening the posterior layer of the sheath of the muscle, the oblique aponeurotic lil)ers which pass from the adductor magnus to the vastus internus — fonning the anterior wall of Hunter's canal— are seen. These may be divided on a director, or the sheath opened half an inch above this point. The saphenous nerve is on the sheath, and the vein is behind and to the outer side (Fig. 304). The Common Femoral above the Profunda. — Make an incision in the femoral line, from three fourths of an inch above Poupart's ligament downward for three inches and a half. Do not divide the ligament, but approach the artery one half inch below. The superficial epigastric vein and artery may be wounded. Divide the fascia lata, and pass the ligature fi'om within out. (Dissec- tion shown in Figs. 302, 303.) The Profunda Femoris. — Make an incision in the femoral line, three inches and a half long, the center opposite a point one inch and a half to two inches below Poiipart's ligament. As above, approach the common trunk and search along its outer border for the origin of the profunda* (Fig. 303). Pass the ligature from with- in out, one inch from its origin. Avoid the branches of the ante- rior crural nerve. In wounds of the posterior fem- oral region it may be necessary to tie this vessel as well as for aneurism. Ligation of the com- mon femoral is rarely called for, and should only be done in ex- treme cases. In modern surgical practice, deligation of the super- ficial femoral is comparatively free from danger. Ligation of the Popliteal — Operation. — Place the patient on his belly, with the popliteal space looking upward. Make an incision, four inches long, beginning two inches and a half above the level of the joint, at the outer edge of the semi-membranosus tendon, and extending down through the middle of the space. Dividing the dense, deep fascia, the areolar tissue which sur- FiG. 311-1. — LiL'ation of tlie popliteal artery. Kelations of contents in the left lower extremity. * In a large majority of subjects I have found this branch given oif one inch and a half be- low the ligament. 268 A TEXT-BOOK ON SURGERY. rounds the vessels and nerves of the space will be seen, and at the same time, and superficially, the popliteal nerve. Draw this and the vein which is immediately below outward, and the artei'y will be seen deeply situated, and in the upper part of the space internal to the vein. Lower down the relations change, the nerve crossing sujierlicial to the vein, and this overlying the artery (Fig. 304). Ligation of the Posterior Tibial Artery at the Middle of tlie Leg. — Make an incision, half an inch from and parallel with the inner margin of the tibia, three inches and a half long. Avoid the internal sai)henous vein. After passing the deep fascia, look for the lower tibial fibers of the soleus. which pass ob- liquely fixmi this border of the tibia backward and slightly downward. Divide these on a director, and with the finger separate the sural from the flexor muscles. Eetracting the edges of the wound, the artery will be seen, with a vein on either side and the posterior tibial nerve lying just behind. The vessels are held down by the common sheath of the deep muscles (Fig. 305). Opposite the Ankle-joint. — Half way from the tip of the internal malleolus to the ante- rior edge of the tendo Achillis commence an incision, which extends directly upward for one inch and a half. Dividing the skin and fascia upon a director, cut the dense internal annular ligament. The artery, with its two veins, will be found with the posterior tibial nerve and Fig. 305. — Ligatiou of the posterior tibial above the malleolus. tendon of the flexor longus pollicis behind, and the flexor longus digito- rum and tibialis posticus in front. As the artery curves around the mal- LIGATION OF ARTERIES. 269 leolus it will be found one third the distance from the tip of the mal- leolus to the convexity of the heel. The Anterior Tibial at t7ie Middle of tJie Leg. — A line from a point half way between the anterior tuberosity of the tibia and the head of the fibula to a like point between the two malleoli, in front of the ankle, \^"ill indicate the j)Osition of this artery. At the middle of the leg make a four-inch incision in this line, di- viding everything down to the dense fascia im- mediately over the mus- cles. Split this on a di- rector and dissect it up carefully, searching for the interspace between the tibialis anticus in- ternally and the exten- sor proprius pollicis ex- ternally. Finding this, discard the knife, and with the finger sepai-ate the muscles, and the ar- tery, veins, and nerve will be found deep down upon the interosseous membrane, the nerve be- ing external and slight- ly in front, and the veins wound about the artery. In order to re- lax the muscles and ad- mit the light, flex the tarsus on the leg (Fig. 306). At tTie Lower Por- tion. — One inch above the tip of the internal Fio. 306. — Ligation of the anterior tibial in the muldlc and lowet tliird of the leg, and of the dorsalis pedis artery. 270 A TEXT-BOOK ON SURGERY. malleolus begin :in incision, and carry it two inches npward, in the tibial line above given. This incision is along the fibular border of the exten- sor pollicis, between which and the tendon of the extensor communis digitorum the artery will be found, with the nerve on the iibular sitle, and its companion veins on either side. The Dorfy Cornil and Ranvier that the protection of the cajal- laries, in bone which is nndergoing active develoi^ment, is so delicient that extravasation occurs with such frequency that tlie process may be almost considered as physiological. This is especially true of the sliort, spongy bones, the epiphyseal regions of the long bones, the sternum, and vertebrae. If to this be added the fact that these bones are the most frequent seat of the inflammatory change, and that the period of life in which ostitis usually occurs is the period of greatest nutritive activity, it is not difficult to conceive that an extravasation of blood which would be practically harmless in a vigorous and healthful condition of the bones might induce serious inflammatory changes in tissues already deficient in nutrition. Si/iitpfoms. — Osteo-periostitis^ whether acute or chronic, is usually characterized l)y pain at the seat of inflammation before any tumefaction is recognized. The severity of the pain is in proportion to the intensity of the mcjrbid process. It is markedly increased on pressiire, and is usTially more severe at night. The symptoms of j^ressure upon the end- organs of the sensory nerves are coincident with the remarkably rapid development of the embryonic tissue from proliferation, chiefly of the cells of the periosteum, the new formation lifting the covering from the bone. The disease may be ushered in with or without a chill or rigors. The exacerbations of temperature are, as a rule, not so high in osteo-peri- ostiiis as in oafeo-mi/elitis. In this latter form of ostlfls the symptoms are more giave in charac- ter. The sense of pain is deep-seated and intense in most instances, while in all tlie febrile movement is high. The soft parts become swollen, red, and ojdematous, and, as a rule, septic absorption becomes, in the early history of the case, a prominent and dangerous symptom, terminating in l)yff a blow from the head the ulna may be broken by the force of a cane immediately beneath the contusion of the soft parts. A blow on the vertex which fi-actures the base of the skull, or a fall on the foot which breaks the femur, are common examples of fi-acture from indirect vio- lence. Contraction of the quadriceps extensor may fracture the patella, or the same lesion may result from a fall on the knee, in which the direct violence and the action of this powerful muscle unite to cause the fracture. In addition to these direct agencies, certain conditions of the tissues pre- dispose to fracture. The bones of the aged break more readily and are slower in repair than the young and middle-aged. There is a not infre- quent condition of fragility in the bones of the insane which, either alone 276 A TEXT-BOOK ON SURGEllY. or together with excessive and uiicontroUable iuusciil;ir jiction, renders them liable to break. I have seen one specimen of this nature in which every ril) was broi'ven, and some ol' these in two or more places. As hereto- fore stated, fracture is common in the disease known as osteomalacia, and may occur, though less likely, in rachitis. Sex, vocation, and manual preference also predispose to fracture. Men suffer much more frecjuently than women, and any vocation which exposes to violence increases the proportion of fractures. The bones of the right, the i)re- ferred side, are more frequently broken than the left. Symptoms'. — The symptoms of fracture are: Loss of function ; ab- sence of normal contoKr ; preternatural mot)Uity ; crepitus. A l)roken bone which is not impacted no longer acts as a support, or sustains mus- cular contraction. The natural shape or outline is more or less distorted by displacement and overlapping of the fragments. Caieful niani))ula- tion will determine the overriding, measurement will show shortening, while comparison with the uninjured side will detennine the degree of asymmetry. Crepitus, which is not always necessary to correct diagnosis, is the sensation imparted to the touch, and occasionally recognized by the ear, when the rough fragments are moved so as to grate upon each other. The diagnosis of an impacted fracture is more difficult, since crepitus and mobility are absent. Shortening must of necessity exist, which, with partial loss of function and more or less pain and thickening at the point of fracture, will lead to the recognition of the lesion. A longitudinal fracture or fissure is often with difficulty recognized, and may escape detection. Process of Repair. — The first and immediate residt of a fracture is ha5morrhage, which occurs from the arteries, arterioles, capillaries, venules, and veins of the medulla, compact substance, periosteum, and any surrounding soft parts which may be involved in the injuiy. As a result of the irritation determined by the accident and beemorrhage, in- flammation is precipitated. Hyperspmia of the bone and contiguous soft tissues ensues. As in ostitis, absorption of the bony walls of the Haver- sian canals occurs with the dilatation of the vessels, and general cell-pro- liferation follows. In the medullary cavity proper, in the medullary spaces of the Haversian systems, in the periosteum, and the inflamed surrounding tissues, this process is common. As in all inflammatory processes, the leucocytes are present in great numbers. The medullo- cells, myeloplaxes, osteoblasts, periosteal cells, and connective-tissue corpuscles, undergo rapid proliferation, resulting in the formation of a mass of common embryonic cells, which inflltrate the clot between and around the fragments. New-forined capillaries are pi'ojected into and through this graniilation-tissue in the same manner as in the process of repair in wounds of the soft parts. If the broken ends do not come in contact with the air — that is, if the fracture is not compound — the jirocess of repair in bone after an injury is similar to the physiological process of development of this tissue — namely,' the embryonic tissue is develojjed into cartilage -cells, and these, FRACTURES. 277 undergoing proliferation, develop into a secondary embryonic tissue, which is formed directly into bone. If, however, air is admitted to a wound in bone, the process of ossification in the embryonic tissue is moi'e rapid and direct, since the intermediate stage of cartilage-cell formation does not occur. A portion of this new-formed tissue, which results from the irritation following a fracture, undeigoes a process of calcification by the absorp- tion of inorganic material from the blood, and is then known as calhis. That portion which lies around and on the outer side is the ensheafhinrf callus ; between the fragments, the intermediate ; and within the medul- lary canal, the central or '•'•pin" callus. In an adult or middle-aged person, commencing within the first few hours succeeding a fracture, the embryonic tissue, which is formed in varying quantity, remains soft and yielding until about the tenth day, when the cells begin to be infiltrated with calcareous matter. The pro- cess of solidification in the callus is complete at a period varying usually from fifteen to thirty days. It is more rapid in children, and slower in the old. "When complete displacement with ovei'lapping occurs, or when an aponeurosis or tendon, or other dense tissue, sej^arates the broken ends, the process of callus-building is interfered mth, and failure of ossification may result. Usually a greater portion of the callus becomes absorbed within from thirty to sixty days after the fracture. This is especially true of the ensheathing layer and the central callus. That portion which intervened between the opposing surfaces becomes organized into pei'manent bone. The pin callus remains for a while, and may completely occlude the medullary canal, Init usually at a later period undergoes absorption. In some cases the medullary canal is not re-establislied. Fig. 307 shows a section of a broken femur in which, after a considerable lapse of time, the canal was still occluded. The peculiar stalactite (exostosis) occurred at the seat of fracture. The permanency of the external callus and its de- velopment into exostoses depends chieiiy upon the disturbed nutrition of the part (Fig. 308). It has been noticed that when a fracture occurs near the insertion of a group of muscles (as at or near the trochanter), exostosis is the rule, and may be very extensive. Prognosis and Treatment in General. — The prognosis of a simple fractxire in a healthy child or adult is always favorable. The danger is increased with the multiplicity and complications of the accident. A compound fracture is siifficiently grave to demand the greatest attention. Death may result from sepsis or fatty embolism. A longitudinal fractui-e is a nu)re serious injury, esjiecially grave, as far as the integrity of the member is concerned, when a joint is implicated. In all forms of fracture the ]u-ogno'en the dtira mater and the skull. Ii the dura be torn, the bleeding should be arrested by catgut ligatures, 'k' \ Flo. 310. — FruL'ments removed by the tropliino ami ele- vator in n depressed fracture eausL-d by a bbiw with a baminer. The bcvelinij at tlie expeiisic ut" the vit- reous tiible is wull sliowu. 282 A TEXT-BOOK ON tSURGERY. and the wound in this membrane closed by sutures of the same material (Fig. 310). The wound should be treated under strict antisepsis, and sliDuld be kept open with a light dressing of iodoformized and sublimate gauze The trephine should not be applied over the track of the longitudinal or lateral sinuses and the middle meningeal artery. l)epress(Hl bone may be lifted from these vessels. Hjcmorrhage, if it occur, may be controlled by the ligature or by compression. JVasal Bones. — One or both nasal bones may be fractured and de- pressed, and in severe injuries the nasal processes of the superior maxilla and the perpendicular plate of the ethmoid are involved. Hfcmorrhage from within the nose is usually severe, and may require the tami)on of the anterior and posterior nares. The reposition of the fragments should be effected with great care. A strong, blunt, and nar- row instrument passed along the septum nasi until it is in contact with the inner surface of the fragments, together with lateral pi-essure fiom without and at the base of the nose, will best reduce the disj)laced pieces*. In order to hold the fragments m position, the method of treatment in- troduced by Dr. Le\Ais D. Mason will be found preferable. After reposi- tion, as alK)ve described, a steel drill (a straight surgical needle will suf- fice) is passed directly across the nose, being entered through the line of fracture. Over the ends, which project through the integument on either side of the nose, a strip of pure rubber "is jjlaced, across the bridge of the nose, by puncturing either end on the head and point of the needle, giving the rubber sufficient tension to exert a gentle downward and lat- eral compression, but not enough to interfere with the circulation or to exert a degree of pressure on the fragments. The point and head of the needle may be i:)rotected by small pieces of cork."* The needle may be removed about the sixth to the tenth day. When the blow is received on the side of the nose, the fracture and depression may be unilateral. In such cases, replacement effected after the manner just described will usually suffice, since the fragments are not likely to be displaced when once in position. At times, and esitecially in children, wlien the nasal arch is struck from the front, the fracture occurs at the naso-maxillary suture, and the nasal bones are driven in without comminution. In this variety of de- pression considerable force is needed to effect reduction. Such is the rapidity with which repair and union occur here, as in all the bones of the face, that, if the effort at reduction is delayed for more than twenty- four or forty-eight hours, it will be exceedingly difficult, if not impos- sible, to accomplish. Fracture of the malar hone occurs rarely, and is the result of violence so great that usually the upper jaw and other bones are broken. Every effort should be made to restore the normal contour to the face by repo- sition of the fragments, none of which should be removed, since the vitality of the bones of the face is so great that necrosis after injury is exceptional. * "Annals of Anatomy and Surgery," vol. ii, pp. 110 and 199. FRACTURES. 283 AVlien the fracture is compound, and this is usually the case, the fraf;:ments may be lifted into place through the wound, by means of the l)ul]et-scre\v elevator, or other instruments ; or, as advised l)y Hamilton, the linger or thuml) inay be passed underneath the lip to the zygomatic arch, which can be utilized as a point for pressure. At times, however, it may be necessary to enter the antnini riiaxiUare by trephining or drill- ing through the anterior wall of the antrum. The jioint of enti'ance should be immediately above the first (or anterior molar) tooth, at a dis- tance of from one half to three fourths of an inch below the inferior mar- gin of the orbit. Fracture of the zygomatic process, either of the malar or temporal bones, may occur singly or as a complication of the fracture just treated. If the force which j)roduces the lesion does not wound the temporal or maxillary arteries, the treatment is simple. If the depression is sufficient to cause deformity, cut down to the arch, insert a hook elevator, and lift the bone into i^lace. It may be necessary to limit mastication by the ap- plication of a bandage, as in fracture of the lower jaw. The siqjen'o/- maxilla may alone be broken, although it is usually complicated with fracture of other bones. A blow received at the roots of the teeth may drive the alveolar and palatal arch downward, or, if the direction of the impinging body is from before backward and upward, the antrum may be ojiened. The treatment is to cleanse the wound antiseptically and replace all pieces of bone as well as possible. The following case illustrates in a remarkable degree the vitality and reparative ]iower in the bones of the face : In September, 1884, a robust Irishman, about forty years of age, came into my service at Mount Sinai Hospital. He had just been kicked by an unshod horse. The crescentic wound extended from the center of the forehead down by the nasal pro- cess, along the facial groove, and out beyond and below the malar bone. The soft tissues were lacerated, and the bones extensively comminuted. Tlie wound was cleansed of particles of manure, straw, and pieces of hoof. Strict antisepsis was employed, thoroughly cleansing the wound and replacing every piece of bone. Tke torn edges were pared and closed by silk sutures. Rapid union ensued, without the exfoliation of any portion of the bone. The great desideratum is the prevention of a scar. Upon the face the greatest care must be taken to avoid deformity. If the soft tissues are torn and contused, the edges of the wound should be smoothly pared and nicely approximated by tine silk sutures. When the destruction of the bone is so extensive that, even after re- l)osition of the pieces, the fragments will not remain in jilace. it may be necessary to use the lower jaw as a splint, bj^ fixation of the two rows of teeth, with the head and chin figure-of-8 dressing, as for fracture of tlie lower jaw. The interposition between the teeth of short strips of gutta-percha, thoroughly softened in warm water, will firmly fix the l)roken to the unbrokt>n Ixmes, and admit of the introduction of liquid food between the upper and lower incisors. 284 A TEXT-BOOK ON SURGERY. Frat'ture of the iiifcrlnr maxilla niny ocoiu- in rare instances through the symphysis mentis but much more frecjuently external to this and near the o]ienin,ed in warm water for a minute or two, until it becomes softened. It is then laid across the chin, the upper and nar- row ends are turned back over and parallel with the body of the jaw, while the lower ends are turned upward anain or abnoi'mal mobility be caused at tliat point, tlie diag- nosis of fracture is fairly clear. If crepitus is obtained, all doubt is dissi- pated. Displacement of the ujiper fragment is always slight. The lower may be drawn toward the radius by the pronator quadratus. The obliquity of the cleavage, and the direction of the force which produced the lesion, wOl almost always determine the displacement. Radius. — Fracture of the radius above the bicipital tuberosity is one of the rarest forms of injury, and, when present, is with great difficulty recognized. The cause is direct violence. Displacement of the upper fragment will be slight, unless the fracture is comi)li(,'ated with a disloca- tion at the radio-humeral joint. The action of the biceps will tend to draw the lower fragment forward. The best position for treatment is to flex the forearm on the ami, with the palm turned upward, and to apply an anterior splint, wider than the arm, and provided with an interosseous pad. If the displacement forwai-d is extreme, a compress may be em- ployed. Fracture of the radius between the bicipital tuberosity and the in- sertion of the pronator radii teres is also usually from a direct blow, although it may result from a fall 071 the hand, or from muscular ac- tion.* While the obliquity of the line of fracture will in great part determine the displacement, the tendency is for the lower fragment to be carried toward the ulna by the conjoined action of the pronator quadratus and pronator radii teres muscles, while the upper fragment is Fio. 324.— Disi>laccment of the frngments in fr.icture of tlie radius in its lower third. (Alter Gray.) * Packard, iu Aslihurst's " Encyclopajdia," William Wood & Co., New York. FRACTURES. 295 rotated oxitward by the biceps. When the bone is broken below this point the lower fragment tends toward the ulna. The upjier may be held out by the biceps, or carried toward the ulna if the pr- tained in a sufficient degree to re- lieve the injured structures from the greater part of the superincumbent weight. ^Yhen the bodiesare injured, dorsal extension throws, in part, the weight from the spongy bodies on to the compact processes. AVhen the plaster jacket can not be worn, Taylor's or Shafer's brace may be em- ployed mth advantage. Fractures of the sacrum are rare, and, when occurring, are due to direct violence by penetrating bodies, or to falls from such heights that other and serious complications render the prognosis grave. No treatment except enforced quiet is called for primai'ily. When ostitis and necrosis occur as a result of comminution, operative interfer- ence may be required. Fracture of the coccyx, with displacement foi'ward, is not uncommon. The accident occurs from a fall or blow directly upon the tip of the spine. The symptoms are those of pressure upon the rectum, causing difficult defecation, proctitis, and at times fissure or ulcer. Pain is always pres- ent, and is due to infiammation as well as pressure upon the fifth sacral and coccygeal nerves (coccyodynia). The (mly treatment is removal of this bone, which is almost always fcdlowed by relief. The incision is made over the bone, in the posterior median line, the muscular attachment being divided close to the bone. Care must be taken to avoid wounding the posterior plexus of veins, or the rectum. The wound may be sewed in its upi^er portion, leaving the lower end open for drainage. Os Innominafum. — Though rarely fractured as compared with other portions of the skeleton, the ilium, ischium, or pubes may be broken Fig. 32S. — Fracture of the vertehrse. FRACTURES. 301 singly, or all may be involved in a common lesion at the acetabulum. The force causing the fracture maybe directly applied, or, less frequently, by an indirect blow, as a fall on the foot or great trochanter, in which the head of the femur may be driven into the acetabulum with such violence as to cause fracture. When the fracture is confined to the iliac crest the diagnosis will be determined by preternatural mobility, crepitus, and pain, in conjunction with the history of the case. When the bones of the deeper basin are broken, exploration by the rectum or vagina will be necessary. The treatment demands reposition and rest. AVhen the acetabulum is involved, extension to the foot and leg (Buck's method), with the foot of the bed elevated, should be practiced. When possible, the bed should be so arranged that defecation may be accomplished without lifting the pelvis. A modification of Crosby's fracture-bed would answer this pur- pose well. Fixation of one or both thighs, including the pelvis and lower portion of the abdomen and spine, could be well effected by surround- ing these parts with a plaster-of-Paris dressing. The prognosis will de- pend, in great part, upon the extent of the injury sustained by the pelvic viscera. Fractures of the /ej7ivr may be best studied in three groups, viz. : (1) of the upper extremity (including the neck and trochanter) ; (2) of the shaft ; (3) of the lower or condyloid extremity. Fracture of the 7iec7i of the femur may take place wholly within, partly within and partly without, or wholly outside of the capsule. This accident rarely occurs in the young and middle-aged. It is a lesion of old age, and women suffer more than men. The anatomical cause is chiefly a condition of senile rarefaction, which begins usually about the fiftieth year.* It has been demonstrated that the change in the relation of the axis of the neck to that of the shaft in the aged is not enough to account for the greater prevalence of this accident in the old, nor is there a marl-i:ed diminution of the animal constituents of bone at this time of life. The change is one of senile atrophy. Fracture of the neck of the femur is usually caused by force trans- mitted from below upward, and along the shaft of the femur. In many instances the accident is trivial. The specimen shown in Figs. 329 and 330 was taken from a patient who broke her femur while in the act of kneeling in church, f It has been known to occur even whUe turning over in bed. The line of fracture may be at any part of the neck, and in exceptional cases is through the epiphysis. When the fracture is near tlie trochanteric line, or when these tuberosities are involved, it is usual- ly the result of direct violence— that is, a fall or blow upon the hip. The diagnosis of fracture of the neck of the femur may be detennined by a study of the liistory and the symptoms. If, after a fall upon the * Prof. L. A. Stimson, " Treatise on Fractures." irenrv C. Lea's Son & Co. t This patient was treated by Dr. Selden, of Norfolk, Va., and, from the history of the case, together with the appearance of tlie specimen, I consider it an intrai-apsuhir fracture, witli osseous union. Prof. F. II. IIuMiiltiin, to whom I sljowod tlie specimen, considered it rather a condition of senile atrophy. 302 A TEXT-BOOK OX SURGERY. foot or knee, or directly ujion the trochanter, there results pain in the hip, etersion of the foot, loss of function in the member, sJiortening, y'\.rf'f%i}f^" Fig. o. Fin. 3,30. and crepitus, fracture at the neck is probable. These symptoms are, however, not always present. Pain is the most constant, eversion is the rule, inversion the ex- ception, in about the proportion of eight to one. The turning out- ward of the leg and foot is probably due to grav- ity, and when inversion occurs it is due to a peculiarity in the lock- ing or overlapping of the fragments. Loss of function is not always entire, for in some in- stances — and very prob- ably in impacted fract- ures — the i^atient has been known to walk a considerable distance upon the limb after the fracture. This is, how- r., . ^ ,• , . .r.i <■ , ■ r , , ever, a rare occurrence. -Showinc the displ.icement of the fraimfnta lu fructure ot ' ... the neck of tbe femur. (Atler Gray.) Shortening IS deter- ProrrottMis CCHCLLus supenion OBTURATOR INTERNUI CEMClLUs iNFCniOlt OBTURATON tKTERMUB OUADBRTUt rCMORIX Fir.. 331. FRACTURES. 303 miripcl by comparative measurement of the two sides, from the ante- rior superior spine of the ilivim to the inner malleolus. The internal malleoli should be made to touch, and should be directly in a line with the symphysis pubis, umbilicus, and interclavicular notch. The end of the tape should be held on the thumb-nail, and pressed well into the notch, just under the anterior su^jerior spine. It is then earned along the inner side of the thigh, knee, and leg, to the under edge of the inner malleolus. The degree of shortening will vary from one fourth of an inch up to two or more inches. The occasional nonnal inequality in the length of the two lower extremities should not be lost sight of. Tills varies from one eighth to, in some instances, as much as one inch and over. To determine that the shortening is between the trochanter and the acetabulum, apply Nelaton^s test ; a line drawn from the tuber- osity of the ischium to the anterior superior spine of the ilium passes over the upper surface of the great trochanter. The distance the tip of the trochanter may be above this line will give the degree of shortening. Bryant's test is, with the patient resting upon the back, the legs parallel and extended, to drop a line from the anterior superior spine and to measure the distance between this line, at its nearest point to the tro- chanter and this tuberosity. If the fracture is above the trochanter the tuberosity will be found nearer the line than on the sound side. Crepitus can not always be obtained. In the cases of impaction it is not possible without the employment of force sufficient to unlock the fragments, and in many cases of fracture above the trochanteric line, without impaction, crepitus is not felt. Any unnecessary manijiulation of the hi]3 is contrary to the best rules of practice, and an effort to elicit crei^itus should, therefore, not be made. It is difficult, and at times impossible, to determine at what particular portion of the neck the fracture has occurred. Prac- tically it makes little difference, as the treatment is the same. Treatment. — Rest in the dorsal decu- bitus, with fixation of the pelvis and the affected limb, are the immediate indica- tions. To secui-e fixation, extension in a limited degree is desirable. To obtain this, place the patient upim a hard mat- tress. If the bed is too soft and yielding, place wide boards underneath the top mat- tress in order to hold it smooth and firm. Elevate the foot of the bedstead from six to ten inches, by placing the legs at this end upon Ijlocks of wood or bricks. Cut two stiips of strong adhesive plaster (Maw's moleskin is preferable) about two inches wide and long enough to extend from the \\\\^ to be- yond the sole. Lay one of these upon the inner and outer surface of the Fio. "I' the neck of the fumur, witU imijaetion. (Bigulow.) ;504 A TEXT-BOOK ON SURGERY. thigh and leg, exactly opposite each other, and hold them in f)lace by V well-adjusted roller. The strips can be more nicely applied if they are partially divided with the scissors, in a direction upward and inward, at intervals of about two inches. Wlien within four inches of the anlde the bandage is interposed between the strips and the integument. In order to prevent pressure upon the malleoli, a stick about six inches in length is placed between the ends of the adhesive strijjs, and the exten- sion-weight is attached to this. A piece of board provided with a pulley is next fastened to the foot of the bed, so that the tip of the pulley will be on a level with the malleoli. The weight will vary from two or three up to eighteen pounds. A pound for every year of life up to eighteen is the rule ; but this is too much for fracture above the trochanter. About ten pounds is sufficient for all ordinary cases. Shot in a bag, or sn)oothing-irons, are usually emjiloyed for the extension-weight, which is tied to the string (Fig. 383). The pa- tient's body serves as the counter-extending force, the gravitation toward the head of the bed being about counteracted by the weight attached to the foot. Additional benefit and comfort may be obtained by laying small, long bags, filled with sand, on either side of the thigh and leg. When the limb tends too strongly to outward rotation (or inversion) this may be corrected by the sand-bags, or by Prof. Hamilton's long splint, which Is shown in Fig. 333, and which is tied by strips of bandage from tlie axilla to the ankle. The foregoing is practically Buck's ex- tension, to which may be added Hamilton's long splint. In some instances it may be found advantageous to use Volkmann's sliding foot-piece, seen in Fig. 334. This consists of a posterior splint for the leg. to which is attached a foot-piece having the angle shown in the cut. This splint should be perforated for the heel, and rest upon two cross-bars of wood, which in turn slide up and down on a rectangular frame. Upon the upper edge of these parallel bars a tongue is cut, and FRACTURES. 305 a corresponding notoli or gTOove in the cross-bars. This apparatus is complicated and will rarely be needed. Buck's extension, with Hamil- ton's long splint, or preferably the sand- bags, wDl meet almost every re- quirement, and give the greatest satis- faction. In order to i)re- vent the bed-cloth- ing from coming in cf)ntact with the fractured limb, wire screens (Figs. 335, 336) may be em- ployed. In some instances plaster of Paris may be used; but this method of treating fractures ^"- 3^*-^'°>k-""'« -^"^"s »bot-piece. above the trochan- ter is now rarely employed. The most easily managed and simply constructed apparatus for making the necessary extension and counter-extension, in applying the fixed dressing for fractures of the lower extremity, is made as follows : Into each end of a ta- ble, about five feet long, two holes are bored, and into these two perpendic- ular pieces are fitted, two feet long and about two inches in diameter, while a strong horizontal bar connects the two upper ends. One of these up- rights is smoothed, round- ed, and padded, to pre- vent injury to the peri- njeum. The foot of the injured side being nicely band- aged, the patient is placed upon the table, astride the i)added upright (Fig. 337), with the perinaeum against it, and is suspended by a strap passed over the horizontal bar and underneath the sacrum, being elevated from the table sufficiently to allow free manipulation of the bandages under the back. The head and shoulders are sui)ported upon pillows, the foot 20 Fig. 335.— (After Esmarcli. \ Fio. 33ij. — [AtV-T Esmarcli.) 306 A TEXT-BOOK ON SURGERY. Fio. 337. of the uninjured limb rests upon a stool, a elove-liitch or double loop is thrown around the ankle, and to this a block and pulley is attached, the opposite end of which is fastened to the wall. Extension is then applied until, by measure- ment from the ante- rior sui)erior spinous process of the ilium to the lowest point of the inner malleo- bis, the two legs are found to be of the same length. The jielvis, thigh, and leg are then covered with a dry roller, or a trousers' leg, or j)iece of soft blanket, and the plaster rollers applied. Accessory splints of zinc, coj^- per, tin, or hoop-iron may be worked in with the plaster bandages if desired. The prognosis in this class of cases should always be guarded. Use- ful limbs result in a large majority of cases, but the function of the hip is not often fully restored. Fracture of the TrocJtanter. — Separation of the great trochan- ter is a rare accident. The cause is direct violence. A diagnosis must rest upon independent mobility of the tuberosity, with crepitus. The treatment should be fixation, firm compressicm by bandages, and rest. Fracture through the Trochanters. — Fracture through the trochan- ters is also comparatively of rare occurrence. The diagnosis may be determined by shortening, crejoitus, pain, and loss of symmetry and func- tion. A strong diagnostic feature is, that a portion of the trochanter may remain attached to the neck.* The treatment does not differ from that just given. The prognosis is more favorable as to restoration of function. Occasionally enormous exostosis occurs after fracture at this locality. Fractures of the Shaft. — The shaft of the femur is usually broken by direct violence, or indirectly by a force transmitted from below upward. In exceptional instances the fracture is caused by muscular contraction alone. The line of fracture is generally oblique, and the displacement is determined chiefly by the direction of this line. In complete fracture overlapping is the rule. When the break is in the upper portion the lower fragment is drawn iip by the long muscles extending from the pelvis to the neighborhood of the knee-joint, and, as shown in Fig. 338, * Prof. L. A. StimsoD, op. cit. FRACTURES. 307 tlie upper fragment is usually rotated outward by the external rotators, and tilted up and to the front by the psoas and iliacus. When the fract- ure is near the knee-joint the lower fragment is tilted backward by the action of the gastrocnemius, popliteus, and plantaris muscles. The up- per fragment is acted iipon in a milder degree by the same muscles that caused its displacement in the higher fracture (Fig. 339). Fractures at the condyles may include, trans- verse fracture near the epi- physeal line, or through the epiphysis proper ; transverse fracture, -with a split into the intercondyloid notch ; or one or the other condyles may alone be broken off. The diagnosis of fracture of the shaft of the femur is not difficult, as a rule. Preternat- ural moliility, crepitus, pain, and shortening will usually de- termine the character of the injury. When the joint is in- volved, in addition to the usual symptoms of fracture the knee becomes much swollen. Treatment. — In the treat- ment of all fractures between the trochanters and the knee- joint the choice rests between the method by Buck's extension and the plaster- of-Paris dressing. In general the first method is preferable. Unless the fracture is too low down, the traction of the adhesive strips should be upon the condyles as well as upon the leg below. Even when it is determined to employ the gyp- sum fixed dressing, it is wise to defer its application until after all danger of swelling is past, usually after from four to eight days. ^Vhen the fracture is below the middle of the thigh the plaster-of-Paris dress- ing may lie applied without anaesthesia. The bandages need not extend higher than the level of the perina?um. After a few days the patient may move about on crutches. In the higher fractures the same prin- ciples are involved as in fractures of the neck. When the knee-joint is involved, passive motion should be commenced on the third week, and continued at intervals thereafter. Whatever method is emjiloyed, immobilization at the seat of fracture should be maintained for five or six weeks. In fracture of the femur in children the plaster-of-Paris dressing is to be preferred. The reposition of the fragments should be made un- der anaesthesia, and the parts immediately immobilized. This class of SCMJ. rfMOIK. Fig. 339. — Displacement of tiagnicnts in fract- ure of the thigb in the lower third. (Alter tirav.) Fig. 338. — Displacement of fi-ai;ments in fracture of the thigh in the upper third. (After Gray.; 308 A TEXT-BOOK ON SURGERY. patients are not easily controlled and kept quiet by the use of the ordi- nary apparatus.* Patella. — Frnctui'e of the i)atellii may bo caused by violent contrac- tion of the qua(lrice])s extensor muscle, or by a ))low or fall upon tliis bone, ni- lioth of these factors may combine to cause this lesion. The line of cleavage is usually transverse, and in the majority of instances just below the middle of the ])atella. It may, however, be broken in an oblique or longitudinal direction, or in several directions at once — " stel- late fracture." When muscular contraction is the chief or sole factor in this break, the line of cleavage is usually transverse. Longitudinal and stellate fractures are the result of direct violence. Fracture of the patella is usually complete, the separation of the fragments varying from a small fraction of an inch up to two or more inches. The separation is generally more marked on the internal than the external border. In rare instances incomplete fracture may occur, the cartilage not giving way. Such cases are scarcely rec- ognizable without exploration, the few recorded being seen post-mortem. Fracture of the patella is more frequent in men than in women, and occurs mostly in the decades from the twentieth to the fortieth years. The diagnosis may be made from loss of function, pain at the seat of injury, and separation of the frag- ments. Inability to extend the leg, or marked impair- ment of function, is always ju-esent. The limb may, however, be used to support the body if it is allowed to fall into the straight position. One of my patients, with a separation of three fourths of an inch, walked, unaided, a quar- ter of a mile immediately after the accident. TTjemorrhage between the fragments occurs in all cases, and therefore communicates with the syno- vial membranes, which are interposed between the posterior surface of the patella and the general cavity of the joint, and, in cases where the separation is well marked (from half to one inch and over), it is more than probable that the reflection of the synovial lining, from the low- er anterior portion of the joint below the patella upward and forward to the front of the intercondyloid notch, is torn, and that whatever of extravasation occurs is into the general cavity of the joint. This occurred in the only knee I have opened, immediately after this fract- ure. More or less effusion into the joint follows in the large majority of cases. In longitudinal and stellate fractures the separation is usually slight. Treatment. — A patient with a broken knee-pan should be immediately Fio. 340. — Displiicc- jnent of fragments in fracture ol the pa- tella. (After Gray . ) * In one instance, in tlie case of a child tliree and a half years old, with a fracture at the middle of the thigh, chloroform narcosis was obtained during natural sleep, the child not he- coming conscious while passing under the influence of the anesthetic. FRACTURES. 309 put to bed, in the dorsal decubitus, the affected limb kept straight, and the foot and leg elevated on i)illo\vs. In case of swelling and inflamma- tion at the Ivuee, cold cloths or the ice-bag should be apijlied. The mechanical treatment should commence at once. A posterior splint is made to extend from near the heel to the gluteal fold. Shellac-board is best suited for this purpose, but sole-leather, gutta-percha, or a piece of plank will sufiice, if these lighter articles can not be obtained. If either of the first three articles is employed, the piece should be cut wide enough to envelop from one half to two thirds of the circumference of the limb. Tkree inches above and below the center of the knee-joint a tongue, one inch wide and two inches long, should be cut, and turned out so that the attached end is nearest the joint. The sjilint is dipped in warm water until soft enough to be molded to the part, when it is lined with a sheet of absorbent cotton and applied on the posterior aspect of the limb. The cotton ru" padding material should be consider- ably thicker opposite the jjopliteal space, in order to prevent complete extension of the leg. Secure the upper and lower ends by turns of the roller thrown around the thigh and ]eg, and next begin the oblique or approximating turns by carrying a flannel bandage around the leg, so that it catches behind the lower tongue, w^hence it is carried obliquely upward above the upper fragment, across the quadriceps, and back to the starting-point. This is con- tinued until the upper frag- ,.,,,,,•,, . ^ ^ ^ ° iiG. 311.— Uumilton's apparatus tor fracture ot the patella. ment is brought into appo- (Uamiiton.) sition with the lower. For the lower fragment the bandage is made to catch behind the upper tongue upon the splint. When the fragments are approximated the entire limb is invested by the roller. After the dressing is applied the same jiosition is maintained for two weeks. The portion of the bandage immediately over the fracture should be opened on the fifth or sixth day, and a careful inspection made, in order to determine whether the roller has slipped and re-separation oc- curred. If tlie bandage is at all loose it should be tightened, but never drawn so tightly that it produces any discomfort. This inspection should be repeated every five or six days, but the splint is never taken off until the fourth week, when passive motion at the knee-joint should be made. In doing this the surgeon should grasp the patella between the thumbs and fingers, in order to hold the frag- ments firmly in contact, and while thus held should have an assistant move the leg back and forth, not flexing it for the first time more than 15° or 20°. This should be repeated each week until the ninth week, and twice a week after this for the next two or three months. After the first two weeks the patient may be allowed to sit uj) in bed, or to be moved 310 A TEXT-BOOK ON SURGERY. upon a sofa or chair about the room. Al'ter I'oui' wcfka he may be per- mitted to move about on crutches. Except when passive motion is being made, the splint should be worn ni^lit and day for the iii'st ten weelvs after the injury. After tins it may be removed after retiring for the night and adjusted before rising. The long splint and ligure-of -eight bandnging about tlie knee should V)e worn for si.\; montlis, to prevent a re-separation. After six months it may be shortened to a, length of eigliteen inches, and tliis or a strong leather flexion-check shoidd be worn for the next twelve months. After eigliteen months of careful watching, such a ligamentous unicm will not give way, except under conditions which would brenk the bone. In two cases which came under my ob- servation (the patients both males, one forty and the other about fifty- live years old) tin? ligamentous union was so strong that, several years after the first accident, they suffered a second injury, and the u])per frag- ment parted transversely, the ligament holding intact. The foregoing method, which is practically that of Prof. Ilamiltcm, is by far the most preferable treatment for this injury. Many innovations have been made in the treatment of this fracture, some of which are unnecessary, others unjustiiial)le. Among the fomier may be mentioned asplratlun of the effusion into the joint and between the fragments. This should only be done when the capsule is distended in an extraordinary degree. The most unjustifiable method of ti'eatment ever introduced in this fracture is that of opening into the joint and wiring the fragments together. Unjustifiable because, first of all, it is dangerous ; secondly, it is unnecessary. A careful observance of the rule of practice just laid down will secure a ligamentous union, with a resto- ration of the function of the extremity, equally as good in many cases as that enjoyed before the injury, and in the vast majority of cases equal to all the ordinary requirements of the limb, and this is accomi)lished without the slightest risk to tlie patient's life, and with no distuibance of his comfort beycmd confinement to bed for two weeks, to the room f(n' four weeks, and to his crutches and cane for about six months. On the other hand, although an osseous union may, in tlie majority of cases, be obtained, the restoration of function is not more complete, the confinement in bed is longer, and the danger to life and the integrity of the part sufficiently great to deter the surgeon from employing this method of practice. In September, 1881, induced by the reported successes after this operation, I wired a fractured patella on the twentieth day after the ac- cident, in the case of a woman twenty years old. The strictest antisep- tic pi'ecautions were employed, and free drainage was secured. Osteo- arthritis with destruction of the joint resulted, and the patient barely es- caped with her life, the limb having been amputated in the lower third of the thigh.* Another patient, in the hands of a New York surgeon, died as a result of this operation. If the full histories of all these cases * For a full report of this case, and a synopsis of otlier cases, see the author's paper in the " Medical Record," vol. xxi, 1882. FRACTURES. 311 were written I think few surgeons would have the temerity to repeat the procedure. Introducing v/ires beneatli the two fragments, from above downward, without cutting the integument, and securing approximation by twisting in front of the Joint, is also unjustifiable. The use of Malgaigne's hooks is also unnecessary. The plaster-of-Paris method is employed by some operators ; but it is not to be preferred to the method of Hamilton. In this procedure the fragments are ap- proximated by adhesive strips. One piece is cut in the shape shown in Fig. 342, the broad part of which is applied just above the up2)er margin of the upper fragment, and fastened here by a roller. The entire limb is now covered by a bandage wliich leaves ex- posed the two narrow strips of the adhesive plaster. Over this the plaster bandages are ajjplied, strong trac- tion being made upon the adhesive strips in order to hold the fragments approximated until the gypsum hardens. The limb should be enveloped from the anlile to the perina^um. In old fractures, with wide separation of the frag- ments and permanent loss of function of the extensor muscles, the best prothetic apparatus is a strong leath- er shield worn around the knee. This prevents too much flexion, and I)artly stiffens the joint. Many cases of wide separation, however, retain the function of the limb in a remarkable degree. In a case occurring in my practice. ^xm Fio. 34-2.— Gauutlc't of adliesive plaster for exerting traction on the upper fragment of a tractui'ed tella. pa- Fio. 343. FiQ. 344. — Wide separation nf rnriiiiifuts (tV.'Ui a to A). witli perlect funetiou of liuib. from which the two accompanying cuts were taken, there is a separation of more than three inches with the leg tiexed (Fig. 3-43), and nearly one inch 312 A TEXT-BOOK ON SURGERY. and a half in extension (Fig. 344) ; yet this patient has perfect use of the limb. No approximation of the fragments was ever attempted in this patient. ITe was kei)t in bed, witli the log elevated, for six weeks, and an ordinary roller apjilied after this, witliout any effort at bringing the fragments together. Ln)ifiifii(Jiii^. cavity of this process. If this can not be accom- plished without ether, after one or two trials the an- aesthetic should be given. After reduction a shoul- der-cap of book-binder's board, leather, or gutta- percha should be applied, and worn for at least one week. Second Method. — Fix the scapula by placing a folded sheet or long cloth around the body, so that the upper margin of the cloth will touch the axillary folds. The ends are inti'usted to an assistant, who, standing on the sound side, makes counter-exten- sion. The surgeon now takes hold of the arm about fio. its middle with one hand, and near the elbow ^^•ith the other, and carries it slowly and steadily away fi'om the body, and (Brj-aot.) 324 A TEXT-BOOK ON SURGERY. Fig. 360.— (After Hamilton.) in the direction of least resistance. Wlien it is at a right angle to the axis of the body, strong traction is made, with slight axial rota- tion. If the manoeuvre is still iinsnccessful, carry the aim higher, until extension is made in the line of the axillary border of the scapula (Fig. 359). Third Method. — Place the patient in a chaii', so that, with the foot of the opera- tor on the edge of the seat, his knee will come snngly into the axilla. Place one hand npcm the shoulder to steady it, while tlie other seizes the aim near the elbow. With the knee as a fulcrum, use the hu- merus as a lever, which, being depressed, carries the head of the bone into position ( 1 'ig. 360). Extension from the forearm, and counter-extension through the me- dium of the opposite arm, may also be employed. 8ubcoracotd and SubdaiHcular Dislo- cation. — In the first of these two disloca- tions the head of the humerus rests upon and in front of the inner rim of the gle- noid cavity, and Just underneath and in contact with the coracoid pro- cess (Fig. 355). The strain upon the long head of the biceps and supra- spinatus is not so great as in the preceding variety, while that upon the infra-spinatus is more severe. The ten- dons of the coraco-brachialis and short head of the biceps rest anterior to and upon the displaced head. The rupture of the capsule is below and in front. The cause of this displacement is violence applied directly to the shoulder, from without inward and forward, or to the elbow or hand when held in an extended position. The symptoms and methods of diagno- sis are in general the same as those of the subglenoid luxation, the principal difference being in the appreciable location of the head of the bone just below the coracoid pro- cess, and on a plane considerably higher than' in the lower displacement (Fig. 361). The distance from the acro- mion to the olecranon is shorter in this than in the subglenoid dis- placement. The suhdaincular variety of this forward di.slocation is only an exag- geration of the subcoracoid, in which the head of the bone slips under- neath and internal to the coracoid, and rests against the serratus mag- nus and behind the pectoralis minor, below the clavicle (Fig. 356). The causes are the same, and the symj^toms differ in little else than the pres- Fio. 361.— Subcoracoid. (Bryant.) DISLOCATIONS. 325 ence of the head of the humerus nearer to the clavicle. The arm stands slightly out from the body, and the elbow is tilted backward. The ten- sion on the posterior scapular muscles is gi-eater, and rupture of their attachments often occurs, while the anterior insertion of the subscapu- laris may be dissected up. Pressure on the axillary vessels and nerves is more marked in this luxation. The rupture of the capsule occurs on its anterior-inferior aspect. The treatment of the subclavicular variety consists in judicious exten- sion and counter-extension in the line of displacement, until the head of the bone is carried into the subcoracoid position. The subcoracoid dislocation may be reduced by the method just de- scribed for the subglenoid ; that is, with the foot in the axilla as a ful- crum. This will rarely fail, and, if the patient is etherized, is easily accomplished. The subglenoid irnd suhcoracoid\\\x.a.t\ons maybe reduced by manipu- lation, as follows : ^Vith the patient fully anaesthetized (for the right side), grasp the shoulder with the right hand, placing the thumb upon the head of the bone, and the fingers over the clavicle and spine of the scapula, and the flexed forearm, near the elbow, with the left hand. Carry the elbow out from the side, make firm extension, and slowly Fig. 3C2.— (Bn-ant.) Fio. 363.— Brvant.t rotate the humerus outward on its axis (Fig. 362). The elbow should now be raised and the arm made to describe a semicircle in the direc- tif)n of the sternum and face, and then suddenly brought down to the side of the thorax, the head of the humerus at the same time being ro- tated inward (Fig. 303). The thumb of the opposite hand should give the right direction to the head of the bone. (Thomas Bryant.) The subacromial and suhspinoiis dislocations are reducible by exten- sion and counter-extension in the line of displacement. Counter-exten- sion may be made by an assistant holding the arm of the sound side, or by the folded sheet (already described) apyjlied just in the axilla. The operator makes extension from the arm and forearm, imparting to the humerus a slight axial rotation. General Considerations. — Recent dislocations at the shoulder may not always be reduced, and some which are readily replaced are with 326 A TEXT-BOOK ON SURGERY. difficulty held in position, lluptnre of any nniscle, or group of muscles, renders the luxation subject to recurrence, since there is no antagonism to tlie reniiiiniui;' muscles. Ev<»n when reposition is eflecti'd and 7iia1n- tained, the functiuii of the joint may be permanently impaired on account of injury to the surrounding structures. Injury of the circunitlex nerve has been followed by atropliy of the deltoid and teres minor, while trau- matism of the great cords of tlie axillary i)lexus and injury of the ves.seLs have led to impairment or loss of function in the extremity. Ligature of the subclavian aitery and amputation have been necessitated after dislo- cation of the shoulder-joint. These injuries may occur at the time of the displacement, or they may be produced by a lack of skill or the employment of too great force in the efforts at reduction. After one or two days from the date of a luxation at the shoulder (as elsewhere) the difficulties of reduction increase, and ai'e in geneial pro- portionate to the length of time which has elapsed since the accident. At the expiration of the first week inflammatory adhesions occur, and the cavity of the joint is in part filled with the products of inflammation. In rare cases reduction has been accomplished at the end of three, six, and twelve months. The propriety of attempting reduction in ancient shoulder luxations will depend upon the individual case. It will frequently occiu' that, in tile new position, attachments are formed, with ligaments, cartilage, and synovial membrane, with fair, yet limited, motion in the false joint, which, together with the free mobility of the scapula upon the thorax, gives a useful degree of motion to the arm. Under such conditions any attempt at reposition is unnecessary. In well-selected cases, where an ancient dislocation can not be reduced by any other means consistent with safety to the tissues about the joint, and where motion is so limited that the usefulness of the arm is seriously impaired, direct incision, under strict antiseptic precautions, may be employed, and reduction thus efi'ected, with or without excision of the head of the humerus. After the head of the bone is returned to its nor- mal position, drainage should be secured through the rent or incision in the capsule. A Neubefs bone-drain, or a soft rubber tube, may be em- ployed, and should be so placed that it will lead downward from the most dependent portion of the capsule. Dislocations at the Elbow-Joint. — The upper end of the radius may be displaced forward on to the anterior surface of the humerus, near the coronoid fossa, or backward upon the olecranon process. The anterior displacement is met with somewhat more frequently than the posterior. In the displacement forward the orbicular and a portion of the external lateral and anterior ligaments are ruj^tured ; in the opposite luxation only the first two are lacerated. The forward displacement is caused by direct violence applied to the posterior aspect of the upper end of the radius, or by falling upon the palm of the hand while the forearm is completely extended, the full force DISLOCATIONS. 327 of the contraction of the biceps being thus added to the force transmitted along the shaft of the bone. Si/mptoms. — Careful palpation -will reveal the abnormal presence of the head of the radius near the center of the humerus, while pressure along the outer condyle will demonstrate its absence from its natural position. The forearm is semiilexed and slightly pronated. Treatment. — Flex the arm and push the head of the bone forcibly downward in the direction of the articulation. When reduction is ac- complished place a compress over the upper end of the bone and the external condyle, and bind it firmly in position. The arm should be snugly bandaged, and carried in a sling for several weeks. The backward dislocation is I'ecognized by the jiresence of the head of the bone in an abnormal position near the olecranon, behind the external condyle. Treatment. — While an assistant makes strong extension and counter- extension from the hand and arm, the operator makes direct pressure upon the head of the bone, forcing it in the direction of the articulation. As the displacement is being corrected the assistant should carry the forearm in a position of supination. The after-treatment consists of a compress and bandage, worn for several weeks. The jjrogjios/s of this injury is generally not favorable, since it is very apt to recur after reduction, and may become permanent. A fair degree of usefulness is maintained, however, in many cases of chronic luxation of this end of the radius. Complete forward dislocation of the ulna alone, at the elbow, can not occur without fracture of the radius or extensive laceration of the radio- ulnar ligaments. Dislocation of bot7i radius and ulna at the elbow may take place in all directions. The dislocation backward may be produced by falling upon the hand with the forearm almost extended ; by a blow uj^on the anterior aspect of the forearm, near the elbow, a blow upon the posterior surface of the humerus, in its lower portion, or force applied at the same time, in oppo- site directions, upon these surfaces. The coronoid process will be found lodged in the olecranon fossa, the upper end of the radius restiug on the posterior aspect of the external condyle. The anterior ligament and the anterior fasciculi of the external and in- ternal lateral ligaments are torn loose, and in extreme cases the orbicular ligament may give way, although the yielding of the external ligament usually saves the circular ligament from being torn. The tendon of the brachialis anticus is stretched or is broken loose fi'om the coronoid pro- cess. Pressure upon the brachial artery may be so great that pulsation at the wrist is diminished or absent, while in extreme cases the median, ulnar, or musculo-spiral nerves may be injured. The usual position of the forearm is one of almost complete extension, with pronation. Measurement from the inner condyle to the stjdoid process of the ulna will denu)nstrate shortening. Muscular rigidity is marked, and motion of the displaced bones difficult and painful. From 328 A TEXT-BOOK ON SURGERY. these symptoms the diagnosis can be readily made. If swelling has ensued, and the tumefaction is great, it is not always easy or i)ossiJ)le to recognize the character of the injury. Under such conditions it is wise to reduce the swelling by rest and local application for a few days, until the exact character of the luxation may be determined. Treatment — Red urtiun— Method ofAstlei^ Cooper.— V^ith. the patient seated in a chair, the operator places his foot on the seat so that the anterior aspect of the patient's forearm will be brought in contact with the anterior sur- face of the surgeon's knee. The forearm should now be grasj)ed near the wrist and forced flexion made, using the knee as a fulcrum, and at the same time as a point of resistance to the extension made by pull- ing upon the forearm (Fig. 364). Flexion unlocks the coronoid process from the olecranon fossa, and extension cari'ies both bones forward into position. Unless the operator is j^ositive that perfect reduction has been accomplished, the joint should be freely flexed and extended to test its working capacity. Care must be taken to hold the muscles in check while this manipulation is going on, for fear the bones may again slij) out of place. Band- age the arin and forearm, and apply a splint, which should be worn for a w^eek or two. When an ana?sthetic is used the recumbent posture should be maintained. The bare foot may be utilized instead of the knee. A cloth or sheet folded around the arm, just above the elbow, may be used for counter-extension. Liston advised strong extension from the forearm, and counter-exten- sion from the shoulder, with the arm and forearm held straight. Dislocation of the radius and ulna forward, without fracture of the olecranon, is of rare occurrence, and is always the result of great violence. Rupture of the posterior and lateral ligaments occurs, and the triceps tendon is torn or greatly stretched, while the brachialis anticusand biceps are relaxed. The posterior portion of the olecranon rests upon the ante- rior articular aspect of the humerus, or may slip into the coronoid fossa. The forearm is bent at an angle varying from 9U° to 120° to the anterior surface of the humerus, and is well supinated. Motion is painful and limited. The character of the injury may be determined by the absence of the olecranon projection, the smooth, bi'oad, posteri(jr surface of the lower end of the humerus being readily appreciated. Treatment. — An ana>sthetic is usually required. With the forearm held at about a right angle to the arm, make extension from the wrist, and counter-extension from the lower anterior surface of the humerus, in Fio. 364.— (Eriohsen.) DISLOCATIONS. 329 order to disengage the olecranon process from the coronoid fossa, and, when this is effected, make direct pressure downward upon the anterior aspect of the forearm, near the elbow. After the bones .slip seemingly into position, careful examination should be made to see that the radius is in its proper relation to the external condyle, for the ridge between the two sigmoid cavities of the ulna may lodge in the groove between the trochlear surface and the articular surface for the head of the radius. In the outward lateral dislocation the luxation is usually partial. The cause is direct violence applied to the inner aspect of the forearm, near the joint, or to the outer aspect of the humerus, low down, or to force applied simultaneously, in opposite directions, upon these two surfaces. The diagnosis will rest chiefly upon the increased prominence of the inner condyle, and the difficulty of recognizing the outer condyle by pal- pation. The angle at the elbow is about 120^, motion is wanting, and the hand is pronated. Reduction is best effected by strong extension from the forearm, counter-extension from the humerus, and direct lateral pressure in the direction of the displacement. Inward dislocation is always incomplete (Hamilton). The causes are direct violence in the opposite direction to that given for the luxation outward. The internal condyle will be less prominent, the external more prominent, the olecranon will be seen crowded over to the inner aspect of the joint, while the head of the radius rests near the middle of the articular surface of the humerus. The position of the forearm is that of flexion. Reduction is difiicult, and should be effected in ether narcosis. Extension and counter-extension should be made in the flexed, position, and the arm gradually brought out straight, while at the same time direct pressure is made, in proper and opposite directions, upon the humerus and forearm, near the joint. Dislocation of both bones backward is the most frequent form of dis- placement at the elbow. Incomplete external and incomplete internal luxation are next in order of frequency, while the forward dislocation is most infrequent. In the posterior variety the direction of the force may be such that a deviation to one or the other side may occur. The treatment is practi- cally the same. Direct lateral pressure in the line of the normal position of the bone may be required in addition to the mechanism of reduction above given. Partial anchylosis is not infrequent after these lesions. Passive motion should be begun within two weeks after the injurj^ and repeated daily if no acute inflammation is produced. Wrist-Joint. — Dislocations at the carpo-radial joint are very rare. Only a few instances of complete backward or forward luxation of the carpus are on record. Lateral dislocations are considered impossible without fracture of the styloid process of the radius or ulna. The two principal displacements occur with about equal frequency. In the back- ward variety the anterior aspect of the carpus rests upon the dorsal rim of the cancellous expansion of the radius, the reverse being true in the dislocation forward. The anterior and posterior ligaments are partially 330 A TEXT-BOOK ON SURGERY. or completely ruptured, and tlie annular ligament, which binds the ten- dons down, may be torn and the tendons displaced. The cause of the hacliward displacenit^nt is a fall on tlie back of the hand, or a blow upon the (lorsum of tlu; radius, just above the wrist, while the hand is in extreme Hexion. Violence of a similar character, applied in tlie opposite direction, will produce {\\e forwarfl luxation. The didjjuosis must be matle between Colles's fracture and disloca- tion. In d/slocaiion the deformity from the over-riding carpus is iiiucli greater than after fracture. In CoUes's fracture the swelling on the dorsum of the wrist is smooth and rounded. When impaction has not occurred crepitus may be obtained. Reduction is effected by extension and counter-extension from the forearm and hand, to which direct pressure in the line of displacement should be- added. Dislocation of the metacarpal Ixmes, at their carpal extremities, is rare. Luxation of the metacarpal bone of the thumb is most frequently met with. The carpal end of this bone may be displaced partially or completely, in a forioarcl or backicard direction. When the end of the bone rests upon the dorsum of the trapezius it can be easily recognized. Extension and counter-extension, with direct pressure, is usually suffi- cient to accomplish reposition. A clove-hitch or snare may be thrown around the thumb to insure extension. Reduction is at times difficult, and the history of this accident is not without a record of failure both as to replacement and retention when replaced. In the displacement forward, on account of the thickness of the soft parts, the end of the bone can not be easily recognized. An unusiud depression may be observed on the radial and dorsal aspects of the wrist, just in front of the os trapezium. Strong extension with counter-extension is necessary, and to this should be added direct pressure, applied near the end of the displaced bone. Luxation of the remaining metacarpal liones occurs rarely, and, when met with, the disjilacement is usually partial, and toward the dorsum of the carpus. The phalanges may be dislocated either hacJiward or forward at the metacarpal articulations, or at the interphalangeal joints. The character Fio. .305.— (After Hamilton. I of the lesion is easily recognized and the reduction not difficult. Exten- sion with a clove-hitch, or with the api)aratus shown in Fig. 365, will effect reduction. Hip-Joint. — While the head of the femur may be displaced from the cotyloid cavity in any direction, it is customary to consider. /"o^r distinct DISLOCATIONS. 331 luxations: (1) Ujwn tlie dorsum il'il ; (2) into the ischiatic notch; (3) into the obturator foramen ; (4) upon the os pubis. Practically these lesions occur in each of the quadrants of a cu'cle, the center of which is the center of the acetabulum. As shown in Fig. 366, about 50 per cent of all luxations at the hip occur in the iliac quadrant, 30 per cent in the ischiatic, 11 per cent in the obturator, and 7 per cent in the pubic. Two per cent occur beyond these regions. Cases are on record where the head of the bone was lodged on the tuber ischii, in the perinfeum, and just beneath the anterior- superior spine of the ilium. The capsule is usually torn at its inferior and posterior sur- face. It may be a slit or tear in the long axis of the liga- ment, or frequently a broad rapture occurs along the edge of the cotyloid cavity. The ligamentum teres (when pres- ent) is always torn. The ilio- femoral (or Y) ligament is very rarely completely ruptured. The injury to the muscles and sur- rounding structures is always severe, and varies in proportion to the degree of violence which caused the luxation, together with the particular direction of the displace- ment. In the displacement upon the dorsum ilii the glutei muscles may be lacerated, bruised, or lifted from the ilium by the head of the bone, but not by tension on their tendons, for, with the exception of the lower fibers of the maximus, their axes are slightly shortened in the new posi- tion. The obturator intermis, externus, gemelli, and quadratus femoris are greatly stretched, or torn entirely loose. The pyriformis is not so apt to suffer. The pectineus, iliacus, and psoas are carried upward and outward. When the head of the bone is projected into the ischiatic notch, the conditions as to the muscles are practically unchanged. The sciatic nerve and vessels are pressed upon and may be contused or lacer- ated. In the displacement upon the pubes the psoas and iliacus may be injured, while the femoral vessels and anterior crural nerve are more or less pressed upon. When the head of the bone is lodged in the obturator foramen, the obturator externus muscle and the obturator vessels and nerves are more or less contused, while the glutei and the remaining external rotators are put upon the stretch. Causes. — Dislocations at the hip may be congenital, pathological, or traumatic in cause. Congenital luxations, rare in occurrence, are the result of interference Fig. 306. — Showing the proporticn of displacement in the four quadrants of a circle about the acetabulum. 332 A TEXT-BOOK ON SURGERY. with iiDrmal development. Failure to complete the process of ossification in the three bones which compose the acetabulum leaves a soft and fibro- cartila-/ X-'-''- OS calcis should be smoothed off with the .I'")'"!" chisel or key-hole saw, and brought up in |/V'\ apposition with the plane surface of the *// bones of the leg. Fig. 402 represents a foot after recovery upon which I did this opera- tion in 1885. The Shoulder- Joint. — Exsection of the head of the humerus is readily effected by a single straight incision, about five inches in length, made from the acromion process directly down the arm, parallel with and splittiug the fibers of the deltoid (Fig. 403). The periosteum should be carefully lifted as far as the ostitis extends, and the soft tis- sues about the capsule raised with the ele- vator. The edges of the wound should be held wide apart by blunt retractors, and the tendons of insertion of the supra and infra spinatus, teres minor, and subscapularis di- Fio. 403. 368 A TEXT-BOOK ON SURGERY. Fio. 404. — Lonffitudinal section tlirnufh tlie shoulder-i"int, showing the relations of the bones, li^jainents, and niuH- cles immediately about the articulation. 1, The capsu- lar ligament. 2, The acromion. 3, Epiphysis. (Alter Braune. ) vided close to the tuberosities with the curved blunt scissors. The sheath for the long head of the biceps should be laid open, and this tendon held aside. If the exsector is used, tlie bone should now be divided at the limit of the disease. ^Vllen the section is completed a strong hook should be fastened into the end of the upper fragment, in order to lift it and facili- tate the separation of the soft tissues on the inner and un- der surface from tlie bone and capsule. The capsular liga- ment should be trimmed from the margins of (he glenoid cavity and removed with the head of the humerus. All diseased tissues should be dissected out with the curved scissors, and, if the head of the scapula is involved, all disorganized bone should be scraped away with the spoon or rongeur. If the exsector can not be had, the capsule should be di- vided and the head of the bone dislocated upward through the wound. The division is then made with a narrow saw, taking the precaution to protect the soft parts from injury. Upon examining the wound left after this operation, it will be seen that the deepest portion is behind and to the outer side of the end of the shaft. Into this depression carry a closed dressing-forceps, and bore through to the skin, pointing the in- strument to the inferior and outer asi)ect of the arm. Divide the skin over the point of the forceps, dilate the opening by separation of the handles, and draw a drainage-tube from below upward through the hole. A second shorter tube should make its exit through the anterior and lower angle of the wound of incision, and the wound closed throughout with catgut. The forearm should be held in a sling or fastened across the abdomen. The application of Esmarch's bandage, and the rubber tubing in the axilla and over the clavicle and scapula, renders this oper- ation practically bloodless. The rate of mortality is exceedingly low. AVith careful antisepsis it is practically without dan- ger to life. A second ojier- ation for the removal of dead bone is occasionally required. TheM.how-Jomt.-Yla-s. the forearm on the arm and make a straight incision, commencing in the middle of the posterior aspect of the humerus, about one inch above the condyles, and extending over the center of the olec- FiG. 405. EXSECTIONS OF THE JOINTS. 369 ranon process, along the ulnar, for fmni two to three inches (Fig. 405). The tissues should be carefully lifted from the bone and capsule, and held to either side by blunt retractoi's. When the trough between the olecranon and interiinl condyle is approached, extra care should be taken not to wound the ulnar nerve, which passes in this groove. It may be avoided by keeping close to the bones with the knife or elevator. After the posterior ligament is divided, the olecranon may be displaced, and, if involved in the destructive ostitis, may now be sawn off in order to facilitate the operation. The articular end of the humerus should be exposed, as high as the point of section, by peeling off the soft tissues with the periosteum, after which a retractor is applied and the bone divided with a Butcher's saw or the exsector. Tliis line of section should be at an angle of 90° to the shaft of the humerus. The ends of the ulna and radius may now be readily displaced backward, exposed to the point of section, and divided on a line parallel with that through the humerus. t;/i»' Fio. 406. — Longitudinal section tlirouo-h the elbow-joint. 1, Kadial nerve. Superficially on the fle.xor surtiice the median basilic vein is seen cut acro-sa. (After Braune.) As in all the joint exsections, a careful dissection of all the diseased cap- sule and soft parts must be made. The wound is drained from the mo.st dependent portion, and closed with catgut sutures. An anterior splint, previously fitted to the arm and forearm, and fashioned so as to hold the forearm half way between flexion at a right angle and complete extension, is wrapped with gauze and laid on the anterior aspect of the extremity, and fixed by a roller to the arm and forearm, to within a few inches of the incision. A sublimate dressing is next applied to the wound, with cotton and protective, and a bandage over this to effect compression and to hold it in position. Wlien a change of dressing is required, this last bandage only is removed. The rule in this exsection is fibrous anchylosis, with limited motion of the joint and function of the extremity. Exsection of the elbow is not a dangerous procedure, and, although not usually attended with the success which follows some other opera- Si 370 A TEXT-BOOK OX SURGERY. tions (as those upon the shoulder and ankle), it should be preferred to amiMitation. The anatomical relations at this joint are shown in Fig. 40G. The Wrist -Joint. — The exsection of this joint is attended with con- siderable difficulty, not only in the performance of the opeiation, but in Fig. 407. — Bourcfery's operation (modified). Fio. 408.— Lanpeiibcclv's incision. (Allir Esmarcb.) the after-treatment. Moreover, it is more apt to be followed by failure, resulting- in amputation. Of the two procedures — viz., the double lateral and parallel inci-sions (Fig. 407), and the single longitudinal dor.sal incision (Fig. 408) — the latter is preferable when the destructive pi'ocess is not so extensive, and when the sjjoon or gouge may be used, while the foi-mer will give the freest access to the bones when the saw or exsector is to Fio, 403. — EsmarL-h's lutuiTUijtud splint for exsection of the wrist. be employed in the removal of a large portion of the bones which enter into the composition of this joint. EXSECTIOXS OF THE JOINTS. 371 Fig. 410. — TLe same applied. lu the operation v.itli a single dor- sal inci.3ion the wrist should be made prominent, by flexing the hand on the foreai-m, and the integument divided along the tendon of the extensor com- munis digitorum, which goes to the index - finger, the incision extending from the middle of the metacarpus to one inch and a half above the tip of the styloid processes. The tendon may be retracted to the side most conven- ient. The i^osterior segment of the an- nular ligament is divided, and the tis- sues lifted from the bones with the elevator. The end of the radius should be removed with the exsector or gouge,- when the carpus may be displaced backward through the incision, and removed wholly or in jjieces. When the section is completed, the surfaces should be brought in apposition and fixed upon a well-adjusted anterior splint. Or an inten-uj^ted dressing may be applied by incasing the forearm in jilaster of Paris to within an inch of the incision, and the fingers and hand in the same material, back as far as the anterior limit of the wound. A piece of hoop-iron (or several pieces of telegraph-wire twisted into a single piece) is shaped as shown in Fig. 409, incorporated into the plaster upon the arm, and made to loop over the wrist to the tips of the fingers, where it is turned back underneath the hand, and is fastened to the plaster here by an additional gypsum liandage (Fig. 410). In the other operation one incision 372 A TEXT-BOOK ON SURGERY. is made along tlie outer and dorsal aspect of the metacarpal l)one of the little finger, over the styloid of the ulna, and one inch along this bone. The radial incision should coiunience on the dorsum of the metacarpal bone of the index-tinger, jjass backward and slightly toward the radial surface of the forearm to a point half an inch above the tip of the styloid process, and thence directly ui^ward along the dorsal aspect of the radius. In extensive operations it may become necessary to divide the tendon of the extensor ossis metacarpi pollicis, which is crossed by the incision. When done, the ends should be reunited l)y silk sutui'es when the f>per- ation is finished. The tissues are lifted from the bones and capsule as before, and the sections made with the exsector or key-hole saw. CHAPTER XIV. REGIONAL SURGERY. — THE HEAD. Tumors of the Scalp. — The most common tumors of the scalp are cysts. They are congenital and acquired. Congenital cysts are rare as compared with the acquired. They are deeply situated, being beneath the skin, and not infrequently below the fascia and muscles. Their contents are chiefly white or yellow fluid, and at times hairs. Each tumor may consist of a single cyst, or there may be several grouped together (multilocular), the mass rarely attaining a size greater than an inch in diameter. If left alone they may ulcerate from pressure or injury, or, in rare instances, may cause atrophy and perfora- tion of the calvaria and dura mater. They should be removed in early childhood. The operation consists in dissecting oiit the sac, with its contents. As a rule, small wounds of the scalp, situated where a scar will not be apparent, do not need to be stitched. The edges should be approximated and held thus by a dressing of sublimate gauze and a bandage. Acquired cysts, commonly called " wens," are of two varieties, one due to retention of sebum in a sebaceoiis follicle, the duct of which has been obstructed ; the other caused by extravasation of blood, where the clot has been absorbed, leaving the serum more or less stained by the decomposition of hsematin. They are round, smooth tumors, are super- ficial, and found most frequently upon the upper and posterior portion of the scalp. They are mostly multiple, are unilocular, and contain a granular, cheesy substance. The treatment is removal with the knife. The hair should be shaved from the tumor, and for a slight distance be- yond its base. Complete anaesthesia can be obtained by injecting about TT, XX of a 2-per-cent solution of cocaine in the line of incision, and around the base of the tumor. With a sharp bistoury transfix the mass through its base, and lay it open. The integument over the center of the tumor will be found exceedingly thin (not thicker than ordinary writing-paper), and may be easily separated from the thickened sac, Avhich should now be seized with a strong pair of forceps and torn out of its bed. If any strong adhesions are found they should be divided with the blunt scissors. Sebaceous cysts occasionally become inflamed, the capsule breaks down, the contents escape, and a mass of granulation-tissue replaces the original tumor. The new-formed capillaries in this tissue frequently give 374 A TEXT-lJpOK OX SURGERY. way, causing repeated li;cinoirlui,u'e. They .should l)e seraped out with u sharp spoon, and the sac removed by dissection. Horns, or dense ei)itlielial outgrowths, are t>ccasionally seen upon tlie scalp and face. Some of these excrescences attain hirge size, Tliey should be removed by an elliptical incision around the point of attach- ment. Tlie incision slioidd remove the entire thickness of the integu- ment. Lipomata., or fatty tumoi's, are of infrequent occurrence beneath I la- scalp, and, on account of the dense integument, they grow very slowly, and rarely attain large size. The diagnosis between sebaceous and fatty tumors of this region is not always easy. The treatment is removal by dissection, which is easily effected by lifting the tunioi' from its cap- sule with the finger or the blunt scissors. The capsule need not be re- moved. JVcBDt, porf-wine marJcs, and other vascular tumors, are quite comnion upon the seal]). Tiiey have been treated of in a previous chaiiter. Papillomata, or warts, occasionally covering a large territory, are found in this region. In one case which came under my care a flat y>n])il- lonui, two inches in width, extended from the right temple to the middle line of the scalp. They should be clipped closely with the curved scis- sors, their bases bui-ned with the actual cautery or nitric acid, and the operation repeated until a cure is effected. Elephantiasis, or general thickening of the scalp from connective- tissue new-formation, is, fortunately, rarely met with. Ligation of the vessels feeding the diseased area will afford temporary relief, and is a justifiable procedure. JRcinafoma has been considered in the chapter on Wounds of the Scalp. Abscess of the scalp requires free incision, irrigation, and drainage. Any doiibts as to the character of the swelling may be dissipated by ex- ploration Avith the hypodermic syringe and a. good-sized needle. Pneumatocele, or "rt7>-^;f??ior," is occasicmally met with beneath the scalp. It results from disease or fracture of some of the bones, permit- ting communication with the cavities, as the frontal sinus, or the Eusta- chian tube, etc., and the escape of air beneath the skin. Evacuation of the contents by pressure, with or withoiit puncture, and a compress to prevent recurrence, will produce inflammatory adhesions and cause a cure. Ostitis, or periostitis, is not uncommon in the calvaria. The causes are the same as for ostitis elsewhere. Great care should be observed in the treatment, on account of the proximity of the meninges and brain. Ostitis with exfoliation demands early recognition and immediate opera- tive interference. A free horseshoe or crucial incisicm should be made, ami all the diseased bone removed with the sharp spoon. When the exfoliation is confined to the outer table of the skull the prognosis is favorable. The wound should be kept open, well drained, and allowed to heal by granulation. If pus is found beneath the inner table, enough REGIONAL SURGERY.— THE HEAD. 375 of the bone should ))e cut away with the rongeur to permit the free escape of all of the products of inflammation. The jiatient should be required to rest in the position which secui'es most perfect drainage. A loose antiseptic dressing should be applied. Osteoma, or exostosis, occurs quite frequently upon the bones of the skull. "When not due to syphilis they should be removed eai'lj", by the gouge or chisel, as there is always danger of pressure uj^on important organs if allowed to remain. Syphilitic hyperostosis requires the specific treatment given for this dyscrasia. Encephalocete, or ?ieruia cerebri, is a protrusion of the brain-substance through an opening in the calvaria. This condition usually occurs in children suffei'ing from liyfl roceplialus, the protrusion taking place through the abnormally enlarged fontanelles. The dura mater sur- rounds and is carried in front of the mass, lying in contact with the peri- cranium. When the meninges alone protrude, the tumor is known as a meningocele. Hernia cerebri may occur after perforation of the skull from any cause, as fracture or necrosis. More fre- quently the mass which protrudes is made up of a granulation-tissue containing no ele- ments from the brain-substance, while at times these masses are composed of both brain- and granulation-tissue (Fig. 412). The character of the tumor will be recognized from its rapid development after perforation of the calvaria. Treatment. — AVhen the mass is small, and is just beginning to project, compi-essii )n should be employed to prevent a further protrusion. It is not safe to attempt a re- duction of the tumor. The hair should be shaved from tlie scalp near the opening and disinfection accomplished by sublimate irri- gation, and a compress of sublimate gauze and absorbent cotton applied. If the tumor does not rapidly slough away, it should be removed at the level of the scalp with the elastic ligature or the actual cautery. Sarcoma of the dura mater is a grave condition, fortunately of infre- quent occurrence. In the process of development the tumor is aj)t to cause absorption of the calvaria, and finally perfoi-ation. This iisu- ally occurs long after symptcmis of pressure from witliin have been de- velojied. If the patient sui-vive the compression of the brain, the tumor ultimately undergoes necrosis and breaks down into a dirty mass, in which the process of ulceration is accompanied by frequent haemorrhage. Carcinoma of the meninges may occur as a result of metastasis, al- though rarely if ever occurring primarily in this situation. In sarcoma and carcinoma of the dura mater little more can be done than to relieve pain by the employment of narcotics. Flo. 41'2. — .\Ia>s C'liiiiK.si'il of brain- substiinc'c ami fjriiuulatioii-tissue, removed by Dr. E. .1. Beall from a boy whose skull had been fract- ured. Exact size. 376 A TEXT-BOOK ON SURGERY. Hydroeepkalus is i)nniaiily a disease of the arachnoid and pia nutter. It is a disease of childhood, resultinff from inherited tubercu- losis. Tiie gross lesion is a transudation of a serous fluid from the i)ia and arachnoid into the cavities of the ventricles, the arachnoid, and sid)- arachnoid spaces. Distention of the ventricles, compression of the brain- substance, se]«iration of the sutures, enlargement and deformity of the head, projection of the eyeballs, downward squint, and loss of cerebral function, are the symjitoms, invariably ending in death. Treatment. — Tapping will at times relieve the more urgent symp- toms of distention and compression. Careful antisei)sis should be prac- ticed, and the aspiration made through one of the lateral angles of the anterior fontanella. A small needle should be introduced, ami three or four ounces slowly withdrawn, the operation occujiying froui fifteen to thirty minutes. This treatment is palliative, and is only justifi- able in the effort to relieve the suffering of the patient. A cure is impossible. Wounds of the scalp should be treated as wounds of other parts of the integument. Incised wounds should be rendered aseptic, and may be closed by sutures, or the edges brought into apposition by a sublimate- gauze compress and bandage, according to the extent and location of the injury. Sutures are as well tolerated here as elsewhere. When there is no especial desire to avoid a scar, sutures may be omitted, unless the wound is so extensive and gaping that apposition can not be effected by com- pression. Silk is preferalde in stitching wounds of the scalp. Tlie hair should be trimmed for a fourth or half inch from the edges of the wound. When no large vessels have been divided, the introduction of the sutures will suffice to arrest the bleeding. It is a safe precaution to insert a small twist of catgut into one angle of the wound to .secure drainage in case of suppuration. Lacerated wounds of the scalp are at times very extensive and for- midable. Several instances are reported of complete avulsion of the female scalp from the entanglement of the hair in machinery. In such cases transplantation of integument becomes necessary, in order to pre- vent ostitis from denudation of the calvaria. Ordinary lacerated wounds should be rendered aseptic, and treated by a compress of sublimate gauze. No sutures should be employed, excej:)! when a scar is to be avoided, and then only after the torn and bruised edges have l)een trimmed off with the scissors. Contused wounds of the scalp are usually followed by marked swell- ing, due to extravasation of blood (ha^matoma) beneath the pericranium. The treatment consists in cold applications, by means of the ice-bag or cloths taken from ice-water. If suppuration occurs, incision should be promptly made. A form of serous cyst sometimes results from haema- toma of the scalp. It should be treated by aspiration, and, if one or two evacuations do not effect a cure, it should be incised, and the cyst-wall dissected out. Gunshot wounds in this part require no especial conisideration. Punctured wounds of the scalp are not serious, as a rule, when no REGIONAL SURGERY.— THE HEAD. 377 poison is introduced through the wound, and when the bones are not penetrated. Penetrating Wounds of the Skull. — \Vhen a foreign body has pene- trated the cranial cavity and passed ont, and the patient survives the im- mediate effect of the accident, the wounds of entrance and exit should be cleansed of loose fragments of bone, or any foreign body. To accomplish this it will be not only justifiable, but often imperative, to enlarge both openings, by use of the trephine, and, while employing strict antiseptic precautions, to secure free drainage for the discharge of blood or other fluids from the track of the missile. When severe intra-cranial haemor- rhage occurs, no attemi)t should be made to arrest it by plugging the wounds through the skull, for fatal compression of the brain might thus result. If the vessels involved can not be reached from the enlarged openings, and secured by haemostatic forceps or the ligature, the head of the patient should be elevated, in order to diminish the pressure at the bleeding point. This may in part be aided by ligation of the extremi- ties, as heretofore described. If there is only a single opening, and the body is lodged within the cranium, a careful inspection should be made about the wound of en- trance, and, if the presence of the missile can be recognized, it should be at once extracted, even if the ajiplication of the trephine is required. If the bullet shall have entered the substance of the brain — which can be determined in jjart by the careful employment of a light Nelaton's probe, jsrovided with a good-sized porcelain tip, introduced through the wound in the skull, sufficiently enlarged by the trephine— the probabilities are that it has passed through the brain in the line of projection of the missile, and is lodged beneath the skull, at or near a point directly in the line of its projection. This condition was found to exist in the remarkable case operated on by Prof. "W. F. Fluhrer, in Belle- vue Hospital, in 1884. The patient, aged nine- /''TTT^ teen years, received a pistol-shot wound, enter- / \ ing at the forehead and passing through the /^ _^ J brain, in the line shown in Fig. 413. The hole V' }y / of entrance was enlarged by biting off the edges y ' 7 of the bone with a rongeur. An alarmino- ^^ ^^?^^\ haemorrhage from a vessel of the pia mater was y/t^^ y^ ^ controlled by a small artery-clamp, or forceps. / l^_S>'^~''^ \ The i:)atient's head was placed so that tlie sup- // h !^ posed track to be explored was perpendicular ' / ' to the surface of the table. A good-sized por- fic. ^s.-Fiuiircr'scaseofpenc- celain-pomted Xelaton's probe was carefully in- [heL^inlur'tArtorFiuilf) troduced, and allowed almost to find its o^vn way in the track left by the bullet. This instrument passed to a depth of six inches, where, a slight resistance being met ^vith, it was allowed to remain. The direction of the probe indicated the point on the oppo- site side of the skull, at which the missile had most i)robab]y struck. Three fourths of an inch below this line the trephine was applied. Upon removing the disk of bone the dura mater appeared dark from blood 378 A TEXT-BOOK ON SURGERY. effused beneath it. An incision was made through this, and the traok of the bullet through the pia mater was discovered. It had struck the iiuici- surface of the calvarin, had ivbounded with a downward dellection, and was found about half an inch from the hole made by the trephine. A small rubber drainage-tube was passed entirely through the track made by the bullet, and left ])i'ojecting at each opening. Irrigation through the tube was not attempted. The wounds were dressed with iodoform- ized gauze, loosely laid on, and an antiseptic dressing over this. The patient recovered and returned to his occu]iation, suffering only with a slight impairment of memory and occasional muscular spasm. The important lesson from this case is, that the careful exploration of the cranial cavity, and of the brain-substance, for the removal of a foreign body, is a rational and justifiable surgical procedure. The careful em- ployment of a light, broad, dull-pointed prol)e will enable the operator, in a certain proportion of cases, to follow in the track of a foreign ])ody and indicate its place of lodgment. Not infrequently compression of the brain occurs from hjemorrhage between the skull and the dura mater, or from a collection of pus, exos- tosis, depression of bone, or tumor within the cranium. "Within recent years researches in cerebral anatomy and phjsiology have enabled scien- tists to determine, with accuracy sufficient to justify the application of their conclusions to sxirgical practice, from the disturbance of function in certain portions of the economy, the region of the brain involved in the zone of -compression. That portion of this subject which is most Fissure of Rolando. Fissure of Sylvius. Fig. 414.— (llodified .qftcr Cbampionnierc.) capable of demonstration, and therefore most practical, relates to the interference with motion in certain muscles, or groups of muscles, which have their "centers of motion" situated contiguous to the fissure of REGIOXAL SURGERY.— THE HEAD. 379 Rolando, and to certain disturbances of the mind and the senses chiefly located in the cortex of the brain. According to Lucas-Championniere,* who adopts the conclusions of Charcot and Pitres, our knowledge of this subject may be summarized as follows : " In a lesion followed by paraly- sis of the lower extremity the trephine should expose the summit of the ascending jyarietal convolution, on both sides of the upper end of the fissure of Rolando (Fig. 414). Of the upper extremity, the middle third of the ascending frontal convolution, also on both sides of the center of the fissure ; vpper and loioer extremities, both regions just given ; upper extremity alone, with motor aphasia, foot of tJiird frontal and lower third of ascending frontal convolutions, in zone marked motor aphasia in Fig. 414. Facial paralysis, lower third of the ascending frontal and foot of second frontal convolutions. Aphasia alone, foot of third frontal.'''' After a careful analysis of all the cases of cortical lesions of the brain published in America, and a thorough review of the results of foreign Investigators, Prof. Starr arrives at the following conclusions : f "1. Various powers of the mind are to be connected with activity in various regions of the biain, the surface of the organ being the seat of conscious mental action. "2. The highest qualities of the mind — intellect, judgment, reason, self-control — require for their normal display integrity of the entii'e brain, but especially of the frontal lobes. A change of disj^osition and charac- ter may be considered as symptomatic of disease of the brain, and, in the absence of other symptoms, of disease of the frontal lobes. "3. The power of sensory perception is distributed over the various regions of the brain ^ith which the various sensory organs are anatomic- ally connected. In these regions objects are not only first consciously perceived, but are also subsequently recognized ; and hence it is in these regions that the memory pictures are stored, by whose aid the act of recognition is accomplished. " («) Disturbance of sight, whether in the form of actual blindness, or of failure to recognize or to remember familiar objects, or of hallucina- tions of vision, may indicate disease in the occipital lobes. An examina- tion of the field of vision will indicate which lobe is affected, since blind- ness in the right half of both eyes may be due to destx'uction of the left lobe, and l)lindness of the left half of both eyes may be due to destruction of the right lobe. " (6) Disturbance of hearing, either actual deafness in one ear or hal- lucinations of sound on one side (voices, music, etc.), may indicate disease in the first temporal convolution of the opposite side. Failure to recog- nize or to remember spoken language is characteristic of disease in the first temporal convolution of the left side in right-handed persons, and of the right side in left-handed persons. Failure to recognize printed or * " La trepanation guiJue par lis localisations cerebrales." V. A. Delahaye ct Cie., Paris, 18V8. t " Cortical Lesions of the Brain." M. Allen Starr, from "American Journal of the Medi- cal Sciences," July, 188-t. 380 A TEXT-BOOK ON SURGERY. HTitten language has accompanied disease of the angular gyrus at the junction of the teniiioral and occipital regions of the left side in three foreign and in one American case. " (c) Disturbance of smell, either as an hallucination or as a loss of power to perceive odors, may possibly indicate disease in the temporo- sphenoidal region on the base of the brain. "(fZ) Disturbance of taste can not, as yet, be connected with disease in any region. This is due to lack of care in testing this sense in cases of brain disease. " (e) Disturbance of general sensation — including the senses of touch, pressure, pain, and temperature, together with the sense of the location of a limb — may occur either in the form of subjective perceptions of such sensations without objective cause, or in the form of impairment of these sensations. In either case it indicates a disease in the central convolu- tions, and possibly in the adjacent i)ortion of tlie parietal lobules. " 4. The power of voluntary motion of the muscles of tlie opposite side of the body is located in the two central convolutions which border the fissure of Rolando. Motions of the face and tongue originate in the lower thml of this region ; motions of the arm, in the middle third ; motions of the leg, in the upper third. " Spasms in a single group of muscles, or paralysis of a single group of muscles, may indicate disease of its motor area. Extensive spasms or paralysis may indicate a large area of disease in this region ; but if more marked in a single group of muscles than in others it may indicate a small focus of disease in the motor area of that group affecting other motor areas indirectly and coincidently. Paralysis following spasm in one group of muscles is a characteristic symptom of disease in the central region. " 5. Disturbance of the power of speech indicates disease in the convo- lutions about the fissure of Sylvius, on the left side in right-handed persons, and on the right side in left-handed persons. If the i:)atient can under- stand a question and can recall the words needed for a reply, but is un- able to initiate the necessary motions involved in speaking, the disease is jn'obably in the third frontal convolution, and in the adjacent portion of tlie anterior central convolution. If the patient can not recognize spoken language, but can repeat words after another, or can use exclamations on being irritated, the disease is probably in the first temjioral convolu- tion. If the patient can understand and can talk, ]mt replaces a word desired by one that is unexpected, the disease is probably situated deep within the Sylvian fissure, or in the white substance of the brain, and involves the association hbers which join the convolutions just named. " In making a diagnosis of cortical disease care must be taken to dis- tingiiish between direct and indirect local symi)toms ; and also to sepa- rate clearly lesions of the cortex from those of the various white tracts within the substance of the brain.'' As far as the disturbances of motion are concerned, these points of interest bear such close relation to the fissure of Rolando that it is neces- sary to determine approximately its location. Championniere's line is as REGIONAL SURGERY.— THE HEAD. 381 follows : From the posterior border of the malar process of the frontal bone, at the upper outer angle of the orbit A (Fig. 415) draw a line A B, directly backward, a distance of two and four lifths inches. From B draw a perpendicular line, one inch and one fifth long, to C, then from C, upward and backward, to Z>, which shall tei-minate in the sagittal suture, two and one fifth inches directly' behind the junction of the coronal and sagittal sutures, B. The point of junction of the sagittal and coronal sutures is not always easily recognized in the adult. If, however, the distance from the root of the nose (the naso-frontal suture) to the poste- rior-inferior border of the occipital protuberance be measured, the point D (Fig. 415) wiU be found to vary from three quarters of an inch to an Fig. 415.— (Modified after Championniere.) inch po.fterior to the center of this line. The junction of the sagittal and coronal sutures is directly above the external opening of the auditory canal. The researches of Championniere may practically be applied as follows : In complete and persistent hemiplegia, where the history of the case may exclude extravasation in the deeper ganglia, the center or bit of a large-sized ti-ephine should be placed in the middle of this line, at 2 (Fig. 415), on the side opposite to the jiaralysis. If there is loss of mo- tion or convulsive movements of the lower extremity alone, the trephine should be applied in the upper third of the line, at 3. When the upper extremity alone is involved (the lesion being probably in the middle third of the ascending frontal convolution), the operation should be performed opposite to the middle and in front of this line. When simple aphasia is present, the trephine is to be applied at the lower end. and well in front of this line, 1. If, when the button of bone is removed, the cause of the compression is not revealed, the opening should be enlarged by the ron- geur, or by reapplying the trephine. The after-treatment is the same as given in trej^jhining for injuries of the skull. 382 A TEXT-BOOK ON SURGERY. Surgery of TirE Face. Wounds. — Incised- wounds of the face usually blood profusely. The two esseutial features in treatment are to arrest hsoniorrhage and secure repair with the least possible deformity. When the l)l<'edinn: is only slight, bringing the edges together with line silk sutures will arrest it. When ligatures are applied, catgut should invariably be employed. Every wound of the face should be treated with the strictest antisepsis. The approximation of the edges should be accomplished with exactness. The finest black ii'on-dyed silk is the best material, and the interrupted suture should be preferred. If the character of the luemorrhage necessi- tates central deligation, the external carotid (not the common trunk) should be tied. This necessity could scarcely arise in an incised wound, unless the internal maxillary or npper part of the external carotid was involved. Contusions of this region require, as in other parts of the liody, local applications, usually of cold water or the ice-bag. Ecchymosis is, as a rule, present, and is i)ersistent in the tissues about the eyes. Lacerated wounds of the face are serious, on account of the danger of disfigurement after repair. If the procedure does not involve much loss of tissue, the edges may be pared smoothly and united \\ith silk sutures, under careful antisepsis. If there has been extensive contusion, a small catgut-twist drain should be left at each end, to guard against the danger of infiltration of pus in the subcutaneous tissue. In wounds which involve the circular muscles of the eyes and mouth, great care must be taken to guard against contractions and deformities. Punctured wounds require no sjiecial consideration. Deligation of the external carotid may be necessitated to arrest bleeding from deep wounds of the spheno-maxillary fossa. Shot wounds of the face are not, as a rule, dangerous to life, even in military practice. Of 3,312 cases, in which fracture of the bones of the face occurred as a result of shot wounds, as given in the " Medical and Surgical History of the Civil War," by Dr. George A. Otis, only 340 died, wdiile of 4,914 llesli wounds only 58 died. In civil practice the rate of mortality is still lower. When the missile has penetrated the siiheno-maxillary fossa, or di- vided any deei:)-seated vessels, the necessity of tying the external carotid may arise. A ball or any foreign body lodged in the bones or tissues of the face should be immediately removed, when this can be accomplished without an operation which may incur the danger of deformity. When, however, the missile is deeply lodged, and is of small size, it should not be molested until there is evidence that it will not remain encapsuled and harmless. Bones or fragments of bone which have been displaced in part, but not entirely stripped of periosteum and vascular attachments, must not be removed, since, if replaced and held in proper position, they usually become reunited to the sound bone. DISEASES OF THE EYELIDS. 383 Surgery and Surgical Diseases of the Eyelids and of the Or- bital Cavity (xot including Lesions of the Globe). Wounds of the eyelids and of the circular muscle of the eye scarcely require special consideration. In incised or lacerated wounds a careful approximation of the edges of such wounds with the finest silk sutures, and the maintenance of the parts in a condition of perfect quiet, are essential. The sublimate and carbolic-acid solutions can not be emi)loyed when the surface of the eye is exposed. A saturated solution (about grs. XV - 5 j of water) of boracic acid is to be preferred for purposes of clean- liness. Contusions about the eye should be treated by cold applications, using a very small and light ice-bag, or frequent changes of bits of linen cloth, taken from a block of ice. NeiD Formations. — Vascular groictTis (njevi or angeiomata), usually of the capillary variety, are not infrequent in the vicinity of the eye. When of small size, not exceeding a half or three fourths of an inch, they may be successfully destroyed by the hypodermic injection of from two to five minims of a 50-per-cent solution of carbolic acid. Great care should be taken not to allow any of the solution to enter the eye. Removal by free excision is not practicable when the tumor is of large size, and when the palpebral margins are involved, or when their shape and situation are such that deformity is apt to follow the excision. A careful application of the rules of plastic surgery to the region of the eye will often oljviate deformity, even after extensive dissections with loss of tissue in the vicinity of this organ. What has been said of the excision of vascular growths applies equally to all fomis of neoplasms in this region which — themselves a deformity, or malignant in character — require removal. When the lower lid is encroached upon, it is of the utmost importance that the palpebral margin be left intact for at least one eighth of an inch, Fig. 416. Fig. 417. and as much more as is consistent ^^-jth the free excision of the tumor. One incision .should be parallel with the border. The palpebral branch of the ophthalmic artery, which runs j)arallel with and about this dis- 384 A TEXT HOOK ON SUKGKRY. tance fmiii I In- I'lvc iimruin of tlip lid, f^lioiikl not be wounded when it is possible to avoid it. When tlie dissection is completed, a tonp:ue of skin may be slid from the malar re- gion across the wound. Fig. 416 represents the space left after the removal of a myxo- sarcoma of the face, and Fig. 417 the method of covering in the deJiciency. From the outer angles jiarallel incisions were continued through the skin toward the ear, as far as was necessary to secure integument enough to slide across the gap. The transverse facial artery, which runs about one fourth of an inch below and i)arallel with the zygoma, should be kept in the flap, which is dis- sected up until the end near- est the nose can be carried across to the edge of the wound upon the nose and stitched at this point. The lower border is next fastened, and after this the palpebi-al border is stitched to the upper margin of the tongue of skin with the finest suture ma- terial. The sutures may be re- moved in from two to four days. It is necessary to aiTest all bleeding from the bottom of the cavity left after a dissec- tion ; that from the edges wall be arrested by the sutures. The tension on the flap should not be so great that the blood- supply is seriously interfered with. After the first sutures are inserted it will be well to wait for a few minutes in order to see that the circulation is established. Figs. 418 and 419 are taken from a patient from whom a large na?vus was ex- cised, and the wound iilled by free dissection and sliding of the integument of the cheek. Little or no eversion or drag- Fio. 418. Fig. 419. DISEASES OF THE EYELIDS. 385 ging down of tlie lid will follow in these operations when carefully j-jpr- formed. Sebaceous tumors (retention-cysts) are occasionally met with on tlie outer surface of the lids, and in the skin about the orl)it. They should be removed by thorough dissection of the sac. When situated upon the lids they rest between the integument and the tarsal cartilage. The line of incision should be parallel with the free border of the lid, to avoid dividing the horizontal fibers of the orbicularis muscle. A more frequent swelling of the edge of the lid, commonly known as a stye {hordeolitm), results from an inflammation of the sebaceous and hair follicles at the palpebral margin. It is a furuncle of the lid. The treatment consists in early evacuation of the contents of the Ixtil by pricking with a needle or lancet. Warm or emollient applications hasten the suppurative process and soften the covering of epidermis. Obstruction of one or more of the ducts of the MeiboTnian glands causes a swelling and inflammation of the gland, or tube beliind the point of obstruction. These protrusions appear on the conjunctival surface of the tarsal cartilage, and should be treated by puncttire, with evacuation of their contents by pressure ; or by pressure on both surfaces of the lid, directed from the base toward the free border, in the effort to squeeze out the plug and thus restore the normal condition of the excretory duct. Any incision on the under surface of the lids should be nuide parallel with the ducts of these glands. A rare form of cystic tumor, known as chalazion, occasionally develops in the substance of the tarsal cartilage. It may be cured by incision and destruction of the sac, or by evacuating the contents and injecting one minim of 50-iDer-cent carbolic acid into the cyst. Blepharitis or inflammation of the lids may affect all or a limited portion of these organs. It most frequently involves the ciliary margins, and is known as blepharitis ciliaris. In rare instances the cartilages are involved. Acute blepJiaritis demands rest and local antiphlogistic appli- cations. Cloths dipped in warm water are in general more agreeable. In chronic blepharitis ciliaris the scaly covering of the inflamed borders of the lids should be removed by the prolonged use of warm boracic-acid water and a mop of soft lint, having first trimmed the lashes closely. When this is dcme the inflamed surface should be lightly touched with a pencil of lunar caustic. At night the lids should be lubricated with a small quantity of cosmoline. Conjunctivitis or inflammation of the ocular and palpebral conjunc- tiva may be acute or chronic in character. The causes are traumatic, idiopathic, and contagious. A severe form of this disease, in which the formation of pus is abundant, is known as p^irulent conjuncti- vitis. Another form, known as phlyctenular conjunctivitis, is charac- terized by the apx^earance of one or several centers of inflammation, each spot being somewhat elevated above the general surface. This variety is almost always met with in children suffering from an inherited dyscrasia. Among the more common forms of contagious conjunctivitis are those - 25 386 A TEXT-BOOK OX SURGERY. met with in the newly born {oplithalmia neonatorum) : gonorrhoeal and diph fheritic ophthalmia . Trrdfiitrnf. — Acute simjile ronjunctivitis, whetlipr trainiiati(" or idio- pathic, should be tr^-ated by iH-rrecl rest to the parts involved. When a foreign body is lodged upon the cornea, sclerotic, or conjunctiva, its removal is essential. The employment of cocaine (2-4-per-cent solu- tion) renders the operation painless, and is useful in other forms of conjunctivitis. Recovery is always much more rapid if the patient is confined in a dark or dimly lighted apartment. Bits of borated cot- ton or lint, wet in cold water, or taken from a block of ice, and laid over the organ, will hasten recovery. If pus should be present and collect in the angles of the lids, it should l)e mopped out with pellets of borated cotton moistened in boracic-acid solution, grs. x-xv to § j of water. Chronic conjnnct'nHtis (granular lids or trachoma) may follow any form of acute inflammation of this membrane. The pathohxj;/ of this condition, from whatever cause it may result, is practically the same. The conjunctiva is injected with newly formed capillary loops and thick- ened by the formation of an embryonic tissue, the result of cell-prolifera- tion. This granulation-tissue may be confined to the mucous membrane alone, or it may involve the submucous tissue, the cartilages, cornea, and sclerotic. Ulceration occurs in a certain proportion of cases ; in others cicatricial contractions take place, leading to distortions of the lids, or adhesions between the lids and globe. The treatment is local and general. The local treatment looks to the absorption of the products of the inflammatory process ; the general treatment, to the improvement of the patient's nutrition. The application of solid sulphate of copper is a remedy of unequaled excellence. It is far preferable to nitrate of silver on account of the danger of the latter of staining the cornea when the excess is not immediately washed off. Before using the blue-stone the eye should be deprived of its sensi- bility by dropping two or three minims of 4-per-cent cocaine into the organ at intervals of five minutes for from twenty to thirty minutes. The upper lid should be everted by directing the patient to look down, while the operator with the thumb and index-finger seizes the lid with the ciliae at its margin, and depresses it further. The upper margin of the cartilage should now be fixed by the tip of one of the fingers of the other hand, while the lid is suddenly turned up. Or, when the lid is depressed, lay a probe parallel with the upper margin of the cartilage, and evert the lid over this. The copper pencil may now be swept over the granulations. The extent to which the caustic is used will depend upon the condition of the organ. If the granulations are not exuberant, it may be lightly swept over the surface, and the excess washed off by boracic-acid solution. If the injection is deep and the vascularity great, the i)oint may be more slowly carried over the membrane, and the wash- ing omitted. The cocaine should, however, be continued, in order to prevent the severe pain which otherwise follows the application. As a rule, it is better to use the milder treatment at frequent intervals rather DISEASES OF THE EYELIDS. 387 than run the risk of indncing too great reaction by deeper cauterization. In the successful employment of this agent it is essential that it be car- ried into all the folds and pockets of the thickened conjunctiva. Suet, oil, or cosmoline shoukl be rubbed on the edges of the lids to prevent adhesions. In severe cases of trachoma, which resist all conservative measures, three radical methods are recommended. The first of the.se is scarification of the lids, and is applicable when the granulations are con- fined chiefly to the palpebral conjunctiva. Anaesthesia should be induced by cocaine, as heretofore, the lids everred, and from two to eight lines of scarification through the granulations made by the lancet carried parallel with the free border of the lid. The division of the vessels and the cicatrization which ensues cause a diminution of the blood-supply, and absorption of the products of inflammation. When the ocular conjunctiva is also seriously involved, a cure may be effected by the induction of gonorrhopal ophthalmia. A small quan- tity of the virus is placed upon the conjunctiva, and the resulting in- flammation is treated, as given hereafter, for this specific form of con- junctivitis. The use of jequirity-bean is at this date very popular with ophthalmic surgeons in the treatment of jJcinm/s. Prof. Webster advises its employ- ment in one of the following ways : One jeqiairity-bean coarsely powdered is placed in an ounce of water for four hours. The patient is then re- quired to bathe the affected eye very freely with this solution for ten or fifteen minutes, letting some of it get into the eye. One thorough wash- ing will usually produce the characteristic membrane of the conjunctiva If this does not succeed, the operation should be repeated. Or the bean, very finely pulver- ized, may be applied to the whole palpebral conjunctiva. It is desirable in all forms of conjunctivi- tis to shield the eye from the light. A con- venient shade or screen for this purpose is shown in Fig. 420. Conjunctivitis in the new-born {opJdTial- mia neonatoriijri) is a form of purulent oph- thalmia which usually results from the inocu- lation of the conjunctiva with septic matter present in the genital passages of the mother. It may come from carelessness on the part of the nurse, herself affected with a leucorrhoea, etc., or from the lodgment of any virus in the eye of the child. The treatment is propliijlactic as well as curative. The eyes of a child bom of a mother known to be suffering from a vaginal discharge of a purulent character should, as soon as possible after birth, be washed or mopped out with clean warm water, or boracic- acid solution, to be followed with one or two drops of a 2-per-cent ni- trate-of-silver solution (grs. ijss.-§j) once or twice a day, for three or four days. Fig. -120. 388 A TEXT-BOOK ON SURGERY. Wlipn the disease is declared, tlic i»us slumld be gently removed from the eye by pellets of soft lint or absorbent cotton, dipped in warm boracic-acid solution, the lids everted, and nitrate-of-silver solution (grs. v-x to 3J) ai:)plied to tlie inllamed surfaces by means of a camel's-liair brusli. The excess should be immediately washed away by the free use of warm water. This shoidd be re])eated every day until the ])urulent discliarge is notably diminislied. Boracic acid water (grs. v-5 j) should be used several times each day after the application of the nitrate of silver. Gonorrliaal Op/t///n////itoiu of this painful affection. I'sually a single organ is attacked. It is ini])ortant that, while the eifort to cure one is being made, the other should be protected from the contagion. To effect this, a watch-glass, to the edge of which adhesive plaster is at- tached, is placed over the sound eye and closely fastened to the skin about the orbit by the plaster, so that it is hermetically sealed. This should not be removed until the other eye is well. In the local treatment of the affected eye it is required to remove the purulent discharge by frequent irrigation with waiTQ boracic-acid water or by the pellets of lint or absorbent cotton, and to brush over the everted lids once or twice a day, as the attack is light or severe, a solution of nitrate of silver (grs. xx to 3J). The excess slumld be immediately washed off with tepid water. Cold applications are of great importance, and a very efficient method is to apjily frequent changes (every one or two minutes) of pieces of lint about two inches square, which are taken directly from a block of ice and laid over the inflamed organ. In this form of conjunctival inflammation, as in others where the injection is mai-ked and the thickening great, and where painful bh'jjJta/u-ym.s-m occurs, or where a free discharge of purulent matter can not be elfected by ordinary means, canfJiopJaMi/ is required. Tliis operation consists in slitting the outer canthus in the direction of the ear, and in this way dividing the fibers of the orbicular muscle. In gonorrhceal conjunctivitis the impairment of function in the mus- cle is not intended to be of long duration, and the wound is left open. In some cases of spasm of this muscle, and where a chronic inflammation exists, the mucous membrane is stitched to the skin along the edges of the wound, thus preventing a reunitm. Reunion may be effected later by paring the edges and bringing the parts together after the lesion for which the canthoplasty was performed is healed. Cocaine should be used to relieve pain, and all adhesion between the ocxdar and paljiebral mucous surfaces .should be liroken up as soon as discovered. DipMlieritic conjunctivitis is a rare form of disease in which the diphtheritic membrane is formed upon the conjunctiva. It should be treated by cold, apjilied as in gonorrha'al conjunctivitis. The eyes should be cleansed with warm boracic-acid solution, as heretofore de- scribed, and nitrate-of-silver solution applied once a day, in the strength of grs. v-x to 5j. DISEASES OF THE EYELIDS. 389 Phlyctenular conjunctivitis, as has been stated, is almost always an expression of a constitutional disease, as syphilis, tuberculosis, etc., and requires, in addition to local measures, a course of treatment for tlie palliation or cure of the dyscrasia which prevails. The local treatment of the pMyctenul(B is to dust the inflamed spots once a day with calo- mel, or to introduce Isetween tlie lids a small quantity of calomel oint- ment (grs. j-ij to Z j of cosmoline). Astrinneuts, as already described in chronic conjunctivitis, should also be employed to cause absorption of the products of inflammation. Symhli'pJiaron, or adhesion of the lids to the globe of the eye, may fol- low any form of conjunctivitis. The treatment in mild and recent cases consists in repeatedly breaking up the adhesions until the epithelium of the conjunctiva is develojDed over the raw surfaces, or the edges of the wound left by the dissection may be brought together by sutures. In severe cases, after the adhesions are dissected loose, a cure may be efi'ected by making a plastic operation, which consists in sliding the contiguous healthy mucous membrane across the raw surface and se- curing it by fine silk sutures. Ectropion, or eversion of the lid, usually follows chronic conjuncti- vitis and blepharitis, or is caused by cicatricial contractions after injuries located in the tissues near the eye. The treatment is chiefly operative, and consists in the relief of the ten- sion which is causing the displace- ment. When cicatricial contractions have produced the deformity, a par- tial or complete restoration of the function and position of the lid may be obtained by a careful and thor- ough dissection of the cicatrix, and immediately filling in the wound by transplantation of skin. The integument about the eye is remarkably tolerant in plastic opera- tions, and, with care and skill, relief will follow in almost eveiy instance. The operation known as sliding was done in the case of the patient from whom Fig. 421 was taken, as repre- senting a typical traumatic ectro- pion. The eversion was caused by an injury to the integument of the naso-maxillary region, with fracture of the nasal process of the superior maxilla. The first opei-ation consist- ed in a removal of the cicatrix from near the inner canthus and side of the nose. Two incisions were then made — one parallel with and about #^ Fig. 421. — Ectropion due to cicatricial contrac- tions tbUowiiig a wound of the naso-mu.\illary rciiion. 390 A TEXT-BOOK ON SURGERY. one fourth of an inch I'lnm the edge of the everted lid, and ;i second aboiit three quarters of an inch below this — out as far as the malar protuberance. This rectanijular Hap was dissected up and stretched across the gap already made, and stitched in position, as in Fig. 417. As this was done the lid was lifted high enough to permit the complete closure of the eye. Tiie second operation consisted in the removal of a long elliptical strip from the thickened granulation-tissue which covered the evertetl conjunc- tiva. This was done by picking it up with fine mouse-tooth forceps and clipping the mass thus seized with the curved scissors. The long axis of this wound was parallel with the edge of the lid, and extended from the punctum lachrymale almost to the outer canthus. The edges of the con- junctiva were stitched with fine silk sutures. It is of great inii)()rtance that too great tension be not made upon the flap. If, after it is stitched across the gap to be covered, the circulation is interfered with, the ten- sicm should be relieved, and that jiart of the wound left open should be filled by grafting or transplantation en masse. Eversicm of the lid, with great thickening of the cartilage and conjunctiva from chronic blej^ha- ritis, may be in part corrected by the excision of an elliptical piece re- moved in the long axis of the lid. The section should include a portion of the cartilage, and the wound closed by bringing the edges of the con- junctiva together with fine silk sutiires. Another procedure is to remove a kite-shaped segment, including all the tissues of the lid and skin near the orbit, as shown in Fig. 422, and then bringing the edges of the wound together by pin or silk sutures, as shown in Fig. 423. The section is made near the outer canthus. Fio. 422.— (After Gross.) Fig. 423.— (After Gross.) Entropion, or incurvation of the lids, may be relieved by removing an elliptical piece of the integument covering the lid. The width of the section must be determined by the degree of inversion. When there is shortening of the lid in its long axis, much relief will be afforded by canthoplasty . In extreme cases, where the cartilage is greatly thickened, the section should include a strip of this substance. Ptosis, or inability to raise the upper eyelid, is due to paralysis of the levator palpehrce muscle. The medical treatment looks to the im- provement of the tone of this muscle, or to the cure of the central lesion DISEASES OF THE EYELIDS. 391 whicli may cause it. The surgical treatment consists in the excision of an elliptical piece from the skin of the upper Ud and the approximation (jf the edges by sutures. Trichiasis, or turning in of the eyelashes, occurs with entropion, but may exist independently. Occuning with inversion of the lid, it does not require any other interference than that given for the cure of entro- pion. When the cilise turn in without inversion of the lid, the proper method of treatment is total excision of the hair-follicles. This should be accomplished by two parallel incisions made along the margin of the lid, one on either side of the row of hairs, and extending deep enough to insure the complete removal of the roots of the cilife. When depilation is demanded, the instrument shown in Fig. 424 will be found of great service. Epiphora, or overflow of the lachrymal secretion, may be due to paralysis of the orbicularis palpebrarum, or to any condition which causes displacement or obstruction of the lachrymo-nasal duct. In mild epiphora due to displacement of the inferior punctuin lachrymale the treatment consists in the dilatation of the canaliculus by the repeated introduction of a conical probe, followed by incision. This latter oper- Fia. 424. — Gruening's depilating-forceps. ^n** W H""-*!*!"!"*) Fig. 425. — Jsoves's movable blade canaliculus-knifo. C TrEWAfWaCO Fig. 426. — Weber's curved canaliculus-knife. ation is done by inserting the probe-pointed knife or scissors (Figs. 425, 426, 427), made for this purpose, into the punctum and along the canal for about one sixth of an inch, and slitting the canaliculus to this extent. The w^ound should be kept open by forcibly separating its edges once or twice a day, ^^ntil the cut surfaces are covered with epithelium, and the trough remains open. Obstruction of the lachrymonasal duct may in some cases be over- come by dilatation. In acute or chronic dacnjo- cystitis it is the common practice to slit open the upper canaliculus ; in case of abscess, to give free discharge to the inflam- matory products, and, if stricture is threatened, to permit the introduc- Fio. 427. — Maunoir's eanaUculus-scissors. 392 A TEXT-BOOK ON SURGERY. tion of dilating-sounds. The upper piinctum should l)e dilated in the same manner as given for tlie lower, a i)ro))e-p()iiited knife or scissors introduced, and the canal slit ■well into the lachryino-nasal sac. The bulb-pointed dilating-probes should now be carefully introduced, be- ginning witli the smaller sizes (Fig. 42.8). As soon as the bulb enters Fio. 428. — Williams's set of hichrymal probes, a, b, Probes, c, Dilator, n, e, Styles. the sac it should be gently and slowly directed along the nasal duct until it is arrested by the floor of the nose. The larger sizes may be intro- duced as in the treatment of stricture of the urethra. After full dila- tation is secured the channel should be washed out daily, for about ten days, with a 1-per-cent boracic-acid solution. For this purpose Anel's syringe (Fig. 429) will be found useful. The probe-pointed nozzle Fig. 429. — .Unci's silver eye-syringe, silver and gold points. is introduced into the sac and the water forced through until it flows freely into the nose. If the obstruction recurs, the probes should be re- introduced. Tlie Orbital Capify. — Wounds, absces.ses, and tumors of the orbital cavity demand no especial consideration. The same rules of practice prevail here as elsewhere. Benign neoplasms do not, as a rule, involve the eye in their removal. Malignant growths usually demand a tlior- ough extirpation of all the contents of this cavity. Vascrilar tuitiors of the orbit, so-called infra-orbital aneurisms, not infrequently require deligation of the common carotid artery, and in some instances extir- pation of the mass from the orbital cavity. The indication for the first operation is marked arrest or diminution of the pulsation and size of the tumor after compression of the carotid in the neck. (See chapter on the Arteries.) SURGERY OF THE EAR. 893 Surgery of the Ear. Neoplasms of the auricle require extirpation as in other portions of the body. Angeiomata of small size may be cured, without excision, by injecting the tumor with a few minims of 50-per-cent carbolic-acid solu- tion. Cart Hag Inous growths are occasionally met with about the ear. Their usual location is just in front of the tragus. I removed two in front of one ear and one from the opposite side in a patient twenty-two years of age. Similar tumors were present in the person of his father and another member of the family. Wounds of the auricle should be treated with the view of preventing any distortion of this organ. Lacerations of the lobule from the violent removal of an ear-ring may be corrected by paring the edges and uniting them by fine silk sutures. The hypodermic use of cocaine will secure pei-fect anaesthesia in all or- dinary operations upon the auricle. Drooping of the ears to a degree amounting to deformity should be treated in children by strapping the auricles close to the skull, by means of an elastic band around the forehead and occiput. Fio. 430.— (.\fter Keeves.) Fig. 431.— (After Beeves.) Adhesions of the auricles to the scalp should be dissected loose, the organs crowded forward, and, if necessary, skin shoiild be transplanted to fill in the gap and prevent a i-ecun-ence of the deformity. Hyper- trophy of the auricle should be corrected by excision of a triangular piece, after the method of Martino, shown in Figs. 430 and 431. Fio. 432.— Se.\ton's hard-rubber double probe. Auditory Canal. — Foreign bodies in the auditory canal maybe recog- nized by inspection or with the light gutta-percha probe (Fig. 432), and should be removed by the careful employment of the angular forceps 394 A TEXT-BOOK ON SURGERY. (Fig. 433), or, if firmly impacted, the ring curette (Fig. 434) may be re- quired. For locating and seizing the body the head-mirror should be employed to concentrate the light in the canal. The solid-silver specu- FiG. 433. — Sexton's ear-forceps. Fig. 434.— Sexton's double ear-hook, to extract foreign bodies. him of Wilde, always required in examinations of the deeper portions of the canal and of the membrana tympani, may also be of assistance in locating the foreign body, although this can usually be done, if the light is properly directed, by pulling ux^on the auricle so as to straighten the canal. Impactions of cerumen should be removed by irrigation with warm water. The stream should be delicate, and should be directed to one side of the obstruction in order to melt away a portion sufficient to allow the force of the injection to operate upon the mass from behind. The curette or scooji may also be advantageously employed in removing im- pactions of cerumen. Furuncles of the auditory canal are quite frequently met with. Their presence is marked by acute pain, located in a circumscribed area, and by redness and swelling. The treatment consists in alleviating pain by the use of anodynes if necessary, and by softening the skin over the inflammatory process by the use of emollients. Cotton lubricated with vaseline should be intro- duced. As soon as the formation of pus is evident, it should be evacuated by puncture or incision. Flo. 435. — Sexton's snare. Neoplasms of the auditory canal demand removal by the snare (Fig. 435), forceps, or by excision. Polypus of this tube may be single or SURGERY OF THE EAR. 395 multiple, and, when of sufficient size to fill the canal and become con- stricted, may break down and cause a foetid discharge. Occasionally the auditory canal is occupied l)y a parasite known as aspergillas^ the spores of which are developed with great rapidity, fill- ing up the canal and causing inflammation, obstruction, and more or less interference with hearing. Finely powdered boracic acid should be blown deeply into the canal at repeated intervals until the fungus is destroyed. Middle Ear — Membrana Ti/mjmni. — The drum of the ear may be- come involved by extension of an inflammation from the auditory canal, or it may be secondary to an otitis media, or it may in rare instances be inflamed without either of the foregoing complications. Inflammation of the middle ear is in most cases preceded by pharyn- gitis, and is thus affected by invasion through the Eustachian tube. It may be produced by traumatism, or the initial lesion may be situated within the cavity of the tympanum, or in the mastoid cells, which com- municate with the cavity. Otitis media is not uncommon in children as a sequel of scarlatina or rubeola. The earliest symptom of this affection is pain of a severe character, accompanied by partial arrest of hearing. Fever is present, and may be preceded by a chill or rigors. When suppuration occurs, and the mastoid cells are involved, the j^ain is intensified and the feln-ile move- ment at times very high. In a case of this character which I saw, and in which the operation of puncture and trephining the mastoid process had been delayed, fatal pyjemia occurred. In specimens of blood taken from this patient just before death, the red blood-disks were seen to be filled with bacteria. Percussion with the finger-tip over the mastoid region exaggerates the sense of pain. Ui^on examination with the oto- scope and head-light, the drum of the ear will be seen to be more oijaque than normal, its vascularity increased and bulging toward the meatus if there is pus in the middle ear. The treatment of otitis media should be directed to the arrest of the inflammatory process by warm fomentations, liy the ap])lication of leeches to the temples and mastoid region. Quinia, iron, stimulants, and well-selected diet are indicated in the effort to improve the general condition of the patient. It is of great moment that the tension of the tympanum and of the mastoid cells should be relieved early in the progress of the disease, and, even when there is a doubt as to the pres- ence of pus, explorative puncture of the membrana tympani should be Fio. 43G. — Politzcr's tympamim-perfovator, aiiKular. made. The operation is witlKuit danger, is not difficult of accomplish- ment, and, even when suppuration has not occurred, ^^^ll often give great and immediate relief. A proper instrument for this procedui*e is 396 A TEXT-BOOK ON SURGERY. shown in Fig. 43G. The silver six-culmii nml reflected light sliould be employed so as to bring the ni('iiil)r;ine into plain view, and, while the head of the patient is held motionless, the j)oint of the perforator is carried against the drum on its posterior inferior quadrant, and barely pushed thiougli. The puncture should not be more than cme eighth of an inch in length. If there shall have been an effusion of serum, or if pus is present upon the withdrawal of the instrument, a small quantity <)f fluid will escape through the jtuncture. Tf necessary to the estab- lishment of free drainage, the opening may lie ejilarged. AVhen otitis virdia is complicated with inflammation and suppuration of the mastoid cells, and when the communication with the tympanum is not sufficient to give ready discharge to the products of inflammation into the middle ear, and thence out through the puncture in the nicm- hrana tympani, the cells should be opened and drainage secured at once by removing the outer shell of the mastoid process. In children this pro- cedure is not always necessary on account of the very thin shell of Ixme which incloses the cavity of the mastoid antrum, and which readily gives way and allows egress to the pus formed within. In drilling or trephining the mastoid cells, proceed as follows : The skin over and near the mastoid process should be shaved and cleansed, and a free incision made in a vertical direction, the center of the cut being opposite the center of the auditory meatus and one fourth of an inch from the posterior wall of the bony canal. If any difficulty is exjjerienced in lifting and reflecting the integument, a short trans- verse cut should be made backward from the middle of the perpendicu- lar incision. The iieriosteum should be scratched off at the point where the bone is to be perforated, unless necrosis has already occurred and only a thin shell of bone remains. In this condition the shell should be lifted off and the cells cleaned out. When the bone has a henlthy aj^pearance on the exterior it should be cut through with a trephine, gouge, chisel, or drill. The trephine em])loyed should not be more than a quarter of an inch in diameter, and the center of the hole made (no matter what instrument is employed) should not be farther than a quar- ter of an inch posterior to the wall of the auditory canal on account of the proximity of the lateral sinus and the veins of the diploe which empty into it. After the instrument has traveled about an eighth of an inch into the bone it should be removed and the circular track in- spected. Tlie entrance to the cells will be indicated by a slight haemor- rhage, and, if abscess is present, by a few drops of pus. As soon as the bleeding is seen the button of bone should be lifted by the elevator and the remaining cancellous tissue scooped out with the iron spoon or the scalloped gouge. The abscess should be irrigated with a l-to-3000 sublimate solution, and the wound dressed with a loose sublimate gauze dressing. If the trei^hine is not used, the scalloped gouge (Fig. 69), the bone-drUl (Fig. 72), the scoop (Fig. 68), or the chisel and mallet may be substituted. If (as has occurred in several instances) marked bleeding occurs — probably from wounding some large vein near its entrance into the sinus — it may be arrested by packing with sublimate gauze and THE NOSE. 397 the drainage established a few hours later, when the haemorrhage has ceased, by substituting a loose dressing. The Nose. Acquired Lesions. — Fracture of the bones of the nose has been already considered. HJpistaxis, or liferaorrhage from the nose, is often severe enough to demand surgical interference. The bleeding may at times be ai-rested by diminishing the blood-pressure in the vessels of the nose by ligation of the extremities. This consists in ajsplying an elastic bandage (or an ordinary roller, if the rubber can not be obtained) around the thighs and arms close to the trunk, and making the pressure strong enough to arrest, in great part, the return of blood through the veins without arresting the circulation in the arteries. "When the hfomorrhage ceases the ligatures should be gradually loosened, so that the volume of blood which has been confined in the extremities may not be too suddenly returned to the heart. Plugging or tamponing the nares, if properly done, will succeed if all other methods fail. First, determine accurately the nostril in which the bleeding is occurring. Take a piece of tine sponge at least an inch in diameter when dry (and it should be introduced without being moistened, so that when in position in the posterior nares it will expand as the blood moistens it), and tie around its center three strong silk threads. A soft catheter or bougie is now introduced into the nostril from the front, keeping the point of the instrument well on the floor of the nose. As soon as the end is seen or felt behind the soft palate, it is drawn out at the mouth by the forceps or lingers. Two of the three threads are attached to the point of the instrument, which is then pulled back through the nostril. When the threads come out of the nose in front they are seized by the fingers of one hand while the sponge is care- fully guided into position hehind the soft palate with the other. Once well in the posterior naris it is held in position and made to exert the necessary compression by tying the two anterior strings over a softened sponge packed into the nostril in front. The third thread is brought out of the mouth, and is to be used in dislodging the tampon when the ha^nor- rhage has ceased. Lint, soft rags, or cotton may be used for plugs when a sponge can not be obtained. A long probe or a loop of st)ft wire may be used instead of the bougie. The application of a 4-to-8 per cent solution of cocaine hydi-ochlorate to the mucous membrane of the nose may prove useful as a hsemostatic, since Bosworth has demonstrated that it causes marked diminution in the caliber of the vessels of the lining membrane. Foreign Bodies. — Buttons, seeds, and other substances are often lodged in the cavity of the nose. The usual seat of lodgment is in the anterior part of the inferior meatus, or between the lower turbinated bone and the se])tum, and occasionally they are pushed beyond this into the middle meatus. When allowed to remain, infiamniatitm of the lining membrane always ensues, and ostitis is not infrequent. 398 A TEXT-BOOK ON SURGERY. The diagnosis depends ujioii ]llly^i(•;l] exploration by means of the head-mirror, a strong light, anil the metal i)r()l)e. Tlie presence of a body lodged in the nasal cavity may be at times indicated by the change of the voice from its natural to a nasal tone. Removal is urgent, and may be effected by inspiration thnmgh the month and forced ex])iration through the nose, with the mouth and nostril of the unaffected side closed. In adults the act of sneezing will sometimes succeed in dislodg- ing the substance. A strong, slender forceps, bent at an angle so that the hand of the operator will not shut out the light, is the most suit- able instrument to be employed in its removal. When the body is lodged well back it may be pushed through into the pharynx and eject- ed from there. BhinoUtes^ or lutsnl calculi^ are occasionally found in these cavities. It is pi-obable that they come from the lachrymal apparatus, si«ce they are found in the immediate neighborhood of the entrance of the nasal duct. Moreover, ducJirijolifes, or lachrjMual concreticms, are not very infrequent in the lachi-ymo-nasal apparatus. These bodies should be removed with the forceps as soon as discovered. Neojila-rins. — The most frequent variety of tumor within the nasal cavity is the myxoma, or so-called gelatinous poli/j>u.s. Next in order of frequency is X\\e fibroma, ov fibrous pohjinis. Both of these belong microscopically to the connective-tissue tumors, the myxomata being allied to the embryonic, the fibromata to the more developed connective- tissue tumors. Papillomata, or warts, are not infrequently seen at the edges of the mucous membrane of the nostrils. Lastly, there may be a general hypertrophy of the mucous meml)rane of the nose, causing a tumefaction of the turbinated tufts, and partial, or may be complete, occlusion of the nares. Gelatinous nasal polypi are xisually pear-shaped, the bulk of the tumor tending toward the floor of the nose. The pedicle is attached to one of the thick velvety tufts, most frequently in the upper or middle meatus. There may be a single tumor, although the rule is for them to be multiple. They are of light grayish color, and are covered by a mucous exudation. The symptoms are chiefly those due to pressure and obstruction of the nares. Changes in the voice are not marked until the presence of the tumor has been suspected from pressure and imtation. This ii-ritation gives rise to an excessive secretion and discharge from the nose, and occasionally to prolonged and violent fits of sneezing. The diagnosis may be rendered positive by physical exploration. The shrinkage of the turbinated tufts, following the local use of cocaine hydrochlorate, renders inspection more easy. Treatment. — The only rational method of treatment is removal and destruction of the pedicle and contiguous mucous membrane. Avulsion may be effected by seizing the growth with a long, delicate polypus-for- ceps, and twisting the tumor around until the pedicle is wrung off, then applying pure nitric acid or the galvano-cautery to the stump. The wire ecraseur or snare of Jarvis is greatly to be preferred (Fig. 437) THE NOSE. 399 After the wire-loop has been passed around the tumor, and slipped up to the pedicle, it should be slowly tightened, since by this method the danger of haemorrhage which always follows the use of the forceps is avoided. From one to two hours may be consumed in the division of the growth, the screw being turned from time to time. Nitric acid or the cautery should be applied to the stump in all cases, since without this recurrence is almost certain. Fibro77iata, or fibrous polypi, are much less frequent than the myxomata. As a rule they are deeper situated. They re- quire the same treatment as above given. Occasionally large tumors of the nasal cavities require for their complete removal section of the nasal and superior maxillary bones. In this procedure the skin and periosteum should be left intact, and osteoplasty performed in order to prevent necrosis. PaplUoinata, or limits, which occur at the junction of the mucous membrane of the nares with the integument, should be clipped off with curved scissors and their bases burned with l^ure nitric acid. Hypertrophy of the turbinated tufts may exist to such an extent as to demand interference. Such enlargement should be treated exactly as one would treat true polypus. Fissures of the nares may be relieved by the repeated local use of the lunar-caustic pencil. Oz(ena. — Ozsena is the name given to a chronic intlamma- tion of one or more of the nasal cavities, or the sinuses com- municating with them. It may be confined to a process of ulceration of the soft tissues alone, but not infrequently there is an ostitis. Syphilitic ozfena is probably the most common form. It frequently occurs with other dyscrasise. It is accom- panied by a fetid odor and a muco-purulent discharge, par- tially liquid and partially solid. Atrophy, or destruction of the turbinated tufts, is not infrequent, so that ther-e is abnor- mal space within the nares. The treatment is local and general. The removal of dis- eased or dead bone is imperative, and irrigation with the weaker sublimate or boracic-acid solutions should be regularly made. Dobbell's solution will be found of use : Carbolic acid, gr. x; biborate and bicarbonate of soda, each, 3j; glycerin, 3 X ; to this add water to make § x. This should be used five or six times a day as a douche. The general condition of the patient should ])e improved by the administration of well- selected tonics and food, and by out-of-door life. Superficial epithelioma, situated upon the nose or face, should be destroyed by the application of Marsden's paste. It is made of arsenioi;s acid and powdered gum acacia, equal parts, with enough water to make a fairly soft paste. It may be left on fi-om twelve to twenty-four hours — Fio. 4sr.- Jarvis's snare. 400 A TEXT-ROOK ON SURGERY. as long as the patient can endure the pain. , Poultices are applied after- ward. If the first applirarion is not sufficient, it sliould be repeated. The loss of substance cau.sed by the destructive action of the paste may be repaired by a plastic operation ; but this should not be done until cicatrization has occurred. The frontal sinus may be involved in some of the diseases which affect the nose. New growths, abscess, or ostitis may demand the appli- cation of the trephine in the removal of a neoplasm or dead bone, or the evacuation of pus. Der/'af/on of the nose from the median line may be congenital or acqtiired. The septum alone may project to one side, or the entire organ be disjilaced laterally or upward. When the distortion is due to malfor- mation of the bones, these must be forced into position, with or without fracture. Deviation of the soft parts which form the tip of the nose, sufficient to produce deformity, may be corrected by the method of Prof. John B. Roberts. In case the tip of this organ is turned to the right, proceed as follows : "With a scalpel perforate the cartilaginous septum at its upper and back part, and make a long incision through it, in a direction down- ward and forward. This incision should allow the operator to push the whole cartilaginous portion of the nose to the left. To retain the parts in this position, introduce a steel pin, about one inch and a fourth long, into the right nostril, and pass it completely through the anterior and upper segment of the divided se]:)tum, near the columella. By carrying the head of the pin to the left, the anterior portion of the nose will be also carried in this direction, and may be retained by imbedding the point of the pin deeply in the immovable cartilaginous septum and mu- cous membrane at the back of the left naris. The pin may be removed as soon as fii-m adhesions have formed, usually in from five to ten days. Deviations of the septum alone may be corrected by the same method. Hiipertrophy of the nose, due to increased vascularity, may be cor- rected by repeated incisions across the track of the enlarged vessels, by galvano-puncture, or by causing their obliteration by injections of 50-per- cent carbolic-acid solution, as for nacus. Plastic Surgery of the Nose. Loss of substance may occur from the accidental or surgical ablation of all or a portion of this oi'gan, or from its destruction by disease. The diseases which most frequently produce loss of substance are syphilis and lupus. Carcinoma, sarcoma, elephantiasis, or any neoplasm, may in- volve the nose and cause loss of tissue in their removal, but lupus locates itself by preference here, while one of the most common lesions of tertiary syphilis is necrosis of the cartilages and bones of the nose, resulting in great disfigurement. Occasionally sloughing occurs, from the i)resence of a phagedenic syphilide during the second stage of this disease. Hhis accident occurred in the patient from which Fig. 447 was taken. PLASTIC SURGERY OF THE XOSE. 401 RTiinoplasfy may be partial or complete. Complete rhinoplasty is performed when the skin, cartilages, and bone of the nose have been carried away. In sucli cases nothing remains but an Lrregnlar sunken pit, leading almost directly into the pharynx. The operation consists (1) in paring the margins of the opening and the integument immediately around the opening, in apposition to which the transplanted flap is to be brought ; (2) in the transportation of a properly shaped piece of skin, with its underlying tissues, from its nor- mal to the new position. Tlie flap may 1:)e taken entirely from the forehead, or one half from each cheek, or from the arm. One of the most frequent causes of failure in this operation is the caving in of the ridge of the new nose, and, in order to better support this part, the end of one of the fingers may be iitilized, as follows : First Method — Coinpldc BTilnoplasty from tlie Foreliead and Finger. — Remove the naU and matrix of one finger of the left hand, split and dissect up the integument on the palmar surface of this finger, as far back as the last interphalangeal articulation, and sew this to the already freshened edges of the nasal opening. The arm, hand, and head should now be immovably fixed in a plaster-of -Paris dressing, in which position it remains for about four weeks. "When the circulation is freely estab- lished between the vessels of the face and the transplanted finger, the latter should be amputated at the first or second interphalangeal articu- lations, as may be necessary to have it of suflicient length to support the covering of integument. After several weeks' delay, to assure the permanent vitality of the transplant- ed phalanx, a flap may be turned from the foi'ehead to the nose, as follows : Cut a piece of chamois-skin, or soft, thin leather, of the shape rep- resented in Fig. 438. Adjust this to the line of the nasal cavity, to see if it is large enough and of proper shape. Bear in mind tlie following points: 1. The flap once dissected up tends to contract. It should there- fore be sliglitly larger than a pattern which fits exactly. 2. The isthmus {fh Fig. 438) must not ))e too nan-ow, for fear that the vitalitj- of the flap may be insufficient. It should al- ways be cut so as to include the an- gular artery. B. The distance from the isthmus id) to {e e), where the lower edge of the new no.se is to be, should be considerably less than the distance from d to a c, in order to prevent tension of the flap and inter- ference with the cii-culation through the pedicle, d. Lay the pattern on S6 Fio. 4-38.— I After Linliart.) 402 A TEXT-BOOK ON SURGERY. the forehead and outline the flap by making punctures at intervals of every fourth of an inch along its edges. The incision, made through all the tissues down to the periosteum, sliould begin at d and be carried to a c c a, and tlieu dt)\vn to a poiut near the eyebrow, at (/, in tlie line of the freshened margin of the nasal cavity. The smaller incisions in the flap a b or c b are made to provide for the septum and al;t; of the new nose. If the linger has been grafted for the support of the flap, tlie in- cisions of Labat, cb, cb, will suffice ; if not, those of Lin hart, a b, a b, will give a doubly folded septum, and one less likely to f;dl or cave in. The flap is now dissected up from the periosteum as far as the pedicle, when it is turned down and sewed into position with tine silk sutures. The secondary flap for the septum is first doubled on itself, and then bent in at a right angle to the axis of the nose, and stitched down, as shown in Fig. 439, to the center of the lowest portion of the nose, just above the middle of the upper lip, while the ahe are also folded in and sewed, as represented in the same cut. The operation ,is completed Flu. i,.'. — (Aiier Lialiiirt.) when the entire flap has been ac- curately stitched to the freshened edges of the cavity, as shown in Fig. 440. Pieces of rubber tubing Fio. 440. — (Alter M.-ilgaigne.) may be inserted in the nostrils to hold the alaj in position. The upper part of the wound on the forehead is drawn as near together as can be done, with silk or silver-wire sutures, and a sublimate or iodoform gauze dressing is api^lied. No pressure must be exercised upon tlie pedicle, or flap, which should be loosely enveloped in the dressing. In about two weeks the circulation will have been sufficiently established between the flap and the edges of the cavity to permit the secti(m of the pedicle, the stump of which is used in filling up the gap upon the forehead. In re- turning the pedicle to its original position, it is advisable to scra]ie out the granulation-tissue in the bottom of the wound, so that the returned portion will sink to the proper level. Among other methods of performing complete rlnnoplasty is that of Diefi'enbach, as shown in Fig. 441, or that of Koenig, Fig. 442, in which the pedicle is somewhat wider than in the other flaps. The flap of Langenbeck is shown in Fig. 443. These various oi^era tions of trans- planting the flap from the forehead are modifications of the Hindoo PLASTIC SURGERY OF THE NOSE. 403 Fio. 441.— Dieffenbach's methoJ. (After Linhurt.) method. Fig. 444 represents a rhino- plasty done by a Hindoo surgeon in 1793. Second Method — Complete Rhino- plasty from the Arm. — Freshen the margins of the nasal cavity as before. Fio. 443. — Langenbeck's incision. (After Koenig. ) Fig. Hi. — Koenig's metliod. (.Vftcr Koenig.) Fio. 444. — (.\fter Szymanowsky.) Transplant a portion of the finger as before described, if the septum nasi has completely disappeared. Place the palm of the hand on the top of the head, Fig. 445, so that the anterior surface of the humeral region will be in close proximity to the face. Calculate the length and breadth of the flap required to be raised from the arm, and outline it with ink. Fit a strong wire cuirass or the upper half of Bauer's wire breeches com- fortably and securely, so that the head and neck may be held immovable. Or apply a plaster-of-Paris jacket, which shall cover the head. Mold a strip of one-quarter-inch-thick gntta-percha to the arm and forearm, or, if this material can not be obtained, sole leather or shellac may be sub 404 A TEXT-HOOK ON SURGERY. stituted, so that with the hand on the occiput and the interparietal suture, the strip may be fitted to the anterolateral aspect of the corset and along the arm, forearm, and hand, as in Fig. 445. Next dissect the integument from the delt(»id region down toward the elbow, making it extra long and wide, and lifting every- thing down to the deep fascia. When the li;emorrhage has ceased, di'ess the wound in the arm with sublimate gauze, apply the gutta-percha mold, lix it upon tlie cor- set with a tight roller, fasten it and the underlying hand to the skull-piece or helmet {a a. Fig. 445) and accessory, sup- porting strips of strong adhesive plaster, as at b. Lastly, stitch the edges of the flap to the freshened margins of the nasal rim. The circulation between the face ;ind skin of the arm should be sufficiently established from the tenth to the four- teenth day to permit section of the Hap. Since the skin of the arm is very thin, and after transplantation is apt to shrink away, it is a wise precaution to dissect up the Hap from the shoulder and arm, making it longer than may at first appear necessary— and to do this eight or ten days before the arm is fastened in the immovable apparatus. The liap in this way shrinks, and is covered with granulations, in which condition union with the integument of the face is accelerated and assured. Wlien the vascular connection is safely established, the pedicle is cut, the arm released, and the flap shaped and stitched in position, as in the preceding operation. Fio. 445.— (After Liiiliart.) Fig. 44G. — (After Szymanowsky.) Fig. 447. Wutzer took the integument from the forearm ; Fabrizzi from near the elbow (Fig. 446). PLASTIC SURGERY OF THE NOSE. 405 Partial Rhinoplasty. — When there is only a par- tial loss of substance the operation is less difficult, and the prospect of success (greater. When one ala is involved, as shown in one of my cases (Fig. 447), tlie iiap may be made from the cheek (Fig. 448). In this patient I trimmed the cica- tricial edges of the scar and turned a flap, as indicated by the dotted lines, and stitched it to the nose. The wound in the face was par- tially closed by sutures. The pedicle was divided on the fourteenth day and turned back into the wound, the granulations having been previously scraped out. Or the flap may be l)orrowed from the side of the cheek, leaving the ped- icle above, as in Fig. 450. When the tip of the nose is eroded, the method indicated in Fig. 451 should be adopted. The broad end of the flap is split ; the center strip (a) is for the septum, while those at 6 6 are to complete the eroded alse. Flo. 449. — Transpliinteil portion in the new position after diviMon and return of the pedicle. AYhen in the removal of small neoplasms the ala nasi is perforated, the wound may 406 A TEXT-BOOK ON SURGERY. be closed by sutures, or the gap may be filled by a small graft of skin lifted entirely from the arm or abdomen, and transi)lante(l upon the nose. Operations vi minor im- portance are at times per- fonned to correct lesser de- formities. Fio. 452.— (After Liiiliart.) ¥iV Fig. 453.— (After Linhart.) ^-^' i;>^ Fig. 451.— (After Liiihart.) When the alee are too thick, elliptical pieces may be ex- cised and the edges closed, as in Figs. 452 and 453. If the tip of the nose is too pointed and upturned, it may in part be corrected by exsecting a triangular piece from the septum and closing the gap with sutures. Congenital Lesions of tlie Nose. — Occasionally the lateral halves of the nose fail to unite, resulting in the deformity known as bifid nose. There may be partial or complete absence of this organ, or when present the nares may be occluded, or it may be complicated with the extreme cases of hare-lip. The operative procedure for the relief of this last deformity will be given in connection with congenital cleft of the lip. Occlusion of the nares may be relieved by cutting through the mem- brane in the direction of the normal opening. For the correction of forked-nose, or the absence of this organ, no fixed rule of practice can be laid down. The Lips and Cheeks. WounrJs. — Accidental wounds of the lips are usually incised or lacer- ated. If badly torn, the ragged edges should be smoothly trimmed, washed with sublimate solution, and secured with interrupted silk sutures. When the wound is through the entire thickness of the lip, the sutures should include the mucous membrane. A very fine suture or pin should be used in the vermilion border to insure absolute approxi- THE LIPS AND CHEEKS. 407 mation here. Adhesive strips are not reliable. In children one or two pin-sutures should be i:)referred, as they best resist the constant strain to which sutures of the parts are subjected in the act of crying. Diseases of the Lips. — Among the diseases which involve the lips and the contiguous structures are epitJielioma, liqjus, papilloma, noeims, cysts, lipoma, adenoma, pTdegmon, ulcers, and general hyjjertrojjhg and fissures. Epitlielioma. — One of the most frequent causes of removal of portions of the lips is the presence of epithelioma. It is a disease of middle and old age, involves usiially the lower lip, and occurs in the great majority of instances in males. Ei:)ithelioma may attack the lip without any ap- preciable cause, but in most cases the appearance of the neoplasm is preceded by prolonged irritation at the place involved. A jagged or projecting tooth, the habitual nse of a pipe-stem or cigar, are frequent causes of this disease. It will also result from the initation caused by chronic tissure or ulcer of the lip. Symptoms. — It begins as a small ulcer with rather abrupt margins, in the bottom of which is a dirty granulation-tissue partially hidden by thin pus. In its earlier stages it is not readily distinguished from the benign ulcer which is found upon the lip. The preceding history of a prolonged irritation should always suggest epithelioma, especially if it occurs after the age of thirty, and upon the lower lip. Ulcer is apt to occur in one of the scrofulous or tubercular diathesis. If grave doubt exists as to its malignant nature, the application of the solid stick of nitrate of silver should be made. An ordinary ulcer will heal rapidly under this stimulus, while the epithelioma is not affected. Labial chancre may be differentiated by the indurated base, which is characteristic of this lesion. Adenitis in the line of lymphatics along the lower jaw comes on in the earlier stages of syiahilis, while in epithelioma the sore may exist for months without perceptible enlargement of the lymphatic glands. In syphilis the a^jpearance of the eruption, together with the history of the case, will lead to correct differentiation. Epithelioma of the lip is a dangerous affection. Left alone, it de- stroys life within a period varying from one to four years. It spreads at times with rapidity, eating away the tissues in all directions. It may confine itself to the soft parts, or attack the maxillary and nasal bones. Engorgement of the submental, sublingual, submaxillary, and cervical glands is almost inevitable if the disease is not extirpated in the first few months of its historj^ The glandular enlargement is at first not always due to metastasis, but may result from simple adenitis following the in- flammatory process in the margins of the iilcer. Treatment. — The early excision of the diseased tissiie is imj>erative. The knife should always be preferred to the use of corrosive substances. The incision should be wide of the diseased area — at least half an inch from the infiltrated margin. If the disease has existed long enough to have caused lymphatic enlargement, the infiltrated glands must also be extirpated. The prognosis as to a permanent cure is always doubtful, although 408 A TEXT-BOOK ON SURGERY. when the operation is performed early in the history of the disease a cure may be effected. In ninny cases where recurrence after ojx'ration is ])robable, life may be prolonged and rendered more endurable by ex- cision of the nicer. After a primary excision the patient should be kept under close oliservation, and, njion the rea])pearance of the neoplasm in the scar or lymphatics, a second operation should be performed. In 1884 I removed a large number of infiltrated glands from the neck of a man about fifty years old, who had had an epithelioma of the lip excised twelve years previous to that date. Five years after the lirst operation a gland at the lower edge of the jaw became enlarged and was extirpated. Six years later the glands beneath the jaw began to swell, and a year later, when I saw him, metastasis had seemingly occurred in all the lymi)hatics as far down as the lower third of the neck on one side. The infiltration was so extensive and deep that it took two operations, each lasting about three hours, to effect the removal. The examination of the glands demonstrated the malignant character of the disease. At this date, two years from the last operation, the patient is living and healthy. Lupus. — Lupus erythematosus and vulgaris usually attack the tis- sues t)f the nose, cheeks, and lips, at times producing extensive loss of substance. The erythematous variety is first seen as small red papules, lirojecting slightly above the epidermis, and covered with scales. It is a disease of the sebaceous glands and ducts, causing chronic inflamma- tion of the skin and atrojihy of all the elements of the cutis. Its prog- ress is slow, and the prognosis is usually favorable when the disease is confined to a limited area. It does not affect the general health of the patient, and often heals spcmtaneonsly, leaving a flat, smooth scar. ^Vhen disseminated it is more dangerous, not infrequently ending in fatal complications. The treatment requires generous diet, tonics, and out-of-door life. Among the local agents recommended in lupus ery- thematosus is green soap, which should be sjn-ead on lint and pressed closely upon the affected part, or rubbed in with the finger every day. Prof. A. R. Robinson, in addition to the above, also recommends a 10- per-cent solution of oleate of mercury brushed over the diseased surface. If the disease does not yield to these milder measures, the sharp spoon should be employed and the broken-down tissue thoroughly scooped out. Emollients, cold applications, or poultices may be used afterward, according to the recpiirements of the case. Lupus vulgaris is a more formidable affection. In its earlier stages it consists of a number of soft red dots in the deeper layers of the in- tegument, which gradually appear as papules upon the surface. The characteristic lesion is the infiltration of the skin with an abundant small cell new-growth. It is believed to be a tuberculosis of the skin. The integument breaks down and is cast off as a slough. The new- formed cells also undergo granular metamorphosis, and disappear with the other destroyed tissues. The only disease likely to be mistaken for common lupus in the adult is epithelioma. Lupus begins usually in childhood, while epithelioma is exceedingly rare before the age of thirty. THE LIPS AND CHEEKS. 409 The ulcer of lupus is not so painful as that of epithelioma, nor its edges so hard and elevated. The treatment of this affection is often unavail- ing. The constitutional treatment is the same as for lupus erythemato- sus. Locally, a lU-per-cent ointment of pyrogallic acid, spread upon linen and closely laid upon the diseased surface, is a useful i-emedy. It should be applied twice daily for several days, and then poultices or ointments used until the slough is removed. In certain cases it is ad- visable to scrape the ulcer well with the sharp spoon, and then apply the pyrogallic acid for one or two days. Nceous. — As has been stated in the article on diseases of the vascu- lar system, arterial, capillary, and cutaneous vascular tumors are occa- sionally located upon the lips and cheeks, and require removal by the knife, ligature, or injection. Their excision often causes extensive loss of tissue. When situated in the free border of the lips or nares, the 50-per-cent carbolic-acid injection should be tried before excision is prac- ticed. Moles are less formidable, and rarely require an extensive reparative operation after excision. Papilloma, lipoma, adenoma, and fibroma do not, as a rule, require extensive incisions and loss of tissue in their removal. Cystic tumors of the lip are not infrequent, occurring as spherical swellings beneath the mucous membrane. They are caused by obstruc- tion of the duct of a labial follicle, and contain a thick, ropy fluid. The treatment involves a careful and thorough excision of the sac. Fissures, or "'■ chaps'''' of the lip may occur independently of any constitutional disease. They may be cured by a local astringent, as alum, or caustic, as nitrate of silver, applied once a day for tvro or three days. When these more simple remedies are without avail, excision should be practiced. When tissui-e of the lip is allowed to remain, and the general condition of the patient is bad, necrosis of the mucous mem- brane immediately contiguous ensues, causing a grayish-red ulcer. The treatment consists in the local use of astringents and the improvement of the patient's nutrition. Phlegmon of the lip is rare. It is a painful and dangerous affection. The pathology of carbuncle has been given. The proper treatment is early and free incision through the skin, deep fascia, and muscles, and frequent irrigation with strong sublimate solution. Hypertrophy of the lip is occasionally met with. It may be confined to the mucous and submucous tissues, or the entire thickness of the lip may be involved. It occurs usually in the upper lip, but may be seen occasionally in the lower lip. When extensive enough to require operative interference, the proper method is to dissect out in the long axis of the lip a portion of the tissue between the skin and mucous membrane, and approximate the edges of the wound \y\{\\ silk sutures. Hair on tlie Lips of Women. — Permanent epilation may be effected by introducing into the follicle of each hair the point of a fine platinum needle, which is afterward heated by the galvanic current. The employ- ment of cocaine renders this operation painless. 410 A TEXT-BOOK ON SURGERY. Reparative Surgery of the Lips. — A plastic operation may be de- manded in acquired or con'i'enital lack of tissue in tiie upper li]). In the lower lip congenital del'orniity is exceedingly rare. Ilare-Lip. — Hare-lip is a congen- ital defect cansed by an arrest of de- velojiment in the tissues which form Fig. 455. the upper lip. Instead of uniting Fig. 45i. In the median line, a fissure exists which may include either the soft structures of the face or palate, or the bones of the palate as well. In rare instances the cleavage passes up into the eye and cranium (Figs. 4.j4, 455). The fissiiVe is usually uni- lateral, and may be so small that it is scarcely noticed, as in Fig. 456, or it may extend half way to or completely into the nasal cavity (Figs. 457, 458, 459). One side of the lip is much thicker than the other. In double hare- lip the fissures are about the same distance from the median line. Both may extend into the nose, or one (and rarely both) may be partial. The portion intervening may be Fig. 456. Fig. 457. Fig. 458. Fio. 459. THE LIPS AXD CHEEKS. 411 composed of a portion of the lip and gum, with one or more rudi- mentary teeth, at a varying angle of jirojection. The central piece occasionally is attached to the nose. In incomplete single hare-lip the nostril is not flattened and deformed, as is the case when the fissure extends through the pre-maxillary bone and the palate and alveolar processes of the superior maxilla (Fig. 460). The location of this fissure is most frequently between Fig. 400.— (After Koenig.) Fig. 4i;1.— (After Koenig.) the first and second incisor teeth, and thi-ongh the inter-maxillary bone, and not, as frequently given by some writei's, between the second in- cisor and canine teeth, extending backward through the pre-maxillary fjutnre. In double hare-lip the cleft in the palate is usiially double, while the center-piece may be attached to the vomer (Fig. 461), or the pre-maxil- lary portion may be united to one side of the superior maxilla (Fig. 460). In rare instances the fissure passes obliquely upward and out- ward, involving the eyelid, orbit, and cranium, producing frightful de- formity, as shown in Fig. 455. Treatment. — The only relief from this deformity is in a plastic opera- tion. It should be done early, and, when possible, within the first few months of life. Hearty and well-nourished infants, with simple uni- lateral hare-lip, should be operated ujion at birth. If they are feeble, an effort at forced nutrition should be made, and tlie operation x>osti)oned until the patient is brought into proper condition. Double or single hare-lip, with cleft palate, shovild be operated upcm early, since by drawing the lip together the tension on the suj)erior maxillary bones facilitates closure of the interosseous cleft. The methods of operating are numerous. The essential features of every operation are, to trim the edges of the fissure in such shape that, when they are approximated, the gap will be closed and no depression left in the vermilion border of the lip. Single Incomplete Hare-Lip — First Method. — Having estimated the extent of surface required to fill up the deficiency, with a long, sharp 412 A TEXT-BOOK ON SURGERY. Fio. 402.— (After Linhart.) knife prick the integument of the lip at a, b, c, d, and e (Fig. 462), as guides to the deep incision. Then the operator, standing in the position which best suits his convenience, seizes the lip between his thumb and finger, so as to control haDmorrhage, and, i^^ while the opposite side is held by an assist- g" M V ''^^^^' transfixes it at a, cuts from a to c, by smooth, sliort strokes of the knife, removes and reinserts the blade at d, and cuts into the angle at c. This manoeuvre is repeated in the line a, b, e. With a strong, blunt pair f)f scis- sors the soft tissues are freely lifted from the l)one, until the edges of the wound can be ap- proximated without any degree of tension. If, as frequently occurs, one side is so much thicker than the other that difficulty is expe- rienced in keeping the approximated edges on the same ])lane, a part of the under surface of the thicker side should be clipi)ed oil with the scis- sors. Strong silver hare-lip pins (from two to four in number, owing to the length of the in- cision) are then inserted, being made to enter # i^ about one fourth of an inch from the cut edge, l)assing through the entire thickness of the lip, and out at a corresponding point on the oppo- site side. A figure-of-8 silk thread is wound about these, and one or two silk sutures are in- serted, to secure a jjerfect approximation at all points. The pins should be about one fourth of an inch from each other, and the lowest should be about this distance from the vermilion border. The last suture should pass through the vermilion border (Fig. 463). In adults a light loose dressing of sublimate gauze will suffice in tlie after-treatment. In children it is always wise to siipport the sutures by narrow strips of adhesive plaster, carried from the angle of the jaw across the wound to the opposite side of the face. The pins and sutures are removed between the third and fifth days. No rule can be laid down, but the removal should be made as soon as union has taken place. For the few days im- mediately following the operation the muscles of the face should be kept as quiet as possible. Silk sutures may be employed if the pins are not at hand. "When the fissure is wider, the an- gles b and c should be made deeper, as shown in Fig. 464. When approximation is completed, c and b unite, while the points d and e project below the level of the normal lip. Any re- dundancy of tissue or overlapping should be allowed to remain until all shrinkage has oc- curred, when the excess may be trimmed off at the level of the lip. Fig. 463.— lArtcr Liiiliart.j Fio. 464. THE LIPS AND CHEEKS. 413 Second Method — Operation of Malgaigne. — With a sharp bistoury pare the edges of the fissure, by cutting a stri^D on each side, from the apex down to about one eighth of an inch from the free border of the lip. Fig. 4C5.— (After Malgaigne.) Fir.. 466. — (After Miilgaigne.) The strips are turned down, as shown in Fig. 465, and, after the lip on each side is dissected up from the bone, the edges are approximated and united, as shown in Fig. 466. The projecting portion is treated as in the X^receding operation. Third Method — Operation of Langenbeck. — Upon one side of the fissure, as at b (Fig. 467), remove a naiTow strip from the apex out through Flu. 407.— (AUer Liuhart, Langenbeck.) Fig. i')^. — (Alter Linliart.) the vermilion border. On the opposite side, a, the incision extends only to within one eighth to one fourth of an inch of the free border. After the lip is freed from all attachments, the edges are approximated and fastened, as shown in Fig. 468. Fourth Method — Operation of N'etaton. — Make an incision parallel I'iG. 409. — (Alter Nelutou, Koeni^.) FiQ. 470.— (After Koenig.) 414 A TEXT-BOOK ON SURGERY. with the upper half of the fissure, on either side, the incision arching over the apex, as shown in Fig. 469, a h. When completed and turned down, a diamondsluiped or ellii)tical opening is formed (Fig. 470). The pins should be introduced lioni near the lateral angles. Fifth Method— Operation of Grae/e.—Make a horseshoe-shaped in- cision along the apex of the fissure, as at a (Fig. 471), and remove tlie Fig. 4T1. — (.\l'tcr Koenig, Graefe.) Fig. 472. included tissue together with a narrow otrip along the edge of the fissure on one side, as at b, through the free border of the lip. Upon the op- posite side, and near the middle of the fissure, an incision through the thickness of the lip is made in a direction outward and slightly down- ward, as at c. In approximating the edges (see Fig. 472), the receding angle at a is united to b on the opposite side, and the tip of the free bordei", d, is stitched to c. The modification of this procedure by Koenig is preferable in cases where the gap has unusual width at the vermilion border. The horse- shoe incision at a is the same as in the preceding operation, but there Fig. 473.— (After Ivoenig.) a Flo. 474.— (After I^oenig.) are two lateral horizontal incisions, S-3 (Fig. 473). The wound has the shape shown in Fig. 474, and in approximating the edges the apices of the two flaps, b c (Fig. 473), are brought together at the level of a (Fig. 474). Complete Single Hare-Lip — First Method — Cozies' s Operation. — In certain cases where the fissure is of great width, and extends through the floor of the nose, important modifications of the foregoing procedures are at times necessary. The operation is one of considerable difficulty, not only as to the closure of the fissure, but on account of the flattening of the wing of the nose on the affected side. THE LIPS AND CHEEKS. 415 In the milder cases the procedure of Colles may be undertaken. Upon one side of the fissure (usually the most perpendicular surface is selected) make an incision parallel with and about one eighth of an inch from its free border, a c (Fig. 47.5). Tliis incision terminates short of the wing of the nose and the vermilion border, and is bisected a little nearer its upper than its lower end, b. The opposite surface is freshened by an incision in the line d cf (Fig. 475), this strip being entirely removed. When the soft parts are thoroughly dissected up, the edges are approximated, so that the fiap 5 c is turned down, and its end is stitched to the line ef. The flap i a is turned up, its freshened surface being stitched to the upper part of the line e d, while its upper edge looks into the cavity of the nostrU. fio. 475.— (Alter Linliart, C'olks.) Fio. 476.— (Jlodified from Koenij. ) Second Method. — In the severer forms of complete unilateral hare- lip, proceed as follows : Freshen the edge of one side of the fissure on the line indicated by b a (Fig. 476), and upon the opposite side, as at c d, from d making a division of the lip outward and downward, d e, in the direction of the corner of the mouth, and as far as may be necessary. Dissect up the tissues freely from the bones, and make a horizontal in- cision on either side, as shown at b 1, c 1 (Fig. 476). The length of these incisions wiU depend upon the degree of tension required to bring the flaps into apposition. When the wing of the nose is greatly flattened the defoi-mity may be in good part relieved by carrying a curved incision, c^, around the ala nasi, and dissecting loose the attachment from the maxillary bone. Double Hare-Lip. — The method of operation for doiible hare-lip will depend upon the size and position of the middle piece, and the width Fig. 477.— (After Koenig.) Fig. 478.— (Alter Koenlg.) and depth of the lateral fissures. If the central piece is so prominent that it will exercise too great tension upon the lip when the sutures are 410 A TEXT-BOOK ON SURGERY. inserted, the bony projection should be seized with a strons: forceps and forced back into a safer position, or broken oil with a chisel. The edges of the central tip must be trimmed or freshened. The lenuth of the in- cision, a b (Fig. 477), and the extent of the dissection of the lip from the jaw, will depend upon the space to be covered in. The margin from a to the root of the nose is not freshened, since it forms the floor of the nostril when the operation is completed. The condition of the parts when ready for the sutures (pins are not used where a central piece is pi-eserved) is shown in Fig. 478. The points h h meet in the median line of the lip, while a a are sewed to the central piece. CheilopJadij— Upper Lip.— In addition to congenital deficiency of the lips, not infrequently as a result of accident or disease, or the re- moval of abnormal growths or cicatrices, the surgeon is called upon to relieve the deformity and inconvenience resulting from this loss of tissue. In the upper lip, when the loss of substance is not extensive, as in Fig. 479, the unsightly appearance may be remedied by making two in- cisions, curved as represented by the lines a d, a d, from the side of each ,1 Fig. 4T9. — (.Altur Kosuv.) Fij. 4S0.— (Alter Roscr.) ala nasi downward and inward to the apex of tho fissure. The soft tis- sues should be dissected up and brought into po.sition by sutures applied as in Fig. 480. If after the dissection the tension is still so great that the parts do not come well into position, a horizontal incision should be made on either side, beginning near the root of the nose, and carried directly outward, or slightly outward, and downward, as the shape of the flap may require. AVhere there is greater loss of sub- stance, Burrows's method is advisable (Fig. 481). Make a horizontal incision on each side, commencing in the angle of the mouth, and going entirely through the lip, a b, c d, and unite these at Ic and J. Dis- sect out the triangular piece J a b, 7c c d. Make now two other horizontal incisions, which run into the nasal cavity g Ti and / f , and dissect out two smaller triangles, / e m and g h I. The proximal edges of the quadrilateral flaps gJicd and efab should now Fiu. 481.— (After Linhart.) THE LIPS AND CHEEKS. 411 be freshened and freely lifted by dissection, and the sutures intro- duced. It will be obsei-ved that as the edges are approximated, the lines d7i\ b j\ mf, and 7 7^ will be united with c A", aj, me, and If/. A third method, which is useful in certain cases, is as follows : After the disease is removed, an incision, c a (Fig. 482), is carried from the ala? of the nose iipward and outward. The length of this cut and its obliquity de- jiend upon the distance to be tilled be- tween the normal line of the lip and the nose. A second incision, a b, is now carried deeply downward and out- wai'd, making a quadrilateral flap, which hinges at b d, and is dissected up, and the edges, c «, are brought in apposition and secured in the median line. Lower Lip. — When the loss of tissue has left a cavity triangular in shape, as in Fig. 483, that one of the following methods may be selected which in the judgment of the opera- tor is best adapted to the case : Fig. 482.— (After Linhart.) Fig. 4S4.— (After Linhart.) Both flaps are now loosened and Along the Fig. 433. — (After Szymanowsky.) 1. A horizontal cut, a b (Fig. 484), is made outwartl from the angle of the lip, and a second one, b c, parallel Avith the freshened edge of the Assure. slid toward the median line, and united by pins or sutures free border of the new lip stitch the mu- cous membrane to the skin with fine silk sutui'es. The gap left on either side is also wholly or partially closed by sutures. 2. For the same defect make a semi- circular incision outward and downward from each ingle of the mouth, c g d and afe (Fig. 485). Dissect this flap up freely and slide toward the middle line. The pin- sutures are inserted as in Fig. 480, taking 27 Fio. 4S5. — (.VftcT Szyraanowsky.) 418 A TEXT-BOOK ON SURGERY. r \ Hie precaution to sew the nuicons membrane ^~^»"^_--ev/ / to the integument along the edge of the newly made lip. 3. If the lis.siire is less extensive, make a horizontal incision from each angle of the mouth through the entire thickness of the lip for a sulhcient distance (,Fig. 487), a e, e d^ dissect up the triangular Haps, and ad- just Avitli i)in-suture.s, as shown in Fig. 488. When the apex of the triangular defect does not di]) down too far the teeth, the unilateral sliding operation of Blasius nuiy be pi-ac- FiG. 486.— (Aftur S/yiiianowsk.v.) 4. from Fio. 487.— (Alter Szymanowsky.) Fio. 488. — (Alter Szvmanow.iky.) ticed. Fi'om the apex of the angle, c (Fig. 489), make a deep cut, ced, downward and outward over the side of the chin, in the main a continu- ation of the line of the defect, bfc. The flap, aced^ is dissected up and slid so that c is attached to h (Fig. 490). 5. When the defect extends in the shape of an isosceles triangle with the apex low down upon the chin, the method of Burrows (Fig. 491) is ap- Fio. 48S).— (Aller Szymanowsky.) Flo. 490. — (After Szymaiiowsky.) Fio. 491.— (After Linhart.) plicable. Two triangular pieces, nfJi, hgk, are removed from the tis- sues just above the angles of the mouth. The edges of the fissure are THE LIPS AND CHEEKS. 419 freshened, the flaps, fadgbd, dissected loose, and the lines, a e, he, approximated by sutures. 0. When the defect is long and rectangular, as shown in Fig. 492, the procedure of Von Bruns may be successfully employed. The diseased tissue being removed, the quadrilateral flaps, abed (Fig. 493), are dis- Fio. 492.— (After LiiiLart.) Fig. 493.— (After Linhart.) sected out and brought down, uniting ohm the median line and ab on either side to the line a a. The defect left on both sides of the outer aspect of the upper lip may be wholly or in great part closed by sutures. The outer incision should not be carried far enough back to wound the duct of Steno. 7. Or the flaps may be turned from below, as advised by Sedillot (Fig. 494). The inferior oblique lines are carried to the middle line and stitched to each other. The defect is closed by sutures (Fig. 495). Fio. 494.— (.Vtler Malgaigne.) Fig. 495. — (After Malgaignc.) Cheeks. — When the loss of substance is not extensive, the edges may be dissected up to a limited extent, pared, and brought directly together by sutures. If this can not be accomplished, incisions shaped as shown 4l>0 A TEXT-BOOK ON SURGERY. in Fig. 4'JG (Mutter's method), ab, ae, may be made, the Haps lifted, and brought together by sutures. The gaps left above and below may be also closed at once. Sliding a flap from the neck is sliovvn in Fig. 497, where the llaj), b a d, is brought up to till the oval s\ydce left by removal of the diseased Fia. 490.— (After Roser.) Fio. 4'j7. — (After Ma)gaigne.) tissue, b ca. The pedicle is divided as soon as union has occurred, and the stump returned, as in r7n')/oplast>/. In contrarlion of the mouth the orifice may be enlarged by incising the angles in a horizontal direction, finishing the operation by stitching the skin and mucous membrane together. Or an elastic ligature may be introduced through the cheek at the required distance from the angle, brought out at the corner of the mouth, and tied. During the slow pro- cess of cutting through, the track of the wound becomes covered with epithelia, and reunion is prevented. In the selection of any of the plastic methods heretofore given, the surgeon must be guided by the requirements of each case. It is a wise precaution to make a guarded prognosis, for, no matter how .successful from the surgical standpoint, the operations do not, in the majority of instances, secure the expected improvement in the personal appearance of the patient. Parotid Gland and Duct. Salivary fistula may be confined to the main parotid duct in any part of its course, or to the primary ducts within the substance of the gland. It may result from a wound or any inflammatf)ry and necrotic process due to obstruction from salivary calculi or other disease of the x'iU'otid and buccal regions. Exploration of the duct with a delicate blunt probe is accomplished thus : Find the outlet at the papilla on the mucous membrane of the buccal cavity near the junction of the second bicuspid PAROTID GLAND AND DUCT. 421 and first molar teeth of tlie upper jaw. Introduce the probe, carrying it at first slightly outward. When it is arrested by the natural curve of the duct, pull tlie corner of the mouth and the cheek directly outward, thus straightening the tube. The general direction is backward, toward the auditory meatus. The diagnosis of salivary fistula or of obstructed duct may be deter- mined as follows : By means of absorbent cotton or lint remove all moisture from the mucous surface where the papilla is situated, and place some sapid or acid substance on the tongue. If there is no obstruction, the flow of saliva is immediately perceived. In case of fistula the secre- tion will flow out through it. Calculi of Steno's duct, or of any of the salivary ducts, should be removed by dilatation, if this is possible, and if not, by incision. In the treatment of salivary fistula the object aimed at is to stop the flow of saliva on the outside and turn it into the mouth. Arm a probe with a silk seton and carry it through the fistula into the buccal cavity, bring the thread out through the mouth, and tie the two ends together. In about ten days the flow into the mouth will be fully established, when the seton should be removed and the outer opening closed by a compress imtil cicatrization occurs. It may, at times, be necessary to freshen the edges and bring them together with a suture. Riberi operated successfully by cutting through the integument down ujjon the duct behind the opening, passing a ligature around it, and carrying this and the end of the duct into the buccal cavity where it was left open. The wound in the integument was immediately su- tured. Fistula of the primary ducts within the substance of the gland may require the forced atrojihy or ablation of this organ. An effort at oc- clusion should be made by direct pressure uj^on the abnormal opening. Tumors of tlie Parotid. — About 30 per cent of all neoplasms of this organ are enchondroraata, 25 carcinomata, while the remaining 45 per cent are about equally divided between sarcomata, fibromata, myxomata, and cystomata. Simple hypertrophy is rare, although hyi)erplasia of the gland-tissue occurs in a varying degree in the progress of most of the neoplasms which attack this organ. Tumor of the parotid is rare prior to the thirtieth year of life, being met with chiefiy between the thirtieth and fiftieth years. As to the period when the various forms appear, it maj' be said that carcinoma occurs generally after the fiftieth year, while enchondroma, sarcoma, myxoma, and fibroma develop in the earlier decades. Sarcoma is apt to develop in cliildhood or early adult life. Diagnosis. — All forms of tumor of the parotid, as a rule, develop slowly. In the earlier stages of their development they are movable within the limited area of mobility of the gland. This is true of both the benign and malignant growths. Later, even the benign neoplasms may become fastened between the temporal bone and fascia and the ramus of the jaw, but not to the overlying integument. The malignant growths are more rapid in development, and earlier in their history are 422 A TEXT-BOOK ON SURGERY. bound down to the sniTounding tissncs, may become adherent to the integument, and produce great pain and disturbance by reason of press- ure u]ion the nerves and vessels witli whicli the gland is in close relation. The cartilage tumors are nodular, hard, and slightly elastic to direct pressure. Cancer is also nodular at times, but not so hard as enchon- droma. Cancer comes, as a rule, after the forty-lifth to liftieth year, and the other neoplasms before this period. The lymphatic glands are involved in cancel', and rarely enlarged in any other fomi of neoplasm. Sarcoma occurs earliest of all. Cysts are elastic, may present fluctua- tion, while the exact character of this variety may be determined by exploration with the aspirator. If of great importance in determining the plan of treatment to be pursued, a section of the diseased organ suificiently large for microscopic examination sliould be removed ; in this way a positive diagnosis is assured. Removal of the parotid gland is one of the most difficult operations in surgeiy. In many cases of tumor of this organ in which the neo- plasm is developed at the expense of the under portion of the gland, the internal jugular vein, internal carotid artery, and the important nerves and ganglia situated here become so involved that complete ex- tirpation is impossible during life. This condition was found to exist in a case in which I removed all of the organ anterior to the deep vessels. Having at first tied the external carotid artery, the dissection was com- paratively bloodless. When the tumor is of small size, it may be en- tii'ely removed. Section of the various divisions of the facial nerve or of the main trunk is almost inevitable. If the external carotid is first secured it may be avoided by a careful dissection, provided that the tumor is of moderate size. Operation. — Make a crucial incision over the mass, the perpendicular cut being in the line of the external carotid artery. Turn the flaps back from the anterior aspect of the tumor, and approach its deeper portions from below in the line of the vessels. As soon as the external carotid can be exposed, it should be secured with a catgut ligature. All bleeding should be arrested as the operation proceeds. In lifting the under surface of the tumor from its bed, the operator should keep close to the mass, using a dull instrument for fear of wounding the internal jugular vein and other important vessels or nerves. The blunt scissors curved on the flat, the handle of the scalfjel, or the thumb and finger- nail may be utilized for this j^urpose. The facial nerve and its branches which run through the neoplasm should be saved, if possible. As before stated, if the tumor is extensive, this is scarcely possible on account of the great length of time it woiild require. If, in the course of the opera- tion, it is discovered that the neoplasm dips down beneath the jaw and styloid process, and surrounds the vessels and nei*ves, its complete ex- tirpation is impossible. As much of the mass as can be lifted should now be transfixed near the middle with a double elastic ligature, tied, and the part external to the ligature cut away. The 2^1'ognosis in cancer and sarcoma of the parotid is always grave, even after removal. The anatomical relations of this organ are such PAROTITIS.— SUBMAXILLARY GLAND.— THE JAWS. 423 that a wide and complete extirpation, sacli as is readily made in tumors of the breast, is impossible. The question will naturally arise, Under what conditions should the operation be advised and undertaken ? In malignant disease the propriety of extirpation is very questionable, and should only be undertaken after a clear explanation of the dangers of the operation and the probabilities of recurrence. In benign tumors which show a tendency to increase, operation may be advised, especially if the tumor is still of small size. It is always important to attempt the removal of the neoplasm early in its history. Facial paralysis generally follows the oijeration, and is more or less permanent. Parotitis — " Mumps." Inflammation of the parotid gland occurs chiefly in children, but is occasionally met with in adults. In males it is, at times, accompanied by orchitis, and in females the mammary glands and ovaries are aifected. The symi^toms are pain and swelling of the gland, difficult deglutition, and slight febrile movement. The prognosis is favorable, the disease yielding to warm applications, quiet, and the judicious employment of laxatives. In rare instances atrophy of the testicle has been known to follow the inflammation of this organ, occurring as a complication of "m?/7?i^5." Abscess may occur after an acute inflammation of the parotid from traumatism, or as a complication of the eruj)tive or continued fevers. Under these last conditions the prognosis is always grave. The presence of pus is recognized by the intense character of the pain experienced, the febrile movement, the doughy condition of the skin and areolar tissue in front of the organ, and by aspiration. The abscess should be evacuated by aspiration, puncture, or incision. Submaxillary Gland. This organ may become inflamed and suppurate, or be the seat of neoplasms, yet not so frequently brought to the attention of the sur- .geon as the parotid. Its removal is a simple procedure, and may be accomplished by a crescentlc incision commencing at the angle of the Jaw, dipping three quarters of an inch toward the hyoid bone, and end- ing one and a half inches in front of the angle at the lower border of the jaw. The flap of skin should be raised with the platysma muscle as far as the jaw, and the deep cervical fascia divided. The gland rests be- neath and internal to the bone and upon the mylohyoid and hyoglossiis muscles. The submaxillary branch of the facial artery will be divided. The Jaws. Sitpen'o)' 3IaxiUa. — Periostitis, ostitis, and abscess of the upper jaw may be caused by caries of the teeth, disease of the upper jaw within 424 A TEXT-BOOK ON SURGERY. the antrum, or patliological changes within the bone proper. Ostitis of the niaxilhi is more apt to occiii' in chiklren, and especially in those of a strumous diathesis. Ph()s]ihorus-i)()is()ning and the syi^hilitic dyscrasia lead also to intiamniation and caries of tliis l)one. The symptoms of ostitis and abscess here do not differ from those already given in the general cliajiter on bone diseases. Pain is, ]ierhaps, more acute in ostitis wit liiu the distribution of the trifacial nerve. It iiJ elicited by direct pressure, and, when the process is associated with a carious tooth or its roots, the exact location may be determined by striking the tooth sharply with a metallic substance. The treatment is to relieve the tension by puncture or incision, or by extraction of one or more teeth in case they are connected with the diseased surface. The removal of dead bone is demanded, although it is wise not to operate too early. When exfoliation has occurred, the oper- ation is much simplified. If free drainage is secured by early incision, the arrest of the spread of the disease is practically insured. Chronic alceolar abscess is often cured by extraction of an offending tooth. When this fails, the diseased surface should be exposed by incision, and a thorough removal accomplished. When possible, all sequestra should be removed from within the oval cavity in order to avoid a scar iqion the face. Syphilitic ostitis, and that variety which occurs from absorption of the fumes of phosphorus, require specific constitutional treatment as well as operative interference. Abscess of the antrum of Highmore may occur as the result of an infiammatory process in the mucous membrane lining this cavity, or in connection with ostitis of the upper jaw, or from the presence of foreign bodies or neoplasms within its cavity. The chief symptom is pain, re- ferred to the region of the antrum. The febrile movement of acute ab- scess is usually present. The pus may force its way through the open- ing into the meatus, or cause necrosis in the bone and discharge in any direction. Treatment. — I^ree drainage must be established in all cases. The extraction of the first or second molar and the application of a drill to enlarge the opening may suffice. If necessary, a portion of the alveolar process should be gnawed away with the forceps. In extreme cases an incision should be made through the skin just above the situation of the first molar tooth, and a thorough opening made with a trephine or gouge. It is important to explore the cavity with the finger in order to determine the presence of dead bone or any offending substance. Free drainage must be maintained uutil recovery is secured. In a case which came under my observation, I found the cause of an abscess of thirteen years' duration to be a supernumerary molar tooth which was lying loose in the antrum. The same operation will be most essential in those cases of hydrops antri, or retention of fluid, and in the cure of cysts of this cavity. Among the many other diseases to which the antrum is subject are myxoma, fibroma, pax^illoma, sarcoma, carcinoma, and various hyperos- THE JAWS. 425 toses. The differentiation of these growths is extremely difficult, and, when doxibt exists as to the character of the neoplasm, an exploi'atory operation for the puri:)ose of positive diagnosis should be made. This is done by aj^plying the trephine as just given. Non-malignant new formations may be removed by an osteoi^lastic operation, while malignant growths often require the sacrifice of the entire upper jaw. Osteoplastic Operation for Removal of Benign Tumor from the An- trum of Ilighmore — Langeiibec7c\'^ Procedure. — From the junctif)n of the wing of the nose with the lip an incision is carried outward parallel with the level of the teeth, and is made to divide the soft parts to the bone as far as the center of the malar prominence, where it is curved up- ward and inward, ending a quarter of an inch below the outer angle of the orbit. This is joined by a second incision, which is commenced about a quarter of an inch below the level of the orbit at the suture between the nasal bone and the nasal process of the superior maxilla, and is car- ried outward parallel with the lower margin of the orbital cavity. The tissues must not be lifted from the periosteum within this curved incision. The hjemorrhage, which is always sharp, being arrested, with a blunt instrument carefully lift the eye from the floor of the orbital cavity until the finger can be carried into the anterior portion of the spheno-maxillary fissure. With this as a guide, insert a small, strong key-hole saw into the fissure and divide the ma- lar bone outward in the line of the incision (see Fig. 498). In moving the saw, keep the blade perpendicular, and limit the motion so that the point may not penetrate the temporal fossa and wound the vessels. Next insert the saw in the lower horizontal incision and divide the supe- rior maxilla into the cavity of the antrum and nose. In sawing on this line, keep the mouth Fig. 4y8. open and the finger inserted behind the j^Jilate to prevent the point of the instrument from penetrating too far back. The nasal process of the superior maxilla is now divided with a chisel at a point half way between the inferior orbital foramen and the inner angle of the orbit. The cutting-edge of the chisel shoiild be directed slightly outward for fear of injuring the lachryino-nasal duct. The lines of sec- tion in the bones are shown in Fig. 498. The jjoint of exit of the infra- orbital nerve should be found and this branch of the trifacial divided at the foramen. An elevator is now placed in the fissure made by the saw through the malar bone and the mass dislocated inward, hinging on the undivided soft tissues. This force fractures the floor of the orbit and opens widely the antrum of Ilighmore. When the operation is finished, the bone is neatly replaced and the edges of the wound accurately ad- justed. Drainage may be secured through the wound, or a hole may be drilled through the edge of the alveolus. This same operation is advis- able in section of the second l)ran('h of tlie fifth nerve and extirjiation of Meckel's ganglion. When the ganglion is the objective point, it may be 426 A TEXT-BOOK ON SURGERY. fownd by following the superior maxilhuy branch of the fifth nerve nlong the floor of the orbit to the location of the ganglion on the anterior sur- face of the pterygoid process of the sijhenoid bone. The posterior shell of the antrum must be broken through in order to enter the fossa. Operatiox fou Ke.moval of the Upper Jaw. A quarter of an inch below the inner canthus of the eye commence an Incision and carry it downward along the naso-maxillary groove, curving in the contour of the ala nasi, then horizontally beneath the ala to the median line of the lip, where it tui'ns directly downward, dividing the lip in the median fissure. From the point of beginning carry a second incision one fourth of an inch below and parallel with the inferior mar- gin of the orbit out to the prominence of the malar bone (Fig. 499). Dissect up the soft tis- sues of the cheek, and turn the flap downward and outward. If the disease is so extensive that the incision does not expose the parts ^,^ _-, J sufl[iciently, a horizontal cut may be made out- ''^■^^ > ^. ward from the angle of the mouth. ^^t'. ^^, The bone may be divided by the saw insert- ed in the spheno-maxillary fissvire, as in the preceding operation, cutting through the nasal process with a chi-sel. Extract an incisor tooth, and with large, strong bone-cutting forcejis di- vide the alveolus and the palate-process by in- serting one blade in the nose and the other in the mouth. These sections being accomi)lished, avulsion is made by means of elevator and for- ceps. The operation is completed by the clos- ure of the wounds with fine silk sutures. If, in section of the palate, the Paquelin cautery is used, hsemorrhage will be less annoying. Rec- tal ansesthesia is preferable in these major operations about the mouth. Preliminary tracheotomy and plugging the pharynx and larynx with sponges in order to prevent haemorrhage into the trachea is rarely, if ever, required. If such precaution is considered necessary, an ordinary trachea- tube will suffice.* Neurectomy. — Exsection of a portion of the second division of the fifth nerve may be made at three jioints — at its exit from the infra-orbital canal, within the canal, or at the foramen rotundum. In this last opera- tion the spheno-m«xillary ganglion is also extirpated. If the cause of the neuralgia is peripheral, make an incision aboiit one inch long, par- allel with and half an inch below the lower margin of the orbital cavity. * Trendelenburg's tnichca-tube and tampon is such a complicated apparatus that, when possible, it should he dispensed with. It is more to be commended in laryngectomy than in any other operation about the mouth or pharynx. The mechanism of this tube, and the method of using it, are given on page 457. Fio. 499.— (After Eoser.i THE LOWER JAW. 427 The center of this cut should be over the infra-orbital foramen, which is just half way between the outer and inner angle of the orbit. The nerve may be exsected here or stretched by pulling on the central end. It may be reached at a iioint considerably behind this by trepliining tlie antrum. Make a curved incision, beginning about half an inch below the inner canthus, passing downward to the level of the end of the nose, thence ux)ward to a point about half an inch below the outer canthus. Dissect this flap upward, apply the trephine so that its upper edge will cut just below the foramen and enter the antrum. The nerve runs di- rectly backward, and may be followed by keeping it as a guide and breaking off the lower shell of the canal as far back as the posterior wall of the antrum, where it is divided. The operation for the removal of Meckel's ganglion has already been given. The Lower Jaw. Ostitis of the inferior maxilla is of frequent occurrence. Various forms of fibroma, fibro-myxoma, encysted fibroma, enchon- droma, and, in rare instances, angioma, have been observed in this bone, but of new formations sarcoma is most frequent. Cystic formations resulting from failure of normal development of the teeth are not un- common. Ostitis occurs most frequently in children. It may be an expression of a dyscrasia, or an accident of nutrition, or be secondary to disease of the teeth, or the inhalation of the fumes of phosphorus. While this process may be located at any portion of the jaw, the neighborhood of the angle seems to be most frequentlj^ affected. The symptoms are pain, followed by sweUing of the jaw and contigu- ous soft tissues, ending in abscess, which, if left alone, eventually opens and discharges. Treatment. — As soon as the character of the disease is evident, an incision or puncture should be made through the overlying tissues and periosteum, in order to give free exit to pus and loose particles of bone. The operation for removal of the dead bone may be delayed for several weeks until exfoliation has taken place. Incision should always be made below the line of the jaw if this is feasible, so that the resulting scar will be less ajiparent. Usually by following the track of the abscess it will lead directly to the dead bone surrounded by an involucncm. This often requires to be chiseled or forced open to allow the extraction of the sequestrum, which may be readily removed with ordinary bone- or dressing-forceps. The cavity should be well scraped with a Volkmann's spoon, a drainage-tube left in, and the edges of the wound adjusted with silk sutures. The deformity due to the rich deposit of callus disappears with the absorption of this material. When all or any portion of the entire thickness of the jaw requii'es removal for ostitis, the sub-perios- teal operation is imperative, since by this means alone is it possible to have a reproduction of the bone. The method of procedure, when the 428 A TEXT-BOOK ON SURGERY. bone is tlic seat of a neoplasm, depends iij)on tlie character of the new formation. If there is any doubt as to the benign character of the tumor, a i)iece should be removed and examined iiiicrosco])ical]y liefoi-e operation. In sarcoma, cancer, and enchondroma of the jaw, the sub-periosteal operation can not be performed, since the sound tissues must be included in the ablation, in order to secure immunity from recurrence. Enchon- droma, though not intrinsically malignant, tends to recur if not freely excised. Operation. — When it is safe and i)ossilile, the diseased portion of the lower jaw should be removed without breaking the continuity of the bone. If a portion of the entire thickness of the organ is removed, the tendency to displacement is inward, thereby interfering with mastica- tion. The entire thickness of the jaw should be included in exsection for malignant neoplasm. Partial resection of the upper or alveolar portion of the body of the lower jaw in front may be accomplished, in mild cases, from within the buccal cavity. When the disease is extensive, proceed as follows : At a distance from the alveolar margin sufRcient to permit the exposure of all diseased bone make an incision parallel with the margin of the lip, and also parallel with the inferior border of the jaw. This incision should extend in depth to the bone and in length beyond the area of disease. The bone is next divided by tlie chisel and mallet, the key-bole saw, or removed in small pieces by the ron- geur, in the line indicated in Fig. 500. The operation is concluded by bringing the Hap back into place with silk sutures. When the disease is more gen- eral, necessitating a removal of the Fig. 500. — Line of eection in removing the alveo- lus ot the lower jaw. (.\lter Koser.) entire thickness of the bone, a more extensive incision is required. The lip is divided in the median line down to the under surface of the chin, and thence along the lower border of the jaw (Fig. 501). When the ramus and articular process requii-e removal, the line of incision may be carried to the angle and up the ramus. In disarticulation, while the incision through the skin can be safely carried as high as the zygoma, the incision down to the bone should not extend farther than on a level with the tip of Fig. 501.— (.\ftcr Koser.) THE LOWER JAW. 499 the mastoid process, for fear of dividing the facial nen-e. From this point the coi-acoid process and the articulation may be reached by work- ing np close to the surface of the bone, beneath the periosteum (if the disease is not malignant). The inferior dental artery should be secured when divided, and the other branches of the internal maxillary avoid- ed. The external carotid is left behind the ramus. In the act of dis- articulation it must be remembered that the internal carotid artery and internal jugular vein enter the cranium just behind the vaginal process of the temporal bone, which forms tlie posterior wall of the articula- tion. As this i^rocess is only al)out one eighth of an inch thick, the walls of the vein and artery are in dangerous proximity to the attachment of the capsule. The anterior and outer wall of the capsule should be first separated, and then, while strong outward traction is made on the ramus, the inner wall of the capsule should be divided as close to the neck of the bone as possible. If ablation of the entire bone is demanded, this operation is repeated for the opposite side. It must not be forgotten that when the attachments of the hyoid muscles to the jaw are severed, the action of the remaining muscles, together with gravity, aid in carrying the base of the tongue backward upon the glottis, producing dangerous if not fatal asphyxia. The precaution of passing a thread through the tip of the tongue should not be overlooked. Resection of the inferior dental nerve may be performed at the men- tal foramen, or at the commencement of the dental canal at the angle of the jaw. The mental foramen is situated about half way between the inferior border of the bone and the alveolar border or necks of the teeth. A line let fall perpendicularly from the interspace between the two bicuspid teeth of the lower jaw Avill jiass over the ojiening. A curved or crucial incision will expose the nerve at this point. The foramen of entrance of the inferior dental nerve is very near the center of the qiiadrilateral formed by the anterior and posterior margins of the ramus, the lower horizontal border of the angle, and an imaginary horizontal line on a level with the lowest portion of the sigmoid notch. An incision about two inches long and slightly curved is made so that its middle will be about the center of the parallelogram above de- scribed. The trephine should be applied over the center of the quadri- lateral. The best indication of having reached the nerve is the bleeding through the track of the trephine when it passes into the cancellous tis- sue of the jaw. This comes from the wounded inferior dental vessels. An elevator placed in the cut will now lift the button of bone, and the nerve is exposed. The entire portion in the limit of the trephine should be excised. Temporary relief is almost invarialdy secured, although a recurrence of pain is not uncommon after several months. Anchylosis. — Motion of the jaw may be limited or entirely prevented by muscular rigidity, cicatricial contractions, or true anchylosis at the temporo-maxillary articulation. The area of motion in partial anch^vlosis may be increased by forcible separation of the lower from the ujjper jaw by the apparatus shown in 430 A TEXT-BOOK OX SURGERY. Fig. 37. This should he repeated at frequent intervals, gradually in- creasing the pressure. In severe cases a false joint may be successfully established by section of the bone nntf^rior to the point of fixation, usuiil- ly at or above the angle. Care must l)e taken to make frequent pas- sive motion in order to prevent union of the divided ends. Fia. 502. — Incisor, straight root. Fio. 503. — Incisor, half-curved root. Tino Tektii. Extraction. — Dental forceps should be of different patterns, the jaws bent at various angles to the shaft, and the handles large enough to be grasped firmly and securely by the operator. The gum immediately around the neck of the tooth should be free- ly incised Avith a lancet, since if this precaution is not taken it may be unnecessarily torn away with the tooth. The injection of cocaine around the tooth will render the cutting pain- less. The jaws of the forceps are applied on either side of the neck, and forced down to- ward the root until they grasp the tooth firmly at the margin of its alveolar insertion. The direction of traction is determined by the normal direction of the axis of the tooth. In extracting the incisors and canine teeth, the for- ceps represented in Figs. 502 and 503 are applied as described above, and, when firmly fixed, a slight forward and backward movement, with limited rotation, will loosen the root, while traction should at the same time be made in a direction upward and slightly forward for the low- er jaw, and do^^•nward for the teeth of the upper row. For the bicuspids and molars, the instruments shown in Figs. 504, 505, and 506 are preferable. The bicuspids and molars may be loosened by lateral motion or rock- fiG. 504.— Wolverton's upper bicuspids. Fio. 505.— Wolverton's lower bicuspids. THE PALATE. 431 ing. The direction of traction is slightly inward for the lower teeth, and slightly outward for those of the upper jaw. Fracture of a root or shelving of the alveolus wiU occur at times in the most skillful hands, and abscess and necrosis may en- sue. Fragments of the teeth should be gouged out by using an elevator. Hfemor- rhage, usually insig- niticant, may at times be dangerous, death having occurred from this cause in one or moi'e instances. Cold or heat, or packing the cavity with a compress of cotton or lint, will effect its ari'est. In extreme cases the compress may be saturated with MoDsel's solution, or alum, or any astringent, and left in for forty-eight hours. Anaesthetics may be employed with great safety in dental surgery. Nitrous oxide is of every-day use, and ether is both safe and effective. ChlorofoiTu is not to be employed unless, after full infonnation, the x«- tient relieves the operator of all responsibility. When ether or chloro- form are administered, the patient should be placed in the recumbent posture. Fifl. 506. — Harris's lower molars, tor tlie two sides. The Palate. Uvula. — On account of elongation or hypertrophy of this portion of the soft palate, its excision is at times required. It may be accomplished by taking hold of the tip with a mouse-tooth forceps, and with a long curved scissors removing as much as required. Complete local anjesthe- sia may be obtained by mopping the uvula with a small quantity of a 4-per-cent solution of cocaine hydrochlorate at intervals of three min- utes for tifteen minutes before the operation. Tumors of the palate, abscess, necrosis, and xilceration are not infre- quent, and demand the same treatment as in other portions of the body. Cleft jKilate may be confined to the soft palate ; it may include with this a portion or all of the hard palate and alveolus, or it may be con- lined to the hard palate alone. It is usually congenital, although it may be acquired, as in the perforations which ensue as a result of syphi- litic ulceration and necrosis. The cleft in the hard palate is most often single, the vomer being attached to one side of the palate-process of the superior maxilla (Fig. 460). Occasionally it is double, there being a central piece — the vomer — which runs forward and is attached to the pre-maxillary bone (Fig. 401). Treatment. — When a hare-lip exists as a complication of cleft palate, the oi^eration on the lip should lirst be made in order to enable the child 432 A TEXT-BOOK ON SURGERY. to swallow sufficient ncmrishnient, und to gain tlie additional advantage of pressure of the united lip, wliich aids in approximation of the edges of the cleft in the hard palate. Tlie most suitable age for opei-iting is within the first three years of life, if the infant is sufficiently strong and well nourished to endure so formidable a procedure. One of tiie most discouraging features of this operation, if postponed until later, is that, owing to the shortening and failure of development in the palate muscles, it is practically impossible to acquire a natural arliiiilation, even after the fissure has been success- fully closed. When the cleft is genei-al— that is, entirely through the soft and hard palate— it is advisable to close the soft portion first and finish the re- mainder in one or more sittings, as may be found necessary. In chil- dren, chloiofoiTn should be used; in adults, a sufficient degree of local an?pstliesia may be obtained by the employment of hydrochlorate of co- caine to enable the operation to be done with the very valuable aid of the ])atient. In a case operated upon by myself, the parts to be incised were brushed over with a 4-per-cent solution of cocaine at intervals of two or three minutes tov half an houi' preceding, and about every five minutes during, the operation. The anaesthesia was perfectly satisfactory, and complete union resulted after the first operation. OjH'rafion of Stapliylorrapliy. — The first object in this operation is to keep the mouth of the patient widely opened. For this purpose GoodwilUe's gag Is the best of all instruments (Figs. 35 and 8G). The tongue may be depressed with a simtula if neces- sary. If an anaesthetic is employed, the condition of narcosis should not be pro- found, for, if laryngeal sen- sibility is completely lost, blood or mucus may pass into the larynx and trachea instead of being swallowed. The patient's head being firmly held by an assistant, the soft palate is seized by a mouse-tooth fixation- forceps, and with a blunt- pointed, long narrow knife (Fig. .50) a strip, about one eighth to one sixteenth of an inch wide, is removed from the edges of the fis- Fio. 507.— Froslicnin^ the mnrgin of the cleft in the operation of btiipliylon-aphy. (After Malgaigne.) sure, in its entire length (Fig. .507). In order to steady the palate, a silk thread may be inserted on either angle, or a second forceps a][)plied, although this is not always THE PALATE. 433 necessary. The entire margin of the cleft must be carefully freshened, for if any point is left uncut union will fail. The bleeding is next arrested by small sponges, on staffs (Fig. 83), dipped in ice-water and squeezed dry. In uniting the freshened edges. Dr. Goodwillie's hollow needle (Fig. Fig. 508. — Goodwillie's hollow needle for silk-worra gut suture in the closure of clefl palate. 508) is the best instrument, while the silk-worm gut suture leaves noth- ing to be desired in this operation. To the shaft adjust one of the needles which, from its shape, is best adapted to the peculiar form of the fissure to be closed, and push one of the silk- worm bristles through from the butt to the point until it projects, and then draw it back one eighth of an inch within the eye of the needle. Seize the edge of the flap with the forceps, and at a point between one eighth and one fourth of an inch from the freshened margin of the fissure insert the needle from before backward, through the side corresj^onding to the operator's right hand (left side of the patient), and then through the opposite side, at a like point from behind forward. In order to facilitate the passage of the needle, the flap must be held steadily with the forceps. As soon as the needle has transfixed the second flap and the eye is visible, the operator pushes on the bristle at the butt of the needle-holder, causing the other end to come out of the eye of the needle, when it is seized with the forceps and drawn forward. Holding this end firmly, the needle is withdrawn, leaving the suture in position. The ends of this are now fastened together with a perforated shot, and held aside until all are inserted. The sutures should be about one fourth of an inch apart. When the last one is inserted, the operator ties one after another from above downward. The first knot is single, and this is run down tight and repeated with two additional knots to secure it. The ends are then cut oflf, one fourth of an inch from the knot. This material ties easily, does not slip or break, is not absorbable, and holds its place until removed. After the sutures are tied it will be observed that (as a result of the fissure, the levator pnlati and palato-pharyngeus muscles being shortened) there is now marked tension of the soft palate, which, if not relieved, will pull upon the sutures and cause separation of the edges of the wound. To obviate this, a sharp knife (Fig. 55) is thrust through the palate, about the center of the posterior margin of the horizontal plate of the palate-bone of that side, and an incision made, in a direction downward and outward, to within from one fourth to one half of an inch from the free border of the palate, near the hamular ])rocess, as in 28 434 A TEXT-BOOK ON SURGERY. Fig. 509. This incision divides the levator palati of either side. The anterior and posterior pillars of the fauces should also be snipped with dull-pointed scissors. All of these wounds close later by granulation. It is important to keei) the muscles of this region at rest for a week after the operation. When the cleft extends into the linid palate, as shown in Fig. 510, the lissure may be closed by sliding the membrane lining the vault of the palate. Fio. 509.— (After Agnew.) Fio. 510. — Incisions in sliding the periosteum for clos- ure of the bony cleft, (ilodified from Koenij;.) The edges of the fissured soft palate are freshened, as in the preceding operation. Along the edges of the bony fissure an incision {a h, Fig. 510) is made, with a knife shaped like a gum-lancet (Fig. 57), and, by the aid of curved elevators (Fig. 71), the membi-ane lining the bony palate is carefully lifted with the periosteum. Another incision is now made on either side of the fissure, close to and parallel with the junction of the alveolus with the palate processes, A 7?, through which the elevator is again introduced, and the periosteum lifted until the whole flap included between B A and the edges of the fissure a b is detached. If severe haemorrhage follows the incision, the wound should be temporarily packed with lint, or pressure with the finger may arrest the bleeding. The flaps are now ready for sliding, and the sutures are introduced along the freshened edges, as in the preceding operation. When the cleft extends still farther forward through the alveolus, and the fissure is wide, it will become necessary to carry the palate pro- cesses toward the median line by an osteoplastic operation. In this procedure no effort is made at lifting the periosteum, and it is better to attempt the approximation of only one portion of the cleft at a sitting. In order to secure all the nutrition possible, the soft palate should be THE TONGUE AND BUCCAL CAVITY. 435 first united. The anterior or posterior portion of the bony fissure may be closed at the next operation, as follows : Freshen the edges of the soft parts along the fissure. Drill two holes tlirough the bony palate of either side, one fourth of an inch distant from the edges to be approximated, and insert two strong silver wires, as shown in Fig. 511. On either side, close to and parallel with the alveolus, make two incisions through to the bone, as at A B (Fig. 510), and di'ill with an awl a series of holes in the track of these incisions. A few strokes of a small chisel will now break the palate pro- cesses in tlie line of the holes, when, by twist- ing the wires, the loosened plates will be ap- proximated in the median line. After union has occurred in this portion of the cleft, the operation may be completed in the anterior por- tion, by drilling the palate and alveolus, and breaking this last through from the fi^ont with a chisel, approximating the sides as above. Perforations of the palate are treated prac- tically in the same way as congenital cleft, by freshening the edges, and, if necessary, sliding the periosteum, as above given. Fio. 511.— (After Agnew.) The Tongue and Buccal Cavitt. Wounds of the tongue bleed profusely, especially if the larger vessels along its under surface are divided. The arrest of haemorrhage is easily and safely accomplished by introducing the index-finger well back over the dorsum to the root of the tongue, and bringing the organ well for- ward and forcibly compressing it against the symphysis menti. The tip of the organ should be turned upward, and the forceps applied at the bleeding points. In the substance of the tongue the vessels are also readily secured in the same manner. Should any difficulty arise, a silk thread may be carried around the I>leeding vessel by means of a curved needle, or it may be transfixed with a tenaculum and the thread tied around the hook. Glossitis — Hemiglossitis. — Inflammation of the tongue may result from the same causes and assume all the phases of inflammation common to the soft tissues in other portions of the body. It may be acute or chronic, ending in ulceration or hypertrophy. Tlie process may begin superficially, as after the ingestion of some irritating substance, or it may commence in the deeper porticms of the organ as a diffuse phleg- monous process. In some instances only one lateral half of the organ is involved. Treatment. — Inflammation of the tongue from any cause should be closely watched, on account of the danger of asphyxia from rapid en- largement of this organ. In this emergency tracheotomy should be performed. If abscess forms, incision or j)uncture is demanded. Scarifi- 436 A TEXT-BOOK ON SURGERY. cation may be required in rapid enlargement of this organ from engorge- ment of the vessels. lliipcrtroiihi/ of tlie tongue is both congenital and acquired. It may exist in adult life, although it is in general a condition of childhood. The enlargement is due to hypertrophy of the lymphatic plexuses of this organ and to a general liyperplasia of the oonne(^tive-tissue elements. The muscular substance undergoes granular metamorphosis. Tlie cause of this disease is n(jt understood. The organ may become so large that it protrudes from the mouth, pushes the teeth out of their normal po- sition, and interferes with deglutition and respiration to such an extent that its ])artial or complete removal becomes necessary. Cystic tumors of the tongue may be mistaken for hypertrophy. A diagnosis may be made by exploration with a good-sized aspirator-needle. In mild cases deligation of the lingual artery of one or both sides may be done, and this may be followed by excision of a portion of the organ. The tip may be amputated, or a triangular section may be re- moved from the central portion, the sides being brought together by sutures. Atrophy is a rare disease, and is due to diminution of the blood- supply, or to lesions of the trophic nerves of this organ. Cystic tumors of the tongue may be caused by closure of the outlet to any portion of the follicidar apparatus (retention-cysts), or less fre- quently l)y the lodgment in this organ of a parasite, the cystlcercus. The diagnosis is made positive by exploration. The treatment re- quired is excision of the sac with the scissors, or the less bloody oper- ation of opening it with the Paquelin cautery, burning the lining mem- brane thoroughly, and packing the cavity with iodoformized gauze. The precaution should be taken to make the packing from one piece of gauze, and of securing it by a thread attached outside, in order to pre- vent its accidental escape backward. Angioma of the tongue is rare. When present, the treatment is re- moval by the ligature, or by injection with 50-per-cent carbolic-acid solution. Abscess of the tongue should be treated by aspii-ation, and hyper- distention of the sac with l-to-3000 sublimate solution. If this does not succeed, an incision should be made and drainage secured. Ulcers of the tongue appear as a symptom of various conditions. They occur in syphilis with great frequency. They may occur as a i-esult of general catarrh of the pharynx and mouth, or as a result of any violence. If an ulcer exists as an expression of a dyscrasia, the treat- ment must be chiefly constitutional. The local treatment consists in cleanliness and the application of nitrate of silver, or other stimulating remedies. The tongue is at times the seat of ■papiUoina, lipoma, fibroma, sar- coma, and one or two instances of encJcoiid ronia in this organ are re- ported. EpitJieliom.a is not infrequent, and is the most important of the neoplasms of this organ, not only on account of its greater frequency, but also on account of its grave character and the necessity of ari-iving THE TONGUE AND BUCCAL CAVITY. 437 at an early diagnosis of the disease. The late manifestations of syphilis (ulcers, gumma, fissures), ulcers of tuberculosis, and some speciiic iilcers, and papilloma, may be mistaken for this neoplasm. If a patient has a syphilitic liistory, gunmia or specific ulcer will naturally be suspected. If large doses of j)otassium iodide be adminis- tered for two or three weeks, the speciiic ulcer will respond to this rem- edy. If no impression is made upon it, it should be treated as ma- lignant. As regards all other suspicious sores of this organ, it will be the wiser ])ractice to treat them also as malignant growths, for it is a well-recognized fact that papillomatous, tuberculous, and simple ulcers of the tongue (as elsewhere), chronic in character, are capable of trans- formation into epithelioma. If these sores are removed early in their history, no mutilation is required, the operation is without danger, only a small portion of the organ need be sacrificed, and the focus of dis- ease is removed before its malignant nature is declared or metastasis occurs. If an epitheliomatous ulcer exists, its character may be deter- mined by microscopical examination, as given by Butlin.* If the scrap- ing from a tuberculous, syphilitic, or simple ulcer is placed in a drop of water on a slide, pus- and blood-corpuscles, particles of food, bacteria, and a few normal or almost normal epithelial cells, are observed. If the scraping from an epitheliomatous ulcer be examined, in addition to the above will be seen a great number of abnormal epithelia, varying in size and shape, some flattened scales, others round or oval, others elon- gated, with caudate prolongations. The cells are generally granular, and possess from two to three or more nuclei, much larger than the normal nuclei of these cells. In some instances the "swallow's-nest "' arrange- ment may be observed. If no ulcer is present, a section for microscopical examination may be removed from the indurated mass. Operation. — The method of procedure must be determined by the extent of the organ to be removed. If the induration is confined to the tip, and does not extend more than one inch behind this point, the line of section should be at or near the center of the tongue. It should al- ways be well away from the disease. An inch from the nearest indura- tion will be safer than to allow the line of section to approach the neo- plasm in order to save more of the tongue. When the lateral aspect of the anterior half is involved, the line of section need not pass at right angles to the axis of the organ, but may curve around parallel with the limit of induration at a sufficient distance from it. In this way the an- terior portion of the opposite half may be, in part, preserved. If the floor of the mouth is infiltrated, it should be dissected from its attach- ments to the jaw, and the diseased part removed with the tongue. If the disease extends to the middle of the tongue, and involves its entire width, the organ should be removed at its base, and the floor of the mouth thoroughly cleared of all suspicious tissue. The lymphatics in the middle line below the symphysis menti, in the submaxillary region * " Diseases of th o Tongue," Lea Brothers & Co., Philadolpliia, 1885. 438 A TEXT-BOOK ON SURGERY. and down the neck, should be examined and removed if metastasis has occurred. When the floor of tlie Tiioutli, t(>,ti:('tlier witli the nnterior two thirds of the organ, are involved, and inetastasis is evident in the deeper lym- phatics, the propriety of surgical interference is questionable. A cure is not probable, and the operation f()riiiidal>l(' and dangerous. The re- moval of the ulcerating i)ortion may be done as a palliative measure. Without regard to the manner in which the oi)eration is to be per- formed, the ether shoidd be administered at lirst through tlu^ mouth, and, after the narcosis is complete, when it becomes necessary to work within this cavity, the anjesthesia should be carefully continued by the rectum. It is essential for the teeth to be held widely separated by the gag (Fig. 36), and the lips held out of the way by tlat, blunt retractors. In mild cases, where the disease is situated near the tip of the organ, and where the floor of the mouth is not involved, the operation may be done with the galvano-cautery loop, as follows : The tongue shoidd be drawn well out of the mouth and transfixed from its under surface with a strong needle (armed with a heavy silk thread) at a point in the healthy tissue where the section is to be made. One end of the wire of a galvano-cautery battery is fastened to the thread, drawn through the tongue, attached to the ecraseur apparatus, and the loop tightened so as to grasp the organ in the direction it is desired to make the section. When it is not divided entirely across, the antero-posterior section is first made. The wire is now slowly heated to a red color, and the loop is very slowly tightened and drawn through the organ. If it is made to cut through quickly, the vessels may not be occluded. The transverse section is next made in the same way, and, if any attachments to the floor of the mouth remain, these may also be divided by throwing the loop around them. If the cautery battery is not at hand, the Paquelin thermo-cautery may be employed. If neither of these more modern instruments are to be had, the ecra- seur will suffice. It is not only efficient, but is less apt to get out of order than the other apparatus. When the lingual arteries have not been tied, hemorrhage is apt to occur after section with either of these instruments. It may be aiTested and controlled as directed in wounds of this organ. When a more extensive operation is required, the following method will be advisable : A careful examination of the lymphatic glands of the submaxillary and cervical regions should be made, and if any induration is discovered they should be removed as the first step in the operation. If the dis- ease has existed for several months, in all probability metastasis has occurred, even when the enlargement of the glands can not be detected by palpation. This condition is especially apt to exist in the glands cor- responding to that side of the tongue upon which the disease originated. It is, therefore, a wise precaution to tie the lingual artery of that side, since this not only lessens the danger of hsemorrhage in the removal of THE TONGUE AND BUCCAL CAVITY. 439 the tongue, but exposes the glands of the submaxillary and upper cer- vical triangles, and facilitates their removal if involved. The operation of tying this artery has been given on page 246. It can readily be secured opposite the central tendon of the digastric muscle, at which point it is almost always situated half way between the insertion of this tendon and the hypoglossal nerve, which is from a quarter to a half inch above. In two instances I have divided the posterior belly of this muscle in order to expose the vessel thoroughly. When this is accomplished, the wound should be irrigated with sublimate (1 to 3UUI)), a drainage-tube inserted, and the sutures applied. The ether should at this stage of the operation be transferred to the rectum, the gag inserted, and the lips retracted. It is important, in dissecting out the floor of the mouth and the tongue, to be able to control all hsemorrhage and at the same time to fix the tongue. This may be accomplished in a most satisfactory manner, and may be considered as the second step in this operation. An incision about an inch long is made in the median line, commencing at the hyoid bone and extending toward the symphysis. By this incision the integument and deep fascia are divided. A long steel needle, with the eye at the point (Peaslee's instrument will suffice), armed with a strong silk thread, is introduced through the wound, and, while the tongue is drawn well forward, the point of the needle is pushed along the inner surface of the lower jaw into the mouth by the side of the tongue at its base. One end of the thread is pulled out through the mouth, the needle withdrawn, and the end of the thread projecting from the mouth is again carried through the eye of the needle. This is now introduced by tiie side of the base of the tongue exactly opposite the point at which it entered, and is brought out at the wound below the chin. A strong wire is fastened to one end of the thread and is pulled into the mouth and around the base of the tongue by withdrawing the silk. The wire should now be fastened to an ecraseur and tightened just enough to con- trol the bleeding. In this manner all the vessels going to the tcmgue and the floor of the mouth are surrounded and controlled. The third stage of the procedure is the removal of the tongue and the tissues which form the floor of the mouth. In doing this the Paque- lin cautery-knife will be found exceedingly useful. If it is not at hand, the scissors or knife may be used. A strong silk thread should be passed through the sound tissues of the tongue near the end and intrusted to an assistant. It is tt) be used in lifting the organ as the dissection proceeds. The attachment along the lower jaw should first be divided and the tissues dissected up until the tongue can be lifted freely to a point at least one inch behind the induration. The ecraseur- loop should now be placed around the organ and the division made at the desired point. If at this time the wire loop which is around the base of the tongue is fairly tight, no bleeding will occur after the amputation. If gradually loosened, the bleeding points on the stump can be readily seized with the long-nosed narrow forceps and tied with silk ligatures. In the after-treatment no dressing is applied to the wound in the mouth. 440 A TEXT-BOOK ON SURGERY. I am not aware that this method of controlling hfcmorrhage in this oper- ation has been performed by any other surgeon. When the inferior maxilla is involved, it should be exsected beyond the limit of the disease. If, for any reason, more space is required in the ablation of this organ than can be obtained through the natural orifice, one of the fol- lowing jirocedures may be adopted : 1. Ganfs\m'\s](m through the cheek, froiri the angle of the mouth in the direction of the lobe of the ear as far as required (Fig. 513, a). This incision gives a full view of the lateral aspect of the tongtie, and may be made upon both sides when the disease is bilateral and ex- tends beyond the middle of the organ. The edges of the wound are afterward brought together by hare-lip pins or silk sutures. 2. Billroth employs a curved incision made paral- lel with the arch of the infe- rior maxilla below the symphysis (Fig. 512), dividing all the tissues on this line until the floor of the mouth is opened. 3. KocJter has lately devised an operation the incision in which is shown by the line h dec (Fig. 513). A preliminary tracheotomy is done, and the pharynx stuffed with a carbolized sponge to which a string is attached. The excision extends along the anterior border of the sterno-mastoid muscle, from the level of the lobule of the ear to the level of the hyoid bone, along this bone to near the median line, and thence to the symphysis menti. The skin and platysma are turned tip on the jaw, the lingual and fa- cial arteries and veins are tied as they are encountered, all enlarged glands are extirpated, the muscles and floor of the mouth separated along the attachments to the lower jaw to anv required extent. If „ „ , .. ,„ , „ , , . - . , -, *io. 513. — Incminn of Gant and Kocner. tlie entu-e tongue is to be removed, (After Butun.) Fig. 512.— Billroth's incision. (After Butlin.) THE TONGUE AND BUCCAL CAVITY. 441 the opposite lingual is also tied. Through this opening the tongue is drawn out, dissected from its anterior and lateral attachments, sur- rounded with the cautery-loop and divided, or cut off with the ecraseur or scissors. In the after-treatment the trachea-tube is left in place, and the pharynx, mouth, and wound iilled with sponges dipped in a .5-per-cent carbolic-acid solution, the excess of the acid being washed off with water before the sponges are applied. The wound is dressed twice a day, and liquid nourishment given at each change of the dressing. The operation of Kocher is objectionable on account of the extent of the dissection, the danger of submitting such a large wound to the proba- bility of septic infection from the mouth, and the complication of trache- otomy. The free inspection of the tissues of the neck which it permits, and the command of the base of the tongue which it allows, are in its favor. The operations in which the organ is removed through the mouth are simpler, require much less time in execution, and should be preferred. If the author's method of controlling luemorrhage is adopted, the pro- cedure is practically bloodless, and a preliminary tracheotomy is there- fore unnecessary. The conditions which would call for the operations of Uant, Billroth, or Kocher will rarely exist. The after-treatment consists in rinsing the mouth at frequent inter- vals with a warm solution of permanganate of potassa (gr. ss. to 3J), anodynes to relieve pain, and generous liquid diet. Banula. — This name is applied to certain tumors, cystic in character, which are situated immediately beneath the anterior and lateral portions of the tongue. Ranula is usually acquired, although it may be congeni- tal. The tumor is almost always single ; occasionally there is one on either side of the organ. Commencing as a result of obstruction to the outlet of one of the subdivisions of the sublingual gland (rarely as a result of occlusion to one of the terminal ducts), it may grow, when left undisturbed, to great size, crowding the tongue out of its position, rising above the level of the teeth, and protruding through the muscles of the chin until it appears beneath the skin above the hyoid bone. The only method of treatment is to evacuate the contents and cau.se an obliteration of the sac by inflammatory adhesion. The Paquelin cau- tery is the best instrument to employ in their removal. Etherize the patient, introduce the gag, lift the tongue upward with the forceps, protect the lips and teeth by means of iiat retractors, seize the wall of the cyst with a mouse-tooth forceps, and with the platinum-knife at a red heat dissect away the anterior wall. After the tluid escapes, dilate the cavity, and make a thorough digital exjiloration of the sac. The cautery-knife should now be carried slowly back to the deepest portions, searing all sides of the cyst-wall. The wound should be well packed with a single piece of iodoformized gauze. The after-treatment consists in changing the packing every twenty-four to forty-eight hours, and at each dressing irrigating the cavity with l-to-2()00 sublimate solutiiin. If the Paquelin thermo-cautery is not convenient, seize the cyst-wall 442 A TEXT-BOOK ON SURGERY. with the forceps and dissect it out witli curved, lilunt scissors. Pack the wound firmly with iodoformized gauze, as above. Haemorrhage may be controlled as directed in wounds of the tongue. Toiiffue-Tie. — When tlie fr;enuni extends an unusual distance toward the tip of the tongue, or is so narrow that it checks the free movements of this organ, it should be divided in the following manner : Seize tlie tip of the tongue with a dry towel, carry it upward so as to put the bridle on the stretch, and, with a curved scissors, divide the frsenum from one eighth to one quarter of an inch nearer to the floor of the mouth than to the surface of the tongue. This precaution is necessary to avoid wound- ing the ranine vessels. The gag may be used if required. A congenital defect, very rarely observed, is the adhesion of the tongue to the floor of the mouth. The adhesions should be broken up at birth, and the operation repeated daily until free mobility is secured. Equally rare is the bifid or snake-tongue, which results from arrest of development or failure of union of the two halves from which this organ is formed. Tiie edges shoidd be pared, and the two halves united in the median line by sutures. Tonsils. — Acute tonsillitis is of very frequent occurrence, causing, in a varying degree, pain, difficulty of deglutition, and interference with phonation, deglutition, and respiration. The patholoriy of this affection consists in dilatation of the blood- and lymph-vessels, emigration of leucocytes, and proliferation of the connective tissue and other cell-elements of the tonsil. The gland rapidly enlarges, producing great tension of the pillars of the fauces, and projects toward the median line, at times filling the pharynx and crowding the velum upward and backward. Acute tonsillitis may end in resolution, the gland rapidly diminishing to its normal size, or in ulceration or suppuration (abscess), or the acute process may subside into a chronic form of inflammation, which induces permanent hypertrophy of the organ. The local treatment of acute tonsillitis consists in the application of hot water as a gargle, and scarification of these organs when the tension is sufficient to produce great pain. The internal administration of aco- nite tincture and quinine is highly i-ecommended. Abscess of the tonsil should be opened as soon as its presence is de- tected. The discharge of pus always brings great relief. If the symp- toms lead to the suspicion of pus, exploration with the hypodermic aspi- rator-needle should be made to determine the diagnosis. The internal carotid artery and jugular vein are well back from the tonsil, on a level with the posterior wall of the pharynx. The object in operating early is to prevent oedema of the glottis, which may occur when the abscess is large or situated behind the body of the tonsil. A more remote danger is i-upture of the abscess during sleep, and escape of the contents into the larynx. Chronic hypertrophy of the tonsils should be treated by partial ex- cision, repeated as often as may be deemed necessary. The presence of these enlarged organs forces the patient to breathe through the mouth. THE TONGCTE AND BUCCAL CAVITY. 443 a habit which often induces a catarrhal condition of the mucous mem- brane lining the respiratory tract. The follicles of the tonsil discharge a dirty, cheesy secretion, which at times becomes retained in the gland and undergoes calcification. Calculi one fourth of an inch in diameter have been removed from this organ. TonsiUotoiny. — Excisi<_)n of the tonsils is an operation practically free from danger. In children who can not control themselves, chloroform should be used, the gag in- troduced, and the tongue depressed by an assistant. The operator seizes the exposed portion of the organ with a long mouse- tooth forceps or a tenaculum, pulls it slightly toward the median line, and with a long-handled pair of scis- sors, curved on the flat, clips off from one third to one half the tonsil. A sponge, fixed in a holder, dipped in ice- water and pressed on to the bleeding surface, will arrest the hsemorrhage. In adults local anaesthesia may be insured by cocaine hydrochlorate, and the operation performed as above, with much greater facility, since the intelligent co-operation of the patient is of great value. If the long scissors can not be had, a long, curved, probe-pcinted bis- -i)^!^ Fig. 515.— Tiemann & Co.'s tonsillotome. tonry may be used instead. The tonsil is lift- ed from its bed by a tenaculum, and the knife carried through as above. Various tunsillotomes have been intro- duced, and for some cases are very useful, but for simplicity and general application the in- struments above selected will answer all pur- poses. Among the best of the tonsillotomes is that of Mackenzie (Fig. 514), and Tiemann's instrument (Fig. 515). Tlie tonsil is also occasionally the seat of malignant neoplasms, as sarcoma and carcinoma, while cystic tumors, fibroma, and lymphoma are among the benign new formations which attack this gland. They re- quire early and thorough excision in aU cases. CHAPTER XV. THE NECK. Wounds. — Wounds of the neck may prove rapidly fatal from lispmor- rhatrf inducing synro])e ; from hfpmi)nhap:e into tlip trachea, causing fatal asj)liyxia ; from the entrance of air into the veins ; or from injury to the cord, at or near the medulla. Death from sepsis may occur as a more or less remote sequence of a wound in this region. Treatment. — The immediate indications are to arrest haemorrhage at once, and prevent asphyxia, either by obstruction of the trachea or the admission of air into the veins. Haemorrhage should be controlled bj' pressure directly in the wound, until the injured vessels can be secured by the ligature. The entrance of air Into the veins must be carefully prevented, by constant pressure on the cardiac side of the lesion, until the forceps have been successfully applied at the bleeding point. When the wound is incised or lacerated., and is above the hyoid bone and has severed the hyoid muscles, in addition to the prevention of haemorrhage into the larynx the tongue must be drawn forward, for when these muscles are divided it falls back upon the glottis, and may occlude the larynx. If the trachea is opened, the edges of the wound should be held apart with tenacula, the head dropped over the end of a table (Fig. 44), any clots removed, and artificial res])iration practiced by Sylvester's method (page 30). In the closure of all wounds of the neck the antiseptic precautions should be taken, and drainage secured. When the pneumogastric, hypoghjssal, or other important nerves have been divided, the ends should be brought together by a delicate silk suture. It is also advisable to unite the ends of divided muscles by sutures. An incised wound of the oesophagus should be closed immediately. Lacerated wounds of this tube should be allowed to close by granulation. Difficulty in deglutition follows severe wounds f)f the throat, not infre- quently necessitating the introduction of liquid food through the tt'so- phageal tube, or feeding by the rectum. Punctured wounds of the neck should be dressed antiseptically, and compression employed to arrest haemorrhage. If this does not succeed, the ligature should be applied. Gunshot wounds should be treated in practically the same manner. Missiles of small caliber deeply lodged should be left alone, since they usually become encapsuled and remain harmless. When superficial and readily detected, they slK)uld be extracted by the forceps. In the effort to locate a bullet it is always important to place the parts in about the THE NECK. 445 same position as at the time when the missile penetrated. If this is not done, the muscles and fascia become displaced, and tlie trade of the wound obstructed. Gimsliot wounds traversing the outer lateral and superficial posterior regions of the neck are not, as a rule, dangerous. If the vertebral column is involved, tlie prognosis becomes grave. A mis- sile traversing the tissues of the neck laterally, and in front of the ver- tebral column, is apt to intlict fatal injury. Abscess. — Abscess of the neck occurs most frequently in children, and may follow an injury, or result from an idiopathic inflammation of the tissues of this region. It occurs very frequently as a result of adenitis, or periadenitis, tonsillitis, and in caries of the upper cervical vertebrae, or base of the skull (retro-pharyngeal abscess). It may also follow the lodgment of a foreign body in the oesophagus. Collections of pus in the upper cervical regions, and in the superficial i)ortions of the root of the neck, tend to become encapsuled, or may open iiltimately through the integument. Retro-pharyngeal abscess, if left alone, not infrequently travels downward along the deeji fascia of the neck, and may ojaen into the mediastinum. The diagnosis of abscess in the neck, from the various tumors which are found in this region, depends upon the febrile movement pi-esent in ab- scess, the acute and persistent chai-acter of the pain, and fluctuation. The value of exploration, with an aspirator-needle large enough to carry pus, should not be lost sight of in the effort to arrive at a positive diagnosis. The treatment is evacuation, either by the method of aspiration and hyper-distention already given, or by puncture or incision, and free drain- age. When the abscess is situated in a portion of the neck rich in ves- sels, it should be opened by cutting carefully down upon it, so that any haemorrhage encountered may be immediately and readily controlled. If a puncture is determined ujion, the knife shoixld be introduced in the part farthest from the vessels, and along the aspirator- or exploring-needle as a guide. As soon as the sac is entered by the instrument it is withdrawn and a dull-pointed dressing-forceps, tightly closed, is carried into the ab- scess, when, by forcible separation of the jaws, the puncture is enlarged. The finger may now be introduced, or, if this can not be done, the forceps will indicate the size and most dejiendent portion of the sac. If the first ox)ening has not been made at the lowest part of the abscess, or is not so situated that thorough drainage is secured, it should be enlarged so as to extend this far, or a counter-opening made by boring through with the forceps until the skin is distended over the point of the instru- ment, when it can be safely incised. Drainage should be maintained, and the cavity irrigated with l-to-3000 sublimate solution. The diagnosis of retro-pharyngeal abscess depends upon the follow- ing symptoms: Pain, a feeling of soreness and stiffness in the neck, swelling, with protrusion of the posterior wall of the pharynx if the dis- ease is high up, interference with deglutition and respiration. In the earlier stages all of these symptoms will not be present, but as soon as this dangerous condition is suspected an effort should be made to locate the abscess by i^alpation and aspii'ation. 446 A TEXT-BOOK OX SURGERY. In evacuating the pus an incision should lie made lu the pharynx, as near the median line as possible. Wlien a large quantity of liuid is present the head sliould be inclined downward as the incision is made, so that the contents of the abscess may not gravitate into the larynx. This danger may be obviated by partially emptying the sac by the aspi- rator before the incision is nuide. When the sac extends low down the neck it should be entered and drained from below. Deep retro-pharyn- geal abscess may be reached, as a rule, by the incision and dissection laid down in the operation of oesophagotomy. Phlegmon of the neck demands free incision in all cases, when such incision does not encroach upon the important organs of this region. Tumors of the Neck — Solid and Cystic — Lymplioma. — Pathological changes in the lymphatics of the neck account for the large majority of swellings in this region. Lymphoma of the neck may be solid or cystic, benign or malignant. Tumors of the cervical glands may comprise simple lymphoma, the result of hypertrophy and hyperplasia ; tubercular lymi)homa, lympho- sarcoma and lymijhangiectasis. Lymplioma occurs most frequently in the submaxillary and upper ca- rotid triangle, and next in order of frequency ak>ng the line of the great vessels beneath the mastoideus, and lastly in the subclavian region. In some instances these tumors attain enormous proportions, filling in the neck to the level of the lower jaw and clavicle, and, if not removed, pro- duce death by pressure upon the respii-atory apparatus or the oesophagus. Fatty tumors are apt to occur upon the posterior aspect of the neck, and occasionally in the clavicular region. They are comparatively rare in the anterior and upper triangles. Cystic Tumors. — Cysts of the neck are congenital and acquired. Congenital cysts are rare. The form most frequently observed is that already mentioned as a dilatation and hypertrophy of the lymphatic ves- sels (lymphangiectasis). They are usually multilocular, and may extend deeply and, at times, assume enormous jn-oportions. Acquired cysts are seen chiefly along the line of the mastoid muscles, having a tendency to occur in the neighborhood of the parotid gland, less frequently in the subclavian triangle. Cysts resulting from extravasations of blood may also occur here, and occasionally distention of the bursse in the thyro-hyoid region produces cystic tumors. Thyroid Body. — Hypertrophy or hyperplasia of this organ may be partial or complete. All, or a part, of one lateral lobe is usually af- fected ; less frequently the isthmus is alone involved. The offshoots of this body which are met with at times near the hyoid bone, near the inner edge of the sterno-mastoid muscle, and occasionally dipping down behind the oesophagus, may also become enlarged. Goitre, or broncho- cele, is usually endemic, and attacks females more often than males. No climate or condition of living affords a positive immunity from this dis- ease, although in certain localities, as in the valleys of Switzerland, it is frequently met with. The cause of goitre is unknow^n. It is undoubtedly THE NECK. 447 prone to occur in those whose surroundings are damp and unwholesome, and among the poorly fed. The influence of heredity is recognized in the occurrence of this disease in the children of patients affected with bronchocele. A goitre may be solid or cystic. In solid goitre the enlargement may be caused by a general hypertrophy of the normal elements which com- pose this body, or some of these elements may undergo proliferation and increase at the expense of the others. When the tumor is hard and tense, it is called fibrous goitre, and in this form the chief i^athological change is an increase in the connective-tissue elements of the stroma. In cystic goitre the tumor is caused by the accumulation of a dark- brown fluid within the substance of the organ. There may be one or more separate collections of fluid, although a multilocular arrangement is most common. The diagnosis of goitre is not difficult. The presence of a tumor in the region of the thyroid body, usually unilateral, occasionally bilateral, moving with the trachea in the act of deglutition, capable of very percep- tible enlargement during coughing or any prolonged and violent expira- tory effort, are symptoms which point quite clearly to bronchocele. As to determining the character of the tumor, one must depend upon pal- pation in great part, and also upon exploration with the aspirator. Fi- brous goitre is dense, hard, very slightly elastic, often presenting irregu- larities in surface. Cystic bronchocele is round, smooth, elastic, movable, and, even when the capsule is greatly distended, fluctuation is percepti- ble. The use of the exploring-needle, and the withdrawal of a portion of the fluid contents for microscopical examination, is important in diag- nosis. The fluid from a cystic goitre varies in color from amber to dark brown and almost black. Under the microscope crystals of cholesterin, crenated red blood-corpuscles, large compound granular cells, leuco- cytes, etc., are seen. The characteristic contents of Tiydatid cysts are easily recognized and excluded. Fibro-cystic, or mixed goitres, jiossess some of the characteristics of both the foregoing varieties. The feeling of solidity is not so great as in the fibrous, and is less elastic and with a less appreciable sense of fluctuation than in cystic bronchocele. Sarcoma and carcinoma of this organ are hard, solid tumors of rapid development, steadily increasing in size, and in their growth binding the invaded organ to the integument, muscles, and fascia of the neck. Abscess would have a previous liistory of inflammation, pain, and febrile movement. Aneurism of the carotid appears usually to the outer side of the thyroid region, and presents the symptoms of expansicm with the heart's systole, the aneurismal thrill and murmur, all of which symp- toms disappear after pressure upon the artery on the cardiac side of the tumor. The diagnosis of other cervical tumors may be considered here. Tu- bercular lymphomata are recognized by their anatomical locations, by their slow process of development, together with the personal and family history of the individual. 448 A TEXT-BOOK ON SURGERY. In many instances these tumors of the glands remain quiet for a period, and, responding to some irritation, an adenitis and periade- nitis are developed, which lajiidly lead to the formation of abscess. Tliey are found most frecpieiilly along the lower border of the inferior maxilla, in the lower parotid region, along the under surface and poste- rior Ixmler of the sterno-mastoid muscle, and in the subclavian triangle. Metastatic lymphoma, secondary to epithelioma or other malignant dis- ease of the face, will be recognized by the history of the case. Lympho- sarcoma of the neck is, in its earlier stages of development, with difliculty differentiated from simple adenoma. It grows, however, with much greater rajndity, and, by its tendency to become fixed to the surround- ing tissues, suggests its malignant nature. It is most usually located about the center of the neck and beneath the sterno-mastoid muscle. Treatment. — Cystic goitre does not yield to constitutional measures. Solid tumors should be treated by the administration of full doses of potassium iodide. If marked diminution in the size of the tumor does not follow within the first few weeks of this treatment it should be dis- continued. Brcmchocele, either solid or cystic, which is small in size and not per- ceptibly increasing, does not demand surgical interference. Such tumors should be kept under observation, and if at any time there is a marked increase in size operative interference is called for, before the mass has assumed such proportions that its removal involves considerable danger to life. According to Kocher, another centra-indication to surgical inter- ference is the presence of a goitre involving the entire organ, since — al- though the operation may be recovered from — death results in fi'om one to two years, from the development of a strumous condition not unlike that known as myxoedenui. Physiological experiments have shown that a like condition results from the total extirpation of the thyroid body in animals. Under no circumstances, therefore, is a complete removal of this body justifiable. One side and the isthmus may be removed, and in extreme cases both lobes may be extirpated, provided the isthmus is left undisturbed. Another contra indication is calcareous degeneration of a considerable portion of the mass, causing a condition of friability in the vessels which renders their deligation unsafe. Operation — Cystic Goitre. — Make a perpendicular incision, about three inches in length, over the center of the tumor. Divide the integu- ment, fascia, and intervening muscles down to the sac. Upon approach- ing this, the dissection should be carried on between two anatomical for- ceps, lifting only a thin bit of tissue at each grasp of the instruments, and looking closely for any vessels which may run upon or through the anterior wall of the tumor. When the wall is reached it should be divided in the same manner, and, upon the escape of the contents through the opening, this should be enlarged by introducing the dressing-forceps and dilating. The opening in the wall should be about one inch long. A continuous catgut suture should be carried through the integument, stitching this to the edges of the sac. The cyst should now be well irri- THE NECK. 449 gated with l-to-5000 sublimate solution, and rubber drainage-tubes intro- duced, one into the deepest and another in the upper portion of the sac. A loose sublimate dressing should be applied. The indications for changing the dressing are haemorrhage, rise in temperature above 103° after the second day, and for purposes of cleanliness. In two of my cases in which larger cysts were evacuated there was consideraljle febrile move- ment for the first week after the operation. As the cyst becomes filled with granulation-tissue the tubes should be gradually shortened. In the removal of a solid goitre a crucial incision is preferable. This should be very free, in order to give a full view of the wound. The dissection should expose the entire anterior surface of the mass before attempting to get beneath it at any point. Care must be taken not to tear or incise the substance of the tumor, since it bleeds profusely, and is often so friable that it will not hold a ligatui'e. Whenever a vessel is seen in the track of the dissection, it should be seized in two places with forceps (the narrow-Jawed instrument, Fig. 82, is preferable), divided be- tween them, and each end tied with stout catgut. In lifting the tumor the operator should Avork along the outer side, and pass under the mass fi'om this aspect. In this way the superior and inferior thyroid vessels may be ligatured in the earlier stages of the operation, and the chief source of bleeding controlled. The presence of the recurrent laryngeal nerves, as they pass upward on either side, in the space between the trachea and oesophagus, should not be forgotten. It is not always possible to avoid them, but by keeping close to the capsule of the tumor the least risk will be incurred. The veins passing into the mass are at times of great size, and the walls of those in the tumor are in some cases very friable, causing much annoyance and delay, in repeatedly breaking down under the ligature and recurring hsemorrhage. In one of my cases the internal jugular vein was involved in the mass to such an extent that it was necessary to tie this vessel above and below, and divide it. When all of the tumor is free, except the isthmus, this should be surrounded with a small elastic ligature, and divided. The edges of the wound are now closed with catgut, the drainage-tube and rubber ligature brought out at the most dependent portion of the incision, and a subli- mate dressing applied. The ligature comes away by drawing upon it about the eighth day. The prognosis from this operation is favorable in the large majority of cases. It only becomes grave in the larger tumors, and the chief ele- ment of gravity here is the exhausted condition of the patient, resulting from pressure of the mass. It must, however, be classed among the more formidable operations. Hydatid cysts may occasionally be met with in this organ. They should be treated by incision and drainage, or by aspiration and disten- tion of the sac, with l-to-20 carbolic-acid solution, withdrawing the solu- tion and applying compression. Carcinoma and sarcoma of this body are treated in the same manner as solid goitre. When their removal is possible, the dissection should be carried well into the healthy tissues beyond the neoplasm. 29 450 A TEXT-BOOK ON SURGERY. The Larynx axd Trachea. The operations upon these organs in the neck are thyrotomy, laryn- gotomy, larym/o-tracheotomy, tracheotomy, and exsection of the larynx. T/iyrotomyis indicated in the removal of neoplasms or foreign bodies from the larynx, which can not be reached through the month by the aid of the laryngoscope and forceps or snare. The patient should be placed upon the table, with the head well depressed. Make a perpendicular incision from near the center of the hyoid bone, exactly in the median line of the pomum Adami, as far down as the cricoid cartilage. The bleeding is thoroughly arrested, and the two wings of the thyroid carti- lage divided exactly in the angle of union. This should be done with great care, in order to avoid wounding the vocal bands, which are at- tached on either side of the median line, in front. If at this stage of the operation a tenaculum is inserted, on either side, the alje may be drawn apart, freely exposing the interior of the larynx. In closing the wound the cartilages are not included in the sutures, it being sufficient to bring the edges of the skin together. In larynr/otomy the opening is made through the crico-thyroid mem- brane. It is indicated in oedema of the glottis, obstruction of the larynx by new growths, foreign bodies, and excejjtionally in rapid inflammatory swelling of the tonsils or jjharynx, Vith occlusion of the larynx. AVhen the emergency demands it, rapid laryngotomy may be per- formed as follows : Make a single incision from the notch in the upper margin of the thyroid cartilage, in the median line, to the lower edge of the cricoid ring, then turn the knife-edge upward and thrust the point through the crico-thyroid membrane. A hook should now be quickly inserted on either side, and the edges of the wound separated. Traction not only opens the wound in the membrane to admit the air more freely, but it also arrests the bleeding. When tenacula can not be had, a fair substitute may be extemporized from wire, or the ordinary metal hair- pin. The opening in the membrane may be enlarged by a transverse incision when necessary. When expedition is not urgent, the bleeding from the wound in the integument should be arrested before the open- ing into the larynx is made. If it is necessary to keep the wound open, a silver trachea-canula (Fig. 516) should be in- serted. This instrument is secured by a tape tied around the neck. AVhen it becomes ob- structed, the inner canula shovdd be withdrawn, cleansed, and reinserted, and, if necessary, the larger tube remaining in the larvnx should be Fig. 516. — Double trachea-tube, , , , .. -ii, n i u ' Tfv silver, plain. brushed out With a small brush or mop. V\ hen this instrument is worn it should be carefuUy watched, as long as any danger of its becoming obstructed exists. It may be worn indefinitely in cases of permanent laryngeal steno.sis. THE LARYNX AND TRACHEA. 451 Laryngotomy loltlwut a Tube. — When a canula is not at hand, a needle, armed with fine, strong silk, should be passed, on either side, through the integument and cricoid membrane, brought out through the opening in the larynx, and the suture tied. It is best to employ two sutures in each side of the wound. These may be tied behind the neck, or attached to bits of adhesive plaster and fastened to the integument, so as to keep the wound open. A strip of plaster should be laid on each side of the wound, to prevent the thread from cutting into the integu- ment. Laryngo-tracTieotomy (an operation rarely performed) consists in extending the incision of laryngotomy through the cricoid cartilage, and the upper one or two rings of the trachea. TracTieotomy is more frequently done than either of the operations just given. The trachea may be opened (1) above the isthmus of the thyroid body, the upper three or four rings being divided ; (2) the isthmus may be tied with a double ligature, divided, and the trachea opened beneath it ; (3) the opening into the tube may be altogether be- low the isthmus. It will rarely be found necessary to divide the isthmus. The opera- tion above the isthmus is simpler, and should be preferred in all cases where the obstruction is in the larynx. For the removal of a foreign body lodged in the bifurcation of the trachea, or in either bronchus, the lower procedure should be adopted. This op- eration should also be preferred in diphtheritic croup when all other measures have failed. The results achieved with the laryngeal tube of Dr. O'Dwyer, of New York, justifies a faithful trial with this instrument before resorting to the for- midable operation of tracheotomy in diphtheritic croup. Dr. O'Dwyer's directions are as follows : The tubes are of various sizes, and are constructed on a scale (Fig. 517) somewhat like the urethral sounds. No. 1 is intended for a child eighteen months old, or less ; No. 2, betv>-een eighteen months and three years ; No. 3, for the fourth year ; No. 4, for the fifth year, and so on. When the proper tube is selected for the case to be oper- ated on, a fine silk thread is passed through the small hole near its anterior angle, and left long enough to hang out of the mouth, its object being to remove the tube should it be found to have passed into the ti'sophagus instead of the larynx. The obturator is then screwed tightly to the intro- ducing instrument, to prevent the possibility of its rotating wdiile being inserted, and passed into the tube. The child is held upright on the nurse's lap, witli its arms secured by the sides or behind the back. An assistant holds the head, which he inclines backward at the proper time, while the operator, seated in front, inserts the gag (Fig. 518) well back between the teeth, in the left angle of the mouth, and opens it as widely as possible, without using undue force. He then inserts the index-finger of the left hand, which serves to &TlEMANNi:o. 8 -12 — 3-4.— I Fio. 517. Scale. 452 A TEXT-BOOK ON SURGERY. elevate the epiglottis and guide the tube into the larynx. The handle of the introducing instrument (Fig. 619), held close to the patient's chest in the beginning of the ojieration, is rapidly elevated as the glottis is ap- proached, and the tube pushed down- ward without using natch force. It is tlieu detached, and the obturator quickly removed. The joint in the shank of the obturator is for the pur- pose of facilitating this part of the operation. I^est the tube should also be withdrawn, it is necessary to keep the finger in contact with it. Fio. 519. — Introducer. When it is ascertained with certainty that the canula is in the larynx (and for this purpose it is better to wait Tintil the child coughs, or until it is evident that the dyspnoea is relieved), the finger is again placed in con- Tubes, tact with it and the thread removed. It is important that the attempt at introduction be made quickly, as respiiution is practically suspended from the time that the finger enters the larynx until the obturator is removed. It is, there- fore, under the circumstances much safer to make several abortive at- tempts than one prolonged effort, even if successful. The removal of the canula is a more difficult operation than its intro- duction, owing to the fact that the aperture of the tube into which the extracting instrument (Fig. 520) has to be inserted is so much smaller than that of the larynx. At the same time more deliberation can be used, and an anfesthetic, which is never necessary for the introduction, can be given if required. There is no danger whatever of these tubes slipping through into the trachea, even if used on older children than those for which they are intended. Some practice on the cadaver is a very necessary preliminary to using them on the living subject. It is well also to bear in mind that it is much more difficult to reach the larynx in the dead than in the living. High Operation. — Place the patient on the back, in such a position that the head falls well over the end of the table. If an anaesthetic is THE LARYNX, TRACHEA, AND BRONCHI. 453 not given, one assistant should hold the extremities immovable, while a second steadies the head. The operator should stand to the patient's right, facing the light. It is important tliat the head he held so that the nose and sj-mphysis menti will be directly in line witli the inter- clavicular notch and umbilicus, for if this precaution is not taken the trachea may be displaced, an accident which might lead to great annoy- ance, especially in children, in whom this tube is always very small. The incision should be exactly in the median line, commencing at the center of the thyroid cartilage and extending downward one inch and a half, or more if necessary. The edges of the wound should be separated by retractors, and the incision continued down to the tube. All bleeding should be arrested by the forceps and ligature before the trachea is opened, for fear of suffocation from the entrance of blood. In some subjects it will be found that the isthmus of the thyroid body is situated so high that an opening sufficiently long can not be made without displacing it downward. This may be done by dividing with the curved scissors the muscular and ligamentous bands which are at- tached to the isthmus below, and the hyoid bone and thyroid cartilage above. This section should be made on either side of the incision, oppo- site the first ring of the trachea. After all bleeding has ceased, the knife should be carried into the trachea with the edge directed upward, and the two or three upper rings divided. Low Operation. — The incision through the integument extends from the cricoid cartilage to the level of the inter-clavicular notch. Separate the sterno-thyroid muscles in the median line, and carry the dissection carefully down to the trachea, avoiding the istlimus of the thyroid body and the inferior thyroid vein, a branch of which is in front of this tube. The anterior jugular vein occasionally is in the median line. Any of these vessels coming within the line of incision should be secured with a double ligature before being divided. The trachea will be found deep- ly situated, and should be incised through four or live rings, in the same manner as advised in the preceding operation. If a trachea-tube is not at hand, the operation may be completed, as advised in laryngotomy, with- out a tube. Foreign Bodies in the Larynx, Tr.\chea, and Bronchi. Foreign bodies in the respiratory tract are, in almost all instances, introduced by way of the larynx, into which they may fall by gravity or be drawn in by the suction-force of the inspiratory effort. Occasion- ally they enter directly from without, as in stab- or gunshot wounds, or may make their way in from the oesophagus by perforation or from the rupture of an aneurism or abscess. Pieces of coin, buttons, teeth, seeds, threads, pins, blow-gun darts, shot, particles of food, etc., are among the most frequent substances lodged in the air-passages. A foreign body may lodge just behind the epiglottis, across the rima glottidis, in the ventricle between the true and false bands, between the vocal cords, or, passing these, it may descend into the trachea or bronchus. If it be a 454 A TEXT-BOOK ON SURGERY. solid and smooth body, it will pass into tlie bronchus and continue to descend until the smaller diameter of the tube arrests its progress. Any substance with projectini!;, sharp e(l3 Fio. 628. — Portions of the left claricle removed on account of ostitis. /'^ ^' 0.0" w Exsection of the clavicle may be demanded in ostitis of this bone. In a case operated iipon by myself for necrosis resulting from a disloca- tion at the sternal end, the incision extended the entire length of the bone, and the excision was subpe- riosteal throughout. A new and strong clavicle formed, with pei'fect motion at the sternal and acromial articulations. The shortening was a little less than one inch. Six years after the operation the function of the injured side is perfect (Figs. 528, 529). Empyema. — Pus may collect in the pleural sac as a circumscribed abscess, or exist in the general cav- ity of the pleura. The diagnosis may be determined from the elevation of temjierature iisually present, by dullness on per- cussion over the fluid, and by aspi- ration, using the smaller needles. The treatment consists in evacuation of the purulent contents with the as- pirator, or by incision. If the symp- toms of septic absorjition are not urgent, aspiration may l)e tried and repeated at intervals until recovery ensues, or until a failure of this method is demonstrated. The contents of the pleural cavity should not be too rapidly evacuated. Fatal syncope has occurred in several in- stances during this operation. Incision should be done in all ui-gent cases, and in those instances in which aspiration fails. The object of this operation is to drain the cavity of the abscess at its most dependent portion. An effort should be made to determine the lowest point by the introduction of the needle in several of the intercostal spaces. The opening should be made about opposite the center of the rib, preferably a little posterior to the middle. The incision should be in the intercostal space, half-way between the ribs. When the costal pleura is divided, it will be indicated by the escape of pus and the entrance of aLr. Partial Fig. 529. — The .luthor's c:\tomaoli. — Gadrostomy* which operation has been described in the article on oesoiahageal stricture, is required occasionally in the removal of foreign bodies which have been carried into the stomach and can not find an exit through the pylorus or be ejected in the act of vomiting. Although a considerable degree of tolerance may be present, if the size and shape of the foreign body are such that the probability of its re- moval by natural means is remote, the stomach should be opened. The method of jjrocedure is the saine as that already described. Since the (Esophagus is patent, the stomach should be thoroughly washed out with warm water introduced by means of the cesophageal tube and the pump. No solid food should be allowed within twelve hours of the Incision into the wall of this organ. This double precaution will pre- vent the otherwise possible escape of ingested matter into the peritoneal cavity. The stomach should not be opened nntil it has been securely stitched to the edges of the wound in the abdominal wall, as heretofore directed. The foreign body may be felt vrith the finger and extracted with a pair of dressing-forceps. The opening should not be closed at once, but allowed to heal by granulation. Gastrostomy may also be justifiable in certain cases of stricture of the pylorus, in which at least temporary benefit may be obtained, by dilatation of the stricture by the finger introduced through the stomach, or by mechanical means used in the same way. An incision about five inches in length should be made from the apex of the ensiforui cartilage downward and to the right, parallel with and about one inch below the curve of the right costal cartilages. On account of the over-distention of the organ, the i^ylorus may be farther to the right of the linea alba than normal. The incision in the abdominal wall should be free ; the stomach drawn into the wound, and a longitudinal incision fi'om one to one and a half inch in extent made on its anterior wall near the pylorus. The finger should be introduced gradually and forcibly into the stricture. If the stenosis is so great that the finger can not be used, the dressing- forceps or any dilating instrument may be substituted. After the dila- * The operations of gastrostomy and gastrotomy differ only in tliis, that the former is intended to be more or less permanently used for the introduction of nourishment, while the latter is either closed at once or allowed to close in a short time. 478 A TEXT-BOOK ON SURGERY. tation is completed the incision in the stomach should be closed by Lem- bert's suture. If the oixTution shall luive proceeded thus far and the pylorus found to be occluded, or so nearly closed that the passage of ingesta is impossible and its dilatation can not be successfully accom- plished, one of two procedures may be adopted : 1, exsectlon of the pylorus ; 2, (jastro-enterofitoin!/. Exsection of the pylorus (j>ylorectomy)iov malignant disease involves almost of necessity a removal of a portion of the lesser end of the stom- ach (f/asfreefomy) with the diseased portion of the duodenum. Even for intlammatory stricture (contractions after ulcer, etc.) siinj)le pylorectomy is scarcely possible. The operation is preceded by washing out the stomach with warm water once a day for several days, and a thorough irrigation just before it is incised. A purgative to clear oiit the intestinal canal is scarcely necessary, since, as a rule, only licpiids jjass through the stricture. The most careful antiseptic details should be carried out. Tlie center of the incision through the abdominal wall should be immediately over the recognized position of the part to be excised. If a neojjlasm is present, it may be readily located by palpation. If no apjareciable tumor exists, the pylorus will be found Just to the right of the median line about the level of the costal cartilages, curving downward on the right side of the ensiform appendix (Fig. 530) ; the incision should extend from near the appendix, parallel with and about one inch from the border of the cos- tal cartilages of the right side. It should be about five inches in length. All lijemorrhage should be arrested before the parietal layer of the peritonjeum is incised. When this is done, the finger should be intro- duced and the pylorus located by following along the anterior smooth surface of the stomach, beneath the overlapping free border of the liver. If it be discovered that the incision is not sufficiently free, a lai'ge Hat sponge shoidd be placed in the abdomen between the edges of the wound and the viscera, to prevent the escaj^e of blood into the cavity while the opening is being enlarged. The wound siiould Ije widely 'Hlated, the liver and gall-bladder held up out of the way (care being taken not to wound this friable and vascular organ), and the parts to be removed brought into view. Having detennined the extent of stomach and duodenum to be removed, these organs should lie lifted as far as possible into the wound, and the omental attachments, on both curvatures, divided between two rows of catgut ligatures as far as the line of excision, and no farther. As soon as the peritoneal attachments are divided, a fiat sponge, which has been taken from a vessel containing Thiersch's solution warm (boracic acid, grs. iv ; salicylic acid, gr. j ; water, grs. 500), and squeezed fahly dry, should be placed under the parts to be excised in order to prevent blood or other matter from getting into the jieritoneal cavity. The wall of the stomach is next cut through in a transverse direction, and, when a sufficient opening has been made, all fluids or other matter should be removed by small soft sponges attached to holders. Some o])erators apply a clamx) across the stomach just above, and to the duodenum just GASTRO-PYLORECTOMY. 479 below the line of excision. All haemorrhage should be arrested as the operation proceeds. If a clamp is not employed, a silk loop should be thrown around the duodenum to prevent its slipping downward. When the diseased portion is removed, the wound in the stomach shoidd be closed from the lesser curvature downward, until the ojiening left is of the same size as that in the divided duodeuum. The materials to be 480 A TEXT-BOOK ON SURGERY. used are fine iron-dyed silk, small needles half-cuivcd and perfectly round on section, and the needle-holder. The method of closure is by the Czerny-Lemhert suture (Fig. 531). The first row are inserted from the inner sitle, the needle iiassing only through the mucous membrane and sulnnucous tis- i-ue, but not including the peritonaeum. The pos- terior half of the wound should be closed first. The outer suture, which is that of Lembert, passes beneath the peritoneal covering, practically run- „, „ , ning through the muscular layer, but does not Fio. 531.— The Czprnv-Lem- . '^ , ° , ' , -,, . . bert suture. Tiie" upper pierco the mucous membrane. The needle is in- suturc is Lemhert's, the ^ n n • n j_i • ^ ..i i» • i lower Ls Czeniy's. troduced ou one Side three sixteenths of an inch from the cut edge of the viscus, and is made to emerge one sixteenth of an inch from the margin (passing about one eighth of an inch beneath the peritoneal coat). It is then carried to the opposite side and introduced in the same manner one sixteenth of an inch from the cut edge and brought out one eighth of an inch farther on. This suture should be repeated every eighth of an inch. As fast as in- troduced the ends should be tied together and intrusted to an as.sistant. The sutures are not finally tied until all are inserted, and are then secured from above downward. When the upper portion of the aperture in the stomach is closed, the sutures should be carried from the edges of the remaining aperture across to corresponding points upon the duodenum, and, when the entire cir- cumference is completed, should be tied and cut off close to the knot. After a careful cleaning of the peritoneal cavity, the edges of the peri- toneal layer of the abdominal wall are brought together with catgut sutures, while silver wire or strong silk sutures are carried through the integument, muscles, and fascia down to the peritonfeum, and the wound closed. The stomach should be kept at i-est for the first day or two. An enema of beef-tea and whisky should be given every four or five hours. From two to four ounces of the former to 3 j-ij of the latter may be administered at each injection. Crushed ice in moderate quan- tities may be given in the mouth. After two days, milk and licpiid food in small quantities may be given by the mouth, and solid food by the tenth day. Oastro-enterostomy is an operation in which an opening is established between the stomach and some point along the small intestine, usually the upper portion. On account of the position of the duodenum and its relations to the pancreas and great mesenteric vessels, it can not be util- ized. The nearest loop of the jejunum should be selected. In Wolfler's* operation (Fig. 532) the stomach was opened a finger's breadth above the attachment of the gastro-colic omentum to the greater curvature. The incision was in the long axis of the organ, and measured five centime- tres (about two inches). A similar incision was made in the nearest loop * This operation was performed in the case of a patient in whom tliere was a cancer of the pylorus too larfre to be excised. The man recovered and was much improved. "Centralblatt fur Chirurgie," Xo. 45, 1881, p. 706. GASTRO-ENTEROSTOMY. 481 Fig. 532. — Wolfler's operation forgastro-enterostomy. of small intestine opposite to the mesenteric attachment. The posterior wall of the wound in the intestine was first stitched to the corresponding edge of the incision in the stomach, and the operation completed by uniting the anterior walls. Car- l)olized flat sponges were placed beneath the organs during the op- eration. The incision in the abdominal wall in this procedure may be the same as that for exsection of the pylorus, or a free longitudinal in- cision in the linea alba may be em- ployed. Exsection of the pylorus is a difficult operation, requiring a most perfect knowledge of the anatomy of the parts involved, and a thor- ough drilling in the practice of intestinal suture and the management of intra-abdominal wounds. The long duration of the operation, together wi.;h the already weak condition of the patient, renders a fatal termi- nation very probable ; and if done for malignant disease, and recovery follow, the recuri'ence of the neoplasm is almost certain. For malignant neoplasm it is scarcely justifiable ; for non-malignant stricture limited in extent, its propriety may be entertained. The operation of Wolfler {ga-^tro-enterosfomy) is more simple, requires less time in its execution, and otfers a better chance of recovery and pro- longation of life. By this procedure the food acted upon by the gastric juice passes into the small intestine and then meets with the bile, pan- creatic and intestinal juices. As far as can be determined by the study of a limited number of cases, dilatation of non-malignant stricture of the pylorus is a justifiable operation. If the stenosis recurs within one or two years, and if the contraction is limited in extent, the surgeon should choose between pylorectomy and gastro-enterostomy. If the cause of the stenosis is cancer, dilatation can only produce a temporary relief. The danger of the operation is practically as great as in gastro-enterostomj-, and this last procedure, if successful, offers the best hope of prolonging life and lessening suffering. When, as a result of pyloric stenosis, life is en- dangered to such an extent that operative interference is determined upon, the abdominal wall should be opened by the curved incision above given, and a careful examination made. If malignant disease is discovered, and if from the size and appearance of the neoplasm in- filtration of the neighboring tissues has taken place, or if the neoplasm involves the stomach, necessitating if exsected the removal of a portion of this organ, exsection should be abandoned and gastro-enterostomy jierformed. Duodenum. — Operations upon this organ must be chiefly confined to the upper portion on account of the relations of the bile and pancreatic 31 482 A TEXT-BOOK ON SURGERY. ducts to the middle jjortion, and the body of the pancreas and great mesenteric vessels to the lower third. Duodenostomy has been performed in several instances for the relief of stenosis of the pylorus, but without success. The incision through the abdominal wall is the same as in pylorectomy. The oi)ening should be made in the upper portion of the organ, after adhesions have been secured by stitching the intestine to the edges of tiie wound in the ab- dominal wall, as in gastrostomy. Digital or instrumental dilatation of the stricture is done through the fistulous opening. The benefit to be derived from this operation is less than that after gastro-enterostomy or dilatation of the pylorus, and is fully as dangerous. Obstiiuction of the Alimentary Canal below the Pylorus. Partial or complete occlusion of the alimentary canal may occur from a variety of causes, namely: 1, imi)acti(m of fecal matter; 2, foreign bodies ; 3, intussusception ; 4, volvulus ; /), constriction by bands ; 6, by adhesions ; 7, omental and mesenteric slits ; 8, diverticula ; 9, neo- plasms ; 10, stricture ; 11, true hernia. The impaction of ingested matter may occur at any part of the ali- mentary canal, although this accident occurs in the great majority of cases in the large intestine. The coecum and ascending colon are the most common seats of fecal impaction, the sigmoid flexure next in order. The symptoms upon which a diagnosis is made are the presence of a tumor in the line of the colon, which is ncjt painful on pressure, may be molded by firm and prolonged compression, is movable, has formed gradually, and has a history of constipation. In the sigmoid colon and rectum digital exploration will denK)nstrate the nature of the mass. Vomiting, tenderness, and shock, so common in acute obstruction, are absent, or, if present, only occur in the latter stages and in extreme cases. The treatment consists in the repeated injection of warm water until the bulk of the tumor is softened, when laxatives may be given by the mouth. The method of injection is as follows : Place the patient in the knee-elbow position, or upon the right side with the pelvis elevated. In this position the pressure is in great jiart taken off the rectum, and a greater degree of tolerance is obtained. If tenesmus results, a full hypo- dermic injection of morphia should be administered. The fountain-irri- gator is the best instrument, and from two to four pints or more may be thrown slowly in at one operation. The water should be allowed to remain in the colon as long as possible. When the impaction is near the anus, it may be removed with the finger or by a spoon. Foreign Bodies. — Indigestible substances of various kinds, intro- duced by accident or intentionally, at times pass through the stomach into the intestinal canal and become lodged. In rarer instances they are introduced through the anus. OBSTRUCTION OF THE ALIMENTARY CANAL. 483 Biliary calculi which have passed through the common duct into the duodenum, or causing idceration of the gall-bladder and duodenal wall, enter the canal in this manner, may also cause intestinal occlu- sion. Again, obstructi(m has been caused in a number of instances by concretions (enterolithes) composed of magnesia, iron, or any inorganic matter administered for a long period of time. They are met with chiefly in the colon as a solid mass, or are precipitated upon organic and indi- gestible matter in the canal. The symptoms vary with the suddenness or completeness of the obstruction, as well as with its location. Sudden occlusion is accom- panied by pain of a colicky and violent character, usually referred to the seat of the obstruction. Shock is also present in acute stoppage of the canal. Vomiting is an early and prominent symptom of occlu- sion of the small intestine, coming on at a much later period, when the colon is involved. On the other hand, constipation is a feature of stoppage in the large intestine, while fecal matter in varying quan- tity may continue to jiass ^?er anum for several days after occlusion above the ileo-coecal valve. In arriving at a diagnosis, palpation and percussion will be of value. The knowledge of the accident when a body has been swallowed will, of course, establish the character of the occlusion. Insane or hysterical individuals often indulge in such practices. Biliary colic not infrequently precedes occlusion from cal- culi which escape by the common duct, while tenderness in the region of the liver and duodeniim must be present in a varying degi-ee in cases of perforation of the duodenal waU by large calculi from the gall- bladder. Tenderness is also present in cases where delicate sharp objects (pins, needles, etc.) have passed through the walls of the intestine and are wandering in the cavity of the peritoneum or in the pelvis. The treatment which should be instituted in obstruction by foreign bodies will depend in great part upon the symptoms which ensue. If the occlusion is complete and the symptoms are alarming, operative in- terference should not be delayed. The only doubt which may be thrown upon the propriety of operating is the presence of shock or collapse in an extreme degree. If this condition is present, morphine and whisky hypodermically should be administered in the effort to bring about re- action. If no urgent symptoms follow the presence of a foreign body in the alimentary canal, expectant measures may be employed in the hope that it may pass out by the rectum. When a foreign body has been swallowed and has gone beyond the stomach, and its shape is known to be such that it may cause perforation of the intestinal wall, or that the possibility of its being passed through is remote, it is the wiser policy not to lose valuable time by procrastination, but to operate at once. When introduced through the anus or lodged in the rectum or lower portion of the sigmoid flexure of the colon, they may be removed through the natural opening. Intussusception, or the telescoping of one part of the intestinal canal into another, may occur at any portion of the bowel (Fig. 533). It is 484 A TEXT-BOOK ON SURGP^RY. met \vith iu tlie follo\vin<^ order of frecpieiicy : at the ileo-colic. region, the lower part of tlie jejunum and ileum, and the colon. The invagination is usually from above downward ; in rare instances from below upward. Very exceptionally both conditions exist in the same subject.* It oc- curs in males more fre- quently than in fe- males, and, while it may be met with at any period of life, it is niui'h more common in children than in adidts. A large pro- portion of cases occur in the first six years of life, and of these the first, second, and third years are most prolific. Intussusception is usually caused by spas- modic contraction of a. limited portion of the circular muscular fibers of the intestinal wall, whereby this por- tion, becoming small- er and firmer, is either overlapped and in- cluded by the i)art im- mediately below, or falls into it. Paralysis of the circular muscle would produce the same condition. It may result from the dragging of a neoplasm developed in the wall of the gut, from the lodgment of a foreign body, or fecal matter. Invagination may be acute or chronic, may cause complete obstruc- tion at once, or only partially occlude the intestinal canal during its en- tire existence. The character of the sjonptoms will in part dei:)end upon the location of the accident. When the ileum and ccecum are involved, the symptoms of obstruc- tion are more acute. In subacute and chronic cases the colon is usually involved. The symptoms of intussusception may be those of acute or gradual obstruction, as the invagination is acute, subacute, or chronic. In general, pain is present, and is continuous or spasmodic, being referred to the region in which the lesion exists. Tenderness is not present at first, but is developed as the inflammatory changes in the in- testine and peritonseum appear. V(miiting occurs early when the ob- Fio. 533. — Intnssueception of the jejunum, n, Internal ovlimler. b, Middle cylinder, c, External cylinder. (At'lur Treves.) * " Intestinal Obstruction," by Frederick Treves. Lea, Sons & Co., Philadelphia, 1884. INTUSSUSCEPTION. 485 stniction is in the small intestine, and later when the large intestine is involved. Tenesmus exists in a certain proportion of cases, and is especially apt to occur in intussusception in the colon. Fecal matter may pass in complete obstruction above the colon until the contents of the large intestine are evacuated, and may persist throughout the attack when the occlusion of the gut is only i)artial. Mucus and blood are dis- charged in those cases in which tenesmus is extreme. The symptoms of shock and collapse are present early in the history of a majority of all cases. The tumefaction caused by the invagination may be felt through the abdominal wall or per rectum. The distention of the abdomen is not great when the lesion is in the jejunum or ileum. It is apt to be present when the colon is affected. The prognosis is always grave. Death occurs in 70 per cent of all cases, being about equal in both sexes (Treves). The only methods of recovery, if left to nature, are accidental reduction, sloughing and elimi- nation of the invaginated gut, or fecal fistula. Accidental reduction can only take place in the milder varieties and in the earlier stages, be- fore adhesions or strangulation have occurred. Distention of the intestine by gas, or assuming a suitable position, might reduce the invagination. Sloughing occurs in a certain proportion of cases, the dead gut being passed by the rectum. Fecal fistula may form in very exceptional instances. Treatment. — The conservative treatment consists in the administra- tion of an anodyne to relieve pain and sj^asm, and the introduction of tepid water in volume into the rectum and colon, with inversion of the patient, or the employment of gas or air in a like manner. If the lesion is recent, and if it is located in the large intestine, this practice should be tried. As it is often impossible, and under all conditions extremely difficult, to overcome the resistance of the ileo-coecal valve, it is an un- justifiable waste of time to attempt a reduction by these measures in in- tussusception above the ileo-colic junction. The objections to this method of treatment may be formulated thus : 1. The administration of opium masks the symptoms by dulling sensi- bility, and may induce a dangerous if not fatal procrastination of more radical and certain measiires. 2. Distention from below by water, gas, or air — within the limit of safety from rui)ture — fails to reduce an invagi- nation in which strangulation or adhesions have occurred. In all proba- bility only the mildest forms are reducible by this method, even when no adhesions exist. 3. It fails in such a vast majority of cases that it induces a procrastination in surgical interference, and of itself induces a certain amount of shock, which in a measure detracts from the prog- nosis after abdominal section. The only means of decreasing the heavy mortality following intussus- ception is in abdominal section. It is important that the operation be not deferred too long; in fact, not longer than the recognition of the lesion. Within the first twenty-four hours the prognosis will be much more favorable, and the danger of a fatal termination will be increased with each day thereafter. 486 A TEXT-BOOK OX SURGERY. In favor of al)(loiiiinal section it maybe said : 1. That a death-rate of 70 per cent in treatment without operation justifies surgical interference. 2. It is now well known that, in a patient not exhausted ])y asthenia or prolonged suffering, exploration of the abdominal cavity under careful antiseptic precautions is attended with little danger, and, in the earlier hours of intestinal obstruction, it does not add much to the gravity of the prognosis. 3. If recovery by sloughing occurs, stricture of the in- testine is always to be considered as a probable sequel. If the invagi- nation is reduced early, or if exsection is practiced, stenosis will rarely occur. 4. In the rare cases of recovery by fecal fistula, operative inter- ference is ultimately demanded. Volvulus, or twisting of a loop of intestine, occurs usually in the sig- moid flexure of the colon, although the remaining portions of the colon, or coecum and small intestine, may be occluded by this accident. The loop may become twisted upon itself at its mesenteric attachment, or one loop may be twisted over a second. The last variety is more apt to occur in the ileum and lower jejunum. The principal cause of volvulus is an abnormally long mesentery, allowing unusual freedom of motion to the loop of intestine which is attached to it. This defect may be congeni- tal or acquired. Constipation and the habitual distention of the sigmoid flexure by fecal matter is probably the most frequent caiise of elongation of the meso-colon and increased length of this part of the large intestine. It occurs more frequently in men than in women, and is met with in adults more than in children. When the conditions are favorable, a suit- able position or an accident in movement is sufficient to rotate the loop on its axis, causing occlusion by the weight of the loop and mesentery brought to bear upon a limited surface. The symptoms of volvulus are those of acute intestinal obstruction. Pain similar to that of colic is pres- ent from the start. Constipation is the rule, and indicates the sigmoid colon as the seat of the lesion. Tenesmus is present in a certain number of cases, and is additional evidence that the colon is involved. Disten- tion of the abdomen to an extreme degree occurs in a large proportion of cases, developing more rapidly in volvulus of the colon. Vomiting is rarely present until late in the history of the case, and, when it appears early, it suggests obstruction in the small intestine. A condition of shock more or less profound supervenes if relief is not obtained. Diminution in the quantity of urine is present in a certain proportion of cases. The .prognosis is fatal probably without exception in every case of complete volvulus. Strangulation of the loop and enormous distention of the part involved occur. Treatment. — If the symptoms point to the sigmoid flexure or colon as the seat of the twist, the introduction of warm water into the rectum is indicated. The patient should be placed in the knee-elbow position. The introduction should be made gradually, and may prove successful in recent cases where adhesions have not occurred, or where the disten- tion of the gut is not too great. If this measure is not successful within a few hours, abdominal section should be performed, the hand inti'o- duced, and the loop untwisted. CONSTRICTION BY BANDS— DIVERTICULA. 487 Constriction hy Bands. — Bands of cicatricial tissue resulting from peritonitis cause intestinal obstruction in a certain proportion of cases. This accident occurs cliietly m adults, about equally in both sexes, being due to pelvic iuHammations in women and to typhlitis and traumatic peritonitis in men (Treves). The bands vary in length, breadth, and points of attachment. The lower jejunum and ileum are involved in almost all cases. The symptoms are in general those of acute obstruc- tion of the small intestine. Pain is violent in the beginning, and in the majority of cases is referred to the part involved. Vomiting is an early and persistent symptom, and, as is common in obstruction above the ileo-ccBcal valve, is apt to be stercoraceous. Shock is usually more prominent in this form of occlusion than in those heretofore given. The urine is diminished in quantity. The abdomen is not tympanitic as a rule, although the constricted loop may be greatly distended, and may be recognized as a distinct tumor by palpation or percussion, or by vagi- nal or rectal exploration. The diagnosis must be made from the history of a former peritonitis and the presence of the symptoms above given. The prognosis is fatal, and the indication for treatment is early operative interference. In addition to inflammatory bands, intestinal occlusion is occasionally caused by the pedicle of an ovarian or uterine tiimor, or the Fallopian tube maj^ act in the same manner. Adhesions between contiguous loops of intestine, resulting from peri- tonitis, may occur in such a manner as to lead to occlusion. The symp- toms do not differ materially from those just given, and the treatment is the same. Strcmgiilation through Slits in the Omentum and Mesentery. — Occa- sionally a loop of intestine slips through an opening in the omentum or mesentery, becomes imprisoned and strangulated. The rent may be con- genital or result from an injury, penetrating or non-penetrating. The small intestine (ileum) is most frequently involved, and the aperture oc- curs as a rule in the mesentery of the last part of this organ. Strangula- tion of the colon in this manner is exceedingly uncommon. With the exception of the presence of a tumor, the symptoms are the same as those in hernia of the small intestine with strangulation. Early opera- tive interference offers the only h()i)e of relief. Constriction by Diverticula. — Pouches or cavities communicating with or attached to the intestines may be true or false — i. e., congenital or acquired. Meckel's diverticulum, which is attached to the last two or three feet of the ileum, may remain patulous and open at the umbilicus, or more frequently it ends in a blind extremity which may be continued as a cord to the umbilicus. When it exists it represents the vitelline duct of the embryo, in which the normal process of closure and oblitei-a- tion has not taken place. The vermifoiTn appendix may also be classed with the true diverticula. False diverticula occur in both the small and large intestine, being slightly more common in the colon. Their mode of origin is not as yet satisfactorily explained. They are found to pro- ject between the two layers of peritonaeum along the mesenteric border 488 A TEXT-BOOK ON SURGERY. of the small intestine, and into the appendices epiploice of the colon (Treves). They are hernije of the mucous membrane projecting through an aperture in the muscular layer. Constriction and strangulation of a loop of intestine by Meckel's di- verticulum are much more apt to occur than by the false pouches. The vermiform appendix in rare instances may become twisted ui)()n its axis and strangulated, or it may cause the constriction of a neighboring loop of the ileum. There are no symptoms peculiar to obstruction from true or false diverticula, and the nature of the lesion can only be discovered by abdominal section, which is indicated in this form of intestinal occlusion. JSfeopJdsms. — Various new-formations, Ijoth benign and malignant in character, may occur in the intestinal canal and lead to obstruction by projecting into the lumen of the gut, or by pressure from without or by development within the wall proper, producing narrowing or stricture. Fibroma, Jlhro-myovni, and lipoma are of rare occurrence. Angioma is also exceptional in this location. Adenoma is a more common form, developing from the glandular apparatus, and more particularly from the follicles of Lieberkiihn in the large intestine. Sarcoma and carcinoma are also met with, both as primary and secondary growths. The symptoms of obstruction are, as a rule, gradual in development, and the presence of a tumor may be recognized by pal- pation with the abdominal muscles in complete relaxation. Cancer is the most common of these new formations, and is apt to be located in the colon or rectum. According to Haussmann and Treves, the variety of cancer met with in the large majority of instances is a cylindrical epithelioma, encephaloid and scirrhus being very exceptional. The growth may cause constriction by extending completely around the lumen of the tube, or, by developing on one side, cause stenosis by its bulk and by the contractions which result. The diagnosis of cancer may be made in those cases in which the disease is situated in the rec- tum or lower portion of the sigmoid flexure by digital examination or by the aid of the speculum. Situated higher up, the presence of a tumor, the age of the patient (over forty as a rule), and the peculiar cachexia, will aid in arriving at a correct diagnosis. Strict wre. — The jmrtial or complete occlusion of an intestine, by cica- tricial contractions following inflanmiation or ulceration of its mucous and submucous or muscular layers, constitutes a true intestinal stricture. Constriction by peritoneal bands, or the infiltration accompanying can- cer, is not considered as stricture proper. Any disease which produces loss of substance in the inner layers of the wall of the gut may produce stricture. The ulcers of typhoid fever, tuberculosis, dysentery, syphilis, and chi'onic intestinal catarrh, or those resulting from injury by ingested matter, by traumatism, or the necrosis following strangulated hernia, are the chief lesions which precede true stricture of the intestine. Cicatrization in an ulcer which has its long- est axis at a right angle to that of the intestine is more apt to lead to obstruction than one which has its long axis in an opposite direc- ABDOMINAL SECTION FOR INTESTINAL OCCLUSION. 489 tion. Stricture occurs in adults, of forty years or more, oftener than in the young, being rarely met with in children under ten years of age. Women suffer from this lesion in a far greater proportion than men. No portion of the alimentary canal, from the pylorus to the anus, is exempt, yet stricture of the duodenum and upper jejunum is compara- tively rare ; the ileum, near the coDcum, is more frequently attacked, while the large intestine, and especially the sigmoid flexure and rectum, is the most common seat of this grave and painful affection. The symptoms of stricture are those of progressive narrowing of the intestine. The intensity of the symptoms will be proportionate to the rapidity with which stenosis results and to the portion of the canal in- volved. Pain is not marked until the narrowing has arrived at a point where ingested matter jjasses through with difficulty. It is spasmodic in character, and occurs at varying intervals. Distention of the intes- tine above the seat of stricture, with consequent hypertrophy of the wall, follows sooner or later in all cases. The continued ii-ritation of the bowel from the pressure of fecal matter induces ulceration of the mucous and submucous tissues at and above the seat of stenosis, and perforation may occur. Vomiting is an earlier symptom in stricture of the ileum and jejunum than when the colon is involved. There may be diarrhoea or constipa- tion, or these conditions may alternate, and are therefore of no diagnos- tic value. Tenesmus is rare, and tlie abdomen is not distended except in case of peritonitis. As far as the previous histoiy may be of value in locating the seat of the lesion, it is known that dysenteric ulcers are usually found in the rectum, sigmoid flexure, and coecum, and in the order of frequency in which these organs are given ; typhoid ulcers (which rarely cause stricture) in the lower ileum and coecum ; those of chronic catarrh in the colon ; syphilis (gumma) in the rectum and ileum ; and tubercular ulcers in the lower ileum (Treves). The diagnosis of stricture must be based upon a study of the symp- toms above given, except the cases in which the lesion is in the rectum or lower part of the sigmoid flexure, where digital or instrumental ex- ploration may be made. Treatment. — Stricture of the rectum and lower part of the sigmoid flexure of the colon should be treated by dilatation or division. Above this point the only hope of cure is by exsection of the part involved. Enterostomy and colostomy are palliative surgical measures. Abdominal Section for Intestinal Occlusion. In all lesions of the small intestines and of the transverse colon in which it becomes necessary to invade the abdominal cavity, the incis- ion should be made in the linea alha, between the umbilicus and the symphysis pubis. When the seat of the obstruction can not be deter- mined without exploration, the same incisicm should be practiced. The coecum, ascending and descending colon, can be more directly approached 490 A TKXT-BOOK ON SURGERY. from an opening in the lateral aspects of the abdomen immediately over these viscera. The sigmoid flexure and upper portion of the rectum may be well exposed by the median incision when the small intestines and mesentery are lifted to one side. In general, it may be said that the smaller the incision the better, yet the opening should always be sufficient to admit of thorough exploration, and, if necessary, large enough for inspection. The patient should rest upon the back, with the head and shoulders .slightly elevated, in order to relax the abdomi- nal muscles. Strict attention should be paid to the antiseptic details already given. An effort should be made to strike the median line so exactly that the incision \vi\\ pass between the two recti muscles. All bleeding should be arrested before the parietal peritoneum is incised. This should be punctured, and a very dull-pointed, grooved director in- serted, and the peritonanim divided on this instmnient. The ojjening should be at least four inches in length. As .so(m as this is accom- plished, the hand, disinfected in sublimate solution, and afterward in Thiersch's solution, should be introduced and the seat of obstruction sought. The escape of intestines or omentum through the wound should be prevented by holding large flat sponges over these viscera and press- ing them back into the peritoneal cavity. All sponges, towels, etc., brought in contact with the viscera should be disinfected in Thiersch's solution, since the ordinary sublimate solutions are too irritating. If, upon exposing the small intestines, some of the coils are found to be greatly distended while others are coUapsed, it is pretty safe to conclude that the obstruction is near at hand, and the collai^sed loops should be carefully passed between the fingers up to the obstruction. It is scarcely possible, in the condition in which the viscera will be found, to determine exactly which is the upward or downward direction of the coils, and it may be necessary to begin at the coecum and work upward. If the coils which present are so enonnously distended that they in- terfere with the exploration, the gas should be evacuated by multiple puncture with the finest hypodennic needle. The gas escapes through the needle, the hole made by which is so delicate that it is closed by contraction of the muscular fibers of the gut. If the ccpcum is found to be distended, the lesion is evidently in the colon, and this organ should be followed to the obstruction. If biliary calculi, a foreign body, or enterolithes are found, the part involved in the obstruction should if possible be brought out at the wound, protected by warm Thiersch towels, the escape of matter into the cavity of the peritonaeum prevented by flat sponges, and the body removed by an incision in the long axis of the gut, and, when possible, opposite the mesenteric attachment. The length of the opening should be sufficient to aUow of the removal of the body without bruising or tearing. If the part can not be brought out, it should be laid upon a flat sponge and the peritoneum in this way protected from the escape of fecal contents. This accident may be in great part prevented by compression of the gut above the obstruction. The wound in the intestinal wall is next closed by Lembert's suture. ABDOMINAL SECTION FOR INTESTINAL OCCLUSION. 491 Wlien intussusception exists, the invaginated portion should be brought into full view, and careful traction employed in the effort at reduction. If this can not be accomplished, or if strangulation and necrosis exist, exsection of the necrosed portion should be made at once — if the condition of the patient is sxich as to justify a prolonged opera- tion. If not, the dead loop or portion should be brought out at the incision in the abdomen, cut away, and a fecal tistula established. The restoi-ation of the intestinal canal may be accomplished at a subsequent operation. If the operation has not been too long postponed, it will be advisable to proceed with the exsection at once. Exsection — or, as it is sometimes called, resection — of the intestine is a very proper operation, and one which, when performed early enough, with the careful attention to details it requires, will succeed in the ma- jority of cases. The part to be removed should, if possible, be brought out at the abdominal incision, and protected as advised above. The same precau- tions should be observed to prevent the contents of the intestine from escaping into the cavity of the peritongeum. At a distance of about one inch from the lines of section occlude the gut by a broad tape ligature, or, preferably, by a soft, rubber-tipped clamp. A triangular piece of the mesentery, the base of which corresponds exactly to the portion of intes- tine which is to be exsected, should be removed with the gut. The apex of the triangle should extend above the intestine far enough to prevent too great knotting of the mesentery and kinking of the gut after the ends are stitched together. The vessels should be seciired by fine catgut ligatures before being divided. The line of section of the intestine should be through sound tissue, and sqiaarely across the long axis of the gut. The edges of the divided mesentery should be first stitched together with silk sutures. In uniting the ends of the intestine the inner row of sutures (Czerny's), through the mucous and submucous tissues, should be first inserted and tied, and the outer row (Lembert's) afterward.* The for- mer should be about three sixteenths of an inch apart, and the latter one eighth of an inch distant from each other. Especial care should be exercised at the point where the mesenteric attachments of the two ends come in contact, and one or two extra sutures should be applied here. The clamp or ligatures are now removed, the loop carefully cleansed in Thiersch's solution, and returned into the abdomen. The peritoneal cavity should always be cleansed with sponges moistened in this solution before the wound in the abdomen is closed. * In a ease of resection of the small intestine, performed by Dr. R. S. Sutton, of Pitts- burg, Pa., a raodifieation of Lembert's suture was employed. Upon one side the needle was introduced through the peritoneal hiyer one eighth of an inch from the edge of the incision, passed between the muscular and mucous layers, and emerged between these on the free bor- der of the divided intestine. It was tlien cnrried across to the opposite side, introduced between the mucous and muscular coats, and brought out through the peritoneal layer one eighth of an inch from the cut edge. By the courtesy of a colleague who did a laparotomy on this same patient several years later, I had the privilege of inspecting the line of union after the resection. The ends were firmly united, and there was scarcely any diminution in the caliber of the intestine. 492 A TEXT-BOOK ON SURGERY. Exsection of tlie colon is somewhat more difficult than the operation upon the small intestine, on account of its irregularity in size and the deeper location of all of this organ except the transverse ]iorti(m. It should be brought into or out of the incision if possible, or, if this can not be done, the opening in the linea alba may be enlarged in the direc- tion best suited to the case. If, after exploration through an incision in the linea alba, the obstruction is found to be in the cfficum, ascending or descending colon, and the part involved is so lirmly fixed that it can neither be brought into view through the wound in the median line nor by an additional transverse incision of two or three inches, it will be advisable to close this opening and expose the part by an incision imme- diately over it. Fecal fistula is established by bringing the loop or portion of intes- tine which is involved in the obstruction into the wound and stitching it to the edges of the incision as directed in gastrostomy. Strangulated and necrotic portions should be cut away. If the obstruction is due to volvulus, it will be indicated by unusual distention of the twisted loop, which, in case the sigmoid flexure is involved, is enormous. An effort should be made to untwist the gut without puncture ; but if this can not be accomplished, the hypodermic needle should be employed as above directed. In case of gangrene or adhesions amounting to stricttire at the point of crossing of the two por- tions of the gut, the operation of exsection or for fecal flstula should be done. "When the constriction is caused by peritoneal bands, these should be divided and the intestine liberated. If a loop of intestine has been caught beneath the pedicle of a tumor (of the ovary, uterus. Fallopian tubes, etc.), the occlusion may be relieved with or without removal of the offending body. In adhesions of the contiguous peritoneal surfaces of a loop of intes- tine, or the matting together of several loops in siu^h a manner that obstruction occurs, exsection or the formation of a fecal fistula is indi- cated. If the adhesions are limited, they may be dissected apart ; but this procedure is not unattended with danger from sloughing or a recur- rence of the lesion. Strangulation or constriction of a loop of gut in a slit of the mesen- tery or omentum should be treated by enlarging the slit, reduction of the loop, and closure of the opening by catgut sutures. If necrosis has resulted, exsection or the formation of a fistula may be done. In limited necrosis the dead portion may be cut away and the hole closed by Lem- bert's suture, provided that the lumen of the gut is not too gi-eatly occluded by this operation, and always provided that the margins through which the sutures pass are sound. Intestinal obstruction due to diverticula should be treated by division of the constricting tissues. A false diverticulum can scarcely be removed with safety, but, if necessary, Meckel's diverticulum or the vermiform appendix may be excised. In closing the stump of the appendix, the peritoneal coat should be turned in by Lembert's suture. HERNIA. 493 The removal of neoplasms may require the exsection of a part of the intestinal canal. In general, the rules above laid down are applicable here. Cylindrical epitheliomata, with no infiltration of the neighboring lymphatics or mesentery, are included among neoplasms which may with propriety be excised. When, however, the extent of the infiltra- tion is such that a complete removal is improbable, the palliative ojiera- tion of forming a fistula is advisable. Stricture of the intestine above the rectum may be excised in favor- able cases, or life may be prolonged by establishing an artificial opening in the gut above the seat of occlusion. Exsection will afford a more satisfactory result in the majority of instances when undertaken before the patient is exhausted by inanition and prolonged suffering. When the obstruction is located in the lower portion of the ileum or in the first part of the colon, ileo-colostomy may be performed when exsection, in order to be successful, mnst be an extensive procedure. In this operation tiie end of the ileum is stitched to the margins of a suitable opening in the colon below the obstruction. It is analogous to gastro- enterostomy. Hernia. — Literally defined, a hernia is a tumor formed by the escape of the whole or a portion of any viscus from its normal cavity. The tenn is now by common consent almost wholly restricted to protrusions of intestine or omentum (or both) from the cavity of the abdomen or pelvis. The protrusion may occur through an opening which is congenital or acquired. Complete inguinal hernia following the descent of a testicle, or ventral hernia, due to failure of perfect union in the aponeuroses of the abdominal miiscles, are instances of the former ; while a protrusion of the intestine after a wound in the abdominal wall is an example of the latter. The hernia may take place into an adjoining cavity, as the thorax (diaphragmatic), or protrude beneath the skin (femoi-al, umbilical, ventral, etc.). ITernise are classified according to their place of esca])e : inguinal, femoral, umbilical, ventral, diaphragmatic, gluteal, obturator, lumbar, and vaginal. The term ventral is applied to aU herniee occurring at points on the alidominal wall other than those indicated in the classifi- cation just given. Of hernijK? in general the inguinal variety forms about 80 per cent of all cases ; femoral, 10 ; umbilical, 5 ; the remaining vari- eties, 5. Of every five patients affected with liernia four are males. Inguinal hernia in males occurs more often in the first ten years of life than in any subsequent decade, the period from the twentieth to the fortieth year being next in order of frequency. According to King- don, femoral hernia in males of all ages is met with in 4 of every 100 cases ; in the first decade, in 1 of every 300 ; the second, 2 per cent ; the tliird and fourth together, 4|- per cent ; the fifth and sixth, 6 per cent ; and after this, 8 per cent. In females, inguinal and femoral hernise are met with in about equal proi)ortions. The latter variety is rarely met with befoi'e puberty, but occurs chiefly during the child-bearing period (Bryant). The contents of a hernia are inclosed in a sac almost always fonned 32 494 A TEXT-BOOK ON SURGERY. by the perironiciiiu lining the ut)(h)niinal cavity. The sac may be car- ried immediately in front of the escaping intestine or omentum (femoral, umbilical, etc.), or these viscera may descend into a sac already formed by the escajie of S(mie other organ (inguinal, scrotal). In the rare cixses of hernia of those j^ortions of the large intestine not covered by perito- ngeum there is no true sac. If the intestine alone enters into the foinia- tion of a hernia, it is called enterocelc ; if omentum alone, (qi'rplocdc ; if both are inclosed in the sac, enter o-epiplocele. The coverings of a hernia outside of the sac will vary with its location, and will be given in the consideration of the different varieties. A hernia is said to be reducible, when the contents of the sac can by any means be rettirned into tlie cav- ity of the abdomen ; irreducible, when adhesions exist to such an extent that this can not bo effected ; sfra/u/ulated, when the circulation in the tumor is arrested by constriction at any portion (^usually at the neck). Jb'TG. 534.— The relations of the points of escape of oblique and dirert iiitrninal anJ obturator heraiffi to the important vessels of tbe pelvis. 1, Internal abdominal riuix. 2/ Point at nhieh a direct inguinal hernia commences. 3, Obturator canal, arte-ry, and nerve. (Modified from Maclise.J Special HernicB, Inguinal. — An inguinal hernia may be direct or indirect, complete or incomplete, congenital or acquired. The indirect or "oblique" variety is much more frequently met with. In tlie male the contents pass into the internal abdominal ring and follow INGUINAL HERNIA. 495 the spermatic cord along the inguinal canal, at times descending into the tunica vaginalis testis. In tlie female the descent is in the canal of Nuck, following the round ligament into the inguinal canal, and at times as far as the labium. The epigastric vessels are internal to the neck, and behind the body of an oblique inguinal hernia (Figs. 534 and 546). Fig. 535. — Showing, at 1 and 2, openinss at which oblique and direct herniae escape, and their relations to the deep epigastric artery. ^Modified from Maclise.; A direct hernia does not enter the internal abdominal ring, but pushes the fascia, which is to the inner side of the epigastric vessels and imme- diately behind the external ring, directly in front of the tumor and out at the external ring. The epigastric vessels are external to the neck, and may be displaced slightly in front and to the outer side of a direct inguinal hernia (Figs. 535 and 545). An inguinal hernia is said to be complete when the contents protrude beyond tlie external ring ; incomplete, when the tun^or is within this limit. A complete inguinal hernia in the male may descend into the cavity of the tunica vaginalis testis, the contents resting in contact with the 496 A TEXT-BOOK ON SURGERY. Fio. SSfi.— Confrenital oblique inguinal hernia. Sac fornu'd bv the tunica uapinalu et funiculi. 1, t'avitv oi'the tunica. (After Maclise.) Fig. .'537.— Infantile honiia (acquired), the Intes- tine cnrryintj with it a process of pcritomeuin by the side of the occluded siieriniitic tulie. (Alter Maclise.) Flo. .538.— Complete inj,'uinal hernia as it occurs in the adult. Not conimunicatinor with the cavity ot the tunica vaginalis ttstis. (After Maclise.) testicle {congenital) (Fig. 536) ; or it may be arrested in the tubular sheath which surrounds the spermatic cord {infantile), the contents not in contact with, but pressing upon, the testicle (Fig. 537). Crt?/se.— Inguinal hernia may be congenital or acquired. A congenital hernia exists at birth, and usually descends into the tunica vaginalis testis. It results from the patulous condition of the process of peritoneum, which is carried downward in the descent of the testicle and spermatic cord. Acquired hernia is one which comes on after birth. It is caused by the pressure of the intestine or omentum, from gravity and muscular effort combined. Femoral hernia is always FEMORAL HERNIA. 497 acquired. The tumor enters the crural canal beneath Poupart's liga- ment, just to the inner side of the iliac and femoral vein (Fig. 539). If it remains in the crural sheath, it is an incomplete, but if it protrudes at the saxjhenous opening, it is a complete femoral hernia (Fig. o-lOj. Fig. 539. — Showing the femoral rinir and its relations to the iliac vein and the obturator artery when derived from the deuj) epigastric. 1, Femoral ring. 2, Obturator foramen. .3, Deep epigastric artery. 4, .Abnormal origin ot the obturator running internal to the neck of a femoral hernia. 5, The same, descendir.g external to the neck of a femoral hernia. tJ, Normal obturator artery. 7, Circumflex branch of external iliac. (Modified from Maclise.) Umbilical hernia is congenital or acquired. It exists not infre- quently at birth in both sexes, on account of the patulous condition of the omplialo-mesenteric duct. In this variety the only covering of the tumor is the sheath of the umbilical cord. In the acquired form the intestine escapes either directly throiigh the navel, or more fi-equently to one side of tliis contracticm. The sac of an acquired umbilical liernia is composed of the parietal layer, of the peritonaeum, and the outer cov- ering of integument. Ventral hernia may also be congenital or acquired. The protrusion may occur at birth, as a result of failure of development in the muscles of the abdomen. It is usually met with along the linea alba above the umbilicus. The acquired form may occur at any point, and residts from accidental or surgical wounds of the muscles and fascia. It is quite frequently met with in the wounds of incision in the operation of lapa rotomy. 498 A TEXT-BOOK ON SURGERY. Diaphragmatic hernia is usually due to a wound or rupture of the diaphragm. It may result from a congenital defect in this muscle. It generally occurs on the left side, on account of the prdtecrion afforded by the liver on the right side. Gluteal hentia is extremely rare. The escape of the viscus is through the sciatic notch, and it may occur above or below the pyriformis muscle. M Flu. 540. — Showing' the relations of a complete femoral hernia to the important organs of the groin. 1, .Sapl)enous vein pa-^sinj; beneath the liiloiform process. 2, Femoral vein and artery. 3, Crural nerve. 4, Plexus of femoral lymphatic glands. (Modified from Maclise.) Obturator Jientia takes place in tlie thyroid foramen, and usually in the upper portion, in the canal which gives exit to the obturator ves- sels and nerves (Fig. 534). It is more common in women than in men. Lumbar hernia occurs in the region situated between the twelfth rib and the crest of the ilium. Hernia into the vagina occurs after partial or complete prolapse of the uterus, or after loss of substance, allowing escape of the intestine. Symptoms — Inguinal Hernia. — AVhen gradually acquired, the pres- ence of a small swelling or tumor near the center of Poupart's ligament, or a little to the inner side of this i)oint, is usually the first symi)tom of inguinal hernia. In a certain proportion of cases the appearance of the swelling has been preceded by a feeling of weakness or uneasiness referred to this region, which only disappeared when the recumbent HERNIA. 499 posture was assumed, or wlien strong upward pressure was made by the hand. If suddenly acquired, the presence of the tumor is noticed soon after a violent strain of the abdiit jiosiiiren vniicoccle and a noii-iDrnTrei-ntod intiuinal hernia will l)()th disappear. II' alter tlie disajipearance linn pressure is made with the fingers, and the patient is directed to resume the ui)right posture, the varicocele will return, while the heiiiia can not descend. Coughing does not affect varicocele. The accumulation of tluid in hydrocele of the tunica vaginalis is first noticed in the most inferior portion of the scrotum ; the swelling is spherical at first, and becomes pyriform after the cord is involved. Hydrocele is translucent, and fiuct- nation may be detected. Encysted hydrocele of the cord near the external ring or within the inguinal canal may make differentiation more difficult. The impulse from coughing is not marked in hydrocele, the sense of weakness is absent, the cyst is small and usually remains so. If, after full consideration, doubt still exists, aspiration with the finest hypodermic needle will clear up the diagnosis. Bubo. — In chronic adenitis the glandular character of the swelling can be made out distinctly. In acute adenitis, although the peri-lymphatic infiltration is so exten- sive that the glands can not be recognized, the redness of the skin, the great tenderness on pressure, and the superficial character of the pain, with the coexistence of a urethritis or sore upon the penis or scrotum, will serve to establish the character of the lesion. Incarcerated testicle may be suspected if there is absence of the organ on that side. If the testicle is not extensively atrophied, pressure will give the peculiar and characteristic sense of pain experienced in in- jury of this organ. In neoplasms there is a history of progressive development entirely disassociated from that of hernia as heretofore detailed. Abscess, which not infrequently appears above Poupart's ligament, is accompanied with inflammatory and septic symptoms which do not accompany hernia. Abscess of this region occurs with adenitis, as Just stated, and with ostitis of the vertebrae or ilium. The recognitum of either of these lesions will lead to the diagnosis of abscess. In the manipulation of a hernial tumor the sensation imparted to the fingers will vary with the contents of the sac and the condition of the mass. If it contain only omentum, it is doughy to the feel, and will yield dullness on percussion ; if the mass is composed of intestine, it is elastic, and more or less tympanitic on percussion. The "colicky" pain felt when the intestine is firmly compressed is of diagnostic value in determining the presence of a hernia. Whether a hernia is reducible or not, there is always a perceptible impulse imparted to the tumor in coughing or sneezing. In strangulated hernia the diagnosis rests first upon the existence of a tumor, which is present in almost all cases. In very exceptional instances there is no pro- trusion noticeable. The next symptom is pain at the seat of the hernia. In character it is com])ared to that of intestinal colic, and, when not in- tensified in the neighborhood of the strangulation, it is usually referred to HERNIA. 501 the umbilical region. The symptoms of occlusion are more remote, and, while very strong in a diagnostic point of view, are not of such impor- tance ijractically, because a diagnosis shoiild be made and treatment in- stituted before the effects of obstruction are made evident. The cessation of fecal discharges may not occur in intestinal obstruction for several days after the occlusion, when the small intestine alone is involved, since the contents of the Ixiwel below the constricted point may be evacuated. The vomiting of recently ingested food or drinks, followed by stercora- ceous matter, is the last and strongest evidence of occlusion. Distention of the abdominal walls, with tympanitic resonance, is, when taken in connection with other symptoms, a sti-ong link in the chain of symptoms which make the diagnosis conclusive. Hiccough is i:)resent in many cases, but is apt to be one of the later evidences of obstruction. Shock, that condition in which, as a result of an emotion or injury, the functions of the nerve-centers are more or less completely suspended, is present in a varying degree in almost all cases of strangulated hernia. It is evident in the rapid and weak pulse, occasionally missing a beat, or varying in exacerbations of rapidity and slowness ; coldness of the skin, with un- natural perspiration ; lack of facial mobility, the only expression being that of pain and anxiety. In omental hernia the pain is not so intense as in intestinal hernia, and the symptoms of occlusion are always absent. Treatment. — The treatment of inguinal hernia may be considered under three heads : 1, reducible ; 2, irreducible (not strangulated) ; 3, strangulated. A rediicihle inguinal hernia should be returned to the abdominal cavity and retained there by the constant and careful employment of a truss or bandage and compress. In accomplishing the reduction the patient should rest upon the back, with the thighs flexed ujion the abdo- men and the pelvis elevated. In this position gravity carries the intes- tine and omentum toward the diaphragm, and this traction from within readily reduces the mass. If this should not succeed, gentle jDressure with the hand will suffice. Once reduced, an effort should be made to prevent a recurrence. For incomplete or slight hernia in patients who are not compelled to do heavy work, the elastic truss is most comfortable and safe. In all other cases the steel-spring truss must be worn. The i)ad will vary in size as the character of the rupture may require. The hard-rubber or wooden pads ai'e preferable in the gi'eat majority of cases. A truss should be applied before leaving the recumbent posture, and should not be removed again until this posture is resumed. When ordering a steel- spring truss the following rule should be observed : Describe fully the character of the hernia. If the case is one of complete oblique inguinal hernia of the left side, take a lead-tape, lay one end directly over the internal ring of this side and carry the tape aci-oss the abdomen to the right, just below the anterior superior spine of the right ilium, and across the gluteal region back to the same point below the left sujierior spinous process. Press the malleable lead closely to the integument in 502 A TEXT-BOOK ON SURGERY. oixItT to get :m exact outline of the surface to which tlie truss is to be applied, and trace this directly upon a sheet of i)aper. Tlie instriini(Mit- niaker in using this tracing can model the s])ring to lit more comfortably, and after this temper the metal to make the required pressm-e. When a direct and indirect hernial exist upon the same side, a single pad prop- erly adjusted will suffice to secure both openings. When there exists a bilateral hernia, a douljle truss should be worn. A fair temporary truss may be made as follows : A piece of cloth or a tuft of wool, cotton, or oakum is rolled into a compress about half the size of the list, covered with adhesive plaster (tlie adliesive surface being external), and is laid immediately over the inguinal canal, after the hernia has been reduced ; and while the patient is in the recumbent posture a spica bandage is carried around the pelvis and thigh so that the com])ress is held tii-mly in position. It is prevented from slijjping out of place by the adhesive plaster. When an inguinal hernia can not be retained by a triiss, operative interference is indicated. Of the various procedures which have been introduced, that known as Ileaton's operation is tlie simi)lest in execu- tion, involves less danger and annoyance, and oilers fully as great a prospect of success. It is performed as follows : The integument within a radius of three or four inches of the internal ring is cleanly shaved and washed with soap, then with ether, and, lastly, mth sublimate solution, 1 to 2000. The patient is placed in the recum- bent posture, with the pelvis elevated on pillows until gravity carries the intestines away from the vicinity of the inner ring. A syringe made for this purpose (Fig. 544), having been tlujroughly disinfected by immer- FiQ. 544. — Syringe for nciiton's operation. sion in 1 to 20 carbolic-acid solution, is filled with nineteen minims of the following solution, to which one minim of carbolic acid is added : Extract of quercus alba, fourteen grains ; fluid extract of quercus alba, ludf ounce. Mix over a hot-water bath. One eighth grain of sulphate of morphia may be added to each injection. An anaesthetic is not required. The needle of this sj^ringe is sharp at the end, and one eighth of an inch from the point are two holes, from which the fluid escapes. In order to insure the exclusion of air, the instrument is held perpendicu- larly and the i:)iston forced up until a bead of the injection-fluid stands on the point of the needle. Being thus prepared, the operator carries the index-finger of the hand most convenient to himself into the canal, invaginating the skin through the external ring, and up the canal until the outlines of the inner ring are appreciated by the finger-tip. With this finger resting here, the point of the needle is introduced exactly over the center of the internal ring, and enters perpendicularly to the plane of the abdomen at this point. When the impact of the needle-point is HERNIA. 503 felt by the tip of the index-finger, which serves as a guide to the ring, the finger is slightly withdrawn, so that the skin, wliirli has been carried ahead of it, may not be transfixed. Tlie needle is now in front of the internal ring and outside of the peritoneum. Pressure is made upon the piston, and about three minims of the fiuid expelled, and this mancruvre is repeated by carrying the point of the needle a half -inch to the right, left, above, and below this center. The finger is now withdrawn, and the needle is made to follow it down to the external ring, discharging the remainder of the fluid iii its track. When the instrument is removed, a pellet of iodoformized gauze is placed over the puncture, and over this a compress of sublimate gauze, cotton, and a spica bandage. The patient ^'etains the dorsal decubitus from ten days to two weeks, not even being allowed to sit up in bed. The i)ain is insignificant, and the infiammatory process which supervenes is mild. In three or four days a hard, round, indurated mass of embryonic cells will be found to occupy the canal and tissues immediately adjacent. This generally disapj)ears, and at the end of a month all ti-aces of the process will have disappeared. A truss, with a wide, soft pad, should be worn for a i:)eriod varying from three to six months after the operation. If success does not follow the first attempt, it may be repeated. The majority of cases are not cured. Incipient hernia, and those in which the canal has not been too widely stretched, offer a better prognosis. Even when the canal is so large that a cure can scarcely be hoped for, it may result in a contraction of the opening to such an extent that reten- ticm with a truss is secured. The operation for the radical cure of ingui- nal hernia by direct incision will be given in the opei-ation for strangu- lated hernia. Irreducible (incarcerated) inguinal hernise, not strangulated, under certain conditions justify operative interference. If the patient can be kept under constant supervision, so that at the first indication of strangu- lation proper surgical aid can be obtained, the treatment should consist of some form of truss fitted over the tumor to prevent the further pro- trusion of the intestine. In the adaptation of such an apparatus, great care must be taken to avoid compression at the neck of the sac, for in this way strangulation might be precijjitated. This i)lan of treatment will be more apt to prove satisfactory In those who are not compelled to do heavy labor. In elderly persons with large hernite, operative inter- ference is not justifiable on account of the danger it involves. The indications for operation are : 1, in those patients with small- sized heniipe who must of necessity go upon long journeys, which take them out of reach of proper surgical aid in case of strangulation ; 2, in those upon whom a suitable apparatus has failed to prevent a further descent of intestine ; 3, those who by reason of a hernia are incapaci- tated for work, and who consent to the operation after a full ex])lanation of the dangers attending it. The jirocediire is the same as for strangu- lated hernia, although a much more fa\-orable jirognosis may be made. Sfrangulafed Inguinal Hernia. — With the first symptom of strangu- lation the patient should be jjlaced in the dorsal decubitus, with the foot 504 A TEXT-BOOK ON SURGERY. of the bed elevated about twelve inches, the pelvis raised upon a pillow, the legs flexed on the thighs, and the thighs on the abdomen, so that the intestines and omentum will gravitate toward the diaphragm ; or the knee-shoulder position may be assumed. Ojjium narcosis should be secured at once to relieve pain :ind to relax the muscles of the abdo-' men. Towels dipped in hot water and partially squeezed should be laid upon the tumor. If within an hour or two the hernia is not re- duced, direct and careful pressure with the fingers may be added. The neck of the tumor should be grasped and steadied between the thumb and fingers of one hand, and the contents pushed gently in the direc- tion of the canal with the other. Taxis should not be continued longer than five or ten minutes at any one effort. It may be repeated at in- tervals of a half-hour or hour within the first six hours of the his- tory of strangulation. The manipulation of a hernial tumor (taxis) after the first six hours of strangulation is of doubtful propriety, and after twelve hours should not be attempted. It is not only to be condemned for the injury intiicted upon the parts involved by this procedure, but on account of the procrastination in operative interference which it invites. It is true that occasionally reduction is effected after symp- toms of strangulation lasting for a longer period than this, but these cases are so extremely rare, and the danger of a fatal termination so much increased by the delay, that it will be wiser to proceed at once to the operation. In justification of early operation, it may be said that the large ma- jority of cases which end fatally are those in which strangulation has existed for from twelve to twenty-four hours and upward before surgical interference ; and that abdominal section in a patient not exhausted by suffering or disease is almost free from danger. The high rate of mor- tality after kelotoray will only be materially reduced when it is per- formed not later than twelve hours, and, better still, within the first six hours of strangulation. Operation. — The pubes, scrotum, and integument near the tumor should be shaved, washed with ether, and finally with 1 to 3000 subli- mate solution. The patient, fully anaesthetized with ether, should be placed upon a table nearest the edge most convenient to the operator, with the pelvis slightly elevated. Before proceeding with the operation, a final effort at reduction should be made. An as.sistant is directed to place the legs of the patient over his shoulders, and to lift him until nothing but the shoulders and occiput rest upon the table. While in this position careful taxis shonld be made. If, after five minutes, reduc- tion is not effected, the attempt should be abandoned. The parts about the field of oi)eration should be covered with warm sublimate towels (1 to 3000), leaving a space about six by eight inches uncovered. The incision should be in the long axis of the tumor, and may be made by cutting directly down upon the mass, or by pinching up the skin and fat immediately over the swelling, transfixing it and cutting outward. It should be of good length, with the center a little below the internal ring. All bleeding should be arrested at once with catgut liga- HERNIA. 505 tures. The wound should be irrigated with 1 to 5000 sublimate every live or ten minutes. The tirst difficult point in the operation is the recognition of the sac. It is safe to cut carefully down until through the puncture of the sac a yellow or brownish-black fluid escapes. It is very exceptional when there is not enough Huid between the hernia and the sac to demonstrate its i^resence. When this fluid begias to escape, a grooved director, with a very dull point, is inserted through the puncture, and the sac further Flo. 545. — Shonins the relations of a direct inauinal hernia to the epigastric vessels and the spermatic cord. 1, Hernial tumor. 2. Epiga-stric vessels in IKmt of and e.vtemal to the neck of the tumor. 3, Saphenous opening and vein. 4, Spermatic vessels. 5, Femoral vessels. 6, Crural nerve. divided until the finger can l)e admitted, when it is introduced and the sac divided in the entire extent of the tumor. At this stage of the opera- tion the contents of the sac are clearly in view. The finger of the opera- tor's left hand is now carried toward the constriction, palmar surface upward, and the nail slipped under it. Holding the intestine out of the way. a long probe-pointed bistoury is carried flatwise along the palmar aspect t)f the finger until the didled point passes between the sharp edge of the ring and the nail. The edge is now turned upward against the 506 A TEXT-BOOK ON SURGERY, ring, and pressed against tliis l)y tlic linger upon wliirh it rests. The direction of this cut is upward and very slightly inward in inguinal her- nia. It should not extend beyond the eighth of an inrh. The finger- nail is usually sufficient to enlarge the oj)ening after the first few libers are divided. As soon as the strangulation is relieved, the wound and exposed intes- tine should be covered in with towels dipped in warm Thiersch solution, and left for from five to fifteen minutes in order to determine whether the circulation can be re-established • or not. The cohu- of strangulated / Fig. 54R.— Showing the relations of an oblique inL'uinal hernia. 1, Tumor covered by cremasteric fascia. 2, Episastric vessels behind and to the inner side of the neck of the tumor. 3, Saphenous vein and opennig. 4, Femoral vessels. 5, Crural nerve. intestine varies from pinkish-gray to a black, motley color. The con- tents of a hernial sac should not be returned into the abdomen unless the color changes to a healthy red after the strangulation is freely re- lieved. If, after from five to twenty minutes, the circulation is estab- lished, reduction should be made. In accomplishing this, posture is important, and the intestine should be carefully pushed in between the thumb and finger. Once returned, the inner opening should be stopped -with the finger or a sponge, so that blood or the contents of the sac or HERNIA. 507 irrigating fluid may not run into the peritoneal cavity. If omentum is contained in the hernia, it should be transfixed at the neck of the sac with a large doul)le catgut ligature, tied both ways, and the mass be.vond the ligature cut off. The stump should also be returned into the cavity, never stitched into the opening. This accomplished, the sac requires attention. It is also transfixed at the internal ring with a large double catgut and tied on both sides securely ; all that part beyond the ligatures is cut off. The cut end of the sac is now stitched with catgut to the edges of the internal ring. In this operation strong catgut sutures are employed. In the first row the needle is made to transfix the edge of the ring, then through the sac and up through the oppo.site margin of the ring. These sutures are tied, and the ring tightly closed, so that the escape of fluids into the peritonjeum is impossible. The last sutures, which are of silk or silver wire, include all the tissues from the skin to the deepest portion of the wound. The woiind is again thoroughly ind- gated, and a Xeuber's bone-drain is inserted, so that the end leads out of the deepest portion. Sublimate gauze, borated cotton, and protective, held on with a spica bandage, complete the dressing. In case the intestinal wall is broken down, or is so nearly necrotic that its return into the cavity of the al^domen is attended with danger of rupture of the gut and escape of its contents, two alternatives present themselves, viz.: to leave the intestine protruding, and establish an arti- ficial anus ; or to exsect the dead portion and sew the ends together. If the patient is in good condition, and especially if in the prime of life and usefulness, exsection should be done. If, on the other hand, collapse is imminent, or if there is anything in the condition of the patient to contra- indicate a prolonged operation, the fecal fistula should be established. Exsection is performed as follows : Release the strangulation as above described, and draw out both ends of the bowel until .six or eight inches of sound gut are exposed. Place a clamp or throw a loop of disinfected tape around each end of the intestine near the ring, to prevent the i3o.ssi- bility of retraction or escape of the bowel or its contents inward. With sharp scissors divide the intestine squarely across at each end of the limit of necrosis, and cut a triangular piece from the me.sentery, the base of which corresponds exactly to the section of intestine removed. Ligate all l)Ieeding points in the mesentery. The operation is completed in the same manner as in exsection of the intestine, given on a preceding page. When it is desired to establish an artificial anus, the strangulation should be relieved as already directed, and the bowel incised. As a rule, it is not necessary to stitch the gut to the wound, on account of the adhesions which usually exist. In the course of a few weeks, after the patient has fully recovered from the effects of the strangulation and the operation, the canal may be restored, by opening the abdomen, exsecting the protruding and attached portion of intestine, and imiting the ends by stitches. Or the operation of Dupuytren may be undertaken. It con.sists in gradually breaking down the promontory formed by the contiguous walls of the incarcerated loop, and, when this is done, allowing the external wound to close by 508 A TEXT-BOOK ON SURGERY. granulation, 'i'he instrument used in tliis operation is, in shai)e, not unlike a pair of forceps, with Hat, roughened jaws, and long handles, which can be locked witli a damp. Tlie jaws are introduced at first for a slight distance only, one going into the ascending and tile other into Fio. C47. — Dupuytrcn'.s clamp. (After Gross.) the descending part of the looi? of intestine, when they are closed and clamped in such a manner that the walls of the promontory are held lirm- ly in contact (Fig. 547). The instru- ment is allowed to remain in ixhsition. Adhesion occurs in the contiguous peri- toneal coverings of the gut, while that part of the promontorj' firndy grasjied by the instrument is crushed or slougiis away. As soon as the projection is sufficiently broken down the fistulous opening may be allowed to close. This procedure has been successful in a number of cases sufficient to jus- tify its employment. If a cure is not effected, or if stricture should result, exsection should be perfonned. Inguinal hernia in the female has the same relation to the epigastric ves- sels as in the male subject. In the complete form the contents may de- scend into the labium. The treatment does not differ materially from that just given. Nuck not infrequently simulate a hernial tumor, descends into the canal. Femoral Hernia — Treatment. — This form of hernia is more difficult to retain in place with a truss, and is more likely to become incarcerated and strangulated, than any other variety. The j^i'ognosis is, therefore, more unfavorable. The diar/nosis depends upon the presence of a tumor in the location already given (Fig. 540), the neck of which can be traced to an opening at the inner side of the thigh, just external to the spine of the pubes, and below Poupart's ligament. The impulse in coughing is present, though usually less perceptible than in inguinal hernia. Cysts are less apt to complicate a femoral than an inguinal hernia. Enlarge- ment of the lym])hatic glands will not be apt to mislead, since there will have been a history of adenitis, a gradual increase in the size of the glands, which may be recognized as a group. The absence of impulse with the act of coughing will further aid in the exclusion of hernia. The symptoms of strangulation differ in no essential features from those in inguinal hernia. Treatment. — A reducible femoral hernia should be retained within the abdomen hy a truss, the pad of which presses finnly over the femoral ring, just external to the spine of the pul)is. The pad should be small, so that it may not comi^ress the femoral vein, and the spring should be Cysts of the canal of Occasionally the ovary HERNIA. 509 strong, for this form of hernia is not only diflBcult to retain, but is doubly dangerous when it escapes by the side of the pad. In reducing femoral hernia, position is invaluable, and taxis may be of aid. The best position without taxis is the knee-shoulder posture, in which the abdominal muscles and fascia lata are relaxed, and the contents of the abdomen gravitate toward the diaphragm. Or the dorsal decubitus may suffice, with the pelvis elevated, as well as the foot of the bed, and the thighs flexed upon the abdomen. In performing taxis it must be remembered that the bulk of the hernia must pass directly backward to clear the falciform process of the fascia lata, and then upward in the direction of the femoral canal (Fig. 540). No operation for the radical cure of femoral hernia is justifiable unless it is positively demonstrated that the tumor can not be retained by any prothetic apparatus. If an operation is necessitated, the femoral ring should be exposed by a perpendicular incision, and the outlet closed by stitching the cribilfonn fascia and the falciform process to the edges of the ring with strong cat- gut sutures. A sublimate gauze compress should be applied after the operation, and the patient kept in the recumbent posture for two weeks. A truss should be worn for at least a year after the operation, and, when discarded, should be resumed at the first indication of weakness in the canal. Irreducible (not strangulated) femoral hernia may be treated as ad- vised for the same form of inguinal rupture. Operative interference is, however, more justifiable, from the fact that strangulation is more apt to occur, and that a compress to prevent a further descent of the mass is rarely successful. In strangulated femoral hernia operative interference is indicated immediately upon the first symptoms of this condition. So rapid are the changes which occur in the contents of the sac that early operation, always commendable in every form of strangulated hernia, is especially so in the variety under consideration. Taxis should not be performed until the patient is fully anjesthetized. The preparation for the opera- ti(m is identical with that for inguinal hernia. When narcosis is com- plete, the patient should be lifted by the legs in such a way that the thighs will be flexed upon the abdomen, and the pelvis raised consider- ably higher than the thorax. "While in this position taxis, in a direction at first slightly backward and then upwai'd, should be practiced. If reduction is not effected in from five to ten minutes, it should be discon- tinued. The incision should be vertical in direction, along the middle of the tumor, with its center over the femoral ring. The length will vary with the size of the protrusion, but three or four inches will usiially suffice. It should be made by cutting directly down upon the sac, and, when this is reached, the dissecticm should be continued between two dissecting- forceps. When the sac is opened and tbe fluid escapes, the index-finger should be introduced and carried upward until the end passes beneath the falciform process, and the nail is under the sharp constricting edge of Gimbernat's ligament. At this stage of the operation the hernia' must 32* 510 A TEXT-BOOK ON SURGERY. be kept between the finger and the femoral vein, and the edge of the nail against Gimbernat's ligament, just at its insertion at tlie os pubis. A long, probe-pointed knife is now rarried flatwise along tlit* pabnar side of the finger, with the cutting edge directed toward the median line. The constriction is relieved by lifting or scraping the attachment of Gimbei- nat's ligament from the os pid)is, and in doing this the cutting edge of the knife should not be carried beyoud tiiis ligament, nor should it have any other direction than inward toward the symphysis. If these precau- tions are not observed, a dangerous com])lication may arise in the division of the obturator artery (or vein), in cases in which it is derived from the epigastric branch of the external Uiac. In eight fatal cases of this char- acter the patients were females. This abnornud derivation occurs in women in nearly 50 per cent of cases, and in 25 per cent in men, while the vein is in relation to the femoral ring in a larger proportion of cases. * The manner in which the artery arches over the crural ring is shown in Fig. .531). "When the strangulation is released, and the contents of the sac returned into the abdomen, an effort should be made to effect a radi- cal cure as above directed. Umbilical Hernia. — The diagnosis between this form of hernia and other tumors of the umbilical region will depend chiefly upon the im- pulse conveyed to the hernia in the act of coughing, or in crying in children. If the hernia is made up of omentum — and this is not un- common in adults — it will be doughy to the feel and flat or dull on jier- cussion. Intestine will be more or less resonant on percussion. If the mass is reducible in the recumbent posture, and under direct manipula- tion the diagnosis of hernia is evident. Cyst of the omphalo- mesenteric duct would be translucent, and fluctuation would be present. In con- genital hernia the extreme thinness of the covering renders the recog- nition of the character of the tumor easy. Treatment. — When an umbilical hernia which is only covered by the thin membrane of the cord exists at birth, it should be returned at once, and the opening closed by carefully adjusted sutures, supported by ad- hesive strips, drawn in dove-tail fashion across the abdomen at the weak point. If covered over with integument, it should be reduced, a small, firm compress placed in the opening, and secured in place by a band of adhesive plaster carried around the child's bell.y. The acquired form is treated in the same general way. It should be reduced by posture, aided by careful taxis if necessary, and a truss worn day and night. In mild cases a light rubber belt wiU suffice after retiring for the night, but the heavier apparatus should be adjusted before leaving the recum- ))ent posture. Irreducible hernia, not strangulated, may be held in position by a I>roperly adjusted cup-shaped compress. The danger of strangulation is always present, and the question of the advisability of operating to relieve the incarceration, and of sewing * The anthor's " Essays in Surgical Anatomy and Surgery." William Wood & Co., 1878. " New'York Medical Record," October. 1877. IIERXIA. 511 up the opening, must be determined by the circumstances of each par- ticular case. As a rule, an operation is not indicated unless strangula- tion is threatened, and this is especially the case when the patient is situated within the easy call of a competent operator. Under other con- ditions operative interference may be seriously considered. AVith the first symptoms of straitgulation the patient should be etherized, and a final effort at reduction made by careful taxis. If this does not succeed, kelotomy should be at once pei'formed. The incision should be vertical, with its center corresponding to the neck of the her- nia. On account of the exceeding thinness of the integument and other coverings, great care shoidd be exercised in cutting down upon the tumor. As soon as the sac is punctured, the dull director is introduced, and the sac divided sufficiently to allow the introduction of the finger, upon which the further division of the sac is made. If the finger-nail can now be insinuated between the neck of the hernia and the constrict- ing ring, it should be done, holding the palmar aspect of the finger toward the pubes. The probe-i^ointed bistoury is now introduced flat- wise, and the constriction divided for not more than a quarter of an inch at first. The direction of this cut should be in the median line, and toward the pubes ; or the constriction may be incised on the upper aspect of the neck if mdre convenient to the operator. The management of the strangulated bowel or omentum should be the same as advised in inguinal hernia. The sac should be transhxed with a strong double catgut ligature, tied each way, the part beyond the ligatures cut off, and the stump returned within the abdomen. The radical cure should be attempted by introducing a fiat Thiersch sponge through the opening, which will prevent blood or other matter from en- tering the peritoneal cavity. The margins of the. opening should now be trimmed so as to secure freshened edges for approximation. When all bleeding has ceased, the sponge should be removed. The parietal layer of peritonaeum should be stitched by a separate row of catgut sutures, and the fascia, aponeuroses of the muscles, and integument brought together by silk or silver-wire sutures. If for any reason the separate row of sutures are not introduced, the outside row should trans- fix the peritoneal layer of the abdominal wall about one fourth of an Inch from the margin of the wound, so that, when the sutures are tied, this much of the peritoneal surface of the two sides will be bi-ought into apposition. Ventral Tieniia is amenable to the same general treatment as the acquired umbilical variety. In operation for the cure of hernia after laparotomy, the parietal peritonaeum should be first closed with catgut. In closing the remainder of the wound the sutures should be made to include both layers of the dense sheath of the rectus muscle. In diapJiragmatlc hernia tlie diagnosis must be based upon the symp- toms of obstruction. Pleuritis will be present in a varying degree. The only means of arriving at a positive diagnosis is to make the median incision, with manual exploration. The hernia may be reduced by trac- tion, with or without dilatation of the opening in the diaphragm. The 512 A TEXT-BOOK ON SURGERY. prognosis is unfavorable, and the gravity is increased as operative inter- ference is delayed. The rt'coa-nition of rfhtfeal Itrrnia is also difficult. If with the symp- toms of obstruction there is i)ain in the region of the sciatic notch, or in the distribution of the gluteal or sciatic nerves, which is increased by direct pressure, the presence of gluteal hernia is usually certain. If a tumor is appreciable, it is still more positive. To locate the notch, place the patient on his belly and hold the leg perfectly straight, with the toes i^nnting directly downward. A line, drawn from the posterior superior spine of the ilium to the upper sur- face of the great trochanter, will cross over the foramen. The incision should be free, and the iibers of the gluteal muscles separated with the finger. The vessels should be located before the con- striction is divided. Obturator hernia may be present without any appreciable tumor. It may be recognized by digital exploration through the rectum or vagina. Pressure upon the obturator nei-ve may i)roduce pain in the hip or knee. If the symptoms of obstruction are present, the hand should be intro- duced through an incision in the linea alba, when, by careful explora- tion of the i)elvis, the character of the lesion can be determined. In the effort at reduction by traction from within, the thigh should be ro- tated outward to relax the obturator muscle. If necessary, an incision may be made immediately over the foramen, and the constriction divided from below. The point at which the intestine usually escapes is in the adult between two and two and a half inches external to the symphysis pubis, and on a line with the inner border of the femoral or iliac vein. When the fibers of the pectineus muscle are divided, the tumor will be encoimtered. Lumbar and var/inal hernia do not demand especial consideration. Tlie diagnosis will depend upon the appearance of the tumor, with the symptoms of strangulation, when the constriction is sufficient. The return of the mass which follows prolapsus of the uterus into the vagina may be effected by direct rejiositicm of the uterus, or by conjoined manipulation with one hand introduced through an opening in the linea alba. Fecal Fistula. — A fecal fistula may exist between any portion of the intestinal canal and the external muscle through the integument ; from the intestine into a normal cavity, as the bladder or uterus, and thence to the exterior ; into an abnormal cavity, as an abscess, and thence out through one of the hollow organs or directly to the skin ; or it may lead into a cul-de-sac or blind pocket. Fecal fisiulse are congenital and acquired. Imperforate anus is the most frequent cause of congenital fistula. The pressure of accumulated matter at the extremity of the canal in- duces iufiammation, ulceration, and perforation, with extravasation of the bowel contents. If the congenital obstruction is low down, the open- ing may occur through the penmcum, bladder, or vagina. If higher up, the fistula may open through the abdominal wall at the umbilicus, or FECAL FISTULA. 513 below tliis point in the linea alba, or posteriorly near the spine. A rare cause of congenital fistula is the presence of the omphalo-mesenteric duct, or Meckel's diverticulum, which, as heretofore stated, opens at the umbilicus. Acquired fecal fistulse may be surgical or accidental. Colostomy and enterostomy are examples of the foi-mer, while the latter result from perforating wounds of the intestinal canal, either from the exterior, as by gun-shot or punctured wounds, or by the passage of some ingested sharjj or hard body through the intestinal wall ; or by perforation of the intestine by an ulcer or abscess, or from gangrene due to strangulation, contusions, etc. The diagnosis of a fecal fistula which communicates directly with the exterior is made evident by the escape of gas and ingested matter. Indirect fistulse can also be determined by the careful examination of the discharges from the organs through which they pass. In a case re- jjorted by Dr. Krackowitzer, in the "Transactions of the Xew York Pathological Society," an ulcer of the appendix vermiformis had opened into the bladder. The diagnosis of entero-vesical fistula was established by the escape of a lumbricoid worm from the urethra. Blind fistulfe can not often be made out until demonstrated by exploration. In determining what portion of the intestinal canal the fistula opens into one must consider, first, the character of the discharge ; second, the distance from the rectum, as determined by injections. In congenital fistulce opening into the perinaeum the inference is natural and generalh^ correct that the lower portion of the large intestine is involved. If bile is freely discharged through a congenital or ac- quired fistula, it is safe to conclude that the opening is not very far removed from the duodenum or upper ])ortion of the jejunum. The odor of gas or ingesta escaping from the large intestine is usually more offensive than that from the small bowel. When caused by a wound, the known direction and character of the penetrating body will aid in arriving at a correct idea of the gut pene- trated. A fistula resulting from perityphlitic abscess occurs almost always in the ccecum, more rarely in the lower portion of the ascending ct)lon or lower ileum. When the colon is involved the location may be deter- mined by slowly injecting milk per rectum, having measured the quan- tity injected until it begins to flow out at the external opening. The prognosis of fecal fistula depends upon its character. Congeni- tal fistulffi are obstinate under treatment. Acquired fistulse maybe cured in the majority of instances. Treatment. — Congenital fistulse, resulting from imperforate anus, can only be healed by the establishment of an opening in the perinseum which shall communicate with the most dependent portion of the blind gut. When this is done, a pad worn over the fistulous opening will lead to its gradual occlusion. When the fistula is the result of a patu- lous omphalo-mesenteric canal, it may be closed by sutures or by a com- press. 33 514 A TEXT-'BOOK ON SURGERY. Acquired fistnlpc not infrequently heal spontaneously. The opera- tion consists in cuttinf;; down ui)()n the opening in the gut and lay- ing freely open all sinuses wliicli ('(ininiunicate with the fistulous outlet. As the track of the fistula is ol'teii tortuous, it is at times ex- ceedingly difficult to follow it. A repetition of the method employed in the following case will be of service in the more complicated oper- ations : In 1880 a young man came under my observation on account of a pistol-shot wound. The bnll had entered the abdomen on a level with and about one and a half inch to the inner side of the left anterior su- perior spine of the ilium. From the direction in which the weapon was aimed, the missile was thought to have passed directly back and lodged in the iliac fossa. There were no immediate symptoms of perforation of the intestine. An abscess formed which discharged from the wound of entrance, and, about six weeks after the receipt of the injury, a fecal tistnla was established. The fistulous track was so long and tortuous that it could not be followed. After the anlaced to the right, while the sigmoid Hexure is brought u}) to tlie wound and fastened by two rows of sutures. The first, of line silk, attach the edge of the parietal peritonaeum to the peritoneal layer of the gut, while those of the second row jiass through the integument and into the lumen of the intestine, as in colostomj'. A like operation may be done upon the transverse colon, although either of these pro- cedures will be rarely indicated. Peritonitis. — In properly selected cases, abdominal section for the relief of peritonitis with effusion has, within late years, become a recog- nized operation. It is more a})plicable to cases of local peritonitis, and in chronic inflammation of this membrane, than in acute general perito- nitis. The operation is justitiable in the acute inflammation which fol- lows perforation of the alimentary canal, in which closure of the perfo- ration, and a thorough cleansing of the cavity of the peritonaeum, are essential. Left without operation, these cases, almost without exception, end fatally. Also in chronic local peritonitis, due to any cause in which the symptoms of septic absorption are prominent. The same principle should apply in these cases as in chronic effusions into the pleural cavity.* Mr. Treves, in his excellent monograph, cites a series of cases : one in which Mr. Hancock opened the abdomen for chronic local peritonitis. due to disease of the vermiform appendix ; Mr. Tait, in several cases of chronic peritonitis ; Dr. Savage, in eight cases of pelvic peritonitis treated by laparotomy ; Dr. Playfair, in one case of chronic pueijieral perito- nitis — all ending in recovery. f When the incision is made, any effused liquid or pus should be removed by means of soft Thiersch sponges on holders, and the cavity of the peritonaeum flooded with warm Thiersch solution or l-to-20000 sublimate solution, or, if neither of these can be had, with clean warm water at a temperature of about 100° F. As so(m as it is introduced it should be removed with the sjjouges, and the irri- gation repeated until it comes away clear. * "Intestinal Obstruction." Lea, Sons & Co., Pliiladclphi.!, 1884. t Ibid. ABSCESS OF THE ABDOMINAL REGION. 517 In two instances I have seen the sublimate solution employed in this manner in disinfection of the entire peritoneal cavity with success. In severe and obstinate cases, drainage should be established in the same manner as descril)ed in the after-treatment of certain ovarian tumors. In the diagnosis of peritonitis, pain is in the majority of instances an early and prominent sj-mptom. It is intense in character, almost constant, being first noticed in a given point and extending later with the progress of the inflammation to any portion of the abdominal cavity. Tympanites exists in a varying degree, the patient generally lying upon the back, with the legs drawn up and the thighs flexed upon tlie abdo- men. . The abdominal muscles are usually rigid, taking no part in the respiratory act. Constipation is the rule in a lai'ge majority of cases. Vomiting is not so common a feature, though often occurring in perito- nitis. Difficulty in urinating, or compjlete retention, occurs in some cases, especially in those in which the inflammatory process is marked ' in the pelvic region. The pulse is increased in frequency. Peritonitis is in almost aU instances secondary to a lesion of one or more of the abdominal viscera. Abscess in the Abdominal Region. — Abscess may occur between the parietal layer of the peritonjeum and the muscular walls of the abdo- men, within any circumscribed area of the peritoneal cavity, in the loose tissues behind the peritonaeum (retro-peritoneal abscess), and in the sub- stance or %vithin the capsules of any of the viscera. The diagnosis of extra-peritoneal abscess wiU in part depend upon the localized pain or tenderness under pressure, and the induration and oedema which are characteristic of acute inflammation with pus-fonna- tion, together with the usual exacerbations of temperature, with or with- out rigors or a chill. Fluctuation may be appreciable in extra-peritoneal abscess in patients with thin abdominal walls, and, if situated between the muscles or in the subcutaneotis tissues, is usually diagnosticated without difficulty. The employment of the exploring-needle and aspi- rator is always invaluable in the recognition of an abscess. The imme- diate indication in treatment is to cut down upon the tumor, using the needle which has indicated the presence of pus as a guide, until the sac is reached, puncturing this sufficiently to admit the point of the closed dressing-forceps, and enlarging the opening by separating the handles of the instrument. The principles of irrigation and free drainage apply here as to other recent collections of pus. Intra-peritoneal abscess is usually single, although in exceptional instances there may be two or more different centers of supjiuration. The most frequent locations are the iliac regions and the pelvis. In- flammation of the copcum and vermiform appendix, and the peritonaeum immediately about these organs (tijpTilitis and 2^€ritgp7ilifis), is a not infrequent cause of abscess. All of the lesions considered under the head of intestinal obstruction may induce the formation of pus in the cavity of the peritonpeum. Abscess occasionally forms between the upper surface of the liver and spleen and the diaphragm as a result of tearing loose portions of the suspensory ligaments of these organs. 518 A TEXT-BOOK ON SURGERY. D/'agnosln. — Intni-peritonenl abscess must be differentiated fi'om neo- plasms, cysts, fecal impaction, with ccecitis or colitis, all tumors resulting from ohstriiction, liydrone))!ir<)sis, aneurism, lia'niatoni:!, and aliseess within the solid viscera. The characteristic features of ne()i)lasnis, fecal impaction, and the varioiis lesicms which induce intestinal occlusion, have just been considered. Hydronephrosis develo]is slowly, and has a his- tory of obstruction of the ureter or urethra which can not be mistaken, while the expansile pulsation and brtdt of an aneurism render it easy of recognition. Abscess develops quickly, and follows an injury or oc- curs in the course of some inflammatory process. If, after a blow in the h}'i)Ochondriac region, or a severe fall, tenderness is develojied along the ujiper surface of the liver or spleen, accfmipanied by the well-known constitutional symptoms of ])us-fonnati(m, i)erihe])atic or peris])lenic ab- scess may be susi)ecfed. The same symptoms, occurring in the course of typhlitis or perityphlitis, point to suppuration in the region of the copcum. In like manner ovaritis, metritis, salpingitis, cystitis, and pelvic cellulitis are conditions which not infrecpiently induce abscess in the pelvic peritonjeum. Induration and fluctuation are scarcely a]>preciable in the earlier stages of abscess between the liver or spleen and diaphragm on account of the resistance offered by the ribs. Localized pleuritis and pain in the re- spiratory act should not be without significance when considen^d with other symptoms. In perityphlitic abscess induration is felt early in the inflammatory process, tenderness is well marked, while muscular rigidity, especially of the right side of the abdomen, is present. There are dull- ness on percussion and cedema of the skin. As the inflammatory process extends, the induration becomes more superficial or descends along the iliac fossa. Fluctuation is deep-seated and difficult of recognition until there is either pus in large quantity, or the wall of the abscess has risen in close proxinuty to the integument. In abscess within the pelvis, ex- ploration by the rectum or vagina will aid in a correct diagnosis. Treatment. — In perihepatic abscess the pus should be evacuated by means of the as^jirator. The needle should be of sufficient caliber to allow the pus to come away freely, and should be introduced in the same opening and to the same depth of the smaller needle which was emploj-ed in arriving at a diagnosis. Washing out the cavity of the abscess, when it is of recent formation, is not advisable for fear of over- distention and rupture of the sac. Incision and free drainage may be employed when the abscess is large, the pus superficial, and when ad- hesions have occurred which will prevent infiltration into the general cavity of the abdomen or pleura. Perityphlitic abscess demands operative interference as soon as the symptoms point to a collection of pus. If the presence of this fluid can be demonstrated l>y the em])loyment of the smaller aspirator-needle, tht^ pi'ocedure is much simplified. In- stances will, however, occur in which the needle fails to find the cavity of the abscess, and in which the characteristic sym})toms of this lesion are present, and in these cases it is equally imjjortant to operate. The ABSCESS OF THE ABDOMINAL REGION. 519 incision should be free, with its center over that part of the swelling in which the pus seems nearest the surface. If the exploring-needle has been succes-sfiilly tried, it .should be left in position as a guide to the pus. The dissection should be made with great care, to avoid opening into the peritoneal cavity, either directly or through the wall of tlie al)- scess. After a small puncture is made in the sac, the dressing-forceps should be employed to dilate the opening. Irrigation with 1-to-lOOOO sublimate solution should be made, and a drainage-tube inserted. In a certain proportion of cases fecal fistula will occur in the course of peri- typhlitic abscess. It should be treated as heretofore directed. As to the propriety of operative interference when, in the course of perityphlitis, perforation of the appendix or rupture of an abscess into the cavity of the peritonseum takes place, there exists a diversity of opinion. The hopelessness of the case, when left alone, would seem to justify an effort at cleansing the peritoneal cavity and closing the per- foration or establishing drainage to the outside. Retroperitoneal Abscess. — Abscess behind the peritonaeum is usually circumscribed, although it may be diffuse. Commencing at any portion of the posterior abdominal wall, pus is apt to dissect up the loose tissues behind the peritongeum, and to travel downward, pointing ultimately in one of the following situations: Above Poupart's ligament, external to its center ; beneath this ligament, in Scarpa's space ; over the iliac crest ; in the gluteal or lumbar region ; at the obturator foramen, or less frequently it may empty into the colon, rectum, bladder, uterus, vagina, or pass out through the perina>um. Occasionally the dissec- tion is upward into the pleura, or it may pass across the spine to the opposite side. Causes. — Ostitis of the vertebrae, ribs, or bones of the pelvis, rupture of the psoas or iliacus muscles ; lesions of the kidneys or supra-renal capsules (cysts, neoplasms, calculi, pyelitis, rupture with the extravasa- tion of blood and urine) ; diseases of the pancreas, liver, spleen, duo- denum, colon, and rectum ; the pelvic viscera, or tubercular changes in the lymphatics of this region — may cause retroperitoneal abscess. Diagnosis. — The physical signs of the earlier stages of pus-forma- tion behind the peritonaium are not well marked. With the muscles fully relaxed, deep pressure upon the abdomen from before backward may demonstrate the presence of the swelling. Rigidity of the muscles of the affected side is apt to be present, and in walking there is usually a perceptible limp. AVhen the inflammatory process is situated in the region of the iliacus and psoas muscles, flexion of the thigh on the ab- domen, however slight, is apt to occur. The constitutiimal symptoms of acute abscess will be the chief reliance in arriving at a correct diag- nosis. Tlie history of an injury, or the i)resence of a lesion of any of the organs situated in this region, will suggest the probability of abscess. Extravasaticm of blood (hfpmatoma), as far as the swelling is con- cerned, may simulate abscess, and in one particular may mislead, since the blood dissects up the loose tissues, and the tumor may present at 520 A TEXT-BOOK ON SURGERY. any of the locations named for the pointing of the abscess. The snd- denness of the tumefaction in hfpniorrhage, the history of an injury (or it may be aneurism), and the absence of sei)ti(' fever, are sufficient to ex- clude abscess. Lesions of the kidneys may be recognized by a careful study of the urine. In hydronephrosis the swelling will occur without marked pain or fever, comes on gradually, while a history of obstruc- tion will be given. Tenderness along the spines of the vertebrte sug- gests abscess. Lastly, the aspirator-needle introduced from behind will determine the character of the swelling. Trcatnwut. — Incision and free drainage should be the rule of prac- tice in acute retroperitoneal abscess. When the pus is deep-seated, opera- tion should be delayed, provided that the symptoms of septic absorption are not too urgent. The patient should be kept quiet and in bed, and in the dorsal decubitus. The operation and after-treatment are practically the same as in extra-peritoneal abscess. The Liver. Hepatic Abscess. — A circiim scribed collection of pus within the sub- stance of the liver is comparatively rare. Usually single, there may be two or more separate abscesses, which vary in size from a few lines in diameter to enormous cavities holding a gallon or more of pus. They may be deep or superficial, and, while no porti(m of the liver-substance is exempt, the most frequent location is in the deeper portions of the right lobe. Causes. — Contusions, lacerations, penetrating wounds, and the lodg- ment of foreign bodies are among the traumatic cairses of suppurative inflammation of the liver. Laceration of the capsule along the attached portion of the suspensory and coronary ligaments not only leads to peri- hepatic abscess, but may induce suj^puration in the deeper portions of this organ. Foreign bodies causing hepatic abscess not only enter through the integument, but ingested substances, as bones, needles, etc., have been known to pass from the alimentary canal into the liver, pro- ducing circumscribed inflammation and suppuration. Abscess of the liver may also occur secondary to an inflammatory process in any of the abdominal organs the blood from which is returned by the jiortal vein. Lastly, it may occur in the course of acute hepatitis, where neither in- jury or metastasis has occurred. As this disease is almost altogether confined to tropical climates, it will be understood why hepatic abscess is so much more frequent there than in the colder zones. Symptoms and Diagnosis. — The early recognition of hepatic abscess is exceedingly difficult, especially when the deeper portions of the organ are involved. Pain is not a ju'ominent symptom, unless there exists a perihepatitis, in which case it is exaggerated. There is a sense of heavi- ness or fullness about the liver, exacerbations of temperature occur, with general impairment of health. Jaundice is not present unless the bile-duct is compressed by the tumor. Cancer of the liver develops ABSCESS OF THE LIVER. 521 slowly, has a history of progressive emaciation, occurs usually after forty years of age, and is nodular to the feel. Empyema may be mistaken for abscess of the liver, especially when the accumulation is considerable and the liver is displaced downward. It may be recognized by the interference with the expansion of the lung of the affected side, and by the change in the percussion-sounds with the change in position of the thorax, in which the fluid of empyema is displaced. Over-distended gall-bladder may be mistaken for abscess; but this error may be eliminated by bearing in mind its location in front and low down, where abscess is exceedingly rare, and also by ol)serving that a distended gall-bladder is appreciably movable independently of the liver. Hydatid cyst of the liver is not painful, and is not accompanied with exacerbations of temperature, with the exception of the very rare occur- rence of inflammation of the cyst, when a differentiation is practically impossible without aspiration and the examination of the fluid. When the accumulation of pus is considerable, the tumefaction may be recognized by palijation and the diagnosis made positive by the ex- ploring-needle. Tlie 'progjiosis is unfavorable. Left alone, a fatal termination occurs in almost all cases — by rupture into the peritongeum in about 30 j^er cent, into the lung in 25 per cent, while in a smaller proportion of cases the abscess opens through the integument. Treatment. — Evacuation is the only rational treatment. In the choice of methods the character of the abscess will determine the employment of the aspirator or drainage by incision. Aspiration is advisable when the abscess is deeply located, and especially so when strong inflammatory adhesions have not been formed between the wall of the abscess and the abdominal or thoracic parietes. In performing this operation the following plan shoiild be adopted : The most siiperficial point of the abscess should be located by care- ful exploration with the smallest aspirator-needle, and the thickness of the intervening tissue measured. In using the evacuator it is necessary to have a good-sized needle to prevent solid particles or shreds of tissue from the abscess- wall from occluding it ; but it is always safer, if firm adhesions have not occurred, to employ the smaller points, since, after the needle is withdrawn, pus is not so ajit to escape and find its way into the pleural or peritoneal cavities. The needle should be introduced in the same opening and to the same de^jth as the exploring-needle, and the x^us slowly withdrawn. It is considered a safer plan not to completely empty the cavity at the first operation. The procedure should be repeated on the second or third daj". A piece of sublimate gauze should be laid over the puncture and held in position by a roller. When, after repeated use of the aspirator, a cure is not effected, and when the tissues between the most superficial portion of the abscess and the integument have been so solidified by adhesions that* infiltration of pus can not occur, the abscess should be 522 . A TEXT-BOOK ON SURGERY. opened by direct incision, its contents allowed to escape, the sac thor- oughly irrigated with l-to-5000 sublimate, and a drainage-tube inserted. If, after cutting dowoi to the wall of the abscess, it is discoveied that adlu'sions have not occurred, the sac sliould not be opened. The wound should be packed with sublimate gauze, and, in four or live days after adhesions have l)een established, it may be incised. Hydddd Tu inuix. — Cystic tumors cau.sed by the presence of the echi- nococcus honiinis, the huva of the taenia echinococcus or tape-worm, occur in the liver more frequently than in all other poi-tions of the body They vary in size, may be multiple or single, and may be lodged in any portion of the organ. The capsule or periphery of the cyst is tirni and dense, and may undergo calcification. Developing in the liver, hydatid cysts may perforate the diaphragm, rupture, and pour their contents into the pleura or lung ; or they may extend into tlie abdomi- nal cavity as far down as the pelvis. In rare instances they open into the stomach, vena cava, duodenum, or colon. The diagnosis of hydatids of the liver may be made from abscess by recognizing an elastic fluctuating tumor, which is free from tenderness or any of the symptoms of inflammation or septicjeraia which are always present in abscess ; from cancer of the liver by its fluctuation, cancer being solid, hard, and nodulated. The cachexia of cancer does not occur in hydatids. In distention of the gall bladder jaundice is apt to exist, while it is an exceptional complication of hydatid cysts. Aspiration with a deli- cate needle will be necessary to positive diagnosis. Hydatid cysts c(m- tain a watery liquid, nearly clear or of a light straw-color. In some in- stances fragments of the booklets and other contents of the cysts may be discovered. Treatment. — The contents should be drawn off with the aspirator, and the operation repeated if necessary. A single evacuation not infre- quently effects a cure. The needle should be introduced into the most superficial portion of the tumor. As the cyst is being emptied, the abdominal wall imme- diately around the needle should be pressed toward the tumor, and, when the operation is finished, this should be continued by a compress of sublimate gauze, held snugly in place by a bandage. The object of this is to prevent infiltration of the fluid into the peritoneal cavity. In performing this operation an anaesthetic should not be administered, on account of the danger of rapture of the cyst from vomiting. Cocaine may be employed locally. Complete rest in the recumbent posture should be enforced for at least a week after the aspiration. If at any time suppuration is precipitated, direct incision and free drainage are imperative. If repeated aspirations fail to effect a cure, adhesions being foiTOed as a result of the frequent introduction of the needle, an incision may be made, or the operation of Verneuil jjerformed. This consists in the introduction of a large trocar and canula, evacuating the contents, and inserting for prolonged drainage a large rubber tube through the canula, which is then withdi'awn, leaving the tube in position. THE SPLEEN. 523 The Spleek. Abscess — Abscess of this organ is much less frequent than in the liver. It may exist in the substance of the spleen or in the perisplenic tissues. Abscess of the spleen may be caused by violence, as from a pene- trating wound, a contusion with laceration, or a more or less extensive rupture of the capsule and spleen-substance near the attachment of the suspensory ligament. IdiopatJtic abscess of this organ may be caused by embolism, or fol- low in the course of any disease which interferes with its nutrition. The pi'ognosis of splenic abscess is unfavorable. If left without sur- gical interference, the contents may escape into the alimentary canal (as the colon oi- stomach) ; into the pleural cavity and lung ; or, in excep- tional instances, open through the integument. Occasionally abscess of the spleen reaches a certain size, remains passive, and becomes a chronic or cold abscess. Hijmptoms and Diagnosis. — Traumatic abscess may be suspected when, after an injury, persistent tenderness is felt in the region of this organ, and when to this symptom is added the constitutional disturbance which is a part of the history of acute abscess. In general, the tender- ness is more marked in perisplenic abscess than in that which is deep- seated. Swelling, with induration, possil)ly fluctuation and oedema when the abscess is near the surface, are confirmatory symptoms of suppura- tion, which may be substantiated by the exploring-needle and aspirator. In idiopathic abscess the symptoms of suppuration may be masked by the febrile movement in the disease in the course of which it occurs. The treatment is the same as for hepatic abscess. Cysts. — The diagnosis and treatment of cysts of the spleen do not difl'er in any essential features from similar lesions in the liver. Hernia of this organ may occur through a wound in the abdomen, or through an opening resulting from extensive sloughing. If the hernia is recent, and the ])rolapsed portion is not strangulated, it should be thoroughly cleansed in l-to-5(»00 sul>liniate solution and returned into its noi-mal position. The structure of the spleen is so delicate that it breaks down readily if undue force is employed. If the organ is lacerated, it will be advisable to throw an elastic ligature around it at the level of the skin, apply an antiseptic dressing, and allow the mass to be removed by sloughing or by tlie scissors, as soon as adhesions have occuired at the opening. When strangulation has taken place, the ligature will not be required. Complete splcnrrfom// may be demanded in displacement of this organ, followed by interference with the function of other viscera, or for the relief of pain caused by the spleen in an abnormal position. It has been performed in several instances on account of the enlargement of this organ in leucocyth.-emia, but without the success which would en- courage a repetition of the oj^eration. 524 A TEXT-BOOK ON SURGERY. In the extirpation of a wandering spleen, the incision slionld be by- preference in the linea alba, when the tumor is near enough to be reached through an opening here. All adhesions should be divided between double catgut ligatures. The splenic vessels should be tied witli a double ligature of strong silk, and divided between the knots. Pancreas. — Cystic tumors of large size are occasionally met with in this organ, and have been successfully i-emoved by incision in tlie median line, the operation being practically the same as in ovariotomy. Wounds of the Abdomen. Injuries of the abdomen are divided into penetrating and non-pene- trating^ and both of these varieties are again divisible into those which involve the viscera and those in which the organs escape. Non-penetrating Wounds of the Abdominal Walls. — Confusions may involve the integument, produce extravasation in the subcutaneous tis- sues, rupture of the muscles, or displacement or rupture of a viscus and death without any external evidence of injury. Simple contused woimds of this region demand no especial considera- tion. If abscess occurs, the same rule of treatment which applies to abscess elsewhere is applicable here. Rupture of one or more of the muscles may occur as the result of a blow on a muscle in tensif)n, or by muscular action alone. The rectus abdominalis is most frequently torn. Hernia is ajit to follow this injury. The treatment consists in pei'fect rest and well-adjusted presstire to hold the viscera within the cavity of the abdomen until cicatrization can take place. A support- er should be worn for some months after recovery, or permanently if necessary. Displacement or rupture of an organ (as the kidney, spleen, etc.) may be caused by direct violence or by a severe fall. The diagnosis will, in the first lesion, depend upon the absence of the organ from its normal place, and the recognition of the tumor in the new position. Laceration is followed by haemorrhage, at times profuse, which is evident from great pallor and a rapid and weak pulse. If the intestine is involved, the escape of gas or fseces is followed usually by profound shock, tym- panites, and peritonitis. Emphysematous crackling may be recognized on palpation. The first indication in treatment of a displaced viscus is to place the patient in such a posture that gravity will aid in the restoration of the organ to its normal position. A compress and bandage may be usefiil in some instances. In rapture of a solid organ, profound quiet should be maintained. AVhen haemorrhage is alarming, deligation of the ex- tremities is advisable. Fluid extract of ergot hypodennically may be added. If the symjitoms of rupture of the alimentary canal are pres- ent, the abdomen should be opened in the median line, the rupture closed, or an artificial anus established, and the peritoneal cavity care- fully washed out. WOUNDS OF THE ABDOMEN. 525 Non-penetrating incised, punctured, or sJiot wounds of this region do not demand especial consideration. The former should be closed, while it is usually safer to treat the jjunctured and shot wounds by placing a sublimate compress over the opening. Penetrating Wounds. — Wounds of the abdomen which penetrate ■without wounding any internal organ should be closed in the same man- ner as directed for the closure of surgical wounds through the belly. If an internal organ is involved, the abdomen should be opened, the charac- ter of the lesion ascertained, and proper surgical treatment, instituted. Among the symptoms wliich aid in arriving at a diagnosis are the follow- ing : If the injury is followed by the vomiting of blood, it is fair to con- clude that the stomach or duodenum is involved ; if blood is passed by the rectum, that the wound is farther along the bowel ; or, if hamiatiiria exists, that the kidney, ureter, or bladder is injured. If the odor of intestinal gas or fjeces is present, the inference is clear that the aliment- ary canal is opened. BUe, gastric juice, or recently ingested matter seen in the wound or recognized by the sense of smell, indicates the character of the injury and the location of the perforation. The crackling sound peculiar to emphysema, elicited by palpation, indicates the presence of intestinal gas in the loose tissues, beneath the peritonseum (Dennis). Tympanitic resonance over the liver, which has appeared suddenly and which is persistent, is a diagnostic sign of perforation of considei'uble value. Shock is usually severe, although in some cases it may be slight and of short duration. In shot-wounds the location of the wound of entrance (and exit, if it exists), together with the known direction of the missile and the force with which it was propelled, will be of aid in determining the character of the lesion within. A bullet passing directly or obliquely into the abdomen, at or below the level of the umbilicus (Fig. 53U), can scarcely miss the intestinal tube, and wll be more apt to make a number of holes than a single wound. Above this point tlie chances of escape are more favorable, yet so fortunate a result is exceptional. The direction and depth of a stab-wound may also be determined by the appearance of the wound and an examination of the instrument with which it was intiicted. The persistence of pain in a given point within the abdomen is a recog- nized symptom of a penetrating wound. Many of the foregoing symptoms may not be present within the first few hours after the receipt of a wound which has penetrated the aliment- ary canal, and, beyond the external wound and a varying degree of shock, there may be no symptom of perforation. Temporary contraction of the muscular fibers of the stomach or intestine, or prolapse of the raucous membrane into the wound, may jirevent, for a time, the escape of gas or ingested matter, and the appearance of the more pronounced symptoms of perforating wounds of the alimentary canal. Treatment. — When a wound exists in the wall of the abdomen, the immediate indication is to determine whether it opens into the cavity. In order to do this tlie disinfected finger, or tlie light and porcelain-tipped Iselaton probe, should be introduced, and, if necessary, the opening 526 A TEXT-BOOK OX SURGERY. should be enlarged. Cocaine anjesthesia may he sufficient for this prtv cedure. If the wound is confined to the abdominal wall, it should be treated in the aseptic method advised for ordinary wounds of the soft tissues. If it extends throut,di the wall, the abdomen shoidd Ix^ opened, and the condition of the viscera examined. As to whether the incision should be an enlargement of the accidental wound, or made in the median line, the location and direction of tlie wound must determine. The sec- tion should be, preferably, tlirough the linea alba. If the lesion is not more than six inches from this line, and if the direction of the wound is backward or tending toward the center, the median incision should be chosen. Under other conditions the section may be through the wound of entrance. In this procedure the details of the antiseptic method should be car- ried out, as directed in operation for the relief of intestinal obstruction. When the peritoneal cavity is opened, if it contain clotted blood which is known not to have entered from the wound of operation, or ingested matter, or if gas escape through the opening, the penetrating character of the wound is evident. If none of these signs are present, the disin- fected hand sliould l)e introduced and the internal surface of the wall examined at the supposed point of entrance. In examining the intestinal canal, it is advisable to begin with the loojxs of small intestine which pre- sent at the incision. These should be carefully drawn out throiigh the opening, and, as fast as inspected, surrounded with towels moistened in warm Thiersch solution, and supported in the hands of an assistant, who will not allow them to drag heavily upon the exposed mesentery. If an opening be found in the gut, it may be at once closed, or noted and passed over until the entire canal and cavity have been examined. If a cutting or puncturing sharp instrument has inflicted the wound, its edges will be found sufficiently smooth to be sutured at once. Fig. 549. — Pistol-shot wound of small intestine. (After Bull.) Fig. M8. — Lembeit's suture for clos- inj^ wounds of the intestines. (Alter Esmarch.) and should be brought together by Lem- bert's suture (Fig. 548). If the hole has been made by a bullet, and has rough and torn borders, as in Fig. .549, its edges should be trimmed smooth, with curved scissors, and then closed. When only a narrow strip of tissue separates two openings (Fig. 549), they should be converted into a single ellii)tical wound, and sutured. WOUNDS OF THE ABDOMEX. 527 The proper distance of the sutures from each other is shown in Fig. 548. While the sutures are being inserted, the intestine sliould be laid upon towels spread over the abdomen, near the incision. The escape of fecal matter into the cavity of the peritonjenm should be prevented by Hat syjonges jilaced around the margins of the wound. If the wound in the wall of the gut is so extensive that, in closing it, the lumen of the tube will be seriously constricted, tlie injured portion should be exsected. After all wounds are stitched and hfemorrhage is arrested, the cavity of the peritonfeum should be carefully cleansed. This is effected by sponges, attached to holders, carried into all parts of the cavity. When fecal extravasation has occuiTed, it will be advisable to fiood the entire cavity with warm Tliiersch's solution, remove it with sponges, and re])eat the irrigation until the liquid comes away free from odor or color. A drain- age-tube should be employed in this worst class of cases. The Sims tube is to be preferred, and the end of this should be carried down to the most dependent portion of the cavitj^ (usually in the pelvis, in the cul-de-sac). The method of employing this excellent instrument is described in the article on ovarian tumors. The intestines shoiild now be returned and the wound closed. Irriga- tion through the drainage-tube may be made when indicated by the tem- perature, tympanites, etc. No especial treatment can be laid down for wounds of the solid viscera or of the great vessels. The arrest of hfemorrhage, the removal of ex- travasated blood, and the establishment of drainage when needed are the indications. The argument in favor of operative interference in penetrating or supposed penetrating wounds of the abdomen may be briefly stated, as follows : 1. The enlargement of a wound sufficiently to demonstrate Its opening (or not opening) into the cavity of the peritonaeum is a simple procedure, practically without danger. 2. Abdominal section is not a difficult, nor, when skillfully and prop- erly performed, a dangerous operation. 3. A penetrating wound of the abdcmien, left without surgical inter- ference, is attended always with great danger. 4. If any vessels of size are divided, haemorrhage is an immediate danger, and peritonitis a serious and probably fatal complication. 5. If the alimentary canal is opened, death is almost inevitable. The few recorded cases of recovery form such an infinitesimal proportion of the whole, that they should carry no weight against interference. CHAPTER XVIII. PELVIC ORGANS. HErrr.U AXD AXUS — OEXITO-VRIXARY OlfOANS. Diseases of the Rectum and Anus — Congenital Defects. — Arrest of development in the rectal and anal portions of the alimentary oaniil, though not so frequent as at the upper or buccal extremity, is unfortu- nately common enough to justify a consideration of the different kinds of deformity which may here be met with, and the mode of treating them. Absence of the anus is one of the most frequent congenital lesions of the alimentary outlet. The rectum may be partially developed, and ter- minate within the pelvis in a blind pouch at a point more or less re- moved from the normal opening (Fig. 550) ; there may be a partial de- Fio. 550. — Atresia of tlie anus. (Atler Esinaich.j Fig. 651. — Atresia of tlic rectum, witli a rudi- mentary anus. (After Esmaroh.) velopment of the anus (Fig. 551) ; or the rectum may be entirely absent (Fig. 552) ; or it may be ])resent in the pelvis, opening abnormally into the bladder, vagina, uterus, or urethra (Figs. 553 and 554). In the sim- pler forms of atresia ani (/nly a thin membrane is stretched across the otherwise normal opening. The more complicated varieties are those PELVIC ORGANS. 529 in which a greater distance intervenes between the end of the defective intestine and the perinjEiim. Diagnosis. — Absence of the anus is easily established l)y inspection. The more important and difficult point is to determine the distance from Fia. 552. — Atresia of the anus and rectum. (After Esmurch.) Fir. 553. — Atresia of tlie anus and lower portion of tlie rectum ; the upper |art opening into the uretlua. (After Esmurch./ the perinfBum to the end of the pouch. When the intervening tissue is thin, the accumulation of matter within the tube may cause a protrusion in the perineeum which is exaggerated when the infant cries. If the finger be pressed into the perinanim, an ini- puLse somewhat comparable to that felt in the expulsive eiforts of a pa- tient with hernia maybe appreciated. Ex23loration by the vagina, when the capacity of this tube will permit, will aid in diagnosis. When the intestine oj^ens into an- other hollow organ, or through the integument in an abnormal position, the only diagnostic sign is the pres- ence of fecal matter in the natural discharge from the organ or at the abnormal opening. In atresia recti in female children, the bowel opens mo.st frequently into the uterus or vagina, and in males into the bladder. At times the communication is established between the bowel and the urethra, or a false opening may occur at any point in the perinseum, and, in rarer cases, in some remote portion of the body. 34 Fig. 554. — The same j tlie upper portion of the rectum opening into the bladder. Esiuarch.) (After 530 A TEXT-BOOK ON SURGERY. Treatment. — The indications are to establish an opening as near the natural position of the anus as possible. , If the blind pouch can be reached by the exjilorin.c; aspirator, the needle should be left in ])lace as a guide. The operative ])rocedure is to dissect gradually toward the supposed location of the end of the gut, keeping an open and clear wound by using retractors and arresting all htPniorrhage. The incision through the in- tegument should be in the median line, with its center just in front of the tip of the sacrum and coccyx, for, if the sphincter ani is present, even in an imi)erfect condition, it is important to preserve it to aid in the voluntary control of the bowel when the operation is completed. When there exists only a thin septum, this muscle is usually well de- veloped, and the operation is a simjjle incision and divulsion of the mem- brane. In more formidable operations, the location of the urethra and bladder, and in females the vagina and uterus, must be kei)t well in mind, for in infants the pelvic diameters are very small, varying from one to one and a half inch. It is a safe rule to proceed cautiously along the sacral curve. Moreover, it is wiser to dispense with an an;es- thetic, since the expulsive efforts in crying may aid in linding the end of the gut. When it is reached, if it is possible, the end should be loosened, drawn down, and sutured to the integument at the edges of the incision. If this is not done, the opening usually contracts, necessitating repeated dilatation by the use of the linger, tents, or a divulsor. In some in- stances it has been found necessary to remove the coccyx in order to effect the union of the bowel with the skin. When, after proceeding as far as the immediate safety of the infant will justify, the bowel can not be discovered, the propriety of colostomy or enterostomy may be entertained. If determined upon, right lumbar colostomy is indicated, on account of the probability of absence or mal- position of the descending colon. When the intestine ends directly in the uterus or vagina, and there is no ])ouching behind these organs to- ward the perinseum, it is best not to interfere. If, however, the bladder or urethra is involved, an opening should be made or colostomy per- formed. In exceptional cases the anus is present in a condition of more or less perfect develoinnent, while at the same time the rectum does not com-, municate with it, but terminates in a blind pouch at a varying distance from the perinpeum. The effort should be made to establish a communication between the two pockets by dissection through the tissues which intervene. When the opening from the rectum is abnormally small (a congenital stricture), dilatation, incision, or divulsion should be performed. The unfavorable prognosis in all these cases should not be concealed. Inflammation, visceral complications, dilatation of the bowel above with retained ingesta, insufficient assimilation, pain, etc., render a favorable issue exceedingly improbable. Pruritus Ani. — Persistent itching about the anus may be caused by a variety of skin-diseases, as eczema, herpes, pityriasis, and erythema, PELVIC ORGANS. 531 or by imtation of the end-organs of the sensory nerves from over- dis- tention in the act of defecation. It is also a symptom of heemorrhoids, fissure of the anus, or may be due to the presence of the thread-worm {ascaris vermicular in). The character of the itching is burning, i;)ain- ful, and aggravating, and the desire to scratch is almost irresistible. The successful management of pruritus ani will depend upon the recognition of the disease of which it is a symptom. Eczema of the peringeum and anus is more apt to occur in a warm temperature, where perspiration is excessive, and in corpulent individ- uals wheie considerable friction o(;curs between the folds of integument of this region. The skin becomes infiltrated and thickened, fissures are formed, and the mucous membrane at the anal opening may become in- volved. Treatment. — The part affected should be kept clean and friction pre- vented as much as possible. In the acute eczema of the anal region a ■vvann bath, without soap, should be taken two or three times a day, the parts thoroughly dried, and sprinkled with powdered starch or lycopo- dium. If excoriations exist, lead-and-opium wash should be tried. In chronic eczema of the anus, in order to effect a cure, it is often necessary to remove the accumulation of scales by the local use of green soap for a day or two, and then smearing the surface with diachylon-salve. Herpes may be recognized by the character of the eruption, which is vesicular, the vesicles being grouj^ed in bunches around the anus. Those which rupture and are subjected to irritation present flat and slightly ulcerating excoriations. The treatment consists in thoroughly washing the surface involved with a warm solution of boracic acid, grs. xv- 3 j of water, by means of pellets of absorbent cotton moistened in the solu- tion. This should lie fullowed by applying an astringent ointment, com- posed as follows : plumbi acetatis, grs. iij ; acid, tannic, gr. j ; niorphise sulph., grs. iij; adipis, §j. Erythema is a mild foi-m of inflammation f)f the integument, occur- ring here as a result of friction between the folds of skin of the two sides and the irritation from perspiration or other fluids. The warm bath, fol- lowed by sprinkling the part affected with starch or lycopodium, will usually effect a cure. Pityriasis versicolor occasionally exists in the ischio-rectal region. This disease can be recognized by the brownish slate-color of the parts involved. The cause is a vegetable parasite, the spores and mycelia of which may be easily recognized by the microscope. It yields readilj" to pure sulphurous acid, which may be applied by means of a camel's-hair pencil. Corrosive sublimate (gr. j to water 5 j) may be applied by wrap- X)ing the parts with absorbent cotton dipped in this solution. When pruritus occurs with luemorrhoids or fissure, the treatment must be directed to these affections. If it is caused by over-disteution or irritation of the rectum and anus, the use of enemata and laxatives will arrest the disease. The local application of a 4-per-cent solution of cocaine hydrochlorate will dull the sensibility of the part and tempo- rarily stop the jjain and itching. 532 A TEXT-BOOK OX SURGERY. Ascarides, or " thread-worms,'' are not an uncommon cause of pru- ritus ani. They vary in length from a quarter to half an inch, are some- what lighter in color than the mucous membrane, and are not readily seen unless this membrane is everted and carefulh' examined. Santo- nin in full doses should be administered for two or three days, followed by a free purgation. When this is accomplished the bowel should be distended \vith an enema of lime-water, retained for lifteen minutes, if possible, and repeated. As soon as the last injection is evacuated, a pint of water, in which grs. xx of carbolic acid are thoroughly dissolved, should be thrown into the rectum and retained for about five minutes. The injection of lime-water and carbolic acid in solution should be re- peated for several days to insure a thorougli destruction of these annoy- ing parasites. Enemata of the infusion of quassia are also highlj' recommended in the extermination of the ascaris vennicularis. Forelfjn Bndiea. — Foreign bodies in the rectum are usually intro- duced through the anus, and not infrequently lodge here, having passed through the alimentary canal. Their presence may be recognized by digital exploration, or, when of small size, the speculum may be em- ployed. Digital exploration of the rectum may be performed with the mini- mum of discomfort by curving the thoroughly lubricated finger to con- form to the shape of the lower portion of the bowel. The direction from the anus is upward and for- ward for the first inch and a half, and then upward and slightly backward. If a speculum is employed, that of Sims (Fig. 555) should be preferred. A small body may be readily removed by seizing it Avith a long forceps after dilatation with this instru- me«t. A large substance may require anaesthesia, with forcible divul- sion of the sphincter, or a posterior linear rectotomy before it can be removed. When the object is made of glass or any fragile substance, great care should be taken to prevent its breaking. Fistula in Ano. — A fistula of the anus or rectum may be complete or incomplete. The last variety is further divided into the incomplete ex- ternal and the incomplete internal fistula. In the complete form the track of the fistula, more or less sinu- ous, leads from the wall of the rectum or the anal margin out through the integument of the perineal, ischio-rectal, or gluteal regions (Fig. 556). In the incomplete external variety, the track opens through the skin, but does not communicate with the rectum (Fig. 5.57) ; while m the incomplete internal fistula the track opens into the bowel only (Fig. 558). Sims's rectal speculum. FISTUXA OF THE AXUS AND RECTUM. 533 The chief causes of peri-rectal abscess are the irritation which follows the lodgment of fecal matter and undigested substances in the rectum ; the over-di-stention of this organ as a result of constipation ; the presence of hsemorrhoidal tumors ; the introduction of hard bodies, as the nozzle of a syringe, etc., through the anus ; and, lastly, dii-ect injury by a blow from without. Abscess in this region occurs by preference in the weak and debilitated, in those suffering from the tubercular diathesis, and is rarely met with before the twenty-lifth year of life. Fig. 556. — Complete tistula Fig. 557. — Incomplete external Fig. 558. — Incomplete in recto. fistula. internal fiistula. Suppuration begins as a rule in the loose areolar tissue around the rectum. Although the inflammation may originate in the mucous mem- brane and wall of the bowel, perforation of the wall is rare until the process of suppuration is well established in the connective tissues of the ischio-rectal fossaJy As the pus accumulates the tissues break down, and the abscess opens into the bowel or through the integument. A complete fistula may be developed from either of the incomplete varieties by partial occlusion of the original opening, thus causing the pus to seek an outlet elsewhere. Abscess of this region may be superficial or deep. When superficial, it is apt to open through the mucous membrane, just above the junction of the skin and mucous membrane. When the deep variety opens into the rectum, it is usually at a point from three fourths of an inch to two inches from the margin of the anus. A single abscess. may have one or more openings into the rectum or through the .skin. The diagnosis of fistula in ano is not diflicult. It depends upon the history of an abscess followed by a constant or frequently recurring dis- charge of pus, the pain being severe until the abscess is evacuated, and recurring in a varying degree with the temporary closure of the out- let. An area of induration usually exist.s, and the opening may be dis- covered either through the skin or within the anus. If an external opening exists through which gas or fecal matter escapes, a comjilete fistula is demonstrated. When an external opening is formed, unless the abscess is very recent, there is almost always an internal opening, although it may not be found. The diagnosis maybe further made clear by exploration with a probe, an operation which is rendered ju-actically painless by the injection of a 4-per-cent solution of cocaine hydrochlo- rate into the abscess cavity. If a single injection does not suihciently dnll the sensibility, it should be repeated. No matter where the external opening is situated, the track will, in the great majority of instances, run just beneath the skin toward the anus. The probe should be allowed almost to find its own way, and. 534 A TEXT-BOOK ON SURGERY. when well in, tlie point at wliirh it impinges upon or opens into the bowel can be determined by the linger in the rectum. The treatment sliould be by free inci.sion. In mild cases local anfes- thesia, obtained by cocaine, is sufficient. One or two hypodermic syringes f uU of a 4-per-cent solution should first be thrown into the cavity of the sinus, and the direction of the opening into the bowel determined by the probe or grooved director. The cocaine should then be injected into the tissues by repeated introductions tif the needle in the line of the proposed incision into the bowel. Thirty minims of tliis solution are usually sufficient in this last procedure, but as many as sixty may be injected if necessary. Of the quantity thrown into the abscess only a small proportion is absorbed, while of that injected into the tissues the larger part escajjes with the blood which follows the incision. When the sinus is long and the cavity of the abscess extends more than one inch above the anus, the operation should be performed under ether narcosis. Operation. — A laxative should be administered the day before the operation, and an enema given two hours before the anajsthetic. The perina?um and region of the anus should be cleanly shaved. The patient should be placed upon the back, with the sacrum resting on the edge of the table, the legs flexed on the thighs, and the thighs on the abdo- men, and separated ; or upon the side in the Sims position. Tlie probe should be carried into the fistula, the lubricated index-finger of the left hand into the rectum, and the point noted at which the instrument strikes the rectum. The probe is now withdrawn, and the grooved di- rector introduced in the same track. If the opening into the bowel can not be found, the operator should determine by the touch the thinnest point on the intervening wall, and at this location bore through into the rectum, supporting the mucous membrane near the point of tlie instru- ment with the finger in the bowel. As soon as the director is felt in the cavity of the gut, the point should be brought out at the anus, the sharp- pointed curved bistoury carried along the groove, and the fistula laid open by dividing the intervening bridge of tissue. If a second sinus exists, it should be incised in the same way. The bleeding is usually in.significant, and may be arrested by pressure, or the ligature. The finger should now be carried into the wound, and, if it is discovered that the abscess extends higher along the wall of the rectum than the point at which the director was canied through, the intervening wall should be divided with the blunt scissors. It is important that the incision in the gut should extend to the depth of the abscess when this point is less than three inches from the anus. A careful search for any pockets or sinuses should be made, and these, if found, shoiild be laid freely open. The fi.stulous track should now be scraped out with the sharp spoon, and the entire wound packed with sublimate gauze held in place by a compress and T-bandage. This dressing should be allowed to re- main in place for two or three days, when, %vith the first evacuation of the bowels, it is carried away. After this the wound is not repacked, but, for purposes of cleanliness, it may be washed out by allowing the patient FISTULA OF THE AXTJS AND RECTUM. 535 to sit in a basin of warm water once or twice a day, or by irrigation, and an outside dressing applied. The wound rajiidly lieals by granulation, and, in the vast majority of cases, a cure is effected by a single operation. Temporary inconti- nence of f feces results in all oases whei"e both sphincters are divided, but a permanent loss of function is exceptional. It is more apt to occur in females, and for this reason a more guarded prognosis should be made in this class of patients. In the rare instances in which an internal in- complete fistula is present, the ca\'ity of the abscess should be opened by incision through the skin, and the operation completed as just given. A division of the external sijhincter is not necessary in the mildest class of cases, in which the abscess is recent and small, and in which the sinus runs just beneath the skin and opens at the margin of the anus. Under all other conditions it should be partially or completely divided. The immediate closure of the fistulous track is an operation which has been recently perfonmed in a number of instances. After the fistula is incised, the wall of the abscess is dissected out and the two perfectly healthy surfaces are brought together with sutures. An older method consists in the introduction of an elastic ligature through the external opening into the bowel and out through the anus, where the ends are tied together. The loop is allowed to cut through slowly, and it may be necessary to tighten it from time to time. Prophylaxis. — Upon the first appearance of inflammation in the ischio-rectal or perineal region, the integument immediately over the most supei-ficial point of the induration should be incised, and a free puncture made into the inflamed tissues. This should be followed by the application of poultices and complete rest in the recumbent post- ure. Too great distention of the rectum should be prevented by the administration of laxatives, and an enema of warm water should be given just before the bowel is emptied. By this method the tension is relieved and an outlet given to the products of inflammation before the process extends into the deeper tissues. A cure without further opera- tion will be effected in a fair proportion of cases. After an abscess is once formed, whether the fistula opens into the rectum or through the integument, or has lioth oixtlets, the case demands operative interference. Tlie proportion of cures by the use of injections into the fistula, or the application of stimulating remedies, is so very small and such valuable time is lost, that their employment is unjusti- fiable. Of the radical operations, preference should always be given to that of free incision. The elastic ligature should only be tried on pa- tients who are unwilling to remain in bed, or to be operated upon with the knife, to whom the merits of the two operations have been explained, and who relieve the surgeon of the probabilities of failure. It is also applicable to those cases in which the fistula enters the rectum so high up that incision is impracticable. A guarded prognosis should be made in this class of patients. Operation by immediate closure should not be preferred to the open method, for the reasons that the old operation cures almost all cases, 536 A TEXT-BOOK ON SURGERY. and is easy of execurion. The new method is more difficult, and is only applicable to the milder cases. The failure to close even a small part of the wound in the rectal wall wf)uld insure failure, while a like result would be apt to follow if the entire wounded surfaces were not in perfect coaptation. This operation would be applicable in those cases where, as a result of incision, there was serious impairment in the function of the sphincter ani. Operative interference is contraindicated in multiple fistulse in the aged, or in patients in a weak and debilitated condition. When the tubercular diathesis is well marked, an operation should not be done unless great discomfort is caused by the fistula, and, when performed, the prognosis should be guarded. Fisgiire. — Fissure of the anus is most frequently met with on the posterior portion of the outlet. It may, however, exist at any part of the anal circumference, or in the rectum above the sphincter. The tear is usually through the mucous membrane, although the muscular fibers may be more or less involved. The chief cause is over-distention of the anus in the evacuation of hardened faeces, together with the presence of sharp substances in the matter discharged. In like manner, foreign bodies introduced into the rectum may produce it. Fisstire may result from the inflammation and ulceration of a hsemorrhoid, or from any chronic inflammatory process in the rectum. The chief symptom is pain of an acute character, exaggerated by an evacnation of the bowel, and continuing some time after the act in a violent spasm of the sphincter muscle. By careful and gentle dilata- tion of the anus, it may be seen or recognized by the touch as a line of induration running parallel with the axis of the bowel. The employment of cocaine wiU render the exploration more thorough, and will permit the introduction of the speculum. Treatment. — ^The administration of laxatives, and the employment of enemata of warm water and olive-oil, will remove the chief source of irritation, while the stimulating effect of the lunar-caustic pencil applied in the fissure, and repeated every two or three days, will usually effect a cure. Cocaine should be employed to deaden the sensibility before the silver is applied. If a more radical procedure is necessary, it will con- sist in— 1, a partial division of the sphincter in the line of the fissure ; or, 2, temporary paralysis of this muscle by divulsion. As the second operation requires ether narcosis, the i:)artial division should be first emjjloyed. In its performance local ansesthesia should be obtained by the ax>plication of 4-per-cent cocaine to the inflamed sur- face, together with the injection of this fluid by introducing the needle just beneath the fissure in its entire extent. The sphincter should now be made tense by .separating the sides of the speculum, and an incision made through the depth of the fissure, dividing about half of the thick- ness of the muscle. In the after-treatment, the bowels should be kept open. Divulsion of the sphincter is performed as follows : The patient, fully anfesthetized, is placed upon the back, with the thighs separated and flexed on the abdomen. The operator, having lubricated both FISSURE AND ULCER OF THE ANUS AND RECTUM. 537 thumbs, introduces one and then the other to their full length, and stretclies the opening directly to the right and left until the palmar as- pect of each thumb is in contact Avith the inner surface of the tuber ischii. A towel, held in place by a roller or T-bandage, should be applied to prevent soiling. The rest obtained by the paralysis of the sphincter allows the fissure to heal. The function of the muscle is restored in from eight to twelve days. Ulcers. — The traumatic causes of ulcer of the rectum are the same as those given for fissure of the anus. Ulcer may also result from any acute or chi-onic inflammatory process of the lower bowel. It is a not infrequent sequence of dysentery, and may be met with in that form of proctitis which results from prolonged diarrhcea. Inflamma- tion of a hsemorrhoidal tumor will produce ulcer of the rectum, and the same is true of the gummatous deposits of the late stages of syph- ilis. A primary chancre or a chancroid may be located at the anal margin, and less frequently in the bowel. These two varieties of ulcer are usually seen in women sufi'ering with pudendal chancre or chan- croid, and in males the subjects of pederasty. Tubercular deposits in the rectum may also break down, and thus cause ulceration in the wall of this organ. The sj^mptoms of iilcer of the rectum vary with the character of the sore and with its location. If the lesion is sitxiated within the grasp of the sphincter muscles, tenesmus is apt to be a marked feature. The ulcer from a traumatism, or following an acute inflammatory process, is more apt to be painful than that which is a part of a subacute or chronic catarrh, or which occurs with tuberculosis or syphilis. A com- mon symptom of all ulcers of this organ is the presence of more or less blood and mucus or pus in the discharges. The diagnosis may be con- firmed by inspection with the speculum, and by digital exploration. Tubercular ulcer of the rectiim very rarely exists before the symptoms of deposits in the lungs are present. Upon inspection they are recog- nized by their yello\vish color, usually small size, and their dissemina- tion over a considerable area of the mucous membrane. In the more fully developed ulcers the caseous degeneration of the inflammatory products may be observed. Mr. Allingham describes a rare form of ulcer which he has occasion- ally observed in the rectum, and which he has named lupoid, or rodent ulcer, of this organ. Its usual location is near the anus. It tends to spread widely, the floor of the ulcer is red and diy, the margins irregular and precipitous. It is very probably tubercular in character. Cliancroidal ulcer of the rectum may be recognized by the precipitous margins of these sores, and by the rapidity with which they spread. In patients affected with phagedenic ulcers of the genital organs, the inoculation may occur by direct ccmtact of the secretion of the venereal sore, or the virus may be conveyed through the medium of the nails in the act of scratching. Under such conditions the sore usually first ap- pears upon the mucous membrane of the margins of the anus, and ex- tends later into the rectum. The diagnosis must be based upon the 538 A TEXT-BOOK ON SURGERY. peculiar appearance of tlu' ulcer, together with the probabilities of in- fection from a contiguous venereal ulcer. Tlie hard syi)liiHtic or true <'hancre is rarely observed in tliis region, and, when met with, is usually conlined to the anal margin. It possesses here the same well-recognized features of the specific \ilcer of the genital organs, fiom which source the virus is conveyed usually by the nails, and occasionally by immediate coutagion. Ulcers of the rectum resulting from the breaking down of the gumma- tous dejiosits of tertiary syphilis are chiefly seen just along the upper margin of the sphincter muscle. From this i)()int they extend upward, and may involve the entire rectum and invade the colon. These ulcers are usually multiple, varying in size from a small point to a half-inch or more in diameter, and in depth may involve only the mucous mem- brane, or the muscular and connective-tissue stroma may be destroyed, and in some instances perforation may occur. The pi-ocess of destruc- tion is greater in the older ulcers, and the various stages may be observed by examining the bowel from below upward. The appearance of the ulcers as above described, together with the history of syphilis, will en- able the observer to arrive at a correct diagnosis. Traumatic ulcers, and those resulting from the breaking down of hiemorrhoidal tumors, will be recognized by the appearance of the sore and the history of an acci- dent or haemorrhoids. As far a3 a cure of the ulcer is concerned, a favorable prognosis may be made in all ulcers of the rectum except the tubercidar. These may be relieved by treatment, but, being expressions of an incurable dyscrasia, permanent relief can not be expected. A more remote, as well as greater evil which often results from ulcer, is stricture of the rectum, and the danger of stricture is usually proportionate to the extent of the destructive process. Phagedenic chancroidal ulcer, and the ulcers of gumma and dysentery, are esi^ecially prone to induce stricture. Treatment. — The common indication in the treatment of all forms of ulcer of the rectum is to keep the bowel in as complete repose as possi- ble. Every effort should be made to keep it clear of fecal matter. This may be accomplished by the repeated employment of enemata, and by the administration of proper articles of diet, all of which should be capable of absorption in the stomach and small intestines. Milk, beef- tea, meat-juice, soft-boiled eggs, wine-jelly, rice, corn-meal mush, etc., will afford variety and sustain the patient's nutrition. In irrigation of the diseased surface, warm or cold water may be used at the temperature which is most agreeable to the patient. The best apparatus for this purpose is the fountain-syringe. The smallest glass nozzle, thoroughly warmed and oiled, should be employed, and from one to two pints of fluid may be introduced at one injection. A larger quan- tity may be employed when the colon is involved. If the patient is placed upon the left side, with the buttocks elevated, a greater degree of tolerance will be obtained in the rectum. The fluid should be re- tained for a few minutes, if jjossible. ULCER AND STRICTURE OF THE RECTUM. 539 When the ulcer encroaches upon the sphincter muscle, causing pain- ful tenesmus, the hypodermic use of morphia or opium suppositories may be required to relieve the spasm. In obstinate cases divulsion or division of the sphincter may be done as a last resort. In the treatment of the ulcers which result from dysentery, catarrh of the rectum, an injury, or breaking down of hsemori'hoids, the plan just given should be adopted. It is often advisable to add from gi-s. v-x of nitrate of silver to the pint of water thrown in, and, if the vilcer can be reached, recovery will be hastened by the local use of the lunar caus- tic. An excellent remedy for the alleviation of pain and the relief of tenesmus is a suppository composed of gr. ij each of iodoform and co- caine hydrochlorate, introduced from three to five times in twenty-four hours. As already stated, in obstinate and extreme cases, lumbar coloto- my may be necessitated . Chancroidal ulcer of the rectum requires the most energetic treat- ment. Ether should be administered, the sphincter divulsed, the ulcer exposed by the speculum, its surface scrajjed with the curette, and a thorough cauterization eifected with nitric acid. The cocaine and iodo- form suppositories should be employed in the after-treatment. True syphilitic chancre of the rectum rarely demands local treat- ment. It yields readily to the constitutional remedies emj^loyed in syphilis. The specific ulcer of the later stages of syphilis requires the consti- tutional treatment recommended for the late manifestations of this dis- ease, and locally, imgation and the cocaine and iodoform suppositories. Tubercular ulcers should be treated chiefly by the administration of cod-liver oil emulsion, the iron tonics, the hypophosphites of lime and soda, and carefully selected diet. Irrigation with warm water will be found useful. AVhen pain and tenesmus exist, relief may be obtained by the means already given. In rodent, or lupoid ulcer, the Paquelin cautery-knife should be em- ployed, and a thorough excision of the diseased surface efi'ected. Stricture of the Rectum. — Stricture of the rectum may be congenital or acquired. Partial and complete congenital occlusion of this organ has already been considered. Acquired stricture is usually the result of an inflammatory process in the walls of the rectum, and at times in the tis- sues which surround this oi-gan (Fig. 5.59). New formations (cancer, etc.) may also cause a partial or complete occlusion of the rectum, not only by reason of the bulk of the cells proper of the neoplasm, but on account of the inflammatory process which it causes in the connective- tissue elements of the bowel. The lumen of this portion of the intestine may be partially or com- pletely occluded by pressure of a tumor not connected with the bowel, or by the presence of some displaced organ, as the uterus, bladder, etc. Lastly, spasmodic stricture may occur from contraction of the circular muscular fibers of the rectum. As stated on a previous page, organic stricture frequently follows ulcer of the rectum, and is esi^ecially apt to occur in the ju'ocess of cica- 540 A TEXT-BOOK ON SURGERY. trization after dysenteric uletrs aiul those of the tertiary stage of syi)lii- lis. The accidents of parturition not infrequently tend to stricture, and this may afcount for tlie <;r(':it('r prevalence of this lesion in females than in males. Stricture of the rectum may be narrow or linear, or hirir/nnA tortuous. The usual location is about two inches above the mar- gin of the anus, although any part of the organ may be involved. The earlier sym])- toms of this lesion are inteiftrence with the act of defecation, pain with the passage of fgeces, and the presence of blood or mucus in the discharges. In some instances the fajces are tape-like, or are al)normally shaped, although this symjjtom may not be ])rpsent when the stricture is high up, since the fecal matter, after it passes through the constriction, may assume the shape of the bowel below. If the constriction is situ- ated within the first four inches of the bowel, its presence and caliber may be de- termined by digital exploration. When with difficulty reached by the finger, the patient should be directed to strain as if at stool, in order; to force the obstruction nearer the anus. Beyond this limit the bulbous bougies must be relied upon. These instruments are of all sizes, each consisting of an oval bulb of hard rubber, attached to the end of a flexible whalebone staff. In introducing them the patient should rest upon the back while the bougie, warmed and oiled, is guided up the bowel, upon the index-finger of the left hand, which is carried its full length into the rectum (Fig. 500). If resistance is met with, only careful and gentle pressure should be ex- ercised, for undue vio- lence may drive the l)ulb through the wall of the gut. The inferior limit of the stricture is indi- cated by the first obstruc- tion encountered. If the bulb can be carried through the constriction, the resistance ceases, but is again experienced when, upon withdrawing it, the shoulder of the instrument catches at the upper limit of the Fig. 559.— Stricture of tho rectum from connective-tissue new-formation in tlie auhmucous layer. (After Bushe.) Fig. 600. — Method of intrnducins the hulljous bougie in explora- tion ot the rectum. (After Bushe.) STRICTURE OF THE RECTUM. 541 obstruction. The lower border of the stricture is again indicated when all resistance ceases in withdrawing the bulb. Treatment. — The surgical treatment of stricture of the rectum may- comprise dilatation or division of the cicatricial tissue or colotomy. The character of the obstruction and its location will deteiTnine the means to be employed. When the stricture is linear, and is located near the anus, relief may be obtained by dilatation. For this purpose the finger should be employed, and the operation repeated at necessary intervals until a sufficient opening is secured. If the cicatricial tissue is dense, and does not yield in the effort at dilatation, it should be in- cised to a slight depth at four or five points of its circumference, and the finger again introduced. The incisions may be made with a probe- pointed bistoury, carried along the finger as a guide, or the anus and bowel may be stretched with the Sims rectal speculum up to the point of obstruction, and the knife introduced without a guide. If this pro- cedure is not successful, the only alternative is posterior linear rectoto- my. In i^erforming this operation the patient is jilaced upon the back, with the anus at the edge of the table, and the legs drawn up and sepa- rated. The parts below the obstruction are dilated with the speculum. A long, curved, sharp-pointed bistoury is carried through the stricture, keeping the ciitting edge toward the posterior median line of the gut. As soon as the point is beyond the obstruction, hut not more than four inches from the anus, it is carried through the wall of the bowel, which, with the stricture, is completely divided out through the anus. If the first incision does not permit the introduction of the first two fingers side by side, it should be made deeper. Hsemorrhage is readily stopped by packing the wound and bowel with gauze, taking the precauticm to insert a stiff rubber tube in the middle of the dressing to allow the escape of gas from the intestine. If any important vessel is divided, it may be secured with the forceps or by transfixion with a tenaculum. The dressing is allowed to remain in place for four or five days, and is not replaced after the bowels are moved unless bleeding should occur. Continence of ffeces is restored after from three to six weeks. No matter how thoroughly divided, the tendency is to recurrence, Fio. 561. — Soft-rubber rectal bougies (twelve sizes). which necessitates interrupted dilatation at intervals of from three to six weeks during the life of the patient. It is iisually not neces- sary to practice dilatation within the first six or eight weeks after the operation. 542 A TEXT-BOOK ON SURGERY. When the stricture is situated more than four inches above the anus, rectotomy is not permissible on account of the proximity of the hirge li.Tmorrhoidal vessels, the peritonaeum, and pelvic fascia. Dilatation with the soft-rubber bougies (Fig. nOl) may be tried, and, if this fails, a rectotomy may be done as high as the limit already given, which will allow the introduction of the hand to tliis point and the finger into the stricture. This may now be nicked with the bistoury, as above de- scribed, and digital or instrumental dilatation eifected. Rectal bougies before being iised should be made thoroughly tl('xil)le by immersion in warm water. In their employment only a mild degree of force should be exercised, for fear of perforating the wall of the intestine. When all other measures fail, left lumbar colotomy is the last resort. Neoplasms of the Rectum and Axus. Carcinoma. — Of the malignant new formations which are found in this organ, epitlieliovia is the most common, .sclrrhus and encephaloid cancer being next in order of frequency. The latter is comparatively rare. Cancer of the rectum occurs about equally in the sexes, and almost always in the middle-aged and old, although in exceptional in- stances it has been observed before the age of twenty-five. Epithelioma begins in the mucous membrane, scirrhus and encepha- loid carcinoma in the submucous tissues. The former is slower in development and less apt to recur after re- moval. The most common location (jf cancer of the lower bowel is at the upjier margin of the sphincter muscle. The prognosis is grave, the duration of life varying from one to two or three years, and in exceptional cases longer. Usually the earliest symptom of cancer of the rectum is pain with the act of defecation. If the disease is located at the margin of the anus, it can be recognized before there is any interference with the discharge of fecal matter. Later, hsemorrhage is of frequent occurrence, although, as a rule, it is not profuse in character. After an evacuation of the contents of the bowel, the pain, though less intense, remains for some time. A sense of fullness or " bearing down" is a marked feature of this disease in the majority of cases. D/'ar/nosis. — If operative interference is to be imdertaken, it is im- portant that an early diagnosis be made. Epithelioma, as has been said, begins in the mucous membrane, the cells of the new formation break down early, the ulcer being present in some instances before there is marked induration. On the other hand, induration and thick- ening are observed early in the history of scin-hus and encephaloid. Non-malignant stricture of the rectum is always preceded by a his- tory of chronic infiauimation. To the touch, the cicatricial character of the tissue may be recognized by its firmness and sharp borders. It is not nodular, like cancer, nor is there a deep and wide infiltration of the suiTounding tissues in simple stricture, which condition is common to NEOPLASMS OF THE RECTUM AND ANUS. 543 scirrliiis and encephaloid, and the later stages of epithelioma. In doubt- ful cases it will be advisable to remove a portion of the mass for micro- scopical examination. The treatment of cancer of the rectum may be palliative or radical. The fomier looks to the prolongation of life and the alleviation of pain by the employment of careful dietetic and medicinal measures. The regular daily introduction of warm water will prevent the lodgment of fecal matter and secure the greatest possible immunity from iiTitation. The iodoform and cocaine suppositories will be found useful in alleviat- ing pain, and morphia may be employed if all other measures fail. As the disease progresses it will be found necessary to practice dilatation of the stricture at intervals which should be as far removed as possible, or partial or complete division niaj' be required. The radical treatment consists in the free excision of the neoplasm. The death-rate after this operation is exceedingly heavy, and, when the dissection is extensive and recovery follows, the condition of fecal in- continence is deplorable. Moreover, the tendency to recurrence is so great that this knowledge should deter the surgeon from undertaking the operation in other than the mildest cases. "When the disease extends higher than three inches from the anus, it is of doubtful propriety, ami in scu'rhus and encejjhaloid cancer, on account of the rapid and wide intiltration which occurs with these neoplasms, the operation does not offer a prospect of relief sufficient to justify the danger which is in- curred. Excision is justifialile and should be done in all cases of epithelioma situated within three inches of the anus which have been discovered before infiltration is deep, or before metastasis has occurred. "When undertaken, the dissection should be carried on well away from the dis- ease, in the perfectly healthy tissues. It is performed as follows : The patient should be prepared for the operation by being placed upon liquid diet for one week, and the lower bowel should be thoroughly cleansed by repeated injections of tepid water. A good light should l)e secured, the patient placed in the lithotomy position, and the parts in the field of operation shaved. The rectum should be well packed with sponges to prevent the escape of fluids or other matter from the bowel into the woimd. The number of sponges shoiild be noted, so that the operator may be sure that none are left in after the excisiim is completed. In order to secure as great a degree of continence after the operation as possible, all or a portion of the external sphincter should be preserved. However, if the disease involves this muscle, it should be removed. An elliptical incision is fii-st made around the anus along tlie junction of the skin and mucous membrane (or wider than this if the extent of the disease demands it), and the dissection earned up through the inner fibei's of the external sphincter, the posterior insertion of which should be split as far back as the tip of the coccyx, in order to give more room. When the disease is approached, the dissection should be kept well out from the gut in the healthy tissues. Within the first inch of the dissec- tion the bleeding points may be readily secured by the forceps, but, 544 A TEXT-BOOK ON SURGERY. beyond tliis limit, tho operation will ln' luiicli iiKne rapidly and satis- factorily ])L'rf(>rmed if the tissues are divided (lirouylioiit between two forcex)s and catgut ligatures applied at once. It is best not to encroacli npon the vagina or urethra and bladder any more than is essential to the thorough removal of tlie disease, but to utilize the isehio-rectal fossa in securing room for the ileeper dissection. As soon as the lower end of the rectum is freed, the wound should be packed temporarily with gauze, the sponges removed, and the bowel closed by tying a strong silk liga- ture around it. It is essential to the complete success of the ojjeration that the gut be dissected loose, not only an inch above the upper limit of the disease where it is nltimately to be divided, but to a sufficient extent beyond tliis point to permit its being drawn down until it can be stitched to the nuirgiu of the incision in the integument around the anus. When this is accomplished the gut should be drawn down, a strong silk suture carried through the integument on each side and into the wall of the intestiue, just al>ove the line of section, and secured. The gut slioidd now be cut off with the scissors, and other sutures inserted. A drain- age-tube should be placed in the ischiorectal fossa, the end i)rojecting on one side of the anus. A sublimate dressing should be applied, leaving a tube in the bowel for the escape of gas. In the after-treatment opium should l)e administered to prevent a movement of the bowels for a week or ten days. Polypus. — Three distinct forms of polypi are found in the rectum, namely — the villous, mucous, and fibrous. The lirst of these is the more important, for, while essentially benign in the earlier stages of its development, it not infrequently, as a result of the irritation to which it is subjected, becomes malignant. It is com- iwsed of new-formed villi, which resemble the normal villi of the rectum. Tliey are very vascular, and differ from the mucous or fibrous polypus not only in their minute structure, but in gross appearances and the character of their attachment to the mucous membrane. While these latter are pedunculated, often hanging by a narrow stem, the villous growth has a broad attachment frequently as thick as the tumor is long. The mucous or soft, and the fibrous or hard, polypus of the rectum does not diifer in any essential particular from that already described in affections of the nasal cavities. In scmie instances the deeper portions of tlie tumor undergo cystic degeneration, forming the so-called cystic polypus. Polypi of the rectum may occur at any period of life, being compara- tively frequent in childhood. The most common location of these tumors is on the posterior wall of the bowel, just above the internal sphincter. The pedunculated variety in some instances protrude through the anus, causing violent tenesmus. When not removed these neoplasms may break down, causing ulcer or fissure of the bowel, severe haemorrhage, or by their weight cause prolapse of the mucous membrane. Tile diagnosis is readily made by inspection or digital exploration, after tlie rectum is thoroughly cleansed by an enema. The treatment consists in removal of the tumor by the forceps, scissors, or ligature. PROLAPSUS OF THE RECTUM AND ANUS. 545 Villous polypus may be safely removed by transfixing its base with a double silk ligature, tying these, and allowing the mass to slough away ; or, with the sphincter fully dilated, the tumor maybe removed Ijy the curette. The haemorrhage is not severe, and may be arrested by packing with gauze. The pedunculated tumors may be twisted off with the forceps or clipped closely with the curved scissors. The stump should be touched with lunar caustic or burned with nitric acid or the cautery. Neuralgia. — Pain, neuralgic in character, is occasionally felt in the rectum or about the anus. In some instances it is caused by displace- ment of the coccyx, the bone in the abnormal position pressing upon the fifth sacral or coccygeal nerve, or directly against the wall of the bowel. The diagnosis is readily made out by direct examination. The only means of cure is by removal of the displaced bone. The operation is performed as follows : The patient is placed upon the side, an incision is made in the median line, from the tip of the coc- cyx to about one inch above the sacro- coccygeal articulation. The tissues are first lifted directly fi'om the dorsal aspect of the bone, and then the anterior surface is exposed by beginning at the tip and keeping close to the smooth face of the coccyx. There is no danger of wounding the bowel if this precaution is taken. When the dissection is completed, the bone should be divided at the sacro-coccygeal junction with the cut- ting-forceps or chisel. Idiopathic neuralgia of the rectum and anus may occur as in other portions of the body. Spasm of the sphincter is occasionally due to this cause. Prolapsus Recti. — Protrusion of the rectum may be complete or in- complete. In the incomplete variety the lining membrane of the bowel is alone protruded. The everted portion may include a narrow ring of the mucous membrane near the anus, or it may measure an inch or more in widtli. In the complete prolapsus more or less of the entire thick- ness of the wall of the rectum is dragged downward and everted. The process commences usually near the anus, and in the complete form the fascia which attaches the rectum to the promontory of the sacrum is elongated, and the peritonaium dragged down toward the anal aperture. In the pocket thus formed a looja of intestine may descend and become strangulated. Prolapsus recti may occur at any period of life, although usually met with in children. In a varying degree it exists as a com])lication in all cases of chronic haemorrhoids. It is chiefly caused by frequent and pro- longed straining at stool. A predisposing cause in adults is habitual constipation, Avith the over-distention of the bowel which is the result of this condition. In children, it is thought that the peculiar shape of the sacrum, the curve of which is much less pronounced than in adults, renders this class of i^atients more liable to prolapsus. It is probable that indiscretions in diet, the lack of restraint, and the low, squatting jiosture too often permitted in children in the act of defecation, ai-e more responsible for this accident than the straight position of the bowel. 35 546 A TEXT-BOOK ON SURGERY. Diseases of the bladder and ])ru.state, uterus and ovaries, pregnancy, or the presence of a tumor, are also to be considered as exciting causes of this lesion. Finally, the weak and infimi are more liable to be affected than the robust. When prolapsus occurs it is accompanied with a sense of distention, heaviness, and di-agging down, which causes great pain and anxiety to the iiatient. In recent cases in which thei-e is only an eversion of the mucous membrane, this will be seen projecting beyond the limit of the anus on one or both sides, or in severer cases including its entire cir- cumference. The prolapsed fold or ring is of a reddish-purjtle color, varying with the degree of strangulation, and is broken at intervals by furrows or depressions which, in the main, seem to radiate from the center of the protrusion. When complicated with haemorrhoids, tliese will be easily recognized by their shape and color, giving a swollen and nodulated appearance, which could not exist in simple eversion. In differentiating partial from complete prolapsus, the chief jioints are the thinness of the prolapsed ring in the partial form, and the radiating du'ection of the furrows. In complete prolapse the mass is markedly thicker, more strangulated, and the folds of mucous membrane are more nearly circular in arrangement. Treatment. — In acute prolapsus the immediate indication is to I'elieve the strangulation and restore the prolapsed portion to its normal i)osi- tion. Tlie removal of the cause or causes of the accident is next in importance. The first indication is met by placing the patient ujion the left side, with the pelvis well elevated, the shoulders and head de- pressed, or in the knee-shoulder position, in either of which the return of the bowel is aided by gravity. The lingers of the operator and the protruded mass should now be well lubricated, and steady and gentle jiressure exercised irpon the tumor in the direction of the ncn-mal posi- tion of the bowel. In almost all cases this practice will succeed. When, on accotint of spasm of the sphincter, the strangulation is so great that gangrene is threatened and reduction impossible, an an;x^sthetic should be administered and forcible dilatation effected by the thumbs of the operator, after which the mass will readily return within the anus. Once reduced, the greatest pains must be observed to prevent the repetition of the accident. Fecal accumulation and straining should be prevented by the injection of cold water when there is a need or desire for an evacuation, and by the use of the bed-pan. In children it is essential that they should not be allowed to squat upon a low vessel, or j^lace themselves in a constrained position at stool. The position assumed should be one where gravitation will not carry the intestines toward the anus. Lying upon the side, with the buttocks slightly projecting over the edge of the bed or table, or defecating in the knee-elbow position, should be insisted upon. Any condition which contributes to the cause of prolapse must be removed or palliated. When, despite all conserva- tive methods, the prolapse becomes chronic, growing progressively worse, operative interference becomes imperative. The preparation of the jm- tient is the same as for other operations about the rectum. After the HyEMORRIIOIDS. 547 narcosis is complete, the patient is placed in the lithotomy position, with the pelvis elevated to such an extent that the intestines will gravitate toward the diaphragm, the mass returned, and a large sponge introduced well U15 into the bowel. The sphincter ani and rectum should now be widely dilated with the speculum until the walls of the bowel are brought clearly into view. The Paquelin cautery-knife, heated to a light-red color, is carried into the bcjwel as high as the limit of the piolapsed portion, and drawn straight down the wall of the gut to the margins of the anus, burning its way through the mucous membrane. The depth of the furrow must be determined by the extent of the prolapse. If the entire thickness of the rectal wall is involved, as in complete pro- lapsus, the wound should extend well into the muscular layer. In par- tial prolapse it will suffice to go down to the muscle. From four to six incisions should be made at equal distances from each other. Partial divulsion of the sphincter should be made before or after the operation, in order to prevent spasm and to secure rest. A complete recovery will follow in the large majority of cases. If the Paquelin cautery can not be obtained, strong iron wire, or rod-iron, may be used by heating in the ordinary furnace. The after-treatment is to keep the jiatient quiet with mild opium narcosis, and after live or six days to move the bowels with a cold-water enema, keeping the patient in the recumbent posture. The cure is effected by the formation of inflammatory adhesions between the mucous membrane and muscle, and between the outer wall of the rectum and the peri-rectal connective tissues and fascise. The older operation of excising a V-shaped piece of the mucous membrane and afterward uniting the edges by sutures, is bloody and troublesome, and not to be compared to the procedure above given. In chronic prolapsus, the operation is the same, provided that reduc- tion can be effected. The incisions with the cautery-knife must extend deeply, as above indicated. When reduction is impossible, owing to the inflammatory thickening of the protruded mass, there is no alternative but in excision. In this operation the integrity of the sphincter must not be impaired. Preferably, the mass should be cut off with a delicate cautery- knife, keeping just outside the sphincter, which is usually slightly drawn out with the gut. The line of incision should be circular, and, by allow- ing the knife to burn its way slowly, all danger of hferaorrhage is avoid- ed. The after-treatment is the same as in the preceding ojjeration. Another method is to insert a series of ligatures of strong silk around the prola^jsed mass at the level of the anus. These extend through both thicknesses of the gut. When tied tightly, strangulation of the jiortion beyond the ligatures occurs, and this should be cut off to within a quar- ter of an inch of the ligatures. *t)-' HEMORRHOIDS. Hsemorrhoids, or "piles," are vascular tumors formed beneath the mucous membrane of the rectum and anus. Tliey are divided anatom- ically into external and internal h.emorrhoids. Internal luemoixhoids 548 A TEXT-BOOK ON SURGERY. are agaia divided into venous, arterio-ve/ious, and capillanj liajnior- rhoids. The veins which are involved in hifmorrlioids belong to two ])lexuse9, between which, ordinarily, tliere is not a free anastomosis. Tiie infeiior or external hjemorrlioidal plexus is situated in the last portion of the rectum, within about one inch of the anus, and the blood from this part returns by way of the middle and inferior hjrmonhoidal veins to the iliacs, and thence by the infeiior cava to the heart. The sujierior or in- ternal plexus occupies the rectum above this point, and from this por- tion the lilood returns by the portal system, passing thi-ough the liver. In their iucipiency, external lice morrii aids are simple varicosities of the inferior plexus. Later, as a residt of engorgement and repeated in- flammation, the walls become thickened from the presence of newly formed connective tissue, which, in the process of contraction peculiar to this product of inflammation, often causes obliteration of the vein within the tumor. The remains of these tumors are seen in almost all cases of chronic external haimoiThoids, where they appear as tags of thickened skin of variable size and shape, collected around the margin of the anus. Internal JiamorrTiolds of recent development are also varicosities of the internal or portal plexus, but when of long duration the tumors very frequently contain arterioles of considerable size. The mucous membrane of the deeper portions of the rectum is at times studded with small, raspberry-like elevations, which bleed profusely, are found to contain a rich network of capillaries, and fur this reason are termed capillary Jicemorrholds. External Hicmorrhoids — Acute and CTironic. — This form of tumor, commonly known as "dry piles," is of frequent occurrence. Few indi- viduals live beyond the age of forty without being aifected with this lesion. The chief cause is habitual constij^ation and the over-distention of the lower portion of the rectum in the act of defecation. Prolonged straining at stool, even without the discharge of fecal matter, will also aid in the develcjpment of piles. Gravitation by reason of the erect posture is also entitled to a consideration in the eetiology of hjemor- rhoids, since man is the only animal thus affected. Pressure upon the iliac veins or the inferior cava by the gravid uterus, or any form of tumor, will also aid in producing varicosities of the hfemorrhoidal veins as well as in those of the lower extremities. A patient who is suffering from an acute external hsemoiThoidal tu- mor will usually give a history of constipation and straining at stool, wath an unnatural sense of fullness and heaviness about the anus, and of consideralne pain while the evacuation is taking place, for several days before the protrusion is noticed. Immediately after an evacuation a swelling is noticed just outside of the anus which is painful to the touch, and which can not be pushed into the bowel. Uj^on inspection, a recent external hjemorrhoidal tumor usually ai)pears tense and glis- tening on the surface, and red or reddish-blue in color. It is partly within and partly outside of the anus. There may be a single swell- IliEMORRIIomS. 549 ing, wMch is spherical in shape, or it may be crescsntic, occupying half of the anal margin. If not observed until after several days have elapsed, and v.hen the tension or partial strangulation has not been re- lieved, ulceration may have occurred, with intlammation and induration of the tissues near the base of the tumor. In other instances vv'hich do not come under the observation of a physician, the patient goes to bed, pushes the tumor within the anus, the symptoms disapj^ear within a day or two, to recur again and again imder the same conditions. Chronic external InemorrJioids differ from the acute form just de- scribed in the following particulars : They are bro\\Ti or bluish in color, are not tense nor painful, are loose and flabby, and have a thickened, leathery feel when pinched between the fingers. Treatment. — The treatment may be palliative or curative. If the palliative treatment is determined upon, the immediate indication is to relieve the tension in the tumor by returning it within the anus. The patient should be placed in the left lateral or knee-shoulder position, the protruded portion and fingers of the operator thoroughly lubricated, ?ind reduction effected by well-directed pressure, combined with slight dilatation of the sphincter. If the tumor is so large that it can not be reduced, relief may be obtained by the local application of the ice-bag, or cold water. The majority of cases will be relieved temporarily by this treatment, and a certain proportion may not suffer a relapse, but the rule is for the tumor to recur from time to time until it is cured finally by an operation. In operating for the cure of external piles, the ligature is rarely de- manded. If the tumor is recent and is inflamed, immediate relief may be obtained by incising it. This procedure may be rendered painless by the following method : The smallest hypodermic needle is attached to the syringe, containing about v\ xv of a 4-per-cent solution of cocaine hydrochlorate. The needle is introduced into one side of the tumor at its base to the depth of about one eighth of an inch, and three or four minims of the solution forced out ; a minute later it is carried farther, and the manoeuvre repeated until the needle has completely transfixed the mass, and all the fluid injected. Within five minutes the anfesthe- sia is usually so complete that the tumor can be laid open with the bistoury without pain. The bleeding is insignificant, and is easily ar- rested by packing a tuft of borated cotton or lint into the wound. No after-treatment is required. The wound heals after five or six days and the pile is cured. Old external piles may be removed by grasping the tumor with a pair of mouse-tooth forceps and clipping it off near its base with a jiair of scissors curved on the fiat. Local anaesthesia should also be employed. Internal HcemorrTioids. — Constipation, over-distention of the rectum, and prolonged straining at stool must also be considered as among the principal causes of internal as well as external piles. In addition to these, any disease of the liver which causes a retardation of the return of blood through the portal circulation will aid in producing internal htemorrhoids. 550 A TEXT-BOOK ON SURGERY. Pressure upon the portal vein, or upon tlie inferior mesenteric veiii, whether due to an overloaded condition of the alimentary canal, or a tumor, will produce the same effect. Si/irij)t()inx. — Internal piles, as a rule, cause little or no pain or an- noyance until they are sufficiently developed to be caught in the grip of the sphincter, or are protruded througli tlie anus. Previous to their descent, however, a variable amount of bleeding has usually occurred, often enough to attract the attention and excite the alarm of the patient. This is especially true of the arterio-venous and capillary tumor, al- though the venous tumor not infrequently gives rise to considerable haemorrhage. Upon digital examination the presence of the haemorrhoids may be easily recognized, and ocular deuKmstration may be made by the care- ful dilatation of tlie sphincter with the Sims rectal speculum. If a free enema of wann water be administered, the tumors will usually ])rotrude with the discharge of the water if the patient is placed in the sipiatting posture, and is dii-ected to make a strong expulsive effort. Treatment. — Venous and arterio-venous internal haemorrhoids may be cured by one of three methods — the ligature, the clamp, and the in- jection of carbolic acid ; the capillary variety by the mild application of the cautery or nitric acid. Of the first methods mentioned there is little room for choice between the ligature and the clamp, and both of these are preferable to the car- bolic-acid injection. Operation by the ligature is deservedly the more popular, for the reason that it is not only simple, radical, and success- ful, l)ut does not require any sjiecial or costly apparatus for its perfomi- ance. The objections to the operation with carbolic acid are, that it does not always succeed, it requires a long time — several weeks, and at times months — in effecting a cure, peri-proctitis and abscess of the ischio- rectal fossa may ensue, and hepatic embolism, witli abscess, is, however remote, a possibility. Not unfrequently ulcer of the bowel results, which of itself requires to be cured. In its favor it may be said that the treatment can be carried on without ether narcosis, in almost aU cases without going to bed, and is not, as a rule, accompanied l)y great pain. Since the operati(Ui by the ligature is almost universall}' recognized by surgeons as the safer and more scientific procedure, it should be recom- mended. If the patient for any reason can not submit to it, the method of injection may be undertaken if, after a full explanation of the differ- ent methods, the opei-ator is relieved of all responsibility. Operation hy the Ligature. — Tlie preparation of the pfitient is the same as in other operations about the rectum. When fully anaesthe- tized, the lithotomy position should be preferred, or, if help is scarce, or the convenience of the operator is better suited, the patient may be placed upon the left side, ^vith the left arm behind the body and the thighs and legs flexed. The first step is the dilatation of the sphincter, which is accomplished by introducing the thumbs and stretching the muscle toward the tuber- osities of the ischia until relaxation is complete. A soft sponge is car- HEMORRHOIDS. 551 ried into the rectum above the piles in order to prevent the descent of fecal matter. The hsemorrhoidal tumors are now carefully examined and drawn downward. If the tumors are of considerable thickness through their bases, it is best to use a double ligature. In narrow, pe- dunculated haemorrhoids a single thread will suffice. The operator, hold- ing the tumor steady and tense by means of a forceps or hook, with a knife or scissors divides the mucous membrane all ai-ound the base of the tumor, going well down to the submucous layer and making a fur- row in which the ligaturs is to rest as it constricts the tumor. This incision not only hastens the separation of the mass, but diminishes greatly the pain which would otherwise be felt if the end-organs of the sensory nerves distributed in the mucous membrane were caught in the grasp of the ligature. When an internal haemorrhoidal tumor is com- plicated by an external pile — that is, when the tumor is mixed — the in- tegument around the tumor should also be incised. The ligatures should be of the very best silk, so lai-ge and strong that they can not be broken in tying. If they are well waxed, they will be less apt to slip when the knot is being made. If a single thread is to be employed, it may be thrown around the pedicle of the tumor and tied. It is almost always advisable to use the double ligature. This may be carried through the base of the hsemorrhoid by means of a good-sized half-curved needle, or Peaslee's needle may be used. If the tumor is not complicated with an external hsemorrhoid — that is, if its base is well within the anus — it may be transfixed directly through its base, the thread divided at the eye of the needle, and this instrument removed. Tlie two ligatures are now separately identified — one for the lower and one for the upper half of the mass — and are then crossed by carrying the lower end of one side once over the upper and back to its place. By this manoeuvre the two loops are interlocked, and, when tied, all the tissues in the grasp of both threads are crowded to the center. As the ligatures are being tied, care must be taken to see that the threads fall into the track of the incision already made through the mucous membrane (or integument). If the threads have been waxed, the "reef-knot" (Fig. 110) should be preferred, since a more complete strangulation can be secured with less strain on the silk than when the "friction-knot" (Fig. 112) is employed. When wax is not used, this last knot is preferable, for the reason that it is less apt to slip. The force employed should be sufficient to arrest the circulation in the tumor, which, when this is done, immediately becomes purple and very tense. When all the tumors have been deligated, they should be clipped off with the curved scissors about a quarter of an inch from the ligatures, and the threads cut short. The sponge should next be removed, a gauze dressing or pad laid over the anal region, and a T-bandage api")lied. It is usually advisable to administer morphia hypodermically at the close of the operation, and to continue this for two or three days. The bowels may be moved on the fourth day. The dressing should be changed as often as cleanliness requires. The ligatures come away between the sixth and tenth days. In this, as in all operations about the rectum, re- 552 A TEXT-BOOK ON SURGERY. tention of urine is apt to follow for a day or two, necessitating the nse of the cathetei". Peimanent incontinence of fseces rarely results from this procedure. It is more apt to occur in females, and this danger should be avoided by a limited divulsiou of the sphincter. When the base of a hjemon-hoidal tumor is more than one inch in its long axis, it is best to insert two sets of ligatures rather tlian to include too much tissue in the grasp of a single tliread. Half-way Ijetween the two sets of threads a perpendicular incision should be made through to the base of the tumor, so that tiie central ligatures may l)e sunk to the sLime level as the others. If this precaution is not taken, an uneven surface will be left when the ligatures come away. The operation with the damp and cautery is perfoi-med as follows : The tumor is drawn out and grasped at its base between the jaws of the clamp (Fig. 562), and the blades closed by tightening the screw in Flo. 562.— Smith'8 htemorrhoid.il clamp (ivory-plated), the handles nntil the hfemorrhoid is strangulated. With the scissors the mass is cut away about one fourth of an inch external to the clamp., and the cut surface thoroughly cauterized with the Paquelin or the act- ual cautery. The ivory plates upon the jaws of the clamp protect the mucous membrane of the bowel from lieing burned. When this is done, the blades should be .slowly separated, and, if any oozing is seen, the bleeding point should be again touched with the cautery. The after- treatment is the same as for the preceding operation. Injection with Carbolic Acid. — The htemorrhoid to be operated upon should be exposed with the speculum or drawn well out with the finger.s. If it is a long pedunculated tumor, the needle should be introduced from the point to near its base. If it is round or oval in shape, the needle should pass through the longer diameter of the mass near the level of tlie mucous membrane of the Iwwel. The mucous membrane and integument should be well covered with vaseline to prevent excoria- tion from the acid which may leak from the syringe or ooze out of the tumor. The ordinary hypodermic syringe will answer every purpose if one or two extra long and fine needles are secured. In Fig. 563 is shown an apparatus especially designed for this operation. From ten to twenty minims of a 4-i)er-cent cocaine solution (the quan- tity being determined by the size of the tumor) are first thrown in, and the instrument unscrewed from the needle, leaving this sticking in the tumor. The carbolic-acid solution is now drawn into the syringe, and t his is again screwed on to the needle. After fiom one to three minutes ILE3I0RRH0IDS. 553 the aiiffistbesia will be complete, and the solution should be forced slowly into the tumor, being distributed in the line in which the cocaine was injected. It is advisable to operate upon a single hfemorrhoid at each operation. The strength of the solution and the quantity to be em- ployed will be determined by the size and condition of the tumor. If a Fig. 563. — Kelsey's hicinorrho'Klal s}•rin^'e. rapid sloughing of the mass is desired, this result may be secured by using a solution of equal parts glycerin and carbolic acid, and from five to twenty minims should be introduced unless the htcmorrhoid ia un- usually large. After injecting a solution of this strength the tumor be- comes hard, and changes to a blue or bluii^h-gray color. In from twenty- four to forty-eight hours the mass sloughs away, and by the fourth or fifth day has disappeared, leaving only a small ulcer in the mucous mem-, brane corresponding to the base of the hajmorrhoid. If a 10-per-cent solution is employed, sloughing rarely occurs, and a much greater quan- tity — from twenty to thirty minims — can be injected. A mild degree of 'inflammation is established, followed within a few days by a diminution in the size of the tumor, which, in a certain proportion of cases, grad- ually undergoes atrophy and entirely disai)pears. The degree of pain following the injection of the stronger solution, after the temporary anjesthesia secured by the cocaine has passed off, varies with different individiuils. In some of my cases it was so insignificant that the jjatients went immediately about their vocations. In others the same solution caused great annoyance and considerable, though never alarming, inflam- mation. The milder solutions are also painful at times, though in a less degree. In choosing between the weak and strong solutions just given, the operator must be guided chiefly by the time in which it is desired to effect a cure. If expedition is demanded, the strong injections should be employed ; if not, the weak solution is preferable to begin with, and, if necessary, this may be increased in strength at a subse- quent operation. 554 A TEXT-BOOK ON SURGERY. In capillary Jicemorrhoids the chief symptom is haemorrhage. The bleeding occurs with and after each stool, or may follow violent exercise or straining. If the finger is carried into the bowel, no tumors are felt, and there is usually no tenesmus. If the speculum is employed, the mucous membrane will be seen to be studded with bleeding points or rufts projecting a slight distance from the normal level of tlie lining membrane of tlie rectum. They are red, not unlike small laspberries in appearance, and bleed profusely at the slightest provocation. They are really new formations or chronic granulation-tissue, lich in capillary loops. The treatment consists in dilatation of the anus and rectum with the speculum, and in touching the bleeding points with the Paquelin can tery until all ])leediug ceases. If the cautery is not at hand, pure nitric acid should be applied. CHAPTER XIX. GEXITO-URIXARY ORGANS. Kidneys. — Certain diseased conditions of the kidneys, resulting chiefly from traumatism, but in some instances idif)pathic in origin, demand a careful consideration, and at times active interference, at the hands of the surgeon. Wounds. — Solutions of continuity in these organs, either as a result of concussion or from the penetration of a foreign body, are among the most dangerous visceral lesions. Rupture of the kidney occurs not only from violence applied immediately over the anatomical seat of this organ, but indirectly, as from a fall on the head or feet. The conditions which result are practically identical, whether there is a penetrating wound or not. Hsemorrhage is immediate, and is jiroportionate to the extent of kidney involved and to the vascularity of the part injured. Shock is usually well marked. Vomiting is present, -nith pallor, cold perspira- tion, rapid and weak pulse. Pain, if severe, is felt in the region of the organ, and is transmitted in the direction of the ureters, down the leg, and into the testicle of the injured side in the male, which organ is usu- ally drawn up toward the external ring. Extravasation of urine takes place, and, when the capsule is torn, finds its way into the loose areolar tissue of the retroperitoneal space. Hremorrhage occurs in the same way, as well as into the uriniferous tubules and pelvis of the kidney. The organ may be displaced by concussion, usually traveling downward and toward the median line. The s>/mj)toms, although varying with the extent of the lesion, are usually those of profound shock. Pain, not only local, but extending in the direction just described, together with the presence of bloody urine, in a patient who has received a wound in the lumbar region, or a severe concussion, and who has no bladder or urethral disease to account for ha^maturia, are symptoms which point quite clearly to the natiire of the injury. Partial suppression of urine is not uncommon. A marked elevation of temperature usually follows the reaction from shock. The febi'ile movement is chiefly due to the inflammation which follows the escape of urine into the retroperitoneal space. With the advent of pus-formation, local tenderness is increased, the area of inflammation spreads, the more superficial structures become tense, the integument is reddened, and rigors or chills occur, followed by exacei'bations of tem- perature. t> 556 A TEXT-BOOK ON SURGERY. The prognosis is imfavorable, but must chiefly depend \\\\^-\\ the ex- tent of the injury, as determined by the earlier symptoms. The treatment may be radical or conserpative. Immediate operation witliin the period of shock is scarcely to be thought of. If the symi>tonis of hsomorrhage are alarming, deligation of the extremities should be practiced, and, if syncope is still threatened, the intra-venons injection of a saline solution should l)e perfoinied. Direct operative interference, by cutting down upon the wounded organ, will be rarely called for. "With the earliest symi)tom of abscess an exploratoiy incision should be made. It is advisable U> insert the aspirator-needle at the points of greatest tenderness and induration, and, if pus is discovered, the incision should be made along the needle as a guide. If ])us can not lie obtained by using the aspirator, the incision is still indicated if the symptoms of sepsis above given are present. The organ may be readily reached by cutting ])ai'allel with, and about three inches and a half external to, the spines of the lumbar vertebne. Tiie kidney is located just in front of the outer border of the quadratus lumborum muscle, its lower extremity reaching down to the level of the umbilicus. If an abscess is found, it should be irrigated with l-to-5UUL)-sublimate solution, and free drainage established. The kidney is often the seat of morbid changes, which occur partly from internal violence and partly from idiopathic causes, which may at times justify the surgical invasion of this organ. Pyelitis, pyonephrosis, calculus, hydronephrosis, and certain new formations, as cysts, carci- noma, sarcoma, rhabdomyoma, adenoma, angioma, tuberculosis, and giimnia, are among the ciiief diseases of a surgical nature. Pyelitis, or inflammation of the pelvis of the kidney, may be caused by the irritating effects of calculi in the calices or pelvis of this organ, which do not escape readily into and through the ureter; to over-disten- tion, resulting from urethral, vesical, or ureteral obstruction, or by exten- sion of an inflammatory process fi'om below u])ward {urethritis, ei/stitis, ureteritis). It is less frequently caused by direct violence from without, or may be part of an idiopathic perinephritis. It is readily understood how a stricture of the urethra, enlarged jirostate, or an obstructed ureter would force the urine back upon the kidney, causing, in severe and chronic cases, destruction of this organ, and a pyelitis before this could occur. In like manner, the intlaniniation in a urethritis or cystitis may travel along the ureter until the pelvis of the kidney is involved. The diagnosis of pyelitis can not be so readily made out by the symp- toms referable to the inflammaticm in the pelvis proper, as by a study of the conditions which precede it. Pain, which is present in this disease, is present in a variety of kidney lesions, and, as in neuralgia of this organ (nephralgia), it is met with when no symptoms of inflammation exist. If, after an attack of renal colic, pain of a more constant and less excru- ciating character is felt, deep in the lumbar region, ])eing on one side only, and on that side upon which the colic occurred, and if pus is pres- ent in the urine where no cystitis or urethritis exists, ]iyelitis should be strongly suspected. Persisting pain in this region, in a patient sufi'ering GENITO-URINARY ORGANS. 557 from obstruction in the urinary track, beyond the pelvis of the kidney, is also strong evidence in favor of pyelitis, notwithstanding that the piis present is known to come from other sources. Added to the above, the febrile movement, and rigors of the inflammatory process, the frequent micturition, tlie exaggeration of pain upon pointed and deep pressure, and, in the later stages, the presence of a tumor, caused by the dilated organ, and the diagnosis of i)yelitis may be determined. In cases of pyelitis with complete obstruction, pus is retained, and, together with the urine excreted by the tubules not yet desti'oyed, dis- tends the pelvis, together with the kidney, causing a hydro-pyo-nephro- sis, ultimately opening into the peritonaeum, jjleura, or retroperitoneal space, or it may open through the integument in the lumbar region, or near Poupart's ligament. Treatment. — This must be directed to the relief of pain, to the removal of the cause of the disease, and to the maintenance of the patient's powers of resistance by judicious feeding. The relief of pain is obtained by the employment of anodynes and by counter-irritation, as by sinapisms, hot cloths, and cups to the lumbar region. When the disease is obstinate, and the destruction of the kidney is evident, incision should be made, and free drainage secured, or, if the patient's condition wiU justify a more formidable procedure, the diseased organ should be removed. Hi/droHepfirosis is both a congenital and an acquired lesion. In the congenital form the arrest of development may be in the ureter or urethra, mth partial or complete occlusion of one or the other of these organs. The urine, being unable to escape, accumulates and distends the pelvis and calices, causing destruction of the tubules and Malpighian tufts, and terminating, if the obsti'uction is sufficiently prolonged, in a cyst, the wall of which is composed of the pelvis and capsule of the kidney. As stated above, obstruction of the urethra usually causes inflammation of the pelvis, the result being not a simple hydronephrosis, but a hydro- pyo-nephrosis. Simple hydronephi-o.sis occurs in rare cases, when the obstruction comes on gradually. In congenital occlusion the distention of the pelvis, the atrophy of the kidney, and the development of a large cyst may occur without inflammation. The character of the obstruction will vary. Calculus in the ureter, or stricture residting from the inflam- mation caused by the descent of a stone to the bladder, pressure by a neoplasm or another organ, and all lesions of the bladder and urethra which retard or aiTest the flow of urine, may produce this condition. At times the tumor is so small that it may escape observation, or it may almost fill the abdominal cavity. The diagnosis is rarely made unless the cyst is suflSciently large to attract attention. The presence of a fluctuating tumor in the lumbar region will serve to suggest hydronephrosis, and the exploration of the cyst with a very fine needle will exhaust, by aspiration, a fluid which, under the microscope, will demonstrate the exact nature of the tumor. In those cases where the obstruction is not permanent, but recurs at intervals, the disappearance of the swelling, with the discharge of an exti-aordinary quantity of urine, may be considered almost a positive 558 A TEXT-BOOK ON SURGERY. symptom of this condition. When tlie cause is vesical or iiretliral, both kidneys will be affected. Ursemic symptoms may occur, and are present in the latter stages, when tlie destruction of the tubules is general. If tlie obstruction is gradual, the tolerance of unemia is at times great, and when only a single kidney is affected, especially if the unilateral occlu- sion is not sudden, the other organ will, in most cases, assume a functional activity sufficient for the work of both kidneys. Hydrone]ilirosis may be mistaken for hydatid cysts of this organ, for ovarian cysts, cyst of the pancreas and spleen, or for abdominal dropsy. In alidominal dropsy the fluid gravitates to the pelvis and changes with the diftVrent positions assumed. Liver-disease almost always precedes ascites. Cysts of the spleen and pancreas are rare, and the early history of their development will point to an origin away from the kidney. In hydatid cysts of the kidney the only jiositive differentiation is in the recognition of the hydatid vesicles in the urine. Treatment. — In mild cases, whether the disease is double or single, operative interference is not demanded. In stricture of the urethra or enlarged prostate, the removal of the obstruction is imperative. Symp- toms of ursemia call for the warm bath and free perspiration in the effort to eliminate by the skin the necessary quantity of urea. To this, mild purgation may be added. "When the cyst is large enough to interfere with the comfort or to threaten the life of the patient, it should be aspirated or cut down npon and drained by incision, or completely re- moved. In introducing the aspirator-needle, the most prominent jiart of the proti'usion near the last rib should be punctured. If the con- dition of the patient will permit, preference should be given to incision and free drainage of the cyst. If the cyst-wall has not adhered fii-mly to the surrounding tissues, the dissection should be carried down to the cyst and the wound jiacked with sublimate gauze for a day or two iintil adhesions have taken place, after which the contents may be evacuated. Renal Calculus. — Stone in the kidney may be formed by an aggre- gation of iirinary crystals in the tubules, calices, or j^elvis of this oi'gan. To the composition of these bodies epitlielia, mucous and other organic substances contribute. Although chiefly composed of uric acid in va- rious combinations, and oxalic acid in combination with lime, renal cal- culi may be as variable as those to be considered in connection with dis- eases of the bladder. The syin2?toins of stone in the pelvis or the kidney are referalde to the degi-ee of inflammation (pyelitis) caused by its presence, and to the interference with the escape of urine into the ureter. The condition of pyelitis is in gi'eat part determined by the shape and composition of the calculus. A mulberry calculus (oxalate of lime) produces here, as in the blad- der, a more acute and therefore more perceptible inflammatory process than the smooth uric-acid or phosphatic stones. Stones with smooth surfaces and of slow formation may remain months in the pelvis with- out causing a disturbance sufficient to attract the attention of the patient GENITO-URIXARY ORGANS. 559 or physician. This is especially tnie if the body does not drop into the opening of the ureter. Sudden occlusion of this tube produces symp- toms of general disturbance. If the stone is small and smooth, it may pass into the outlet and find its way, by gravity and the pressure of urine from behind, into the bladder without attracting the attention of the patient. When a rough stone, or one large enough to distend the tube enters the ureter, symptoms of a more than usually painful nature appear. The pain is usually referred to the neighborhood of the im- pacted substance ; it is violent to a degree rarely experienced in any other aifection. It may be spasmodic or constant. In males the testicle of the affected side is drawn up toward the external ring, and not infre- quently the pain is felt in this organ, in the scrotum, penis, and down the thigh and leg. Vomiting may be present, and constipation is the rule. Suppression of urine follows in a small proportion of cases, and, on the other hand, in some instances the quantity excreted is greater than nonnal. In the majority of cases red. blood-disks may be found in the urine. The duration of the attack varies from a few hours to days. When the stone escapes into the bladder, the relief is as sudden as the attack. In rare instances it becomes hopelessly impacted. The treatment of renal calculus is practically palliatite. The diath- esis of the individual must be corrected. The diet, mode of life, and surroundings which produce one stone in the kidney will cause the same lesion indefinitely. The character of the urine must be carefully studied and an effort made to dissolve the concretion in the pelvis. The object of this plan is to carry in contact with the stone, through the agency of the blood, certain reagents which are known to effect the dissolution of these concretions. The citrate of potash, in doses of from grs. xx-xxx, is a favorite remedy. It is especially commended in the iiric-acid cal- culus, and should be given several times a day, freely diluted with water or flax-seed tea, and continued for several months. In phosphatio calculi the benzoate of ammonia, in doses of grs. v-xx, should be em- ployed. A^Tien renal colic occurs, the chief indication is to alleviate pain, and for this purpose the hypodermic use of morjihia is most efficient. Ether narcosis may also be employed where morphia or opium is contraindi- cated. Pain is not only allayed by this means, but the relaxation of the muscular elements of the ureters secured and the passage of the calciilus greatly facilitated. In case the calcuhis becomes permanently lodged in the ureter, the operation of nephrectomy may be necessitated. This procedure will be described hereafter. Cysts. — In addition to the form of cyst which is caused by obstruc- tion beycmd the pelvis of the kidney, there may exist smaller cysts within the substance of this organ resulting from occlusion of one or more of the tubules. These cysts are usually small. When the obstruc- tion occurs near the apex of a pyramid, the entire tubular structure of that pyramid may be destroyed. Hydatid cysts, due to the lodgment of the ova of the toenia echiaococeus, are occasionally met with in the kidney. 560 A TEXT-BOOK ON SURGERY. The symptoms of renal cyst are usually obscure until the tumor be- comes large enough to exercise pressure on neighboring viscera or to appear as a swelling in the lumbar region. Fluctuation or asi)iration will determine the cystic cliaracter of the tumor. The treatment of renal cysts is conservative so long as life is not endangered by the pressure of the tumor. The danger of ruptuie into tlie peritontBum is not to be overlooked as a possible and fatal accident. Opening into the retroperitoneal space is also an exceedingly danger- r)us comi)lication. It may be put down as a safe rule of itractice that when a tumor of the kidney becomes large enough to be api)reciated by l)alpation or inspection, and is proved to be cystic in character, the con- tents should be evacuated by incision. Carcuioma may be primary in the kidney or secondary by extension from a contiguous organ, or by metastasis. In primary cancer only one organ is affected. When the disease extends from the bladder it is likely to involve both organs, and the same is true of secondary deposits by metastasis. The adenoid or encejdialoid variety is most frequently met with. All ages are liable to this disease. The tumefaction is often very rapid, and may reach enormous proportions, death resulting from asthe- nia due to the mechanical presence of the mass, as well as to the general dissemination of the disease. The diagnosis of cancer of tlie kidney will depend upon the appre- ciation of the tumor and a careful study of the history of the case. The differentiation betveeen the solid and cystic tumors, which has already been given, will eliminate hydatids or obstruction to the outflow of urine and cystic degeneration. The recognition of the cancer must de- pend upon the presence of the peculiar cachexia. The treatment should he directed to the alleviatif)n of pain. The removal of the organ is scarcely justifiable, since metastasis will in great probability have oc- curred before the character of the disease can be recognized. Sarcoma of the kidney is a ra:-e fomi of disease, and this is espe- cially true of primary sarcoma. The presence of this neoplasm, danger- ous in any portion of the economy, is especially so in the kidney, where its deep location renders an early diagnosis almost impossible. Adenoma^ lympliadenoma., and jiupilloma may also be found in this organ. Adenoma and papilloma can scarcely be recognized. The same may be said of lymphadenoma, as far as the kidney proper is concemed, for it can scarcely be recognized during life, the diagnosis depending upon the general condition of lymphadenoma and leucsemia. Anyio- mata of the cavernous variety has been noted in the kidney in rare in- stances. Rhabdomyoma of the kidney, an uniisual form of neoi)lasm. which has lately been described, may be also mentioned here. It is sup- posed to be congenital, and is composed of striped muscle-tissue. Siijjpression of Urine. — Xot infrequently after a surgical operation, especially upon the rectum and genito-urinary organs, the function of the Iddneys is partially or completely suspended. Suppression may also follow an injury to any portion of the body, or any violent emotion. It may occur in patients with healthy kidneys, but is especially ajit to be GENITO-URINARY ORGANS. 561 met with in individuals who suffer from acute or chronic nephritis. It is always fraught with great danger, demanding immediate relief, in the hope either of restoring the function of these organs at once, or of in- ducing a compensatin-y elimination of urea and the i>roducts of tissue- waste by the skin and mucous surfaces. The s>/mptoms are unnatural dryness and heat of the skin ; high febrile movement ; quick, distended pulse ; at times, headache ; pain in the lumbar region ; deluium, coma, and convulsions. These graver symp- toms are usually observed in the latter stages of complete suppression. If not relieved, the exhalations from the skin and air-passages have the odor of urine. Lastly, though not least in importance in diagnosis, is the absence of urine detei-mined by catheterization. In all surgical operations the condition of the kidneys can not be too closely studied or too carefully watched. While nephritis, pyelitis, or any kidney lesion should not deter the surgeon from a necessary opera- tion, it should render his prognosis more guarded, and thus relieve him in great part from the responsibility of failure. The immediate indication in the treatment of suppression is chieliy to excite diaphoresis. Opium is a valuable remedy, for it not only relieves pain, which is at times intense, but excites perspiration. The steam- bath is also very useful, and should be given in the recumbent posture. A ready method is to generate the vapor in a tea-kettle and lead the steam under the bedclothes by a piece of tubing. Or hot water may be poured into a large vessel placed under the blanket which is next to the patient. Next to diaphoresis, mild purgation is advisable, although it should not be carried to the extent of exhaustion. The cautious employment of the muriate of pilocarpin is justifiable in extreme cases. The depress- ing effect of this drug upon the heart should not be overlooked. The dose should not be more than one twelfth of a grain, hypodermically, and repeated in half an hour if necessary. The hot-bath should be admin- istered at the same time. If there are no sj'mptoms of acute nephritis, and if the kidneys do not resume their function within a feAv hours, diu- retics should be given. A decoction of scoparius, or extract of buchu, will be found useful. Operation for exploring the Kidney and for its Removal. — When the kidney becomes the seat of any disease which is progressive, and which, in the opinion of the surgeon, will immediately or remotely en- danger the life of the patient, operative interference is indicated. Exploration witti the Aspirator-Needle. — In operations upon these organs the following anatomical points should be borne in mind : By reason of tlie large size of the liver, the right kidney occupies a position about one inch lower than the left ; anteriorly it is partially overlapped by this organ ; its lower end is a little below the level of the umbilicus ; the ascending colon is in front. The left kidney has in front of it the descending cok)n ; the spleen at times may overlap its upper end ; its lower end is a little above the level of the umbilicus. In exploring a diseased kidney percussion will serve to locate the colon so tliat it may be avoided. If fluctuation is present, the point at 86 562 A TEXT-BOOK ON SURGERY. which it is most superficial should be selected for puncture. In general, the organ will ])e reached most safely three and a half inches from the spines of tlie vertebra'. If an exploratory aspiration demonstrates the presence of fliiid (other than blood), an incision should follow, for the reason that the escape of liquid into the letropt'ritoncal space", or into the jieritoiiaMiiii, is a danger to be avoided by incision and drainage through the lumbar region. Nephrotomy is performed by making an incision fi-om the last lib to near the iliac crest, parallel to and three and a h;df inches from the ver- tebral spines. JJividing the integument, fascia?, and fat, the edge of the quadratus lumbornm is sought, and the ajxmeurotic extension of the transversalis muscle divided, when the linger can be passed into the re- troperitoneal space behind the colon and directly upon the kidney. All haemorrhage should be arrested as it occurs. • By drawing the edges of the wound wide apart with llat retractors, the fatty capsule may be sepa- rated with the lingers or liandle of the scalpel, and the exact condition of the organ determined. If an abscess be discovered, or any lesion de- manding incision and drainage, this should be done. If the pelvis is blocked with stone, or if there is a calculus in the kidney, which may be determined by digital exploration, it should lie removed by incision. The operation is known as nephrolithotomy. The incision should be left open and drained. When the kidney has suffered displacement, and is causing distress by dragging upon its vessels, if it is otherwise normal it should be carried as nearly into its former posi- tion as possible and its capsule stitched to the edges of the wound through the abdominal walls. Catgut sutui'es of large size should be used, and these passed well into the fatty capsule which surrounds this organ. The fibrous capsule proper of the kidney should not be perfo- rated by the needle. The patient must be kept in the dorsal decubitus until adhesions have been formed sufficient to hold the organ in place. Nephrectomy, or removal of the kidney, has been successfully per- formed so often of late years that its advisability in certain diseases of this organ is unquestioned. Before undertaking this ojieration the pre- caution should be observed of determining not only the presence of a second organ, but its condition. A fatal result has followed the removal of a single or "horse-shoe" kidney. It is equally important to deter- mine, if possible, whether the opiwsite organ is capable of carrying on the necessary excretion of urine. The presence of a second organ may be made out by palpation. That it is performing its function satisfac- torily may be determined by a quantitative and qualitative analysis of the iirine discharged. The quantity of the fluid and urea eliminated ahould approximate the noi-mal. If albumen is present, and there is no pus in the urine, the gravity of the prognosis is increased. Anj^ symp- toms of urfemia should contraindicate the oiieration. The organ is reached by the same incision given for nephrotomy. When necessary to secure the vessels at the hilus, the wound may be enlarged bj' a limited transverse incision. All bleeding should be ar- rested as it occurs. When the fatty capsule is reached, it should be GENITO-URINARY ORGANS. 563 scratched through with the finger-nail, or torn between two forceps. As soon as the hilus is exposed, the vessels should be tied with doul)le-strong silk threads, divided between the ligatures, and the organ removed. The wound should be irrigated with sublimate solution, drainage-tubes in- serted, and an antiseptic dressing applied. The Ureters. — The diseases which afTect the ureters do not demand especial consideration. The inflammatory jjrocesses are those which ex- tend downward from the pelvis of the kidney or upward from the blad- der. The same may be said of neoplasms. Partial or complete occlusion from pressure within the canal, as from a migrating or impacted calcu- lus, or by pressure from a, tumor from without (as by an aneurism or neoplasm), may demand surgical interference. Bladder. — Among the congenital lesions of the bladder to which the attention of the surgeon is called, exstrophy is most frequently observed. More rarely there are several sacs, each with a ureter, or there may be a central septum dividing the bladder into two chambers of about equal size, with a ui-eter emptying into each. The bladder is at times absent, the ureters opening into the alimentary canal, vagina, or perina?um, or into the pelvis, at a point corresponding to the nonnal position of the bladder. Exstrophy^ or eversion of the bladder, is almost always met ^^ath in males. It is caused by a failure of development in the anterior pelvic and abdominal regions. The integument, muscles, pubic bones, and anterior part of the bladder- wall are missing. Through this gap the part of the bladder which may be present is protruded, as a mass of variable size (depending upon the extent of the deformity and upon the position of the patient), from one inch up to three or four inches in diameter. In the erect posture it is always largest, being pushed out by the descent of the abdominal viscera, and complicated by hernia of the intestine. The mucous membrane, which covers the mass, is in appearance not un- like a recent non-strangulated prolapsus am. The orifices of the ureters may be found opening at some jjoint on the lower portion of the protru- sion, and are often considerably dilated. In all cases of exstrophy the genital apparatus is rudimentary. The penis is wholly or in great part wanting. The urethra may be seen as a simple groove, into which the seminal ducts enter. The scrotum, at times entirely absent, may in other cases be present, lodging the testicles, or it may be bifid, with one organ in each sac, or entirely missing, the testes remaining in the abdomen, or lodged in the gi'oin or thigh. The degree of exstrophy varies in proportion to the extent of the malformation. In the more favorable cases the pubic bones are almost united at the symphysis, and the protrusion consequently small. In females the genital organs are also rudimentary. The clitoris, nymphse, vagina, and uterus may be absent or disj)laced, and only par- tially develojied. The general appearances of the tumor are the same in both sexes. Exstrophy of the bladder, even in a mild form, is a source of great annoyance. 564 A TEXT-BOOK ON SURGERY. Fio. 564. The treatment is chiefly ])alliative, and consists in the api)lication of an appai-atus to drain the urine off and prevent excoriations. A suitable instrument is shown in Fig. 504. The operative treatment consists in an effort to cover in the protruding mass by integument borrowed from the immediate vicinity of tlie tumor. No definite line of procedure can be advised. The skin may be turned from the abdomen, thighs, and perina'iim. The operati(»n is not without danger to life, and, when not fatal, fre- quently fails to benefit the patient. The chief difficulty lies in protecting the flaps from con- tact with the urine. To obviate this, the pro- cedure of Levis more nearly meets the indica- tions. It consists in establishing a false urethra from that portion of the partly developed blad- der near the orifices of the ureters through to the perina?um. A large and long needle, armed with a good- .sized thread or wire, is carried through the wall of the bladder, just at the openings of the ure- ters, and brought out in the perinseum, about an inch in front of the anus. The wire is allowed to remain as a seton, and through the fistula thus established the urine begins to How. The false urethra is enlarged, by gradual dilatation with bougies, until it is of sufficient size to carry off all the urine. When this is accomplished, the second stage of the operation consists in covering the exstrophy with integument turned over from the immediate neighborhood of the deformity. In males, one in- cision may be earned from near the center of Poupart's ligament, curving downward along the inner side of the thigh, across the scrotum or peri- nseum, as the case may demand, and terminating at a corresponding jjoint upon the opposite side. This flap is dissected up toward the edges of the exstrophy, leaving a line of attachment sufficient to sup])ly nutiition to it. A second flap is turned down from the abdomen, and the two are sewed together, the raw surfaces l)eing now external, while the epidermis is internal, and in contact with the mucous surface of the deformed blad- der. If the penis is sufficiently developed, a hole should be cut in the lower flap and this organ drawn through. The outer raw surface may be left alone to cicatrize, although it should be covered over at a subsequent operation, if there is enough integument left to borrow from. If not, the granulating surface may be covered with grafts. In females the same method of operation may be used, modifying the flap to suit the deformity, and to preserve as much of the functions of the genital organs as possible. Hernia Vesicce, or Cystocele. — Hernia of the bladder is a very rare accident. It is more apt to occur in connection with a perforating wound of the pelvis or supra-pubic region. Idiopathic cystocele occurs chiefly in the aged, and in those who have atony of the walls of this organ from GENITO-URINARY ORGANS. 565 habitual retention of urine, and, at the same time, some form of intestinal hernia. The bladder becomes top-heavy and flabby, and readily pro- lapses into the patulous inguinal or femoral canal, as the case may be. The diagnosis is evident if the tumor diminishes with the evacuation of the organ by catheterization, and becomes distended by injection through the urethra. If it should become strangulated, asjiiration with the finest needle, and microscopic examination of the fluid withdrawn, will confirm the diagnosis of cystocele. Treatment. — Hernia of the bladder should be reduced by taxis, and prevented from recurrence by a truss. If it shoiild become strangulated, and gangrene occur, an incision should be made, and the wound treated antiseptically. A fistula resulting from this practice will close by granu- lation, or can be cured by a subsequent operation. Wounds. — A solution of continuity in the walls of the bladder may be caused by penetration from without, as in the case of a shot- or stab- wound, by rupture from over-distention, by violent concussion, or by direct injury from displaced fragments of bone in fractures of the pel- vis. Penetrating wounds of the bladder are rare, not only on account of the protection afforded by the pelvic bones, but because its usual condi- tion is that of only partial distention. This is especially true of wounds received in military practice, since soldiers going into action almost in- variably empty this organ. The diagnosis of a penetrating wound of the bladder depends upon the escape of urine through the opening, or the sudden appearance of blood or particles of clothing, or other foreign matter, in the urine. Shock is usually profound. Haemorrhage is not severe, unless some of the iliac arteries or their larger branches are involved. The prognosis is always grave, though not necessarily fatal. The immediate danger is from haemorrhage and shock. Peritonitis is in- evitable if the wound is above the attachment of this membrane to the bladder. If below this line, the infiltration will lead to pelvic cellulitis. The indications in treatment are to arrest hsemorrhage, and to prevent infiltration and sepsis by free incision and drainage. When the large vessels of the pelvis are wounded, an effort should be made to arrest the bleeding by compression and the ligature. If extravasation of urine into the cavity of the peritonjpum has taken place, the abdomen should he opened and thoroughly irrigiited with warm Thiersch's solution. If this is not convenient, warm sublimate solution, 1 to 20000, may be employed, or warm water. The entire cavity should be filled with the fluid, and should afterward be thoroughly dried out with clean, soft sponges. In a case which came under my observation, the bladder was wounded at its summit, and urine escaped freely into the cavity of the peritonaeum. Tlie abdomen was flooded with l-to-200()0 sublimate solution, and carefully sponged out. The patient recovered without a symptom of peritonitis. In this case the edges of the incision in the linea alba were held open by retractors, and the warm solution poured in from a pitcher. 566 A TEXT-BOOK ON SURGERY. If tile wound iii ihr l)lii(kk'r is so situated that its edges can be stitched to the edges of the opening in the abdomen, this should be done. Silk sutures should l)e enii)!(>ye(l, and the needle passed thi'dugh the integu- ment, and then thnxigh the muscular layers of the bladder, down to the mucous lining. It is safer not to penetrate entirely through the wall. The urin(> is discharged tlirougli the wound, for a variable time, until it closes by granulation. When it is impossible to bring the edges of the wound in the bladder up to the abdominal wall, it should be (-losed at once. Fine interrupted silk sutures should be inserted, about one eighth of an inch apart. They siiould be introduced after the method of Lembert in suture of the intes- tines. The drainage-tube of Dr. H. Marion-Sims should be em])loyed, as a precaution against peritonitis. In the after-treatment it is ini])ortant that the urine be drawn with the catheter, at frequent intervals, and over- distention thus prevented. If the wound is situated at the symphysis, and is extra-peritoneal, ita edges should be stitched to the integument as above, ^\'hen the wound is through the perineal region, free incision should be made at once, in order to divide all the muscles and fascise down to the bladder, so that tlie urine may escape to the outside without infiltration. In these cases re- covery takes place in the same way as after lithotomy. Rupture of the Bladder. — This accident is much more fre- quent with men than women. When occurring in females it is usually during parturition, or from continuous pressure of this organ by uterine or ovarian tu- mors. Obstruction of the ure- thra is the chief cause of idio- pathic rupture. In enlarged prostate, or close stricture of long standing, the bladder be- comes gradually accustomed to the presence of an abnormal quantity of urine, its walls be- come thin and weak under the jirocess of dilatation, until, af- ter a sudden excessive accumu- lation, rupture occurs. In rare instances the bladder-waU is weakened by ulceration to such an extent that it gives way. Eupture of a diseased or normal bladder may follow a violent concussion, espe- Fio. .5f)5. — The relations of the peritonaeuia to the blad- der when dUtcnded. (After Tinnier.) 1, The situ- ation of the trii-'onum vesicae. 2, Prostatic urethra. GENITO-URINARY ORGANS. 567 cially if the organ be fully or partially distended, and tlie blow inflicted over the lower abdominal region. Fracture of the pelvis is not infre- quently complicated with this grave accident. Fragments of bone may be driven through the walls of the bladder, or the rupture may occur from compression alone. The location of the rupture is, fortunately, in the majority of cases, thrcjugh portions of the organ not covered by peritongeum. The anterior- inferior or sub-pubic portion and the neighborhood of the trigonum vesi- cse are most apt to give way. The symptoms of rupture are not always prominent. When violence may be eliminated, there is usually a history of over-distention, a desire to urinate, a feeling as if something had given way, with partial or com- plete relief from the pressure within the bladder. When the rupture is extra-peritoneal, the signs of infiltration in the perinseum and j^erirectal tissues are early recognized. Direct external palpation, or the introduc- tion of the finger into the rectum, will recognize the doughy condition of the tissues. If the hyjiodermic needle is introduced, a few drops of bloody urine may be withdrawn. When the napture is so situated that urine escapes into the peritoneal cavity, the earlier signs are shock, of a severe tyjie, with dullness on j)ercussiou in the hypogastric and inguinal regions. In confirming a diagnosis based upon any of the foregoing symptoms, an examination of the bladder by the sound or catheter is essential. The passage of this instrument through an opening, so that it maybe felt beneath the abdominal walls, is a demonstration of rupture. The passage of a small amount of bloody urine, with or without the catheter, is a suspicious sign, and if this small quantity is passed with each respiratory act the evidence is almost convincing. The exploration of the pelvic region with the aspirator-needle will determine the presence of urine in the tissues outside of the bladder. Treatment. — In extra-peritoneal rupture immediate and free incision should be made into the infiltrated zone, and, while this is being done under ether, the bladder should be incised as in lateral lithotomy. The free escape of urine tlux)Ugh this incision arrests infiltration and keeps the bladder in repose, thus facilitating a closure of the rupture. The treatment of rupture of the l)ladder into the cavity of the peri- ton?eum has just V)een given in penetrating wounds of this organ. The comparatively slight risk involved in an exploratory incision througli the linea alba into the cavity of the peritonjeum should encour- age the surgeon, even in cases in which tliere may be some doubt as to the correctness of the diagnosis, to perform this operation. The knowl- edge that death has so far resulted in every case of intra-peritoneal rupt- ure of the bladder in which surgical interference has not been made, adds an additional justification to the exploration of this cavity. Cifstitis. — Inflammation of the bladder is one of the most common surgical diseases. It may be acute or chronic. In the majority of in- stances only the mucoiis membrane of the neck and floor of this organ is affected. Less frequently the entire mucous lining is attacked. In extreme cases the inflammation attacks the muscular walls, and spreads 568 A TEXT-BOOK ON SURGERY. to the peritona?um and ])elvic fascia. An acute cystitis ending in rapid recovery rarely leads to hyjiertrophy or thickening of the walls of the bladder. In cJtronic cystitis thickening is the rule. Hypertrophy of the bladder may be true or false. In true hypertrojjhy the thickening is caused by an increase of the muscular elements of the organ ; in false hypertrophy it is due to new-formed connective tissue, which has in great part taken the place of the muscular fibers. When the walls are thickened and the cavity is smaller than nonnal, the hyi)ertrophy is called concentric; when the cavity is increased and the walls thickened, eccentric. Cystitis may be caused by a l)low upon the lower portion of the ab- domen, or in the perineal or ischio-rectal region, or by the direct con- tact of an instrument or any liquid or solid substance carried into the cavity of the bladder. Intlammation of this organ always exists with calculus. It may become involved by extension of an inflammatory process fmm the urethra or prostate, from the vagina, the kidneys, or ureters. Certain abnormal conditions of the urine, excessive indulgence in drinking or eating, the pressure of another organ or a neoplasm, or the presence of a new formation or parasites ^^^thin the cavity or in the walls of this viscus {Bilharzia 7i(ematobia), etc., may also produce cys- titis. To these various causes may be added stricture of the urethra or the prolonged retention of urine. Si/mptoms and Diagnosis. — Pain, and a de.sire to urinate frequently, are the earliest signs of acute cystitis. The character of the pain is burning as felt in the bladder and deep m-ethra, and lancinating as re- ferred to the meatus. It often increases with the close of the effort at urination, developing into marked tenesmus as the last few drops are forced out. It is exaggerated by direct pressure upon the abdomen, in the periiueum. rectum, or vagina. The febrile movement varies with the severity of the disease. A well- marked chill or a succession of rigors may occur with the rise in tem- perature and be present at various times in the progress of the disease. Microscopical examination of the urine will reveal the presence of epi- thelia and pus-corpuscles in varying quantity. The urine is usually alkaline, and, aside from all diseases of the kidneys, will contain a cer- tain proportion of albumen, which is always found when this fluid is mixed with pus. In severe and unusual case.s, shreds of bladder-tissue may be voided with the urine. Treatment. — Rest in bed, and in that position which gives the fullest sense of comfort to the patient, is essential. When the inflammation is confined to the neck and anterior portion of the floor of the bladder, it is advisable to elevate the foot of the bed fi-om four to six inches, and to place a pillow under the patient's hips. By these means the intes- tines and other organs are carried by gravity away from the diseased viscus, and at the same time the urine is to some extent distributed over a wider and less inflamed surface. Morphine is invaluable in the alleviation of pain and the enforcement of quiet. Hot or cold applications — as found most agreeable to the pa- GENITO-URIXARY ORGANS. 569 tient — are useful. The free administration of Vichy water, or citrate of potash (grs. x-xx) at fi-equent intervals, is advisable. The rectum should be thoroughly emptied every day by a cold-water enema. In chronic cj-stitis the treatment must be directed to the cause of the disease. Unfortunately, it is too often incurable, and then only pallia- tive measures may be adopted. In paralysis or atony of the muscular walls, or in the enlarged pros- tate of old men, retention may be relieved by the em- ployment of the soft catheter, and the condition of the or- gan improved by irrigation. When it is desired simj^ly to empty the bladder without washing it out afterward, the soft-rubber catheter of Xelaton 566) should be introduced. An instrument of good size — Xos. 14, U. S. scale — with a perfectly smooth point, should be selected. It should be thoroughly warmed and oiled, and introduced with the pa- FiG. 566. — Xelaton's catheter. (Fig. 12 to Fig. 5G7. — Velvct-t-yed ^'iim catheters, curved and straight. tient resting on the back. It should not pass beyond the neck of the bladder. When it is desired to irrigate the bladder, the double-cur- rent soft catheter (Fig. 568) should be used. A warm solution of boracic acid (grs. x- 3 j of water) is an excellent remedy. From one to two pints are poured into a fountain-syringe, and a small quantity is allowed to G.TIEMANN & CO. Fig. 508. — Double-current snfi catheter, for irrigating the bladder. run out at the end of the tube to drive out the air. The catheter is next introduced down to the constrictor urethr;e mu.scle, when the tulie from the syringe should be connected with the larger end of the catheter and a small quantity of water allowed to run in until it tills the instrument and Hows out at the smaller tube. By this manoeuvre the air is com- pletely expelled, and the catheter should immediately be pushed into the bladder. The mechanism of this apparatus is such that it permits a constant and steady current of water to How in and out of the organ without over-distention. As soon as the fluid comes out perfectly clear, the operation should ceas(\ It may be repeated every day, and oftener when necessary. If the double catheter can not be obtained, an ordi- 570 A TEXT-BOOK ON SURGERY. nary single instrument will .suilice ; but the exclusion of air is more diffi- cult. Chronic cystitis, due to stone in the bladder, pressure of other organs or a tumor, and stricture of the urethra, etc., will, ns a rule, dis- appear with the cure of these various lesions. • In cases which resist all conservative measures, incision through the perinajum, as in the median or lateral operations for stone, will be justi fiable. This operation will be given with affections of the pi'ostate. Farali/sis of the bladder may be partial or complete. It may be caused by violence inflicted directly to the organ or in its immediate neighborhood, 1)y pathological changes in its muscular tissue, or by traumatic or idiopathic lesions of the cerelno-spinal axis ; or it may occur under the influence of certain emotions in which no lesion is rec- ognizable. A blow upon the hypogastric region has been known to cause tempo- rary paralysis of the bladder. The unskillful introduction of an instru- ment, and the prolonged over-distention of the organ which is common in prostatic hypertrophy, will induce the same condition. An operation upon the geuito-urinary apparatus is almost always followed by tempo- rary paresis of this organ. Operations ujjon other portions of the econ- omy under prolonged ether or chloroform narcosis are also frequently followed by loss of function in the bladder. The pressure of jjarturition may produce a like result. Severe concussion of the brain or cord, com- pression of one or both of these ganglia from fracture or displacement of their bony envelopes, hjemorrhage, aneurism, or the presence of neo- plasms and various pathological changes in the meninges and in the gray and white matter of the cord and brain, will lead to paraly.sis of the bladder, varying in duration with the severity of the lesion. In the treatment of this affection the first indication is to prevent prolonged distenticm of the organ by catheterization, which should be repeated at least twice in twenty-four hours. If a catheter can not be introduced, supra-pubic aspiration should be practiced. Cystitis may be avoided if the urine is carefully and regularly draAvn off. Attention should next be directed to the removal of the cause of the paralysis. Retention. — As just stated, paralysis of the muscular walls of the bladder is a cause of retention of urine. Lesions of the sensory nerves of this organ also induce retention, which is proportionate to the loss of sensibility. The chief cause of this condition, however, is some form of obstruction at the neck of the bladder or in the urethra. As will be seen in treating of hypertrophy of the prostate, this is a frequent cause of retention. Organic stricture, spasm of the constrictor urethra (or "cut-off") muscle, and mechanical occlusion of the urethra, are also com- mon causes of this affection. Diar/nosis. — Distention of the bladder may be determined by palpa- tion, percussion, and exploration. In this condition it rises well above the level of the symphysis pubis, at times as high as the uml)ilicus, and causes tension of the recti muscles or protrusion of the abdomen. By direct pressure, the desire on the part of the patient to urinate may usually be increased, and, if the abdominal walls are thin, the spherical GENITO-URINARY ORGANS. 571 character of the organ may be recognized. Upon percussion, dullness is present and fluctuation may be appreciable. In suppression of urine all of these symi)t()ms are absent, the skin is usually hot and dry, the pulse rapid and full, and the temperature is several degrees above the normal. The introduction of a catheter or puncture of the bladder with a small-sized aspirator-needle, just at the ui)per level of the symphysis, will detennine the diagnosis. Fig. SCSI. — Fililbrm catheter. In treatment, the evacuation of the contents of the organ is the im- mediate indication. The patient should be put to bed and given the benefit of a full dose of opium. This agent is useful in alleviating pain, in securing relaxation of the muscular elements of the urethra and pros- tate, and — by producing diaphoresis — in diverting fluids from the kidnevs , , * riG. 670. — Black iicucli cutlicter, l.luut-p'.iuteJ. to the excretory appara- tus of the skin. A soft- rubber (Nelaton) cathe- ter should be preferred ; but, if this can not be •introduced, a lirmer, olive-poinied instrument (Fig. till) should be em- ployed. The silk-woven and gummed catheter (Figs. ,072 and i)7;3) is also a useftU instrument, and if, on account of its elas- ticity, it can not be introduced, the stylet of Prof. Keyes (Fig. U74) should be inserted into the catheter to give it the required stiffness. The Flo. 571. — Black Frencli catl;cter, oUvc-pomtcd. Fig. 572. — Gummed silk-woven catheter. Fia. 573. — Gummed silk-woven bougie. Fig. 674. — Dr. Keves's wire stvlet. ^ — o metal catheter (Fig. 575), if properly constructed and carefully intro- duced, can be made to safely overcome any ordinary resistance. It should be of heavy silver, strong, perfectly smooth, and should have a curve corresponding to that of the normal urethra. In size it should cor- respond to No. 10, 12, or 14, U. S., and the larger sizes should be preferied. 572 A TEXT-BOOK ON SirRGERY. The introduction of a metal catheter or sound thn)U(Kl-C(uj)iisdeK — EpUhcliit. — Pus-cells in the urine may come from an intlamnuition in any ijortion of the urinary tract, from the kidney to the meatus, or from the communication of a sinus or abscess with the urinary apjjaratus. Urine containing jtus may be acid, alka- line, or neutral in reaction. In acid urine the corpuscles are i)rominent and easily recognized ; when the reaction is alkaline, they are usually desti'oyed, and ajjpear as ro]iy or gelatinous sti'ings, more resembling mucus than pus. If the urine is examined immediately after being passed, a few corpuscles may be recognized. When allowed to stand for some minutes, the pus-cells collect in tlie bottom of the vessel. Ex- amined with the microscope, they are seen to be spherical and faintly gninular. On account of the absorjition of water, they are swolh^n and less distinct than i)us-cells from a lecent abscess. The addition of acetic acid renders the nuclei more distinct. The source of pus found in the urine may frequently be determined from the symjjtoms present, to- gether with the microscopical appearances of the urine. If with the pus-corpuscles flat, large epithelia are abundant, the inflammatory pro- cess is in all probability situated in the bladder where these epithelia belong. In females a larger, flat epithelium from the vagina often finds its way into the urine. The cells from the vagina are more often disposed in drifts or groui)s than the bladder epithelia. Large spherical or po- lygonal cells may come from the kidney-tubules or the male urethra. They are about twice the size of a pus-corpuscle. Whether they are derived from the kidnej^ or the urethra may in great part be determined by the presence or absence of urethritis. Conical or ham-shaped cells may come from the pelvis of the kidney, prostate, and glandular appa- ratus of the urethra. They are usually not so abundant as the other varieties. IRenuduria. — Blood in the urine may come from traumatic or idio- pathic haemorrhage into the Malpighian tufts or kidney-tubules ; from the pelvis or ureters as a result of calciili or ulceration ; from the bladder as a result of instrumentation, calculus, wounds, foreign body, neo- plasms, ulceration, parasites, or the hpemorrhagic diathesis ; from the prostate or accessory organs and the urethra. The administration of certain remedies may account iov the appear- ance of blood in the urine. Htematuria occurs at times as a symp- tom of malarial fever, and, in women, as a form of vicarious men- struation. Blood in the urine may lie recognized by its characteristic coagula, by the red or reddish-brown color it imparts to this fluid, the presence of the corpuscles under the microscope, or the fibrinous casts of the tubules of the kidney or ureters. In rare instances the blood-disks are entirely destroyed, and the coloring-matter set free. This condition is apt to occur in ammoniacal urine. When urine containing ])lood is boiled, a white or cloudy coagulum is formed, its density depending upon the quantity of blood present. H.EMATURIA. 579 If bloody urine is allowed to stand without being agitated, the cor- puscles settle to the bottom of the vessel, and may be recognized by their red or amber color. Under the microscope they may assume different shajjes. In acid urine the disks retain their bi-concave conformation for a long time. When the hsemorrhage is slight, thej^ float isolated ; if pro- fuse, tliey may be caught in coagula or collect in rouleaux. If the re- action is feebly acid, or where the c<)ri:)uscles are submitted for a consid- erable time to the action of the urine, they lose their bi-concave shape, and become distended, swollen, and spherical. They may be recognized from pus-corpuscles by their smaller size, transparency, and in not con- taining granular bodies. At times they retain their flat shape and appear with serrated edges. Blood-casts usually come from the kidney-tubules, and are composed of fibrin in which the red disks are entangled in varying proportion. In some, large clusters or groups of blood-corpuscles are seen, with an occasional epithelial cell from the kidney or urinary passages. When the disks have been completely destroyed, as in the decomposition of the coloring-matter in ammoniacal urine, and the organic elements of the blood are not recognizable with the microscope, the spectroscope may be relied upon to demonstrate the presence of the coloring-mattei'. In determining the source of blood in hsematuria the following points should be considered : When the bleeding is urethral, the first discharge of ixrine is most deeply colored. A clot of blood preceding or accom- panying the discharge of urine indicates urethral hsemorrhage. In males, if spermatozoa are entangled in the coagula, the suspicion of hjemor- rhage from the vasa deferentia or x>rostatic apjiaratixs is entitled to con- sideration, although the fact must not be overlooked that these elements may mingle in the urethra with blood from any part of the urinary passages. When the bleeding is from the pelvis of the kidney, pain and other symptoms of stone or pyelitis will often precede the hjematuria. Not infrequently, however, the hajmorrhage is, next to the presence of pus in the urine, the first indication of pyelitis. In haemorrhage from the bladder there are often symptoms of cystitis which will point directly to this organ as the source of tlie bleeding. In diiferentiating the origin of blood from the kidneys, ureters, and the bladder, the method of Thompson and Van Buren may be resorted to with success. Introduce a soft catheter just within the neck of the bladder, draw off the contained urine, and wash out the organ with clean water. If, during the irrigation, the water which flows away contains blood, the hfemorrhage is from the bladder-walls. If it flows away clear, then empty the bladder, place the finger over the end of the catheter, allow it to remain introduced, and wait until a small quantity of urine has accumulated. This is drawn off, and, if it is bloody, and if the clear water now thrown in comes out unstained, the inference is fair that the bleeding is from the ureters or beyond. Hjpmorrhage from the uretlira is rare except from violence, the lodg- ment of calculi, or from ulceration. 580 A TEXT-BOOK ON SURGERY. ILcniatiiria clue to parasitic lodgmont in tlie walls of tlie bladder is exceedingly rare in this country. In 1883 a young man of white parents — a native of Natal, Africa— cauie Tinder my care on account of chronic hsematuria. He was at this time twenty-six years of age, and had had bloody urine at intervals for thirteen years. His health was not seriously impaired. The urine was faintly acid ; specific gravity l-()20, with oidy a trace of albumen, which was readily accounted for by the slight amount of blood. About the middle and toward the last stage of the act of mic- turition, a few strings of clotted blood were dis- charged. Placing these under the microscope, I discovered a number of bodies (Fig. 580) shaped much like a watermelon-seed, except that the small end was more pointed. These were evidently the eggs of the parasite known as Bllharzia hivmato- hi(t, the hsematuria resulting from the rupture of ^'"zirhmni'itobia"' r'cn'- cai^illaries caused by the ]iresence of nests of these Dated Hood -disks. 3, ^va in the mucous membrane of the bladder. This ipithelmm. 4, rus-cell. (From the author's case.) disease IS frequent in Africa and Asia, but almost unknown in North America. The l)ody of the male parasite is about four lines in length, thread-like, and ilattened ante- riorly (Aitken) ; the female a little shorter and more delicate. They inhabit by preference the portal vein and the walls of the bladder. In treating my patient I saturated him with large doses of santonin for a week, and injected the bladder daily with alcohol, beginning with a l-to-20 solution, and increasing it to the extreme degree of tolerance V)y the bladder. The patient improved in every respect, but the hjcmatu- ria was not entu'ely arrested when he returned to Africa in November, 1883, since which time I have not heard from him. The parent distoma is killed by high febrile movement, and with its death the hajmaturia ceases. The treatment of h?ematuria must be directed to the disease of which it is a symptom. The patient should be required to remain in the re- cumbent posture. The administration of the fluid extract of ergot, 3j-ij, is highly recommended without regard to the source of the bleeding. Large doses of citrate of potash will prove beneficial in rendering the urine less irritating. Opium is advisable, not only on account of the relief from pain it affords, but because it secures comi)lete quiet, which is essential, and prevents the too frequent evacuation of the bladder. When the ha?morrhage is from this organ, and does not yield to the measures above given, the injection of cold or hot water, or of astringent solutions, may be employed. If villous growths are present, they should be removed by cystotomy. Stone in the Bladder. Urinary calculi may form in any portion of the kidney, in the pelvis or ureters, in the bladder or urethra. They are concretions of the va- rious inorganic substances which are common to the urine. Organic STONE IN THE BLADDER. 581 particles, such as epithelia, mucus, and various inflammatory products, often enter into the formation of calculi. When an aggregation of the urinary salts occurs within the kidney-tubules, the probabilities are that the stone so formed will remain imprisoned in this organ (renal calculus) until removed by ulceration or operation. Forming in the larger straight tubes of the pyramids, a urinary concretion may, while yet minute, es- cape into the calix and pelvis, and pass down the ureter into the blad- der, or remain lodged in the pelvis or excretory duct. It is, moreover, probable that the majority of calculi found in the bladder, or passed by the urethra, originate as concretions in the straight tubes, calices, or pelves of the kidneys, whence they drift outward to the bladder, and there by continued accretion become large enough to attract attention, even if the transit along the ureter was unnoticed. Undoubtedly a fair proportion of vesical calculi are formed in this organ proper, and the greater number of these may be grouped in the class of calculi which form around nuclei composed of foreign substances, or animal matter, such as epithelia, inflammatory products, etc. Conversely, it is admitted that animal matter may form the nucleus of a kidney or pelvic concretion, while a bladder calculus may also be formed by accre- tion of the purely inorganic elements of the urine. A calculus is rarely of uniform composition, more frequently com- bining two or more inorganic as well as organic elements in its forma- tion. In the nomenclature it is the practice to give to the stone the name of the preponderating element. That most commonly observed is comjiosed principally of tirlc acid and the urates. These stones are of fair consistency, yellowish or light-brown in color, not very smooth when single, yet not so rough as oxalate-of-lirae concretions. They may attain a diameter of two or three inches. As a rule, they form in urine which is distinctly acid in reaction. The mulberry or oxalate-oflime calculus is next in order of fre- quency, and relatively more so in childi-en than in adults. They may exist in all sizes, and vary greatly in color. The smaller concretions are light in color and fairly smootli ; the larger are exceedingly rough, with jagged edges, and are dark-brown in color, in rare instances white. Oxalate-of-lime calculi usually commence in the kidney, and pass as small particles to the bladder. The most severe forms of "renal colic" are due to the slow and painful passage of these rougher concretions along the ureters. PhospJiatie calculi come next in order of frequency, and are divis- ible into three classes : the aiinnoiiio-mafinesian and phospliate-of-Jime {fusible) calculus, neutral phosphate of lime, and ammonio-magiiesian calculus. Fusible calculi are more often met with than the other two forms of phosphatic concretions. They are g'ray or white in color, readily friable, iind light. The hardness is proportit)nate to the lime phosphate present. They attain large size, and conform themselves to the shape of the bladder. 582 A TEXT-BOOK ON SURGERY. The neutral phosphate-of-I i me calculus is rare. It may furni in the kidney, though it originates chiefly in the bladder. All the phosphatic calculi are chiefly vesical ia origin, being found with amniDiiiacal urine, which is present with chronic vesical catarrh. Tlie aminunlo-mugneslan phosphatic concretion is equally rare, and differs very slightly in its chemical and physical characters from that just described. Other and still rarer forms of urinary concretions are the following : Cysthi. — This variety is usually smooth, occasi(mally corrugated, yellow in color when fresh, inclining to a greenish hue when long removed. They break readily, do not show a marked concentric arrange- ment, and are somewhat greasy to the feel. Xanthic or uric-oxide calculi have only been reported in two or three instances. They are of concentric formation, smooth and gi-easy to the feel, and vary in color from gray to brown. Qarhonate-of-llme calculi are usually inultiple, and are light-gray in color and chalky in consistence. Orf/(tnlc calculi, consisting of epithelia, blood, etc., are not infrequent as nuclei for other varieties, but exceedingly rare as independent forms. Stone in the bladder is a misfortune that may befall every age and condition of human life, from the foetus in t/fero, to the old and decrepit. The period of greatest exemption is from twenty to fifty years of age. It is comparatively frequent in children, and here must be of renal origin and due to the excess of inorganic elements in the urine, since obstruc- tion and inflammatory diseases of the urinary tract rarely exist at this age. After fifty, when prostatic, cystic, and urethral obstruction are more frequently met with, the formation of calculi, vesical in origin, is more common. As to sex, stone is more frequent in males. It was formerly argued that there was no difference in the frequency of stone in the sexes, but that the short and dilatable urethra of the female allowed a ready escape to the concretion before it became sufficiently large to produce any organic disturbance. When, regardless of the statisti- cal evidence which shows that the number of deaths in males from urinary calculus is ten times greater than in females, we consider that one of the most frequent cau.ses of stone is the gonty diathesis, and that gout is more frequent in men ; and, again, that prostatic and urethral obstruction is peculiar to this sex — it must be conceded that the conditions for the formation of calculi are more frequently present in males. In the (Btiology of stone in the bladder two great factors are recog- nized : The one includes all conditions of the economy which favor pre- cipitation of the inorganic elements of the urine ; the second all ob- structive and inflammatory lesions which produce decomposititm of the urine in the bladder, the detachment of epithelia, and the accumulation of other organic elements which serve as nuclei around which the salts of the urine are congregated. In the first category are hereditary tendencies, such as gout and I'heu- matism. Certain conditions of malnutrition undoulitedly lead to a pre- cipitation of the urinary salts, for children poorly fed and cared for are STONE IX THE BLADDER. 583 much more apt to suffer from calculus than those which are well fed and comfortably clothed and sheltered. It can scarcely be doubted that residence exercises a causative influ- ence upon the formation of calculus. In the United States, ]yorthern Alabama, Tennessee, and Kentucky afford a large number of this class of cases, while in New York and the New England States stone in the bladder is exceedingly rare. In the group of local causes may be classed all cystic diseases in which the products of inflammation collect in the bladder and fonn nuclei, around which conci'etions occur ; prostatic enlargement induc- ing retention, cystitis, and decomposition of urine ; stricture, and all obstructive and inflammatory lesions of the iirethra which may involve or affect the integrity of the bladder ; the presence of any foreign matter in the bladder, or paralysis of the bladder from any cause. The iiymptoms and Diagnosis. — It may be stated at once that, how- ever much has been and may be said of the value of the various symptoms of stone, the diagnosis rests upon one simple expedient, the introduction of a metallic instrument into the bladder, and in contact with the stone. For this purpose the ordinary steel sound is usually sufficient. The bladder should be allowed to contain about half a pint of fluid, and when the instrument is introduced it should be manipulated so that the convexity of the curve will glide over the floor of the bladder back and forth from the neck to the posterior wall of the organ, at the same time depressing the bladder toward the rectum. By this manoeuvre the stone will be induced to gravitate to the deeper portions in contact with the instrument, or so close to it that a sharp, quick turn to right or left will bring the calculus and metal into appreciable contact. In certain cases of prostatic hypertrophy the calculus may remain concealed immediately behind the enlarged organ, and in such a position that the sound can not be brought in contact with it. Under such conditions Thompson's searcher (Fig. 581) will be found useful. The objection to this instrument is the Fig. 581. — Thompson's searcher. difficulty of its introduction from the abrupt nature of the curve near the tip. When once introduced its value is readily appreciated. Turning its point downward and moving as if to withdraw it, there is no jiortion of the floor that it will not thoroughly search. When a stone can not be appreciated with a full or half-tilled bladder it may be felt if this organ is completely emptied. Not only is the cal- culus driven toward the neck of the bladder when it is emptied of urine, but the hardness and weight are more readily appreciated, since it is held in the grasp of the organ, and can not slip away when the sound touches it. In some forms of vesical calculus the stone becomes partially or completely encysted in some portion of the bladder-wall. The calculus may drop into an abnormal pouch in the bladder ; it may sink by a pro- 584 A TEXT-BOOK OX SURGERY. cess of ulceration into the walls, and be partiallj' or completely snr- rounded by a newly fonned inflammatory tissiie, or it may have been lodfred in the ureter near its termination. Again, a stone may be caught in the upper portion of the bladder without being sacculated. In sounding for stone in adults, ether narcosis is not always required, especially where there are no symptoms of severe cystitis and tenesmus. In children an anaesthetic should always be em- ployed. When the calculus can not be felt after careful search, it is at times a successful expedient to introduce the finger into the rectum and make upward pressure upon the base of the bladder, and firm ])rpssure downward ui)on the abdomen, just above the symphysis pubis. Vesical calculus may be suspected in a patient who has had renal colic, or has passed by the urethra particles of gravel, and afterward develops a cystitis. Not infrecpiently, however, a concretion goes fi'oni the kidney into the bladder without attracting the attention of the patient. If it lodges here, and increases slowly in size, it may remain for mcmths or years without giving any symptoms of cystitis, or mark('(l annoyance. Usually, however, when a stone is present, and is so light and smooth that it does not affect the mucous membrane of the bladder, it attracts attention by mechanical interference with the escape of urine, dropping at times into the orifice of the urethra, and suddenly shutting off the flow during micturition. When a stone, by reason of its size, weight, and roughness, begins to cause cystitis, frequent micturition is a prominent symptom. A burning or smarting pain, referred to the end of the penis, is a frequent symptom in this, as in idiopathic inflammation of this organ. At times the i)ain is referred to the scrotum, penis, uterus, and other organs, or along the nerve-tracts in the lower extremities. In any jolting movement, as in riding on horseback, or in vehicles without springs, or in walking about, the pain is increased. Tenesmus is often violent toward the end of urina- tion, when the stone is grasped by the contracting bladder. The urine almost always contains pus, and blood is frequently present. Ha>matuiia, with calculus, occurs chiefly during the waking hours, when the patient is moving about. It is more apt to be met with in oxalate-of-lime calculi than in the other varieties. In the rare instances in which st(me exists with villous growths of the bladder, h;emorrhage is often excessive. When a calculus is of large size, it may by pressure produce pain and symptoms f>f disturbance in other organs, as the vagina, uterus, or lec- tum. The size and character of a stone in the bladder may, in a measure, be determined by exploration with the sound, as well as by palpation. A large stone is usually felt as soon as the sound enters the neck of the bladder. The sense of resistance is greater, and a fair idea of its proportions may be made out by passing the metallic sound along its surfaces. A small stone is often with difficulty recognized. Pressure above the sj-mphysis pubis, and intra-vaginal or rectal exi^loration, are not without value in estimating the size of a calculus. If the click of the sound is sharp and clear, and if the surface is rough and grating to the sense of touch conveyed along the instrument, an oxalate-of-iime stone STONE IN THE BLADDER. 585 may be suspected, and, if the patient is a child, the suspicion is strength- ened. Hfematuria, and all the symptoms of cystitis, are, as a rule, in- creased with this form of calculus. In patients A\ith the gonty or rheu- matic diathesis, uric-acid stone is the rule. The acidity of the urine in a measure excludes phosphatic calculus. In the exceptional instances in which a portion of the surface of the bladder has become incrusted with the inorganic elements of the urine, this condition may be detennined by the immobility of the concretion when the sound is brought in contact with it. The absence of a spherical calculus can be determined by digital exploration through the rectum or vagina, coraljined with pressure from above the symj^hysis pubis. Treatment and Prognosis. — The attempts to dissolve vesical calculi by the administration of remedies by the mouth, or by solutions thrown into the bladder, have not met with encouraging success. While there is little doubt that the correction of a dyscrasia which is favorable to the fomiation of stone may prevent or retard the further growth of an ex- isting concretion, there is no evidence to prove that a stone in the blad- der was ever removed by this plan of treatment. The proper treatment of stone in the bladder may be divided into the curative and palliative. To the former belong the operations of lithot- omy and lithotrity ; to the latter are systematic medication and hy- giene, together with the employment of all local means calculated to relieve pain and prolong life. In deterndning ui)on the proper method to be adopted, the following points should be duly considered : In male patients under the age of seventeen the cutting operation is preferable, for the reas(ms that (1) the caliber of the urethra is usually too small to admit of the instrumentation necessary to lithotrity ; (2) the mortality rate after lithotomy in this class of patients is very low — about 5 per cent. After this period, as between lithotomy and lithotrity, the former operation is demanded (1) in all cases of stricture of the urethra, where the caliber of this tube is narrowed to such an extent that the re- peated introduction of the lithotrite and washing-apparatus is difficult or impossible; (2) in prostatic disease, with hypertrophy to such an extent that it offers an impediment to the introduction of the instruments, and renders the seizure of the stone or fragments difficult of accomplishment ; (3) when the stone is more than one inch in diameter ; (-1) when it is so hard (oxalate of lime) that it can not be crushed by the employment of a reasonable degree of force ; (5) when chronic cystitis and vesical intoler- ance exist ; (6) in a jjatient suffering from any foi-m of nephritis. Lithotrity. — If the symptoms are not so distressing as to demand immediate interference, from ten days to two weeks should be devoted to the careful preparation of the patient. It is not only important to improve the genera,l condition, but also to accustom the urethi-a to the introduction of the sound. The instruments rec^uired are the lithotrite and an apparatns for wash- ing out the detritus. Of the various crushing-instruments which have been introduced, that of Sir Henry Thompson is to be jiref erred (.Figs. 582-585). It is com- 586 A TEXT-BOOK OX SURGERY. niendable for its lightness, strength, and smooth action. With the heavier instruments the sense of touch is not so delicate and acute. The lighter lithotrite is strong enough to crush any calculus which may be safely removed by this opera- tion. Moreover, it Is especially to be commended for the fenes- trated jaw in the female blade {Fig. 582), which allows the male blade to pass entirely through, and thus avoids the danger of choking and fouling. It consists of a male blade (Fig. 583), or sliding rod, which fits into a fixed or female blade (Fig. 584j, which is deeply hollowed out for its reception. Fig. 582. CTiEMA/an-co. -Fenestrated jaws of Thompson's lithotrite. i. .TIEWftNH &.C3 Fig. 583.— Male blade of Thompson's lithotrite. 0. 7l::MAf\JiM Si CtJ Fin. 584. — Female blade of Thompson's lithotrite, The seizing and crushing action of the lithotrite is double. '\\'hen tlie male blade is carried through the hollow handle into the slot in the female blade, a simple and rapid to-and-fro movement can be executed by push- ing or pulling on the male blade with the right hand, AvhOe the left 6-. TIEMANN. CO.N. k" Fio. 585.— Thompson's lithotrite adjusted. Steadies the female blade, to which the handle is attached. This move- ment can be made very effective in seizing the stone and in crushing the smaller fragments without taking the extra time in sliding the catch which throws on the screw-motion of the instrument. When, however, a stone is caught in its grasp by the sliding move- ment just described, and is so solid and resisting that a sufiicient and safe crushing force can not be employed, the catch on the top of the handle is slipped upward. The sliding movement is now impossible, and the more powerful screw-motion substituted. By turning the wheel at the end of the male blade to the right, the stone can be felt to give way under the crushing force. In the removal of vesical calculi by this operation two procedures are recognized, viz., complete and incomplete lithotrity. In the former, or Bigelow's method, ether narcosis is required : the stone is entirely crushed, and the fragments washed out at a single STONE EST THE BLADDER— LITHOTRITY. 587 operation. In the latter, anfesthesia is not employed ; the calculus is only partially comminuted, and the fragments are left to pass oil with the urine. Complete lithotrity has almost entirely superseded the older operation. It is preferable in all cases where the condition of the patient justilies the risk of shock from a capital operation under ether narcosis. Operation. — Tlie patient, being narcotized, is placed upon the operat- ing-table, in the dorsal decubitus, with the pelvis raised about half a foot, by pillows placed under the sacrum. If the bladder has not been emptied just before the operation, the urine is now drawn off and about one pint of tepid water injected, thus distending this organ and rendering the mucous membrane less liable to injury from being picked iip by the in- strument. The litbotrite, having been properly warmed, oiled, and tested as to its working capacity and strength, is now prepared for introduction, by sliding the male blade completely down until its tip passes into the fenestra of the female blade. As the convexity of the male blade is serrated, great care must be taken not to push the rough surface beyond the level of the female blade, since the introduction of the instrument, improperly adjusted, would do iinnecessary violence to the floor of the urethra. A right-handed operator should stand at the patient's right side. The instrument is locked and carried into the bladder by the same manoeuvres as given for the introduction of the sound or metal catheter. "When the beak is well into the bladder, it is earned along the floor, with the tip pointing upward, until it meets with the resistance of the posterior wall of the bladder, when it should be slightly withdra^^Ti. The handle should now be elevated, in order to depress the floor of the bladder with the con- vexity of the curve. Held firmly in this position, the lithotrite is opened by withdrawing the male blade about two inches. The operator should now strike the handle of the instrument with the knuckles or hand, hard enough to carry the concussion to the bladder, in order to dislodge the calciilus and allow it to fall into the lowest portion of the organ, and within the grasp of the lithotrite, which is now closed by pushing the male blade down. If the stone is seized, it will be made evident by the failure to close the blades, and, when caught, it should be firmly held, the screw-movement adjusted, and the wheel rotated slowly. Having thus secured the stone, the instrument should be moved to and fro, in order to assure the operator that the wall of the bladder is not canght. In crushing a calculus, the rapidity with which it is done should be de- termined by the sense of resistance experienced. It is not safe to employ force sufficient to spring the blades. A stone which can be safely crushed will yield perceptibly under a few turns of the screw. Phosphatic stone can often be rapidly comtniniited without adjusting the screw. Uric-acid calculi require more power, while the oxalate-of-lime at times can not be crushed at all. If the mana?uvre above described fails after being several times care- fully repeated, search must be made in other quarters. Holding the instrument beak upward, the convexity still upon the floor of the blad- 588 A TEXT-BOOK ON SURGERY. 1 *»K STOHLMAg^^!;/ 'TARRF &IOi der, separate the bhules, turn the shal't liali' over to tlie riglit, and then close the blades. If the stone is seized, hold it steady, adjust the screw- motion, tighten the grip by a slight turn of the wheel, and carry the instrument back to the middle line with the beak jjointing upward. If it does not move freely, the indication is that the bladder has been picked up, and of course the blades must be separated and another effort made. With the instrument shown there is little danger of this accident. The same manaHivre may be tried on the ox)posite side. If there is prostatic enlargement, it may be necessary to turn the beak do\\aiward into the pocket on the floor of the bladder. If, after a half-hour's seai-ch, the seizure has not been effected, the operation should be discontinued. Wlien the stone has been seized and broken once, the same manoeuvres should be carefully yet rapidly repeated until no large pieces remain. It will usually be found easy to crush the smaller jjieces by the sliding movement alone. The instrument should now be closed until the blades have the same relatitm as when introduced, and then withdrawn. The evacuator consists of a rubber bulb capable of holding about one |)int. At the upper end is a funnel and stop-cock for filling and closing the appa- ratus. Below is attached a glass globe, in which the particles of stone gravitate as fast as they are drawn into the evacuator. Between this and the rubber bulb is a sec- (md stop-cock, and a place for attaching the catheter. It is advisable to insert a piece of rubber tubing, about five inches in length, between the catheter and the evacuator, in order to prevent the jarring motion impart- ed to the bulb from being conveyed to the instrument in the bladder. The catheters (Fig. 580) are of different sizes and shapes, ranging from No. 14 to No. 25, U. S. The evacuation is much more rapid with the larger instmxments. However, the urethra should not be over-distended. In general, the catheters which are only slightly curved near the tip, with the eye at the extremity, are preferable. In filling the bulb, in order to exclude the air, the glass ball is first detached, filled with clean warm water, and readjusted. Both stop-cocks are now opened, the end of the tube closed with the finger, and water poured into the funnel until the bulb and tube are filled to overflowing. The cocks are then closed, and the instrument intrusted to an assistant. The catheter, well oiled, is car- ried into the bladder, and as the water is escaping the lower end of the rubber tube attached to the evacuator is slipped over the end of the instrument. The bulb is grasped between the thumbs and fingers of both hands and squeezed, thus forcing the greater part of its contents Fio. 586. — Tlionipson's iinj^roved evacu- ator uud catheters. STONE IN THE BLADDER— LITHOTOMY. 589 into the bladder. It is now allowed to expand, the water rashes back out of the bladder and brings with it the smaller jiarticles of stone which fall down into the glass sphere. This i)art of the operation may be expedited by rapidly half emptying the bulb into the bladder, and as rapidly allowing it to expand. When it is seen that particles of the calculus cease to fall into the receiver, the catheter should be withdrawn, the litho trite reintroduced, and a second crushing done. The bladder is again washed out, and these operations should be alternated until all detritus is removed, unless alarming symptoms should supervene, when of course all operative measures should be discontinued. If tlie glass receiver becomes filled, it should be detached and emptied. At times particles of calculus become lodged in the catheter or tube, and require to be dislodged with a stylet. From one to two hours may he allowed for this operation fi'om the commencement of the anaesthesia. The prog- nosis will be more favorable with the shorter period, but it is wiser to proceed carefully and remove the stone thoroughly, even if a longer time is required. The absence of all fragments can be recognized by placing the ear over the bladder at the symphysis while the evacuator is being worked. The click of any fragments against the catheter can be dis- tinctly heard. The introduction of a sound will also determine the presence of any pieces. In the after-treatment opium is essential to relieve pain and tenesmus. Citrate of potash, grs. xx, three or four times a day, with flaxseed-tea, will render the urine less irritating. The soft catheter may need to be employed to evacuate the bladder. In incomplete lithotrity the crushing is done in the same manner as just described. A fair degree of anaesthesia may be secured by the em- ployment of cocaine. The lithotrite is only introduced once, and not more than five or ten minutes are consumed in the ojjeration. The evacuator is not employed, the detritus being expelled in the act of urination. Cystotomy or Lithotomy. — Cutting into the bladder for the removal of stone is performed through the perina^um or through the abdominal wall, just above the symphysis pubis. Incision through the rectum in males is no longer a recognized jirocedure, while the vesico-vaginal jjjo- |^}jg gulde dcvolves, stands beside the pa- tient's abdomen, facing -FergussoD's guide for lateral lithotomy. the Operator. If the bladder is not fairly distended with urine, a Nelaton's catheter should be introduced, and about a pint of lluid injected. A Fergusson's guide, grooved laterally' (Fig. 087), is next carried into the bladder. The probabilities are that the stone will be felt by the sound. If the calculus has been recognized within a day or two, and if in the mean time the urine has been carefully watched and no STONE IN THE BLADDER— LITHOTOMY. 591 solid substance has escaped by the urethra, no prolonged effort should be made at this juncture to demonstrate its presence. The proper posi- tion for the guide is shown in Fig. 588. The shaft is held about perpendicular to the surface of the table, the point well into the bladder, while the convexity of the curve rests against the perinjeum. The scrotum is now lifted directly upward, and the primary incision is made with the sharp scalpel (Fig. 63). It commences in the median line about one inch and a half directly in front of the anus, and is carried downward and outward as far as the Kia. 5S8. — Guide in position in lateral lithotomy. (After Bryant.) Fio. 589. — C D, Line of incision in lateral litliotnniy. J3 A, Imaginary line between the tuberoiiities of the iscliia. (.\fter Maelise. i posterior margin of the anus, jiassing half-way between the inner sur- face of the patient's left tuber ischil and the anal margin (Fig. 589). 592 A TEXT-BOOK ON SURGKRY. The integument and fascife having been divided, the operator proceeds through the upper half of the wound by cutting down upon the guide, which may be readily felt with the finger. When this is neaily reached, the groove in this instrument will be made out, and, by jjicssing the nail of the left index-linger into it, the point of the knife can be guided through t!i(> urethral wall into the groove, making an opening about half an inch in extent. With the linger-nail kept steadily in the groove, the scalpel is laid aside, and the long i)r(jbe-poiiited lithotomy-knife (Fig. 04) taken up and its point guided into the groove of the guide. At this stage of the operation the sound is slightly lifted up, so that the pressure which has heretofore been made upim the floor of the urethra will be tniiisferred to its roof. While doing this the probe-point of the knife should be firmly and steadily pressed upward against the instrument, for, unless this precaution is observed, it may slip out of its proper i)lace. The operator now seizes the shaft of the sound with the left hand to assure himself, by moving this instrument slightly, and also by sliding the knife along the groove, that the two instruments are .in actual contact, and then, turning the cutting edge of the knife obliquely toward the patient's left side, and more nearly parallel with the transverse than with the antero-posterior diameter of the patient's body, pushes it along the grooved guide into the bladder. In executing this manoeuvre it is necessary to tilt the point of the knife upward and press it very firndy into the groove lest it slip out and cause confusion. When the probe- point arrives at the end of the groove and catches, the incision through the left lobe of the prostate may be lengthened by j)ushing the sound with the knife in the proper direction. As the incision is being made, a gush of urine takes place. The knife is now withdrawn, the finger car- ried into the bladder, and the stone located 'oefore the sound is removed. The size of the calculus should be determined, and, if necessary, the lower portion of the primary incision may be enlarged. While this is being accomplished, it is advisable to carry the index-finger into the rectum to avoid wounding this gut. The forceps (Fig. 590) should now be introduced and the stone re- moved. This instrument can not always be carried in through the wound if the finger is allowed to remain, and is at times difficult of introduc- Fio. 590. — Lithotomy -forceps. tion without a guide. To prevent delay, the conductor (Fig. 591 ) should be passed along the finger into the bladder and allowed to remain after the finger is withdrawn. If the blades of the forceps are now closed upon the flange of the conductor, the instrument can be made to slide STONE IN THE BLADDER— LITHOTOMY. 593 accurately along the guide into the bladder, after which the conductor should be removed. G.T!£MANN- CO saBBims Fio. 591. — Scoop and conductor. In removing a stone with the forceps two precautions are essential : 1, not to pick up the wall of the bladder with the calculus ; and, 2, not to employ force enough in grasping the stone to crush it. When the stone is grasped, if the instrument can be moved freely within the bladder, it is evident that this organ is not caught. With small calculi the extraction is easily accomplished. When the stone is large, a certain amount of force is justifiable and necessary to stretch the wound to its utmost ; but this force should never be used unless the operator is satisfied that the stone and jaws of the forceps Fig. 502.— (Jouley's litlioclast. can be brought through the wound without serious injury to the blad- der and prostate. If the stone can not be extracted whole, it should be crushed with the forceps or lithoclast (Fig. 592), and removed in frag- FiG. 593. — Lithotomy-scoop. ments. The larger pieces may be caught with the forceps, the smaller with the scoop (Pig. 598). A stream of water should also be forcibly \'aii Huron's debris-syringe. thrown in through the wound, in order to bring awny any small parti- cles which may have escaped notice (Fig. 594). Finally, a sound should 38 594 A TEXT-BOOK OX SURGERY. be introduced and searcli made for a second stone or any fragments lodged in the more remote portions of the bladder. Among the accidents wliich may complicate perineal litliotomy, in additi(>n to that of wounding tlie rectum, which has Ijeen mentioned, is haemorrhage from the artery of the bulb and other vessels of the periiueuiu. Tlie ligature will control all superticial bleed- ing, and, should a deep vessel ])e divided, it may be transfixed with a tenaculum and tied, or the hook allowed to ivmaiu in the wound for a day or two. If the oozing is free and general, an umbrella-compress (Fig. 595) should be made by tying a piece of oiled silk or rubber tissue to a canula or bougie. This is carried into the wound and compression made by packing sponges beneath the cloth which is brought in contact with the bleeding surface. Fia. 595. — Umbrella-compresB. Fig. 596. — A B, Bulbous portion of the iirethra. 6', Ki;,'ht Literal lobe of the prost.ite. J/, The line of incision in lateral lithotomy. J>, Corpus cavernosum. F, Rectum. j\', V'esicula scminalia. (J, Vaa dcterens. Z, Artery of the bullj. (After Maclise.) The after-treatment of lateral lithotomy is simple. The wound is left open and unmolested. The urine i)asses through this for a few days or STONE IN THE BLADDER— LITHOTOMY. 595 weeks, and gradually resumes the urethral channel as the incision closes by granulation. In some cases the urine passes through the urethra un- interruptedly. The patient should remain in bed for two or three weeks. The anatomical relations of the j'^U'ts involved in this operation are shown in Fig. 59G. Bilateral Litliotomy. — In performing this operation a curved incision is made, beginning half-way between the tuberosity of the ischium and the anus on one side, and terminating at a corresponding point on the other. The incision crosses the median raphe of the periuc'eum from one half to three quarters of an inch in front of the anus. The guide used in this operation should be grooved deeply in the middle of its convex surface. As soon as this instrument is reached, the urethra is opened in the membranous portion, and the finger-nail carried into the groove on the sound. The bisector — a probe-pointed two-edged lithotome — is in- troduced by sliding the tip of the instrument along the nail into the groove. The operator now takes hold of the staff, depresses the handle of the bisector, and, keeping the probe-point in the groove, pushes the knife into the bladder directly in the median line. In this operation the prostate is divided equally on both sides of the urethra. Median Lithotomy. — The position of the patient is the same as in the two preceding operations. The best staff or guide is that of Prof. Little (Fig. 597), which has a deep, wide groove. GJIEMANN & CO Fio. 597.— Little's lithotomy-stafi. It is introduced and held in such a position that the shaft is perpen- dicular to the plane of the body, the tip well in the bladder, with the convexity of the instrument pressing firmly and steadily toward the perinseum. The finger is now carried into the rectum in order to guard against puncture of the anterior wall of this organ. The knife (Fig. 53) is entered just about a half-inch anterior to the anus in the median line, the edge of the blade directed upward, and is pushed straight inward until the point strikes into the conc^avity of the groove in the staff at the anterior limit of the prostate. It is then made to cut forward and upward until the membranous portion is divided, and, as it is with- drawn, the incision in the perinfeum is lengthened in all about one and a half inch. The finger is now introduced, the sound withdrawn, and the wound, prostatic portion of the urethra, and neck of the bladder dilated until the stone can be felt and extracted with a slender forceps. Of the four methods of cutting for stone just described, the lateral and supra-pubic o^jerations are preferable. The bilateral procedure is 596 A TEXT-BOOK ON SURGERY. at this time rarely performed. In the extraction of nn ordinary stone the incision through one lobe of the prostate will be sufficient. When the calculus is so large that a wider incision is required, the right lobe may be readily incised through the lateral wound. Tlie median opera- tion is objectionable on account of the danger of injuring the prostate and neck of the bladder, in the necessary dilatation, or in efforts at extrac- tion. It is only applicable to the removal of the very snudlest calculi in children or youths in whom a lithotrite and evacuating-catheter can not be introduced. Even in this class of cases the lateral operation should be given the preference. The supra-pubic incision has, within latt^ years, become a more popular operation. It is applicable (1) when the stone is of large size — from one and a half to two inches and over in diame- ter — the removal of which by a perineal incision would involve an ex- tensive incision or laceration of the neck of the bladder and prostate ; (2) where the calculus is lodged high up behind the i^ubes, either with or without enlargement of the prostate and concentric hypertrophy of the neck and base of the bladder, since in these conditions a stcme can be reached through the perinpcum only at great depth and with much difficulty. On the other hand, it is readily found through a supra-pubic incision. The high ojoeration is indicated in deformity of the pelvis, with narrowing of the inferior strait. The difficulty and danger of this procedure are increased in corpulent and fat perscms. Stone in the Bladder of Females. — Vesical calculi are not met with in females as frequently as in malee. Many conditions which ccm- diice to the lodgment or formation of stone in the male bladder, and are common in this .sex, are either impossible to, or rarely occur in, females. Among these causes may be mentioned hypertrophy of the prostate with obstruction, and chronic cystitis and organic stricture of the urethra. Another explanation of the comparative infi*equency of stone in fe- males is the short and dilatable urethra, allowing the escape of many small concretions which in men would lodge in the cul-de-sac behind the prostate. The symptoms do not differ from those given in stone in the bladders of males. The diagnosis rests upon exploration with a searcher, combined with digital exploration ^jcr vaginam, and direct pressure over the pubes. Treatment. — The large majority of calculi found in the bladders of females may be readily removed by lithotrity. The short and distensi- ble urethra permits of the introduction of the largest evacuating-cathe- ter, and greatly facilitates the operation. The crushing operation is preferable in small stones to the older method of dilatation or divulsion of the urethra and extraction in mass by forceps. A mucli larger stone may be cmshed and removed from the female bladder than can possibly be done from the male organ within the limit of safety at a single opera- tion. "When lithotomy becomes necessary, the operator must choose between the vesico-vaginal and supra-pubic incision. In the former a second operation for vcsico-vaginal fistula is essential. In case the pa- tient is very fat, the low operation will be advisable. In ordinary sub- FOREIGN BODIES IN THE BLADDER. 597 Jects tbe supra-pubic operation, carefull}' and proj^erly done, offers the best prospect of speedy relief. Foreign Bodies. — Foreign substances in the bladder are usually intro- duced through the urethra. Less frequently they pass through the walls of this organ, as in gunshot-wounds, etc. In exceptional instances for- eign matter finds its way into this organ through a fecal or vaginal fistula. In several cases of this character worms have escaped from the intestines and found an exit through the urethra. The symptoms are usually those of stone in the bladder, Avith cystitis in a varying degree. The diagnosis may be evident from the history of an accidental or intentional introduction of the foreign subslance. The matter can usually be recognized by the searcher. If a few weeks have elapsed, the sul^stance will probably be coated with a deposit of urinary salts, and will impart to the sound the gmting or click peculiar to stone. The treatment consists in removal of the offending substance as soon as possible. If it is smaU, round, and smooth, it may be extracted through the urethra, with the lithotrite. For this purpose the smallest instrument should be employed. If it is too large to be brought out in mass, it may be chopped up or crushed, and then extracted piecemeal, in the jaws of the lithotrite, or washed out through the evacuator. Fig. 598 represents an English gum catheter which was removed in this Fig. 598. — Gum c.itheter removed from the bladder b_v the lithotrite. iThe author's case.) manner. The two larger pieces were grasped by the end and drawn out ; the remainder was caught in the lithotrite, and brought out one piece at a time. When the substance is so large or of such a shape that it can not with safety be brought through the urethra, cystotomy is imperative. In determining upon the method of o^^ening into the bladder, the same rules will apply as given for lithotomy. The Prostate Bod)/. — Disease of the prostate is almost always a con- dition of adult life. This organ is rudimentary in childhood, and while, from direct injury, as in catheterization, lithotomy, or any form of vio- lence, or by the extension of any of the rarer foi-ms of disease which affect the bladder or urethra of children, this body may be involved, it only assumes its true importance after it has taken on its functional activity. « Prostatitis. — Inflammation of the prostate mny be j^artial or comjilete, as well as acute and chronic. It may affect the epithelial and glandular, 598 A TEXT-BOOK ON SUR(4ERY. or niusc'ular and connective-tissue structure of this conij)lex organ. Pros- tatitis rarely originates in the sxibstance of this body, being usually involved by extension of an intianiniation from the bladder, urethra, or other organs and tissues in its inunediate neighborhood. Urethritis, cystitis, e])idydimitis, and proctitis are among the more common causes of prostatitis. To these may be added excessive venereal excitement, all forms of traumatism, whether by violence applied to the rectal or perineal regions, or by instruments in the urethra, and the presence of calcareous or amylaceous concretions. The symptoms are usually well marked. Pain in the acute fonn of inflammation is usually intense and burning in character. There is a sense of fullness and throbbing in the organ. With the finger in the rectum its enlargement may be appreciated, together with abnormal heat and throl^bing of the arteries along its base. Pain is increased by direct pressure in the perinseum or rectum, and also in the act of urination. Fever is present in proportion to the severity of the local process. Sup- pui-ation and the formation of abscess are usually indicated by exacerba- tions of temperature and by interference with micturition. The first indication in the treatment of this painful affection is rest in the recumbent posture. The bowels should be kept open. The ice-bag to the perineum will be found agreeable and of value. If retention of urine occurs, it should lie relieved by the use of the smaller soft catheter. Supra-pubic aspiration may be demanded in severe cases. Scarification of the perinfeum and the application of cups are highly recommended as local measures. If abscess exists, it should be evacuated by the aspirator. Rupture may occur into the urethra, or the abscess may find an oi:)ening through the perinjeum or rectum. Ilypertroiiliy. — Chronic progressive enlargement of the prostate occurs in about one third of all males who live through the period from fifty to seventy-five years of age. The increase in volume is not a true hy- perplasia, for the glandular functions, as well as the muscular power of the or- gan, decrease with the hy- pertrophy. In some por- tions of the mass the mus- cular tissue is increased, but the bulk of the enlarge- Fio. 59S. — Longitudinal section of hypertrophied prostate, in ment is due tO the presence a patient sevcntv-foiir years ot" acre ; showinfj a false i «. t yiassage tunneled "by a catheter, h. Line of transverse sec- of Uewly formed connective tion shown in Fig. 600. a, Duct of vesicula semiualis. (Af- , . " mi • i i- ■ • t«r Socin.) tissue. Ihe luduration IS in HYPERTROPHY OF THE PROSTATE. 599 Flo. 600. — Transverse section through the center of the prostate of a patient seventy-four veal's old. Hypertrophy of fourteen years' duration, a, Lrc- thra. 4, Caput frallmaguinis. (After Socin.j proportion to the excess of the new tissue over the normal muscular and j^landular elements. In some instances, though rarely, the glandular elements are increased ; but this is, in great probability, only observed in the earlier stages of hypertrophy, before the connective-tissue elements are in suf- ticient quantity to cause atrophy of the glandular apparatus. The enlargement may be local or general. In general hy- pertrophy, while the increase in size is in all directions, it is more marked in the posterior portions, where it encroaches upon the neck of the bladder. Not in- frequently one lateral lobe is greatly en- larged, or the hypertrophy may be cen- tral, resulting in the development of a middle or third lobe, which, by progi-es- sive enlargement, not only changes the axis of the nonnal urethra, but occludes, in a variable degree, the outlet of the bladder. This last condition is well shown in Fig. 599, and that of general hypertrophy of the muscular, fibrous, and glandular tissues, with narrowing of the urethra, in Fig 600. Symptoms. — The increase in size is usuallj- so gradual that the condi- tion of hypertrophy does not attract the attention of the patient until interference with the How of urine occurs. As a result of retention the bladder is distended, the contractility of its muscular walls is diminished, and chronic cystitis inevitably ensues. The changes which take place in this organ — thickening of the walls, occasional sacculation, the fonnation of calculi, dilatation of the ureters, etc. — have been given. In severe cases the functions of the rectum may be interfered with. The diagnosis may be determined ^ff°r^ , by the presence of the symptoms ^. just given, by digital exploration by the rectum, and the introduction of a sound or bougie by the urethra. The treat me lit is chiefly pallia- tive. When recognized early in its history, every source of irritation should be removed from this organ. The bowels should be kept open, the iriitnbility of the urine dimin- ished by the administration of alka- line diluents, and all venereal ex- citement prohibited. In those af- fected with gout or rheumatism, judicious diet and medication may aiTest, or at least retard, the prog- ress of the disease in the prostate. Fig. 601. — .Showins the relations of the floor of the bladder to the prostatic urethra in the normal condition of this body. The bristle is passed from the ejaoulatory duct into the uretiiru. {.\rter Socin.) (500 A TEXT-BOOK ON SURGERY. When symptoms of obstruction to the escape of urine supervene, oper- ative interference is frequently culled foi-. If the hypertrophy is gen- eral, and the caliber of tlie urethra is encroached upon, dilatation by means of the olive-pointed French bougies or the conical steel sounds Fia. G02.^Hypertropliy of the prostate, elinwin^' tlie nsyminetrical development of tlio miiliUo or tliiid lobe, o a, Openings of ureters. (Alter Socin.) may be required. When the enlargement is chiefly in the posterior portions of the organ, dilatation is not indicated. In order to i^revent cystitis, it is important that every effort should be made to thoroughly empty the bladder at each act of urination. The relation of the urethra to the base of the bladder, in the normal condition of the prostate, is well shown in Fig. 601. The inqiediment to the complete evacuation of the bladder in enlargement of the posterior and middle portions of this body may be more readily understood by referring to Figs. 6()2 and (303. If the sitting or standing posture is maintained, it is evident that a certain quan- tity of urine will remain in the cul-de-sac, behind the prostate, even if the ball- valve formed by the hyper- trophied middle lobe is held back by the catheter. In many cases this difficulty may be overcome and benefit gained by evacuating the bladder, with or without the catheter, in the knee-shoulder position. The introduction Fig. 003.— Antcro-posterior section ot the same specimen. HYPERTROPHY OF THE PROSTATE. 601 of the catheter in prostatic hypertrophy is such an important feature in the treatment of this disease, and at times is surrounded with such diffi- culties, that it becomes important in each case to study the condition of the neck of tlie bladder and urethra, to determine, with as much accu- racy as possible, the deviation of this channel from the normal. Fig. 604. — The norm.il urethra of a luak- uilult. From a frozen section. Reduced from life size. ^After Braune.) The normal curve of the urethra is shown in Figs. 604, 605. When hypertrophy of the prostate occurs, the distortion is practically an elon- gation and exaggeration of the natural curve from the triangular ligament back to the opening into the bladder (Figs. 606, 607). In the exploration an olive- pointed black French catheter, in size about No. 14 (U. S. scale), will be found to be a safe and satisfac- tory instrument. If warmed and oiled, it will usually pass to the neck of the bladder without resist- ance, and, in a majority of in- stances, the obstruction may be overcome by i)usliing steadily upon the catheter. No harm can arise from this procedure. If, however, the bladder is not entered, the in- strument should be withdrawn, armed with the wire stylet, bent to suit the curve of the deep urethra, and again introduced. A carefui degree of force may now be employed to overcome the obstruction, Fio. 605. — The sound passing around the normal curve of the uretlira. (.\fter Van Buren and Keyes.) G02 A TEXT-BOOK ON SURGERY. but uudne violence must be avoided. Tlie distal end of the catheter and stylet should be well depressed in the etfort to pass by the obstruc- Fio. 606.— The change in the direction of the urethra causetl by hypertrophy of the prostate, ('.\ftcr Socin.) tion. If the manoeuvre is successful, the stylet is withdrawn, leaving the catheter in position until the bladder is emptied. If the intro- duction can not be effected, supra-pubic aspiration may be done, and the patient should be put to bed and narcotized with morphia. Under the quiet- ing influence of this rem- edy spasm of the muscu- lar fibers of the prostate and vesical neck is allayed, frequently resulting in tem- porary relief from reten- tion. Its value can scarce- ly be overestimated in the management of obstinate cases of retention and cys- Fio. 60r.— Showing the increase in the curve of the uretlira titis CaUSed by prOStatlc hy- in prostatic hypertrophy, and the necessity of a longer ■, curve in the catlieter. (Alter Van Biu«n and Keyes.j pertropuy. HYPERTROPHY OF THE PROSTATE. 603 The propriety of operative iuterferenre, beyond catheterization or puncture of the bladder, may be entertained in a certain proportion of cases. When the obstruction is due to hypertrophy of the middle lobe (Figs. 602, 603, and 608), relief may be obtained by the ojjei-ation of INIer- cier. The excisor is shown in Fig. 609. In con- struction it resembles the lithotrite, with the ex- ception that the beaks are shorter and are not seiTated. The mechanism of the instrument is practically the same. The operation is performed as follows : The kiotome is closed, oiled, and car- ried into the bladder, which should be fairly dis- tended. The operator should move the Instrument about freely, and turn it on its axis, in order to be assured that it is well within the organ. Fio. 608. — A ridiie of hypertrophied prostate seen from witliin the bl.idder. (Alter Socin.) It is then withdrawn, with the beak pointing upward, xmtil it is felt to be arrested at the open- ing into the urethra. While in this position the blades are separated a half-inch, the instrument forced to one side (the patient's right), then stead- ily turned to the left and closed. If the obstruc- tion is seized by this manopuvre the screw-move- ment is adjusted and the part grasped is cut off and withdrawn with the closed instrument. Mer- cier's procedure, although not frequently per- formed, has met with a success which justifies its repetition. In well-selected cases it can not but be useful, and when the urethra and bladder are care- fidly accustomed to the use of a catheter, it gives little pain or inconvenience. The employment of an ana3sthetic is not indicated, the sensation of the patient being of value in aiding the surgeon to determine when the tissue is grasj^ed. In hopeless cases of cystitis resulting from obstruction of the urethra, from prostatic hypertrophy, cystotomy, with the establishment of a per- i'lc. iW'.i.— Moreior's instru- ment for the removal of portions of the hypertro- phieil prostate, 'flie eiit- tiiit^ poitinh (b) is life size. (.\fter Socin.) (504 A TEXT-BOOK ON SURGERY. nianent urinary fistula, may become necessary. The various methods of performing' this operation have already been described. Proiitatorrhoea. — Chronic prostatitis, or catarrh of the prostate, in a majority of cases follows an acute intlammaticm of this organ. Its chief cause is, tl;erefore, an extension of a cystitis or urethritis to the epi- tlielial lining of the glandular portions of this body. In a certain pro- ])orti()n of cases it originates as a subacute inflammatory jirocess located in the glandular sul)stance. It is in this form most fre(juently seen in weak, scrofulous, or tubercular adults about the period of puberty. Prostatorrho^a is a symptom of general hypertro])hy of this organ in the earlier stages of enlargement, gradually diniiuishiug as the connect- ive-tissue hyperplasia encroaclies upon and destroys by compression the glandular ajiparatus. The leading symptom of this disease is the discluirge of a small quantity of bluish-white fluid from the meatus. It is noticed particu- larly by the patient before the first micturition in the morning, having accumulated during the night. A drop or two may be squeezed from the urethra by pressure along the under surface of the penis from the perinreura forward. It is carried out with the first flow of iirine, and, if not observed previously, usually escapes notice. In the severer type of cases the iirostatic fluid may be seen immediately after urinating or during the intervals of micturition, as a bluish mucus, moisten- ing the meatus and prepuce, and slightly tenacious and stringy when wiped off. This fluid is also frequently observed when the contents of the rectum are discharged, especially if the faeces are hard and fully formed. Prostatorrhoea occurs in excessive or prolonged venereal ex- citement. The diagnosis of this affection depends upon the exclusion of sper- matorrhani and urethritis. The symptoms of spermatorrhoea are in gen- eral so similar to those of prostatorrhoea, that a positive differentiation can only l)e made by microscopical examination. The fluid which es- capes may be examined alone, or the first ounce or two of urine passed after a comparatively long interval in urinating may be caught in a sepa- rate vessel, allowed to settle, and a drop of the sediment placed ujion the slide. The presence of spermatozoa will confirm the diagnosis of spermatorrhea. The urine first jiassed after a discharge of semen should not be examined, since under such conditions these elements are found in perfectly normal subjects. In differentiating between prostatorrhoea and gleet, the exploration of the ui-ethra will be necessary. The absence of a stricture or of marked tenderness in the canal in front of the pros- tatic portion will exclude urethritis, with the exception (^f a rare form of chronic follicular urethritis, which, as will be seen further on, may or may not be preceded by a gonorrhoea or stricture. In follicular ure- thritis, tenderness is not marked. If a large-sized bulbous wire bougie is carried back to the membranous portion of the urethra, and is then withdrawn while the urethra is held in close contact with it, the yellow- ish-white flakes or plugs of cheesy material will be squeezed out of the follicles and be seen adhering to the bulb. PROSTATORRHCEA. 605 Treatment. — The correction of any diathesis which predisposes to a catarrhal condition of the mucous membranes is an important step in the general treatment of prostatorrhoea. Among- the local measures, distention of the prostatic urethra by the introduction of steel sounds, is advisable. The larger sizes should be Fig. IJIO. — Van Bureu's cupped sound. employed, and if the meatus is so narrow that it will not admit No. 20 or 21 (U. S.), it should be incised up to this point as a preparatory measure. When stricture exists, internal urethrotomy should be perfonned. The dilatation may be commenced with No. 17 and increased to No. 21 at a single operation ; or, if the procedure is attended with pain of a severe nature, the larger numbers may be used at the third or fourth introduction. The point of the sound should not be carried farther than the neck of the blad- der, which is between seven and eight inches from the meatus. The operation should be repeated from two to three times a week — not often enough to cause a general urethritis. Local medication is at times of great value. The cupped sound (Fig. 610), which consists of an ordinary instrument with from six to eight spoon-shaped depressions just be- yond the curve, is a valuable instrument. In employing it, a stiff salve must be made by mixing the medicine re- quired with simple cerate. Lard melts too rapidly, and is therefore objectionable. The cups are filled just to the level of the surface, the instrument thoroughly lubricated and rapidly carried down t6 the prostate, where it is allowed to remain for several minutes, until the heat of the part melts the salve. Tannic acid (grs. x-xx, or xxx to § j) or acetate of lead or nitrate of silver, in proper proportions, may be thus employed. Another method is the introduction of silver nitrate or other escharotics or astringents by means of the canulated sound (Fig. 611), which consists of a metal tube shaped like a catheter, through which a stylet-piston plays. A suffi- cient quantity of the ointment is placed in the cylinder near its open end, and the piston introduced. When the tip of the instrument arrives at the i:)rostate it is emptied by forcing the piston down, at the same time slightly with- drawing the catheter in order to distribute the contents over the entire prostatic surface. Flo. till. — Gar- re au' 8 pros- tatic svrintrc. (^ After 'Sociii.) 006 A TEXT-BOOK ON SURGERY. It is readily understood that, locally applied, no agent is carried to the deeper portions of the glandular substance, but the inflammation precipitated in the more supi'rficial glands and the ducts of those more deeply situated, may readily travel along the epithelial lining until the entire gland-tissue is involved. Beyond the danger of a temporary elevation of tenqiei-ature which may occur in patients subjected to urethral exploration, the additional dangers of cystitis and epididymitis should not be disregarded. Tiie use of the doubh^-current closed catheter, with hot or colli water, is one of the most satisfactory and safe methods of treating this disease. Its employment will be described in the treatment of chronic follicular urethritis. Tiie jtrognosis in i)rostatorrh(r'a should be guarded, for many cases obstinately resist the most careful and energetic measures of treat- ment. Sjjermatorrlicea. — This term is used to designate the escape of semen from the ejaculatory ducts without an orgasm. This tiuid may find its way into the bladder, but usiudly escapes by the meatus. The symp- toms of this disease do not differ materially from those given in pros- tatorrhoea. The diagnosis can only be made certain by the recognition of the spemuitozoa with the aid of the microscope. It occurs at times in conditions of great physical prostration, as a result of excessive and un- natural venereal indulgence, and from interference with the function of the muscular elements of the prostate. The treatment is general and local. Measures looking to the im- provement of the moral and physical condition of the patient should be adopted. The local treatment is the same as that given for jirostator- rha>a. Aspermatlffm. — The spermatozoa are wanting in adults whose testi- cles have been removed or destroyed by disease, in ])atients in whom both organs have failed to descend and have undergone atroi)hy ; in all cases of complete obstruction of the vasa deferentiu or ejaculatory ducts, and in certain cases of senile atrophy of these organs. These conditions are rarely amenable to surgical treatment. TnherculoHh of the Prostate. — Tubercular disease of this organ, tlujugh rarely observed, may be primary, or more frequently is second- ary, to tubercular deposit in other viscera, as the testis, epididymis, lungs, etc. It is more apt to occur in the young and middle-aged than in the old. The diagnosis can not, as a rule, be easily made. In some cases there are no symptoms of tuberculosis. If with a subacute or chronic lesion of this organ there is a history of phthisis, the deposit of tubercular matter may be suspected. When the febrile movement, hec- tic, profuse sweats and emaciation of this disease are present, a correct diagnosis is readily made. The enlargement and nodular character of the prostate may be made out by digital exploration by the rectum. The treatment is altogether palliative. Carcinoma. — Cancer of the prostate is also rare. It is more apt to occur primarily than by metastasis. Primary cancer of this organ is more frequently seen in young adults than in the old. In the middle- PROSTATIC CONCRETIONS. 607 aged and old it is more likely to occur by iavasion from a neighboring organ, as the rectum. In the earlier stages the symptoms of tliis disease do not differ mate- rially from those of simple hypertrophy. As simple hyperti-ophy is rare in the young and middle-aged, the presence of a tumor of this organ at this time of life should be regarded with a suspicion of malignancy. The absence of the symptoms of abscess is in some degree a confirma- tion of this suspicion. If the tumor develops rapidly, carcinoma or sarcoma may be diagnosticated, for, although the disease may continue for one or two years, or even longer, the invaded organ soon assumes a size not met with in non-malignant hypertrophy. Haemorrhage of a pro- fuse character is apt to follow the introduction of a sound or catheter wlien carcinoma or sarcoma is present. Sarcoma is also rare in this organ (Fig. 612). It is more apt to oc- cur in the young than in the middle-aged and old. The symi)toms differ in no essential feature from those present in cancer. The progiiosiH of both diseases is grave, and the treatment palliative. Prostatic Concretions. — Concre- tions in this organ are of two kinds — the corpora amylacea and calculi. «^ f lo. 612. — Sarcoma of the prostate and neck of the bladder, with obstruction. Tlie catlieter has tunneled the neoplasm. (After Sociu.) ^ ^^4^^=-; * - '^-.-7-'- FiG. 613.— Calculi in the prostatic follicles. ^AJter Socin.) The former are small bodies wliich frequently exist in the follicles of the prostate. Their mode of origin is unknown. They give the well- known amyloid reaction witli iodine. Stone in the prostate may origi- nate in the deposit of inorganic elements from the blood and fluids of this organ, either in the follicles originally (Fig. 613) or as accretions upon the amyloid bodies just described. The symptoms of prostatic concreticms are chiefly those due to the inflammation or enlargement which they produce. Corpora amylacea not infietpiently exist in the iirostate, causing little or no discomfort. When of large size, especially when they grow by reason of a deposit of inorganic substances, they cause inflammation of the follicles and destruction of the glandular ejjithelia. A positive diagnosis can onlj' be made by bringing a sound or catheter in contact with the concreticm. When the stone is situated in the deeper portions of the organ, it will 008 A TEXT-BOOK ON SURGER\. escape detection by tins method, but tlie tumefaction it cutises mny be recognized l)y digital exploration per rectum. The interference with the escape of urine caused by calculi of the prostate is analogous to that which occurs with general hypertrophy of the body of this organ. The stream of urine is diminislied, but remains about the same size, and escapes steadily throughout the act of urination. There is no sudden and comi)lete interruption of the current, as in stone in the bladder, or in enlargement of the middle lobe of the prostate. Calculi of this organ may escape into the urethra and lodge there, or work their way back miu the bladder, or pass out at the meatus. The treatinent is palliative until operative interference is necessitated on account of dysuria. The incision is the same as given for median lithotomy. The prostate should not be incised if it can be avoided. The stone may be removed with the scoop or narrow forceps. Neuralgia of the prostate and neck of the bladder is occasionally met with. Pain is present in this organ when no symptoms of inilammaticm are discoverable. It is usually exaggerated during and immediately after micturition, and after a seminal emission. The introduction of a sound shows great tenderness of the deep urethra. The instrument car- ried into the bladder does not produce the tenesmus and pain common to cystitis. An examination of the urine will demonstrate the absence of pus, wMch will also serve to exclude inflammation of the bladder or prostate. The causes of this affection are as a rule obscure. Irregular or excessive venereal indulgence is considered to be one of the most frequent causes of neuralgia in this organ. The treatment involves the removal of every possible source of irritation. The constitutional meas- ures recommended in neuralgia in other jrATts of the body should be employed. Locally the galvanic current is especially indicated. If the urine is extremely acid and burning, benefit will be derived from the administration of large quantities of alkaline and diluent drinks. The Urethra. Urethritis. — Inflammation of the urethra may be traumatic or idio- pathic, specific or non-si3eciflc, local or general. Among the more freqiient causes of traumatic urethritis are direct violence from without, applied to the perinjeum or penis ; violent and excessive sexual intercourse ; the introduction of instruments or corrosive substances ; and the lodgment of foreign bodies carried in from without, or of vesical or prostatic cal- culi, etc. It is usually of short duration, mild in character, and involves only a limited portion of the canal. The treatment demanded is rest, the removal of the cause of the in'itation, and the dilution of the urine by the exhibition of alkalies and diuretics. Specific urethritis (gonon-hcea) is a violently contagious disease affect- ing the mucous membrane of this canal, at times extending into the bladder and seminal vesicles, and along the vasa deferentia to the epi- URETHRITIS. 609 didymis and testicle. The exact nature of the virus is unknown. It is claimed that the pus-corpuscles of the gonorrhoea! discharge contain an organism (gonococcus) peculiar to themselves ; l)ut this claim is not as yet satisfactorily dem(jnstrated nor widely accepted. When the virus is brought into contact with a mucous surface, the period of time which elapses befijre the local symptoms of inflammation are noticeable will vary in different individuals, and even in the same patient at different inoculations. It is very probable that the condition of the mucous membrane at the time of the contact has more to do with the rapid appearance of the inflammation than any variableness in the quality of the virus. The period of incubation may range from a few hours to several days, and in some very excepticmal instances as much as two weeks have elapsed between the contact and the recognition of the inflammatory process. The limit between twenty-four hours and three days will include a large majority of cases of specific urethritis. Usually the earliest symptom of gonorrhoea is a biirning sensation at the meatus, which is more acute as the urine is escaping. The lijis of the meatus soon become swollen and unusually prominent and red. If care- fully separated, a film of muco-pus will be seen to coat over the mucous membrane. The flrst stage of the disease may be considered as beginning with the date of contact with the virus, and ending with the first appearance of the suppuration. The average duration of this stage is from two to ten days. From this period the inflammatory symptoms increase for from three or four days to as much as two weeks. The qiiantity of pus discharged varies from a few di'ops to several drachms in the twentj'-four hours. It is increased by exercise as well as by imjiroper diet. The color varies from the bluish-white hue of the first few droj)s to the yellow or yellowish-green tinge of that discharged during the height of the inflammatory process. In some instances it becomes stained with blood, as a result of the rupture of capillaries in the engorged mucous membrane. The second star/e, or tliat of increasing inflammiation and svppura- tion, lasts usually about twelve days, and is followed by the third stage, or that of decreasing inflanimation and supjyiiration, the duration of which period is usually from three to six weeks. In addition to the purulent discharge and the pain which characterizes the second stage of this disease, there is also a diminution in the size of the stream of urine, due to the swollen and puffy condition of the mucous membrane of the urethra. In the milder foi-ms of gonorrhoea no oth- er sj'mptoms are present in the second stage. Not infrequently, how- ever, the inflammatory process extends into the prostatic urethra, and thence to the bladder or along the seminal ducts to the vesicles and testes. Iiiflltration of the vascular erectile tissue of the corpus s])on- giosum occurs in a varying degree in all instances, and occasionally the exudation extends into the corpora cavernosa. A more frequent com- plication of gonorrhoea is inflammation of the glans penis ihalanitis) and of the prepuce {post7i/tis), due not only to the mechanical effects of the 39 610 A TEXT-BOOK ON SURGERY. discharge, but to diiect iuvasiuu by contagion. As a result of such extensive infiltration, the penis is subjected to various deformities, pain- ful in an extreme degree, and not without danger to the integrity of this organ. Chordee, or bowing of the penis, is a c, if not felt as the bulb goes through, will certainly be appreciated as it is withdrawn, if the instrument is large enough. If 622 A TEXT-BOOK ON SURGERY. the patient is not narcotized, spasmodic contraction of the compressor muscle may arrest the bulb, and, in a certain sense, simulate stricture. In the resistance of tlif muscle there is a roundness, smoothness, and elasticity which differs froMi the rouyli surface of cicatricial tissue and the inelastic grip of a stricture. When the obstruction is felt, tlie same method of measurement and location is to be observed. A stricture may be roughly estimated by the iutroductiou of a catheter, ordinary bougie, or steel sound, but it can not be intelligently or satisfactorily defined without the oval bulbs. Not infrequently it will be found that the meatus is too narnnv to admit a bulb of sufficient size to define the stricture, necessitating divis- ion of the meatus {meatomy). This operation nuiy be done with an ordinary scalpel or bistoury, but with nothing like the exactness and freedom fi-om pain which is secured when the urethrotome is employed. The incision should be made in the median line, and should correspond to the Hoor of the urethra. It sliould not extend deep enough to wound the artery of the fr?enum, nor should it be any deeper than is sufhcient to admit the larger bougies. If the bistoury is employed, the operator grasps the glans between the thumb and finger of tlie left hand, introduces the knife, cutting-edge downward, a distance of a half-inch, and cuts carefully outward. Tlie injection of cocaine solution into the tissues of the part incised will render the operation i^erfectly painless. The iirethrotome of Dr. E. A. Banks, in addition to its usefulness in dividing deeper strictures, is especially serviceable in performing meatomy. It consists of a handle, shaft, and a series of bulbs. The shaft is graduated and hollow, and has extending through it a rod connecting with the blade. The bulbs are of various sizes, are fenestrated, and are screwed on to the tip in such a way that the window falls directly over the blade which is to be pro- jected through it. Upon the handle is a sliding-knob for sheathing or projecting the knife, and, at the end, a screw-gauge which sets the blade for cutting to any desired depth (Fig. 622). I Fig. 622.— Dr. E. A. B.ink»'6 urethrotome, a, Screw-gauge. A, Slidjng-knob. c, Bulb. (/, Knife. The operation is performed as follows : A bulb is selected which will fit the meatus fairly tight, and screwed on to the shaft. The gauge should next be set to allow the knife to cut one eighth of an inch in depth. The blade is now concealed, the bulb oiled and introduced until the knife, j)ointuig directly to the middle line of the floor, is half an inch from the meatus. While the glans is held tightly between the thumb and finger of the left hand, the blade is projected as far as the gauge will allow, and the instrument quickly pulled out of the urethra. Even when cocaine is not employed, this incision gives scarcely any pain. The bulbous bougie should now lie introduced, and, if the meatus is still too narrow, the incision should be made deeper. In order to prevent a THE URETHRA— STRICTFRE. 623 recontraction of the opening, it is necessary to dilate the meatus at in- tervals of from two to four clays for five or six weeks after the operation. In strictures of very small caliber, and in long and tortuous strictures, the oval bulbs can not be used. The extent of such strictures can not be made out with accuracy until, by the use of filiform bougies and care- ful dilatation, the smaller searchers can be introduced. In certain rare cases of lateral stricture, the exact location of that portion of the urethral circumference involved in the contraction may be determined by employing the indicator (Fig. 623), which is practically Vg/* d. BEYNDtBS -CQ Fig. G23. — Indicator tor locitiu;^ lateral striclures of the urethra. a section of half of an ordinary bulb. If this instrument is introduced with the smooth surface directed toward the projecting band, it will pass in and out with equal facility. If, however, it is turned with the opposite side toward the stricture, it will be perceptibly arrested as it is withdi'awn. The knob on the handle which corresponds to the shoulder of the bulb will indicate the part of the urethral wall in which the strict- ure is situated. Treatment. — The treatment of organic stricture of the urethra may be hj division, or dilatation. In the former operation the stricture is incised from within {internal urethrotomy), or from without {external urethrotomy). In the latter, the stricture is gradually dilated by the introduction of bougies or sounds. Dilatation may be confinuons or interrHjjted. Immediate dilatation, or diimlsion of a stricture, as com- pared to urethrotomy, is an unscientific and unsafe procedure, and is rarely, if ever. Justifiable. With the urethrotome, the contraction is di- vided with accuracy and jirecision ; with the divulsor, the force is blindly applied, and the depth and direction of the tear is not safely within the control of the operator. It is difficult to lay down any rule for the selection of the method of treatment to be followed in any given stricture. In general it may be said that internal tirethrotomy is preferable in all strictures antei-ior to the membranous portion, and some form of dilatation in tho.se sitviated in this portion, or in the rare cases behind it. The exceptions to this rule will be presently considered. The method of interrupted dilatation by the frequent introduction of sounds or bougies may be successfully applied to narrow annular strict- ures of comparatively recent date, but division of the stricture and sub- sequent dilatation not only offers the quickest and surest means of relief, but is much less j)ainful than dilatation without incision. The employ- ment of cocaine in urethral surgery has removed two great obstacles to the cutting operation, namely — the patient's dread of pain on the one hand, and that of ether narcosis on the other. Many strictures are, however, of such small caliber that a urethro- tome can not be introduced, and it becomes necessary to dilate them u]i to a size sufficient to admit the urethrotome, or to divide the stricture by 624 A TEXT-BOOK ON SURGERY. cuttinn. The distance from the meatus to the posterior boundary of the sti-ict- ure is then measured on the urethrotome, beginning at the point where the knife is projected, and extending toward the handle. One fourth of an inch should be added to this distance in order to make it certain that the knife is carried well behind the posterior limit of the contrac- tion. This point on the instrument is indicated by a small ring clipped from the end of a rubber tube and slipped over the shaft. It is now ready for introduction. In the selection of a urethrotome, the instrument of Otis will be found to fill all the indications more satisfactorily than any other (Fig. G24). It Fio. 624. — Otis's dilating urethrotome, ^'ith tlie author's cog-'wheel attachment. consists of a shaft, handle, and blades. The shaft is composed of two bars, which can be separated or closed by turning a screw at the handle, where there is arranged a dial which registers the exact degree of dila- tation effected by the separation of the bars. In the upper bar of the shaft is a slot or groove, along which the knife is carried. When it arrives near the point of the shaft, the blade sinks into a depression and disappears. I have added to this instrunu^nt a cog-wheel apparatus, attached near the handle, by the use of which the knife is carried steadily forward or backward, and is made to cut with mathematical precision. The operator should stand to the right side of the patient, who is resting on the back, with the legs fully extended. The knife should be can-ied forward until it disappears near the tip of the urethrotome, the bars of which are now closed and oiled as far as it is to be introduced. The glans penis is grasped between the thumb and finger of the left hand, the organ held in the same position as when the stricture was THE URETHRA— STRICTURE. 625 located, and the instrument carried in until the rubber ring touches the meatus. The left hand, releasing the penis, is made to grasp the handle of the urethrotome and steady it, while with the right the dilating-screw is turned until the arrow on the dial indicates a separation of the bars equal to the diameter of the bulb which located the stricture. By turn- ing the cog-wheel the knife is now made to travel through the moi'e su- perficial jjortions of the stricture from beliind forward and along the median line of the roof of the urethra. The incision should commence a quarter of an inch behind the stricture, and should temiinate the same distance in front of the anterior boundary. Without changing the position of the urethrotome, the knife is rapidly run back to its original position, the dilatation increased one size more, and the knife again carried more deeply through the track of the first incision. This manoeuvre is repeated until the stricture is divided up to Nos. 21 to 23 (U. S.). The instrument is now withdrawn after the knife is concealed and the blades half-closed. If the bars are brought closely together, the mucous membrane may be caught between them. In order to dem- onstrate a perfect division of all the bands, the larger bulbs should be introduced, and, if these catch at any point, a further incision is required. Or a full-sized sound (Nos. 21 to 23) may be carried through the strict- ure, and any undivided fibers torn or stretched. Haemorrhage after internal urethrotomy is usually slight. "NVlien the incision has been made in the pendulous i:»art of the urethra, it may be readily arrested by turning the penis up on the belly, laying a handful of cotton or gauze over the organ, and strapping it down with a band- age carried around the pelvis. Behind this portion, a compress along the peringeum, or a large gum bougie in the canal, will control the bleed- ing. The patient should be put to bed at once, and requii-ed to remain quiet for several days. Not infrequently within twenty-four hours after urethrotomy, or the introduction of a sound or other instrument into the uretlira, the patient is seized with rigors or a pronounced chill, followed by a variable rise in temperattire, or the fever may occur without any premonitory chill. When the thermometer registers 100° F., it is a wnse precaution to ad- minister antipyrin in doses of from grs. x-xx, and repeat this every hour until the decline in temperature is below 100°. If the pulse is cor- respondingly increased, tincture of aconite-root should be given at the same time. The repeated introduction of steel sounds or gum bougies is essen- tial to the successful after-treatment of internal urethrotomy. If there is no marked febrile movement, the dilatation should be commenced on the second or third day after the operation. If fever exists, the use of the sounds should be })ostponed. Cocaine should be employed, for, as a rule, the introduction of the sound is more painful tlian the incision. The urethra should be stretched to the full size of the sound introduced after the cutting. It is well to begin with No. 17, and follow this with Nos. 19, 20, and 21, or higher, if the uretlira is unusually capaciotis. Tliis should be repeated every second or third day for a period of about 40 626 A TEXT-BOOK ON SURGERY. three weeks, every fourtH f)r fifth day for the same period of time, then once a week for three weeks, and twice a month for three or fonr months. It is essential to keep tlie walls of the incision apart until they are lined with new-formed epithelia. If cystitis, epididymitis, or t>rchitis ensue after urethrotomy, all operative measures should be discontinued until these symptoms disap- pear. • The prognosis after urethrotomy should be guarded. ISfany cases do not recur, but a stricture of long standing, with extensive induration, no matter how thoroughly divided and carefully treated, tends to recur. It til us becomes neces.sary to employ dilatation, either with a sound in the hands of the surgeon, or a soft bougie if this duty is intrusted to the patient, at intervals of every two or three months, and in some in- stances oftener, during the life of the individual. That the milder forms of annular stricture may be permanently cured by judicious treatment is satisfactorily established. In a certain proportion of cases the stricture will be found so close or tigl)t that the urethrotome can not be passed through it, and before the division can be effected it is necessary to dilate the constriction until this instrument can be introduced. In accomplishing this purpose two excellent methods are at the disposal of the surgeon, by either of which, if patiently and skillfully utilized, the necessity of external urethrotomy may be obviated in all but a very limited class of cases. The methods are, in order of excellence, (1) immediate dilatation with Banks's dilating filiform bougies, and (2) continuous dilatation by inserting and leaving iu the urethra one or more whalebone filiforms, or a larger gum bougie. Of the procedures of Dr. E. A. Banks and Sir Henry Thompson, the former is by far the most satisfactory. Its adoption has left only a small proportion of strictures for continuous dilatation. The dilating filiform bougie (Fig. 625) is thus employed : The urethra is elongated by pulling upon the glans, and a small syringef ul of sweet- EC ^^ TJTir.yy Flo. 625. — Banks's dilating filiform bouses. oil is thrown into the canal. The filiform is introduced, and, when any resistance is encountered, it is slightly withdrawn and again pushed in. By this manoeuvre the small tip of the instrument may be insinuated through even a long and tortuous tight stricture. Once engaged in the opening, it should be carefully pushed down until it is felt in the gi-asp of the constriction, and then forced steadily through until the full dilat- ing capacity of the largest part of the bougie has traveled through the stricture. A larger size should ))e at once introduced, or the urethro- tome may be carried through the opening. THE URETHRA— STRICTURE. 627 This bougie may be employed with perfect safety. When fully in- troduced, the filiform j)ortion passes into the bladder, and, if this organ is empty, it curls upon itself from the resistance of the vesical wall. It is especially adapted to close strictures of the deep perineal and mem- bi-anous urethra. If, after careful trial, it is impossible to get the filiform into the opening, the patient should be jjut to bed and given the benefit of a full dose of quinia and morphia. If the urine can not be passed, supra- pubic aspiration is indicated. After fi'om twelve t-o twenty-four hours it will usually be discovered that the filiform will slip readily into the bladder. As soon as the dilatation is sufficient to admit the urethrotome, the operation of internal urethrotomy should be performed. zGi^= /Olf=>= CB=>— Fig. 626. — Gum filiform bonnes. In contimtous dilatation, the filiform bougie (Figs. 626, 627), or a small gum bougie, is insinuated through the stricture and tied in position in the urethra by fixing a narrow strip of adhesive plaster around the prepuce behind the corona glandis, and attaching from this to the end of the bougie three or four silk threads (Fig. 628). \ Fio. 627. — Wlialebone filifonn bougies. Fio. 62.S.— Bougie tied in lor continuous dilatatioa. The walls of the stricture break down under the constant pressure of the whalebone or elastic instrument, and it will be found that a bougie, with difficulty introduced and tightly held by the stricture soon after it is carried through, will, within twenty-four hours, become loose and easily movable, and a larger instrument will readily pass into the same opening. As soon as the dilatation has proceeded to the required ex- tent, the urethrotome should be employed and a division effected. Strictures of the Membranous Urethra. — Strictures of the deep ure- thra are amenable to treatment by modi fled internal urethrotomy av-iX by external urethrotomy or perineal section. The former method consists in the rapid dilatation of the stricture with the dilating filiform bougie until the Otis urethrotome can be intro- duced. Tlie straight instrument shown in Fig. 624 can be readily em- ployed in this portion of the urethra. It is carried into the stricture until the knife is at its posterior limit, when, without separating the bars of the urethrotome — that is, without dilatation — the blade is care- 628 A TEXT-BOOK ON SURGERY. fully drawn along the roof of the nrethra, making a shallow incision in the wall of the stricture. It should now be concealed, and the dilating power of the urethrorome employed. Tiiese shallow incisions maybe made on the lateral aspects of the canal as well as along its roof. By this operation the stricture is nicked and then dilated. If the incision were made when the bars of the urethrotome had i)iit the stricture on the stretch, the large vessels of this part of the urethra would be en- dangered. The steel sounds should be used as advised after internal urethrotomy in the anterior portion of the canal. External lirethrotomy, or perineal section, is an operation for the relief of clo.se organic stricture of the bulbous or membranous portions of the urethra which can not be reached through the urethra. With the exception of those cases where urinary fistula or chronic abscess exists as a result of stricture, the conditions which justify this operation are extremely rare. It is performed with or without a guide. When a sound or bougie can be carried through the obstruction into the bladder, the procedure is much simplified. ^Vithout this guide the operation is surrounded with considera])le difhcalty. In external urethrotomy, the patient is placed in the lithotomy position, being prepared as for this operation. After the anaesthesia is complete, a careful and final effort should be made to carry a filiform or soft bougie through the strictuic and into the bladder. If this can not be done, a good-sized sound shduld be car- ried down to the obstruction, and this will serve to guide the operator to the commencement of the stricture. An incision is then made exactly in the median line, the anterior limit being slightly in front of the ascertained commencement of the stricture, the posterior extending towaid the anus a sufficient distance. In making this incision the scrotum should be held up by an assistant, who is di- rected not to disijlace the median raphe to either side. The legs must also be held in the same relative position. The bleeding is usually considerable, as the vascular tissue of the bulb is divided. All vessels should be secured ; but the oozing, which is general, need not retard the operation. As soon as the sound or fili- form, at the anterior margin of the constriction, is seen, the division should continue along the guide until the healthy urethra is reached be- yond the stricture. If no guide has been introduced, the dissection should be carried back in the known direction of the base of the blad- der, guided by the location of the prostate with the finger introduced into the rectum. The first indication that the canal is reached behind the stricture will be a gush of urine. On account of the obstruction, the urethra between it and the bladder is widely dilated, and for this reason is more readily found. It is essential to the success of this operation that all cicatricial tissue be dissected out. A large-sized steel sound should now be introduced through the meatus and into the bladder. If any difficulty is met with in introducing this instrument, a flexil>le bougie may be substituted. It is not advisable to leave the instrument in the urethi-a. If the bleed- THE URETHRA— STRICTURE. 629 ing has not ceased, the- wound should be packed temporarily with sub- limate gauze, held in position by a T-bandage. When there is no haem- orrhage, a loose dressing should be applied. The urine usually escapes through the \vt)und for the first few days, and afterward partly through the wound and urethra. In rare instances it escapes uninterruptedly through the urethra. The after-treatment consists in the introduction of the sounds or bougies (as above directed) through the urethra as far as the neck of the bladder. This opera- tion should be repeated every three or four days until the urine ceases to escape through the wound, and once a week thereafter for several months. Interrupted Dilatation. — In the treatment of stricture of the urethra by this method, there are required steel sounds axi(\ flexible bovgies. Steel sounds are of two patterns, the straight and curved. The former are preferable for dilating strictures anterior to the membranous portion, whUe beyond this point the curved instruments are necessary. The most satisfactory instruments are those constructed upon the United States scale,* which commences with the smallest steel instrument, -^^ of an Fifi. 629. inch iu diameter, and increases -^-^ of an inch in diameter for each suc- cessive sound to No. 25 inclusive, equal to ||^ of an inch. Nos. 1 to 8, inclusive, are filiform and elastic bougies. A straight sound should be six inches in length clear of (he handle, slightly ccmical from the tip, back for a distance of one and a half inch. This conicity should increase one size for every half-inch for this distance. Thus, a sound which measures No. 17 at the tip increases to No. 18 one half inch back, to No. 19 at one inch, and is No. 20 at one and a half inch from the point, and continues this size for the entire shaft. A curred sound should be nine inches long clear of the handle. The curve should involve only the last two inches. The conicity extends also one and a half inch from the tip, increasing one size for every half- inch until the full size is reached at one and a half inch from the point. * The unit of the French scale is one third of a millimetre (about J^ oi an inch), and each size up to No. 30, inclusive, increases one third of a millimetre in diauitter. Divide any given number of this scale by three, subtract the quotient, and the remainder aiipro.ximatcs the oor- respondintr size on the above scale. Thus, No. 3(1, French, divided bv :j = 10; 30 — 10 = 20; or. No. 30, Fi-ench = No. 20, U.'S. 630 A TEXT-BOOK OX SURGERY. Thus, an instrument the shaft of which measures No. 2(>, is 17 at the tip, 18 at one half inch, and 19 at one inch farther back. Fig. 630. — Curved and straight conical sounds. The cune should be made to correspond to that of the normal deep urethra, which is that of a circle with a diameter of three and a quarter inches; "and the proper length of arc of such a circle to represent the 8ub-i)ubic curve is that subtended by a chord two and three quarters inches long"" * (Fig. 631). Fio. 631. Flexible bougies are of various sizes, being conical for two or three inches, and olive-pointed (Figs. 632-635). They are exceedingly use- ful instruments, and, when warmed before introduction, are incapable of injury to the urethra, even when an unusual degree of force is em- * VaD Baren. THE URETHRA— FOREIGN BODIES. 681 Fjg. 632. Fio. 633. Fig. 634. flG ployed. The black French bougie is preferable. The filiform instru- ment has already been described. In dilating a strictxare with the conical steel sound, the method of in- troduction is identical with that given in using the metal catheter. In the interrupted dilata- tion a mild degree of force is exercised, and the seance is repeated on every second, third, or fourth day. The length of the interval between the introduc- tions must be deter- mined by the symp- toms in each case, the object being to accom- plish moderate divul- sion at each sitting with- out producing marked inflammation. The sound should never be carried beyond the point where its full dilating power is applied to the strict- ure. In this way irritation of the prostatic urethra and neck of the bladder may be avoided in all save the deepest variety of strictures. The dilatation of strictures by the use of conical steel sounds should be limited to those cases in which the stricture is of sufficient caliber to admit at least No. 15, U. S., and is narrow or linear in character, so that it may be made to give way without the employment of too great force. The smaller sounds are capable of penetrating the walls of the urethra unless they are used with great skill and carefulness, Avhile the larger instruments will not, within the limit of safety, succeed in the dilatation or rui)ture of a broad or tortuous stricture. Incision with the urethrotome is a safer and less painful operation, and the sounds serve an admiralde purpose in the after-treatment. In using the soft bougies in the anterior portion of the urethra, they may be passed in straight ; but, when the deeper portion is invaded, they should be curved as much as possible^ to correspond to the sub- pubic curve of this canal. Foreign Bodies in the JJretlira. — Calculi occasionally lodge in tlie urethra, and substances introduced through the meatus — as fragments of a catheter, etc. — may require removal by the surgeon. The diagnosis will be evident from the symptoms of obstruction to the escape of urine, by recognition of the body by digital pressure along the canal, and by exploration through the meatus. Stone may be made out by the grating sound which is emitted, or by the sense of friction upon a rough and hard surface which is conveyed to the fingers along the sound. A me- tallic substance may also be recognized by the peculiar click which is elicited when it is brought in contact with the exploring instrument. Removal may be effected through the meatus, or by incision directly through rhe floor of the urethi-a at the point of lodgment. It is always 633 A TEXT-BOOK ON SURGERY. desirable to avoid incision tliroiigh the urethral wall when, by the use of forceps or any mechanism, the extraction can be effected by the meatus without doing too great violence to this canal. If the substance is nar- Fio. 636. — Straight and curved alligator-jawed uretliral forceps. row and smooth, it may be seized with the forceps (Figs. G36, G37) and ex- tracted. The straight alligator-forceps, or the instrument of Hale, is preferable for the anterior portion of the urethra, while for the deeper Fio. 637. — Hale's iiisti-umoiit tbr lemoving foreign bodies from the urctlira. (After Liiiliart.) part the curved instrument is more suitable. For a round body, the scoop or curette will prove more satisfactory (Fig. 638). In using the forceps, the instrument closed should be carried down until its beak strikes the foreign substance, when the jaws should be slowly separated and pushed farther in, so that they may pass between the lining membrane of the urethra and the body. They should then be firmly closed and cautiously moved a slight distance to and fro in oi'der to detemiine whether the mu- • cous membrane has been caught in Fio. 638. — Curette, or scoop, for the re- moval of calculus in the urethra. (At\er Van Buren and Kej'cs. ) Fig. 639. — Calculi removed from the urethra. (The author's case.) the instrument. This danger will in great part be obviated if, just at the moment when the jaws are applied to the foreign substance, the urethra is put upon the stretch by pulling upon and elongating the penis. The canal should be lultricated by an injection oi sweet-oil. If stricture exists, urethrotomy may be necessary before the substance can CONGENITAL MALFORMATIONS OF THE URETHRA. 638 be extracted. In a case which came imder my care, two strictures were divided with the urethrotome. From behind the first constriction two cal- culi were removed, and several after the second stricture was divided (Fig. 639). In this oj^eration a scoop proved more serviceable than the forceps. In a second oi^eration I found it necessary to perform external ure- tlirott)my, cutting directly down upf)n the calculi (two in nunil)er), which were easily removed through the incision. The direct injection of cocaine into the tissues secured complete anaesthesia. The wound should be left to close as in the ordinary operation of perineal urethrotomy. Congenital Ifalformatioiis of the Urethra. — In extrophy of the blad- der the urethra is absent, and, in certain rare anomalies, it may open into the groin, upon the side of the glans jjenis, in the median line of the dorsum penis (epispadias), in the median line below at any point on the corpus spongiosum (hypospadias). Hypospadias is the most common of the congenital deformities of the urethra. When the opening is within one inch of the normal position of the meatus, operative interference is not indicated. When the opening is so far back that in S9xual intercourse the semen can not be ejaculated into the vagina, a plastic ojieration may be undertaken. The chances of failure are always so great that it is scarcely ever justifiable to under- take this' operation in the effort to establish an artificial channel for the urine, for, even when the opening is as far back as the perinaeum, soil- ing may be prevented by urinating in the squatting posture. The operation for the relief of hypospadias consists in introducing a long, delicate knife at the apex of the glans, and carrying it directly back along the normal position of the corpus spongiosum until it emerges in the anterior limit of the urethra at the abnormal opening. This arti- Fio. 640.— (After Liiili;irt.) Fig. 642. iin. 643. ficial channel should be large enough to admit a straight catheter, which is now introduced through it and well into the urethra beyond the hy- pospadias. In closing the abnormal meatus the margins of the integument around it should be trimmed with delicate cui'ved scissors, parallel incisions 634 A TEXT-BOOK ON SURGERY. made on either side of the opening through the skin, the intervening strip of integument carefully dissected up for sliding, and the edges brought together by sutuivs of fine iron-dyed silk. The leni? losp (From a cafe in Mount ispital. I 636 A TEXT-BOOK ON SURGERY. buds of newly formed cells and capillaries, giving it an appearance not unlike a cauliflower (Fig. 64o). Ulceration occurs at various portions of the mass, and a dirty quality of pus is exuded. The odor from the de- comi)osing tissues is X)ecidiarly jjenetrating and offensive. Within a period of time, varying from two to six or eight months, enlargement of the inguinal glands is observed. This enlargement may be inflammatory or metastatic. As a rule, metastasis is not rapid in epithelioma of the penis, and induration of the glands does not, on this account, i)reclude the hope of cure after amputation. The principal cause of epithelioma of the penis is prolonged irrita- tion of the glans and prepuce fi-om retained secretions. All the cases which have come under my observation have occurred in patients with unusually long and tight prepuces.* It is usually met with in the mid- dle-aged and old, although it sometimes occurs in early adult life. The diagnosis of epithelioma is not very difficult after ulceration takes place. The indurated sinuous and everted borders of the ulcer, the red, cauliflower-like appearance of the mass, and the steady i)rogress of the disease in the destruction of all the tissues in its path, are symp- toms not met with in any other lesion of this organ. Warty growths (papillomata), Avhen not seen early in their development, may at times simulate epithelioma, especially when these vegetations are luxuriant, are undergoing ulceration, are covered with jiurulent matter, and are the seat of repeated haemorrhages. No matter how wide-spread the paj)- illomatous neoplasm may be, at the outskirts of the mass will be found tufts or minute warts sufficiently isolated to be recognized. In the very earliest stages of development of the ulcer of epithelioma, it is scarcely possible to make a positive diagnosis between it and chancroid, or even a simple ulcer of the prepuce and glans penis. Treatment and Prognosis. — The only justifiable treatment of epithe- lioma of the penis is an immediate excision of the neoplasm by ampu- tation. The line of amputation should always be wide of the linnt of the disease. If the induration of the ulcer is well defined, and is lim- ited closely to the margins of the erosion, the amputation may be made with one inch of sound tissue intervening. If the inguinal glands are enlarged, and if the surgeon has reason to be satisfied that the enlarge- ment is due rather to inflammatory engorgement than to metastasis, the operation is still advisable, and the prognosis not altogether unfavorable. \Vhen metastasis of the glands is unmistakable, amputation may be done to rid the patient of the foul and ulcerating mass, although a favor- able prognosis can not be entertained. In the earlier development of the growth, where a sufficient extent of healthy tissue intervenes between the induration and the line of excision, amp)utation offers a strong hope of permanent relief. In the earlier period of development of the ulcer, if doubt exists as to its character, it is advisable to administer the * In an experience of several years in attend.ance at Mount Sinai Hospital, I have not met witli a case of epithelioma of the penis in an individual upon wliom in early life circumcision had been performed. THE PENIS.— SIMPLE AMPUTATION. 637 iodide of potassium, together with protoiodide of mercury, for a num- ber of weeks. In this way the differentiation between the later mani- festations of syphilis and epithelioma may be assured. Operation. — Amputation of the penis may be performed by two methods : 1, simple amputation ; 2, amputation with transplantation of tlie urethra to the perineeiim. In the selection of the method, the opera- tor must be guided by the nearness of the disease to the pubes and scro- tum. Ordinarily, when the induration is limited to the glans, a simple ani]>utation may be made at a jwint about one inch posterior to this. If the line of amputation must be chosen at or very near the level of the pubes, the second method will be preferable, for the reason that re- traction of the stump will always occur, and the urine escaping over the scrotum will keep up a constant and annoying excoriation and condition of uncleanliness. In the operation with transplantation of the urethra, the urine is voided in the squatting posture, and escapes freely behind the scrotum.* Sinqjle Amputation. — Having shaved and thoroughly cleansed the pubes, scrotum, and penis, throw an elastic ligature around the organ at the level of the pubes. If the line of amputation is very near the liga- ture, this may be prevented from slipping l)y transfixing the jienis with a large needle just in front of the tourniquet. Seize the mass with a double hook, and, holding it steady, with a long, thin-bladed knife cut tlie organ smoothly off at a j^oint at least one inch behind the disease. A tenaculum should be in readiness to prevent the erectile tissue from retracting. The tube of the urethra should now be dissected up for half an inch, and the tissues of both cavernous bodies again divided on a level with the point to which the dissection of the spongiosum has been carried. The urethra is now split by passing the knife through its roof and floor, and a silk suture carried through the end of each lateral half. A thread is also passed through the dense capsule of the corpora caver- nosa to prevent their retraction when the elastic ligature is removed. All vessels which may be recognized before loosening the rubber band should now be secured with catgut ligatures, and the remaining bleed- ing points caught up as the tourniquet is gradually loosened. The su- tures passed through each half of the urethra are now carried through the edge of the incision in the skin to which it is sewed. A simple dressing completes the operation. Humphrey's Operation. — The elastic ligature is carried around the penis close up to the level of the pubes, as in the preceding operation, and the organ severed as near the ligature as possible. The vessels in the corpora cavernosa should be tied at once. An incision should now be made through the skin along the under surface of the corpus spon- giosum, back to and splitting through the base of the scrotum, so as to expose the tube of the urethra for about two and a half inches. This * I have performed this, the operation of Humphrey, three times, and in none of these patients has any unpleasant symptom followed. Two of the cases are stUl, under observation three years after the operation. 088 A TEXT-BOOK ON SURGERY. tube is carefully dissected out from its attachment beneatli and be- tween the two corpora cavernosa for this distance, and is turned down on to the perinjeum throuiih the slit in the ijosterior wall of tlie scrotum. The urethra should next be si)lit aiouu' the median line of its loof for a distance of half an inch back from the end, antl the edges stitched to the mar- fjins of the wound in the integument of the perinff-um. The oper- ation is completed by closing the i)osterior slit through the scro- tum, and stitching the margin of the wound in the skin of the an- terior wall of the scro- tum to that of the belly at the root of the penis, so as to cover in and include the stump of the am- putated corjtora cav- ernosa. The appear- ance of the ])arts aft- er tills operation is shown in P^'ig. 046. Sarcoma oi the pe- nis is exceed ingl y rare. It may be recognized by its rapid development, the absence of glandular enlargement, the gen- eral invasion of the cavernous bodies — in certain cases producing a con- tinuous and painful erection of the organ — and by its resemblance to the well-known appearance and behavior of sarcomatous tumors in other portions of the body. The treatment should consist in immediate am- putation. FJiimosis, or inaliility to retract the prepuce behind the corona glan- dis, is a frecxuent conditifin of childhood, and occasionally met with in adult life. It is both a congenital and an acquired affection, and may be partial or complete. The prepuce may be adherent to the glar.s, or phimosis may exist without adhe.sions, the opening in the foreskin being so narrow that retraction is impossible. A prepuce ordinarily retractile may become irretractible as a result of any inflammatory pro- cess of the glans and foreskin. This condition is not infrequently met with in gonorrhoea and with chancroid. Congenital phimosis is an unfortunate affection, preventing perfect cleanliness by retention and decomposition of the retained secretions FiQ. 64ii. — Humphrey's opcratinn. fFrnm a ca.«e of the .luthor's, at Mount Siuai llo^llitIlhJ THE PENIS— PHIMOSIS. 639 and nrine, and inducing a condition of irritation whicli it were better to avoid by timely ojaerative interference. Inflammatory or acquired jjhi- mosis always requires careful attention, and very frequently a surgical ()I)eiation, to prevent gangrene or to expose a subprepiitial chancroid. The operative measures may include : 1, amputation of the prepuce (circumcision") ; 2, dilatation of the preiiutial orifice with forced retrac- tion ; 3, incision of the anterior portion of the prepuce and retraction. The first of these procedures should be preferred in all cases in which there is no inflammatory process present, while the latter is advisable in phimosis with acute balano-posthitis. Operation. — In adults, circumcision may be done with perfect free- dom from pain by the proper employment of cocaine. In children under six years of age, chloroform narcosis is advisable. In adults, proceed as follows : Cleanse the parts to be operated upon with l-to-5()00 sublimate solution, and throw an elastic ligature around the penis at the level of the pubis. From ill xx-xxx of a 4-i3er-cent cocaine solution are now injected by inserting the needle at the margins of the preputial orifice, and carrying it back between the mucous mem- brane and integument of the prepxice a little behind the proposed line of section. In the middle of the dorsum three or four minims are forced out of the syringe, the needle partially withdrawn and carried a half- inch to right and left of this point, and a like quantity is injected, and so on until the entire line of amputation is anjesthetized. As a rule, it will suffice to insert the needle once in the median line above, and once at the frpenum, and from these two locations it may be thrust beneath the skin to either side until the prepuce is completely encircled. In selecting the line of incision, the best rule is to aUow the parts to assume their normal relations, and mark the foreskin, by repeated punctures with the scalpel, i)arallel with and one fourth of an inch an- terior to the outline of the corona of the glans. A dull-pointed, grooved director should now be passed between the upper siirface of the glans and the prepuce, in the median line, until the point is at the line of amputation. A sharp-pointed bistoury is next slipped along the groove in the dii'ector, thrust through, and the foreskin si:)lit by cutting from Fio. 647. Fig. 648. behind forward (Fig. 647). Or this incision may be made from be- fore backward with a pair of straight scissors. The edges of the fla]is are now seized with a pair of mouse-tooth fixation-forceps, and trimmed 640 A TEXT-BOOK ON SURGERY. off witli scissors, being careful to follow the line already indicated (Fig. 048). Wlicn these incisions are conii)leted, it will be observetl that the edge of the divided mucous membrane remains at the level of the incision — namely, a quarter of an inch in front of the outline of the corona glan- dis — while the skin retracts beyond the corona. The mucous membrane should now be turned back, and its edge stitched to that of the incision in the skin. Fine catgut should be used, and an interrupt- ed or continuous suture employed. The for- mer is somewhat more accurate, although it requires much more time in its insertion than the latter. It is important, in tlie effort to secure immediate union, tliat at all points the apju'oximation is carefully made between the margins of the integument and mucous mem- brane. After the sutures are inserted, the mucous membrane rolls back, leaving the stitches behind the corona (Fig. 649). The elastic ligature is now removed, and a light dressing applied over the line of sutures. This operation is entirely bloodless. The patient should be directed to prevent the urine from Fio. 649. — (.After Malgaigne.) Fig. 650. — GirJner's pliimosis-lbrceps getting into the wound. Tlie sutures disappear by absorption, and the union is complete in from four to ten days. When the prepuce is adherent to the glans, it will be found impossible to in- troduce the grooved director as above unless the adhe.sions are first broken up. Under these conditions, the following oi)eration should be per- foiined : Carry the phi- mosis-f creeps (Fig. 6r)()) into the oi)ening of the pi'epuce, and allow the blades to expand so that the hooklets at the tip will catch in the mucous membrane. The fore- I **,:.»—--"- 1 \ \ \ skin is now drawn well to the front by an assist- ant, while the operator slips the thumb and fin- ger of the left hand along the penis and grasps the foreskin just in front of the meatus. In young children, considerable care is necessarj' to prevent cutting off a portion of the glans with the pre- ULCERS OF THE PENIS. 641 puce. Tlie foreskin is next amputated with the scissors just in front of ^he finger and thumb (Pig. 651). As retraction takes place, it will be seen that the line of section in the skin is near the corona, while that in the mucous membrane is only a little back of the meatus. This should be seized with the mouse-tooth forceps, and the adhesions broken loose or divided with the scissors. The mucous lining should now be j^ared back to a sufficient distance, and, if necessary, a second division of the pre- puce made. The sutures are ajiplied as in the preceding opei'ation. Dilatation or ditulsion of the prepuce is rarely, if ever, indicated. It is performed by introducing the point of a small, closed dressing-for- ceps into the opening of the foreskin, and stretching or tearing this by forced separation of the blades. The operation is completed by retract- ing the jn-epuce and breaking up all adhesions. In the after-treatment it is essential to move the foreskin back and forth over the glans once or twice daily to prevent the re-formation of adhesions. Incision limited to the anterior half-inch of the foreskin, and in the median line of the dorsum, is a more advisable operation when circum- cision is contraindicated. Retraction should be immediately etfected. Ulcers of the Penis. — Sores may occur upon the integument of the penis, usually near the prepuce ; upon the mucous lining of the fore- skin ; the glans ; within the meatus ; and along the urethra. Venereal sores are occasionally met with upon the integiiment of the scrotum, alidomen, perin.cura, and thighs. Ulcers of the penis only will be con- sidered here. They ai'e divisible into two classes — namely, the non- specific and the specific ulcer. To the former belong the sores which follow aln-asions and the eruption of herpes. They are more or less phagedenic in character, the extent and rapidity of the process of ne- crobiosis being due to the degree of virulence of the inoculating pus- corpuscles, the thoroughness of the inoculation, and the impoverished condition of the tissues attacked. The chancroid belongs to this group. In the second class belongs the specific ulcer of syphilis. Ko a- specific Ulcers. — A simple ulcer of the penis is extremely rare. It may occur here, as in other parts of the body, as a result of trauma- tism, or an inflammatory process not due to the inoculation of a virus. Thus, the molecular death of a variable extent of tissue may follow a simple abrasion if the part involved is not kept free from all irritation, an;l if there prevails a condition of imj^aired nutrition, in which, as is well known, the tissues yield readily to the destructive process. Under more healthful conditions, an abrasion of the glans or prepuce under- goes the simple process of repair seen in similar lesions of the integu- ment and mucous surfaces elsewhere. Abra.sions nsuaUj' occur on the sides of the penis, close to the attachment of the prepuce, just behind the corona or near the frsenum. The glans is rarely involved, although the meatus, especially at its lower angle, may be torn. Bleeding sufh- cient to attract the attention of the patient is rare, unless extensive laceration has occurred. The ulcer of herpes is usually situated u])on the surface of tlie mu- cous lining of the prepuce, less frequently upon its cutaneous surface, 642 A TEXT-BOOK ON SURGERY. and the pclans. It begins as a vesicular eruption. There may be one (tr many. Multiple herpetic vesicles may be scattered or in clusters, linear, semilunar, or circular in arrangement. In the recent state the herpetic vesicle is round at its base, measuring I'rom (me twelfth to one twenty- fifth of an inch in width. It consists of a thin investing membrane rest- ing ui)(m a slightly red and irritated base, and containing a clear, serous fluid, which often escapes by rupture of the meml)raue before the vesicle is observed. Upon the skin they rapidly drj^ on account of evaporation of the fluid contents, and the floor of the patch becomes covered over with a light incrustation. Upon the mucous and moist surfaces, in- crustation does not occur. The circumference of the base exposed after rupture of the vesicle is usually round, Avith well-defined walls leading perpendicularly down to the bottom of a shallow excavation. In typical cases of genital herpes, the morbid process ends here, the sore healing without supi)uration. Not infrequently, however, the floor becomes covered with a layer of pus, the walls are undermined and break down, forming an ulcer which is phagedenic in character. The character of the jiain varies. In some instances there is a sting- ing, burning, sensation felt in the part affected ; in others there exists total insensibility. Herpes is a neurosis due to a local irritation of the nerve termina- tions in the part attacked. In some instances a severe neuralgia of the branches of the sacral or lumbar plexuses exists at the time of the erup- tion on the glans and prepuce. Uncleanliness is a frequent cause of this disease. Any irritation of the glans or prepuce may induce it, and one attack is apt to be followed by a second. In mild and ordinary cases it runs its course in from ten days to two or three weeks. In other forms, especially when inoculation occurs, it may last for a number of weeks, and is usually complicated by lymi)han- gitis and adenitis. Phagedenic ulcer of the genital organs was formerly held to be the result of the inoculation of a specific poison — the virus of "chancroid"'; but, since ulcers which in appearance and behavior do not differ from the so-called chancroidal ulcer have been produced by inoculation with corpuscles taken from the pustules of acne, from gonorrhcral pus, etc., the specific nature of this virus can not be maintained. Even the spe- cific ulcer of syphilis will, as a result of repeated and prolonged irrita- tion, take on a phagedenic character. This ulcer results most fi-equently from direct contagion, the pus-cor- puscles which contain the virus being lodged in an abrasion of the in- tegument, prepuce, or glans The period of incubation — that is, the length of time between the date of the contact and the recognition of the sore — will vary in different individuals. It has been seen within twenty-four hours, and, in rare instances, as much as twenry days have elapsed. In a very large majority of cases the intlammation is observed within the first nine days after the inoculation. The rapidity of its ap- pearance depends in part i;pon the quantity and vinilence of the pus, but chiefly upon the thoroughness with which it is brought into con- ULCERS OF THE PENIS. 643 tart Avith the tissues in an abrasion. The sjuead of the ulcer and its phagedenic character also depend upon the virulence of the poison and the condition of the tissues at the time of the invasion. The ulcer is usually located on the side of the penis, just behind the corona glandis at the preputial attachment, at the points where abrasions are most frequent. It may be on the cutaneous surface of the prepuce, upon the body of the i:)enis, the scrotum, or within the meatus. There may be one or more, owing to the number of abrasions and the distribu- tion of the virus. A single ulcer may result from the confluence of sev- eral contiguous points of inoculation. It is first noticed as a light red- ness or flush, iisuaUy cu'cular or elliptical in shape, or, if the abrasion is irregular in outline, it will confoi-m to this. Within a few hours after the ajipearance of the redness, its center becomes elevated and a pustule is formed, which soon breaks down, discharging a small quantity of matter. If the sore is not seen early, the pustule may escape observation. "When the inoculation occurs upon a surface denuded of its mucous mem- brane or epidermis, a pustule is not formed. The walls of a phage- denic ulcer are usually precipitous. At times the superficial layers of the skin resist disintegration longer than the deeper layers and subcu- taneous tissues, giving the edges an undennined ajipearance. It tends to spread in width rather than in depth, although in a certain propor- tion of cases extensive destruction of tissue may occur in all directions. The floor of the ulcer is covered with pus and broken-down tissues in various stages of decomposition. A small quantity of matter of creamy consistence may be removed with a pellet of cotton. A membrane or film of a yellowish-brown color usually adheres to the floor with con- siderable tenacity. A zone of redness extends along the edges of the ulcer in advance of the tissue-destruction. In many iilcers this is not more than a line in width. If the sore is subjected to irritation, the intiammator\' redness and induration may spread widely into the surrounding tissues. Pain, which is always present, varies, as a rale, %vith the extent of the inflammatory process. In a typical phagedenic ulcer of the penis, lymphangitis and adenitis of the inguinal glands are always present in a varying degree. In the sim- l)ler foiTus, adenitis does not occur, although the lymphatic channels in the neighliorhood of the sore may be involved. Inguinal bubo is always a painful complication. It may be lateral or liUateral. If the sore is in the median line, or if there are ulcers on both sides, both groups of glands will be affected. Suppuration of the inguinal bubo of phagedenic ulcer is not uncommon. The violence of the inflammatory process here is subject to the same conditions as given for the primary ulcei*. One or more glands may be involved and suppurate. In severe adenitis, the inflammation extends to the tissues immediately surrounding tiie glands. The mass ai)peai"s as one large swelling, over which the integument is red and oodematous. and to which it is adherent. Phagedenic bubo is apt to follow a virulent phagedenic ulcer of the penis. 644 A TEXT-BOOK ON SURGERY. Treatment. —?^\mYi}e ulcer of the penis, if left witliont interference, usually lieals williiri ;i few weeks ; the ulcer of herpes is usually more obstinate. The process of repair may bo tjreatly facilitated by a careful removal of all sources of irritation. Strict cleanliness is essential, no matter what form the ulcer may assume. Soaking the jiart in warm black wash (calnnicl 3 j to lime-water Oj) two or three times a day is an excellent method of treatment. The local use of liquor plunibi sul)aceta- tis dilutum is also advisable. In addition to the foregoinj;, it is essential to keep the sore uncov- ered by the prepuce, which should be worn back behind the corona. Circumcision may at times become necessary to obtain a permanent cure. If the simpler remedies just given do not succeed, the local use of the nitrate-of-silver jjencil is indicated. In phagedenic ulcer, as a rule, more vigorous measures are necessary. The severity in local treatment will depend, however, upon the rajjidity of molecular death which the poison is causing in the tissues. If its progress is slow, and the inflammation mild in character, recovery may be brought about by the treatment laid down for simple and herpetic ulcer. If within the first few days of its appearance the spread of the sore is rapid, or if, when first brought to the notice of the i)hysician, it is more than a quarter of an inch in diameter, and the zone of redness spreads well out into the tissues, it should be treated as follows : By the introduction of a delicate hypodermic needle through the sound tissues, after which its point should be carried under the base of the ulcer, from fifteen to twenty minims of a 4-pei'-cent solution of cocaine should be injected, by which means complete ansesthesia may be secured. The pus should now be removed from the bottom of the sore with a pellet of absorbent cotton on the end of a small piece of wood. The parts im- mediately about the ulcer slioidd be coated over with vaseline or oil, to protect them from excoriation. A small quantity of carbonate of soda should be on hand to neutralize any excess of acid. In a]i])lying pure nitric acid, the ulcer should, if possible, be held so that it will con- tain the acid without letting it run over the edges. It is best applied by means of a wooden match or tooth-pick dipped in the acid, and the point immediately carried into the floor of the ulcer. It should be con- veyed into every portion of the sore, and allowed to remain in contact with the virus for one or two minutes. The excess may now be soaked out with the cotton pellets, and the ulcer filled with soda. A piece of lint moistened in vaseline will serve as a dressing. When nitric acid can not be had, the actual cautery should be employed. Iodoform may be dispensed with, on account of the disagreeable odor of this substance. When phagedenic ulcer occurs beneath an irretractible prepuce, this should be incised and the sore treated as above. Ulcer of the meatus should also be bui'ned with nitric acid. Corai^lete rest is essential, and constitutional measures looking to the improved nutrition of the tissues are strongly indicated. If suppuration occurs in the glands of the in- guinal region, free incision should be made and free drainage estab- ULCERS OF THE PENIS— SYPHILIS. 645 lifhecl. Phagedenic bubo should be treated ia the same manner as the pliagedenic ulcer. The Specific Ulcer {Cliancre) — S>/ph/lis. — Syphilis is a disease affect- ing in a varying degree the nutrition of all the tissues of the human body. It is caused by the introduction into the blood of a specific virus. In practice, two distinct forms are met with, namely — the acquired and the inlieritcd. Acquired syjAilis ensues when the specific virus is can-ied into the lymph or blood-channels of a human being not syphilitic at the time of inoculation. Of the physical or chemical properties of this virus practically noth- ing is known. The claims that it exists as a dwarfed or crippled leuco- cyte, a fungus, a special form of pus, a peculiar bacillus, etc., have not been substantiated nor accepted. "While it is generally believed that an abrasion of the skin or mucous surface is essential to tlie absorption of the syphilitic virus, it is ex- tremely probable that, if it is brought and kept in contact with the thin unbroken skin or mucous membranes, absorption may occur. A disease the germs of which are transported within the spermatic elements, and with such potency that the impregnated ovum is affected, can, under favorable conditions, in all i^robabUity be transmitted from unbroken cutaneous or mucous surfaces through wliich it is demonstral)]e that the absorption of other elements occurs. The chief source of the contagion is in the fluid which transudes from the surface of the initial lesion or ulcer (chancre), and, next in order, that from mucous patches. The blood of a sj'philitic patient also carries the poison and produces the disease if injected into or inoculated upon the tissues of another. The same is true of the matter or fluid from the cutaneous lesion of the secondary stage of syphilis. It is doubtful if tlie lesions of tertiary syphilis are capable of reprodiicing the disease. Saliva from a syphilitic subject, unmixed with the discharge from mucous i)atches, fails to produce syphilis. Seminal fluid from a syphi- litic man, in any of the stages of the disease, is held to be not directly contagious. Howevei", the mother may acquire the disease from a child in utero, the child being syphilitic from the spermatozoa. Milk from a woman in any stage of syphilis will not produce the disease if injected into the tissues or ingested as food. The transudation from a fissure in the nipple of a sypliilitic nurse \\\\\, if lodged in an abrasion npon the lips, tongue, or buccal wall of the child, produce the sj>ecific disease in a non-syphilitic subject. On the other hand, a syphilitic child may inoculate a healthy nurse. The urine, tears, and sweat of syphilitic patients do not convey the specific virus. Pus from a vaccine pustule on a syphilitic subject does not con- vey the virus of this disease even when the vaccination is successful. If, however, blood or the fluid from any early syphilitic lesion is mingled with the pus, syphilis results. While the most frequent seat of inoculation is upon the genital or- gans, or in their immediate vicinity, it may occur at any part of the 646 A TEXT-BOOR ON SUIKiERY. body. The contagion may be direct or indirect. In the former, the virus of a specific ulcer is brought directly in contact with an abrasion upon a non-syphilitic subject. In the latter, the poison adheres to some intermediate agent, and thence is conveyed to the abrasion.* The clinical history of a typical case of acquired sy])hilis left without treatment, and in a certain proportion of cases in which treatment is in- stituted, is divided by usage into three stages — primary, secondary, and tertiary. In a majority of cases, when properly managed, the later mani- festations may be eliminated, and the secondary stage made shorter and less severe. The priman/ stage includes: 1, absoi-ption of the virus ; 2, the ulcer; 3, local lymphangitis and adenitis. The symptoms which belong to the second stage are the cutaneous eruptions, mucous patches, fever, arteritis, condylomata, alopecia, iritis, and general adenitis. In the tertiary stage, the pathological changes are chietiy confined to the arteries, viscera, bones, the integument, and the subcutaneous and submucous connective tissues. This is the period of gummy tumors, connective- tissue formations, arterial occlusion, and deep ulcers of the skin and mucous membranes. The usual duration of the first stage is from six to nine weeks. Sec- ondary symptoms may, however, appear at the fifth or sixth week from the date of inoculation. On the other liand, in rare instances, they may be delayed to between the third and sixth month. The limitation of the stages of this disease is in great jjart arbitrary. The duration of the second stage varies from the fifth or sixth week (or in delayed cases the sixth month after contact) to about the end of the first year after the inoculation. The tertiary stage begins at the end of the preceding stage, and may last indefinitely. First Stage. — When the specific virus is brought in contact with a broken cutaneous or mucous surface, absorption may begin at once or be delayed for a considerable period. The abrasion may be so insignifi- cant that the patient's attention is not attracted to it, and, although the virus is lodged in it, it may heal over within a few days. If subjected to irritation by friction, or the simultaneous inoculation with the virus of phagedenic ulcer or other virus, inflammation supervenes, and an ulcer more or less phagedenic in character appears. Absorption takes place chiefly through the lymphatics. It may occur through the blood-vessels, and it is possible that in those cases in whicli constitutional symptoms appear with great rapidity and severity, the dissemination of the virus takes place in this way. The rapidity of lymphatic absorption varies. There is usually a pe- riod of about three weeks from the time of lodgment of the virus untU * la one of my c.nses the inocalation occurred in a fissure of tlie lip in the person of a mer- chant wlio was using a glass in common with a customer in sampliniopliagus. — Partial or complete occlusion of the oesophagus may occur from — (1) connective-tissue hyperplasia in its walls, or the contrac- tion following ulcer (organic stricture) ; (2) the mechanical obstruction from gummatous deposits in the walls or in the immediate neighborhood of the oesophagus ; (3) pressure from exostoses, aneurisms, enlarged glands, etc. Syphilitic ulcers of the stomach and alimentary canal have been observed, though rarely. Gummata form here, however, with a certain degree of frequency, and stricture of the pylorus, and of the in- testinal canal above the rectum, is known to occur in a certain propor- tion of cases. The rectum is especially liable to become seriously in- volved in the late manifestations of syphilis. Here, as elsewhere, strict- ure may result from iilirillation and contraction of the inflammatory tissue with which the walls of this organ and the jieri-rectal tissues may be- come infilti'ated. Again, ulcers originating within the gut, or extending from a like inflamm:itory process about the anus and the external tissues, or the presence of gummatous material, may all induce more or less serious contraction of the lumen of the rectum. Of the solid abdominal viscera, the liver is most seriously affected. The pathological changes are — (1) connective-tissue hyperplasia or chronic interstitial hepatitis or sypliilitic cirrhosis, which may be general or local ; (2) gummata in any portion of the organ ; (3) waxy degeneration from long-continued general sepsis. The spleen, may undergo similar changes. Slight enlargement may occur from the excess of white corpuscles (leucocytha^mia), which is the rule in this disease. The pancreas is rarely affected. Genito-urinary System. — Amyloid degeneration of the kidneys oc- curs as a result of the long-continued sepsis of sypliilis, as with other chronic forms of blood-poisoning. In like manner, under conditions fa- vorable to connective-tissue hyperplasia, the fibrous stroma of this organ becomes thickened, with consequent atrophy of the excretory or glandu- lar elements (chronic interstitial nephritis). Gummata. of the kidney is not as common as in other viscera. Orchitis, although occurring while some of the secondary symptoms may be present, is essentially a late manifestation of this disease. It is important to recognize it, since several varieties of sarcocele require im- 654 A TEXT-BOOK ON SURGERY. mediate surgical interference. Syphilitic orcliitis should be suspected in all cases of tumor of this organ in which there is a history of specitic infection. In syphilis, the enhii'genient is apt to occur in both orgiins about the same time. The growth is smooth and sphericnl, and when lifted conveys the sense of unusual weight. It is not painful, excepting always the sense of dragging, wliich is ;it times annoying. Slight hydro- cele not infrequently accompanies this form of orchitis. The testicles are not exempted from gummatous deposits. In rare in- stances these break down, causing more or less destruction of the sub- stan(^e of these oi'gans. The penis is occasionally the seat of syphilitic iniiltration in the later stages of this affection. The Eye. — Syphilitic iritis lias been given as occurring in the second stage of this disease. It may also occur as a later manifestation. In- tlammation of the sclera, choroid and ciliary bodies, lens and capsule, retina, and (though rarely) of the optic nerve, are of varying fi'equency in the tertiary period. Lesions of the muscles may be due to connective- tissue new formations between the fasciculi, resulting in granular degen- eration of the muscle-substance and contraction of the new tissue. It nay occur in the second as well as the third stage of this disease. These contractions, if not relieved, may result in anchylosis of the joint in im- mediate anatomical relation to the muscles involved. Grummata are not of frequent occurrence. They terminate by suppuration or by absorp- tion, lutiammatiou in the tendons and their sheaths may also occur. Fingers and Toes. — The lingers and toes, during the tertiary period of syph- ilis, in a certain proportion of cases be- come the seat of gummatous deposits, the skin and subcutaneous tissues may be infiltrated, or the bones and cartilages may be involved. When the infiltration is confined to the soft parts, the entire Fio. f>53. — Syphilitic dactylitis. .,, „ ii „ ,„ 1 , .,„„i„ ^.. (After Bergii and Bumstiad.) orgau Will appear swolleu and inirple or reddish in color. When the bone is the seat of the deposit, it may be limited to a single phalanx (Fig. 6.1H) or invade all the bones of the finger. The process terminates in ulcer, necrosis, or granular degeneration of the cells of the new tissue, and absorpticm. Pathol ogy of Si/pJiilis. — The chief feature in the pathology of syphi- lis in all of its stages is the proliferation of an embrycmic tissue, usually of a type so low that it is not capable of organization into a definite tissue. From the initial lesion and the primary lymphangitis and ade- nitis to the final lesions of the viscera, this cell-proliferation continues, and the different effects vdtnessed in different individuals, or in the same individual, in the various stages of the disease, depend chiefly upon the degree of impairment in the nutrition of the tissues. The cell-accumu- lation in and around the capillary loops of the cutaneous papilhe, which produce a macular or papular syi)hilide in one individual whose tissues are in a condition of perfect nutriticm, will i^roduce a squamous or vesic- PATHOLOGY OF SYPHILIS. 655 ular eruption in another, or a pustular syphilide in a third who has the unfortunate inheritance of a gouty, scrofulous, or tubercular dyscrasia. Or a papular lesion of tlie first stage, in which the process of nutrition in the tissues is normal, may be replaced by a rupia in the tertiary pe- riod when assimilation is less perfect. If the initial lesion of syphilis is excised and examined witli the mi- croscope, the following conditions will be observed : The epidermis in the inmiediate vicinity of the ulcer is more or less completely destroyed. The membrane which covers the floor of the ulcer is composed of i)us- cells, fragments of epidermal cells, cells of the Malpighian layer, and fragments of connective-tissue and other detritus. These elements vary in proportion as the process of necrobiosis is limited or extensive. In the deeper i^ortions of the Malpighian layer, and in and around the pa- pillae where these layers are not wholly destroyed, and in the connective- tissue layer of the skin, there is a general infiltration with the embry- onic cells of the syphilitic process. The arterioles, veins, and capillaries are more or less completely oc- cluded. The cell-proliferation is especially marked in the arterioles, the adventitia and intima are thickened, the thickening being more marked in the latter, while the lumen of the vessel is more or less encroached upon by the new-formed tissue. The venules undergo analogous changes. The walls of the lymph-channels are thickened, and many of these ves- sels are crowded with cells. The iniiltration is, however, limited to the immediate borders of the ulcer, and the line between this and the unin- vaded tissue is sharply defined. As the mass of cells gradually obstruct the vessels, the nutrition of the new tissue is interfered with, and it either undergoes granular metamorphosis or breaks down more rapidly as a slough. The absence of pain in the chancre is also explained liy the gradual pressure upon the terminal nerves and the comparative dryness of the typical sore to the arterial occlusion. The lympTiatics immediately around the ulcer, and those leading from it to the nearest glands, are more or less filled with the new cells, and their walls appear tliicker than normal. The changes which occur in the glands in the eai'lier stages of syphi- lis consist in a hyperplasia of the connective-tissue cells of the stroma and thickening of the fibrous framework, together with an increase in the cell-elements of the gland-substance proper. The cutaneous lesions of secondary syphilis result from the more or less complete obstruction of the caj)illary loops of the papillae by the cells of this indifferent tissue. The walls of the capillaries undergo de- generation ; the coloring-matter of the blood escapes, causing the pecul- iar staining of the syphilides. In the macular syphilide the abnormal cell-accumulation is less than in the papular eruption. The changes which occur in mucous patches differ very slightly from those described in the cutaneous lesions. The ejndermis soon breaks down ; the Malpig- hian layer and papillee are infiltrated with the ceU-elements ; while the capillaries, arterioles, and lymiihatic vessels undergo changes almost identical with those described in the initial lesion. 656 A TEXT-BOOK ON SURGERY. In the later or tertiary lesions of the skin in syjjliilis, tlic infiltration is deepei". Cutuneons gummata consist of aggregations of the cell-ele- ments heretofore described, whicli are crowded into the snlxnitaneous areolar tissue, ijito tlic connective tissue of the true skin, in tlie walls of and just outside the vessels, while the endothelia of these vessels under- go prolift>rntion and aid in thiMr occlusion. Ulceration ensues from the rapid arrest of nutrition, and tlie process of necrobiosis is aided by the depi'essed condition of the tissues which usually exists in the tertiary stage of syphilis. The tertiary lesions of the mucous surfaces are analo- gous to those of the integument. The pathology of visceral syphilis pi'esents two distinct morbid pro- cesses : (1) the hyperplasia of the connective-tissue stroma of the organs (cirrhosis) ; and {2) the aggregation of the syphilitic embryonic cells (gumma). The character of these changes in the different organs has been given. Diagnosis. — In a typical case of acquired syphilis a diagnosis may be made upon the following symptoms : 1, an ulcer in appearance and behavior like that described as belonging to the initial lesion of this disease, the sore occurring not less than ten days, and usually about the twentieth day, after an exposure ; 2, induration and enlargement of the nearest lympliatic glands occurring in from eight to fourteen days after the appearance of the ulcer ; 3, after from two to four weeks of seeming arrest of the infection, the development of headache, pain in the back, slight febrile movement, Avlth an eruption (sixth to seventh week after the appearance of tlie sore) over all or a portion of the body, accom- panied with an unusual sense of dryness or soreness of the mouth, phar- ynx, or fauces ; 4, following or occiirring with these symptoms, general adenitis. In the majority of cases, excluding even those in which the sore is concealed, as in the urethra, etc., little value can be placed xipon the appearance of the ulc:^r at the point of infection. The classi(!al "initial lesion" of syphdis, with its well-defined margin of induration, feeling like a "si)lit pea" or piece of cartilage when grasped between the thumb and finger; the absence of pain and peripheral iiiilammation ; the pe- cidiar "scooped-out" concavity of the sore, the surface of which is cov- ei'ed with a scanty, serous transudation, is so frequently absent in cases in which the later and unmistakable signs of this disease are developed, that it alone can not be relied upon in arriving at a diagnosis. As stated heretofore, the syphilitic virus may be lodged in and absorbed from a phagedenic ulcer in which not a single feature of the specific sore is present. The same is true of the herpetic idcei', or that resulting from traumatism or the inoculation of any form of virus. All of these ulcers are grouped under the heading of "mixed sores." Induration of the glands is more reliable in a diagnostic sense. AVhen the typical initial lesion is present, the ensuing adenitis is also typical. In the inguinal region one gland of the group after another is enlarged and becomes indurated. The process is slow and deliberate. There is no periadenitis, the glands do not adhere to each other and the interven- DIAGNOSIS OF SYPHILIS. 657 ing tissues, nor to the integument. Each body may be distinctly made out by palpation and moved beneath the skin independently. There is no tenderness, and the gland is leathery to the touch. Even when the sore is mixed, if the i)hagedenic or intlammatory process is not severe, the adenitis is more apt to be specific than intiammatory, and wUl pos- sess the features of syphilitic bubo in a sufficient degree to admit of recognition. When the specific infection is complicated with a typical phagedenic ulcer or gonoirhoea, the resulting bubo does not possess a single appreciable feature of syphilitic adenitis. The eruption of syphUis is, of all the symptoms of this disease, the most reliable. When the sore is mixed, and the chai-acter of the ade- nitis doubtful, the early cutaneous and mucous lesions are, in the vast majority of cases, appreciable and unmistakable. Headache, rise in tem- perature, pains in the back, etc., are confirmatory symptoms, but inde- pendently of no value. The same may be said of dryness or soreness of the mouth, pharynx, and fauces. Lastly, general adenitis, which occurs in a varying degree in all cases of syphilis in which mercurialization has not been effected at a very early date, is a strong confirmatory symptom, and of great value in diagnosis if all the other lesions have escaped ob- servation. The greatest importance is attached to induration of the epitrochlear, and to the occipital and post-mastoid glands. The former can scarcely be recognized in their normal state. In general adenitis a single body, feeling like a small bean in shape, may be recognized at the inner aspect of the arm just above the elbow, where it lies superficial, and internal to the basilic vein. When any inflammatory process exists in the member beyond the elljow, the enlarged gland possesses no spe- cific diagnostic value. In like manner lesions of the scalp, face, or mouth may cause enlargement of the occipital or mastoid IjTnphatic glands. A diagnosis of syphilis in the tertiary period must depend upon a careful study of the history of the case and the presence of one or more of the lesions which belong to this stage, and which have been fully de- scribed. Prognosis. — A favoi'able prognosis in syphilis will depend upon — 1, the physical condition of the individual affected at the time of inocula- tion ; 2, the recognition of the disease within the first two or three months after the appearance of the ulcer ; 3, the faithful and energetic co-operation of the physician and patient in carrying out the measures to be given. That syphilis is a curable disease there can be no doubt. Under favorable conditions the symi>toms disappear, leaving little or no trace of the infection. In common with ail diseases, its severe or fatal results are seen in patients with an inherited or acquired dyscrasia, and in those whose nutrition is seriously impaired. Even in the worst class of cases the prognosis is not wholly unfavorable if proper treatment is instituted and maintained. The recognition of the disease and the institution of treatment at the time of, or immediately after, the appearance of the eruption, is impor- 42 658 A TEXT-BOOK ON SURGERY. tant in secnrins a favorable result ; foi-, if this is done, the violence of the infection may be modified and the deeper lesions rendered less severe. Treatment. — The treatment of syiihilis is divided into — 1, measures vvhicdi tend to destroy the potency of the virus and aid in absorption of the inflammatory products of this disease ; and, 2, those which tend to improve the nutrition of tlie tissues. Both are essential to the successful management of this formidable affection. To the former belong the preparations of mercury and iodine in com- bination with ])otassium ; to the latter tonics, the careful regidation of the habits of living, nutritious diet, and healthful and moderate exercise. Nothing is more satisfactorily demonstrated in scientific medicine than the power of mercury to neutralize and destroy the virus of syphi- lis. Its administration should usually l)egin with the i)ositive recog- nition of the disease at the appearance of the eruption (usually about the sixth or ninth week). It is always advisable to wait until tlie diagnosis is assured, rather than to begin treatment with the recognition of the sore or bubo. It has been stated that these symptoms are often not reliable, while the early cutaneous and mucous lesions are practically pathognomonic. The greatest objection to the early institution of treat- ment is tlie doubt which may be left in the mind (jf both physician and patient of the correctness of the diagnosis by the early disappearance of the initial lesion and the local adenitis. The individual affected, as well as the practitioner, is too often lulled into a sense of security by the rapid disappearance of the early symptoms ; treatment is either discon- tinued or carelessly carried out until, after several weeks or months, it is discovered that the disease has taken a firm hold ujjon the tissues. Commencing with this date, the management of a case of syphilis should be carried on for a jieriod of two years. It is of the utmost importance that the person affected should be im- pi'essed with the gravity of the situation and the certainty of disaster if the rules laid down by the medical adviser are not strictly obeyed. With the proviso of obedience, the prognosis should be as encouraging as pos- sible. Responsibility for the result of treatment in this disease should not be assumed unless the patient consents to keep himself under ob- servation for the period above given. All excesses should be prohibited. The use of tobacco should not be permitted. Alcohol in any shape is scarcely allowable. In certain cases, where digestion and assimilation are impaired, a small quantity of whisky, claret, or sherry may be taken with the heaviest daily meal. Sexual indulgence, if from no other than humanitarian motives, should cease for at least a year from the appear- ance of the initial lesion. The child of parents, either of whom is within the first year of syphilitic inoculation, becomes the victim of a dyscrasia which, if not fatal to life, is fatal to the i^erfect usefulness of its pos- sessor. In addition to the danger of direct inoculation during the prevalence of the chancre, is that of infection to the mother from the foetus in utero or the child in the act of parturition. A patient iinder treatment for syphilis should retii'e early and at a regular hour, avoid excessive use TREATMENT OF SYPHILIS. 659 of the eyes, especially at night, sudden changes in temperature, and all articles of diet which are not readily digestible. Of the preparatifins of mercury, preference should be given to the protoiodide. It is conveniently administered in pills of one-quarter grain each. To begin with, one of these pills should be given three times a day one hour after eating. The indications for a diminution in the quan- tity are pain of a cramp-like nature in the stomach or bowels, with or without diarrhoea, and the occurrence of salivation. If diarrha^a results, it will be advisable to administer about one-quarter grain of opium with each pill of protoiodide, or to reduce the daily number of the pills. Under such conditions, inunctiims with mercurial ointment are of great value. Salivation may be guarded against by careful observation of the gums. At the earliest indications of tenderness felt when the teeth ai'e lirmly pressed together, or when direct pressure is made ujion the alve- olus, the dose should be diminished, or, if necessary, discontinued for a few days. It will usually suffice to administer one-quarter grain three times a day for the first month, and at the expiration of this time to increase the daily quantity to gr. j. It will rarely be necessary to give more than this quantity, although in some cases the full beneficial effects of the remedy may not be realized until a larger daily dose is given. The mer- cury should be continued M'ithout interruption — excepting for the reasons Just given — for the first six months after commencing the treatment. At the expii'ation of this period it is a good jAan to discontinue the proto- iiidide for two weeks, and then administer the iodide of potassium in doses of grs. x-xx three times a day for one month. This should in time be stopped, and the piUs resorted to for a period of two months, and so on, alternating these two remedies to the end of the first year of treatment. For the first six months of the second year the alternation should be equal — i. e., one month of the potassium salt, and the next the protoiodide. For the last six months of treatment a greater propor- tion of the iodide of potassium should be given. In addition to the foregoing it is of great importance that tonics should be administered from the commencement of the disease, and especially in delicate patients. In carrying out this part of the treat- ment much better results will be obtained in the alternate exhibition of several tonics rather than in the continued use of a single remedy. A l)reiwiration of iron, quinia, and strychnia on one day, given in the iinqier dose immediately after each meal ; an emulsion of cod-liver oil with the liypophosphites of lime and soda, each gr. j to the tablespoonful on the next day ; and tincture of the chloride of iron on the third day, will be found a convenient and useful method of rotation. When protoiodide of mercury can not be obtained, the biniodide, in doses of gr. -^ to Jg^, or chloride of mercury (corrosive sublimate), gr. 2'o~ r( i"i V ™^3^ '^e substituted. If, for any reasons, mercurial inunctions become necessary, proceed as follows : Take about a teaspoonful of mercurial ointment and rub it well into the skin of the groin and under the arms. Or spread the oint- 660 A TEXT-BOOK ON SURGERY. ment on lint and apply it to these parts, holding it in jjlace by lif^htly fitting clothes or bandages. It should be used only at night, and re- moved upon I'ising by washing with wnrm wat(>r and soa]). The hypodermic injection of corrosive subliniate in the treatment of syphilis is objectionable on account of the annoyance produced by the insertion of the solution beneath the integument. It is an unnecessary practice, for the best results can be obtained from the internal adminis- tration of the protoiodide. In the treatment of the tertiary lesions of syphilis, practically the same rule of practice should be adopted as just given for tlie second year following the ap])earance of the initial lesion. The employment of iodide of potassium in full doses hastens the absorption of the inflamma- tory ])roducts of this stage, while the protoiodide destroys the potency of the virus. Both remedies should be administered in doses as large as can be borne without interfering with the functions of the digestive organs or producing any serious constitutional disturbances. Inhcritt'd SypJiJlls. — The f(rtus may beccmie syphilitic from a syphi- litic father or mother. If pregnancy occurs within the first year, and especially in the first six months of the disease in the mother, the child becomes inoculated, eitlier dying in utcro, or, if carried to term, usually perishes within a few weeks after its birth. If, however, the disease is recognized and i)roper treatment instituted, a more favorable prognosis may be nuide. In the second year after infection, if properly treated, a mother may bear a non-syphilitic child, although the chances are against complete immunity. During the third and each succeeding year, under judicious management, the prognosis is still more favorable. A female patient should be advised of the great danger of pregnancy within the two years immediately following inoculation. When she has been under constant and in-ojier treatment for this length of time, and has been perfectly free from symptoms for one year, the gravity of the danger is diminished. If she has not been treated, she should under no circumstances be made liable to pregnancy. In case such a woman should become pregnant, she should be treated carefully for syi)hilis, and in this way the infection of the child may be modified, if not prevented. The virus of syjihilis may be conveyed by the spermatic elements, and the embryo thus become inoculated.* The prognosis is more favor- able in proi)ortion to the length of time which has elapsed after the initial lesion, and to the thoroughness of the treatment instituted. A syphilitic man should not beget a child within two years after the initial sore, nor at any later period unless thorough treatment has been insti- tuted and one year has elapsed since the disappearance of all symp- toms of the disease. * As heretofore stateJ, a non-sypliilitic mother may be inoculated from a syphilitic child in the act of parturition. That the mother is also subjected to the influence of this virus from carrying the offspring of a syphilitic father is proved by CoUex's law, which is, that a previously healthy mother of such a child can nurse it without danger of chancre of the niiiplo and syphi- litic infection, wliile a non-syphilitic nurse will become inoculated. INHERITED SYPHILIS. 661 Symptoms. — The symptoms of specific infection in the child manifest themselves usually within the first eight or twelve weeks after birth. Oc- casionally the disease is latent, and tlie symptoms do not appear until a variable period has.elapsed. Even puberty may be reached before it is evident. Excepting the chancre, the local lymphangitis and adenitis, the evolution of the symptoms of inherited syj^hilis is not unlike those of the acquired form. The lesions are cutaneous, mucous, and visceral. The macular or papular syphilide occurs in most cases, and may be distributed over the general surface or confined to certain limits. It is usually first seen upon the abdomen, and from this starting-point it be- comes more or less widely distributed. At the muco-cutaneous margins, and in the folds of the skin where irritation is greater and moisture exists, condylomata are not infrequent, and are often persistent. Vas- cular, pustular, and tubercular syphilides occur in a certain proportion of cases. The tubercular form is rare. The pustular form (syphilitic pemphigus) indicates a low order of tissue vitality, and justifies an un- favorable prognosis. Lesions of the mucous surfaces occur either before or with the cuta- neous lesibns. Papules and excoriations (mucous patches) are found in the buccal cavity, on the tongue, fauces, and jjliarynx. Fissures of the lips are not uncommon, and especially in the angles of the mouth. The infection of the mucous membrane of the nose and air-passages leads to the distressing coryza and cough so often noticed in syphilitic infants. Gummata of the skin and of all organs occur in the same manner and with the same pathological significance as in the acquired form. Treatment. — The pi-eparations of mercury antagonize the virus in this as in the acquired form of syphilis. The careful mercurialization of the mother during pregnancy is important in preventing the development of the disease in its severer forms. Inunction with the ointment of mer- cury should be fiist faithfully tried in the treatment of syphilis in the newly-born. One drachm of mercury to one ounce of lard is the pro- portion recommended by Brodie. This is spread upon a soft flannel belt and worn continuously around the patient's waist. The ointment should be renewed as needed. If the beneficial efi'ects of the mercury are not secured by this method, the internal administration may be resorted to, but in no case until after a thorough trial of the inunctions. The bin- iodide of mercury, in doses of tt^ grain, in combination with one- quar- ter grain of the iodide of potassium, is advisable to begin with. The dose may be carefully increased if necessary. The nourishment of the child should be most carefully attended to, and it should have the bene- fit of pure air and comfortable surroundings. Scrotum.— Wounds of the scrotum should be treated as similar le- sions elsewhere. On account of the great vascularity of the tissues, re- ]iair is usually rapid. The contractility of the dartos and cremaster muscles will prevent early union unless the stitches are closely ai)])lied. If the testicle is protruded, it should be disinfected with 1-to-lOOOO sub- limate, returned to its normal iiositiou, and the cavity of the tunica vagi- nalis also washed out with the sublimate solution. In closing the woiind 662 A TEXT-BOOK ON SURGERY. with catgut sutures, the edges of the opening in the tunica should bo inchided. A small bone or catgut drain should be inserted into the cavity and emerge at the lower augl(> of the incision. Contusions should be treated by rest in the horizontal posture, cold applications and mechanical support beneath the posterior aspect of the scrotum. (Edema of the scrotum occurs with general anasarca and with ascites. The integument is tense, pale, and doughy ; pits upon pressure, and, lifter puncture with tlie hypodermic needle, a clear, watery serum es- capes. Besides the indications for constitutional treatment directed to the disease proper, puncture with the lancet in several points will tem- I)orarily relieve the tension and danger of gangrene. Eczema and other cutaneous lesions of the scrotum do not demand especial consideration. The same general principles of treatment ai)i)ly with equal force to all the cutaneous surface. The prognosis is unfavor- able on account of the irritation to which this organ is subjected fnmi friction with the clothing and thighs, and especially owing to the peris- taltic movements of the dartos and cremaster muscle. Cysts, due chiefly to the retention of sebum, are occasionally seen in the scrotum. They are usually situated near the raphe, or laterally and posteriorly upon the base of the scrotum. When large enough to cause inconvenience, incision and extirpation of the sac are demanded. Erysipelas, although rare in this jjortion of the body, is met with, and is often obstinate under treatment. Oangrene is one of the chief dangers, and must be guarded against by free incision as soon as the tension is great. Phlegmon of the scrotum should be treated by warm applications, poultices, etc., and by early incisions to relieve tension and give escape to septic matter. Free drainage and sublimate irrigation are indicated. Elephantiasis scroti, comparatively of rare occurrence in the tem- perate and colder zones, is frequently met with near the equator ; and in some of the West Indies and the islands of the South Pacific Ocean it occurs with great frequency. The pathology of this foim of connective-tissue hyperplasia has been given. The cause is undoubtedly one of prolonged irritation. The only treatment is extirpation with the knife. No fixed rule of operating can be laid down. The penis is at times buried in the neoplasm, and should be carefully dissected out. The incisions should be made so as to give a cutaneous flap in front and behind sufficiently large to contain the testes and cord without pressure after the connective-tissue new formation has been dissected out. AVhen the penis is included in the new growth, the integument should be saved, to cover this organ. If this can not be done, flaps may be turned from the thighs and abdomen. The h{emorrhage in this procedure may be controlled by working be- tween fixation-forceps, or by the adjustment of an elastic tcmrniquet around the scrotum near its attachment to the perinseum. Angioma of the scrotum is rare, and demands treatment similar to that advised in the chapter on these vascular formations. HEMATOMA— PERIORCHITIS AXD PERISPERMATITIS. 663 Epithelioma is more frequently seen than either of the foregoing neoplasms, and calls for immediate excision. Fistulcr, or sinuses of the scrotum, may be caused by abscess of the tunica vaginalis tesris, or by any lesion of the testicle. Abscess of the perinseum or urinary fistula may also cause fistula of the scrotum. Stony concretions are occasionally met with in fistulge of the scrotum through which the urine makes its escajse. The treatment should be directed to a relief of the cause of the fis- tulous tracks. If this is accomplished, the sinuses should be laid open and allowed to close by granulation. HoRviatoma. — Extravasation of blood may occur either in the tunica funiculi, in the tunica vaginalis testis, or in both. In the fomier it may be diffuse or circumscribed. It is usually diffuse, the extravasation ex- tending from the abdominal opening to the epididymis. AVhen only a portion of the sheath is involved, the heematoma is generally confined to the upper segment. The chief causes of extravasation are rupture of one or more vessels by direct traumatism, or by over-distention from prolonged strain, which retards the return cii'culation, causing rupture of a vein. Haematoma of the tunica vaginalis testis is rare, except as a compli- cation of chronic periorchitis serosa (hydrocele) or direct violence. The diagnosis of ha:'matoma in either of these positions depends upon its sudden development, the tendency to enlarge progressively, and pain from the sudden distention. The tumor is not translucent. The exact nature may be determined by aspiration. Serous effusion (hydrocele) into the sheath of the cord or testis pro- gresses slowly and painlessly. The tumor is translucent. Exploi-ation with the hypodermic needle and syringe is a safe, painless, and positive means of diagnosis. Hernia may be eliminated by a consideration of the history of the case and the absence of impulse in the tumor upon coiighing. Treatment. — Hsematocele may be treated by the exjjectant method, or by surgical interference. Simple and limited extravasation requires rest in the dorsal decu- bitus, and the ice-bag locally. After the hferaorrhage is arrested, absorp- tion may be expedited by judicious and weU-applied pressure by strap- ping. When the extravasation is extensive, an incision should be made under strict antisepsis, the clot turned out, the bleeding-point ligated, drainage secured, and the wound closed. Death has followed in some instances where operative procedure has been too long delayed. Periorchitis and Perispermatitis. — Inflammation of the serous in- vestments of the spermatic cord and testicle may be circumscribed or diffuse. An inflammation commencing from a lesion of the external or scrotal layer usually involves the entire sac, as does the similar process beginning on the visceral reflection of the tunica. Perispermatitis may be acute or chronic. A type of the acute in- flammation is seen in severe forms of epididymitis, or as the result of direct violence. The transudation of serum may be limited, and, as in 664 A TEXT-BOOK ON SURGERY pleurisy, adhesions may occur with obliteration of the sac, or suppura- tion may ensue ; or, passing into a subacute and chronic stage, a condi- tion of true hydrocele of tlie cord ensues {perispermatitis chronica serosa). Effusion into the sheath of the cord may communicate with the cavity of the tunica vaginalis testis (Fig. 654), or with the peritoneal cavity Fio. (154.— Hydrocele of the cord communicating with tlieiuuica vaginalis testis. Tlie instrument is passed throuirh the membrane wliicli separates the fluid from the neritoHceum. r/, Testis. (Alter Linhart. i Fig. fi.'i.'i. — c, Hydro- cele ot'the cord eom- municatinu; with the peritoneal cavity, ii, Testis. (After Liu- hart. ) Fig. 656.— Encysted hydrocele of the cord. Fio. CiV. — Hydrocele of the tunica vagi- nalis testis. (After Linhart.) (congenital hydrocele) (Fig. O.lo), but these conditions are rare. It is usually confined to the tunica funiculi (Fig. 656). The diagnosis of this form of hydrocele rests upon the recognition of a fluctuating tumor in the line of the cord, and the exclusion of hsema- tocele, varicocele, and hernia. The symptoms of lijematocele have just been given. The peculiar feel of a varicocele, so well compared to the sensation felt in grasping a mass of eartli-wonns between the fingers, can scarcely be mistaken. If the recumbent posture is assumed, the varicose veins are emptied and ' the tumor disappears. This can not occur in cyst of the cord. A hernial tumor gives the characteristic impulse upon coughing ; a cyst does not. A reducible hernia will disappear in the recumbent posture, and if, when reduced, the finger is pressed into the iiiternal ring, it will not recur, while, despite this precaution, a varicocele will reappear. Exploration with a hyi)odermic needle will disclose the character of the contents. The treatment of hydrocele of the spermatic cord is practically the same as that for hydrocele of the tunica vaginalis testis. Periorchitis may also be acute or chronic. In acute Inflammation the quantity of serous transudation may be large or small. When the in- flammatory process is acute, and the transudation of serum so limited that the opposing surfaces of the two walls are not kept ai)art, adhe- sions may occur, with partial or complete obliteration of the sac. The causes include all lesions of the scrotum, the testicle, and epi- didymis, the process naturally extending to the delicate lining membrane. PERIORCHITIS. 665 Chronic epididymitis and orchitis should rank as first in the aetiology of hydrocele. The interference of the return circulation here will pro- duce the transudation of fluid in the same way as ascites occurs in cir- rhosis of the liver. In like manner varicosities in the veins of the sper- matic plexus may induce hydrocele. The pathological changes consist in a general thickening of the visceral and parietal layers of the tunica, due to the development of connective- tissue elements in which new ves- sels are formed. Nut infrequently little pearl-like bodies are seen attached to the vis- ceral surface of the thickened tunica, or they may be found floating free in the fluid of the sac. They are made up of connective-tissue and flat- tened ei^ithelial elements. Occasionally they undergo the calcareous metamorphosis. The sac of a hydrocele of the tunica vaginalis testis is almost always unilocular (Fig. 658), but in rare instances it is bilocular, with a narrow opening of communication between the sacs (Fig. 659). The dividing septum is made up of the products of inflammation. Fig. 658. — Usual form of hydiooele (After Kocher.) Fig. 659. — Bilocular hydrocele. Tc, Parietal layer of tunica. A', Spermatic cord. J\' h. Epididymis. H, Testis. Z>, Cavity of diverticulum. Tt, Cavity of tlie tunica vacrinalis proprius. Zz^ Inflammatory new formation between tlie visceral and parietal layers. {After Koulier.) The fluid of hydrocele is amber in color, or, if blood has been ex- travasated and mixed with it, it may be brownish-black or red. Under the microscope it is seen to contain compound granular corpuscles, leu- cocytes, swollen endothelia, and at times crystals of cholesterin and red- blood disks. S//mpfoms. — Hydrocele of the tunica vaginalis testis is usually single — at times double. In shape the tumor is usually pyriform or oval, with the largest diameter of the swelling l^elow. Tt may, however, assume a conical sliape, with the apex downward, as shown in Fig. 660. The his- tory is generally that of a slow and painless swelling, first noticed in the lower portion of tlie scrotum, and gradually extending upward. In size it may vary from a mass having a long diameter of an inch or two, 666 A TEXT-BOOK ON SURGERY. to as niiioh as ten or twelve inches. In recent oases the walls are thin, fluctuation is easily made out, and the testicle may be recognized in the lower posterior portion of the swelling. In old cases the walls may measure half an inch or more in thickness, and are so tense and in- elastic that to the touch the tumor seems wholly solid. The dilferentia- tion includes hydrocele of the cord, encysted hydrocele of the testis, hernia, varicocele, and va- rious neoplasms or swellings of the testis and epididymis. Hydrocele of the cord is ob- long or spherical in shape, usu- ally of small size, and gives a his- tory of a swelling commencing above tlie testicle, which organ can be made out by palpation be- low the tumor. Encysted hydro- cele of the testicle can only defi- nitely be made cmt by i)uncture with the aspirator-needle and ex- amination of the contents with tiie microscope. The ])resence of the spermatozoa will determine the encysted character of the tu- mor. In hernia the swelling be- gins at the inguinal ring, and travels progressively downward. If reducible, it can be made to disappear by assuming the dor- sal decubitus, while a hydrocele would be unaffected by this ma- nttMivre. Percussion upon an in- testinal hernia will yield resonance, while that upon the tumor of hydro- cele gives dullness. Omental hernia is doughy to the feel, while hydro- cele is tense and resisting. Varicocele can be eliminated by the peculiar impression conveyed to the fingers when the worm like veins are grasped. The solid character of neoplasms of the testis or epididymis can be recognizt^d by palpation. Of most importance, however, is the employ- ment of the exploring aspirator, which safely and easily deuioustrates the liquid character of the contents of hydrocele. Treat me lit .—The cure of hydrocele is effected in almost all cases by operative interference. The transudation of serum into the cavity of the tunica vaginalis testis, symptomatic of specific disease, or any acute local affection, may disappear by absorption under proper medi- cal treatment, or after the disai)pearance of the acute trouble. These cases are, however, exceptional ; and, if absorption does not occur within the first few weeks of the history of the affection, operation is demanded. Fig. cr.n. — Double hydrocele of the tunicft vaciimlis testis. (From a patient operated upon at ilount Sinai Hospital.) PERIORCHITIS. 667 The operative procedures are two iu number— 1, by injection, and 2, by incision. The former method should be preferred in all cases of recent formation, in which there is not great thickening of the walls, and in which the sac is not very large. It may be safe to include in this category all cases in which the long diameter of the tumor is not more than five inches, and in which the depth of tissue between the integu- ment of the scrotum and the cavity of the sac is not more than half an iach. If this procedure fails, it should be repeated once or twice be- fore the more formidable procedure known as Volkmann's operation is undertaken. First Metftod — Levis^s Operation.— Hhaxe the tumor on its anterior aspect, and cleanse the integument thoroughly. Inject from m x-xv of a 4-per-cent cocaine solution in such a way that local anfesthesia will be obtained through the depth of the wall of the sac throughout an area of half an inch in diameter. Twenty minims of pure carbolic acid should now be placed in the syringe, and a long needle attached. Place the patient upon the back, separate the thighs, have a pus-basin convenient, support the tumor with the left hand, making the parts tense by press- ure ; take a trocar-canula in the right hand, firmly seized between the thumb and finger one inch from the point (so that it may not possibly be thrust in farther than this limit) ; remember that the testicle is be- hind and below, and with a quick and accurate thrust carry the instru- ment through the ansesthetized zone into the cavity of the sac. The point of entrance should be about one third of the distance from the lower portion along the anterior aspect to the upper, and the direction of the shaft of the trocar should be upward and somewhat backward. Upon removal of the stylet the liquid rapidly escapes through the can- ula, any remnant being forced out by compression. Care must be taken not to shift the canula from its first position. When the fluid is emptied, carry the hypodermic needle into the canula, and force the carbolic acid into the sac ; withdraw the needle, and then the canula, and knead the scrotum and sac so as to distribute the acid over the entire surface. This operation is almost without pain. In some instances a slight sense of faintness is experienced just as the acid is injected. The patient should be kept quiet on the day of the operation, but with proper sus- pension of the scrotum he may be allowed to move about after twenty- four hours. On the day following, and for about a week afterward, the tumor swells up as if it were refilling, and is solid or doughy to the feel. After this it begins to decrease until tlie sac is obliterated and a per- manent cure is effected. A scrotal wall and the investing serous mem- brane of the testicle which i.s once thickened becomes somewhat thinner after the cure of the hydrocele, but never entirely resumes its natural thickness. Second Mdhod — Volkmnnn's Operation. — Shave the scrotum and pubes, narcotize the patient with ether, and over the anterior middle line of the side affected make an incision varjong in length with the size of the tumor and the thickness of the wall. Usually an incision from two to foui- inches in length will suffice. Cut directly down' until the 668 A TEXT-HOOK ON SURGERY. sac is reached, and incise this to about the same extent as for the wound in the integument, allow the fluid to escape, and, with a good-sized cat- gut continuous suture, stitch the cut edge of tli(» parietal layer of the tunica vaginalis testis to the edge of the wound in the skin, making an opening not unlike a button-hole. Irrigate the sac with l-to-3()00 subli- mate solution, and insert a rubber drainage-tube into the u])per and lower portions of the cavity, and apply a sublimate-gauze dressing. In all antiseptic dressings about the penis it is essential to isolate this organ so that the urine or the usual unclean condition of this or- gan may not infect the wound. To do this after the drainage is secured and the first gauze is placed around the tubes along the edges of the button-hole, make a hole in all the layers of sublimate gauze and the sheet of protective large enough for the penis to pass through without constriction. Lastly, tuck the dressing well iip under the scrotum close to the perinaMim, to keep the gases and fecal discharges from infecting the wound. This operation will cure any case of hydrocele which will not yield to the more conservative procedure of Levis. It can only be dangerous by neglect of careful drainage. In very large sacs a counter- opening should be made through the lower portion. Such wounds rarely require more than one or two changes in the dressings, and only then, as in all surgical wounds, when the discharge soils the dressings, escapes beyond the area of antisepsis, and becomes offensive by decom- position, or when the rise in temperature indicates the ja-esence of sep- tic absorption. Bone-drains may be used in the smaller tumors, but rubber gives a better guarantee of perfect drainage. Suppurating periorchitis, or pus in the cavity of the tunica vaginalis, may be treated by two methods : If the temperature is high, the sac jiainful, and the scrotum swollen, the indications are for free incision, irrigation, and drainage. Under less threatening conditions, the aspira- tor may be employed, the sac emptied and rei^eatedly injected and washed out with l-to-5000 sublimate solution, and compression ajjplied afterward. In this way obliteration of the sac may be achieved, as in the treatment of cold abscesses. Varicocele. — Varicosities of the veins of the spermatic plexus are not uncommon. Varicocele is chiefly caused by gravity and the mechanical interference with the return of blood through the spermatic veins. It occurs with greater frequency on the left side, where the vessels are pressed upon by the sigmoid flexure of the colon with its almost constant weight of fecal matter. In addition to this, the greater length of the left spermatic vein, which enters the renal vein at a right angle to its axis, and is poorly protected by valves, are causes which serve to produce varicosities upon this side more frequently than in the right plexus. Any occupation which necessitates the erect posture is apt to add to the susceptil)ility of this disease. Hereditary tendencies must be considered in its {etiology, for frequently members of a family through several gen- erations will be affected. The earlier symptoms are a feeling of heaviness or dragging down on VARICOCELE. 669 the side affected, with the appearance of a small swelling in the line of the cord. Pain is variable, and is sometimes referred to the cord or to the inguinal region or down the leg. The testicle hangs lower than natural, and along the cord can be felt a network of turgid veins extend- ing from the epididymis toward the external ring. To the touch they seem not unlike a knot of earth-worms. The swelling is apt to be largest at the lower extremity (Fig. 661). The diagnosis is not difficult. The swelling of inguinal hernia is spherical, and, when composed of in- testine, it is resonant on percussion. If the hernia is reducible, and is re- turned into the cavity of the abdomen with the patient in the recumbent posture, and if the index-tinger is car- ried into the internal ring and held there while the patient is made to stand erect, the veins will again refill and demonstrate the varicocele, while the hernia will be prevented from de- scending. Hsematoma, or hydrocele of the cord, can be recognized by as- piration with the hypodermic syringe. Treatment. — Very few cases of vari- cocele require operative interference. A well-adjusted suspensory apparatus constantly worn while in the erect post- ure will obviate the necessity for an operation in the vast majority of in- stances. This bag may be made to include and support only one half the scrotum and a single testicle, or the double elastic apparatus may be employed. "When no palliative measures are effectual, operative interference is demanded. The procedures are two in number, namely — subcutaneous ligature (Keyes), or incision and ligature by the open method. Of these two operations, the former is far preferable, and should be tried repeat- edly before resort is had to the incision. First Method— Keyes' s Operation. — Shave the scrotum and pubes, and thoroughly wash these surfaces with ether and sublimate solution. The patient is made to stand erect, with the legs separated, in order to distend the veins. In cold weather it may be necessary to have him sit in a tub of hot water to induce full relaxation. By the injection of co- caine, local anpesthesia should be obtained in the parts where the ligature is to be inserted. From m x-xx of a 4-per-cent solution will suffice. The ligature should be of Chinese twisted silk, not too large, but capable of bearing all the strain which will ordinarily be brought against Fig. 6G1. — Varicosities of the spermatic plexus of veins, with atrophy of the testicle. (After Kocher.) 670 A TEXT-BOOK OX SURGERY. it. This should be thoroughly soakt'd in l-to-SOOO siiblimate solution for several hours before it is to be used. For jiassing the ligature arouud the mass of veins, Keyes's needle (Fig. 602) should be jireferred. It is better, as Avill be seen, to have two of these instruments. If these can not be obtained, the long needle of Peaslee, or an ordinary darning- needle, may be substituted. With everything in readiness, proceed as T Fig. 662. — Keyes's varicoccle-iieeJle. follows: The operator, by careful manipulation, finds the vas deferens as it is located in tlie posterior part of the cord near the level of the scrotal attachment to the perinaeum, separates it from the mass of veins, and, by tightly pinching the scrotal walls between the thumb and finger of the left hand, holds this important duct behind and to the inner side of the veins. Tlie vas deferens may be recognized by its dense and leathery feel. It i.s, as a rule, smaller than the veins, but, while these may ))e effaced by pressure, the vas deferens is so thick that it can not be obliterated, but will jump from between the tliumb and finger when tightly squeezed. Once eliminated and secured behind the veins, pressure should not be interrupted until the threaded needle is passed entirely through both walls of the scrotum from before backward between the vas deferens and the plexus of veins. If two needles are on hand, the one now passed through should be left in position, and the pressure with the thumb and finger of the left hand being no longer needed, this hand may be used to facilitate the second step in the operation. The second needle, with- out being threaded, should now be made to enter by the side of and in the same opening with the first, and as soon as the point is well within the dartos — but not deep enough to puncture the veins — it .should be carefully worked between the veins and dartos, around the mass to the outer side, and made to emerge behind at the same opening with the other instrument. The thread is now disengaged from the first needle and carried through the eye of the second, whicli, ujjon being withdrawn, completes the circuit of the ligature around the mass. It should now be tied slowly and securely. The single knot is preferable, since the fric- tion of the double knot is so great that the thread may break in the effort to draw it tight enough to constrict the veins (an accident which has twice happened to myself). The first needle should not be with- drawn until the ligature is secured, since, should the thread break, the second needle will alone have to be inserted. As the first loop of the knot is tightened, the mass within its grasp slionld be held by an assist- ant to prevent its slipping before the second loop is finished. When completed, the ends are cut close to the hole of entrance, and the walls of the scrotum separated when the knot and ends disappear inside the dar- tos. A light sublimate dressing is required. The patient should remain in bed one day, and keep quiet about the hou.se for four or five more. THE VESICUL^ SEMINALES. 671 Little or no pain is experienced after the operation, and none in its per- formanfp. The ligature l)ecomes encajisuled and remains harmless. In- flammation and suppuration are scarcely possible where the antiseptic de- tails are proiaerly carried out. The tissues around and below the thread are indurated within a few hours, and remain so for a number of weeks, the coagulated blood undergoing gradual absorption. Recovery follows in a large proportion of cases. Catgut is not reliable as a ligature in this operation, on account of the danger of too rapid absorption. In one case I failed with this material, afterward effecting a cure vv-ith silk, which was employed at the suggestion of Prof. Keyes. Second Method — Ligature tJirough an Open Wound. — Anaesthetize the patient, shave the parts thoroughly, and expose the cord l)y an in- cision several inches in length made alcjng its anterior lateral aspect. Search for the vas deferens, which can be easily recognized after the skin is turned aside, by its cartilaginous feel ; have this held to one side, and, with an aneurism-needle armed with good-sized catgut ligatures, tie the veins separately. In performing this operation it is advisable to leave one good-sized vein to convey the blood back from the testis, and to tie the others in several places. The wound should be closed with catgut, and a bone drain inserted. As stated before, this operation wiU only be justified in case of repeated failure by the former procedure. In very exceptional cases the scrotum may be so elongated that am- putation of the redundant portion is necessitated after the veins are tied. In performing this operation Henry's clamp (Fig. 663) will be found of great service, which, if properly adjusted, allows the amputation to be made and the edges of the wound sewed with close silk sutures while the instrument is in position, thus avoiding all haemorrhage and the necessity for a single ligature in the line of amputation. If this instru- ment can not be obtained, the testicles may be puslaed up into the rings and the amputation effected by cutting across the scrotum below the fingers of an assistant which, by grasping the tissues properly, control aU bleeding. The VesiculcB Semiiinles and Vas Deferens. — The seminal vesicles are occasionally wanting, from failure of development, or from atrophy as a result of infiammation. Wounds of these organs are rare. If incised or punctured, temi)orary fistula may result, with subsequent atrophy. Inflammation of the vesicuhe seniinales occasionally occurs by exten- 672 A TEXT-BOOK ON SURGERY. sion from the urethra or from the epididymis and vas deferens, or with prostatitis or proctitis. Occlusion of the ejarnlatory duet induces over-distention of these organs. Several cases of calculus of the duct have been recorded. The diagnosis in dilatation, hypertrophy, or inflammation of these cysts depends upon careful rectal exploration. The vas deferens is more or less involved iu all inflammator}' ju-o- cesses which occur in the epididymis. It is also subject to invasion by iuflammation from the urethra and i)rostate. Tuberculosis of this ves- sel may follow tuberculosis of the testes and epididymis. Lesions of this organ require no especial consideration. Epididijmis. — Neoplasms of the sheath of the spermatic cord are rare. In his excellent monograph, Kocher mentions isolated cases of lipoma, fibroma, or myxofibroma and sarcoma. Epididymitis results occasionally from direct violence, but is chiefly due to urethritis and the extension of the inflammatory process along the vas deferens. Metastatic or "sympathetic" inflammation of this organ is very rare. It may be acute or chronic. The inflammatory jn'o- cess may be confined to the epididymis or invade the testicle. Acute epididymitis always involves the tunica vaginalis (with which it is in contact), and very frequently the testicle. Specific' urethritis stands first in order in the causation of epididymitis. The introduction of a sound or catheter, the lodgment of a calculus in the urethra or prostate, strict- ure, cystitis, and prostatitis may also cause this disease. The symptoms of acute epididymitis are a sense of uneasiness or pain, varying in intensity in the organ affected, or in the cord or groin. It is increased by pressure, when the erect posture is assumed, or in walking. In severe cases a chill or rigors occur, followed by a marked rise in temperature. Upon inspection there will be more or less induration along the posterior border of the testicle, with heat, redness, and ten- sion. The testicle is more or less enlarged, and very frequently there is a serous transudation into the cavity of the tunica vaginalis testis. The pathological changes consist chiefly of hypersemia and infiltra- tion of the connective-tissue framework with embryonic cells. The epithelial lining membrane is also thickened and injected. The diagnosis depends upon the symptoms above given. The prog- nosis is usually favorable. One attack, however, predisposes to another. In some instances occlusion of the efferent apparatus results from con- traction of the products of inflammation, and sterility follows. Sper- matic fistula is the rule in these cases. The treatment consists in the administration of saline laxatives in order to empty the alimentary canal. The patient should be placed upon his back, and the inflamed organ supported by either a three-cor- nered pillow between the thighs, or a towel pinned around both thighs just below the base of the scrotum. Upon this a small bladder filled with crushed ice may be placed, and the inflamed organ allowed to rest upon it. If cold is not grateful, warm cloths or a poultice may be sub- THE TESTICLE. 673 stitiited. The application of from three to six leeches will at times relieve the local congestion. Usually rest in bed will alone suffice to effect a cure. In some in- stances operative interference is indicated. When the tension is great and the pain extreme, the happiest results will follow multiple jiuncture. Proceed as follows : Take a sharp, narrow knife and push it through a cork until from a quarter to half an inch of the point is exposed. Hold the organ in the left hand so as to ex^DOse the posterior aspect of the epididymis and make the skin fairly tense, and plunge the blade in up to the cork in from two to six or ten points along the most swollen and in- durated portions of the tumor. A free escape of dark blood follows. The operation is very jiainful, but the relief is marked and immediate. A suspensory bandage should be worn during convalescence. The treat- ment of chronic epididymitis will be considered with that of orchitis. The Testicle. — Wounds of this organ do not demand especial consid- eration. Hernia of the tubules not infrequently occurs from incision or puncture of the tunica albiiginea. Reduction is practically impossible. The protruded portion should be tied off with a catgut ligature, the ex- cess of substance beyond the thread cut oflf, and the organ returned to the noi'mal position. Inflammation of the testis (orchitis) may result from direct violence, from the extension of an epididymitis, or from metastasis. Orchitis is frequently met with as a symptom of '* mumps," but the relation between these two processes is not understood. The si/mpfoms are enlargement of the organ, with Y>^m usually in- tense. The swelling is slow on account of the great resistance offered by the tunica albuginea. The skin over the organ is tense and reddened, and at times oedematous, especially when an epididymitis precedes the inflammatory process in the testicle. In severe cases gangrene may ensue, and the tunica vaginalis and scrotal walls may become involved. In mild cases the ixdliological changes are chiefly hyper?emia and the formation of a limited amount of embryonic tissue along the blood-vessels and in the connective-tissue septa of this organ. In the severer forms this process is greatly exag- gerated, and as a result of the extensive hyperplasia the circulation is aiTested, and death of the tubular structure ensues. Or, if gangrene does not occur, atrophy of the secretory apparatus follows as a result of contraction of the products of inflammation. In some instances the swelling subsides, leaving no marked changes in the organ. The prognosis is in exact relation to the symptoms. Slild cases, especially in the forms occurring with urethral epididymitis, generally terminate in one or two weeks in recovery and restoration of the organ to its normal condition. In cases where the symptoms are severe from the start, the prognosis is grave imless early relief is afforded, and even then it is not always favorable. Treatment. — Rest in the dorsal decubitus should be insisted upon in even the mildest cases, for not infrequently dangerous orchitis is pro- voked by neglect of this pi'ecaution. 43 674 A TEXT-BOOK ON SURGERY. The position of the testicle should be elevated, as in epididymitis. The local application of cold is frrateful and advantageous in most cases. The organ is, however, so sensitive that no pressure is tolerated. This can be obviated by making a ring of cloths wrapped around a small hoop, leaving a lumen large enough to include the scrotum and penis. The ice-bag is laid uihjii this ring, which prevents any pressure upon the inflamed organ. When the effusion is rapid, causing dangerous tension of the fibrous cai)sule, surgical interference is imperative. The operation consists in seizing the organ with the left hand, so as to render it steady and the skin tense, puncturing the scrotum and pa- rietal layer of the tunica vaginalis testis, and thus subcutaiief)usly making a series of incisions through the tunica albuginea on its anteriiu- and antero-lateral aspects. The incisions should be about half an inch in length, and are much prefei'able to simple puncture. The danger of hernia testis does not contraindicate this procedure. Chronic orchitis, not due to syphilis, is comparatively rare. When it occurs, it usually follows an acute inflammation. The pathological change consists in a thickening of the tunica albuginea and of the con- nective-tissue septa. Embryonic cells, collected in groups or nests, in various stages of development, are crowded along and around the blood- vessels and seminiferous tubules, as well as scattered about in the inter- tubular spaces. As the process continues, the tubules disappear under the pressure of the new inflammation-tissue. In a certain proportion of cases cysts form in the following manner : The peripheral cells of one or more foci of the embryonic tissue organize into connective tissue and aid in forming the investing capsule. The cells within this new capsule un- dergo granular metamorphosis, and later liquefaction, by absorption of fluid from the surrounding vessels. In other cases foci of supimration (multiple abscess of the testicle) may remain from an acute inflammation and be present in chronic orchitis Icrag after the acute synii)toms have subsided. The contents of these foci may also undergo caseous degen- eration. The symptoms of chronic orchitis are those of progressive enlarge- ment of this organ. In some instances pain is wanting, in others it is present, though less intense than in the acute form, while in a third cate- gory may be classed cases of chronic orchitis with intercurrent attacks of acute inflammation and the accompanying exacerbations of pain. The organ varies in size from two to four or five inches in its greatest diameter. Much annoyance is occasioned in the larger tumors by the dragging upon the cord. The diagnosis is between hydrocele of the tunica vaginalis, inflam- mation of the walls of this cavity, with exudation and thickening and adhesion to the testicle, syphilitic orchitis, and tuberculosis testis. Hy- drocele is easily excluded by fluctuation, translucency, and aspiration. In periorchitis with exudation and adhesions, differentiation will at times be difficult. The obliteration of the cavity of the tunica vaginalis renders the superficial tissues less freely movable upon the body of the testis. TUBERCULOSIS OF THE TESTICLE. 675 In orchitis the surface of the enlargement is smooth, spherical, and of like consistence at all points ; often in periorchitis ridges of new tissue can be made out ; there are soft spots or depressions which can be recog- nized by careful palpation. If syi^hilitic orchitis is suspected (even if the histoiy of this disease is denied), it will be advisable to administer the protoiodide of mercury and the iodide of potassium for several weeks. The marked diminution of the tumor will be confirmatory of the suspicion of the syphilitic dys- crasia. The extraordinary weight of a syphilitic testicle should be borne in mind. Tuberculosis testis is usually preceded by the deposit of tuberculous matter in the epididymis. Pain in this affection is insignificant and en- tirely disproportionate to the rapidity of the infiltration and enlarge- ment. Moreover, orchitis and epididymitis may usually be traced to some direct and exciting cause which is absent in tubercular disease. The indications in treatment are, first of all, to remove every cause of irritation, to keep up the tone of the system by judicious feeding and medication, and to support the heavy organ by suspension. When these measures fail to arrest the disease, or when the pain becomes so gi'eat that the patient's comfort is interfered with, or when the disinte- gration of the organ is threatened, castration may be entertained. Be- fore carrying out such an extreme measure, the precaution should be taken to explore the organ through an incision in the scrotum, in order to determine its exact condition before removing it. Tuhercidosis of the Testicle and Epididymis. — True miliary tuber- culosis of the testicle and epididymis is comparatively rare. Many cases which have been recorded as tuberculosis must, upon analysis, be classed with a non-tubercular inflammation, the embryonic tissue of which has undergone caseous degeneration. Tubercular disease of the testicle alone is the exception. The epi- didymis is usually first invaded, and from this point the new tissue spreads into the testicle, and not infrequently along the vas deferens to the seminal vesicles, as well as to the tunica funiculi and tunica vagi- nalis testis. While it may be slow in some instances, as a rule the invasion is rapid, occupying from two to eight weeks in a general infiltration of both organs. The symptoms are, upon the whole, obscure. One point of great diagnostic value is that the pain is entirely disproportionate to the rapidity and extent of the tumefaction. In simple orchitis and epi- didymitis, pain is extreme and pressure unbearable. In tubereidar or- chitis pain is, as a rule, slight, and may not be present at all. In a certain proportion of cases there aatII be sudden and recurring exacer- bations of pain, indicating a circumscribed acute orchitis, the result of irritation from the presence of the cell-elements of the tubercular pro- cess. Ulceration and the formation of fistulae occur in a certain propor- tion of cases. In simple orchitis and epididymitis, the cord is not involved, while not infi-equently in tuberculosis the deposit rapidly travels along the 676 A TEXT-BOOK OX SURGERY, vas deferens. Grasped between tlie fingers, the tubercular organ is felt to be hard, and its surface uneven and nodular. The initial morbid change is the deposit around the seminiferous tubes of clusters or nests of lymphoid cells. Within the tubes the endo- thelia are thickened and undergoing granular or caseous metamorphosis. Later, the connective-tissue septa become infiltrated with the new cells. The process ends in compression and destruction more or less complete of the tubules. The centers of these clusters of cells farthest removed from the vascular network undergo granular or caseous metamorphosis, form- ing at times cyst-like caverns, or at other times abscesses and listulaj. Treatment. — The prognosis of tubercular disease of these organs is so gi'ave that when an early diagnosis can be made out, extirpaticm of the diseased tissues should be considered. If only one side is involved, and the other organ is fully developed, there should be no hesitation in advising tlie operation of castration. When tlie diagnosis is doubtful, it will be wise to keep the patient under constant observation, with especial regard to the advance of the disease along the cord, and when this is evident, and when there is no positive evidence of tubercular deposits elsewhere, extirpation is indi- cated in order to prevent invasion of the prostate and general dissemi- nation. When both organs are involved, the question of complete cas- tration is one of doubtful propriety. EncTiondroma of the testicle is not altogether infrequent. It occurs most often after injury. While it is prone to originate in the organ, it may spread from the epididymis to the testicle. The volume of the organ varies, at times reaching a large size. Enchondroma testis, as with al- most all forms of neoplasm seated in this structure, is apt to undergo cystic degeneration. The diagnosis must be based upon the hard, elastic feel peculiar to this form of tumor. The treatment is either expectant or operative, as circumstances may demand. Castration is indicated when the disease is unilateral, and when the size of the tumor is such that the function of the opposite organ is threatened. Adenoma testis occurs chiefly from the twentieth to the fortieth year of life. It has so far not been observed during childhood. The development of the tumor is usually rapid, attaining a diameter of three or four inches or more. Only one organ is usually affected. Pain is not a prominent symptom in the earlier history of this neo- plasm, biit, after the growth attains a sufficient bulk, it causes more or less pain by pressure and weight. To the touch it is soft and compres- sible. The formation of cysts in various portions of the neoplasm is frequent (cysto-adenoma) (Fig. 664). Under the microscope the epithelia of the seminiferous tubules are seen to be swollen, while their caliber is more or less completely occluded with the round cells of the new (adenoid) tissue. The prognosis is not favorable, and the diagnosis difficult. Since the function of the organ is wholly impaii-ed, and since the rapid develop- CARCINOMA— SARCOMA TESTIS. 677 ment of the tumor is of itself an indication of the gravity of the lesion, the matter of exact recognition of adenoma is not important. In all of these rapid and threatening neoplasms, especially when a single testicle or epididymis is involved, the safest course is in early and prompt ex- cision. Garcinoma. — Both scirrhus and medullary cancer may develop pri- marily in the testicle or epididymis. The encephaloid variety is most fre- quently encountered. The micro- scopical characters of these different varieties of cancer will be given in the chapter on tumors. Carcinoma of the testis is apt to occur about the age of puberty, al- though it may be met with later in life. One organ is affected as a rule. It is more apt to begin in the tes- ticle than in the epididymis. In the early stages of the development can- cer of the testes is not painful, but as the disease advances the suffer- ing may be intense. Early removal offers the only hope of cure, and this, unfortunately, is not great. Sarcoma testis occurs at all ages, but is chiefly confined to childhood and eai-ly manhood. Following the general law of sarcomata, that of the testicle is rapid in growth, attaining at times an enormous size. This is one of the chief diagnostic points of this tumor, which is hard, usually liyriform in shape, and of comparatively smooth contour. Castration offers the only hope of relief. It will be seen from the foregoing that accurate diagnosis of the va- rious neoplasms which develop in the testicle is difficult and often im- possible. Almost all of these moi'bid processes lead to destruction of the oi'gan and loss of function, and immediately or remotely threaten the life of the individual. Thus tuberculosis, adenoma, carcinoma, and sarcoma may be classed as malignant. Enchondroma, although not intrinsically malignant, leads to loss of function, and in this particular justifies operative interference. The same applies with greater force to cystic degeneration of this organ, since cysts often develop in malignant neoplasms of the testicle. In view of these facts, when only a single organ is involved, it will be advisable in the early history of any neoplasm of this organ to consider the pro- priety of castrati(m. The operation is thus performed : Shave the scrotum and pubes, and make an incision extending from tlie external abdominal ring along the anterior surface of the cord and testicle to the base of the scrotum. Fio. 664. — Cystic degeneration cf iidenoma of tiie testicle (cysto-adenoma). (Alter Kocber.) 678 A TEXT-BOOK ON SURGERY. When the morbid process involves tlie serotal tissues, and even when there is a suspicion of involvement, the primary incision should be car- ried well away from the suspected tissue into the healthy structures. Two points of importance are suggested in the removal of this organ. The first is to make an incision into the mass in order to clear up the diagnosis; the second is to secure the vessels by the ligature ai)])lied near the external ring, and thus prevent the danger of forcing septic or metastatic matter in the lymph channels or vessels leading toward the center. The cord should be exposed at the ring, the vas deferens iso- lated, and a large, double catgut ligature thrown around so as to in(;lude the entire cord except tlie vas deferens. This is twisted around the cord while the exploratory incision is being made, and, if the diagnosis is confirmed, the catgut is tied and the cord divided betw^een the two liga- tures. The diseased organ is then dissected out, the hjemorrhage ar- rested, a drainage-tube introduced, and the wound clo.sed with catgut sutures. A single dressing will usually suffice. When the vas deferens is divided, the accompanying artery will have to be separately tied. Malposition. — One or both of these organs may be absent from the normal position in the scrotal sac. The descent from the abdominal cavity may be prevented by narrowing or closure of the inguinal rings, or the inner ring may be passed, the testicle being arrested at the outer opening, and thus imprisoned in the canal ; or, passing both rings, it may lodge beneath the skin near the pubic crest, or in the perin;euni or groin. Occasionally the testicle remains entirely within the abdominal cavity. Another rare form of malposition is when the organ is turned obliquely or crosswise in the scrotum. Misplaced testicle does not usually give rise to great inconvenience until the approach of puberty, when its normal development is inter- fered with by compression. If it is lodged in the inguinal canal, where it is acted upon by muscular contraction, it may cause pain at an earlier period. The descent of a hernia upcm a testicle thus imprisoned gives rise to considerable annoyance. An imprisoned testicle is occasionally the seat of a neoplasm. The symptoms are those of pain, neuralgic in character, and the diagnosis must depend upon the absence of the organ from its normal place and its recognition in the position of the abnormal swelling. Misplaced testicle requires no special treatment until it becomes a source of inconvenience or annoyance, or is the seat of some new forma- tion. Extu'pation is then demanded. Supernumerary testicle does not occur. In several instances a cyst or other neoplasm has been mistaken for an extra organ. Diseases of the Female Organs of Generation demanding Abdominal Section. Hysterotomy and Hysterectomy.— Hysterotomy., or cutting into the uterus for the extraction of the foetus from the living mother, is an op- eration which has been greatly perfected within the last few years, HYSTEROTOMY. 679 chiefly owing to the labors of Saenger and Leopold. It is indicated when at full term, labor having begun, it is found impossible, on account of insurmountable disproportion between the diameters of the pelvic outlet and the child, to effect delivery by the vagina. AVhen this condition is evident, proceed as rapidly as possible in the following manner : If the membranes are not already ruptured, break them. Disinfect the vagina and genitals with sublimate solution, 1 to 3500. Prepare the abdomen as for an ovariotomy, and make a long abdominal incision, controlling all bleeding with catgut ligatures as the operation proceeds. Having entered the abdominal cavity and made the opening large enough, place three or four silk sutures at the upper end of the wound in order to narrow the opening as soon as the uterus is drawn out of the incision, thus avoiding extrusion of the intestines. Drag the uterus outside the abdominal cavity, and close the upper portion of the wound by tightening the sutures already in position. If the intestines should be protruded, protect them with warm towels wrung out of Thiersch's solution, and beneath the uterus pass a piece of rubber cloth, disinfected in the same solution, to protect the abdominal cavity from the entrance of blood. Around the cervix uteri pass a stout piece of elastic tubing, and draw it tight. Immediately incise the uterus in the median line and in its long axis, limiting the incision below to the peritoneal reflec- tion, thus avoiding the large circular sinuses about the os internum, and extending it upward if necessary. Remove the cliild, and hand it to an assistant to resuscitate. The uterus will now usually contract. Intro- duce the hand into the uterus and remove the placenta. The uterine cavity is to be next disinfected with a l-to-5000 sublimate solution. Un- less the cervical canal is widely dilated (and this should be ascertained before the operation), the use of a iitero-vaginal drainage-tube is indi- cated, and this latter must be of stifl' rubber. The next step in the operation is the insertion of the sutures in the wall of the uterus. First ascertain whether the peritoneal covering of this organ is sufficiently Mucosa. Fio. 665. — Sutures in Cscsnrcan section. Method of passing tlie sutures in closin? tlie wall of the uterus after hy^terotomy. «, The prritoni'al coverini.' ilissected up alon and cut off above the elastic ligature. The stump is next grasped by strong forceps and trimmed. Sutures are then passed, first through the parietal peritonaeum near the incision and then tlirough the stump below the ligature, in such a way that when drawn tight the lower part of the incision will surround tlie stump just below the ligature, with the peritoneal surface of the incision fastened to that of the stump. Steel pins or skewers should be passed thi'ough the stump above the ligature. The sutures around the stump are then drawn tight, the wound closed as after ovai-iotomy, the stump dusted fi-eely with iodoform, and the dressing applied. The indications for pelvic drainage will be the same as after an ovariotomj'. The cervical canal in the stump should be curetted before passing the steel pins ; otherwise, a fistulous opening may persist through the vagina, uterine stump, and the line of incision. Frequently the fibroid is attached to the unen- larged uterus, and has a narrow pedicle. In such a case, the uterus and appendages are left, and the new growth removed, forming the stump where the tumor joined the uterus. Surgical Diseases of the Fallopian Tubes — Salpingitis. — Inflamma- tion of the Fallopian tubes may demand surgical interference when peri- tonitis is precii^itated, or when from occlusicm of one or both outlets of this organ the products of intiammation are retained, and the tube is dis- tended, forming a cyst-like tumor. The most prominent symptom of salpingitis is pain. When peritoni- tis does not exist, it is confined to the affected side. It is usually con- tinuous, with exacerbations of severity, which are especially marked just before, during, and after the menstrual flow. In some instances, when the flow is established, the suffering is less intense. The menstrual dis- charge is, as a rule, increased in quantity. Salpingitis, in the vast majority of cases, results from the direct extension of some inflamma- tory process from the uterus. Endometritis or metritis following gonor- rhcea, abortion, noi-mal parturition, or that resulting from a chronic in- flamnuition due to malposition of this organ or other cause, are the chief conditions which precede this affection. By direct j^alpation over the abdomen of the affected side, it will be seen that the muscles of this side are abnormally tense, and that acute pain is present confined to a limited and well-marked area, which corresponds to the normal position of the tube. In the vagina, a leu- corrhoeal discharge is usually observed, and diligent examination will reveal great tenderness near the cervix, upon the side involved. The uterus may be normally situated, but is laterally displaced when the tumor is at all large. With bimanual examination, often necessary under ether, there will be found an elastic, if not fluctuating, tumor, s])ringing from one or the other uterine cornu, and directly attached to the uterus ; SALPINGITIS. 683 perhaps bulging into ttie vagina ; sausage- shaped when moderately large, but round when as large as an orange ; often movable, but almost always with false attachments. This tumor may be but a part of a general inflam- matory mass filling up the pelvic cavity and rendering fluctuation hard to obtain. In such a case, the uterus is fixed to this mass. As a rule, the tube is prolapsed, and drags with it the ovary, the latter l)eing exter- nal to and above the cyst. In many cases the diagnosis is easy, but in others it is difficult. Treatment. — When the diagnosis is satisfactorily determined, and the symptoms are urgent, removal by abdominal section is indicated. The preparation of the patient and for the operation are the same as for ovariotomy. When the peritonseum is opened, the tumor may be dis- tinctly felt, and should be removed without rupture of the cyst-wall when this is possible. Adhesions to the neighboring organs will be found to exist, in a varying degree, in all cases. Some of these, which are vas- cular and of good size, require to be tied with double large-sized catgut ligatures and divided, while others may be torn off. The silk ligature should be passed around the tube, close to the surface of the uterus, tied, and the mass removed. The stump beyond the ligature should be care- fully disinfected and seared with the actual cautery. If rupture should occur, or if there is a considerable amount of oozing, the Sims's drainage- tube should be used. The Ovaries. — Removal of the ovaries may be necessitated on account of — 1, cystic degeneration ; 2, cirrhosis ; 3, abscess ; 4, cystic, and 5, solid tumors. In cystic degeneration the ovary is enlarged, and the interior of the organ is filled with small cysts wdth dense, fibrous capsules. They can in some cases be seen through the investing membrane, and, if punct- ured, will give exit to a fluid usually clear, but at times brown, or even decidedly stained with blood. The tumor is elastic to the touch, usually spherical, and rarely attaining as much as a diameter of two inches. The fimbriated extremity of the Fallopian tube is often adherent to the diseased ovary. In rare instances the broad ligament and tube may surroiind the cystic tumor. The left organ is affected more frequently than the right, for the same reasons as given for the more frequent oc- currence of varicocele in the left scrotum (see Varicocele). The pa- thology of this affection is not yet definitely settled. In cirrhosis the ovaries are usually small, and have a furrowed or withered appearance ; occasionally they are found normal in size, or even slightly enlarged. The normal Graafian follicles are entii-ely destroyed in well-marked cases. In more recent cirrhotic disease of these organs the cavities of the follicles are distended with a bloody fluid. This condition is almost always due to a connective-tissue hyperplasia, resulting from a subacute inflammatory process in the ovary. In abscess of this organ it is enlarged, and may contain one cavity or several separate collections of pus. When the abscesses are small and multiple, the gross appearances of the organ are not unlike those of an 684 A TEXT-BOOK ON SURGERY, ovary with cystic degeneration. Suppurating salpingitis (or pyo-salpinx) may be present with abscess of the ovary, and, in rare instances, by reason of fusion and rupture of the contiguous walls, there results a large single abscess. Multiple extravasation of blood may occur in ab- scess of this organ. If not relieved by operation, the pus may eventually find an exit thi-ough the vagina, bladder, or intestine. Adhesions, as a rule, occur between the ovary and one or more of the contiguous organs, or to the pelvic fascia. Symptoms. — In ei/stic degeneration and cirr/wsls; dj'smenorrhoea is the most prominent symptom. It is more- severe with the former, but is severe in the cirrhotic ovary. The pain usually precedes the menstrual flow from a few hours to several days, and in extreme cases may continue from one period to the next. It is usually referred to the groin of the affected side, and thence the painfiil sensations may radiate over the abdo- men and down the extremity. Hysterical convulsions are very apt to be present in the more severe cases. The menstrual flow is scanty or normal in amount when the ovaries are cirrhotic ; but with cystic degeneration the flow is generally increased, and hjemorrhage may be the must promi- nent and dangerous symptom. The uterus is apt to be slightly above the nonnal size, with the ovaries in cystic degeneration, and somewhat smaller when these organs are cirrhotic. Not infrequently i-etroversion is observed as a symptom of cystic ovar^y, in which case this last-named organ is prolapsed. The uterus is commonly free and movable, unless ha^matocele or peritonitis has occurred. If cystic, the ovary is easily felt, often low down in Douglas's pouch. If cirrhotic, it is hard to find. From clinical manifestations it appears that cystic degeneration ^is due to a degree of inflammatory action more severe than that which leads to cirrhosis, because peritonitis and pelvic luematocele more often accom- pany the formei". Cystic and cirrhotic ovaries are always sensitive to pressure. In ovarirm abscess there is ustuvUy a history of gonorrhtpa, puerperal septicaemia, an acute exanthema, or a severe attack of metritis or peri- tonitis. When the abscesses are small, the symptoms do not greatly differ from those of cystic ovaries ; but when at all large, the patient has hectic fever and rigors. The pain in the pelvis is constant, but is liable to exacerbations. Repeated attacks of pelvic peritonitis follow each other. When the ovary is converted into one large abscess, and the tube is not affected, dysmenorrhoja is not a constant symptom, and ■ there is an absence of the nervous phenomena observed in the other forms of ovarian inflammation. The uterus is usually drawn to the affected side as a result of the pelvic peritonitis which usually accompanies these cases. The lateral fornix of the vagina is encroached upon when the abscess is large, and then fluctuation can be obtained. The abscess, whether large or small, is usually but part of the mass of inflamed tissue which occui^ies the pelvis on the affected side. The ovary is enlarged and low down. As abscess of tlie ovary does not often occur alone, and as the sole lesion of the pelvic oj'gans and tissues, the symjitoms which apj)ear are j^artly LARGE CYSTIC TUMORS OF THE OVARY. 685 due to the intercurrent diseases— salpingitis, h?ematocele, peritonitis, etc. When an ovarian abscess ruptures into the j)eritoneal cavity, a fatal general j^eritonitis is the result. If it ojiens into the vagina, it usually does so just below the cervix in the posterior wall, at the bottom of Douglas's pouch, where the vaginal wall is thinnest. Treatment. — If the ovarian abscess is but part of a i^elvic inflam- mation which unites together rectum, bladder, uterus, and broad liga- ment into one mass, and if the abscess is low down, fluctuation being obtained in the vaginal roof, it may be opened per Tag i nam and drained. But in cases of jielvic abscess it is better to try to remove them by abdominal section. Exploratory incision has but little mor- tality. A certain and i^ositive knowledge of the condition of the parts in these cases can be obtained by abdominal section only, and by it only can a radical cure and extirpation of the abscess be effected. These are the most difficult cases the surgeon has to deal with, especially when associated with pyo-salpinx or hajmatocele. The drainage-tube should be employed whenever ruptiire of the abscess occurs in the efforts at removal, and when there is much oozing after the adhesions are In-oken up. The operation is similar in its technique to that of removal of the tubes. Cystic and cirrhotic ovaries are to be removed by abdcmiinal sec- tion when, aU conservative measures having failed, the patient's health or reason is seriously threatened. The objection of sterility can not be maintained, for these women are already sterile. The operation may also be performed in cases of acute mania and epilepsy which appear to be due to ovarian disease and which are incurable by other means. The operation is simple. An incision large enough to admit two fingers is made in the median line. The lower angle of this wound should be about two inches above the os pubis. Tlie ovary and tube are freed from false attachments, brought toward the incision, and the broad liga- ment transfixed close to the uterus ^vith a double ligature. The ligatures are crossed — one is tied above the tube close to the uterus, the other below the ovary ; the tube and ovary cut off, and the ligatures cut short. The abdominal wound is closed as heretofore given. Drainage is rarely indicated. Large Cystic Tumors of the Ovary and Broad Ligaments. — Cystic tumors of the ovary are occasionally unilocular. In the vast majority of instances they are multilorular. The pathology and pathogenesis of these neoj)lasms are not yet definitely settled, and, since a discussion of the va- rious theories advanced is scarcely permissible in a text-book, the student is referred to the various standard works upon pathology. The most common form of ovarian tumor — the cyst-adenoma — is al- ways multilocular. The surface of such a tumor is glossy, often silver- white. The sac is usually firm, its contents being a thick fluid, with a grayish-brown or reddish tint. The outline of the cyst may be perfectly symmetrical and roimd ; or it may have one main cyst, and numbers of smaller ones springing from it ; or two or three cysts of about equal size may constitute the entire mass. But, be the shape what it may, second- ary cysts will always be found in some part of the tumor. At one or 686 A TEXT-BOOK ON SURGERY. more points the cyst- wall may be exceedingly thin or softened as a re- sult of the rupture of inter-cystic walls, those of the secondary cysts being thinner than that of the larger. Softening of the wall may also occur when the neoplasm is malignant ; or as a result of interference with its nutrition from twisting of the pedicle ; or from suppuration in the cyst- wall. In exceptional instanres in old cysts there some- times exists a communication between the cyst-cavity and the bowel or bladder as a result of necrotic changes where the two have become adherent. In size cysto-adenomata of the ovary may vary from a few inches in diameter up to those of enormous size, weighing many pounds, and filling the entire abdomen. The veins lie both superficially as distinct vessels and dee^jly in the cyst-wall as sinuses ; the arteiies are more deeply situated and are large. This tumor may be generally adherent to the peritonjpum and other organs with wliicli it comes in contact, or connected at various points by isolated bands. In rarer instances no adhesions may be met with. The pedicle of an adeno-cystoma may be attached to both sides of the uterus, two distinct tumors having met and coalesced. At times the tumor derives its nourishment from bands unit- ing it to the abdominal parietes or viscera, its own pedicle having been twisted off. A form of multilocular cyst, connected with the ovary, known as '''RokitansJci/s tumor,'" has been observed in a few instances. It consists of a series of cysts containing a clear fluid. The cysts hang in bunches and are connected with each other by delicate fibrous bands. The entire mass does not usually reach a size larger than the fist. Dermoid cysts are not altogether infrequent in the ovary. These tu- mors have thick walls, are dark-colored, are filled with a dark fiuid in which are found particles of hair, teeth, bone, etc. They may be mul- tilocular, or they may contain but one cyst. Hanging from the fimbriated extremity of the Fallopian tube, or just beneath it, is also found a small, thin-walled cyst, with clear contents, called by some the "hydatid of Morgagni." If examined carefully while it is floated in clear water, it will be seen to be a continuation of the horizontal tube of ihe parovarium. Cyst of the Broad Ligament. — There is also met with a cyst of con- siderable size, with perfectly clear contents and very thin walls, which is sometimes pedunculated, but generally with a broad attachment located either upon the broad ligament or the uterus. A small cyst of a simi- lar nature may spring from the covering of the Fallopian tube and be pedunculated, or arise just beneath the Fallopian fimbrije, and be either sessUe or pedunculated. Solid Tumors. — Fibro-myomata appear as. smooth, firm bodies. They do not, as a rule, contract adhesions with neighboring structures. Sarcomata have about the same clinical appearance, except when very vascular, in which state they are softer and more elastic than are fibro- myomata. Carcinomata of the ovary are very nodular, and when large they may contain one or more cavities in their interiors. Secondary SOLID TUMORS. 687 deposits in other viscera are found with these tumors. The symptoms of all solid tumors are so obscure that the exact character of any of these neoplasms can scarcely be determined, excepting by microscopic exami- nation. Symptoms. — Tumors of the ovary are usually first noticed upon one side of the ijelvis. The ordinary cysto-adenoma is not painful until it is so large that it presses upon the pelvic and abdominal viscera. If iniiam- mation supervenes from any cause, pain is a prominent symptom. Amen- orrhoea is the rule, although in a certain proportion of cases men- struation is normal. Menorrhagia is rare. If left without interference, pressure upon and displacement of the neighboring viscera is the rule, and, if peritonitis does not ensue, death ultimately results from jesthenia. Not infrequently adhesions ai-e formed between the bladder and the neo- plasm to such an extent that, as the tumor grows, the bladder is dragged upward to the neighborhood of the umbilicus. In large tumors, dysp- noea, oedema of the lower extremities, enlargement of the supei-ficial abdominal veins, and nephritis occur as a result of pressure. Upon examination, it is usually easy to detect the presence of the tumor. The uterus lies in front of the cyst, or is displaced laterally if the tumor be large enough to crowd it out of its noi-mal position. The uterus is not increased in size, and is movable independently of the neoplasm. The latter is an important feature in differentiation, and may be best determined with the aid of the elevator carried into the uterus. When the cyst is large, the uterus is dragged high xip and fixed against the symphysis pubis. The bladder may lie over the front of the tumor as high as the umbilicus. But when the tumor is so large as to have completely risen out of the pelvis, the bladder reaches, even when not adherent to the cyst, a point somewhat above the suprapubic notch. The enlargement of the cyst gives to the abdomen a rotundity not seen with distention from ascites alone. Ascites commonly coexists with large cysts. If not large and non-adherent, the tumor can be raised out of the pelvis without the uterus. It may also be dej^ressed in the pelvis. When the secondary cysts are large and project from the surface of the main cyst, they may be quite readily distinguished. If one hand is laid flat upon one side of the mass and the other side is given a sharp tap with the fingers, the fluid character of the contents of the neoplasm may be easily appreciated. When the walls of the tumor are very thick and the distention marked, fluctuation may not be felt. In solid ovarian neoplasms pain is apt to be present early in the history of the growth, and the general health of the patient may show signs of deterioration before there is any marked increase in the size of the tumor. This is especially true of malignant new formations. Filjro-myoma of the ovary is so often associated with similar changes in the uterus that the slight menorrhagia which occasionally accompanies these cases may reasonably be ascribed to uterine hyperplasia. Upon abdominal jialpation, with vaginal exploration, a hard and usually mov- able tumor may be appreciated. At times it is attached to the surround- ing structures to such an extent that mobility is absent. The uterus is 688 A TEXT-BOOK ON SURGERY. not enlarged, is often dis])lacecl backward, and is generally freely mova- ble with small tumors. AV'hen malignant, the tumors are of rapid growth. Ovarian libr()-myortion of the spine is exempt, the disease is much more frequent in the dorsal vertebrge, which are involved in about two thirds of all cases. The lumbar and cervical portions of the column are about equally liable to destructive ostitis. Occipito-cervical disease is rare. Ostitis in the lower cervical region is apt to involve the upper dorsal by extension, and the same is true of ostitis of the lower dorsal in their relation to the lumbar vertebra;. Lumbo-sacral disease is not altogether uncommon. Destructive ostitis of the spine is divided into occrpito- cervical, cervical, cervico-dorsal, dorsal, dorso-lumbar, lumbar, and lumbo-sacral, according to the recognized location of the disease. Causes — Predisposing and Exciting. — Any disturbance of the nor- mal process of nutrition in the tissues in general — as in the syi:)hilitic, tubercular, goiity, or rheumatic dyscrasia — or the impairment of vitality resulting from any acute disease, predisposes to inflammatory changes in the bones, and especially in the cancellous tissue of the vertebra?.* These bones, together with the sternum and ribs, are the last to take on the changes which occur in the adult bones — the bones of comi:)leted gTowth and full development. In the pathology of ostitis it has been Ijointed out that the medulla of these bones remains in its red or embry- onic condition long after that in the other bones has undergone the adult change, and that, consequently, they are for a prolonged period liable to accidents consequent upon rapid nutritive changes, and especially to capillary rupture and extravasation, f How much more liable to acci- dent and disastrous inflammation are these structures Avhen they are weakened in the general impairment of nutrition? The chief exciting cause is violence, either directly or indirectly applied. A fall upon the feet, buttocks, or hands, or violent flexion or extension of the vertebral column, a blow upon the sternum or ribs, or a penetrating wound, may each lead to destructive ostitis. Carcinoma, sarcoma, and aneurism may also cause destruction of one or more vertebrae. It is believed that as * " Les tubercLilcs dcs os s'sobservent haliituollement dans les tissii spongionx iles os longs et dans les os courts, mais leur si6ge de prfidileetion est le corps des vert6bres, lo sternum ot les C6te8." — CORNIL ET Ranvier. t "Les OS des jeunes sujets et coux qui chez I'adulte contionnent encore la moelle foetale comme le storniim et les corjis vertebraux sont partieuli^rement expos6 aus troubles patho- logiques nutritifs ou fonnateurs."' — Cohsil et Kanvieb. 700 A TEXT-BOOK ON SURGERY. between the predisposing and exciting causes of Potfs disease, the for- mer deserve by far the greater consideration. Clinically, destructive ostitis is met with in two forms— the dry and the suppurative. The latter variety is more common. In dry ostitis the bone-cells undergo granular metamorphosis, and, together with the inor- ganic salts of this tissue, are al)sorl)ed. Suppuration, if present, is lim- ited, and the products of inflammation undergo fatty degeneration. In these cases the breaking down of the bodies of the vertebra?, to the ex- tent of marked deformity, may occur without recognized febrile move- ment. In the suppurative form the destructive pi-ocess is more rapid, and is accompanied by the formation of a variable quantity of embryonic tissue, the bone breaks down in bulk, and particles varying in size aji- pear in the pus which results from the inflammatory process. The ear- liest pathological change in such cases is in the cancellous tissue of the body. In rarer instances the lesion commences as a synovitis in the costo-vertebral or interarticular joints, whence the disease may invade the intervertebral disks and bodies. Primary inflammation of the inter- vertebral tibro-cartilage is believed to be very rare. As the destructive process continues, the cancellous tissue of the body, and chiefly of the anterior portions of the column, breaks down (Fig. 079), causing abnoimal FlQ. 679. — Destructive ostitis of the anterior portion of the bodies ot the vertebrffl. (Alter Noble Smith.) Fio. 680. — The same process in the posterior portion of tlie bodies of the vertebne. (After Noble Smith.; Fio. 681. — Deformity resultin? from fracture of a vertebra. (After Noble Smith.) curvature, with sharp projection of the spinous proce.sses. The angular deformity is less apt to be present wlieii the disease attacks the posterior portion of the body, where the superincumbent weight in great part falls upon the articular processes (Fig. 680). Symptoms. — The clinical history of Pott's disease may be divided into two stages : The first stage includes all the phenomena which occur up to the time when deformity is recognized ; the seennd stage embraces all the changes met with after deformity. The usual symptoms of the first stage are pain and muscular rigidity, with varying exacerbations ot temperature. Pain may be elicited when the patient assumes the erect posture, by direct pressure upon the spines of the vertebrje involved, SPONDYLITIS. 701 and by concussion of the column transmitted from the head downward. VVlien the bodies alone are involved (the usual condition) it may be less- ened or made to disappear entirely by susi^ension of the patient from a portion of the column al)ove the lesion ; by bending the spine backward, thus throwing the weight upon the healthy articular i)rocesses ; or by laying the patient face downward across the surgeon's lap, and making extension by sejjarating the knees. Muscular rigidity is recognizable in a majority of instances, and in children may be observed as a symptom of j^ain, when the presence of pain is denied. Fixation of the dorsal muscles is evident in the stiff and unusual manner in which the back is held as the patient moves about, and in the awkward jiosture assumed while sitting down. If directed to bend the vertebral column, as in stooping to pick \\\) some- thing from the floor, the movements are cautious and constrained, alto- gether lacking in the celerity and suppleness which are seen in flexion and extension of the vertebral column in health. In the earlier stages pain is dull and steady in character, and is usually local, being confined to the neighborhood of the part affected. Elevation of temperature may be present at any stage of Pott's dis- ease. It is, as a rule, the index of the extent and rapidity of the inflam- matory and destructive processes. The thermometer may register from the normal as high as 101°-102° F., and only in exceptional instances as high as 104°. In a fair proportion of cases in the early stages, and esj^e- cially in the dry form of ostitis, no elevation of tem])erature can be detected. The second stage of the disease, that of deformity, may be present in the course of a few weeks after the appearance of the first stage, or sev- eral months may elapse. All of the symptoms of the preceding stage are jjresent in the second stage of Pott's disease. If proper treatment has not been instituted, interference with the functions of the cord at and below the seat of lesion, or of the nerves which pass out between the diseased vertebrae, is apt to occur, from displacement of the bones or as a result of inflammatory products pressing upon the spinal cord and nerves. Paralysis of motion and sensation, in a varying degree, occurs in a certain i)roi)ortion of cases. When deformity occurs the convexity of the curve is posterior in about 95 per cent of all cases. The "knuckle" may consist of a single sjjinous process (Fig. 328), or several spines may project, as in Fig. 670. The degree of deformity depends upon the location of the disease, its extent, and in part to genei-al relaxation of the erector muscles. It is greater when the lower cervical and upper dorsal vertebrae are involved. The formation of pus and the resulting abscess and sinuses belong chiefly to the last stage of ostitis of the si)ine. The abscess may travel along the psoas muscle, ojiening near the middle of the groin above or beneath Poupart's ligament, the pus may escape through the inguinal canal, over the iliac crest, or through the sacro-sciatic notch : or it may be arrested at a higher point and escape recognition, unless careful examination is made under ether narcosis. 702 A TEXT-BOOK ON SURGERY. Spinal abscess is usually single, occasionally double. "WTien occur- ring in the ujiper dorsal region it may be arrested by the diaphragm, or pass behind this into the slieath or fascia of the psf)as muscle. Abscess in ostitis of the bodies almost always travels downward on one or the other side of tlie anterolateral asj)ect of the spine. AVhen the articular processes or laminjp are involved, the pus may penetrate the dorsal mus- cles and point posteriorly. In occipito-cervical or upper cervical spondylitis, the pus collection often appears at the posterior wall of the ])harynx {refrophanjnf/cal abscess), where it may be recognized by insijecfion or iligital exploration. Interference with deglutition and phonation is not infrequent. The con- tents of an abscess resulting from destructive ostitis of the cervical ver- tebne may also descend along the deep fascia of the neck and j)ass into the thorax or the mediastinum. In this manner it occasionally linds its way into the jiericardium. Amyloid changes of the viscera are among the late symptoms of chronic spondylitis. I)i(t(/)iosls. — In general the recognition of the disease will depend upon a histcn-y in accordance with most of the symptoms Just detailed. As to the portion of the column involved, the appreciation of localized pain by direct or indirect pressure is an indication of value. When the effei'ent nerves are involved by pressure from the i)roducts of inflamma- tion, certain disturbances in their course or distribution are of diagnostic importance. Spasm of the larynx, jjharynx, diaphragm, pain down the arm, etc., naturally attract attention to the points of exit of the nerves supplying these parts. When tenderness in the region of the psoas muscles is evidenced by habitual indisposition to extend the thighs, lumbar ostitis may be suspected. When the gibbosity is recognized, a diagnosis is no longer doubtfid. The early recognition of abscess in the abdominal region is possible only by palpation under profound narcosis. K the articular processes are diseased, bending of the sjainal column backward will increase the pain. Placing the patient on the abdomen, with the head and lower extremities depressed, will diminish it. When the bodies and intervertebi'al disks are involved, bending the spine back- ward will relieve the pressure symptoms. Treatment. — In the mechanical treatment the indications are to se- cure fixation of the spinal column in the position of least discomfort to the patient. Judicious medication, good food, and pure air are the indications in the constitutional treatment. The character of the mech- anism to be used will dei)end in good part upon the portion of the vertebral column involved. It is essential, in order that any apparatus may fully meet the indications, that not only shall the diseased bones and the healthy tissues be held laractically immovable, but the sujjer- incumbent weight must in whole or part be lifted. Fixation may be accomplished by any form of well-adjusted apparatus, but lifting the weight of the body, which is above the seat of disease, is a more difficult undertaking. SPONDYLITIS. 703 The downward pressure upon the bodies when, as is usual, these structures are involved and breaking down, can be in great part obviated by extension or backward bending of the spine, in which mananivre the pressure is transferred from the bodies and intervertebral disks to the articular processes and pedicles. Much of the api^aratus devised for the arrest and cure of Pott's dis- ease is based upon this principle. Another method is based upon the principle of lifting the parts above the seat of the lesion, and removing the pressure in a greater or less degree not only from the bodies but also from the articular ijrocesses (extension and counter-extension, or sus- pension). To accomplish the former the spinal braces of Drs. Davis, Taylor, and Shaffer have been constructed. For complete extension or lifting, the plaster-of-Paris jacket or the jury-mast of Prof. Sayre, and the suspen- sion-carriage of Dr. Meigs Case, more nearly meet all the indications. In appropriate cases each of these forms of apparatus, if properly adjusted and intelligently worn, will accomplish all that is possible in the mechanical treatment of Pott's disease. Much of the discredit which is brought ui:)on particular apparatus can justly be charged to the lack of judgment in the selection of cases, want of skill in the adjustment of the instrument, and failure on the part of the attendant or patient in persisting in its use a sufficient length of time. The selection of the apparatus best adapted to succeed will depend upon the location of the disease and the age and conformation of the patient. Clinically the spinal column is divisible into three regions: 1, embracing the occipito-cervical • articulation, the cervical vertebrje, and down to the third dorsal ; 2, fi'om the third to the tenth dorsal ; 3, from the tenth dorsal to the sacro-lumbar articulation. The lower region is more amen- able to treatment, the upper next, while the middle region, which is most frequently involved in osti- tis, is the most difficult to man- age. Third Region. — In the mechan- ical treatment of Pott's disease in the third region, Sayre's plaster- of-Paris jacket, of light make and properly adjusted, is preferable. In its application the following articles are essential : 1, a suspen- sion apparatus : 2, a tight-fitting, ^'°- 682 -Suspension apparatus fnr applying plas- '^ '^ ' ' o " ""^""n^ ter-ol-Puns jacket. ^ After Sayre.) seamless, knit shirt ; 3, plaster-of- Paris bandages. The suspension apparatus of Reynders & Co. (Fig. (382) gives perfect satisfaction. It consists of an iron cross-bar from 704 A TEXT-BOOK ON SURGERY. which are suspended padded loops for each axilla, and acliin and occi- put swing for lifting from tlK^se points. The crows-bar is attached at its center to a block and pulley. After the knit shirt is a])plied, the arms of the patient are slipped through the padded loojjs, while the col- lar is buckled around beneath the chin and occiput. The center and lateral suspension-straps shoidd be adjusted so that when the lift is made the tension will be equally distributed. The block of the jjulley apparatus may be fastened to a hook in the ceiling or to the tripod (Fig. 683). The plaster bandages — the method of preparing which is given on Fio. G83.— Suspension apparatus and tripod in position for lifting. (After Sayre.) page 10 — should be perfectly fresh and well made, for a good deal of suc- cess depends upon the quality f>f the gypsum and the thoroughness with which it is worked into the meshes of the crinoline. As the direction for applying this jacket, as given by Prof. Sayre — to whom the profession is indebted for bringing it so prominently into use — can not be improved upon, I give it in his language : "Before applying the plaster bandage, I place over the abdomen, be- tween the shirt and the skin, a pad composed of a towel folded up so as to form a wedge-shaped mass, the thin edge being directed downward. SPONDYLITIS. 705 This is intended to leave room, when removed, for the expansion of the abdomen after meals, and so I call it the 'dinner-pad.' It is important to make it thin where it comes under the lower edge of the jacket, or else the jacket would tit too loosely about the lower part of the abdomen. It should be taken out just before the plaster sets. It is always a good plan to get the patient to eat a hearty meal before the jacket is applied, but this precaution of allowing room for meals should never be neglected. " If there are any very prominent spinous processes which, at the same time, may have become intiaraed in consequence of pressure produced by instruments previously worn, or from lying in bed, such places should be guarded by little i^ads of cotton or cloth, or little gloA'e-fingers tilled with wool placed on either side of them. Another detail, which I have found to be of practical value in some cases, is the application under the shirt, over each anterior iliac spine, of two or three thicknesses of folded cloth three or four inches in length. If these little pads be removed just be- fore the jilaster has completely set, such bony processes will be left free from pressure. ' ' If the patient be a female, and especially if she be developing at the time, it will be necessary to apply a pad iinder the shirt over each breast before the jslaster bandage is put on. These jiads should be removed just before the plaster sets, and at the same time slight pressure should be made over the sternum for the purpose of indenting the central portion of the plaster jacket, and of thus giving form to the body, and of remov- ing pressure from the breasts. "The skin-fitting shirt having been tied over the shoulders, and then pulled down, and kept stretched by means of tapes applied, one in front, the other behind, near its lower edge, and tied tightly over a handker- chief placed on the perinjeum, the patient is to be gently and slowly drawn up by means of the apparatus until he feels perfectly comfortable, and never beyond that point, and while he is retained in this position the plaster bandage is to be applied. A prepared and saturated roller, w^liich has been gently squeezed to remove all surplus water, is now applied around the smallest part of the body, and is carried around and around tlie trunk downward to the crest of the ilium, and a little beyond it, and afterward from below upward in a spiral direction, until the entire trunk from the pelvis to the axillje has been incased. The bandage should be placed smoothly around the body, not drawn too tight, and especial care taken not to have any single turn of the bandage tighter than the rest. Each layer of bandage should be rubbed most thoroughly with the hand by an assistant, that the plaster may be closely incorporated in the meshes of the crinoline, and bind together the various bandages which make up the jacket, thus making it much stronger than if attention is not paid to this particular. If you notice any spot which seems weak or likely to give way, pass the bandage over it, and then fold it back on itself, and do this until you have placed several tliicknesses of bandage over this point, being careful to wet all well together, and then pass a turn com- pletely around the trunk to retain any ends which might have a tendency to become detached. 45 706 A TEXT-BOOK ON SURGERY. "In ;i very sliort time tin- phistcr sets with sufRcient firmness, so that the patient can be removed from the suspending apparatus, and laid upon his face or back on a hair mattress, or — what is preferalde, es])e- cially wiieii there is much ju-ojection of the spinous processes or sternum — an air-bed. Before the phister has completely set, the dinner-pad is to be removed, and the plaster gently pressed in with the hand in frt)nt of each iliac spinous process, for the purpose of widening the jacket over the bony projections. In the case of a young child with a small pelvis it may liappen that the circumference of the body at the umliilicus is as great as around the pelvis, but, as the soft parts in the ]und)ar region allow us to mold the plaster as we choose, you can still obtain a i)oint of support at the pelvis ; if, as the jacket hardens, you will press it in at the sides above the ilium, and in front and rear above the pubes, the an- tero-posterior diameter above will be the longer, while below it will be the transverse one.'' When the angular projection is extreme, or when an ulcer exists, it will be advisable to cut a hole in the jacket at this point, large enough to prevent any undue pressure. In case of abscess, a window of sufficient size to allow free drainage, and a frequent change of dressing, should be made. The commendable features of this plan of treatment are the extension obtained by suspension, fixation by the plaster while in the most favor- able position, and the cheapness and readiness with which it may be em- ployed. The objections are, uncleanliness by reason of the immovable nature of the apparatus, and the excoriations which are a cause of considerable comidaint. The first objection may be met by splitting the corset down in front, and reapplying it while the patient is suspended, and making it tight by a roller carried around the body several times. As for excoria- tions, it may be said that no apparatus which grasps the body tight enough to secure fixation is free from this danger. When they occur with the plaster jacket, the fault generally lies either in the im])roper manner of its application or carelessness on the part of tlie attendant. Second Rer/ ion. — When the middle or dorsal region is involved, the plaster jacket is not so serviceable as in ostitis of the vertebra^ in the lower region of the spine, altliough much good will be accom])lished by the partial fixation of the thorax as high as to the level of the axillge. The efficacy of this method diminishes the higher the diseased process is located, and, when the lesion invades the sixth dorsal, or above this point, the jacket without head-suspension is almost useless. In all cases of Pott's disease above the tenth dorsal, suspension of the head is an essential feature of treatment. A favorable result would be achieved in a greater proportion of cases if this point were insisted upon, and the prejudice against the suspension apparatus overcome. In its application the patient should be suspended as just described, and a plaster jacket applied, from just above the trochanters up as high as the axilliP. After two layers of the plaster bandages have been ap- plied, the jury-mast is adjusted, and its framework covered in with the SPONDYLITIS. 70^ suceeeding layers of bandage. The jury-mast (Fig. 684) consists of a back-piece, in shape not unlike the inverted letter U, made of soft ii-on, which enables it to be accurately molded to lit the surface to which it is applied. To this are fastened two or three strips of tin, made rough liy a series of perforations with an awl. To the upper end of the back-piece a curved bar of light steel is attached, in such a manner that it can be raised or depressed at will. At the end of this crane is a light cross-])ar, hooked at each extremity, from which the collar is suspended. After the first two layers of plaster bandages have hardened, the apparatus is ])ent to fit the surface of the back, and is adjusted to the jacket, with the middle-piece or crane exactly in the median line of the back of the neck and occiput, and its extremity over the center of the top of the head, so that traction by the strips will be directly upward. It is ^rr Fio. 684. — Sayre's jury-mast head-swing. '( After Say re.) F:g. 685. — Jury-mast apparatus applied. (After Sayre.) fastened by carrying plaster rollers over the tin strips and back-piece, and working in plaster-mortar. "When the plaster hardens the apparatus is immovably incorporated into the jacket. The suspension-collar shoidd now ])e buckled beneath the occipital protuberance, and the strips tight- ened enough to lift the weight of the head from the neck. The jacket may be couA^erted into a movable corset, by splitting it along the middle line in front and attaching hooks for lacing (Fig. 68^). If the jury-mast can not be applied, in ostitis involving the vertebrjB between the third and ninth dorsal, Shaffer's modification of Taylor's brace should be pre- ferred. " It consists (Fig. 686) of the pelvic band, A, to which are riveted two perfectly plain uprights, B B, of annealed bar-steel, which uprights ex- tend to the shoulder-pieces, D D, and are steadied at a point opposite 708 A TEXT-BOOK ON SURGERY. the scapuljB by tlie cross-pieces, E E. The pads at CC are simple rolls of Canton tiannel stitched to the uprights by transverse threads, shown in the eni^ravinc:. P represents the location <»f the deformity, and F F F F shows the plaster zcme securing the uprights in lirni contact with the tissues Ij'ing over the transverse processes. " Fig. 687 illustrates the anterior appearance of tlu' ai)inu"itus. F F are the shoulder-strai)s, passing from the ends of the shoulder-pieces, D D (Fig. 686), to the buckles, H H (Fig. 686). J" is a piece of padded webliing crossing the anterior and superior wall of the tlifmix. It is secured -oX G G (Fig. 686). L is also a piece of padded webbing, which Fio. 686.— Shaffer's apparatus. (Alter Shaffer.) Fio. 087.- ■Front view of Shaffer's apparatus. (Aaer Shaffer.) completes the circumference of the pelvis by fastening at the biickles attached to the pelvic band A (Fig. 686). K represents the anterior ap- pearance of the plaster zone. " At Z> D (Fig. 686) and at 8S (Fig. 687) are the shoulder-pieces, which prevent pressure and serve as points of attachment for the axillary straps, so that these axUlary straps, in i)assing over the shoulders, shall not exert undue downward pressure. Being annealed, these shoulder- pieces may be bent in any direction desired ; and they should lie curved so that a very little sjpace exists between them and the subjacent parts. The SPONDYLITIS. 709 pelvic base forms a sufficient support for tlie apparatus, and it becomes quite frequently necessary to apply perineal pads to prevent the moving upward of the apparatus, rather than to adjust shoulder-pieces to keep the appliance from slipping down. "To prepare and adjust the apparatus: 1. Take two light bars of annealed steel, of a length which corresponds to the distance between the commencement of the anal commissure and the spinous process of the second dorsal vertebrae. These fomi the uprights. 2. A piece of sheet- steel, about one inch wide and long enough to reach from the top of one trochanter major to the other ; bend it to coiTespond with the transverse sacro-iliac region, and cover with chamois or other soft material. This forms the hip-band. 3. Two cross-pieces, four or five inches long, which are riveted to the uprights at points which correspond to the lower border of the axilla and the inferior angle of the scapula. 4. Two small pieces of light bar-steel, about two and a half inches long, which are covered and riveted to the upper end of the uprights, at an angle of about 45°, and bent as shown in the engraving. Buckles are now attached to the ends of the shonlder-pieces, the cross-pieces, and the pelvic band. The distance between the uprights should be aliout one inch and a quarter, or sufficient to avoid any pressure upon the spinous processes. These com- ponent parts being riveted together, two rolls of Canton flannel, about three eighths of an inch thick, and a little wider than the upright bar, are now prepared. They should reach from about one inch above the pelvic band to the lower cross-piece. Two broad webbing-bands, as shown at / and L (Fig. 687), are then made ready.* " The patient is placed upon two tables of equal height, and the tables are then separated so that the parts selected for the zone may be freely accessible from all sides. One assistant grasps the ])atient under the axillfe, the other makes steady but easy traction at the thighs. While the patient is in this prone position, the operator fits the uprights to the line of the transverse processes ; in other words, adjusts the apparatus to the defoimity. A pair of 'monkey-wrenches' may be easily used as a pair of levers with which to bend the annealed steel uprights into any jiosition. It takes but a few moments to adapt the uprights to the deformity. In the mean time the patient is quiet. He does not struggle nor cry. The traction is affording relief, and is not producing any injury. ^Vhile ho lies quietly, and the Canton flannel pads are sewed on, we pass a piece of Canton flannel, or merino gauze, around the body over the projection. Then, the plaster bandages and everything being in readiness, the apjia- ratus is laid on the back accurately, traction is steadily maintained, the thoracic and pelvic straps are fastened, and the jtlaster zone is snugly applied. The axillary straps are left until the plaster is hardened, and * •' Messrs. Tieraann & Co., No. 67 Cliatlinm Street, New York, will furnish tliis apparatus at a cost of from five to seven dollars, according to size. It would also be well, in sending tlio mcasureiuents, to inclose an outline of the spinal column, from the spinous process of the second dorsal down. This may be done by idacing a strip of lead along the spinous processes, and molding it accurately to the outline |>resented. Ky transferring this lead carefully to a sheet of paper, .an accurate protile of the spine may be obtained with a lead-pencil tracing. 710 A TEXT-BOOK ON SURGERY. the patient is ready to sit up. When the operation is complete, the patient is finnly secured in an apparatus which affords a stip- port that can be maintained by the thoracic, axiUary, and pelvic straps, and the uitrights are held, without undue pressure, in their position by the plaster zone."* The value of this apparatus consists in the fair degree of hxa- tion which it secures, but chiefly in the dorsal spine is extended, that Fig. 689. — Dr. Meig-. Case's suspension-carriage, for both tbe standing and sitting postures. Flo. 688. — Extension in tbe recumbent posture. (After Reeves.) the fact that, when properly applied, is, bent backward to such a degree that the weight from above is removed from the diseased bodies and transferred to the sound articular processes and pedicles. If this posi- tion is properly main- tained, relief will usual- ly follow in those cases where the bodies alone are involved. Instead of the plaster zone, a broad canvas or soft leather belt may be used. First Region. — In ostitis of the vertebral column, from the third dorsal to the occipito- atloid articulatirm, the treatment should be by sitspension from the chin and occiput. In accom- plishing this end the jury-mast, applied and worn as just described, is entitled to the first con- sideration. Much good may be obtained from the judicious use of ex- tension in the recumbent posture (Fig. 688). This apparatus may be worn at night, when the head- • "Pott's Disease," etc., N. M. Sbatler, M. D. (i. T. Putnam's Sons, New York, 1879. SPINA BIFIDA. ■11 stall of jury-mast is removed. la the worst class of cases it is advisable to employ the extension in bed until the symptoms of paralysis are relieved. Instead of the block and pulley, with weight, the extension may be made by elastic bands attached to the chin-and-occiput collar and the head of the bed, while, if necessary, fixation may be secured by elevating the head of the bed six or eight inches. The suspension-carriage of Dr. Meigs Case, which lifts from the axillfe, chin, and occiput (Fig. 689), is a valuable apparatus in the treatment of Pott's disease in tlie cervical and upper dorsal region. If the degree of elastic susi^ension from the chin and occiput which it affords during the waking hours is continued during sleep, by the method of extension in the recuml>ent posture above given, success would be achieved in the majority of cases. It is chiefiy objectionable by reason of its high price, which places it beyond the reach of many who can obtain the jury-mast. The successful management of Pott's disease depends not (mly upon a thorough practical knowledge of the construction and application of the mechanical apparatus required, but upon the careful and constant atten- tion of a competent surgeon during the entire time, from the incipiency of the spondylitis until several months have elapsed after consolidation is effected. The prevention of chafing and sores, the opening and drain- age of abscesses, the renewal or tightening of the apparatus, require just as much skill as in the diagnosis and first adjustment of the mechanism. As regards abscess in ostitis of the vertebral column, it may be said that incision and drainage are generally indicated, whether occurring on the back, in the way of the apparatus, or pointing near the groin (p.soas abscess). Fresh air, well-selected articles of food, and tonics, are essen- tial. In the severer cases, in wliich a myelitis is developed from compres- sion by the products of inflammation, potassium iodide, in full and contin- ued doses, is reconuneud- ed by Professor Gibney. In all cases where the re- cumbent posture is as- sumed, an effort should be made to keep the pa- tient on the back, with a pillow so arranged that the s])inal column is bent well backward, and the pressure on the bodies in this way partially relieved. The suspensory cradle of Reeves (Fig. 690) will accomplish this end more successfully. A splint or shell is made of gutta-percha or sole-leather, and molded accurately to the back, from the sacrum to the neck. With this held in position by a roller, the patient, while lying down, is supported by the swing, as shown in Fig. 690. Spina Bifida. — This condition results from a failure of development in the laminae and spines of one or more of the vertebrae. Through the opening left by this incomplete closure of the bony canal the membranes of the cord are protruded, forming a sac of variable size, which is dis- Fio. 690. — Reeres's suspensorr cradle. (.Vfter Reeves.) 712 ATFA'T-BOOK ON SURGERY. tended by the cerebro-spinal fluid. 'Hie cord itself may be wholly or in part Hjjread out, and roTni)rt'.ssed a,ii:ai:ist tlie saf. Spina bifida is met with most frequently in the lumbosacral re- gion, next in frequency in the neck, rarely elsewhere. One tissuie may exist l)elow and one above in the same child, though it is very rarely multiple. The tumor may vary in size from one inch to six or eight inches in the longest diameter, and may be sessile or pedunculated. It is elastic to tlie touch, and is usually covered by the integument, which is thinner than normal. In some instances the skin is wanting over the mass, the pro- truding dura mater forming the outside covering of the mass. The character of the swelling may be recognized by its congenital origin, its location in the median line of the back, almost always in the lumbo-sacral region, its smooth contour, elasticity, and chiefly by its variable size. It becomes larger and more tense during the act of crying, and liy pressure its contents may in part be forced back into the sjjinal cord and ventricles of the brain. Convulsive movements may follow too great and prolonged compression of the tumor. The prognosis is, as a rule, very unfavorable. Ulceration of the integument over the mass, fol- lowed by rupture of the sac, is apt to occur, usually ending in death. A recovery after this accident is rare, although such cases are reportt^l. Or the tumor may remain indelinitely in about the same condition as at birth. Paralysis, more or less complete, in the lower extremitie.s, is the rule. The palliative treatment of spina bifida consists in the application of moderate compression over the tumor, at the same time protecting the integument from all irritation and injury. This plan of treatment should be followed out for one or two years, unless more radical measures are indicated by the failure of this method to arrest or greatly retard the growth of the swelling. When the tumor is suddenly increased in size and tension, temporary benefit may be obtained by drawing off a small quantity of the fluid. From 3 j to 3 j may be withdrawn by the aspira- tor. The smallest needle should be employed, and the contents slowly evacuated. The quantity of fluid to be removed will vary with the size and tension of the tumor, and the effect produced by the asj)ii'ation. Two or three drachms w-ill usually suffice. The operation may be repeated as often as the symptoms demand. It is advisable to intr.jduce the needle through the side of the tumor rather than in the middle line. In sjjina bifida when the tumor is well pedunculated and the communication be- tween the sac and membranes of the cord is not large, a cure may be effected by the method of Morton, which consists in the injection of the following solution : iodine, grs. x ; iodide of potassium, grs. xxx ; glycer- ine, 3J. From §ss to 3J or more of the fluid is withdrawn from the sac, and from 3 ss. to 3 iij of the iodine solution injected, and the punct- ure covered with collodion. This operation may be repeated if necessary. \Vhen the communication between the sac and the spinal cord is wide, and the tumor is sessile, operative interference is not indicated. DEFORMITIES OF THE LOWER EXTREMITY. 713 DBFORMrriES OF THE LOWER EXTREMITY. The deformities of the lower extremity may be divided into those — ], of the coxo-femoral region; 2, of the shaft of the femur in its en- tirety ; 3, of the condyles ; 4, of the tibia and fibula ; 5, of the tarsus and metatarsus ; and, 6, of the phalanges. In this classification, distortions of the pehis, such as in malacosteon and rachitis, are excluded, since they concern the obstetrician rather than the surgeon. At the hip there may exist preternatural mobility, or partial or com- plete immobility with malposition. Preternatural mobility may be due to the following causes : Arrest of development in the bones which form the acetabulum ; congenital failure of development of the head of the femur, or atrophy of this portion ; to both of these conditions combined : abnormal length of the capsular ligament, and absence of the ligamen- tum teres. Immol)ility with malposition results from inflammation of the joint and anchylosis, with or without destructive ostitis and loss of substance. Contraction of the psoas and iliacus or other muscles about the hip which are not overcome before anchylosis ensues is the chief cause of deformity. Dislocation with failure at reduction always induces de- formity, and the same is true of fracture when not properly treated. In preternatural mobility at the hip-joint (congenital dislocation) the symjitoms are chiefly a peculiar rolling gait, or oscillation to right and left in the act of walking, especially when the deformity is bilateral. While standing erect, the trochanters will be closer to the iliac crest than normal, which condition can be acciirately determined by Nela- ton's or Bryant's test. In these cases the anterior convexity of the curve in the lumbar region is exaggerated, giving the patient a sway-back ap- pearance. If extension is made from the feet, while the trunk is fixed in the recumbent posture, the length of the patient will lie considerably increased over that measured in the erect position. Absence of the head of the femur may be determined liy palpation with outward rota- tion. Perforation of the acetabulum may also be made out by digital exploration per rectum. Treatment. — Locomotion in some cases may be much improved by persistent effort on the part of the patient to train the muscles to hold the femur well up in the acetabulum in the act of walking. In this man- ner the rolling character of gait may be in great part corrected. One im- portant indication in the treatment of these cases in children is to keep the head of the femur from too great pressure against the soft structures placed in the bottom of the cavity of the acetabulum. The double hip- sjilint of Dr. Sayre will accomplish the necessary extension, while locomo- tion may be effected by crutches, or Dr. Case's carriage. In anchylosis at the hip with malposition the thigh is generally flexed upon the abdomen and addiicted with outward rotation. "When destruc- tive osteo-arthritis has occurred the trochanter will be seen nearer to the 714 A TEXT-BOOK ON SURGERY. iliac crest than on the soiiml side, a condition which does not exist when the anchylosis is simply due to muscular contractions. On account of muscular riu:idity the exact condition of anchylo.sis can not usually be determined witlioiit ether nai'cosis. A certain degree of mobility is pi-esent as a rule. Treatmrnt. — "When the malposition is such that usefulness is im- paired, or comfort inteifered witli, an effort to relieve the deformity by operation is justifiable, jjrovided that all local inflammatory symptoms are absent and that the general condition of the patient is such that no risk is incurred liy the procedure. Under ordinary conditions the opera- tion is not attended with danger. In osteotomy at the hip for the relief of deformity three pi-ocednres may be entertained : Section of the neck of the femur, just above the great ti'ochanter (Adams, Fig. 691) ; the inter-trochanteric section of Sayre (Fig. 692) ; or the sub-trochanteric operation of Gant (Fig. 693). Fio. 691. — Adams's line of sec- tion. (After I'oore.) Fi(i fifl2. — Sayre's inter-troc-lian- teric line of section. Fig. 693. — Gant's sub-trochanteric line of section. (After I'oore. j The objections to Adams's line of section is that often, on account of dis- appeai'ance of the head and neck of the bone, it is impossible ; and, sec- ondly and chiefly, if disease has existed at the joint, this line of section is so near the old seat of osteo-arthritis that the process of inHammation may be re-established. In anchylosis, without osteoarthritis at the hip, it is to be preferred. In the vast majority of cases, (iant's .section — just at the lower portion of the lesser trochanter — is preferable. The ol)jects to be accomplished are, a section of the bone at this point at a light angle to the axis of the shaft, rotation of the femnr into its normal 2)osi- tion, and abduction. 8nh-frorhanteric Odeotomy at tJie Hip. — The patient is placed on the sound side, so that the femur to be divided is well exposed. The strict details of antisejisis should be carried out. The upper surface of the great trochanter is felt, and tlie femur grasped between the thumb and linger. Upon the outer portion of the SUB-TROCHANTERIC OSTEOTOMY AT THE HIP. 715 femur an incision is made, commencing about one incli below the most superior surface of tlie trochanter major, and extending downward about one inch and a half. Wlien the bone is exposed, the wound is held open by retractors, and the bluntest of Macewen's bone-chisels introduced flatwise with the incision until the bone is reached, when it is turned so that the cutting edge is across the axis of the femur. In a child twelve years old the lower portion of the lesser trochanter (the line of section) is about one and a half inch below the tip of the great trochanter. While the limb is steadied by an assistant, a few blows with the mallet drives the chisel through the outer rim, when a thinner chisel is inserted and the bone cut from one half to three fourths through. Grasp- ing the thigh near the knee with one hand, while the other steadies the part above the section, the remaining portion is readily fractured by carrying the thigh toward the median line. The wound is now thor- oughly irrigated and closed with catgut sutures, leaving a bone-drain out at the lower angle. A sublimate dressing is applied. The thigh is rotated slightly inward, abducted to about five degrees from the axis of the spine, and flexed on the ab- domen so that the axis of the femur Joins that of the body at an angle of fifteen de- grees (Fig. 694). If in the position of de- formity the thigh is abducted — a condition which rarely exists — the corrected jiosition should be that of adduction about five de- grees beyond the normal. The after-treat- ment is the same as for fracture at this point, namely, Buck's extension and Ham- ilton's long splint (page 3()4). In order to secure the necessary five de- grees of abduction, the padding to the splint should be made several inches thicker op- posite the acetabulum than at the knee, and the thigh and leg should be elevated upon pUIows enough to secure the fifteen degrees of flexion required. When consolidation occurs with the extremity in this position, locomotion is good and more comfort ex- perienced in the sitting posture than when the leg is jierfectly straight. At the end of four or five weeks the patient may be al- lowed to go about on crutches, and in eight or ten weeks to walk with- out them. The result to be achieved is osseous reunion at the point of fracture with the limb in the improved position. A false or new joint is not desirable. Esmarch's bandage is not essential in the performance of the operation, although it may be em])loyed if desired. The h;rmorrhage is usually slight, and a few catgut ligatures readily control all bleeding Fio. fi04.— ' jtropor position of the extremity alter sub-troohanteric os- teotomy. i^Altor I'oore.) 716 A TEXT-BOOK ON SURGERY. points. Tlie free incision advised is safer than to use the osteotome through a narrow wound. Forcible breaking up of adhesions or fracture at the joint is not permissible. Adams's section is made through an in- cision in the line advised for hip-joint exsection. Its center should cor- respond to a point just above the great trochanter. The chisel should be preferred to tlie saw in making the section, on account of the bone- dust and detritus left by this latter instrument. Sayre's line is half-way between Adams's and Gant's lines. The bone should be divided squarely across. The attempt to form an arti- licial balland-socket joint by nudving a concavity in the upper fragment, or rounding off the upper extremity of the lower fragment, is not justi- iiable, because it prolongs the operation, and is a])t to be followed by necrosis, with ultimate anchylosis. It is better to accomplish reunion at once. The deformities of the shaft of the femur are also congenital and acquired. An occasional congenital malformation is due to failure of development of this bone in its long axis. The femur may not be more than six inches in length, while the til)ia and til)ula are normal in devel- opment. As a consequence of rickets, the femur is occasionally curved outward, causing genu varum, or bow-legs, although, as will be seen later, the bones of the leg are chiefly involved in this defonnity. Shortening, with or without angular malposition, is sometimes seen after badly united fractures. For the relief of these deformities osteotomy and osteoplasis may be done when the deformity is sufficient to justify the operation. In oste- otomy the incision should be along the anterior and external aspect of the thigh farthest removed from the vessels. The only artery of im- portance here is the descending branch of the external circumflex. Oste- oclasis is not permissible unless the fracture can be effected by manual force. In recent and badly united fractures, and in rachitic subjects, this may be don(\ The osteotome is preferable to the osteoclast. In over- lapping fractures, with marked shortening (two to Ave inches), if the union is not angular, the deformity may be corrected and lateral spinal curvature oV)viated by a compensating high shoe. If for {esthetic reasons the patient insists upon it, a section may be taken from the sound femur and the ends brought together, as was done by Weir in one instance. The conditions which will justify this procedure are, however, rare. Occasionally overlapping and badly united fractures of the thigh will be met with in which the callus, which persists, is so extensive that operation at the seat of fracture is imi:)ossible. The deformities of the lower extremity of the femur are those of hypertrophy or elongation of one or the other condyle. The outer condyle is only exceptionally enlarged. The consideraticm of these pathological changes belongs properly to genu valgum and rariim. Genu Valgum. — When a normal subject stands erect, the inclination of the femur of each side is inward and toward its fellow, until the inter- nal condyles are almost in contact. In other words, by actual measure- ment in a descent of eighteen inches from the head to the condyloid GENU VALGUM. 717 extremity, a separation of seven inches between the acetabula is reduced to three and a half inches from obliquity is slightly increased in females, owing to the broad- er development of the pelvis. If the articular facets of both tibiae are brought firmly and evenly in contact with the con- dyles of the femur, it will be seen that the axis of the tibia is parallel with that of the spine. Any outward deviation of this i)arallelism of the tibia with the axis of the body con- stitutes the deformity known as fienib valgum, knock-knee, or in-knee (Fig. 695). Kudck-knee may occur on one or both sides, in both sexes and at all ages. In exceptional instances genu valgum may ex- center to center at the knee. This Fui C95. — Genu valiium — Knock-knee or in-knee. (Alter Poorc.) Fig. 698. — Genu valpum nnd varum in the same patient, in Mount Sinai Hospital. Fio. 097.— The sanae, after osteotomy of both femora. (,The author's case.) 1st on one side and varum on the other, as shown in Figs. 696 and 697. Knock-Jinee is usually acquired ; occasionally corir/rnital. It is most frequently seen in children and young adults suffering from an acquired 718 A TEXT-BOOK ON SURGERY. or hereditary dyscrasia. As to tlie causes, we must look chiefly to changes in the bones at or near tlie knee-joint. Any interference with the normal processes of nutrition and development in the bones will account for most cases of knock-knee, and the chief pathological condition is either that of rachitis, or one so closely allied to it that a distinction is difficult. The most classical osseous lesion in genu valgum is the enlargement of the internal condyle as compared to the external, and the resulting increase of the normal obliquity of the tibio-femoral articulation. This increased obliquity may be due to hy])ertrophy of the inner condyle ; or to hypertrophy of the inner half ()f the ujjper tibial epipiiysis ; to atrophy of the outer condyle, or atrophy of the outer half of the upper tibial epiphysis; to a combination of two or more of tliese conditions; to a curve of the femur (convexity inward) from rickets, and to a like curve of the tibia and fibula. There is no anatomical reason why the intei'ual condyle should enjoy a better nutrition ;uid gi'eater development than the outer. There is, however, a very good mechanical explanation in this, that by reason of the marked ol)liquity of the femoral axis and the perpendicular directi(m of the tibial shaft when the subject is standing erect, tlie line of gravity brings the greater weight upon the outer facet of the tibia and the cor- responding condyle of the femur. The distribution of this pressure equally over the entire articular surface belongs to the muscles control- ling this joint ; but owing to the excessive number and greater power in the adductor as compared to the abductor group, the internal obliquity is maintained and the pressure upon the outer articular surfaces increased. In the rachitic condition the bones are softened, and become distorted under pressure, and as a result of muscular action, while such deformi- ties are resisted by the normal bones. Knock-kuee from incurvation of the shaft of the os femoris alone is exceedingly rare. When not due to abnormal changes in the condyles, the cause of this defoi'mity will usually be found in rachitic disease of the tibia and fibula, in which these bones are bent inward at the middle or lower third. The principal changes in the soft parts are elongation of the internal lateral ligaments, and a contractured condition of the ))iceps and popliteus muscles. Symptoms. — The symptoms of knock-knee vary in different stages of the deformity. The approximation of the knees is a less noticeable feature than the divergence of the tibiae. With the lower extremities fully extended, and the knees in contact, it will be noticed that the inner malleoli are separated from a few inclies to a foot or more. When the lesion is due to changes in the inner condyle of the femur, it will be observed that, if the leg is flexed upon the thigh at an angle of 90°, the deformity is less apparent ; and if complete flexion is made in mild cases of in-knee, it will disappear altogether ; i. e., the tibia in extreme flexion will be parallel with the femur. The patella is displaced outward, and locomotion is more or less impaired. Pain is often present, from the unnatural strain upon the tissues, and fatigue with the slightest exertion is often noticed. GENU VALGUM. 719 The diagnosis rests upon the recognition of the symptoms just detailed, and the proiinosis is generally favoiable when judicious and persistent treatment is instituted. Constitutional remedies and mechanical appliances are indicated early in the disease, and opei-a- tive interference is justifiable when mechanical treatment can not effect a cure. The first indication is met in out-of-door life, good food, diversion, tonics, cod-liver oil, and the hyi)oph(jsphites of lime and soda. The mechanical treatment should be insisted upon in all cases of chil- dren in which the deformity is not exaggerated, and should be persisted in for several years, if necessary. Any mechan- ism which is applicable in this deformity must afford a fixed point, opposite to and on the ex- ternal aspect of the region of the knee-joint, from which constant traction may be made. The appa- ratus of Prof. Sayre (Fig. 698) will be found of great use in meeting the chief indications. It consists of a pelvic belt of steel, padded so as not to excoriate, and a bar of steel hinged at the knee, and passing down from the belt to the sole of the shoe, where it is fastened, as in the long hip-splint already described. Opposite each knee, and just above and be- low the joints — in order to distribute the press- ure over a wider area, and thus prevent chafing or excoriations — are padded belts or bands which surround the limb ; these are attached to the side-bars, and may be tightened at will in exer- cising the required traction to overcome the deformity. Elastic tension by means of rubber bands or webbing may also be utilized in this man- ner. The hinges at the knees allow the patient to bend these joints in walking and when it is desired to assume the sitting posture. The instrument should be worn during the waking hours, and at night it will be advisable to make extension from both legs by Buck's method. The cost of this apparatus places it beyond the reach of many patients, and in this class of cases renders early operative interference more jus- tifiable. Osteotomy of the femur for the correction of chronic cases of genu valgum is an operation practically free from danger, and yields excel- lent results. The section should be made above the joint, and away from it a sufficient distance to avoid all danger of entering the aiticula- tion or injuring the epiphysis. Linear section should be preferred, since it is simpler than cuneiform osteotomy, and is ecpud to the correction of all cases excepting those in v.hich there is extreme angularity at the seat of deformity. Such conditions rarely, if ever, occur in the femur. The older operations of Ogston, Reeves, Chiene, and IMacewen, which in- volved the joint, are practically discarded. They are objectionable in this, that they invade the joint and endanger the functions of this im- Fio. 608. — Sayre's apparatus for the correction of kuock-kiiee. (After Sayre.) 720 A TEXT-BOOK ON SURGERY. portant articulation.* Transverse section above the epiphyseal line, from the outside (MacCormac) or inner side (Macewen), should be prefei-red (Fig. 703). Jfaceicen^s Operation. — In this procedure it is intended to divide the femur at a right angle to its axis through two thirds to three fourths of its thickness, at a point well above the level of the lower epiphysis. In a child ten years old the line of section should be one and three quarter inch above the most dependent portion of the articular surface of the internal condyle, and in an adult two and a half inches. Strict antiseptic precautions should be taken. If Esmarch's bandage is a])]ilied as high as the mid- dle of the thigh, the wound will be kept dry and the operation greatly facilitated. I-i'lex the leg on the thigh and rotate the thigh outward so as to bring the inner aspect of the joint upward. Make an incision one inch long, following the dii-ection of the internal condyloid lidge. The center of this in- cision should be opposite the point of section above given. The internal sphenous vein and the anas- tomotica magna artery should be avoided, and the tubercle for the insertion of the tendon of the adductor magnus felt. As soon as the bone is reached the chisel is carried down to it, parallel with the incision, and immediately turned with its cutting edge at a right angle to the axis of the femur. The inner and anterior shell of compact tissue should be first divided, and when the posterior portion is cut through the osteotome should be directed to the front so that when struck with the mallet it wiU be carried away from the vessels. As soon as the bone is cut through two thirds of its thickness, the remaining piece may be fractured by grasping the limb above and below the section, and using the other hand for a fulcrum and the leg as a lever, which is caiTied outward. As soon as the bone snaps, the leg is handed to an assistant, who is directed to steady Fio. 703. — (J, MacCormnc's line. A, Macewen's line. * Figs. 699-702. (After Poore.) Fig. 699.— Ogston. Fig. 700.— Reeves. Fig. 701.— Chiene. Fio. 702.— Maeewen. GENU VARUM. 721 it by making strong extension. The wound should now be inigated with 1-3500 sublimate, a si)onge ai)plied as a compress, held in place by a roller, and the tourniquet removed. In live minutes, if no bleeding of impor- tance occurs, the sponge may be removed and a di-essing of iodoform and sublimate gauze ajiplied. The limb should be brought into the straight position by extension, and steadily held until a plaster-of-Paris bandage is put on and hardened. This dressing is allowed to remain for four or five weeks, as in simple fracture, when it is removed, and passive motion made at the joint. It is reapplied for a week longer, and then, as a rule, may be discontinued. MacCormac's procedure is practically the same as the above, with the exception that the section is made fi'om the outer side of the femur. Of these two operations the incision from the outer side (MacCoimac's) is preferable, for the reason that there are no vessels in the way. On the inner side the long saphenous vein and the anastomotica magna artery are endangered. Moreover, it does not matter from which side the bone proper is divided, as far as the correction of the defoi-mity is concerned. When the tibia and fibula are involved in the deformity, section of these bones may be required at the same or a sub- sequent operation. Oeiiu Varum. — In bow-leg, or outward curvature of the lower ex- tremity, one or both members may be involved. The bones of the leg are usually alone involved, although in some instances the femur may take part in the deformity (Fig. 704). The principal cause of bow-legs is rickets, the softened bones yielding to the weight of the body or to muscu- lar contractions. Genu varum is usu- ally met with in childhood, but may occur in adults who are rachitic. In treatment, the indications are the same as for knock-knee. The adjustment of any mechanical apparatus is, how- ever, more difficult. Splints should be adjusted to prevent further deform- ity, or the patient should be prevent- ■» ,. . , • 1 , e •{ ''0. T04. — Genu varum, or bow-legs. etl trom bringing the weight of the (After Pooie.) body upon the diseased bones. In the mean while every effort should be made to correct the dyscrasia. As long as the bones remain in the softened condition of rickets, oper- ative interference is not indicated. Osteotomy of the tibia and fibula at the point where the outward curve is most pronounced will, in the majority of instances, correct the deformity. In extreme cases it may be necessary to make sections at two or more points. If the feuuir is involved it should also be divided, although this complication will rarely be met with. The details of the operation and the after-treatment are practically the same as for genu valgum. Osteoclasis should be substituted for osteotomy only in those cases 46 722 A TEXT-BOOK ON SURGERY. in which the fracture may be accomplished with little force and with the hands of the operator. It is objectionable when performed with the osteoclast, for the reason that the soft tissues are bruised to an extent which does not occur in osteotomy. Moreover, the line of fracture can not be directed with the same accuracy as in cutting with the chisel. The necessity for the exclusion of air no longer exists in the use of std)- liniate irrigation and the antiseptic dressing. Ancliylosis at the Knee, with Malposition.— For the correctinn of tliis deformity osteotomy is at times performed. "When the degree of malposition is extreme, it may become necessary to divide the femur at a point from three to four inches above the most dependent portion of the articular surface of this bone. If after this section the limb can not be brought out straight, division of the tibia just below the tuberosity may be done. Exsection of the knee is, however, a preferable operation; and, since in modern practice the danger of this precedure is so greatly diminished, it is believed that the operation through the articulation will supersede section of the bone in continuity. Talipes. — Club-foot is a deformity in which there exists cither an abnormal relation between the bones of the foot to each other, or to the tibia and fibula. There are six simple and several compound forms of talipes. The simjile varieties are talipes equinus, calcaneus, varus, valgus, cavus, and ^plaiius. Among the compound forms are those of equino-valgus, equino-varus, calcaneo-valgus, calcaneo-varus, etc. In talipes equinus the heel is drawn up, and the weight of the body falls upon the plantar aspect of the metatarsus, the toes and phalanges ; the gastrocnemius and soleus are shortened, the tendo Achillis tense, and in extreme cases the heel can not be brought down to the ground. Fig. 705. Fio. roe. CongCDital talipes equinuR. (Aft*r Cliurchill.> Callosities are formed upon the sole of the foot along the metatarso- phalangeal line. When paralysis of the anterior muscles of the leg has taken place, the toes are turned under, as in Fig. 708. In this conditicm TALIPES. r23 there are atrophy and complete loss of power in the tibialis anticus, pero- neus tertius, extensor longus digitorum, and extensor pollicis muscles. Simple talipes equinns is not of very frequent occurrence, since it is Fig. VOr. Acquired talipes equinus. In Fig Fig. TOS. TOS there has ocpurrod complett paralysis of the extensor muscles. (Alter Churchill.) almost always complicated wdth inward rotation of the tarsus, or talipes equino-varus. Treatment. — "When complete paralysis has not occurred, and if taken early, talipes equinus, whether congenital or acquired, may be cured, or marked deformity prevented, by the institution of proper treatment. Section of the tendo Achillis is rarely necessary when the case has not been neglect- ed. The propriety of tenotomy can be determined by the degree of resistance met with in the effort to bring the sole of the foot to a right angle with the axis of the leg. If this can not be accomplished, or if, when the tarsus is firmly Hexed on the leg, pressure Tipon the sural muscles produces a painful and marked spasm (Sayre), tenotomy is indicated, especially in those patients who can not afford the long-continued expense of mechanical treatment, and who of neces- sity can not remain long in the hands of an experi- enced surgeon. In simple equinus the indications are to overcome the muscular contraction by artiticial ap- pliances, and to restore the normal tonicity and power to tlie anterior tibial group of miiscle. AVhen a child is born with taliiies equinus (and all forms of congenital club-foot sliould be treated from birth), deformity of the bones of the foot, and the too great stretching or elongation of the anterior muscles, may be prevented by the following sim])le means: Cut a ])iece of light board as wide as the sole, and a little longer than the foot, and cover it Fig. 709.— Bone-i of the loot of an adult with talipes equinus. (Aft- er Chance and Noble Smith.) 724 A TEXT-BOOK ON SURGERY, witli adhesive plaster in siu-h a way that the sticking surface is next to the skin. This is laid along the sole of the foot, to which it is fastened by adhesive stri])s, and a light bandage, leaving the end of tlie board to project a little beyond the toes. From the end of tlie board traction may be made by a strip of plaster carried njiward and fastened along tlie front of the leg near the knee, sufficient tension Ix-ing exercised to draw the foot into its natural position. Or, if deemed necessary, arti- ficial muscles (rubber tubing) may be attached from the tip of the board to insertions fastened near the knee on the antero-lateral aspects of the leg. Tlie apparatus must be carefully readjusted whenever it becomes loose or causes pain. AVhen the patient is able to walk, simple cases of e(piinus may be corrected by weaiing a stiff, solid, and well-constructed laced shoe, which will hold the instep well down and keep the sole of the foot in close contact with the sole of the shoe. The weight of the body, falling upon the anterior portion of the foot, will aid in carrying the heel to the ground with each step. In moi-e obstinate cases the Sayre shoe (Fig. 710) more nearly meets the mechanical indications than any other apparatus. When there is no inversion of the foot (varus), the lateral rub- ber muscle J G is unnecessary. In ordering this shoe it is advisable to send to the instrnment- maker the shoe at tlie time worn by the pa- tient, and with this the distance from the sole of the heel to the upper articular margin of the tibia, as well as the circumference of the leg at this point. To this may be added the measure- ments around the foot, at the bases of the toes, and around the malleoli. In all cases of talipes in walking children and adults, it is important that all excoriations be healed before any a])i)li- auce is adjusted. The idea must not, however, be entertained that the simple api)lication of the shoe, or any mechanical appliance, will correct the deformity. The after-treatment is a most important feature in these cases. Electrici- ty and massage are important adjuvants. The weaker galvanic current should be prefeiTed, the positive pole being placed along the track of the nerve which supplies the affected muscles, while the negative sponge is carried over the bellies of these muscles. The application should be made about twice each week, whUe massage should be employed twice daily. In those cases where tenotomy is deemed advisable, the operation is lierformed as follows : The patient being placed under the influence of an anaesthetic, the tarsus is Hexed forcibly upon the leg, in order to place the tendo Achillis and plantar fascia upon the stretch ; a slight puncture of the skin is then made, a little anterior to the tendon, and on the inner side of the leg, slightly above the malleolus ; this opening is now carried KlB •">ir,:. . ;,_ 710. — Sayre's rlul'-tbot shoo. (A:ter Suyre.) TALIPES CALCANEUS. 725 to the edge of the tendon by traction ui)()n the integument, and the tenotome introduced, with its flat surface toward the tendon. The ten- sion upon the tissues is now relaxed, and tlie edge of the knife turned toward the parts to be divided ; the tarsus is flexed strongly upon the leg, and the tendon again made tense, when the knife is pressed forward and outward through the tendon, which separates with a very audible snap. The thumb of the operator being placed over the tendon exter- nally, acts as a guide and support, preventing the blade from passing through the integument and causing an open wound, an accident which should be carefully avoided. As soon as the division of the tissues is effected, the blade of the knife should be withdrawn, flatwise, and the thumb of the operator slipped over the slight puncture, which is at once covered with one or two strips of adhesive plaster ; the plantar fascia can be divided in a similar manner, if desirable, the whole foot being then enveloped in cotton, and a snug roller bandage applied. The foot is now secured, by mechanical appliances, at a right angle to the leg, as hereto- fore described. Division of the extensor tendons of the toes is not often required. The best point of section is just over the metatarso-phalangeal articulation. Talipes Calcaneus. — In this rare form of club-foot the toes are drawTi upward and the tarsus flexed upon the tibia ; impairment of function exists in one or more of the sural muscles ; the tibialis anticus, pero- neus tertins, extensor longus digito- rum, and pollicis are shortened. This deformity may be either congenital Fill. 711. — CotiiTonital talipes calcaneus. (AltLT Churcliill.) Fig. T1'2. — Acquired talipes calcaneus. (Alter fhureliill.) or acquired (Figs. 71], 712). It is usually met with in children, or may occur at any period of life, from rupture of the tendo Achillis, or paral- ysis of the muscles of the calf of the leg, ununited fracture of the os calcis, etc. In this condition the mechanical and suigical appliances and treatment are exactly opposite to those of the preceding variety. An nnunited section of the tendo Achillis should be corrected by cutting down upon this tendon at the seat of the division, freshening the divided 726 A TEXT-BOOK ON SURGERY. ends, and sewing them together with .silk .sutures. Mild cases of calca- neus m:iy be relieved by the wearing of a well-lit ting, laced shoe, the weight of the body aiding in correcting the deformity. AVhen the toes can not be brought down without the aid of additional pressure, the ai)paratus in construction similar to the one recommended for flat-foot can be api)lied. Tlie object to be obtained is to elevate the lieel and depress the toes by mechanical means. For this purjiose, the shoe as devised by Dr. Sayre (Fig. 713) is admirably adapted. This is a strong, laced shoe, with steel rods running up on either side of the leg to a collar below the knee, the rods being hinged at the ankle to allow of free motion at this joint ; from the heel of the shoe a small steel spur is seen, to which is secured a strong piece of elastic, passing uj) to the collar around the leg. This rubber artificial muscle, taking the place of the gastrocnemius and soleus muscles, if made of sufficient tension, will elevate the heel and restore the foot to its normal position. There are, how- ever, various instruments for the correc- tion of this deformity, the surgeon modi- fying the shoe as may be required to suit each case. In addition to the mechani- cal appliances, the after-treatment, by electricity, massage, etc., should be car- Fia. 713. — Sayrf's shoe t'lr t.ilipcs calcaneus. (After Say re. J ried out as in otlier forms of club-foot where atrophy of the muscles and loss of power exist. Talipes Varus and Eqnino-Varus. — These deformities consist of an inward rotation of the foot, and are the most common forms of talipes (Figs. 714-717). The majority of cases are those in which spastic contraction of the sural muscles also occurs (equino-varus). Talipes varus and equino-varus are more often congenital, but are frequently acquired, one or both feet being in- volved. The degree of deformity varies from slight inversion of the foot Fio. 714. — Talipes cqnino-vanis in an adults (After Churchill.; talipp:s varus and EQUINO-VARUS. 7-27 to the most exaggerated form in which the sole looks upward, while in the act of walking the dorsum rests upon the ground. The changes which the structures of the foot undergo are shortening of the plantar fascia and the internal lateral ligaments, together with Fiij. 710. Three gnules of talipes varus. (Atler Cliurehill.) Fio. 717 a contractured condition of the tibialis anticus and. posticus muscles. This defoi-mity, therefoi-e, places those muscles and ligaments upon the stretch which are situated Tipon the outer aspect of the leg, and re- sults from complete or partial paralysis of the peronei muscles. The displacement of the bones of the tarsus will correspond to the extent of the deformity ; the astragalus being tilted downward, the scaphoid is displaced inward and downward by the action of the tibialis posti- cus, the tubercle on this bone becoming very prominent ; there is in addition marked rotation at the astragalo-scaphoid and oalcaneo-cuboid junctions, the displacement being especially marked in this last-named articulation. When the deformity exists at birth, if not corrected early, the bones will become ossified, and the deformity permanent. In these cases tar- sotomy and exsection are the only means of bringing the foot into its normal positicm. The ti'eatment of talipes equino-varus in the infant consists in the application of small rubber bands or ])ieces of tubing, which will make constant and gradual traction in the line of the weakened or jiaralyzed muscles. This [BarwelV s) method is as follows : Cut a piece of strong adhesive plaster into the shape of a fan, whicli is split into four or five strips converging toward the apex of the fan (Fig. 718). " The apex of the triangle is passed through a wire loop with a ring in the top (Pigs. 718, 719), brought back ujion itself, and secured by sewing. The plaster is firmly secured to the foot in such a manner that the wire eye shall be at a point where we wish to imitate the inser- tion of the muscle, and that it shall draw evenly on all ]iarts of the foot when the traction is applied. Secure this by other adhesive straps and a smoothly adjusted roller. 728 A TEXT-BOOK ON SURGERY. "The artificial origin of the muscle is made as follows : Cut a strip of tin or zinc plate, in length about two thirds that of the tibia, and in width one quarter the circumference of the limb (Fig. 720). This is shaped to tit the limb as well as can be done conveniently. About an Fid. T19.— (After Sayre.) Fio. 718.— (.-Vfter Sayre.) Fig. T20.— (After Sayre.) inch from the upper end fasten an eye of wire. Care should be taken not to have this too large, as it would not confine the rubber to a fixed point. The tin is secured upon the limb in the following manner : From stout (mole-skin) plaster cut two strips long enough to encircle the liml), and in the middle of each make two slits just large enough to admit the Fio. 721.— (From Bam-ell.) Fio. 722.— (From Barwoll.) tin, which will prevent any lateral motion ; then cut a strip of plaster, rather more than twice as long as the tin, and a little wider : apply this smoothly to the side of the leg on which the traction is to be made, beginning as high up as the tuberosity of the tibia. Lay upon it the tin, TALIPES VARUS AND EQUINO-VARUS. 729 placing the upper end level with that of the plaster (Fig. 721). Secure this by passing the two strips above mentioned around the limb (Fig. 722), then turn the vertical strip of plaster upward upon the tin. A slit should be made in the plaster where it passes over the eye, in order that the latter may protrude. The I'oller should then be continued smoothly up the limb to the top of the tin. The plaster is again ^ reversed and brought down over the bandage, another slit being Q made for the eye, and the whole secured by a few turns of the fig. 723. roller. A small chain, a few inches in length, containing a dozen or twenty links for gi'aduating the adjustment, is then secured to the eye in the tin. "Into either end of a piece of ordinary India-rubber tubing, about one quarter of an inch in diameter and two to six inches in length, hooks of the pattern shown in Fig. 723 are fastened by a wire or other strong ligature. One hook (Fig. 722) is fast- ened to the wire loop on the plaster on the foot, and the other "^ to the chain above mentioned, the various links making the fig. T24. necessary changes in the adjustment. "The dressing, when complete, is shown in Fig. 722." (Sayre.) A roller should now be carefully and smoothly applied over the plas- ter and between the leg and the artificial muscles. When the muscles can not be obtained, and in mild cases, in which the foot may be brought readily into position, a correction may be effected by means of one or more strips of adhesive plaster as follows : One end of the strip is laid upon the dorsum of the foot, near the bases of the third and fourth toes, whence it is carried in a slightly spiral direction to the inner border of the sole, and across the sole to the outer margin of the foot. As the foot is now brought into a normal position by the hand of the operator, the strip of plaster is laid along the outer and anterior aspect of the leg and thigh, and firmly secured by encii-cling strips of the same material. A bandage over all will hold the dressing in position. When the patient is able to walk, the club-foot shoe (Fig. 710) will give the greatest satisfaction. The rub- ber muscles should be applied and regulated in such a way that they will imitate as nearly as possible the nor- mal action of the muscles they are intended to assist. A less expensive instrument, one which yields good results in the mUder forms of talipes eipiino-varus, and which may be readily made by any ordinary worker in iron, is shown in Fig. 725. It consists of a sole-jnece of sheet-iron, which is riveted to a heel-piece of the same material, and is roomy enough to hold the heel of the patient without chafing. It should be nicely padded, Fio. 725.— Iron shoe to prevent the danger of excoriations. To tliis heel- ami equmo-va'r'ii! piece is attached, by a hinge-joint with limited forward and backward motion, an iron bar which extends to the padded iron collar around the leg, near the knee. The foot of the pa- tient is secured to the sole-piece by adhesive plaster, with the aid of the 730 A TEXT-BOOK ON SURGERY. instep-strap shown in Fig. 720, and a flannel roller carried over all. As the perpendicular bar is now carried parallel with the leg, and held in this position by buckling the collar around the leg at tlie knee, the foot is turned outward and held in its normal position. An ordi- nary lacing-shoe should be ■worn over the brace. Outer view. Inner view. Fio. 727. — Reeves's universal shoe, as it is being applied in the treatment of talipes equino-varus. (.\fter Keeves.) Fio. 726. — Iron shoe tor talipes vanis and equino-varus in position. Tlie adJie- aive strips and bandage have been omitted in the cut. An apparatus, the mech- anism of which is some- what similar to tliis, is high- ly recommended by Mr. Reeves, and is shown in Fig. 727. The mollification of Scar- pa's shoe (Fig. 728) possess- es some advantages over the iron shoe above described, and should be preferred to it when it car) be obtained. Tenotoimj ^nii fasciotomy will be found necessary in a large proi)or- tion of cases of talipes equino-varus, and, when not es.sential to ultimate success, it will greatly expedite the permanent restoration of the mem ber to its normal i)osition. The application of Esmarcirs bandage from the toes to above the knee, though not essential, renders the ojjei'atix e procedure more rapid and easy of execution. The tendo Achillis is divided as heretofore directed. In addition, the til)ialis anticus and the til)ialis posticus will, as a rule, require to be divided. The tendon of the tibialis anticus should be cut sul)cutaneously about one inch above its insertion into the internal cuneiform bone by introducing the tenotome beneath it from the middle line of the foot. It can be made prominent by forcible eversion of the foot. Division of the tendon of the tibialis Fig. 728. — Modified Scarpa's slioe for talipes varus and equiii"- varui. (Alter Keevcs.) TALIPES VARUS AND EQUINO-VARUS. 731 posticus is best effected by an incision parallel with the inner border of the tibia just above the internal malleolus, wliere it lies in close relation to this surface of tiie bone. As soon as it is exposed, an aneurism-needle should be passed beneath it, v/hen it can be drawn out tlirough the wound and divided ^yith the scissors. Subcutaneous section of this tendon is a very difficult and uncertain procedure, while no mistake is possible through au open wound. If careful antisepsis is practiced, and if the wound is at once closed with catgut sutures, no suppuration can occur. The plantar fascia should be divided by introducing the tenotome flat- wise under the fascia from the inner border of the foot, turning the edge outward, and cutting the fascia as it is made tense. Several lines of section through this fascia may be made when necessary. Bits of adhe- sive plaster should be j^laced over each puncture. Tarsotomy. — In exaggerated auil chronic cases of congenital talipes eqnino-varus, a wedge-shaped exsection of a portion of the tarsus will at times permit a restoraticju of the foot to its normal position, and serve to restore in great part the usefulness of the member. In two recent cases in which I performed this operation, the most gratifying results were obtained. In each case the patient walked with the dorsum of the foot on the floor, and, in one instance, the toes pointed directly back- ward. After Esmarch's bandage has been applied, a free incision is made along the fibular side of the foot, extending from below the external malleolus to the tarso-metatarsal junction. All the tissues should be lifted from the bones by the periosteal elevator, and the wedge-shaped section of the tarsus removed by the gouge or chisel. The anterior por- tion of the astragalus wUl require to be removed, and as much of the tarsus should be exsected as is needed to permit the restoration of the foot to the natural position ; for it is not only neces.sary to evert the foot, but to make at the same time a marked rotation of that part of the member anterior to the line of section. The tendo Achillis should now be divided, and, as soon as the proper position is obtained, the wound should be irrigated with sublimate solution, the incision closed and covered with iodoformized gauze, and a light sublimate dressing and compression-bandage applied tight enough to arrest all oozing. A plaster-of-Paris dressing is now put on, and the foot held in position until this hardens. This last procedure can be facilitated by adjusting two strips of adhesive plaster, one of which will serve to hold the foot at a right angle to the axis of the leg, and the other to keep it rotated outward while the plnstiH- is being a]iplied and is hardening. The dress- ing may be removed not earlier than the tifteenth day, and should not be disturbed for a month unless from soiling or smelling it is necessi- tated. Talipes Valgus.— \\\ this deformity the normal arch of the foot is lost, and the foot is everted (Figs. 729, 730, 731, 732). The contracted muscles are the ]ieroneus longus and brevis, while the i>aralysi.s, as a rule, affects the tibialis posticus, anticus, and flexor muscles. When the tarsal arch gi\es way, the plantar fascia, calcaneocuboid ligaments, and 732 A TEXT-1500K ON SURGERY. short flexors become stretched, and the tibialis anticiis is elongated. The yielding of these nauscles may be due to paralysis, or to strain from the habit of carrying heavy -weights. Flo. 729. — Conjenital t.alipes valgus. (After Churohill.j Fio. 730. — Acquired talipes valgus. (After Churchill.) Fig. 7.31. — Inner view of a severe v.ilffus of tlie right fint. (.\fter Reeves.) ], Inner malleolu.s. i. Inner surface of head of astragalus. 3, Tubercle of scaphoid. Treatment. — Tn talij)es val- gus in an infant the eversion may be corrected by means of the adhesive strips applied as in the ti'eatment of varus. The direction of traction is of course opposite. The artificial muscles, after the method of Barwell, are also as applicable here as in varus. The iron shoe (Fig. 725), made with the bar to come upon the inner side of the leg, is as service- able in mild cases of valgus as in varus or equino- varus. This apparatus is always worn in- side of an ordinary shoe. Ny- rop's boot (Fig. 733) is highly recommended by Mr. Reeves. It consists of a stiff-soled lacing- shoe, with a leg-collar and iron or steel bar attached to the outer side of the shoe, with a lateral hinge opposite the out- er malleolus. To the inner side of the sole, near the heel, is attached a strong piece of elastic webbing, l)y which inversion of the foot is effected by buckling the strap to the collar near the knee. Flo. 732. — Inner view of the bones of a severe valgus. l'.\ttcr Reeves. I 1, Tubercle of smiphoid. 2, Astrag- alus. 3, Os calcis. 4, Internal cuneiform bone. 0, First metatarsal. TALIPES CAVUS.— TALIPES PLANUS. 733 'V\Tieii tenotomy of the peronei muscles is indicated, they should be divided subcutaneously from three quarters to one and a half inch (ovping to the age of the ijatient) above the external malleolus. Cuneiform tar- sotomy may be ajiplied to the correction of this de- formity in exaggerated cases in adults. When the bones are thoroughly ossified it will be impossible to change the shape of these organs and restore the normal shai:)e of the part by any mechanical appa- ratus, no matter how persistent in its use. The in- cision is made along the inner side of the foot, and the apex of the conical section must be at the outer border of the tarsus. The details of the operation and the after-treatment are practically the same as given for equino-varus. Talipes CavKS. — Hollow-foot is almost always an acquired deformity, although it may be congenital. It occurs with talipes calcaneus, equinus, and, in a fic. 733.— Nyrop-s shoe mild degree, may complicate varus and equino-varus. (After''Eecves T"'^'"*' In this deformity the antero-posterior arch of the foot is exaggerated, the plantar fascia and the muscles of the plantai' region which have their origin behind the medio-tarsal joint, and are inserted anterior to this articula- tion, are shortened. The plantar fascia '• '^ and the calcaneo- cuboid ligaments are >, ' also shortened. The sole of the foot -_ — -* no longer rests upon the floor, as in the Fio. T34.-Showine the surface of the sole normal Condition (Fig. 734), but touch- fooi''\Aft'erTyrelr "°°'" "'" °°™''' es Only at the heel and along the meta- tarso-phalangeal line. Any inflammatory process of the plantar region may induce contrac- tion of the fascia or ligaments ; or spastic contraction of the muscles of this region from local or remote causes may produce this deformity. Com- mencing before the bones are softened, the distortion of the foot is apt to become i^ermanent unless exsection or crushing is perfomied. Of these two procedures, tarsoclasis is the most readily accomplished ; but, when the tarsoclast can not be had, section through the tarsus, with a thorough division of the plantar fascia, will be justifiable. For- tunately, few instances will occur where such harsh procedures will be called for. In recent cases the deformity may be relieved by wearing a plain shoe with a low, broad heel and straight, thick sole. The plantar fascia should be divided in all cases which do not readily j'ield to mechanical treatment. Tal'qjes Planns. — Flat-foot has been partially considered with talipes valgus, with which condition it is almost always associated. The antero- posterior arch of the foot is more or less obliterated, and in severe cases the anterior portion of the sole spreads out or widens in its transverse diameter (Fig. 73j). 734 A TEXT-BOOK ON SURGERY. Fio. 735.— Cast of the r'yiit foot in case of talipes planus, at tbe Poly clmlc. The plantar fascia and calcaneo-cuboid ligaments are stretched, the internal lateral ligaments of the ankle-joint are generally involved, while the tibialis anticus and the antero-jjosterior muscles of the jtlantar as- pect of the foot are elongated. Tlie jirinci- pal cause of this deformity is the habitual carrying of heavy burdens, or }iressure of tile superincumbent weight of the body upon the arch of the foot, together with lack of tonicity in the muscles, and of strength in the ligaments and fascia. Treatment. — It is exceedingly difficult and in the majority of cases im])ossib]e to con-ect this deformity. The best method is to support the arch of the foot by a comfortable adjustment of pressure by inserting a piece of felt in the sole of the shoe, just beneath the arch. The deformities of the toes are congenital and acquired. The con- genital deviations from tlie normal are the presence of one or more su- pernumerary toes {polydactylus)^ or the absence of one or more of these members {si/ndactylus). In polydadytus the most frequent supernumerary toe is one connected with the great-toe, attached usually on its inner or tibial aspect, near the junction of the metatarsal bone and phalanx. In a rare case of this de- formity, reported by Prof. Sayre, there were eight toes on the right and ten on the left foot. Treatment.— AW minor deformities the removal of which does not endanger the life of the individual, or diminish the usefulness of tlie member affected, demand amputation within the first year or two of life, before the patient is old enougli to become conscious of possessing a de- formity. Syndactylus is a term applied not only to the partial or entire ab- sence of one or more fingers, but also to the condition known as congen- ital iceb-toe. Web-toes may be treated in tlie same way as web-fingers. If neglected until the child is old enough to become accustomed to the deformity, operation is of doubtful proj^riety. When one or more toes are missing, as in Fig. 736, even when the deformity is offensive to the sight, the question of operative interference (except for relief from pain) should depend upon the de- gree of usefulness enjoyed by the deformed mem- ber. An important principle in the surgery of the foot is to save every particle of surface for the sup- port of the body. This conclusion gains additional force in the ability to conceal the deformity by a properly constructed shoe. The acquired deformities of the toes result in almost all cases from improperly adjusted shoes. The displacement may be in all directions, although those of the great and little toes are usually toward the median Fig. Vol). — S.yiidactylus in the right foot of a boy. (After Reeves.) HALLUX VALGUS. 735 line of the foot. The middle toes may be flexed in one joint, extended in another, or crossed over each other. Hallux valgus, or displacement of the great-toe toward the hbular or outer side of the foot, is a common deformitj^ (Fig- 738). In exagger- ated instances mechanical or surgical interference is demanded. Hallux valgus is caused chiefly by shoes which are i)ointed at the tip and are too short for the foot. It may also occur with club-foot, and generally with talipes varus and planixs. The action of the muscles inserted into the base of the great-toe must not be altogether overlooked in the jetiology of this deformity. Of the tive muscles which arise from the tarsus and metatarsus and ai-e inserted into this toe, all but one tend to cany it to- ward the fibular side of the foot. In being displaced, the great-toe usually is carried above the second or third toe, occasicmally beneath it. The phalanx is more or less com- pletely dislocated from the original articular surface of the metatarsal bone, being twisted around to its outer lateral aspect. The cartilage of the old portion disappears, and a new joint-surface is developed on the external aspect of the metatarsal bone. From pressure, a callosity of varying thickness develops over the tip of the metacarpus, adding greatly to the appearance of deformity. Treatment. — Mild cases of hallux valgus may be cured by elastic ten- sion steadily applied, as follows : A soft kid or chamois-skin cover is made for the affected toe, and to the end of this a piece of thin elastic webbing is at- tached. To the webbing a strip of adhesive plaster is stitched, and this is earned around the heel and is made to adhere along the Fig. VST. — Savro's aietlind of treating liallux vaigiis. (At\er Sayrc.) Fig. 738.— Hallux valgus. (From a patient at Mount Sinai Hospital.) Fio. 739.— The same, alter operation. outer side of the foot in such a way that the webbing is made to draw the toe outward (Fig. 737). In severe ca.ses, operative interference can alone restore the toe to its normal position. The operation consists in an incision made along the inner side of the foot, the center of which is over the angular projection at the end of the metatarsal bone. The callosity should be removed, the Joint opened, a wedge-shaped segment removed from the end of the metatarsal bone and tlie phalanx. Enough should be removed with the oxsector or metacarjial saw to permit the bones to be brought into jiroper 736 A TKXT-BOOK ON SURGERY. position, where they should be lield by a silver-wire suture passed welll into tlie bon(^ a liiilf-iiich from the cut surface; or the bones ni:iy be held in apijosition by transhxion Avitli small steed drills. Fi<;. 738 is from a cast taken from a jiatient at Mount Sinai Hospital upon wlumi I did this operation in both feet. The degree of cori'ection is shown in Fig. 730. This operation is preferable to that of osteotomy of the lii-st metatar- sal bone just behind the articulation, for the reason that the callosity and projection ojtposite the joint can only be removed by excision. Hallux rants, or pigeon-toe, is a much rarer deformity, and occurs usually as a result of cicatricial contractions or from sjjastic action of the abductor-pollicis muscle. The treatment consists in adjusting a well- made shoe which will push the toe into its proper position. Division of any cicatricial tissue or the tendon of the abductor muscle may be necessary. Disphicemi'id of the little toe is usually inward and beneath the fourth. The same treatment may be ap^tlied in this deformity as given for hallux valgus. Flexion of the toes may be com])lete when there is ]iaralysis of the extensor muscles. The most usual form is that in which the lirst phalanx is tilted upward, that is, seemingly extended, while the distal phalanx is drawn downward, so that the nail is to the front, and the tij) of the toes rests upon the ground. This condition is also known as Jiainiaer-toes. The cause is chiefly one of improper shoeing, by which the toes are not allowed to be fully extended, and, being held in this cramped position by the shoe, the muscles and fascia) b-ecome permanently shortened. The plantar fascia is usually involved in chronic cases. The extensor mus- cles become shortened as well as the flexors, which are, however, tlie principal agents in producing the deformity. Extension of the toes beyond the normal line is a rare condition. It could only be caused by paralysis of the flexors. Treatment. — In mild cases of incipient hammer-toes a cure may be effected by wearing a shoe long enough to allow these nu'ml)ei-s to be extended. In more chronic and obstinate cases, a metal sole should be adjusted so that an ordi- nary shoe can be worn over it. Just beneath the middle of the toes is a series of perforations in the sole, through which loops are ])assed. The toes are straightened by traction on the loops, which are tied below (Fig. 740). In some in- FiG. 740.— Aiipuratiis for hum- . , , r ^^ -x a i ^ mer-toe3. (.\rter Keeves.) stauces tenotomy of the long flexor and extensor muscles and of the plantar fascia is essential. The tendons of the extensor digltorum should be subcutaneously divided just over the bases of the toes ; the flexor tendons near the middle of the j)lantar surface of these members. Bunions are callosities resulting from intermittent pressure upon cer- tain portions of the foot. Corns are both hard and soft. A hard corn differs from a bunion only in size. Soft corns are small ulcers situated between the toes or in IN-GROWING NAIL. 737 the fissures on the under surface. They are caused by friction of opposing surfaces and moisture. Bunions and hard corns are to be treated by relieving the unnatural pressure which caused them. Comfortably fitting, yet not necessarily loose shoes, of soft leather, should be worn. Pieces of Canton flannel, cut into rings and laid uj^on each other so that the pressure will be dis- tributed to the surfaces near the corn, will be advisable, in simple cases, even when loose shoes are adopted. A small tuft of cotton dipped in vaseline will aid in softening the hard covering. Soft corns may be readily cured by inserting jiellets of absorbent cotton moistened with borax dissolved in glycerine, and applied so as to protect the raw sur- faces and prevent friction. In-growing nail is one of the commonest affections of the feet, and is almost always met with in the great toe. The palliative treatment is to cut away portions of tlie nail near the infiamed surface and protect this by a small pellet of lint mcdstened in the borax and glycerine mixture. The employment of cocaine, however, enables the surgeon to remove the offending nail without a particle of pain, and in this way a pennanent and radical cure is readily effected. I have performed this operation repeatedly after the foUovdng method : The foot and toes should be cleansed and thoroughly disinfected. An elastic ligature should be thrown around the toe, as close to the metatarsal junction as possible. The anaesthesia is effected by introducing the hypodermic needle of the cocaine-syringe beneatli the skiu on the dorsum of the toe, half an inch behind the nearest surface of the nail — i. e., just about the posterior bor- der of the matrix. Three or four drops of a 4-per-cent solution are forced out here and the needle pushed under the skin, to right and left, until from fifteen to twenty minims have been injected across the toe and on either side of the nail toward the tip. of the toe. The line of this injec- tion is in the shape of a horseshoe. The needle should now be removed, and reinserted through the anaesthetized skin, and carried thence subcu- taneously until the anaesthesia is complete at all points around the nail. Forty minims of a 4-per-cent solution may be employed. In from three to five minutes insensibility is perfect. An incision is first made from the middle of the posterior margin of the nail directly backward for half an inch. A second incision across the top of the toe, extending as low down as the most inferior portion of the nail, on either side, uniting the perpendicular cut, gives the entire wound a T-shape. The two quadri- lateral flaps f)f skin are now dissected up, turned one to the right and one to the left side, and held away by the weight of an artery-forceps or by retractors. The nail should next be split from before backward in the middle line, the incision extending through the matrix as far back as the transverse incision through the skin. Botli halves and the matrix should be thoroughly extirpated, all granulation-tissue scraped out, and the foot dipped into a basin of warm sublimate solution, 1-2000. At this juncture tlie ehistic tourniquet should be removed, and the wound allowed to bleed for a minute. By this means the excess of cocaine solu- tion is washed out of the tissues. The ligature should then be reapplied. 47 738 A TEXT-BOOK ON SURGHRY. The flaps arc now brought info ])()siti()n, the spac(f foriiH ily occupied by the horny i)art of the nail paclvecl with sublimate f^auzp, and the entire toe enveloped in the same material. A narrow bandage should be applied finnly enough to hold the gauze in place, and to exercise sufficient com- pression to prevent bleeding. Over this a generous jiiece of jjrotective should be thrown and a second bandage applied. When, in applying this bandage, the elastic ligature is reached, it should be tako/fta/ when the connective tissue is excessive, fibro-llpoma ; in bone, osteo-lipoma ; when very vascular, angelo-lipoma, etc. Lipomata may undergo granular and calcareous metamorphosis, and may also become intiamed and break down as a very olfensive and slough- ing mass. They are altogether benign, and can only cause death by ulceration, sepsis, and haemorrhage, or by pressure upon important or- gans. The diagnosis depends upon the soft, uneven feel and the mobility of the mass. It is only to be differentiated from old abscesses or cystic tu- mors. If the history does not point to the diagnosis, the aspirator-needle will be of service. The ti-eatment is removal with the knife. The incision may be straight for a small tumor, but should be elliptical for large growths, in order to do away with redundancy after the tumor is turned out. The capsuln FIBROMA.— :MYX0MA. 761 should be opened, and the tumor may be turned out almost wholly with the fingers. Fibroma. — This variety of neojilasm is made up of fibrous tissue, the filaments of which are at times arranged in bundles which run in all directions ; at others, there is little or no fascicular arrangement, the fila- ments being entangled in all directions. In the interstices of the bundles, or between the fasciculi, are found connective-tissue cells, the poles of which communicate with each other. The vascular sui^ply is limited. Fibromata develop chiefly in the skin and subcutaneous tissues and peri- osteum, but may exist in any other portion of the body. They are usually single and small, occasionally multiple, and this form of tumor may attain an enormous size. In steipe, those developing fi'om the deeper tissues are spherical, and are hard to the touch. In the skin they are often pedunculated and pyriform. Fibromata may undergo a mucoid, granular, or calcareous degeneration, and are subject to inflammation and suppu- ration, as are other neoplasms. Not possessing a high degree of vascu- larity, the danger of hemorrhage is not great, unless a rich granulation- tissue has sprung up as a result of prolonged irritation. tiimple fibroma is benign, and the indications in treatment are removal by the knife. Myxoma. — This neoplasm is made up of primitive connective-tis.sTie cells, similar to those observed in the umbilical cord at birth. The cell- elements are spherical and fusifoi-m in shape. The former are isolated and float freely in the gelatinous-like intercellular substance. The latter may possess two or more poles, and anastomose freely with each other, forming a continuous network or stroma throughout the mass. The vascular supply is rich. These neoplasms occur, as a rule, in the skin and subcutaneous tissues and upon the mucous surfaces, especially in the nose (mucous or soft polypi). They may develop, however, in any portion of the body, and have been observed in the muscles, bones, and nerves, the mammary gland, kidney, brain, etc. In shape, they are iisually spherical, of small size, and are soft and doughy to the touch, and not painful unless by accident the sensory nerves are pressed upon by the tumor. As a result of rupture of the blood-vessels, cysts fre- quently occur in this variety of neoplasm. The treatment is early and complete removal. Pure myxoma does not tend to recur after a tliorough removal. In some instances, owing to the peculiar location of the neoplasm, a thorough extirj)ation is impos- sible, and in these cases the tumor may rapidly recur. The cases of gen- eral metastasis after supposed myxoma were probably instances in which the sarcomatous nature of the growth had been overlooked. Myoma is a tumor composed of new -formed muscular elements. There are two varieties, namely, those composed of striated or voluntary, and those of non-striated or involuntary muscular flbers. The flrst variety are extremely rare, and are of less clinical importance than the nou-sti'iated myoma. In two instances the striated myoma has been seen in a congenital tumor of the testicle, and in a few other instances of tumors developed 762 A 'rEXT-r>OOK ON SURGERY. wliolly or in part in the embrj'o or foetus. Dermoid cysts at times con- tain traces of .striated niiisclo. A diat/JioNi.s- can only be made out by the reco), 1(1. for tlie abdomen and thorax, 10. for the breast, 16, 17. for the head and face, 17, 18, 19, 20. knotted, 18. for the eye, 18, 19. four-tail, 19, 20. Bands constricting the intestine, 487. Banks, Dr. E. A. L'rethi'otiimy and mcatoniy. 622. Banks's method of dilatation of stricture with conical filiform, 026. Barlow on syphilitic arteritis, 179-183. Barton's fracture, 295. Barwell, Richard. Club-foot, 727, 728. Operation for removal of vascular tumors, 189. O.x-aorta ligatures, 206. Ligation of carotid and subclavian, 211, 213. Ligation of carotid, 212. Basilar artery, occlusion of, 178. Bayer. Ligatif)n of subclavian, 220. Beall, Dr. K. .1. Hernia cei-ebri, 375. Bickersteth. Ligation of iimominate, 219. Biesiadecki. The initial lesion of syphilis. 178. Bigelow on hip-joint dislocations, 333, 334, 335, 336. Rapid lithotrity. 586. Bilharzia ha>matobia, 508, .580. Biliary calculi in the intestine, 48.3. Billroth. Venous varis, 195. Removal of the tongue, 440, 441. Bladder, 503. INDEX. 769 Bladder, wounds of, 5G5. ni[)tiire of, 566. Iiaralysis of, 570. aspiration of, 573. punctvire of, 573. new ionnation of, 574. stone in, 580. foreign bodies in, 597. Blepharitis, 385. Blood-letting, 56, 57. Bone-drains, Neuber's, 7. Bones, snrgery of, 371. of the tarsus, dislocations of the, ■'541. Borated cotton. 8. Bow- legs, 731. Brachial artery, ligation of, 257. Brain, penetrating wounds of, 377. Brasdor"s operation for aneurism, 202, 303, 305. Braune, Prof. Frozen sections, 134. Breast, lesions of, 465. ampiitation of, 472. Breschet. Arterial varix, 187. Briddon's double tourniquet, 304. Broad ligaments, G86. Broca. Operation for cirsoid aneurism, 189. for innominate aneurism, 314. Bronchi, foreign bodies in the, 453. Bronchocele, 446. Bruns's amputation, 141, 142. Bryant, Mr. Thomas. Ligation of carotid artery, 312. Ligation of subclavian, 214. Reduction of dislocation of the humerus, 335. Femoral hernia, 493. Bubanoff. Process of occlusion of arteries after deligation, 185. Buck, Dr. Gurdon. Extension in fracture of the thigh, 304, 307. Bull, Dr. W. T. Ligation of innominate artery, 219. Bunions, 73G. Burns, 90. ISutcher. Ligation of carotid and subclavian arteries, 314. Butlin. Diagnosis of epithelioma of tongue, 4:37. lUizzard on syphilitic arteries, 179, 18.'i. Calcaneo-astragaloid disarticulation, 135. Calcification of arteries, 176, 177. Calculi, biliary, 483. of the [irostatc, ()07. of the bladder, 580. of the kidney, 558. Callaway on diagnosis of dislocation jt the shoul- der-joint, 333. Callisen's operation for colostomy, j15. Cancer, 747. Capillary cutaneous tumors, 191. Ca])illaries. new formation of. in inflammation. 66. 67. 49 Carbolic-acid solutions, 3, 4. CarboHzed gauze, 8. Carbuncle, 94, 95. Carcinoma, 747. of the kidney, 560. of the prostate, 606. of the |)enis, 035. Carden's amputation, 148. Carpus, fi'acturcs of, 298. Case, Dr. Meigs. Treat mcnt of Pott's disease, 703, 710. Catgut ligatures, 1,2. sutures, 1, 2. drains, 7, 8. Cerebral localization, 378, 380. Championniere. Cerebral localization, 380, 381. Cheiloplasty of upper lip, 41(i. of lower lip, 417. Chest, wounds of, 475. Chiene. Osteotomy for knock-knee, 719, 730. Chloridc-of-zinc solution, 4. Chloroform narcosis, 24, 33. Cholesterin crystals in pus, 60. Chondroma, 764. of finger, 745. Chopart's operation, 135, 143. Chnimic-acid catgut, 3. Cicatricial tissue, 07. Circumcision, 639. Cirsoid arterial tumor, 186, 187. Clavicle, fracture of, 287. dislocation of, 320. cxsection of, 474. Cleft-palate, 432. Club-foot, 722. Club-hand. 740. Coagulation-necrosis, 176. Cocaine ana?sthesia, 31, 22, 23. ('occyx. fracture of, 300. Cold as a haMiiostatic, 70. local use of, in inflammation. 58, 59. as an antesthetic, 23. CoUes's operation for hare-lip, 414. ligation of subclavian artery, 220. fracture, 295, 296. law. 660. Colloid cancer, 748. Colostomy, 514. Comnum carotid artery, aneurism of. 216. ligation of, 233. Common iliac artery, ancui'ism of, 360. ligation of. 260, 261. Compinind fractures i)f leg, 315.316. Compression, in inflammation. 57. Condylomata of syphilis, 648. Congenital inguinal hernia, 496. Conheim. Calcification of arteries. 170. Conjunctivitis, 385, 386. Constriction of the intestine by bands, 487. by diverticula, 488. 770 A TEXT-BOOK OX SURGERY. Cooper, A. Reduction of dislociition at tlie elbow-joint, ii'2S. Lijiation of aorta, 225. Cootc, Holmes. Serous cysts with angiomata, 143. Coracoid process, fracture of, 288. Cornil and Kanvier. Tubercular ostitis, 699. Permanent occlusion of arteries after deliga- tion, 185. Formation of angiomata, 192. Venous varis, 195, 190. Phlebitis, l(i3, 104. Histology of arteries. 168. Syphilitic arteritis, 179. Histology of the veins, 161. Classification of tumors, 746. Induration and hy])ertrophy of the glands, 748. Giant-cells in sarcomata. 753. Prejiaration of myoma. 762. Coming's method of producing cocaine anaesthe- sia, 20-23, 290. Corns, 736. Corrosive-sublimate solution. 3, 4. Cotton, borated and absorbent, 8. styptic, 70. Cranium, fractures of, 278. Crinoline l)audages, 9. Crosby, Prof. A. B. Treatment of aneurism, 204. Reduction of hip-jniut dislocation, 335. Cruveilliier on phlebitis, 196. arterial varix. 186. Cyphosis, 691. Cystitis, 567. Cystocele, 564. Cysts of the mammary gland, 465-469. of the spleen, 523. of the kidneys, 559. Cysts, 759. Czerny-Lcmbert sul ure, 480, 491. Dacryocystitis,' 391. Davidson. Sypliilitic arteritis, 179, 183. Davis's apparatus for Pott's disease, 703, 710. Deformities of the spinal column, 691. of the lower extremity, 713. of the upper extremity, 738. Delpech. Ligation of axillary artery below the clavicle, 256. Denis. Theory of coagulation of blood. 163. Dennis, Prof. F. S. Open method of treating amputation-wounds, 105. Dermoid cysts. 759. Deviations of the septum nasi, 400. Diaphragmatic hernia. 498-511. Dieffenbaeh's operation of rhinoplasty, 402. Diphtheritic conjunctivitis, 388. Disea-ses of the joints, 342. Dislocations, 319. Dislocation of the lower jaw, 319, 320. of the clavicle, 320. Dislocation of the shoulder, 320, 32L of the elbow, 326, 327. of the wrist, 329. of the phalanges. 329. of the hip, 329. 330. of the knee, 338. of the patella, 339. of the ankle, 340. of the tarsus, 341. of the vertebnc, 341. of the ribs, 342. Dissection-wounds, 81. Dobbell's solution, 399. Dorsalis pedis artery, ligation of. 270. Drains of rubber, bone, catgut, and horse-hair, 7, 8. Dugas's diagnosis of dislocation of the shoulder- joint, 322. Duodenum, oper.itions upon. 481, 483. Dupuytren's amputation, 130. contraction, 743. operation for restoration of the intestinal canal after fecal fistula. 507. Durante. Process of permanent occlusion of an artery. 185. Ear, surgery of, 393. Ectropion, 389. Eczema of the nipple, 465. of the anus, 531. Elbow-joint, dislocation at the, 326, 327. disease of, 358. exsection of, 308, 309. amputation at, 120. anchylosis of, 739. Eliot. Aneurism of innominate artery, 213. Embolism, 103, 184. Empyema, 474. Encephaloid cancer, 748. Endarteritis, 167. Enostosis, 765. Bnsor. Aneurism of innominate artery, 213. Enteroeele, 494. Enterolithes, 483. Entropion, 390. Epidydimitis, 014, 072. Epiphora, 391. Epiplocele, 494. Epistaxis, plugging the nares in, 397. Epithelioma, 748, 752. of the anus and rectum, 542. of the nipple, 465. Erichsen. Treatment of na?vus, 194. Erysipelas, 81-84. Erythema of the anal region, 531. Esmarch's bandage, 9, 40, 09. 70. treatment of aneurism, 205. Ether and ether narcosis, 24, 25. spray, 23. narcosis by rectal administration, 31, 33. Evans. Aneurism of innominate artery, 214. INDEX. 771 Exostosis, 745, 765. Exsection of the intestine, 491, 507, o£ tiie rectum, 543. of the hip, 360. of the Ivnee, 361-305. of the ankle, 305. of the astragalus, 307. of the slioulder, 307, 368. of the elbow, 308, 309. of the wrist, 370, 372. Exseetions of the joints, 359. Extrophy of the bladder, 503, 504. Eye, bandage for, 18, 19. Eyelids, surgery of, 383. Face, bandage for, 17, 18, 19, 20. surgery of, 383. Facial artery, ligation of, 246. Fecal fistula, 493, 508, 512. 513, 514. Femoral artery, aneurism of, 230. ligation of. 305, 367. Femoral hernia, 508. Femur, fracture of, 301. Fibrin, theory of its formation, 103, 164, Fibroma, 701. of the nipple, 405, Fibula, fracture of, 312-315. Fingers, bandage for, 12, 18. amputation of, 110, 120. deformities of, 741-743. Fissure of the anus, 536, Fistula in ano et recto, 532, Fletcher, Dr, Robert, Snake-bite, 76, 77. Flexion, of the toes, 736, Flint, Prof. A. Hydrophobia, 79. Fluhrer, Dr, W, P. Gunshot-wounds of the brain. 98, 377, Foerster, Classification of tumors, 746. Foot, bandage for, 14, 15. Forbes's amputation, 134. Forearm, amputations of, 133. fractures of, 293, bandage for, 13, 14, Foreign body in the larynx, 453. in the trachea, 453, in tlie bronchi, 453. in the pharynx, 459, in the a'sopliagus, 400. in the intestine, 483. in the urctlira, 631. in the bladder, 597. Foster. Coagulation of the blood, 164. Four-tail bandage, 19, 20, Fractures, 375. Fracture of tlie skull, 278. of the nasal bones, 282. of the upper jaw, 283. of the lower jaw, 284. of the OS hyoides, 386. of the clavicle, 387. Fracture of the acromion process, 288. of the coracoid process, 288. of the glenoid process, 289. of the scapula, 288, of tlie humerus, 289, 290. of the forearm, 293. of the ulna, 293, of the radius, 294. of the carpus, 298. of the metacarpus. 298. of the phalanges, 299. of tlie sternum, 299. of the ribs, 299, of the vertebra?, 300. of the sacrum, 300. of the coccyx, 300. of the OS innominatum, 301. of the femur, 301. of the patella, 308, of the leg. 312. compound, of the leg, 315. of the tarsus, 317. Freund's operation of hysterectomy, 681. Frey, pathology of phlebitis, 161, 163. Frost-bite, 94, Furuncle, 94. Galactocele, 409, Gangrene, 97-101. Gant's line for sub -trochanteric osteotomy, 714. operation for removal of tongue, 440, 441. Gastrectomy, 478, Gastro-enterostomy, 478, 480, 481. Gastrostomy, 462, 477. Gauzes, 8. Genito-virinary organs, 555, Genu valgum, 716, varum, 721. Gcrster, Prof, A. G, Aneurism of innominate, 213, Gibney, Prof, V. P, Myelitis from compression in Pott's disease, 711. Ostitis of head and neck of femur, 345. Girdner, Dr. .1, H. Skin-grafting, 92, Glanders, 79, 80, Glenoid process of scapula, fracture of, 289, Gleet, 617, Glossitis, 435. Gluteal artery, ligation of, 263. hernia, 498-513. Goitre, 446. Gonorrhoea, 60S, 609. Gonorrhoea! i-heumatism, 016. ophthalmia, 388, Green. Formation of thrombi, 164. Greenfield, .Syphilitis arteritis, 179-183. Gritti's amputation, 148, Gross, Prof, S, W, Ligation of internal ju^ar vein, 249. 772 A TEXT-BOOK ON SURGERY. Gunshot-wounds, 87, 88, 89. missiles, 88. Gunther's amputation, V.V.). Iln'inaturia, 578. Ila'inonliase, arrest of. .lO, 68, 69, 70. IlaMuorrlioiils, 547. Hallux valgus, 735. varus. 7;i6. llamiltun, Prof. F. II. Tetanus, 85. Phleliilis, 164. Fracture of malai' bone, 283. Fract ure of lower jaw. 285. Fracture of humerus. '2'.)Z. Fracture of radius. 297. Fracture of thigh. 304. Fracture of patella. 30!), 310. Dislocation at elbow. 329. Dislocation of hip-joint, 337, 338. Hammer-toes, 73G. Hancock's modification of Malgaigue's operation, 136. operation of peritonitis. 51G. Hand, bandage for, 12, 13. amputation of, 122. deformities of, 740. Ilanilkerchief bandages, 19, 30. Ilare-lip, 410. Head, surgery of, 373. bandages for, 17-20. net, 20. and chin bandage, 17, 18. Heart-failure in ether and chloroform narcosis, 31. wounds of, 476. Heat as a hieraostatic, 70. Heaton's operation for hernia, 502. Heitzmann. Histology of the veins, 161, 162. Of the arteries. 168. Henry's amputation of scrotum, 071. Hepatic abscess, 520. Hernia cerebri. 375. strangulated inguinal. 504. of the spleen, 523. of the bladder, 564. Hernia. 493. inguinal, 494. femoral. 4!)6, 508. umbilical, 497,510. ventral, 497. 511. diaphragmatic, 498, 511. gluteal, 498, 512. obturator, 498, 513. lumbar, 498, 512. vaginal. 498, 512. diagnosis of. 498-500. treatment of, 501. Herpes of the anal region, 531. Heubner. Syphilitic arteritis, 179. Hey's amputation, 133, 143. Hip-joint, dislocations at tlie, 339. disease, 344. exsection of, 360, 361. deformities at the, 713. osteotomy near the, 714. Hood-liandage, 20. Hordeolum, 385. Horse-hair drains, 7. 8. Humerus, fracture of, 389, 290. Humphrey'soperation for cancer of the penis, 037. Hunter's method of ligation of arteries in aneu- rism, 202, 203, 205. Hutchinson. Syphilitic ))hlebitis, 164, 165. Multii)le na^vi. 193. Hydatids of the liver. .523. Hydrocele of the tunica vaginalis testis, C64. of the cord, 664. Hydronephrosis. 557. Hydrophobia, 78, 79. Hyoid bone, fracture of, 286. Hypertrophy of the prostate, 598. of the mammary gland, 407. Hysterectomy. 691. Hysterotomy, 678. Ileo-colostomy. 493. Iliac arteries, aneurism of, 285. ligation of, 262.264. Incontinence of m'ine, 514. Infantile hernia, 496. Inferior ma.xilla, fracture of, 284 dislocation of. 319, 330. Infiltration of urine, 506. Inflammation, 53-55, 56, 57, 58. In-growing nail, 737. Inguinal hernia. 494. congenital, 496. Inhalers for ether, 25, 26, 37. In-knee. 717. Innominate artery, aneurism of, 213. ligation of, 331. Instruments, 34. Intercostal artery, ligation of, 258. Internal pudic artery, ligation of, 364. carotid artery, ligature of, 238. mammary artery, ligature of, 255. iliac artery, ligature of. 262. Intestine, constriction by bands, 487. constriction by diverticula, 487, 488. abdominal section in occlusion of, 489, 490. exsection of a porti(m of, 491. wounds of, 536, 527. Intussusception, 483, 484. Iodoform solution, 4. gauze, 8. Irrigation, continuous, 115, 116. Irrigators, 4, 5. Janew,ay. Prof. E. G. Albuminuria .after mental labor, 577. INDEX. 77: Jarvis's snare, 398, 399. Jequirity-bean in panniis, 387. Jork-finger, 743. Joints, surgery of, 319-343. Juniper-oil catgut, 1, 2. drains, 7. Jute, 8. Kidneys, surgery of, 5.55. neoplasms of, 559, 5(!0. King, Dr. E. P. Snake-bite, 76. Knee, anchylosis of, 722. Knee-joint, dislocations at the, 338. disease of, 353. exsection of, 3G1, 305. Knock-knee, 717. Knotted bandage, 18. Koch. Corrosive sublimate as an antiseptic agent, 3. Kocher"s operation for r(?moval of tongue. 440, 441. extirpation of thyroid body, 448. Koenig's operation for rhinoplasty, 402. KoUer. Introduction of cocaine aniBsthesia by, 21. Krackowizer. Spontaneous cure of cirsoid aneu- rism, 190. Ulcer of appendix vcrmiformis, 513. Kunkler, Dr. (r. A. Snake-bite, 76. Labat's operation for rhinoplasty, 402. Lacerda, de, on the treatment of snake-bite. 77. Lange, Dr. F. Ligation of common iliac, 226. Langenbeck's operation for rhinoplasty, 402. for hare-lip, 413. osteoplastic exsection of upper jaw, 425. Laparotomy for intestinal occlusion, 489, 490. for removal of the ovaries, etc., 688. Larrey's amputation at the shoulder, 130. Laryngectomy, 456. Laryngotomy, 450. Larynx, surgery of, 450. intub.ation of the, 451, 452. foreign bodies in the, 453. Lateral curvature of the spine, 694. Lee's amputation of leg. 14:J, 144. Leeches, aiiplication of, 57. Le Port's amputation, 139, 140. 142. Leg, bandage for the, 14, 15, 16. amputations of, 142. fractures of, 312. Lembert's suture for tlic intestine, 480, 491, 526. Leopold's operation of hysterostomy, 679. Levis's operation for extrophy of bladder, 564. for hydrocele, 667. Ligature material. 1, 3, 3. Ligatures, method of applying, 50. 51. Lignerolle's amputation, 135. Lingual artery, ligation of, 244. Linhart's operation for rhinoplasty, 403. Lipoma, 760. Lips, surgery of, 407. Lisfranc's amputation, 134. Lithotomy, 589. Lithotrity, 585. Little, Prof. J. L. Innominate aneurism, 213. Median lithotomy, 595. Littre's anterior or intra-peritoneal colostomy, 595. Liver, surgery of the, 530. Local anajsthesia, 21, 22, 23. Lock-jaw, 84, 85, 86, 87. Loffler. Bacillus of glanders, 80. Lower extremity, deformities of, 713. jaw. fracture of, 284. Lucas-Championniere. Cerebral localization, 378. Lumbar hernia, 498. 512. Lu|)us of the nose, cheeks, and lips, 408. Lymphadenoma, 752, 764. Lymphangioma, 763. Lymphatic vessels, diseases of, 158. glands, diseases of, 160. Lymphatics, wounds of, 161. Macewen's operation for knock-knee, 719, 730. chromic-acid catgut, 3. MacCormac's operation for genu valgum, 720. Mackintosh cloth for protective, 8. Macnamara's operation for incipient ostitis of head and neck of femur, 352. Malgaigne's operation for hare-lip, 413. at calcaneo-astragaloid articulation, 135, 136. JIalignant pustule. 80. Mammary gland, 465. hypertrophy of, 467. tumors of, 467. extirpation of, 471. 472. bandage for, 16, 17. Marion-Sims, Dr. H. Drainage of peritoneal cavity, 566. 689. Ether-inhaler, 27. Martin's rubber bandage, 9, 96, 196. Mason, Dr. L. D. Fracture of bones of nose, 282. Mason, Prof. Erskine. Amputation at hip, 151. Mastitis. 466. Maxilla, superior, 423. inferior, 437. Meatomy, 632. Meckel's ganglion, removal of, 435. Mesarteritis, 167. Metacarpus, fractures of, 298. Metatarsus, amputations through the. 131. Micrococci. GO, 61. Jlitchell. Prof. S. Weir. Snake-venom. 76. Moles, 196. Moore. Pnif. Fracture of clavicle, 287, 288. Colles's fracture. 396. Morbus coxarius. 342. Mucous cysts, 760. 774 A TEXT-BOOK OX SURGERY. Miiller. Recurrent angioiiiii, 193. Miillor's law, 740. Muslin banilages, 9. Mussey. Arterial varix, 188. Myelitis from cunipression in Pott's disease, 711. Myoma. 761. Myxonui, 7G1. Na-vus pigment osus, 197. pilosus, 197. Nail, in-growing, 737. Nasal bones, fracture of the, 283. Neck, surgery of, 444. Neoplasms of the intestine, 488. of the urethra, (!34. Nephrectomy, 5(i2. Nephrotomy, 5()2. Neuber's bone-drains, 7. Neuralgia of prostate, 608. Neuroma. 762. New formations, 746. Nipple, Assure of, 465. Nose, bleeding from, 397. foreign bodies in the, 397, 398. deviation of septum, 400. plastic surgery of, 400. Obstnietion of the alimentary canal, 483. Obturator hernia, 498-512. Occipital artery, ligation of, 340. O'Dwyer, Dr. J. Intubation of larynx, 451, 452. (Esophagectomy, 463. Q5sophagi)tomy, 401. CEsojihagus, surgery of, 459. stricture of, 461. Ogston's opei-ation for knock-knee, 719, 720. Oil-silk protective. 8. Operating-i-oom and paraphernalia, 43, 45. Operation, a snrgical, 49. 50. assignment of duties, 106. Ophthalmia neonatorum. 386. Orbital cavity, surgery of, 392. Orchitis, 615, 673, 674. Os innominatum. fracture of, 300, 301. hyoides, fracture of, 286. Osteo-arthritis, 342. Osteoclasis. 721. Osteoma, 765. Osteomalacia, 274. Osteotomy of femur. 714. Ostitis, 271. Otis. Prof. P. N. Location of stricture, 620. Otis, Dr. G. A. Shot-wounds of face, 382. Otitis media. 395, 396. Ovaries, 683. Ovariotomy. 688. Oza-na, 399. Paget. Transformation of embrj'onic into cica- tricial tissue, 67. Paget. Gouty phlebitis, 165. Palate, surgery of, 431. Pancreas, 524. Pannus, 387. Papilloma, 757. Papilloma of nipple, 46.5. Parotid gland and duct, 420. Parotitis, 423. Pasteur on hydroi)hobia, 78. Patella, fracture of, 308. dislocation of. 339. Peat as an absorbent, 8. Penis, surgery of, 634. ulcers of, 641. Periarteritis, 167. Perineal lithotomy. 590. Periorchitis. 6(i3. Perispermatitis, 603. Peritonitis, laparotomy on account of, 516. Perityphlitis, 517, 518! Peroneal artery, ligation of, 268, 269. Phalanges, fracture of, 299. dislocation of, 329. Pharynx, surgery of, 459. Phimosis, 638. Phlebitis, 161. Phlebolites, 191-190. Phlyctenular conjunctivitis. 389. Pitcher, Prof. L. S. Colles's fracture. 296. Piles, 547. Pirogoff's method of rectal etherization, 31, 33. amputation, 134, 139, 142. Pityriasis versicolor of anal region, 531. Playfair. Laparotomy for peritonitis, 510. Pneumatocele of the head, 374. Polydactylus, 734, 741. Polypus of the rectum, 514. Pope, Dr. Thomas A. Tarantida-poison, 78. Popliteal artery, ligation of, 267. aneurism of, 227. Porro's operation for hysterectomy, 680. Port-wine mark, 197. Posterior auricular artery, ligation of, 248. tibial artery, ligation of, 2G8. Posthitis, 613. Potfs disease, 699. fracture, 313, 315. Prepuce, divulsion or dilatation of the, 641. amputation of, 639. Profunda femoris artery, ligation of, 267. Prostate body, surgery of, 597. tuberculosis of, 606. cancer of, 606. sarcoma of, 607. calculus of, 607. neuralgia of, 608. Prostatorrhcca, 604. Protective, 8. Pruritus ani, 530. Ptosis, 390. INDEX. 775 Pus, 59, 60, 61. Pyelitis, 550. Pylorectomy, 478. Rabies, 78, 79. Kaeliitis, 374. Radial ai-tery, ligation of, 258. Radius, fracaure of, 294. Ranula, 441. Ranvier. See Cornil and Ranvier. Rectal etherization, 31, 33. Rectum, surgery of, 538. foreign bodies in, 533. fistula of, 533. ulcers of, 537. stricture of, 539, 540. neoplasms of, 542. carcinoma of, 543. exsection of, 543. neuralgia of, 545. prolapsus of, 545. Reeves's operation for knock-knee, 719, 730. club-foot, 730, 732. Regional surgery, 373. Reichert, Dr. E. J. Serpent-venom, 76. Coagulation of blood in the vessels, 1(34. Renal calculus, 558. colic, 559. cysts, 559. Resuscitation from ether and cliloroform narco- sis, 29, 30, 31. Retropharyngeal abscess, 703. peritoneal abscess, 519. Rheumatism in gonorrhoja, 616. Rhigoline, 33. Rhinolites, 398. Rhinoplasty, 401. Rib, exsection of, 473-475. Ribs, fracture of, 299. dislocation of, 343. Richardson's ether-spray apparatus, 33. Rick(-ts, 274. Rindflcisch. Formation of angeioraata, 193. Roberts, Dr. John B. Deviation of the septum, 400. Robin, arterial varix, 186, 187. Roliinson, Prof. A. R. Lu))us, 408. Carbuncle, 94. Rokitansky. Origin of angeiomata, 193. Rotary-lateral curvature of the spine, 691-094. Rubber drainage-tubes, 7. tissue-protective, 8. Sacrum, fracture of, 300. Saenger's operation for hysterostomy, 679. Saline solution, intravenous in'eetion of, 74, 75. Salpingitis, 083. Sands, Prof. 11. B. Ijigation of carotid and sul)- clavian artery. 210. Compression of iliac artery, 226. Sands, Prof. IT. B. OSsophagotomy, 401. Sarcoma, 753-756. Savage. Laparotomy for peritonitis, 510. Sawdust as an absorbent, 8. .Sayre, Prof. L. A. Operation at the liip, 300, 361. Club-foot, 723, 724, 736, 739. Polydactylus, 734. Fracture of clavicle, 380, 287. nip-joint disease, 350. 353. Hip-joint exsection, 359, 300. Muscular torticollis, 093. Treatment of knock-knee, 719. Osteotomy of femur, 714. Treatment of Pott's disease, 703, 704, 705, 707. Scalds, 90. Scapula, fracture of, 388. Scarification in inflammation, 57. Schmidt. Coagulation of blood, 104, 176. Schrooder's operation for hysterectomy, 681. Sehutz. Glanders bacillus, 80. Scirrhus cancer, 748. Scoliosis, 691-694. Scrotum, surgery of, 661. Sebaceous cysts, 759. Sedillot's amputation, 143, 144. Senile gangrene, 100. Septum nasi, deviation of, 400. Serous cysts, 7()0. Shaiter's apparatus for Pott's disease, 707, 708, 709. Sheppard, Dr. F. C. Statistics of amputation at hip-joint, 155. .Shoulder, bandage for, 13, 14. Shoulder-joint, amputation at the, 129, 130. dislocations of the, 320. disease of the, 357. exsection of the, 3(i7, 308. anchylosis of the, 738. Silk sutures, 2. -worm gut, 2, 3. Silver-wire sutures, 3. Sims, Dr. J. JIarion-. Exploration of rectum, 533. Skin-grafting. 91, 92, 93. transplantation of, 93. Skull-net, 20. Skull, fracture of, 278, 281. penetrating wounds of. 377. Smith, Prof. Stephen. Amputations of leg, 142, 143, 14(i. 147. 14S. Snake-liito. 75. 7(i, 77. Snap-finger, 743. Solutions, antiseptic, 3, 4. Sounds, 629. Spermatorrhoea, 600. Spica, single and double, for the groin, 10. Spina bifida, 711. Spinal column, deformities of, 691. Spleen, sui-gery of, 523. abscess of. 523. cysts of, 523. 776 A TEXT-BOOK ON SURGERY. Spleen, hernia of, 523. Splencc-tomy. 523. .Spondylitis, Gi)». Sponges, preparation and preservation of, 5, 6, 7. Spray-machine, Dr. Weir's, 4 Staphylorraphy. 432. Starr, Dr. M. Allen. Cerebral localization, 379, 380. Staton, Dr. L. L. Gastrostomy, 403. Sternum, fracture of, 299. cxsection of. 474. Stimson, Prof. L. A. Fracture of thigh through the trochanters, SOO. Stomach, surgery of, 477. foreign bodies in, 477. exsection of a portion of, 478. Stone in the bladder, 580. Strangulation of intestine by bands. 487. by slits in omentum. 4S7. by diverticula, 487. 488. Strangulated hernia. 504. Stricture of the intestine, 488, 489. of the rectum. 540. of the urethra, 018. of the urethra, location of, 021. of the urethra, treatment of. 023. of the urethra, dilatation of, 020, 029. of the oesophagus, 401. Stye, 385. Styptic cotton, 70. Subclavian artery, aneurism of, 218. ligation of. 249. Sublimate gauze, 8. Submaxillary gland. 423. Sub-trochantcric osteotomy, 714. Superior thyroid artery, ligation of, 244. maxilla, fracture of, 28:5. Suppression f)f urine, 500. Suppuration. 59, 00. Supra-pubic lithotomy, 589. Surgical dressings, 1. method of applying, 52. Sutton. Dr. R. S. Essection of intestine, 491. Suture-material, preparation and preservation of, 1, 2, 3. Suture, interrupted, 72. continuous, 72. mattress, 72, 73. quill, 72. 73. wire, 72, 73. pin, 73. cross, 73. double-needle. 7-'?. Sylvester's method of resuscitation applied in ether and chloroform narcosis, 30, 31. .Symblcpharon, 389. Syme's amputation, 137, 138. Syndactylus, 734. Svndcsmitis, 343. Synovitis, 342. Syphilis, 045. 001. .Syphilitic arteritis, 180-187. occlusion of the basilar artery in, 178, 179. Tait, Jlr. Lawson. Laparotomy for peritonitis, 510. Talipes, 722. equinus, 722. 724. calcaneus, 725. varus, 720. etjuino-varus, 720-730. valgus. 731. cavus, 733. planus. 733. Tarso-metatarsus, amputation through, 132. Tarsotomy, 731. Tarsus, amputation through, 132. dislocations of, 344 fractures of, 307. Taxis, 504 Taylor, Dr. C. F. Treatment of Pott's di.scase, 703. Tcale's amputation, 143, 144 Teeth, 4;». Testicle, 073. Tetanus, 84-87. Textor's amputation, 135. Thecitis. 342. Thigh, bandage for, 14, 10. Thompson, Sir Henry. Operation for lithotrity, 580. Continuous dilatation of stricture of the ure- thra, 027. Thorax, bandage for, 16. surgery of, 405. Thrombosis of the veins, 103. of the arteries, 184. Thumb, amputation of, 121. Thyroid body, 440. ThyTotomy, 450. Tibial artery, aneurism of, 228. ligation of, 208. Tibio-tarsal joint, 137. 138. Toes, deformities of. 730. amputation of, 130. bandage for, 14, 15. Tongue. 435. method of controlling hiemorrhage in ampu- tation of, 439. -tie, 442. TonsiLs, 442. Torsion of arteries, 70. Torticollis, 091. Tourniquets, 08, 70. Trachea, 450. foreign bodies in, 453. Tracheotomy, 451. Trachoma, .386. Transfusion, 74, 75. INDEX. 777 Treeves, P. Intestinal obstruction, intussuscep- tion, 4S5. Trendelenburg's trachea-tampon, 457. araputation at hip, 150. Trepliiuing the skull, 381, 383. Trichiasis, 391. Tuberculosis of the prostate, GOG. Tufnell's method of treating aneurism, 203, 208, 225. Tumors, 74G. of the scalp, .373. of the bladder, 574. Typhlitis, 517, 518. rieers. 96, 97. of tlie rectum and anus, 537. Ulnar artery, ligation of, 258. Tl'mbilical hernia, 497, 510. Upper extremity, deformities of, 73S. Ureters, surgery of, 5G3. Uretlira, surgery of, GOS. cocaine an.-esthesia, G31. foreign bodies in, G31. congenital malformations, G33. neoplasms of, G34. Urethritis. GOS. Urethrotomy, iutemal, G23, G24 external, G37, 028. Urine, infiltration of, 5GG. incontinence of, 574. analysis of, 575. suppression of, 5G0. Vagina, hernia into the, 408-513. Valsalva's method of treating aneurism, 201-208, 221 222 Van Buren. Xormal curve of the uretlira, G30. Vance, Dr. A. M. Corsets for spinal curvature, G97. Varicocele. GG3. Varicose aneurism, 199. veins, 194. Vascular system, surgei-y of the, 158. (umors, 18G. Vas deferens, 671. Vein, ligation of internal jugular, 233-249. Velpeau's bandage in disloitation of the acromial end of the clavicle, 321. Venesection, 56, 57, Venous cutaneous tumor, 191. varLx, 194. Ventral hernia, 497-511. Verneuil's operation for hydatids of liver, 533. Vertebra, fractures of, 300. dislocations of, 341. Vertebral artery, ligation of, 255. aneurism of, 224. Vesicular semiuales, 671. Virchow. Classification of tumors, 746. phlebitis, 1G3, 164. Volkmann's sharp spoon in gangrene, 103. sliding foot-piece for fracture, 304. operation for hydrocele, G67. Volvulus, 486. Wardrop's method of treating aneurism, 203, 203. Wardwell, Dr. W. L. On calcification of arteries. IGO, 101. Warren, J. Mason. Angeioma following frost- bite, 192. Wassilieff. Bacillus of glanders, 80. Weber, Dr. L. Occlusion of basilar artery, 178. Weber, 0. Process of occlusion of an artery after tlie application of a ligature, 185. Web-fingers, 741. Webster, Dr. David, on jequirity-bean in pannus, 387. Weigert. Coagulation-necrosis, 176. Weir's antiseptic spray-machine, 4. Wire-eoi-aseur of Jarvis, 399, Wolfler's operation, 480, 481. Wood, Prof. J. R. Open treatment of amputa- tion-wounds, 105. Wood-wool, 8. Wounds, 65. closure of, 71-74. poisoned. 75-78. gunsliot, 87-89. of tlie lymphatic vessels. 100, 161. of the chest, 475. of the heart, 476. of the abdomen and viscera, 524. of the kidney, 555. of the bhidder, 505. Wrist-joint, amputations at, 123. dislocations at, 329, disease of, 358. exsection of, 370-372. Wry-neck, 091. Zinc chloride, solution of, 4. THE KND. REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE I]ew York EQedical ^ouri]al, Edited by FRANK F. FOSTER, M. D., Published by D. APPLET ON & CO., New York, T)ECAUSE : It is the T.KADINO JOURNAL of Amc.ica and contains more reading, matter than auy otlier journal of its class. "DECAUSE ; It is the exponent of the most advanced scientific medical thought. "DKCAUSE : Its contributors are among the most learned medical men of this country. T)ECAUSE: Its "Original Articles" are the results of 6:;ient:fic observation and re- search, and are of infinite practical value to the general practitioner. 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